[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]



 
 THE OLDER AMERICANS ACT: IMPROVING QUALITY OF LIFE FOR AGING AMERICANS

=======================================================================

                             FIELD HEARING

                               before the

                    SUBCOMMITTEE ON SELECT EDUCATION

                                 of the

                         COMMITTEE ON EDUCATION
                           AND THE WORKFORCE
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                  April 28, 2006, in Westerville, Ohio

                               __________

                           Serial No. 109-37

                               __________

  Printed for the use of the Committee on Education and the Workforce



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                COMMITTEE ON EDUCATION AND THE WORKFORCE

            HOWARD P. ``BUCK'' McKEON, California, Chairman

Thomas E. Petri, Wisconsin, Vice     George Miller, California,
    Chairman                           Ranking Minority Member
Michael N. Castle, Delaware          Dale E. Kildee, Michigan
Sam Johnson, Texas                   Major R. Owens, New York
Mark E. Souder, Indiana              Donald M. Payne, New Jersey
Charlie Norwood, Georgia             Robert E. Andrews, New Jersey
Vernon J. Ehlers, Michigan           Robert C. Scott, Virginia
Judy Biggert, Illinois               Lynn C. Woolsey, California
Todd Russell Platts, Pennsylvania    Ruben Hinojosa, Texas
Patrick J. Tiberi, Ohio              Carolyn McCarthy, New York
Ric Keller, Florida                  John F. Tierney, Massachusetts
Tom Osborne, Nebraska                Ron Kind, Wisconsin
Joe Wilson, South Carolina           Dennis J. Kucinich, Ohio
Jon C. Porter, Nevada                David Wu, Oregon
John Kline, Minnesota                Rush D. Holt, New Jersey
Marilyn N. Musgrave, Colorado        Susan A. Davis, California
Bob Inglis, South Carolina           Betty McCollum, Minnesota
Cathy McMorris, Washington           Danny K. Davis, Illinois
Kenny Marchant, Texas                Raul M. Grijalva, Arizona
Tom Price, Georgia                   Chris Van Hollen, Maryland
Luis G. Fortuno, Puerto Rico         Tim Ryan, Ohio
Bobby Jindal, Louisiana              Timothy H. Bishop, New York
Charles W. Boustany, Jr., Louisiana  [Vacancy]
Virginia Foxx, North Carolina
Thelma D. Drake, Virginia
John R. ``Randy'' Kuhl, Jr., New 
    York
[Vacancy]

                       Vic Klatt, Staff Director
        Mark Zuckerman, Minority Staff Director, General Counsel
                                 ------                                

                    SUBCOMMITTEE ON SELECT EDUCATION

                   PATRICK J. TIBERI, Ohio, Chairman

Cathy McMorris, Washington Vice      Ruben Hinojosa, Texas
    Chairman                           Ranking Minority Member
Mark E. Souder, Indiana              Danny K. Davis, Illinois
Jon C. Porter, Nevada                Chris Van Hollen, Maryland
Bob Inglis, South Carolina           Tim Ryan, Ohio
Luis P. Fortuno, Puerto Rico         George Miller, California, ex 
Howard P. ``Buck'' McKeon,               officio
    California,
  ex officio
                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on April 28, 2006...................................     1

Statement of Members:
    Hinojosa, Hon. Ruben, Ranking Minority Member, Subcommittee 
      on Select Education, Committee on Education and the 
      Workforce..................................................     3
        Prepared statement of....................................     4
    Tiberi, Hon. Patrick J., Chairman, Subcommittee on Select 
      Education, Committee on Education and the Workforce........     1
        Prepared statement of....................................     2

Statement of Witnesses:
    Bibler, David, executive director, Licking County Aging 
      Program....................................................    11
        Prepared statement of....................................    13
    Gehring, Charles W., president and chief executive officer, 
      LifeCare Alliance..........................................    18
        Prepared statement of....................................    20
    Geig, Elise, legislative liaison, Ohio Department of Aging...     6
        Prepared statement of....................................     8
    Horrocks, Robert, executive director of the Council for Older 
      Adults of Delaware County..................................    23
        Prepared statement of....................................    25
    Ragan, Ginni, chair, Legislative Affairs Committee, Ohio 
      Advisory Council for Aging.................................    29
        Prepared statement of....................................    31

Additional Submissions for the Record:
    The National Council on Disability, prepared statement of....    51


                        THE OLDER AMERICANS ACT:



                       IMPROVING QUALITY OF LIFE



                          FOR AGING AMERICANS

                              ----------                              


                         Friday, April 28, 2006

                     U.S. House of Representatives

                    Subcommittee on Select Education

                Committee on Education and the Workforce

                            Westerville, OH

                              ----------                              

    The subcommittee met, pursuant to call, at 2:30 p.m., at 
the Westerville Senior Center, 310 W. Main Street, Westerville, 
Ohio, Hon. Patrick Tiberi [chairman of the subcommittee] 
presiding.
    Present: Representatives Tiberi and Hinojosa.
    Staff Present: Kate Houston, Professional Staff Member; 
Lucy House, Legislative Assistant; Ricardo Martinez, Minority 
Legislative Associate; and Moira Lenahan-Razzuri, Legislative 
Assistant for Mr. Hinojosa.
    Chairman Tiberi. Quorum being present, the Subcommittee on 
Select Education, the Committee on Education of the Workforce 
will come to order. We are meeting today to hear testimony on 
the Older Americans Act: Improving Quality of Life for Aging 
Americans. I ask for unanimous consent that the hearing record 
remain open 14 days to allow member statements and other 
extraneous material referenced during the hearing to be 
submitted for the official record. Without objection, so 
ordered.
    Good afternoon. Thank you all for joining us this afternoon 
for a hearing of the Select Education Subcommittee of the 
Committee on Education of the Workforce. I have a prepared 
formal opening statement that I'll ask to be submitted for the 
record.
    Let me begin by extending our sincere thanks to Tim and the 
folks here at the Westerville Senior Center for so graciously 
hosting and opening this room up for this hearing. I also want 
to thank my friend and my colleague from Texas, Ruben Hinojosa, 
for traveling to central Ohio to join us here today for this 
important hearing.
    I'm especially proud to bring this hearing to central Ohio 
to hear from constituents and others to provide us with a local 
perspective and expertise on aging issues and inform us about 
this process that they work on every day.
    I want to just acknowledge and also recognize the former 
Director of Aging for the State of Ohio and a constituent and 
former colleague, Joan Lawrence, who is here today. Joan, thank 
you for being here.
    Over the past several months, this subcommittee has been 
examining the current program, learning about the evolving 
issues facing older Americans, listening to seniors in their 
own words, laying out a plan for strengthening services to 
seniors that are authorized by this Act and relied upon by 
millions of aging Americans each year.
    It is with great pleasure to have my colleague and friend 
from Texas, Mr. Hinojosa, as a partner in this process. We had 
a hearing actually down in Texas recently; and as we move 
forward, I hope to work with not just my colleagues on the 
committee but all of you to ensure that the Federal Government 
is making the most out of the taxpayers' investment in this 
program and programs authorized by this Act.
    Today we are honored to have with us a distinguished panel 
of experts to help us frame the issues for this hearing. I look 
forward to hearing your recommendations on the issues and 
actions for this subcommittee's consideration.
    Before I introduce each of our witnesses, however, I do 
want to recognize my colleague, Mr. Hinojosa, for an opening 
statement.
    Mr. Hinojosa?

 Prepared Statement of Hon. Patrick Tiberi, Chairman, Subcommittee on 
       Select Education, Committee on Education and the Workforce

    Good morning. Thank you for joining us for this hearing of the 
Select Education Subcommittee of the Committee on Education and the 
Workforce. I want to extend my thanks to the Westerville Senior Center 
for so graciously hosting this hearing. I also want to thank my friend 
and colleague, Mr. Hinojosa, for traveling to the 12th District of 
Ohio.
    This is the second and final field hearing on the Older Americans 
Act, which this Subcommittee is scheduled to consider this Spring. 
Field hearings offer Members of Congress a unique opportunity to listen 
to witnesses who can give us a local perspective on an issue. Field 
hearings are an important part of this reauthorization and I am 
especially proud to bring this hearing to the 12th Congressional 
District of Ohio to hear from constituents with tremendous expertise on 
aging issues to inform this process.
    The Older Americans Act recognizes the specialized needs of all 
seniors. These needs may include meals and nutrition, transportation, 
employment, recreational activities and social services, information 
about prescription drug benefits or long term care--to name a few. We 
are fortunate that the United States has a sound infrastructure to 
support these needs. In fact, our robust aging network includes 655 
local and 56 state agencies on aging. This year, the federal government 
invested nearly $1.8 billion to support the delivery of these services.
    Today, supporting the needs of older Americans is as important as 
ever. It is estimated that more than 36 million people in the United 
States are over the age of 65, making it the fastest growing age group 
in our country. According to the U.S. Census Bureau, by the year 2050, 
persons over age 65 will reach nearly 90 million and comprise almost a 
quarter of the total U.S. population. These astounding statistics make 
the upcoming reauthorization of the Older Americans Act all the more 
important. This year, the first baby boomers turn 60 making this a very 
relevant time to be considering amendments to the Act.
    Over the past several months, this Subcommittee has been examining 
the current program, learning about the evolving issues facing older 
Americans, listening to seniors in their own words, and laying out a 
plan for strengthening services to seniors that are authorized by this 
Act and relied upon by millions of aging Americans each year. It is a 
great pleasure to have Mr. Hinojosa as a partner in this process. I am 
also pleased that each of you, and many advocates for seniors 
nationwide, are contributing to our effort. As we move forward, I look 
forward to working with all of you to ensure that the federal 
government is making the most out of the taxpayer's investment in the 
programs authorized by the Older Americans Act.
    Today we are honored to have with us a distinguished panel of 
experts to help us frame the issues for this hearing. I look forward to 
hearing your recommendations on issues and actions for this 
Subcommittee's consideration. Before I introduce our witnesses, I yield 
to the Ranking Member of the Subcommittee, Mr. Hinojosa, for his 
opening statement.
                                 ______
                                 
    Mr. Hinojosa. Thank you very much, Chairman Tiberi. I want 
to express my appreciation for inviting me to Westerville, 
Ohio, to be able to participate in this public hearing, one 
that is very important.
    My parents had 11 children; and my mother lived to the age 
of 95, and she taught me the importance of taking care of older 
Americans.
    The Older Americans Act is one of the most important pieces 
of legislation that our subcommittee has the privilege to work 
on. I thank you again for calling this hearing. I am pleased to 
be in Ohio and to visit another part of your district. I would 
especially like to thank the Westerville Senior Center and all 
of the staff and participants for being such gracious hosts. I 
must share with you that we have a growing Ohio/Texas 
connection. At our last field hearing in Ohio, we met a number 
of students from my district in south Texas who were attending 
Ohio State University as part of a college assistance migrant 
program; and, of course, we now have a University of Texas/Ohio 
State football rivalry brewing.
    It was ironic that we arrived here in Ohio at the airport 
and one of the students who had attended the last hearing that 
we had over at Ohio State University campus happened to see the 
chairman and me and hurriedly ran up to us and introduced 
herself and told us how she had weathered the first winter in 
Ohio. Coming from south Texas where we have semitropical 
weather--I don't think we have had snow except once in a 
hundred years. That was last Christmas. And this young lady was 
telling us how she had weathered the snow and all the winter 
here in this region and delighted to tell us a little bit about 
how she was enjoying the university.
    Another connection is the growing number of Ohio residents 
who we adopt as winter Texans. We get approximately 150,000 
winter Texans to my area because of the climate. And I must say 
that they do contribute a great deal to the economic successes 
that we are enjoying.
    Last month, a couple of winter Texans from Ohio were 
featured in our local paper. These women, on the plus side of 
85 years young, tutor and read to children in some of the 
poorest schools in my area. Their knowledge and caring make a 
real difference for our students. Our seniors are a valuable 
resource for our communities across the nation. We should look 
for ways to maximize their resource.
    As we prepare for the reauthorization of the Older 
Americans Act, we should never lose sight of the great 
potential in our older population. Our nation cannot afford to 
waste it. I'm looking forward to our discussion today, and I'm 
looking forward to hear the witnesses who have an impressive 
record of service and experience. It's essential that we hear 
from people who are directly involved with making the Older 
Americans Act the success that it is. I share the witnesses' 
concern about the resources to meet the challenges of increased 
costs and a growing population. I share with you the concern 
that you all have expressed at lunch today regarding the 
reduction in the budget. We must work together to build the 
capacity of our aging network to meet demographic challenges 
ahead. We have already asked you to do more with less, but 
there comes a time when a system stretched to the limit will 
break. We cannot allow that to happen with the Older Americans 
Act.
    In closing, Mr. Chairman, I want to thank you for inviting 
me again. I want to invite those of you in the audience--thank 
you for coming to be with us. I am looking forward to the 
witnesses' testimony and continuing the dialog about how we can 
achieve our goal of enabling all of our older Americans to 
enjoy the dignity they deserve. And I yield back.

  Prepared Statement of Hon. Ruben Hinojosa, Ranking Minority Member, 
   Subcommittee on Select Education, Committee on Education and the 
                               Workforce

    Thank you, Mr. Chairman. The Older Americans Act is one of the most 
important pieces of legislation that our subcommittee has the privilege 
to work on. Thank you for calling this hearing today.
    I am pleased to be in Ohio again and visit another part of your 
district. I would especially like to thank the Westerville Senior 
Center and all of the staff and participants for being such gracious 
hosts.
    I must share with you that we have a growing Ohio--Texas 
connection. At our last field hearing, we met a number of students from 
my district in South Texas who were attending the Ohio State University 
as part of the College Assistance Migrant Program. And of course, we 
now have a University of Texas--Ohio State football rivalry brewing.
    Another connection is the growing number of Ohio residents who we 
adopt as winter Texans. Our winter Texans contribute greatly to our 
community. Last month, a couple of winter Texans from Ohio were 
featured in our local paper. These women--on the plus side of 85 years 
old--tutor and read to children in some of the poorest schools in my 
area. Their knowledge and caring make a real difference for our 
students.
    Our seniors are a valuable resource for our communities across the 
nation. We should looks for ways to maximize that resource. As we 
prepare for the reauthorization of the Older Americans Act, we should 
never lose sight of the great potential in our older population. Our 
nation cannot afford to waste it.
    I am looking forward to our discussion today. The witnesses have an 
impressive record of service and experience. It is essential that we 
hear from people who are directly involved with making the Older 
American's Act the success that it is.
    I share the witnesses' concern about resources to meet the 
challenges of increased costs and a growing population. We must work 
together to build the capacity of our aging network to meet the 
demographic challenges ahead. We have already asked you to do more with 
less, but there comes a time when a system stretched to the limit 
breaks. We cannot allow that to happen with the Older Americans Act.
    Thank you for being with us today. I am looking forward the 
witnesses' testimony and continuing the dialogue about how we can 
achieve our goal of enabling all of our older Americans to enjoy the 
dignity they deserve.
    I yield back.
                                 ______
                                 
    Chairman Tiberi. Thank you, Mr. Hinojosa.
    Let's get right to our witnesses. And I will introduce all 
of you, and then we'll begin from left--my left to right with 
the testimony. First off, I want to recognize Merle Kerns, 
Director of Department of Aging, who couldn't be here today; 
but in her stead, we have Elise Geig, who is the legislative 
liaison for the Ohio Department of Aging. In this capacity, she 
tracks and reviews state and Federal legislation and makes 
policy recommendations to the Ohio Department's Director on 
issues concerning older Americans. Ms. Geig started her career 
in the Ohio House of Representatives where she served on the 
staff of State Representative Jim Hoops and as a legislative 
aide to the Chair of the House Education Committee 
Representative, Arlene Setzer.
    Thank you for being here today.
    Mr. David Bibler is the executive director of the Licking 
County Aging Program in Newark, Ohio. The Licking County Aging 
Program is a nonprofit organization that provides services 
supporting independent and healthy lifestyles for older 
individuals. Mr. Bibler is responsible for overall operations 
of the agency including overseeing the budget and preparing 
funding proposals, personnel policymaking, as well as Federal 
and state compliance.
    Thank you for being here today as well.
    Mr. Charles Gehring is president and chief executive 
officer of LifeCare Alliance, one of central Ohio's oldest and 
largest nonprofit organizations. LifeCare Alliance's mission is 
to provide health, nutrition services to those in need in 
central Ohio. LifeCare Alliance markets meals to other Meals on 
Wheels providers, child care programs, providers and hospitals.
    In addition to his work at LifeCare Alliance, Mr. Gehring 
is a professor at Franklin University where he helps instruct 
students interested in the management of not-for-profit and 
public organizations.
    Professor Gehring, thank you for being here.
    Mr. Robert Horrocks is the executive director of the 
Counsel for Older Adults in Delaware County. He has led the 
organization through its early development; is credited with 
its successful growth. The counsel provides a variety of 
community services to help Delaware County become a better 
place to live and grow older. Prior to accepting the position 
as the executive director of the Counsel for Older Adults, Bob 
served as the assistant director of the Ohio Department of 
Aging. In 1997, Mr. Horrocks received the highest honor of the 
Columbus based Vision Center when he was selected to receive 
the Medic Award as the outstanding visually impaired citizen of 
Ohio.
    Thanks for being here, Bob.
    Last but not least, Ms. Virginia Ragan is here today to 
represent the senior community of Westerville, Ohio. She's an 
active and engaged member of the community currently serving on 
a number of boards and organizations that work to assist and 
improve the lives of older individuals. Ms. Ragan has served a 
long and distinguished career with the Ohio legislature and was 
serving on the staff of Representative John Ashbrook for a 
number of years. Her knowledge spans a wide range of issues 
including tax reform, financing, in addition to her expertise 
in issues involving older Americans. In 2002 and, again, in 
2004, Ms. Ragan was appointed by Governor Bob Taft to the Ohio 
Advisory Counsel for Aging. She was also named as an Ohio 
delegate to the White House conference on aging held this past 
December.
    Thank you for being here as well.
    Before you all begin with your testimony, I want to remind 
each of our witnesses to please limit your statements to 5 
minutes--your oral statements to 5 minutes. Your entire 
testimony that we have already received, Representative 
Hinojosa and I have already received, will be submitted in the 
record for this hearing in full and will be part of the 
official hearing record.
    So with that, we will begin. Each of you will give oral 
testimony for 5 minutes; and then we will have at least one, 
maybe two, maybe three or four rounds of questioning--just 
kidding. It's really painless. But we'll go ahead and have you 
all testify, and then we will both then question the witnesses. 
With that, I can't think of anything else that I missed.
    Ms. Houston. You're all set.
    Chairman Tiberi. Ms. Geig.

 STATEMENT OF ELISE GEIG, LEGISLATIVE LIAISON, OHIO DEPARTMENT 
                            OF AGING

    Ms. Geig. Thank you, Congressmen Tiberi and Hinojosa, for 
the opportunity to be here today. My name is Elise Geig, the 
legislative liaison for the Ohio Department of Aging. On behalf 
of Director Merle Grace Kearns, and Ohio's aging network, I 
want to thank the committee for scheduling this field hearing 
in Ohio.
    A little less than a year ago, former director of the Ohio 
Department of Aging, Joan W. Lawrence, who is here today, 
provided testimony to this committee. On behalf of the 
Department, she acknowledged the wisdom of the 89th Congress, 
which created the Older Americans Act and praised the elegance, 
simplicity, and purpose of OAA. This afternoon I will discuss 
how Ohio's aging network is implementing the major objectives 
of the OAA and provides some recommendations for 
reauthorization.
    OAA is the foundation of Ohio's dynamic aging network that 
includes the Ohio Department of Aging; 12 Area Agencies on 
Aging; the Long-term Care Ombudsman Program; and more that 
1,200 service providers, including more than 400 senior centers 
like the one hosting this field hearing today.
    In addition to managing OAA funded programs, our aging 
network manages the PASSPORT program, one of the largest 
Medicaid home and community-based service waivers in the 
country. ODA also has other programs that support older 
Ohioans, including the popular Golden Buckeye Card.
    In 2005, Ohio received $46 million in OAA funding. Every 
dollar Congress provides through the OAA leverages two 
additional dollars for services. In addition, Ohio participants 
contribute over 7.5 million toward the cost of services 
annually through contributions or costs sharing. Ohio is one of 
a handful of states that have implemented the cost sharing 
provisions allowed by the 2000 OAA reauthorization.
    In 2005, the combination of Federal, state, and local 
dollars helped to support over 300,000 older Ohioans and their 
caregivers.
    While these numbers sound impressive, the need for services 
exceeds supply across our state. Many service providers must 
place individuals on waiting lists and/or reduce service levels 
to existing consumers. Over the past year, service delivery has 
been drastically impacted by rising gas and food costs.
    Prior to the White House Conference on Aging, we developed 
eight recommendations for reauthorization of OAA. Our 
recommendations include increase the authorized Federal funding 
level of OAA titles and parts by at least 100 million each 
above the fiscal year 2005 appropriated level, except Title 
III, Part E, National Family Caregivers Support Program, which 
should be authorized at 250 million more.
    Please note that nationally from 1980 to 2005, there has 
been a 50 percent drop in buying power for OAA, Title III, 
nutrition and supportive funds. This drop is based on a 
comparison of per capita appropriation of OAA Title III, 
nutrition and supportive service funds in adjusted dollars 
versus age 60, plus, population.
    Strengthen and broaden the Federal role of the Assistant 
Secretary for Aging to establish new partnerships with centers 
for Medicare and Medicaid Services.
    Fund statewide initiatives that help communities address 
the needs of their growing aging populations.
    During the past half century, we have built Peter Pan 
communities and housing for people who never grow old. Most 
communities require people to use automobiles to get to 
shopping and services. Our housing is typically multiple story 
and not conducive to aging in place. Now that our population is 
aging, we need to encourage smart growth that creates 
communities for all ages. This may include retrofitting our 
existing communities, neighborhoods, and housing. Funding 
statewide initiatives could support the capacity building and 
coordination that needs to occur to make age-friendly 
communities a reality. Provide grants to sustain and expand 
Aging and Disability Resource Centers.
    While under the Administration on Aging's proposed Choices 
for Independence Program, which we support, funds can be used 
by states to fund ADRCs. States will have to compete for these 
funds and decide what initiatives to pursue, all while 
absorbing an estimated 25 percent overall cut in OAA funding 
for these specific activities. We recommend that if AoA and 
Congress believe that ADRCs are the front door to the aging 
network, funds be made available and awarded to states annually 
by formula to support the development and ongoing operation of 
ADRCs throughout the nation. Ensure that the Older American's 
Act promotes the effectiveness of the office of the State Long-
term Care Ombudsman.
    Congressman Tiberi, you will be pleased to learn that the 
Long-term Care Consumer Guide that you created through 
legislation in Ohio has been expanded. In March of this year, 
all licensed residential care facilities were added to the 
website.
    Revised Title III, Part D, Disease Prevention and Health 
Promotion provides states with funds to support evidence-based 
prevention, disease management, and health promotion programs. 
AoA has proposed to eliminate Title III, Part D, in its 2007 
budget request. While AoA's proposed Choices for Independence 
Program funds can be used by states to support evidence-based 
disease prevention, we recommend that AoA and Congress maintain 
Title III, Part D, in OAA.
    Add provisions to OAA that will help the aging network 
promote senior mobility and coordinate human services 
transportation.
    Currently there are 63 federally funded programs that 
provide community transportation. These programs each have 
their own union definitions and service delivery requirements. 
Coordination and expansion of transportation resources could be 
facilitated by having common service delivery requirements 
across all programs and funding sources.
    And, finally, reduce statutory and regulatory barriers to 
participation in the Federal employment and training programs 
and increase funding to train older adults to compete in a 
changing workplace.
    We are concerned that the U.S. Department of Labor views 
the Senior Community Service Employment Program as an 
employment and training program and is proposing changes that 
would limit or potentially eliminate the important community 
service benefits of the program.
    Ohio is very proud of the aging infrastructure we have 
developed over the past 40 years with the support of the Older 
Americans Act and is up to meeting the challenges that the 
future will bring.
    Again, thank you, Representatives Tiberi and Hinojosa, for 
the opportunity to share Ohio's progress and recommendations.
    [The prepared statement of Ms. Geig follows:]

         Prepared Statement of Elise Geig, Legislative Liaison,
                        Ohio Department of Aging

    Thank you, Representatives Tiberi and Hinojosa for the opportunity 
to speak here today. My name is Elise Geig the Legislative Liaison for 
the Ohio Department of Aging. On behalf of our director Merle Grace 
Kearns and Ohio's aging network, I want to thank the committee for 
scheduling this field hearing in Ohio.
    A little less than a year ago, former Director of the Ohio 
Department of Aging Joan W. Lawrence, who is here today, provided 
testimony to this committee. On behalf of the Department, she 
acknowledged the wisdom of the 89th Congress, which created the Older 
Americans Act (OAA) and praised the elegance, simplicity and purpose of 
the Act. This afternoon I will discuss how Ohio's aging network is 
implementing the major objectives of the Act and developing ``a 
comprehensive array of community-based, long-term care services 
adequate to appropriately sustain older people in their communities in 
their homes.'' I will also provide some recommendations for 
reauthorization of OAA.
    OAA is the foundation of Ohio's dynamic aging network that includes 
ODA, twelve area agencies on aging, the Long-term Care Ombudsman 
Program, and more than 1,200 service providers, including more than 400 
senior centers like the one hosting this field hearing today.
    In addition to managing OAA funded programs, our aging network 
manages the PASSPORT program, one of the largest Medicaid home and 
community based services (HCBS) waivers in the country, as well as 
other community long-term care programs. ODA also has other programs 
that support older Ohioans, including the popular Golden Buckeye Card 
which provides savings on goods and services for Ohioans age 60 or 
older and adults who are totally and permanently disabled.
    Further, Ohio is one of a few states where local aging network 
partners generate revenue from county senior services property tax 
levies. Sixty-one of Ohio's eighty-eight counties have passed such 
levies, which collectively raise over $100 million in additional 
funding.
    The Office of the State Long-term Care Ombudsman and twelve 
regional programs, funded by Title VII of the OAA, advocate for the 
rights of home care consumers and residents of long term care 
facilities.
    The Ombudsman program investigates more than 10,000 complaints and 
provides nearly 42,500 hours of advocacy and information services 
annually. They also collaborate with community organizations and 
provide abuse prevention education programs and consultation, and 
facilitate legal support for older adults.
    The OAA funds the Senior Community Service Employment Program 
(SCSEP) administered by the U.S. Department of Labor, through grants to 
ODA and six national organizations (i.e., AARP Foundation, Senior 
Service America, Inc., Experience Works, Inc., Mature Services, Inc., 
National Center and Caucus on Black Aged, Inc., USDA/Forest Service) in 
Ohio. These funds provide for 2,611 SCSEP participant slots. However 
service level goals bring the total number of seniors served in Ohio 
through SCSEP to 3,655 annually.
    In 2005, Ohio received $46 Million in OAA funding for home and 
community based services. Every dollar Congress provides through the 
OAA leverages two additional dollars for services to Ohio seniors. In 
addition, Ohio participants contribute over $7.5 million towards the 
cost of services annually through contributions or cost sharing. Ohio 
is one of a handful of states that have implemented the cost sharing 
provisions allowed by the 2000 OAA reauthorization.
    The combination of federal, state and local dollars and participant 
contributions helped 300,000 older Ohioans and their caregivers. 
Nutrition and transportation services are Ohio's leading services, with 
more than 8.5 million meals and 1.4 million miles provided in 2005, 
respectively. In 2005, Ohio served 57,000 caregivers through the 
National Family Caregiver Support Act (Title III, Part B).
    While these numbers sound impressive, need for services exceeds 
supply across our state. Many AAAs and service providers must place 
individuals on waiting lists and /or reduce service levels to existing 
consumers. The risk for institutionalization increases the longer these 
individuals remain on a waiting list and go without needed services. If 
not for the creativity of our aging network and the commitment of local 
voters to pass senior service property tax levies, waiting lists would 
grow and waits would be longer.
    Population growth and the increasing cost of service delivery 
limits our ability to meet the needs of our seniors.
    Population Growth: Census data confirms that during the past decade 
(1990 to 2000) Ohio's 85-plus age cohort grew by 28 percent (39,700 
people.) Based on Census Bureau 2002 estimates, this cohort has grown 
an additional 11 percent (19,604) since the 2000 Census. It is this 
group that has the greatest level of disability and is most in need of 
nutrition and supportive services.
    The first baby boomers began to turn age 60 in 2006. Based on 2000 
Census Bureau estimates, Ohio's 55 to 60 age cohort includes 553,174 
individuals, representing 5 percent of the state's population. As these 
individuals turn 60, they will be looking to Ohio's aging network for 
supports and services. The services baby boomers will seek are far 
different than the age 85-plus cohort and will likely include benefits 
counseling (e.g., Medicare, insurance and retirement benefits), 
caregiver support, and disease prevention and health promotion 
activities.
    Costs of Services: Most of the costs associated with community 
services and nutrition programs are for the direct provision of 
services to older Ohioans. Costs vary by service, but generally include 
labor, supplies and transportation. Costs have increased over the past 
two years and are anticipated to increase at a rate equal to or more 
than the Consumer Price Index (CPI) for the foreseeable future.
    Two cost categories have increased significantly during the past 
year: transportation and meals. Rising fuel costs have negatively 
impacted the provision of transportation-intensive services (e.g., 
home-delivered meals, medical and adult day care transportation). 
According to the American Automobile Association's Daily Fuel Gauge 
Report, cost of regular gasoline in Ohio has increased 29 percent and 
averaged $2.77 per gallon in the last year (as of April 18, 2006).
    Furthermore, approximately 43 percent of all state, federal and 
local service dollars support nutrition services. While in the past 
year (February 2005 to February 2006) the Consumer Price Index (CPI) 
for food and beverages has risen 2.7 percent. A major component of a 
nutritious diet is fresh fruits and vegetables, and during this period 
the CPI for this component increased 7.9 percent while the overall CPI 
increased 3.6 percent.
    I am proud to say Ohio's aging network is a good steward of 
federal, state and local funds. We target our funds to those citizens 
most in need. We have been active in AoA's Performance Outcomes 
Measures Project (POMP) since its inception seven years ago. Partnering 
with AoA and other states, we have developed various service based 
outcome measurement tools. In 2004, we put these tools to work and 
surveyed our OAA consumers and found that we are doing an excellent job 
in delivering our services to those in greatest need and making a 
difference in the lives of our consumers and their caregivers. Some of 
what we learned:
    Home-delivered meal consumers depend on this service to provide 
one-half or more of their daily food intake;
    Transportation consumers use the service to get to a doctor or 
health care provider;
    Homemaker consumers report annual incomes under $15,000; and
    Caregiver program consumers believe that services allow them to 
provide care longer than they could without services.
    The survey also found that consumers were highly satisfied with 
their OAA services.
    Prior to the White House Conference on Aging, we developed Ohio's 
Top Eight Recommendations for Reauthorization of the Older Americans 
Act that, if implemented, will have a positive impact on the lives of 
Older Ohioans and their caregivers. I am happy to say that our 
recommendations are consistent with the top ten WHCoA resolutions.
    Our recommendations include:
    Increase the authorized federal funding level of OAA titles and 
part by at least $100 million each above the FY 2005 appropriated level 
except Title III Part E National Family Caregiver Support Program which 
should be authorized at $250 million more.
    Please note that nationally, from 1980 to 2005, per capita 
appropriation of OAA Title III B & C in ``adjusted dollars'' vs. age 
60+ population has dropped 50% in buying power. The result: support per 
older American has fallen dramatically since 1980. Support per capita 
fell from $15.82 in 1980 to $7.90 in 2005.
    Strengthen and broaden the federal role of the Assistant Secretary 
for Aging to establish new partnerships with Centers for Medicare and 
Medicaid Services (CMS) for the administration of HCBS Medicaid Waiver 
and other long-term care programs.
    Coordination across organizations is essential. Developing a 
coordinated long term care strategy has been a priority of the Taft 
Administration for the last seven years. Since 2001, multiple state 
departments, including the ODA and the Ohio Department of Job and 
Family Services (Ohio's equivalent to CMS) have worked together to 
implement Ohio Access: Strategic Plan to Improve Long-Term Services and 
Supports for People with Disabilities.
    Fund statewide initiatives that help communities address the needs 
of their growing aging populations.
    Provide grants to sustain and expand Aging and Disability Resources 
Centers (ADRC) in Ohio and 42 other demonstration states and 
territories.
    Last year Ohio received a grant from AoA and CMS to develop an 
ADRC. Our pilot ADRC, to be anchored in the Western Reserve Area Agency 
in Aging in Cleveland, will link local and regional entities and create 
a seamless service experience for consumers age 60 and older, as well 
as adults age 18 and older with physical disabilities. Consumers will 
access the network via Internet, phone or in person.
    While under the AoA proposed Choices for Independence Program, 
which we support, funds can be used by states to fund ADRCs, states 
will have to compete for these funds and decide what initiatives to 
pursue (e.g., ADRC vs. disease prevention), all while absorbing an 
estimated 25% overall cut in OAA funding for these specific activities. 
We recommend that, if AoA and Congress believe that ADRCs are the front 
door to the aging network, then funds be made available and awarded to 
states annually by formula to support the development and ongoing 
operation of ADRCs throughout the nation.
    Ensure that the OAA promotes the effectiveness of the Office of the 
State Long-Term Care Ombudsman at all levels in the context of a 
comprehensive elder rights system.
    Congressman Tiberi, you will be pleased to learn that the Long-Term 
Care Consumer Guide that you created through legislation in Ohio has 
been expanded. The website was launched in 2002 to assist consumers in 
selecting a nursing home. The site includes regulatory compliance 
information, consumer satisfaction data, and federal quality measures 
in addition to information provided by each nursing home and is 
maintained by the office of the State Long-Term Care Ombudsman.
    In March of this year, all licensed residential care facilities 
(assisted living) were added to the website. This year nursing home 
family members will be surveyed for new satisfaction data, and next 
year residential care facility residents will get their turn to tell 
the public how they like their home.
    Revise Title III Part D Disease Prevention and Health Promotion and 
provide states with funds to support evidenced-based prevention, 
disease management and health promotion programs.
    AoA has proposed to eliminate Title III Part D in its 2007 budget 
request. While AoA's proposed Choices for Independence Program funds 
can be used by states to support evidenced-based disease prevention, we 
recommend that AoA and Congress maintain Title III Part D in the OAA.
    Add provisions to the OAA (e.g., interagency coordination) that 
will help the aging network promote senior mobility and coordinate 
human services transportation.
    Reduce statutory and regulatory barriers to participation in the 
federal employment and training programs and increase funding to train 
older adults to compete in a changing workplace.
    We are concerned that the U.S. Department of Labor views the SCSEP 
as an employment and training program and is proposing changes that 
would limit or potentially eliminate the important community service 
benefits of the program. For 40 years the SCSEP program has had a dual-
focus: community service, and employment and training. The community 
service element has provided SCSEP participants with the needed 
training and experience to compete for un-subsidized employment while 
affording the aging network (e.g., senior centers, nutrition programs) 
and other community organizations (e.g., libraries, hospitals, schools, 
police stations, and various governmental agencies) with needed support 
to operate their programs. If the community service element of SCSEP is 
dropped from the program, we conservatively estimate that 330-400 FTEs 
that directly support OAA activities and programs will be lost. This 
loss is magnified more when we consider that OAA funds are proposed to 
be cut in the FFY 2007 budget and the first of the baby boomers are 
turning age 60 this year.
    Clarification of Congressional intent for SCSEP is needed. If the 
program is meant to serve as only an employment and training program, 
then SCSEP should be removed from the OAA and placed in the Older 
Worker Opportunity Act or as a title in the Workforce Investment Act. 
If you believe, as we do, that SCSEP is a vital resource for seniors 
and the OAA, then the program should remain a dual focused program on 
community service and employment and training.
    Regardless of the decision of Congress, ODA is dedicated to 
advocating for older workers. We fully support the need for greater 
employment and training options for older Ohioans. To that end, the 
Ohio Department of Aging is actively pursuing the creation of a Mature 
Worker Council as part of the Governor's Ohio Workforce Policy Board. 
We believe this council will fill a desperately needed gap in 
understanding the benefits as well as needs of an aging workforce.
    Ohio is very proud of the infrastructure we have developed over the 
past 40 years with the support of the Older Americans Act and is up to 
meeting the challenges that the future will bring.
    Again, thank you Representatives Tiberi and Hinojosa for the 
opportunity to share Ohio's progress and recommendations.
                                 ______
                                 
    Chairman Tiberi. Thank you, Ms. Geig.
    Mr. Bibler.

 STATEMENT OF DAVID BIBLER, EXECUTIVE DIRECTOR, LICKING COUNTY 
                         AGING PROGRAM

    Mr. Bibler. Since its initial enactment in 1965, the Older 
Americans Act has made an enormous positive difference in the 
lives of millions of older Americans. Our challenge in 2006 and 
beyond is largely one of demographics. It is projected that the 
65 years and older population, which numbered 35 million in 
2000, will more than double in size in the next 26 years.
    The delegates to the once-per-decade White House Conference 
on Aging held in December 2005 were asked to vote on their 
priorities from among 73 proposed resolutions. A majority from 
the over 1,200 delegates from across the Nation chose as their 
No. 1 priority the resolution advocating reauthorization of the 
Older Americans Act.
    The Licking County Aging Program is a multipurpose senior 
center based in Newark, Ohio. From 1997 to 2005, our Title III 
services to seniors increased 34.8 percent while our funding 
increased only 1.8 percent. The funding clearly has not kept 
pace with the increased demand for services.
    The services provided by agencies such as the Licking 
County Aging Program allow seniors to remain independent and 
living in their homes as long as possible. This is where they 
prefer to live. This is also a great savings to our government 
and taxpayers because institutional care can cost as much as 
$60,000 per year, compared to $12,600 for the annual cost of 
in-home care. It simply makes sense both economically and 
socially.
    I would like to discuss with you what I think are four 
priority initiatives. The first initiative is to increase the 
authorization levels. The Aging Network seeks to raise the 
authorized funding levels of all the titles of the Older 
Americans Act by at least 25 percent above fiscal year 2005 
over 5 years, except for Title III, E, which should be 
authorized at $250 million. In Licking County, the number of 
meals we have served has risen for seven consecutive years. In 
1998, we served over 128,000 meals; and by 2005, that number 
had grown to 191,000 meals. During that timeframe, our food 
costs have increased 73 percent. We are on pace to exceed 
200,000 meals this year.
    Title III, E, the National Caregiver Grant, is relatively 
new but has been a great asset not only for the seniors that we 
care for but for the family members who care for their loved 
ones. The 24-hour caregiver faces a great amount of stress. At 
the Licking County Aging Program, we have been able to help 
caregivers in creative ways that have simplified their lives 
and given them peace of mind. We are helping family members who 
are caring for their loved ones at home, again, saving 
taxpayers millions of dollars that Medicaid doesn't have to pay 
for institutional care.
    The second initiative is to senior mobility and 
transportation services. Include statutory language in the 
Older Americans Act that increases support to the Aging Network 
to promote senior mobility and to facilitate coordination of 
human services transportation. At the Licking County Aging 
Program, our aging vehicles traveled more than 300,000 miles in 
2005. That is equal to circling the earth 12 times. For a rural 
county such as ours, transportation is vitally important to get 
clients to their much-needed destinations. We don't have public 
transit systems to get them there.
    Strengthen Coordination to prevent elder abuse. The Aging 
Network seeks an increase in authorization of Title VII 
provisions and services to enhance the Aging Network's capacity 
to increase training of law enforcement officials and medical 
staff, broaden public education and community involvement 
campaigns, and facilitate coordination among all professionals 
and volunteers involved with the prevention, detection, 
intervention, and treatment of abuse and neglect of vulnerable 
older adults. Individuals and agencies that are dedicated to 
protecting older adults against abuse, exploitation, and 
neglect often do so within a fragmented system and with limited 
resources.
    In Licking County, we have only case manager and Adult 
Protective Services for a senior population of more than 
23,000. This is an injustice to our elderly. Too many seniors 
are abused and neglected, many by their own family members. 
This area needs to be addressed.
    The fourth initiative is tapping the potential of civic 
engagement. Healthy older adults represent a powerful asset to 
meet the needs of frail elders and solve other serious social 
problems. The Older Americans Act has historically focused on 
the needs of the frail elderly while paying insufficient 
attention to the significant benefits to be derived from older 
adults making meaningful contributions. This reauthorization is 
the time to correct this increasingly costly oversight. Many 
older adults across the country could be strategically 
mobilized to bolster the long-term care system, tutor and 
mentor children, facilitate access to health services, 
strengthen families, give advice to businesses, and provide 
respite to caregivers.
    I would like to thank Representative Tiberi for inviting me 
to share my perspective and the general views of my colleagues 
from Ohio senior centers, and also I would like to thank 
Representative Hinojosa for attending this hearing as well. We 
urge prompt and decisive congressional action to renew the 
Older Americans Act in 2006.
    [The prepared statement of Mr. Bibler follows:]

        Prepared Statement of David Bibler, Executive Director,
                      Licking County Aging Program

Why Is It Needed?
    Since its initial enactment in 1965, the Older Americans Act (OAA) 
has made an enormous positive difference in the lives of millions of 
older Americans. The Act established the primary vehicle for organizing 
and delivering community-based services through a coordinated system at 
the state level. Nutrition, home care, senior center services, 
transportation, employment, protections against abuse and neglect, 
disease prevention, family caregiver support--all of these have been 
extremely beneficial to seniors over the years. These OAA programs 
provide vital support for elders who are at significant risk of losing 
their ability to remain independent in their own homes and communities, 
enabling them to avoid or delay costly nursing home care.
    According to the Centers for Disease Control and Prevention (CDC), 
roughly 26 million older adults over the age of 65 have physical 
limitations or need assistance with activities of daily life, such as 
eating, bathing, dressing or getting around (2003). Among adults over 
age 80, almost three-quarters (73.6 percent) report at least one 
disability.
    The most preferred form of long-term care is provided through home 
and community-based services, such as home-delivered meals, personal 
care, homemaker services and respite care. Community based supports and 
services allow older adults with physical limitations to remain 
independent and live where they choose, saving the federal government 
and the nation's taxpayers the cost of expensive institutional care.
    Recent data from the Administration on Aging (AoA) show how 
successful OAA programs and services have been in assisting older 
adults and their caregivers. AoA reports that 86 percent of family 
caregivers of OAA clients said the services ``allowed them to care 
longer for the elderly than they could have without the services.'' 
Additionally, OAA-provided meals and services have allowed the nearly 
one-third of elderly home-delivered meals clients who have health 
conditions that make them nursing home eligible remain in the 
community.
    The breadth and depth of OAA programs and services provide 
essential support to older adults who wish to age in place. One of the 
reasons the OAA is so successful is that it is based on an effective 
and efficient system--the national Aging Network--which serves as the 
infrastructure for aging service delivery at the federal, state and 
local level. The OAA binds together all 650 Area Agencies on Aging 
(AAA) and 240 Title VI Native American aging programs across the 
country, providing a support structure for planning, service 
coordination, oversight, and advocacy on programs and services that 
reach more than eight million older Americans every year. AAAs serve as 
the focal point at the community level to link seniors and their family 
caregivers to a myriad of services.
    AAA's and senior centers serve as points of entry for the complex 
and fragmented range of home and community-based services for older 
adults and their caregivers. AAAs and Title VI agencies leverage 
federal dollars with other federal, state, local and private funds to 
meet the needs and provide a better quality of life for millions of 
older adults. According to AoA: ``In FY 2003 state and local 
communities leveraged approximately $2 from other sources for every $1 
of federal funding; for intensive in-home services, the ratio was 
closer to $3 to $1.''
    Our challenge in 2006 and beyond is largely one of demographics. It 
is projected that the 65 years and older population, which numbered 35 
million in 2000, will more than double in size to about 70 million in 
the next 26 years. By 2030, one out of every five people in the U.S. 
will be age 65 and older. People 85 and older are currently the fastest 
growing segment of the population, increasing at a rate four times 
faster than any other age group.
    In 2006, the first of the 77 million baby boomers reach the age of 
60. The aging of the baby boomers over the next 25 years will impact 
every aspect of American society. The rapid increase in the aging 
population will challenge the Aging Network to meet the accompanying 
rise in demand for adequate health and supportive services. The 
reauthorization of the Older Americans Act in 2006 provides an ideal 
opportunity for Congress to ensure that the necessary system of 
services is in place to meet the needs of the current aging population 
as well as the needs of the aging baby boomers.
    The delegates to the once-per-decade White House Conference on 
Aging (WHCoA), held in December 2005, were asked to vote on their 
priorities from among 73 proposed resolutions. A majority of the over 
1,200 delegates from across the nation were selected by members of 
Congress and the governors. Those delegates--leaders in the aging 
network from every part of the country--chose as their number one 
priority the resolution advocating reauthorization of the Older 
Americans Act. That is a powerful statement to Congress and the nation.
    The aging network applauds the wisdom of those delegates and 
supports a non-contentious reauthorization of the OAA, with the hope 
that it can be accomplished this year. A small set of controversial 
issues delayed the last reauthorization for five years. We believe 
that, on balance, the Act is in good shape and that these same 
controversial issues should not be revisited in the upcoming 
reauthorization. We should learn from the experience of the previous 
reauthorization and not reopen carefully crafted compromises that are 
now working well.
A Local Perspective
    Multi-purpose senior centers across the nation are an integral part 
of the service delivery system. The creation and long-term support of 
such senior centers was an important component of the original intent 
of the OAA. The Licking County Aging Program is a multi-purpose senior 
center based in Newark, Ohio. In 2005 we served 4,134 seniors, 
providing a total of 274,751 units of services, including 191,665 home 
delivered and congregate meals, 35,031 hours of home services (personal 
care, homemaking, respite and chore), and 28,778 one-way trips to 
medical appointments and meals sites. In 1997 those respective numbers 
were 128,962 meals, 33,511 hours of home services and 26,990 one-way 
trips. By comparison, in 2005 we received $361,973 in Title III funds 
and in 1997 we received $355,449. During this 9-year period the 
services that we provided increased 34.8 percent while our funding 
increased only 1.8 percent. The funding clearly has not kept pace with 
the increased demand for services.
    The services provided by agencies such as the Licking County Aging 
Program, allow seniors to remain independent and living in their homes 
as long as possible. This is where they prefer to live. This is also a 
great savings to our government and taxpayers because institutional 
care can cost as much as $60,000 per year, compared to $12,600 for the 
annual cost of in-home care. It simply makes sense both economically 
and socially.
    I would like to share with you a story that epitomizes what our 
agency, and many others like us, is all about. Mrs. Potter called our 
office one day asking if the agency would send her a meal. She said she 
was tired of her son's macaroni cheese dishes. Our nutrition secretary 
could tell Mrs. Potter was quite elderly but was not prepared for her 
story. Mrs. Potter was born in 1894 during the second administration of 
Grover Cleveland. At the time we had initial contact with her she was 
103 years old.
    She had become bedridden and was dependent on her son for care. He 
was in his late 70's and caring for his mother was wearing down his 
health. The Licking County Aging Program responded with our noontime 
meal program, along with home services to care for Mrs. Potter's 
domestic and hygienic needs. Mrs. Potter had two favorite ``dishes'' 
from the agency as she called them: our applesauce and the man who 
delivered it, Brad, himself a senior citizen.
    Brad is typical of our drivers. He does not just deliver a meal, he 
delivers a smile and some of his time. For some of our senior clients, 
our meal driver is the only person they see. That is what is so 
critical about our meal program. We deliver not just meals, but a knock 
at the door, a smile and a little conversation.
    Mrs. Potter lived until she was 110 years old. Shortly after her 
death the Licking County Aging Program held one of our popular monthly 
events. Mrs. Potter's son read in our newsletter that we were going to 
be serving coconut cream pie for dessert and he thought no place made 
better coconut cream pies. When he called in his reservation, our 
nutrition department baked him an additional pie to take home.
    This is a story behind our services. It is the story of people and 
caring. It is the story of a life connection for seniors who vitally 
need to know they matter, that people still care about them.
Priority Initiatives
            1. Increase Authorization Levels
    The aging network seeks to raise the authorized funding levels of 
all the titles of the Older Americans Act by at least 25 percent above 
FY 2005 over five years except for Title III E which should be 
authorized at $250 million. The increased authorization levels will 
ensure the Aging Network has the necessary resources to adequately 
serve the projected growth in the numbers of older adults, particularly 
the growing ranks of the 85 and older population who are the most 
frail, vulnerable and in the greatest need for aging supportive 
services.
    The OAA is the major federal social services program for older 
adults in the United States. It has provided vital community-based 
supports to millions of older adults for almost forty years. Since 
1980, however, there has been a substantial loss in the OAA program's 
capacity at the state and community levels to provide services to older 
Americans due to rising costs due to inflation, increasing numbers of 
older adults requesting services, and expanding service demands as 
life-spans have been extended.
    As the aging population grows, so does the need for home and 
community-based services. The impending demographic shift will create 
an unprecedented level of demand for health and social services as 
millions of aging baby boomers begin seeking such supports. The OAA 
provides well-established, trusted, community-based infrastructure of 
services responsive to the needs of older people and their families.
    To illustrate how the cost of providing services has risen over the 
last five years, I would like to share examples of a few situations in 
the state of Ohio. In many areas of Ohio, especially the more rural 
areas, a pattern that holds up across the country, transportation is 
one of the most requested services by older adults. It is also one of 
the most under-funded and suffers from the most rapidly rising costs. 
Lack of funding has forced the Toledo-based AAA to provide 40 percent 
fewer trips in 2005 than it did in 2002. Its AAA neighbor to the 
southeast, PSA 5 out of Mansfield, reports it had to offer 
transportation services to 21.5 percent fewer consumers between 2000 
and 2005. Besides the oft-recognized increases in fuel costs, vehicle 
maintenance and insurance costs have also risen dramatically.
    Food prices have also risen in recent years, driving up the cost of 
home-delivered and congregate meal programs that are funded under OAA 
Title III. The Central Ohio AAA paid $4.60 for each home-delivered meal 
served in 2000; that same meal is $5.05 today. In Southeastern Ohio, 
the cost of a home-delivered meal has reached $6.53, up from $5.81 five 
years ago.
    The Perry County Senior Center reports that they keep waiting lists 
for home-delivered meals and homemaker services, but that ``many of the 
clients are deceased before we can serve them.'' In Lucas County, the 
number of seniors enrolled in programs has increased by 42 percent 
since 2000.
    In Licking County, the number of meals we have served has risen for 
seven consecutive years. In 1998 we served 128,613 meals and by 2005 
that number had grown to 191,665 meals. During that time frame, our 
food costs have increased 73 percent. We are on pace to exceed 200,000 
meals this year. Unfortunately, appropriations for OAA programs have 
not reflected this explosive growth and increased costs. Additional 
funding is needed.
    Title III-E, the National Family Caregiver Grant is relatively new 
but has been a great asset not only for the seniors that we care for, 
but for the family members who care for their loved ones. The 24-hour 
caregiver faces a great amount of stress. At the Licking County Aging 
Program we have been able to help caregivers in creative ways that have 
simplified their lives and given them peace of mind. For example, we 
have used Title III-E funds to purchase an airline ticket to fly a 
client to Texas to live with her sister, her only living relative that 
was able to care for her. We have moved a washer and dryer upstairs for 
an elderly man who is caring for his wife but was unable to get up and 
down the stairs to wash their clothes. In addition, the National Family 
Caregiver Grant has allowed us to provide thousands of hours of respite 
to family members who desperately needed a few hours of relief from the 
responsibilities of care giving. We are helping family members who are 
caring for their loved ones at home, again saving taxpayers millions of 
dollars that Medicaid doesn't have to pay for institutional care. 
However, Title III-E is grossly under funded and much more is needed.
    Another factor also needs consideration. In Ohio and nationwide 
this year, the roll-out of the new Medicare Part D prescription drug 
plan has placed additional responsibilities on local providers, largely 
without additional funding. Older adults and their families have turned 
to local senior centers en masse during the 2005-2006 enrollment 
campaign. Yet only a small number of local aging programs received new 
resources from states or national pilot projects to support their one-
on-one counseling and enrollment assistance efforts.
    To respond to the overwhelming demand for Medicare Part D 
assistance, senior center staff members were often shifted from other 
responsibilities to help with enrollment, making this level of effort 
unsustainable and taking them away from their other jobs. Even when the 
initial enrollment period ends, the public will continue to turn to 
local senior centers. Millions of seniors will continue to need 
counseling and enrollment assistance every year, as they become newly 
eligible for Medicare or seek to change their prescription drug plans.
    In order for senior centers to continue the tremendous amount of 
work that Medicare Part D enrollment assistance has generated, we need 
new funding to support and sustain this effort.
            2. Strengthen Senior Mobility/Transportation Services
    Include statutory language in the Older Americans Act that 
increases support to the Aging Network to promote senior mobility and 
to facilitate coordination of human services transportation. Mobility 
is essential for an individual to live at home and in the community. 
Transportation provides necessary access to medical care, employment, 
shopping for daily essentials and the ability to participate in 
cultural, recreational, and religious activities. As the population 
ages, enhanced efforts are needed to help older drivers remain on the 
road for as long as safely possible and to provide safe, reliable and 
convenient alternative means of transportation for those for whom 
driving is no longer an option.
    Transportation is a priority service under Title III of the Older 
Americans Act. However, transportation competes for limited funding 
against many other support services. Coordination of transportation 
services among human service providers has been identified as a means 
of increasing the capacity of local providers to provide, in the most 
cost-efficient means possible, their older adult clients with the 
transportation services necessary to maintain their independence and 
quality of life.
    At the Licking County Aging Program, our agency vehicles traveled 
more than 300,000 miles in 2005. That is equal to circling the earth 12 
times. We have the second largest county geographically in the State of 
Ohio and we currently have seven vehicles with more than 200,000 miles 
on their odometers. Safety for our clients is our utmost concern and 
more funding is needed that would allow us to purchase vehicles and 
provide more services. For a rural county such as ours, transportation 
is vitally important to get clients to their much-needed destinations. 
We don't have public transit systems to get them there.
            3. Strengthen Coordination to Prevent Elder Abuse
    The aging network seeks an increase in authorization of Title VII 
provisions and services to enhance the Aging Network's capacity to 
increase training of law enforcement officials and medical staff, 
broaden public education and community involvement campaigns, and 
facilitate coordination among all professionals and volunteers involved 
with the prevention, detection, intervention and treatment of abuse and 
neglect of vulnerable older adults. Abuse, exploitation and neglect are 
common occurrences for far too many of today's older adults and this 
problem will only be exacerbated by the rapid growth of the aging 
population over the next decade. To date there is no federal law that 
comprehensively addresses elder abuse and neglect, from prevention to 
intervention through prosecution. Individuals and agencies that are 
dedicated to protecting older adults against abuse, exploitation and 
neglect, often do so within a fragmented system and with limited 
resources.
    In Licking County we have only one case manager in Adult Protective 
Services for a senior population of 23,534. This is an injustice to our 
elderly. Too many seniors are abused and neglected, many by their own 
family members. This area needs to be addressed.
            4. Tapping the Potential of Civic Engagement
    Healthy older adults represent a powerful asset to meet the needs 
of frail elders and solve other serious social problems. Tapping 
healthy older adults as an asset to solve social problems is an 
economic imperative with the potential of raising our standard of 
living. An article in the June 27, 2005, Business Week stated: ``If 
society can tap Boomer talents, employers will benefit, living 
standards will be higher, and the financing problems of Social Security 
and Medicare will be easier to resolve.'' The article goes on to say: 
``Increased productivity of older Americans and higher labor-force 
participation could add 9% to gross domestic product by 2045 on top of 
what it otherwise would have been. This 9% increase would add more than 
$3 trillion a year, in today's dollars to economic output.''
    The OAA reauthorization creates the opportunity for AoA to play a 
central role in developing the resource potential of aging into real 
value for the nation. The OAA has historically focused on the needs of 
the frail elderly while paying insufficient attention to the 
significant benefits to be derived from older adults making meaningful 
contributions. This reauthorization is the time to correct this 
increasing costly oversight. As part of AoA's established aging 
network, many older adults across the country could be strategically 
mobilized to bolster the long-term care system, tutor and mentor 
children, facilitate access to health services, strengthen families, 
give advice to businesses and provide respite to caregivers; all civic 
activities shown also to contribute to their own well-being. There is 
much to gain by leveraging relatively small investments in civic 
engagement into major returns on the value of contributions in 
education, health care, transportation, housing, and long-term care.
            5. Recommendations from the Administration on Aging
    We are supportive of the Administration on Aging's Choices for 
Independence initiative. AoA's Choices for Independence proposal can 
strengthen and improve the OAA and provide significant benefits to 
seniors in need.
    The initiative has three components. The Consumer Empowerment 
component can provide important information on planning for long-term 
care, including using reverse mortgages to stay at home. The Community 
Living Incentives component can help address the expensive 
institutional bias in our nation's long-term care system by improving 
access to more cost effective home and community services for 
vulnerable, moderate income seniors. The Healthy Lifestyle component 
can build on AoA's current, highly successful Evidence-Based Prevention 
Demonstration Program to assist older adults to make behavioral changes 
that have proven to be effective in reducing the risk of disease and 
disability.
    Although we appreciate the proposed $28 million investment in the 
initiative, we believe additional resources will be needed to fully 
achieve the proposal's goals, and that funding should not be taken from 
current OAA programs such as Title III-D.
    We oppose AoA's recommendation concerning consumer contribution, or 
cost sharing. This was one of the major controversies that held up 
reauthorization last time. To help break the logjam, the National 
Council on Aging (NCOA) and the National Association of State Units on 
Aging (NASUA) collaborated on a delicately balanced compromise that is 
the foundation of the current law provision. We oppose reopening this 
contentious issue for two basic reasons:
    1) Nutrition providers are currently required to provide 
participants with an opportunity to make non-coercive, voluntary 
contributions, and AoA data show that many seniors do contribute. These 
voluntary contributions by seniors account for 32% of the total income 
in congregate meals programs and 25% in home-delivered meals. That 
system works well and should be retained. Congress should not be 
erecting additional barriers to participation in nutrition programs. 
Congress should do its utmost to assure that no senior who needs 
nutrition assistance is denied because of inability to pay mandatory 
cost-sharing.
    2) The 2000 reauthorization required the AoA to complete a study of 
cost-sharing practices, to determine their impact on participation. 
That study has not been completed. Congress should await the results of 
this analysis before considering any change to the compromise in 
effect.
            6. Recommendations from the Department of Labor
    The Senior Community Service Employment Program (SCSEP), authorized 
by Title V of the OAA, is our nation's premier workforce program for 
low-income older Americans, and we strongly hope that it is not again a 
source of controversy in this reauthorization, as it was in the 
previous reauthorization. SCSEP builds employment skills, renews each 
individual's sense of self worth, and provides needed wages to low-
income seniors. It also offers valuable social and economic benefits to 
communities, and extends the reach of community-based organizations. 
All across our nation SCSEP enrollees perform valuable community 
services in senior centers, libraries, schools, and health and social 
service institutions.
    In sharp contrast to the approach that AoA has taken, the 
Department of Labor is pushing for revisions in OAA that will harm 
seniors, their families and their communities. The best course for 
Congress to take with Title V is to continue it as it is, with minor 
improvements.
    We strongly oppose DoL's proposed far-reaching structural changes 
to SCSEP, such as block-granting the program to the states, eliminating 
national grants, de-emphasizing community service (which benefits 
program participants, the aging network, and communities served), 
eliminating participants under age 65, and eliminating fringe benefits 
for participants. These changes would make the program far worse, not 
better. Such changes are unwarranted, and would be disruptive and 
harmful to older workers and communities.
    We support the broad consensus--which was recently developed by all 
13 national SCSEP sponsors and subsequently supported by many other 
aging organizations--that the following principles should help guide 
Congress's efforts in reauthorizing Title V: (1) Continue the current 
system of funding both national and state grants, including the current 
percentage split of the funds; (2) Maintain the program's historic dual 
emphasis on both community service placements and unsubsidized 
placements for participants; (3) Maintain the current age and 
eligibility requirements for participants, so that services can be 
targeted to persons with the greatest economic and social need; (4) 
Retain current policy on program budgets; and (5) Strengthen the role 
of the Administration on Aging in SCSEP, because Section 505(a) of the 
OAA does not appear to be working as intended.
    SCSEP is a proven program that has a good track record of providing 
training and placement for difficult-to-serve populations of older 
adults. The program should be allowed to continue doing what it does 
well. Many not-for-profit organizations such as the Licking County 
Aging Program rely on the assistance of the Title V programs to provide 
employees at no cost, while at the same time we are giving them 
valuable job training. The paycheck they receive from their SCSEP 
sponsor is needed to supplement their social security income just so 
they can meet their basic daily needs.
    I would like to thank Representative Tiberi for inviting me to 
share my perspective and the general views of my colleagues from Ohio's 
senior centers. We urge prompt and decisive Congressional action to 
renew the Older Americans Act in 2006.
                                 ______
                                 
    Chairman Tiberi. Thank you.
    Mr. Gehring.

STATEMENT OF CHARLES W. GEHRING, PRESIDENT AND CHIEF EXECUTIVE 
                   OFFICER, LIFECARE ALLIANCE

    Mr. Gehring. Thank you for allowing me this opportunity to 
share thoughts, and the thoughts of the thousands of clients 
served every day by LifeCare Alliance regarding the critical 
importance of the Older Americans Act. I'm Chuck Gehring, 
President and Chief Executive Officer of LifeCare Alliance, 
central Ohio's oldest and largest provider of services to 
seniors and chronically ill individuals. To give you some 
scope, founded in 1898, LifeCare Alliance prepares and serves 
over one million meals each year to more than 5,000 clients in 
Franklin and Madison Counties. We operate 28 congregate dining 
centers, which serve over 182,000 meals annually, where seniors 
and chronically ill individuals find friends and needed social 
contact. Over 4,200 people actively serve as volunteers in our 
Meals-on-Wheels program, contributing 116,000 volunteer hours 
and donating more than 350,000 miles of travel in their own 
vehicles. We also operate the federally funded Senior Farmers 
Market Program, which provides critical food to many needy 
seniors in our community.
    Our Help-at-Home program provides over 18,000 homemaker 
visits and 14,000 home health aid visits annually. Our visiting 
nurse program, which is how we started, completes over 11,000 
home visits annually, while our 11 senior wellness centers 
receive 6,400 annual visits. And we also provided 11,000 flu 
shots last year, and we are the chairs of the Central Ohio Flu 
Coalition.
    We also operate two other agencies that have merged into 
us: Project Open Hand Columbus, which provides home-delivered 
meals and congregate dining centers for those living with HIV/
AIDS; and the Columbus Cancer Clinic, which provides screenings 
and home care support to those living with cancers. Please note 
that most of these clients are in the later stages of their 
diseases, they have poverty-level income, and many are seniors. 
The vast majority of LifeCare Alliances are below the Federal 
poverty level. Seventy percent live on less than $600 per 
month. Seventy percent see no other adult on a regular weekly 
basis other than our workers. Seventy percent have diabetes. 
All are homebound in need and hungry.
    The work this subcommittee is doing today is of critical 
importance to LifeCare Alliance and our thousands of clients, 
and we commend you for holding this hearing. The 
reauthorization of the Older Americans Act in 2006 must be the 
highest priority for Congress. The Meals-on-Wheels program, 
paid for in part by the Older Americans Act, is about hunger in 
America. I understand that when hunger in America is discussed, 
we normally talk about children. The fact is that millions of 
elderly Americans would be hungry if not for the Older 
Americans Act and the Meals-on-Wheels program. They would also 
spend considerably more time in the hospital and die sooner. 
For many of our clients, our program provides the only meals 
they receive each day and the only visitor to their home.
    Finally, without the Older Americans Act, American 
taxpayers would pay significantly more in taxes to support our 
senior clients in governmentally supported facilities and 
nursing homes where none of our clients want to be. In fact, 
the latest figures provided by AARP indicate that for each 
senior that we keep independent and in their own homes, where 
100 percent of our clients tell us they want to be, taxpayers 
save over $40,000 per year. This means that LifeCare Alliance 
alone saves Ohio taxpayers over $300 million a year. What other 
act of Congress for the American people has this kind of return 
on investment for the American people while giving our seniors 
exactly what they want?
    LifeCare Alliance, working with funds from the Older 
Americans Act saves taxpayers hundreds of millions of dollars 
additionally each year. By keeping seniors safe and healthy in 
their own homes, we keep them out of hospitals, saving 
significantly more by not using Medicare/Medicaid funds. The 
national average for seniors is that they spend nine and a half 
days each year in the hospital. Our clients, using services 
from the Older Americans Act, spend less than 1 day a year in 
the hospital.
    As you can see, the practical side of the Older Americans 
Act is incredibly positive, providing staggering financial 
savings to taxpayers. It allows seniors to remain in their own 
homes where they want to. Meals-on-Wheels reduces and often 
eliminates hunger for seniors in America. Our nurses and home 
health aids keep clients clean and healthy. Nothing could make 
more sense in America. LifeCare Alliance works every day and 
has a dramatic and positive community impact every day. Our 
people and programs substantially improve and change lives 
every day saving billions of taxpayers' dollars nationally each 
year, reducing hunger among our seniors, providing quality of 
life, providing services and comfort that cannot otherwise be 
provided. And this is the legacy of the Older Americans Act.
    Where do we go from here? Here are a couple of thoughts:
    First, obviously, we encourage you to please reauthorize 
the Older Americans Act.
    Second, the Older Americans Act needs more funding. In 
recent years, many of the titles of the Older Americans Act 
have been kept at existing levels or even reduced. The fact is 
that while LifeCare Alliance continues to fundraise 
aggressively, continues to initiate social entrepreneurship 
efforts to generate funds, continues to improve operational 
efficiencies, there is a limit to how much we can raise. 
LifeCare Alliance's policy is to accept all clients who call; 
and with ever increasing numbers of seniors, we simply will run 
out of funds at the rate we are going.
    Third, please consider linking the Older Americans Act 
funding increases to increases in senior populations. In 
Franklin and Madison Counties, and I know in Delaware County, 
the number of seniors will more than triple during the next 12 
years, according to statistics from Scripps Gerontology 
Institute at Miami University. By linking funding to the number 
of seniors, we can better ensure services as the baby boomers 
reach senior age.
    Fourth, please consider the discontinuation of moving funds 
from Title III, C, to Title III, B, that's meals to support 
services. All services funded by the Older Americans Act are 
critical and meals provide reduced hunger amongst seniors in 
America. Also Title III, C, can no longer act as the bank to 
support other services. In the last 5 years alone, $174 million 
have been transferred from Title III, C, to Title III, B, 
representing a national loss of 38 million meals.
    Fifth, please support increases in transportation funding, 
especially for individual trips for medical care. 
Transportation to doctors and treatment facilities continues to 
be a tremendous need in central Ohio.
    Thank you for this opportunity to present critical 
information to your committee. I stand ready to assist you in 
any way I can with your efforts. Please feel free to call upon 
me or any of the other panelists in any way we can to help you.
    And, finally, since we're in Westerville, may I just share 
a brief story. For many years, for the last 12 years, the 
students of Westerville North High School have--they were the 
fist high school in Columbus as part of a class to deliver 
Meals-on-Wheels. We now have 12 high schools in central Ohio 
delivering Meals-on-Wheels.
    A year ago at Christmastime, two 18 year-old girls from 
Westerville North High School went to a client's house who was 
deaf. And, you know, deaf people cannot hear the knock on the 
door; but she did not answer. They knew how much she enjoyed 
her Meals-on-Wheels. They went the extra mile and found the 
manager. To make a long story short, the lady was found on her 
floor of her apartment passed out. She had terminal cancer. The 
girls didn't know this. Nobody can know this. It's private. But 
she had terminal cancer and that lady was going to die the next 
day anyway; but because of the program and because of what the 
Older Americans Act did and because of what these two 
Westerville North High School students did, this lady was able 
to die in her daughter's arms instead of on the floor of her 
home. Her daughter still tells us there is no greater gift she 
could have ever been given. That's the legacy of the Older 
Americans Act.
    Thank you for your time.
    [The prepared statement of Mr. Gehring follows:]

        Prepared Statement of Charles W. Gehring, President and
               Chief Executive Officer, LifeCare Alliance

    Thank you for allowing me this opportunity to share thoughts, and 
the thoughts of the thousands of clients served everyday by LifeCare 
Alliance, regarding the critical importance of the Older Americans Act.
    I am Chuck Gehring, President and Chief Executive Officer of 
LifeCare Alliance, Central Ohio's oldest and largest provider of 
services to seniors and chronically ill individuals. Founded in 1898, 
LifeCare Alliance prepares and serves over one million meals each year 
to 5,000 clients in Franklin and Madison Counties. We operate twenty 
eight congregate dining centers, which serve over 182,000 meals 
annually, where seniors and chronically ill individuals find friends 
and needed social contact. We provide a wide selection of meals, 
including diet, vegetarian, pureed, soft, frozen, Kosher, Somali, and 
other ethnic meals. Over 4,200 people actively serve as volunteers in 
our Meals-on-Wheels program, contributing 116,000 volunteer hours, and 
donating more than 350,000 miles of travel in their own vehicles. Our 
volunteers equate to almost one hundred full time employees, saving 
millions for this critical program. We also operate the federally 
funded Senior Farmers Market Program, which provides critical food to 
needy seniors in our community.
    Our Help-at-Home program provides over 18,000 homemaker visits and 
14,000 home health aide visits annually.
    Our Visiting Nurse Program completes over 11,000 home visits 
annually, while our eleven senior wellness centers receive 6,400 annual 
visits. We also provided over 11,000 flu shots last year, and provided 
the chair of the Central Ohio flu coalition. We assist in arranging 
medications, and have started a falls prevention program.
    In addition, two other agencies have merged into LifeCare Alliance 
since December, 2004. Project Open Hand provides home delivered meals 
and congregate dining centers to those living with HIV/AIDS. The 
Columbus Cancer Clinic provides screenings and home care support to 
those living with cancer. Most of the Project Open Hand and Columbus 
Cancer Clinic clients are in advanced stages of their afflictions, 
unable to work, and with poverty level income. Many are seniors. Most 
would need to live in governmentally supported facilities if we did not 
assist them in remaining in their own homes.
    The vast majority of LifeCare Alliance's clients are below the 
federal poverty level. 70% live on less than $600 per month. 70% see no 
other adult on a regular basis other than our workers. 70% have 
diabetes. All are homebound, in need, and hungry.
    The work this subcommittee is doing today is of critical importance 
to LifeCare Alliance and our thousands of clients, and we commend you 
for holding this hearing. The reauthorization of the Older Americans 
Act in 2006 must be the highest priority for Congress. The Meals-on-
Wheels program, paid for in part by the Older Americans Act, is about 
hunger. I understand that when hunger in America is discussed, we 
normally talk about children. The fact is that millions of elderly 
Americans would be hungry if not for the Older Americans Act and the 
Meals-on-Wheels program. They would also spend considerably more time 
in the hospital, and die sooner. For many of our clients, our program 
provides the only meals they receive each day, and the only visitor to 
their home.
    Finally, without the Older Americans Act, American taxpayers would 
pay significantly more in taxes each year to support our senior clients 
in governmentally supported facilities and nursing homes, where NONE of 
our clients wants to be. In fact, the latest figures provided by AARP 
indicate that for each senior LifeCare Alliance keeps independent and 
in their own homes, where 100% of our clients tell us they want to be, 
taxpayers save over $40,000 per year. This means that LifeCare Alliance 
ALONE saves taxpayers over $300 million each year.
    What other act of Congress has this kind of return on investment 
for the American people, while giving our seniors exactly what they 
want.
    LifeCare Alliance, working with funds from the Older Americans Act, 
saves taxpayers hundreds of millions of dollars each year. By keeping 
seniors safe and healthy in their own homes we keep them out of 
hospitals, saving significantly more by not using Medicare/Medicaid 
funds. The national average for seniors is that they spend 9.5 days 
each year in the hospital. Our clients average less than one day per 
year in the hospital.
    As you can see, the practical side of the Older Americans Act is 
incredibly positive, providing staggering financial savings to 
taxpayers. It allows seniors to remain safe and healthy in their own 
homes, where they want to be. Meals-on-Wheels reduces, and often 
eliminates hunger for seniors in America. Our nurses and home health 
aides keep clients clean and healthy. Nothing could make more sense for 
America.
    One of our clients is a 90 year old female, living alone in the 
home she has lived in for fifty years. Her husband was also a client 
until he passed away two years ago. She receives Meals-on-Wheels, and a 
homemaker to clean her home. She uses a walker and notes that while her 
health and mind remain reasonably sound, she simply can not cook for 
herself any more. ``Standing at a stove, trying to cook is 
impossible'', she says. ``With a walker, I can't stand very long, and 
I'd lose my balance and fall or burn myself. People just don't realize 
how hard it is to chop a carrot or cook food at my age''. This client 
raves about our Meals-on-Wheels, takes advantage of our special lenten 
menu, and saves Ohio taxpayers over $40,000 each year by remaining 
independent and in her own home, where she wants to remain.
    Other clients report similar amazing stories. LifeCare Alliance 
engages over seventy businesses and schools to volunteer with 
delivering Meals-on-Wheels. One local high school, which has allowed 
their seniors to deliver Meals-on-Wheels as part of a class for the 
past eleven years, reported the following story. Two senior girls were 
delivering to a deaf client. When the woman did not answer the door, 
the girls searched for the building manager, knowing that this woman 
looked forward to her meal every day. They could have simply placed a 
notice on her door that they could not find her. But, being well 
trained volunteers of LifeCare Alliance, they cared about the client 
and went far beyond what was expected. These two eighteen years old 
girls were delivering the meal as volunteers because the Older 
Americans Act provided funding, and developed programs that could use 
volunteers, thus vastly reducing costs. To make a long story short, the 
girls' efforts resulted in finding the client on the floor, in 
distress. The girls did not know that this client had terminal cancer. 
The client's cancer would cause her to die the following day, and there 
was nothing they could do about that. However, their efforts by being 
LifeCare Alliance and Older Americans Act volunteers allowed this 
elderly client to die in the arms of her daughter, instead of alone, on 
the floor of her home. Her daughter has noted to us that being able to 
hold her mother in her final hours was perhaps the greatest gift she 
had ever received. As you can see, the value of the Older Americans Act 
is way beyond my previous calculations of savings to American 
taxpayers.
    LifeCare Alliance, working with funds from the Older Americans Act, 
has a dramatic and positive community impact EVERY DAY. Our people and 
programs substantially improve and change lives EVERY DAY. Saving 
billions of taxpayers dollars nationally each year, reducing hunger 
among our seniors, providing quality of life, providing services and 
comforts that can not otherwise be provided, this is the legacy of the 
Older Americans Act.
    Where do we go from here? I am listing below my thoughts for your 
committee as you continue your work to reauthorize the Older Americans 
Act.
    First, please reauthorize the Older Americans Act.
    Secondly, the Older Americans Act needs more funding. In recent 
years, many of the Titles of the Older Americans Act have been kept at 
existing levels, or even reduced. Retaining funding at existing levels 
means that the programs I have described receive annual cuts. As the 
funds are distributed by Area Agencies on Aging, those agencies must 
retain funds to pay for pay increases, and increased expenses. This 
results in funding cuts to organizations like LifeCare Alliance. The 
fact is that while LifeCare Alliance continues to fundraise 
aggressively, continues to initiate social entrepreneurship efforts to 
generate funds, continues to improve operational efficiencies, there is 
a limit to how much we can raise. LifeCare Alliance's policy is to 
accept all clients who call. With ever increasing numbers of seniors, 
we simply will run out of funds.
    As an example, in the summer of 2003, Madison County Hospital 
contacted us about assuming their Meals-on-Wheels and Congregate Dining 
program in Madison County. The hospital had lost $155,000 the previous 
year operating the program. We agreed to do this, because nobody else 
would. In the past three years, we have greatly reduced the loss, but 
we still have a loss. The Older Americans Act funding in Madison County 
is supplemented by funds from United Way, client contributions, and our 
new fundraising efforts. We constantly strive to obtain new volunteers 
to reduce our costs. We have reconfigured distribution routes, changed 
the way we deliver meals, and reduced staff. We still have a loss. The 
Madison County clients receive Meals-on Wheels from LifeCare Alliance 
everyday because we know that nobody else will take over this program. 
How many other programs like the one in Madison County will cease to 
exist in the upcoming years? We can avoid this with reasonable 
increases in funding for the backbone of these critical senior 
programs-The Older Americans Act.
    Thirdly, please consider linking Older Americans Act funding 
increases to increases in senior populations. In Franklin and Madison 
Counties, the number of seniors wills more than triple during the next 
twelve years, according to statistics from Scripps Gerontology 
Institute at Miami University. By linking funding to the number of 
seniors, we could better insure services as the ``baby boomers'' reach 
senior age.
    Fourth, please consider the discontinuation of moving funds from 
Title IIIC to Title IIIB (Meals to Support Services). While all 
services funded by the Older Americans Act are critical, meals are the 
most needed to reduce hunger among seniors in America. Also, Title IIIC 
can no longer act as the ``bank'' to support other services. All 
services must be supported with funding. In the last five years, $174 
million have been transferred from Title IIIC to Title IIIB, 
representing a loss of 38 million meals nationally.
    Fifth, please support increases in transportation funding, 
especially for individual trips for medical care. Transportation to 
doctors and treatment facilities continues to be a tremendous need in 
Central Ohio.
    Thank you for this opportunity to present critical information to 
your committee. I stand ready to assist in any way I can with your 
efforts. Please feel free to call upon me for information and 
assistance. Finally, thank you for all your efforts. I truly realize 
that you support the Older Americans Act, but struggle with federal 
budget reductions. I hope I have assisted in sharing information as to 
how important the Older Americans Act is. Thank you.
                                 ______
                                 
    Chairman Tiberi. Thank you.
    Mr. Horrocks.

 STATEMENT OF ROBERT HORROCKS, EXECUTIVE DIRECTOR, COUNCIL FOR 
                OLDER ADULTS OF DELAWARE COUNTY

    Mr. Horrocks. Congressman Tiberi and Congressman Hinojosa, 
thank you so much for this opportunity to testify; and thank 
you for bringing this field hearing into central Ohio. You'll 
forgive me--You have my written testimony. You'll forgive me 
for not reading a statement today. I thought it would be good 
to chat about our experiences up in Delaware County and the 
Counsel for Older Adults; and hopefully those experiences will 
be helpful as you go about the important work of reauthorizing 
the Older Americans Act.
    I'm struck by the fact that as I listen to my colleagues 
today that many of the recommendations are the same and many 
are in my written testimony, and I guess that's just because 
they're so obvious. We haven't compared notes; and yet many of 
the recommendations surrounding the nutrition program, 
transportation, and family caregiving, and civic engagement are 
all very similar.
    So I just want to share with you what we're doing in 
Delaware County. I don't have to remind Congressman Tiberi that 
we are the fastest growing county in the state. I think the 
last count was the 12th fastest in the country. Our older 
population has mirrored that growth. Our older population grew 
by 64 percent in the 90's; and we're projected by the Scripps 
Gerontology Foundation to grow from about 12,700 seniors in the 
year 2000 to almost 43,000 seniors by 2020. So we're right in 
the midst of that growth right now, and that's about a 337 
percent increase. And so our community is struggling to keep 
pace in every way, and that also affects or older population.
    Our nutrition program--through our nutrition program--and 
very similar to the situation that Chuck spoke of here, this is 
keeping people from being hungry. And it is also affecting 
their isolation because every one of our customers in our 
nutrition program gets a visit every day by a volunteer. And 
sometimes that visit is just as important as the meal. And as 
Chuck described, we have also found folks lying on floor and 
got them into the hospital because that volunteer knocked on 
the door with the meal.
    We've gone from serving 61,000 meals in 1999 to serving 
149,000 meals last year. We're projected to be close to 160,000 
meals this year. The program--all of our programs are growing 
to--as our older population grows.
    I would ask in terms of nutrition services to provide some 
flexibility. Every community is different. We have found that 
in Delaware County as we coordinate all of our services into 
one care plan and make things simple for clients and for their 
families, we use a sliding fee scale; and we would like to have 
the opportunity and the flexibility to use that similar scale 
with our nutrition program.
    Transportation is a--is of vital importance as our older 
population grows, as the character of our community changes, as 
small rural roads become fast moving thoroughfares, it becomes 
dangerous for folks. And we have a lot of folks that don't go 
to certain places anymore even when they can drive, and keeping 
up with the transportation needs has been a real issue for us.
    In Delaware County, we provide--we're one of the few non-
profits in Ohio that does investigations of abuse, neglect, and 
exploitation. It is a big issue. Elder abuse is a big issue, 
and it's a shame. A lot of that neglect is self-neglect. And we 
think it's organizations that are able to provide services and 
response to the neglect is a good place to house those 
investigations, and we would invite you to take a look at Title 
VII of the Older Americans Act which addresses some of that. 
There is no national legislation that really is comprehensive 
in terms of elder abuse. Ohio, I believe, receives about 
$200,000; and that's for 88 counties. And I ask just really 
what kind of significance can that play with that amount of 
money? And so most communities end up with maybe a part-time 
person for the whole county or, at best, a full-time person to 
investigate abuse, neglect, and exploitation of our elders.
    I want to talk real quickly about the Family Caregivers 
Support Act. It's been wonderful. It's just been in place in 
the Older Americans Act for the last five or 6 years. That 
supports us working with caregivers. And as you know, 
caregivers really provide the bulk of the care this country for 
our elders. And we've seen some heroic efforts by sons and 
daughters and spouses caring for their loved ones. And we've 
also seen what it's like when family is not available and the 
kind of intensive services that are needed when family is not 
available. And this particular provision of the Older Americans 
Act/Family Caregivers Support Program, has really helped us 
keep people involved. It's helped us from keeping folks from 
burning out. It's helped us to do some training and education 
around how to care for a loved one, and it's allowed us to 
provide support for those folks so that they know that we're 
just a phone call away. And I can't tell you how important that 
program is for our caregivers, and I think it's time to expand 
that. It's been somewhat of an experiment. It's been just 
wildly successful throughout the country, and we've heard calls 
for large expansions of that program. I really do think it's 
time.
    One last comment about civic engagement. Forty-three 
thousand folks in Delaware County that are going to be 60 years 
of age or older in 2020. Twenty-five thousand of those folks 
are going to be between the age of 60 and 69. I hope to be one 
of them. The fact is that that group of people is going to have 
a different set of issues, a different set of needs. Most of 
our resources right now are going for the very frail, the very 
vulnerable at the other end of the age span; but we need to pay 
attention to these younger older folks. There is so much 
opportunity. We tend to think of the older population growth 
and think of problems and challenges. And there are some, but 
there is so much opportunity. If we are smart and if we 
position ourselves in ways and develop the kinds of programs 
that are going to bring those folks in, whether it be through 
life-long learning, whether that be through health and wellness 
programs; expanded, really sensitive targeted volunteerism 
programs. There's a lot of energy and experience there that we 
need to tap into. And it's going to be a big part of the 
solution. And I really encourage you to take a look at Part D 
of the act in terms of health promotion and disease prevention 
and also look in terms of volunteerism and civic engagement and 
what we can do to address that part of our population.
    We've all talked about funding today. In my testimony 
today, I inserted a chart by one of my colleagues that I think 
the Department of Aging's testimony refers to the 50 cents on 
the dollar. It is true. It's real hard to run a business when 
you've got 50 percent of the dollar from what you had 25 years 
ago. And that's what we're all trying to do. We're trying to 
run businesses that serve people in a caring way. And it's--
funding is really important. We all go out of our way to find 
other sources of funding, but the Older Americans Act is really 
the foundation and has really been a foundation from which many 
great things have grown.
    And so I applaud you for your work in strengthening the 
Older Americans Act. And we'll be here to help in any way that 
we can. Thank you so much.
    [The prepared statement of Mr. Horrocks follows:]

   Prepared Statement of Robert Horrocks, Executive Director of the 
              Council for Older Adults of Delaware County

    Members of the House Committee on Education and the Workforce 
Subcommittee on Select Education, my name is Robert Horrocks and I am 
the Executive Director of the Council for Older Adults of Delaware 
County. Thank you for this opportunity to testify today about the work 
of our organization in Delaware County, Ohio and our thoughts about the 
Older American's Act. I want to emphasize that I am not an expert on 
the Older Americans Act. The Council for Older Adults does receive 
approximately $300,000 a year in OAA funding from the Central Ohio Area 
Agency on Aging. I refer you to the written testimony of Cindy Farson, 
the director of the COAAA for the more comprehensive views of our Ohio 
Association of Area Agencies on Aging.
    My purpose here is to simply provide the perspective of an 
organization which has focused on planning, program development and 
providing services at the local level for the past fourteen years. I 
have had the privilege of working and serving in Delaware County since 
the creation of the Council for Older Adults. It is my hope that this 
experience can help you as you deliberate about this important 
legislation.
About Delaware County's Older Population
    A quick look at some of the demographic characteristics of Delaware 
County will put my remarks in perspective. Delaware County has been the 
fastest growing county in Ohio for the past two decades, as well as, 
one of the fastest growing counties in the nation. The growth of our 
older population has mirrored and in some cases surpassed the increase 
of our general population and this is projected to continue into the 
future.
    While Ohio's population growth was 4.7% in the decade of the 90's, 
Delaware County's total population growth was 64% during the same 
period of time. Similarly, while the states older population grew by 
just 3% during the decade of the 90's, Delaware County's older 
population increased by 46%. It is projected that from the year 2000 to 
2020 Delaware County's general population will grow by 90% while our 
older population will increase from 12,734 to 42,896--a 337% increase.
    Another way of thinking about the growth of our older population in 
Delaware County is to understand that on average we will be adding 
about 1,500 seniors to our population each year for the 20 year period 
between 2000 and 2020. While about 9% of our county's older population 
was age 60 or above in the year 2000, it is projected that by 2020 this 
percentage will grow to nearly 20 percent of the general population. 
While the percentage increase of those aged 85 and older will be 
significant in the years ahead, much of the growth of the county's 
older population can be attributed to the aging of baby boomers during 
this time frame. Of the nearly 43,000 older adults projected to reside 
in Delaware County by the year 2020, over 25,000 of these individuals 
will be between the ages of 60 and 69.
    The challenge for our community will be to continue to serve a 
growing number of disabled individuals age 85 and over while at the 
same time effectively responding to the very rapid growth of those 
younger seniors who are likely to have a very different set of needs as 
they adjust to a changing lifestyles and plan for their future.
About the Council for Older Adults
    While formally incorporated in June of 1992, the organization's 
origins can be traced to over a year earlier when a group of concerned 
citizens, service providers, older adults and elected officials came 
together and began talking about the needs of the growing older 
population in Delaware County. From these discussions and subsequent 
community forums came the development of a task force which 
incorporated community concerns into a blueprint for an organization 
designed to meet the current and evolving needs of older adults 
throughout all of Delaware County. The Council for Older Adults emerged 
in 1992 to fill this void.
    The Council is responsible for planning, coordinating, developing 
resources and providing services for the older population in Delaware 
County. The Council's mission is to improve the quality of life of the 
older population of Delaware County by being a catalyst to develop, 
sustain and continually improve a comprehensive, coordinated community 
based system of effective services and opportunities.
    Looking back at the early 1990's, it is now easy to see why the 
community came together to create the Council. While a variety of 
services were available, the capacity of local service providers was 
very limited and large waiting lists were the norm. Services were often 
fragmented and not well coordinated causing those in need, if they were 
able to find local providers, to deal with a variety of differing 
administrative procedures and eligibility requirements. These 
roadblocks made it unlikely that the ``system'' could respond quickly 
or efficiently to individual needs for service. The result of these 
factors was that many local older adults found that nursing home care 
was the first and most viable option when they were having difficulties 
living at home. Not surprisingly, in the early 90's, local nursing 
homes were full to capacity. As the community examined these issues and 
began to understand how quickly our local older population was 
increasing in size, it became clear that action was needed to both 
increase the amount and quality of community-based care. Just as 
important, a local coordinated system was needed to improve the 
accessibility to services in a timely manner for those who were most in 
need.
    One indication of the impact of our local system change is that now 
despite more than the doubling of our older population, nursing home 
bed occupancy is far below capacity in the county.
    The Council directly manages the Senior Choices program, providing 
a one stop access to information, assistance and in-home services for 
older adults and their families. Through this program Care Consultants 
are in daily contact with local seniors and their families arranging 
for and overseeing the delivery of services designed to assist older 
people to remain as independent as possible in their own homes. In 
addition, the Council manages the countywide Senior Nutrition Program, 
Caregiver Support Programs including the designated Caregiver Resource 
Center, Adult Protective Services, Prescription Assistance Program, 
Insurance and Medical Bill Counseling, Income Tax Assistance, Durable 
Medical Equipment Loan and a number of smaller direct services. The 
Council also purchases services from a wide range of for profit and 
nonprofit businesses.
    Due to the nature of the Council's origins, the manner in which the 
Council's Board of Directors is appointed and its mission, partnership 
building is and has always been a core and fundamental principle of 
this organization. The multi-disciplinary nature of aging services has 
required the Council to be actively engaged in multiple local 
partnerships. The Council has pursued working relationships with dozens 
of local entities and has in place dozens of formal and informal 
agreements with these entities. One of the goals of the Council has 
been to be ``at the table'' wherever major decisions are being made 
which will affect service delivery for older adults and this approach 
has led too much of the partnership building activities of the 
organization.
    As an extension of its leadership role throughout Delaware County, 
the Council authors several publications, including: Senior Services 
Directory, listing available services for seniors, LinkAge, a monthly 
newsletter, and Council Communicator, a bimonthly newspaper. The 
Council also sponsors a number of special events, educational seminars, 
legal clinics, and community forums.
    The Council is uniquely organized to insure that it remains both 
responsive and accountable to the citizens of Delaware County. The 
Council's eighteen member volunteer Board of Director's is responsible 
for policy development and the overall direction of the Council for 
Older Adults. Board meetings are open to the public and are held at 
noon on the fourth Tuesday of each month at the office of the Council 
for Older Adults.
Thoughts About Our Work in relation to the Older Americans Act
    I am sure that you have heard from national aging organizations and 
that have provided very comprehensive analysis and recommendations 
regarding the Older American's Act from a national perspective. I want 
to emphasize that my following thoughts about the Older American's Act 
are not intended to be comprehensive. These recommendations are 
intended to represent the view of someone working at the local level on 
those issues that are most important from our perspective. These 
include the following:
Nutrition Services
    Good nutrition is obviously important. Poor nutrition can aggravate 
or lead to many costly healthcare issues. For our customers who receive 
in-home services, home delivered meals is our most frequently requested 
service. In addition to the hot healthy meals, local older adults also 
benefit from the daily contact by our volunteer drivers who delivery 
their meals. These relationships are very important and should be 
encouraged.
    Currently the Older Americans Act prohibits cost sharing for 
nutrition services only. States are provided flexibility to allow cost 
sharing for other in-home services. In Delaware County we provide our 
in-home services on a sliding fee scale based upon our customer's 
ability to pay. Because Older Americans Act funds support our nutrition 
services we are required to exclude our nutrition service from our 
sliding fee scale. The result is that we are required to treat this 
service differently than any other service. We must spend time and 
effort to inform every nutrition customer of this difference. We 
believe that this leads to needless confusion in addition to increased 
administrative time and effort with no apparent benefit.
    We are sensitive to the concern that cost sharing could lead to 
people in need not receiving services due to the inability to pay for 
these services. Our sliding fee scale has been carefully devised to 
make sure that this does not occur. It is also designed to insure that 
those who can afford to pay all or a portion of the cost of services do 
pay their fare share. Those who pay for services help enable us to 
provide free care for those less fortunate. Currently, about 68 percent 
of our customers pay nothing for their in-home services, 12 percent pay 
100 percent of the cost of their services and the remaining 20 percent 
of our customers pay some portion of the cost of their care.
    We recommend that you permit states to allow nutrition service 
providers the flexibility to use cost sharing and that where 
coordinated systems like ours exist, local communities be permitted to 
do so within the scope of the systems existing cost sharing policies .
Transportation
    Adequate transportation service is a huge issue for seniors. Some 
can not drive, some increasingly can not afford to drive and others 
choose not to drive in certain situations. In rapidly growing areas 
like Delaware County once quiet roads have suddenly become very busy 
thoroughfares which creates the potential for increased confusion and 
risk for some older drivers who are not accustomed to these changed 
conditions. In our society, the inability to drive equals loss of 
independence. Affordable and convenient public transportation will help 
prevent isolation of those unable to drive and will help insure that 
these individuals remain active and involved in their community. We 
encourage increased funding for transportation services in the Older 
Americans Act.
Family Caregiver Support Program
    As you are aware, family caregivers provide the bulk of the care 
provided to older adults in this country. We witness everyday the 
impact of this caring and we marvel at the heroic efforts that 
routinely occur as sons and daughters and spouses provide enormous 
amounts of care for loved ones. We also see what happens when family is 
not available to provide care or when informal caregivers become 
overwhelmed and burned out and resign this role in frustration.
    The Council for Older Adults is the designated resource center in 
Delaware County for caregivers. These services are made possible 
through the Older Americans Act. These funds make it possible for us to 
provide education and support to our caregivers which provides them the 
tools and support to be better caregivers, understanding that help, if 
they need it, is just a phone call away. We have particularly 
appreciated the flexibility that these funds provide allowing us to 
provide the kind of assistance needed quickly and easily.
    The need for these services continue to grow with the growth of our 
older population and we encourage a substantial expansion of this very 
successful program through the Older Americans Act. Money spent here 
helps insure better quality care by our caregivers. Additionally, 
caregivers save us all the cost of formal community based and/or 
institutional care. When caregivers remain in the picture, everybody 
wins.
Civic Engagement, Health and Wellness, and, Volunteerism
    The growth of our older population is often discussed in terms of 
being a problem to be resolved. Certainly, rapid growth does create 
challenges and we need to be prepared for these challenges. However, 
there are also wonderful possibilities and opportunities that would be 
a grave mistake to ignore.
    If we are smart we will recognize and prepare for the tremendous 
potential that exists to engage and tap into the wealth of talent, 
experience and energy that exists in this population. The more 
individuals who we can actively engage into our mission of service, the 
better we will be able to address the needs of those truly frail and 
vulnerable in our communities. The better job we do at providing 
meaningful opportunities to remain engaged, the more likely, I believe, 
it is that these individuals will remain active and well and not in 
need of costly services.
    We are in the process of building a new senior enrichment center 
for Delaware County. This facility will bring together our social 
services headquarters, our nutrition program and local active seniors. 
We believe that making a commitment to life long learning, health and 
wellness, good nutrition, creative programming, meaningful volunteer 
opportunities and dynamic outreach will pay huge dividends not only for 
our older population, but our entire community.
    Stable quality programs that engage people require an on-going 
commitment in terms of good management and coordination. These 
activities require both leadership and a stable funding source. 
Language and funding which recognizes the importance of these services 
would strengthen the Older Americans Act. Additional funding in Title 
IIID for health promotion and disease prevention would add capacity 
throughout the aging network and expand the impact of these services.
Elder Abuse
    The Council for Older Adults through agreement with the Delaware 
County Department of Job and Family Services is responsible for the 
investigation of abuse, neglect and exploitation of older adults. This 
problem is far too common and we expect may grow as our older 
population increases. There is currently no federal law that 
comprehensively addresses this problem. Language in the Older Americans 
Act that would strengthen the role of the aging network and provide the 
resource to train and coordinate the efforts of those most likely to 
encounter abuse, neglect and exploitation of our elders would have a 
positive effect on the safety of our older population.
Funding
    The attached chart illustrates the fact that despite incremental 
increases in funding over the years to implement this important 
legislation, we have fallen far behind funding level of 1980. When one 
considers the growth of our country's older adult population and Older 
Americans Act funding levels adjusted for inflation, per capita 
spending for Older Americans Act services has, in fact, been cut in 
half since 1980.
    The Older Americans Act has been an important legislation of older 
Americans since its inception. It has provided a foundation of support 
from which many important services have emerged. It has been a catalyst 
for the development of much state and local funding and has provided a 
mandate and leadership for the development and expansion of community 
based services which have had and continue to have a substantial and 
meaningful impact on the health and independence of our older 
population.
    I thank you for the opportunity to share my thoughts with you and I 
encourage you to continue to improve and strengthen this legislation 
and the impact of the aging network throughout our nation.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
    Chairman Tiberi. Thank you, Mr. Horrocks.
    Ms. Ragan.

STATEMENT OF GINNI RAGAN, CHAIR, LEGISLATIVE AFFAIRS COMMITTEE, 
                OHIO ADVISORY COUNCIL FOR AGING

    Ms. Ragan. Thank you, Representatives Tiberi and Hinojosa, 
for the opportunity to present my thoughts on the Older 
Americans Act. I am Ginni Ragan from Westerville, and I am a 
volunteer aging and Alzheimer's advocate and chair of the 
Legislative Affairs Committee of Ohio Advisory Council for 
Aging. The Ohio Advisory Council for Aging is appointed by the 
Governor to review and advise the Ohio Department of Aging on 
plans, budgets, and issues that affect older Ohioans and 
advocate specific administrative and legislative actions. I was 
also a member of the Ohio delegation to the 2005 White House 
Conference on Aging. I have extensive personal history as a 
family caregiver providing care for my husband, my father, and 
my mother.
    In Ohio, a combination of Federal Older Americans Act and 
state and local funds are used to provide a wide array of home 
and community-based services to older adults at different 
points along the aging continuum, including:
    Home delivered meals, home accessibility modifications and/
or transportation services to older adults who need minimal 
support.
    A package of case managed services, e.g., home delivered 
meals, adult day services, personal care to frail older adults 
at risk of being institutionalized.
    Help for older adults to maintain their physical and mental 
health and prevent the onset of disabling disease. These funds 
support exercise classes, walking programs, and other wellness 
activities at local senior centers and recreation centers such 
as we are at today.
    Supporting the needs of unpaid family caregivers that 
assist frail parents or relatives; in many cases allowing 
caregivers to continue to work and remain active in their 
communities; and giving older workers skills an experience to 
help them be part of a labor force that in the future will have 
to rely on mature workers.
    The No. 1 priority of Ohio White House Conference on Aging 
Delegation going into the meeting in December of 2005 was the 
reauthorization of the Older Americans Act. Our top 
recommendation for reauthorization is to increase the 
authorized Federal funding level of Older Americans Act titles 
and parts by at least $100 million each above the fiscal year 
2005 appropriated level except for the Title III, Part E, 
National Family Caregiver support program which should be 
authorized at 250 million more.
    While we recognize that the reauthorization and 
appropriation processes are separate, reauthorization provides 
the opportunity to increase the funding authorization for 
various titles and parts in the Act to ensure that the future 
appropriations can support and proactively prepare for the 
growth of the baby boomer generation.
    I recognize that budget constraints make it difficult for 
Congress to meet this challenge; but with proper funding 
authority, a reauthorized Older Americans Act is a dynamic 
foundation that will help the aging network set the course for 
the future. A reauthorized Older Americans Act without proper 
funding authority is just words.
    I am proud to say Ohio's Aging Network is well coordinated, 
efficient, and a very good steward of Federal, state, and local 
funds.
    By being creative and innovative, we have saved taxpayers' 
dollars and have been able to aid more of our neediest, aged 
citizens and their families responsible for their care.
    Coordination across organizations and programs is 
essential. In addition to managing OAA funded programs, Ohio 
Aging Network managers the PASSPORT Program, one of the largest 
Medicaid home- and community-based services waivers in the 
country as well as other community long-term care programs.
    I am pleased to say that developing a coordinated long-term 
care strategy has been a priority of Governor Taft for the last 
7 years. Since 2001, multiple state departments including the 
Ohio Department of Aging and the Ohio Department of the Job and 
Family Services, Ohio's equivalent of CMS, have worked together 
to implement Ohio Access: Strategic Plan to Improve Long-term 
Services and Supports for People with Disabilities.
    Coordination of services across funding streams and 
populations works. We recommend that Congress follow Ohio's 
lead and reauthorize the Older Americans Act to strengthen and 
broaden the Federal role of the Assistant Secretary for Aging 
to establish new partnerships with CMS and other HHS agencies 
for the administration of HCBS Medicaid Waiver and other long-
term care programs.
    We also recommend that reauthorization also contains 
separate funding to sustain and expand aging and disability 
resources in Ohio and 42 other demonstration states and 
territories.
    A good measure of society is how it cares for those most in 
need. In 2004, the Ohio Department of Aging surveyed Older 
Americans Act consumers and found that they were doing an 
excellent job in delivering our services to those in greatest 
need and making a difference in the lives of consumers and 
their caregivers. Some of what they learned: Home delivered 
meal consumers depend on this service to provide one half or 
more of their daily food intake; transportation consumers use 
the services to get to a doctor or health care provider or 
medical services; homemaker consumers report annual incomes 
under $15,000; and caregiver program consumers believe that 
services allow them to provide care longer than they could 
without those services. The survey also found that consumers 
were highly satisfied with their Older Americans Act services.
    I am proud of Ohio's Aging Network and the good work they 
do to serve older Ohioans and caregivers. I urge Congress to 
give the Aging Network through reauthorization of Older 
Americans Act the resources they need to serve the future 
generations of older Americans.
    Thank you, Representatives Tiberi and Hinojosa, for 
allowing me to participate in today's field hearing.
    I would like to leave you with what I believe is a very 
powerful statement authored by one of your former colleagues: 
The future of a society may be forecast on how it cares for its 
young, the quality of a civilization may be measured on how it 
cares for its elderly.
    Thank you very much for this opportunity.
    [The prepared statement of Ms. Ragan follows:]

     Prepared Statement of Ginni Ragan, Chair, Legislative Affairs 
               Committee, Ohio Advisory Council for Aging

    Thank you, Representatives Tiberi and Hinojosa for the opportunity 
to present my thoughts on the Older Americans Act. I am Ginni Ragan 
from Westerville and I am a volunteer aging and Alzheimer's advocate, 
and Chair of the Legislative Affairs Committee of Ohio Advisory Council 
for Aging. The Ohio Advisory Council for Aging is appointed by the 
Governor to review and advise the Ohio Department of Aging on plans, 
budgets and issues that affect older Ohioans and advocate specific 
administrative and legislative actions. I was also a member of the Ohio 
delegation to the 2005 White House Conference on Aging. I have an 
extensive personal history as a family caregiver; providing care to my 
husband, father and mother.
    In Ohio, a combination of federal Older Americans Act, state and 
local funds are used to provide a wide array of home and community 
based services to older adults at different points along the aging 
continuum, including:
    Home-delivered meals, home accessibility modifications and/or 
transportation services to older adults who need minimal support.
    A package of case managed services (e.g., home-delivered meals, 
adult day services, personal care) to frail older adults at risk of 
institutionalization.
    Help for older adults to maintain their physical and mental health, 
and prevent the onset of disabling disease. These funds support 
exercise classes, walking programs and other wellness activities at 
local senior centers and recreation centers.
    Supporting the needs of unpaid family caregivers that assist frail 
parents or relatives; in many cases allowing caregivers to continue to 
work and remain active in their communities; and
    Giving older workers skills and experience to help them be part of 
a labor force that in the future will have to rely on mature workers.
    The number one priority of Ohio's White House Conference on Aging 
delegation going into and coming out of the December 2005 conference 
was reauthorization of the Older Americans Act. Our top recommendation 
for reauthorization is to increase the authorized federal funding level 
of Older Americans Act titles and parts by at least $100 million each 
above the FY 2005 appropriated level except Title III Part E National 
Family Caregiver Support Program which should be authorized at $250 
million more.
    While we recognize that the reauthorization and appropriation 
processes are separate, reauthorization provides the opportunity to 
increase the funding authorization for various titles and parts in the 
Act to insure that future appropriations can support and proactively 
prepare for the growth of the baby boomer generation.
    I recognize that budget constraints make it difficult for Congress 
to meet this challenge but with proper funding authority, a 
reauthorized Older Americans Act is a dynamic foundation that will help 
the aging network set the course for the future. A reauthorized Older 
Americans Act without proper funding authority is just words.
    By being creative and innovative, we have saved tax-payer dollars 
and have been able to aid more of our neediest, aged citizens and their 
families responsible for their care. I am proud to say Ohio's aging 
network is well coordinated, efficient, and a good steward of federal, 
state and local funds.
    Coordination across organizations and programs is essential. In 
addition to managing OAA funded programs, Ohio's aging network manages 
the PASSPORT program, one of the largest Medicaid home and community 
based services waivers in the country, as well as other community long-
term care programs.
    I am pleased to say that developing a coordinated long term care 
strategy has been a priority of Governor Taft for the last seven years. 
Since 2001, multiple state departments, including the Ohio Department 
of Aging and the Ohio Department of Job and Family Services (Ohio's 
equivalent to CMS) have worked together to implement ``Ohio Access: 
Strategic Plan to Improve Long-Term Services and Supports for People 
with Disabilities.''
    Coordination of services across funding streams and populations 
works. We recommend that Congress follow Ohio's lead and reauthorize 
the Older Americans Act to strengthen and broaden the federal role of 
the Assistant Secretary for Aging to establish new partnerships with 
CMS and other HHS agencies for the administration of HCBS Medicaid 
Waiver and other long-term care programs.
    We also recommend that reauthorization also contain separate 
funding to sustain and expand Aging and Disability Resources Centers in 
Ohio and 42 other demonstration states and territories.
    A good measure of a society is how it cares for those most in need. 
In 2004, the Ohio Department of Aging surveyed Older Americans Act 
consumers and found that they are doing an excellent job in delivering 
our services to those in greatest need and making a difference in the 
lives of consumers and their caregivers. Some of what they learned:
    Home-delivered meal consumers depend on this service to provide 
one-half or more of their daily food intake;
    Transportation consumers use the service to get to a doctor or 
health care provider;
    Homemaker consumers report annual incomes under $15,000; and
    Caregiver program consumers believe that services allow them to 
provide care longer than they could without services.
    The survey also found that consumers were highly satisfied with 
their Older Americans Act services.
    I am proud of Ohio's aging network and the good work they do to 
serve older Ohioans and caregivers. I urge Congress to give the aging 
network, through reauthorization of the Older Americans Act, the 
resources they need to serve the future generations of older Ohioans.
    Thank you Representatives Tiberi and Hinojosa for allowing me to 
participate in today's field hearing.
                                 ______
                                 
    Chairman Tiberi. Thank you. Thanks to all of you for very 
good written testimony and oral testimony as well. And thank 
you for showing our guests from Texas that Ohio and central 
Ohio specifically has a lot more going for it than just college 
football. You all did a very, very good job.
    And we both have heard, quite frankly, loud and clear a 
couple issues. First and foremost, the White House Conference 
has told us, and you all have confirmed to us, that the No. 1 
issue is to reauthorize the Older Americans Act. And as Mr. 
Hinojosa, I think, would tell you, as well, is there are a lot 
of issues in Congress today. If you read the Washington Post 
every day, they will tell you a lot of the important issues 
that are going on. And, unfortunately, if you read the 
Washington Post or the New York Times or the Wall Street 
Journal or any other national newspaper, Older Americans isn't 
one of those things that they talk about. But we agree with 
what Mr. Gehring said that this is an extremely important 
issue; and so my commitment to you, and I know Ruben's 
commitment, is to try to move this process along to force 
others' hands.
    And I think one of the ways that we're going to try to do 
that is in the month of May is try to move this piece of 
legislation through the process that we can best control--and 
the first is the subcommittee--that we will try to move in 
process through the subcommittee in May. And then I've got a 
commitment--I talked to the Chairman of the full committee, and 
he wants to be helpful in moving the process to the floor here 
soon, as well, through the committee--excuse me--to the floor. 
And then we have a former education and workforce chairman from 
Ohio now who is the majority leader who controls the floor 
calendar, so I like our odds. If we can get a bill out of 
committee, the two of us, at least, I think we can get some 
floor time.
    But that's only part of the process. We have a Senate that 
we unfortunately have to work with; and they haven't started 
this process, and they will have a process and then that will 
go to conference committee. And hopefully both of us will 
participate in that. And so I think it's critically important 
for us to begin showing you that we hear you loud and clear, 
and that we're going to try to jump start this process in May, 
which will begin with a hearing next Tuesday in Washington, 
D.C., May 2nd; so we hear that loud and clear.
    The funding issue is one that we hear all the time as well 
from everybody who testifies before any committee that we're 
on; and you all make a very strong argument, obviously, to your 
needs and what you do. And we obviously are sensitive to that. 
There, you know, obviously are a lot of pieces of the puzzle 
when you look at the whole scheme of things; but we want to be 
as supportive as possible. And I'll let Ruben speak to that as 
well. The process now--And those are the two big issues that I 
heard about. And I heard about a whole lot of other issues as 
well and read about other issues in your testimony.
    What we'll do is we'll begin a series of give and take here 
with questions and hopefully answers. And I'll just go down the 
line. And I'll turn it over to my colleague from Texas; and 
he'll ask you questions as well, and they involve a number of 
different issues that I think many of you touched on.
    First I'm going to ask Ms. Geig--By the way, thank you for 
mentioning the consumer guide. Joan Lawrence and I spent way 
too much time trying to get that done, and thank God she helped 
save it while I was gone. And I'm glad to hear that you 
strengthened it as well. And please thank Director Kearns, 
because I think it's a program for seniors to really have an 
opportunity to get more information and their families to get 
more information and compare.
    Could you elaborate on the PASSPORT Program in our state? 
I'm obviously very familiar with it; but for the record and Mr. 
Hinojosa, how does it operate; and what lessons can the 
committee learn from Ohio's success on this program at the 
Federal level, in your mind?
    Mr. Hinojosa. Can we pass the mike?
    Chairman Tiberi. The mike, yes. Thank you. Good point. If 
you could speak into the mike for the benefit of everybody in 
the room.
    Ms. Geig. OK. The PASSPORT program in Ohio is very 
successful. It's probably been one of our most popular Medicaid 
Waiver programs in Ohio, and most of our consumers have----
    Chairman Tiberi. Can you explain the program? Because I'm 
familiar with it because I was on the legislature--but for the 
committee and Congressman.
    Ms. Geig. It is a Medicaid Waiver program that we have here 
in Ohio that allows a consumer who is in a nursing home to come 
out of a nursing home and have care inside of their home--to 
receive services inside their home. Someone could probably 
explain it much better than I can from our department. I'm 
fairly new to our Department. We can get more information to 
you on that. We have several other Medicaid Waiver programs 
within our department, but the PASSPORT program is probably our 
most popular program--to get them outside of the nursing home 
and into the community and receive care inside of their home.
    Chairman Tiberi. Can you provide for the Department some 
documentation on the PASSPORT Program?
    Ms. Geig. Yes. That will be no problem.
    Chairman Tiberi. Mr. Bibler, you mentioned in your written 
testimony and touched on transportation services for seniors in 
your oral testimony. Can you think of or describe maybe some 
specific ways in which the Act could help promote more senior 
mobility throughout the country?
    Mr. Bibler. I think one of the biggest issues we face is 
replacing vehicles. As I stated in my written testimony, we 
have seven vehicles with over 200,000 miles on them. There used 
to be a great program through the Ohio Department of 
Transportation called the specialized transportation program 
that made funds available to the counties to purchase 
handicapped accessible vehicles for this purpose. That money 
has since disappeared essentially. This year is the first year 
that there has not been any money allocated for that. It has 
slowly been drying up, but that is one of our biggest concerns 
right now with the number of miles we're putting on our 
vehicles is being able to replace those and keep our rolling 
stock in good condition, because the safety of our seniors, 
obviously, is one of our utmost concerns. So I think that would 
help us tremendously.
    There's been a great effort within the state of Ohio for 
coordinated transportation. We have tried that with limited 
success in our communities; and I think that there would be 
some way to make funding available as well, too. For example, 
we have discussed about having a web-based program that we 
could use so that all the providers in our community could 
enter data into it so that the routes could be assigned to 
specific providers so that we wouldn't be duplicating the 
places that we would be going. However, that software runs over 
$100,000; and obviously we don't have the resources to purchase 
something like that. That would help us tremendously, too, so 
that those of us that do have vehicles could work together to 
coordinate transportation so that we're not going up the street 
and 2 minutes later another service provider is going up the 
same street picking up clients for their program and 2 minutes 
later another vehicle from another agency is going up the 
street.
    Chairman Tiberi. OK. I want to switch to Mr. Gehring here. 
Can you describe some of the partnerships that you have? I was 
over at MidOhio Food Bank within the last few weeks, and they 
mentioned some of the work they do with you. Can you talk about 
partnerships, both public and private partnerships, that 
LifeCare Alliance has to the benefit of the seniors and how 
maybe the Act can better encourage some of the things that you 
guys have done so well?
    Mr. Gehring. We have literally, if you really added it up, 
dozens of public and private partnerships. The 28 dining 
centers that we have are all in cooperation with some other 
organization that allows us to use their facility at no cost to 
provide the meals and the socialization for the seniors. But 
those locations do not receive any funds from that. We have 
partnerships with people that provide specialty meals to us. We 
have--such as Kosher or Somali. We have a huge Somali 
population, as you know, in central Ohio. I think some of our 
better partnerships are with some of the folks that assist with 
the assessment of the clients; things like that, such as the 
Ohio Area Agency on Aging and Franklin County Agency on Aging 
and all these other counties have offices on aging generally. 
Those folks, COAAA and Franklin County Office on Aging, work 
hand in hand with us to try to divide up the work to ensure 
that we are not duplicating services as Dave just referred, to 
ensure that we are as efficient and effective as possible.
    And I guess in answer to your question, What could the Act 
do to, you know, further those partnerships? Many--And I don't 
want to get this specific in the Act. I don't think anybody 
wants to get this specific in the Act. But I'll tell you, a lot 
of the grants we apply for anymore, both public and private, 
request collaborations. OK? And I know when we just finished 
our United Way reporting for the year, we probably listed 40 
different partnerships that we have on a fairly large level in 
order to ensure that. Because United Way is a group that really 
values, here in central Ohio, collaborations--that you're 
working together, that you're truly not duplicating services as 
Dave was saying. So I think--I don't know how exactly you put 
that in the Act, and I don't know that we need more items in 
the Act that would restrict how we work; however, I would tell 
you that most of the grants we apply for anymore, if you don't 
have collaborative partnerships, you're not working with other 
groups; you're not taking care of other groups; it's difficult 
to get those grant funds.
    Chairman Tiberi. Thank you.
    Mr. Horrocks, you obviously are aware of the long-term care 
consumer guide that Joan Lawrence and I worked on. I'm 
interested in learning more about how you all up in Delaware 
succeeded setting up a resource to help seniors make informed 
choices about long-term care needs and costs as well and--
again, how you think that maybe more local offices can do that. 
And is there a place that we can encourage that?
    Mr. Horrocks. I have a tendency of telling folks that you 
never look for the computer ads in the newspaper unless you're 
thinking about buying a computer. And I think that's real 
similar to--for caregivers, for older folks, for families. They 
don't think about these issues until the issue is there. And so 
what we try to do is to pull as much information--as much 
relevant information as possible and have it in one place and 
then to really go out of our way to be out in the community 
letting people know that those resources exist and reminding 
them that, you know, it may not be an issue for you today; but 
down the road, it might be. Or you might have a neighbor or 
somebody at church who it's an issue for now. And they need to 
be giving us a call if they think that we can help. So there's 
a ton of information available, and it's important to--
sometimes too much information for any of us to sort through; 
and so having some people that are kind of experts in that and 
are, you know--work with it on a daily basis and then having an 
easy way for the community and individuals in the community to 
access that information. A lot of it is being out in the 
community and talking to groups every week. We have our own 
newspapers, as you know; and we do a lot of other things to 
communicate with folks of all ages that our office is there, 
and this is what it's for.
    By the way, I thought of one thing that you could do to 
help with transportation.
    Chairman Tiberi. OK.
    Mr. Horrocks. Just lower the price of gas a little bit.
    Chairman Tiberi. I'm going to rely on my Texas friend here. 
I'll let you respond here a little bit.
    Mr. Hinojosa. I couldn't help but hear the word 
``transportation'' and the problems that it is presenting 
throughout the presentations that were made by all five of you. 
And I think it was Mr. Bibler who said that it would be much 
easier if they had the software program. Was it not you?
    Mr. Bibler. Yes.
    Mr. Hinojosa. If they were able to avoid going to the same 
residence twice or more. And I was just thinking of an 
individual who came by my office not long ago. His name is Bill 
Gates, Sr.; and he runs the Melinda--Bill and Melinda Gates 
Foundation--and a very philanthropic individual. Have you 
thought of possibly communicating with Mr. Gates, Sr., and 
asking if they might be able to consider a donation of that--of 
a software program comparable to what you need and thus be able 
to reduce the costs by not having that, you know--repeating as 
you said, going to the same residence two or more times. That 
was one thought that came up.
    The other one is to join a group of Texans who sent me 
several e-mails saying that they had come to the conclusion 
that the only way to reduce the cost of fuel prices was to 
reduce the demand. And the way they were doing it is they were 
sending out e-mails to at least a hundred people, and those 
hundred had to send it to another group of hundred to stop 
buying Mobile--Exxon Mobile gasoline--just to not buy from any 
Exxon gasoline station and thus reduce the demand and thus let 
them take note that if it is supply and demand, maybe they will 
have to reduce the prices and stop giving $400 million bonuses 
to the head of the Exxon corporation as they announced last 
week for making such high profits. Those are things that 
sometimes we don't think about because dealing with the most 
basic problems of how to reach the senior citizens and bring 
them to where they can socialize and be able to eat a meal and 
all of that seems to be our foremost priority; but the 
Congress, as you have learned from your very able Chairman, is 
going through some very difficult times because of our very 
high deficit as we debate the budget for 2007. And that has 
resulted in a lot of domestic cuts including Meals-on-Wheels as 
everyone in this audience has learned. So we are going to take 
recommendations that you all have given us and try to bring 
them to Congress, to other members, so that this next month of 
May as Pat was saying--that we can try to bring this to a vote 
in our committee and then eventually to the House. So we're 
going to certainly use your written statements, which will 
become part of the permanent record of this hearing; and we're 
going to see that this information gets into the right hands.
    At lunch, I was convinced that all of you are very well 
informed, knowing so much about Ohio versus University of Texas 
Longhorns. And there is no doubt in my mind that you will find 
ways in which to begin collaborating with us. There's no sense 
in just fighting over football. I think that we have to find 
ways of collaborating with you to make each state get their 
share of the budget.
    But I'm going to ask my first question of David. It's 
apparent that in Licking County, your food costs increased 
significantly, you said, about 73 percent over the last five or 
6 years; and your waiting list grows larger every year. Do you 
have some estimate as to how much funding you would need just 
to stay even with your current and the projected demand over 
the next 2 years?
    Mr. Bibler. Well, that's a good question. No, I have not 
thought that far ahead to try and project how much additional 
funds that we would need. The 73 percent that I have in my 
testimony not only includes the costs for the number of 
increased meals that we've done but, of course, the cost of 
food as well. As we all know, the cost of food is affected by 
the cost of transportation. And we've certainly beat that horse 
enough today as well. But with the numbers that we're looking 
at continuing to increase our meals at a pace that soon is 
probably going to exceed our capacity to continue delivering 
those meals. We've been very fortunate to this point that we 
have never had a waiting list for our meals program. We 
continue to find a way to get those meals out and serve it to 
the people. But with the continued growth that I have expressed 
in my testimony, it would make it very difficult for us to 
continue to do that. So to answer your question, I really don't 
have, I guess, a projection at this point as to how much 
additional funding we would need. I guess if you could look at 
the growth and our food costs over the course of the last five 
or 6 years and project that over the course of the next couple 
years, we could be looking, again, at an additional 10 to 15 
percent a year possibly in the growth of our meals program 
because it does continue to escalate. And I really don't see 
that slowing down, especially when I've heard this is the first 
year that the baby boomers will be hitting retirement age. And 
as those ranks continue to swell, those numbers are going to 
continue to grow.
    Mr. Hinojosa. Well, I'm going to yield to the Chairman so 
that he can finish his questions. But do know that Texas does 
have a lot of oil and a lot of oil magnets, and I think that 
you will really get their attention when you stop buying Exxon 
oil along with some of my other Texans who have agreed to 
collaborate and let the demand come down.
    Chairman Tiberi. I'm going ask one more question of our 
last witness, and then I'll go back to you for another round--
we can go another round after that.
    Ms. Ragan, I obviously know of your particular interest in 
helping people with Alzheimer's disease. I know it's something 
near and dear to your heart, and we're beginning to learn more 
and more about Alzheimer's. And one of the things that I think 
we're beginning to see is, obviously, you know, that 
Alzheimer's can strike someone prior to the age of 60.
    Do you believe that under the Older Americans Act it would 
be helpful to allow for nutrition services to be provided to 
people under the age of 60?
    Ms. Ragan. Absolutely. I wouldn't stop at nutrition 
services. I would continue with a lot of services primarily 
because up until not long ago--and because of the advances in 
diagnosing Alzheimer's, when you had someone who was in their 
30's, 40's or 50's who seemed to have had behavior problems, et 
cetera, it was diagnosed as mental illness. It was not 
conceivable that somebody 40 years old could have Alzheimer's 
or anyone of the other 26 definable dementias. Now we know--and 
in central Ohio, we have people in their 30's, 40's, 50's who 
are early onsets, frontal lobes, Pick's disease, Lewy Body 
disease. There are no services and no money for these people 
under any program that comes under the Ohio Department of Aging 
because of the age constraints. We go through this in the state 
budget every year. I believe that nutrition would be one, 
assistance--You save the state a lot of money; and we proved 
this last year in House Bill 66, which was the state budget. 
You proved--you saved the state a lot of money. You give people 
dignity. You give them choice by enabling them to remain in the 
community in the long-term care continuum that they choose to 
be in and with a little bit of help. On the other side with our 
Home First Program now, we have people coming out of nursing 
homes on the 525 funds. We're saving the state a tremendous 
amount of money on that in giving people the dignity that they 
deserve. I absolutely believe that if possible to have some of 
these services--nutrition would be a good start--but there are 
a lot of other services that also I would like to see available 
to Alzheimer's and related dementias and their caregivers--
families, friends, et cetera--available under the Older 
Americans Act. Thank you very much.
    Chairman Tiberi. Thank you. I want to turn it over for a 
round of questioning to my colleague.
    Mr. Hinojosa. Thank you, Mr. Chairman.
    Elise, I'm going to ask you--because I notice that your 
state is doing a tremendous job with the resources available. 
I'm interested in your efforts to get 60 out of the 88 counties 
to pass levies to raise over the $100 million in additional 
funding that you requested. Are there other states that you 
know of doing this?
    Ms. Geig. Yes. Chairman Tiberi and Congressman Hinojosa, 
Michigan; Kansas; Louisiana; and North Dakota have local senior 
levies as well.
    Mr. Hinojosa. That's good. That's good. Are any Ohio 
corporations or other industries helping to provide the 
financial resources to help you cover the growing unmet need of 
your clients in a collaborative manner with the other members 
who testified?
    Ms. Geig. I'm sure someone else on the panel would be 
better able to answer that.
    Mr. Hinojosa. Well, maybe Mr. Gehring can tell me what 
corporations are collaborating on it.
    Mr. Gehring. Many of them right into--and in a different 
ways. One is corporations and their foundations provide grants 
to assist us in our efforts, and it defrays our costs. And, 
second--I think this is a great way to do it--we have over 50 
companies right now in central Ohio that volunteer their 
employees to deliver Meals-on-Wheels. And what happens with 
that is we even have one company here in central Ohio, the 
Huntington Bank, that has currently 355 employees actively 
delivering meals to eight routes, 5 days a week from four 
locations.
    And just so you know, if we don't have a volunteer to 
deliver that route, we have to pay a driver. Now, a paid driver 
to us is generally a retired person earning to about 8 to $9.00 
an hour for 3 hours a day's work; plus mileage on their car, 
which they drive. But that still adds up to between 10 and 
$12,000 a year. So if you have 50 companies running routes from 
1 day a week to 5 days a week or 7 days a week, whatever it 
might be--normally they don't do the weekends for us--that 
defrays our costs incredibly. Last year alone with just the 
companies we added, we took--we saved almost $190,000 in our 
budget alone last year by these companies doing it. And I would 
tell you that the Huntington Bank will tell you, one of their 
executive vice-presidents, that it's the best moral builder 
they have. So if we----
    Mr. Hinojosa. Not only would it be a big morale builder for 
the employees who do this work, I wonder if you're working with 
the newspapers and television stations to give credit where 
credit is due and help their name visibility as givers as they 
are to get their name into the newspapers.
    Mr. Gehring. We do that every single chance we have. And, 
in fact, last evening we had our volunteer recognition evening 
for our agency; and we honored a couple of the companies that 
are doing it. And there was a reporter there. Sometimes, 
though, those stories do not carry quite as well as we would 
like to see them. So any emphasis that someone like you could 
place on that and highlight it to the news media would really 
be helpful because throughout the country--I can tell you 
there's another major city in Ohio who really--until a couple 
years ago never used volunteers. They used all paid drivers. 
And we had helped them kind of get going with that. And I'll 
tell you the savings is just amazing. And it's a great thing 
that can really help us be more efficient and effective as the 
years go by with the Older Americans Act money.
    Mr. Hinojosa. I'm delighted to hear that you are working so 
hard to give them credit; and I can tell you that any time your 
Congressman comes to an event, it will certainly bring the 
media. And when he speaks, people hear; and they listen. So I'm 
sure that if you could just work it out so that our Chairman 
can be at some of these recognition banquets that you're 
talking about that those individuals will get a lot of 
recognition.
    Chairman Tiberi. There is a reporter present in the room.
    Mr. Hinojosa. Good. They're going to listen very well to 
you for sure.
    I'm going to ask Charles Gehring, you have a tremendous 
organization; and you mentioned that the average for the senior 
stay in hospitals is something less than 10 days per year; 
however, your clients average less than 1 day per year. How 
have you been able to do this?
    Mr. Gehring. Through the services provided with the funding 
from the Older Americans Act such as Meals-on-Wheels. I'm very 
serious about that. If--When you do the research, the No. 1 
reason when people come out of hospital that they go back into 
a hospital is that they do not get proper nutrition.
    If you think through this for a minute, as I know you 
have--Let's say you're a senior. You have a problem that you 
have to go to the hospital for some surgery that perhaps you 
were not prepared to do. Maybe you need your gallbladder taken 
out or something like that. You have that 8-week recovery 
period afterwards. What do you do for yourself? I told you 
earlier that 70 percent of our clients say they see no other 
adults on a regular weekly basis other than our workers. And 
with our mobile society in this country, many times the kids 
who are my age, being a kid, live far, far away. So how do 
these seniors take care of themselves during that recovery 
period? And the answer is they end up eating what's ever on 
hand, which might be potato chips and cookies; and that's not 
going to keep them safe and healthy. They end up back in the 
hospital. So by being able to assist them with things like 
that--Like we'll do frozen meals for people coming out of the 
hospital, which reduces our costs a little bit. Anymore it 
doesn't, because we've become more efficient--and our hot 
meals. But just by giving them proper nutrition; sending nurses 
to their homes, which is Medicare/Medicaid sponsored often 
times--the Older Americans Act sponsors homemakers and home 
health aids that go out and clean their homes. You can imagine, 
once again, someone in distress who's a senior who's had 
surgery or just is elderly and is on a walker.
    Perhaps--We have a 90-year-old client that I deliver to all 
time who's on a walker. She literally can't cook for herself, 
because she can't stand at a stove. She can't chop up a carrot, 
because she's on a walker. And what does she do about cleaning 
her home? For example, her bathroom? How would she do that? I 
can tell you she can't do that because she'd fall over.
    So through the service funding of the Older Americans Act, 
these folks are allowed to stay safe and healthy in their own 
home; and they don't go back into the hospital. Because if they 
should go to the hospital, when they come out, there are 
services there to protect them and help them through their 
recovery period.
    Now, let's say you didn't have the blip and you never went 
into the hospital in the first place. You just happen to be 85 
years old and on a walker. The fact of the matter is, you know, 
if you're trying to take care of yourself, problems are going 
to occur.
    We just started a falls prevention program at our place. 
It's a big, big issue for seniors if they fall. And often times 
they can't rock themselves back up, et cetera, et cetera. So 
there's just a need for these types assistance for them.
    The homemakers that are sponsored by the Older Americans 
Act--Gosh, what an important program that is. When you're an 
elderly person and you're not as mobile as you used to be, do 
you really clean your house? And the answer is they can't. So 
what happens? You end up in squalid conditions.
    And I would tell you just as an aside to that, who does 
stay with these seniors every day? And the answer is the 64 
percent of our clients have a dog and 62 percent have a cat. 
Those are their families.
    I have a client that I deliver to, an elderly gentleman, he 
has a beagle like Snoopy. When you walk into his house, you 
smell beagle. OK? And we have had to go out and assist him many 
times in cleaning his house so that he has more hygienic 
conditions so that he does not get sick and then stays out of 
the hospital.
    So it's just all these things; and I think, you know--We 
talk about congregate dining and the transportation and the 
congregate dining sites for socialization. When you don't have 
that, you get depressed because you're lonely. The clients we 
all service are lonely. And depression puts you in the hospital 
in one way or another, whether it calls you to be sad; not 
sleep at night; have a heart problem; fall; whatever it might 
be. All these things are issues that are bad for our seniors 
but are solved through the funding of the Older Americans Act.
    Mr. Hinojosa. Thank you for that input.
    Bob, is it pronounced Horrocks?
    Mr. Horrocks. Horrocks.
    Mr. Hinojosa. I want to ask you a question, but let me 
first make a comment that we're moving in the amendments in our 
bill to increase the opportunities for organizations such as 
yours to help states plan for futures services for the aging.
    You are very active. Are other counties in Ohio as 
supportive in this regard as is Delaware?
    Mr. Horrocks. There are 88 counties in Ohio, and there are 
88 different counties; and, unfortunately, resources are not 
equal in every place. And so for example, when we were able to 
take PASSPORT, our state PASSPORT program statewide, that made 
a huge difference because no matter what county you live in, 
you will at least have that Medicaid Waiver Program in your 
county; and you will be treated equally. But for our Older 
Americans Act services, for example, you will find, you know, 
very poor counties in Ohio that just don't have available very 
many local resources. And they may rely totally on the Older 
Americans Act funding. And it's--You've heard about the problem 
with 50 cents on a dollar with Older Americans Act funding; and 
that has really impacted probably most the poorer counties in 
Ohio, because there's not other resources available to them. 
And so, yeah, I would think that we're fortunate in many ways 
to have a statewide--the waiver program. We're fortunate to 
have 12 strong Area Agencies on Aging in Ohio and our State 
Department of Aging. But we do have large pockets of poverty, 
and those folks are probably hurt the worst when it comes to 
not enough funding available for the Older Americans Act.
    Mr. Hinojosa. Let me ask you, you make a very compelling 
case in the presentation that you made on the financial 
resources for the Act due to loss of purchasing power for the 
services. We face some of the same issues trying to support 
Pell Grants for college students in our education committee. 
Mr. Tiberi and I are very sympathetic to your concerns; but we 
have to convince House and Senate colleagues as well as the 
White House--the administration will have given us the proposed 
budget for 2007. I'd urge you to contact every member, as we 
talked during lunch, at the right time that Mr. Tiberi sends a 
signal, because they're going to pay close attention when they 
get inundated with messages that all of you said is very 
important to Ohio. And I think that would make our work easier 
to bring back some of those cuts that were proposed.
    I've learn a great deal from each one of you from your 
presentations, and I think I'll wait and ask any other 
questions that I have.
    With that, I yield back to you, Chairman.
    Chairman Tiberi. Thank you Mr. Hinojosa. You know, it's 
interesting, one of the things that I have found as a Member of 
Congress, probably the most important thing that a President 
budget provides--because I don't think it provides a whole lot 
other than a lot of controversy usually because it's very 
rarely implemented, it's usually dead on arrival--is that it 
does get people engaged in the Federal process; and if it 
weren't for the budget quite frankly, I think most people 
wouldn't be engaged in the Federal funding process. What do I 
mean by that? I have people constantly--and I'm sure you do 
too--complain to me that they never--you know, they pay a lot 
of taxes; but they don't get any Federal services. And people 
are shocked to find out that actually Federal services touch 
them a lot, and one of them is a the Older Americans Act.
    I think--I had an aunt who was a Meals-on-Wheels volunteer; 
and she had no clue that Federal Government was involved, 
because she told me, ``What a great program. You know, 
government always doesn't solve all the problems, and this is a 
perfect example. Meals-on-Wheels is a totally volunteer 
program.''
    And I said, ``Well the Federal Government is a bit involved 
in the program.''
    Here's my point, though, Chuck, I think what's important 
about what we're today, having this hearing today and having 
one in Texas and having a debate on budgets--And I think if you 
walk through this senior center, it wouldn't surprise me that 
most of these seniors probably don't realize that the Federal 
Government is providing a service to them that they don't 
realize the Federal Government is providing. They might think 
the state's providing it, but the state may be only a pass 
through. They might be thinking the county provides it. And the 
county certainly is a partner as well as the state, but it 
really is all about partnerships. And LifeCare certainly as a 
nonprofit exemplifies that partnership more than most, both at 
the local; state; national; private sector; and nonprofit 
level.
    To that point, Chuck, let me ask you a question. With 
respect to the private sector, do you think the Act currently 
makes it difficult for you all at LifeCare to generate income 
from private sources outside of what you do? And can we do 
something to help you?
    Mr. Gehring. I would say it does not make it difficult. The 
only way it might make it difficult is that there is a 
perception out there that because we or any other program 
receives governmental funding for our organization that that 
covers everything. OK? And I will tell you, I've had that said 
to me a number of times. So one thing that perhaps would help 
us is if we could better educate as we attempt to do every day 
of the week. And I know these folks around this table do this 
every day of the week, too, try to educate our private sector 
partners as to how the whole system works. And sometimes it's 
very difficult for them to understand. We're not going to kid 
you here. But with increased education, they start learning 
that they are a key part of it--different things that they can 
do, and then we move on from there.
    Meals-on-Wheels of America for the Meals-on-Wheels program 
is really trying to promote to other areas some of these 
private/public partnerships, especially with the companies. You 
know, we think that the companies delivering meals for us--It's 
just a no-brainer, to use a technical term there. The fact of 
the matter is it costs them nothing. You know, companies 
nowadays--A few years ago there was a shift, and there was a 
lot of literature about this in the magazines and things like 
this--is that companies wanted to cut back. They had to cut 
back because of tight budgets in their own areas with how much 
they could give to charities in this country. You know, 
delivering meals doesn't cost them a dime, so it's a way for 
them to really get involved; to promote themselves.
    We have a number of public companies that talk about this. 
They're volunteering constantly, because their shareholders 
like to hear about their involvement in the community; and that 
it's smart involvement. It's not just writing a check, walking 
away, and not knowing what happened to their money. So I think 
there's just--so from that standpoint, I think there is a 
perception that the governmental funding covers all, which, of 
course, it doesn't; and the more we can educate these folks, 
the better off we can be.
    Chairman Tiberi. I think Ruben's right. If I were an 
aspiring reporter or a really important reporter, I think, 
writing a column about how LifeCare Alliance couldn't exist 
without the private sector support and how it complements the 
public sector. It's a great story for any inspiring reporter.
    Mr. Horrocks, I read in your testimony--You didn't talk 
about it in your oral testimony, but I read about your Senior 
Choice Program--your Senior Choices Program managed by the 
counsel. It appeared to me that it was very similar to what the 
Bush Administration has proposed called the Choices for 
Independence Plan in their proposed budget. Can you tell me how 
participants have responded to your program in Delaware County? 
Am I reading something wrong in the fact that it sounds--Has 
the Bush Administration come and copied you?
    Mr. Horrocks. I might have a hard time living that down in 
some circles. Well, the fact of the matter is that program 
started because we just listened to people in our community; 
and they were telling us two things. One was we don't know 
where to go for help. And usually in a crisis you're desperate, 
and it wasn't obvious where to go for help. The other thing we 
were told was when we do go--when we do find a place, there's 
most more often than not a waiting list; and we wanted to--You 
know, if you need three or four different services in order to 
stay out of a nursing home and only a couple of them are 
available and you've got to wait for the others for a few 
weeks, a lot of the times the path of least resistance is to a 
much more expensive care environment. And if you only need a 
little bit of help--if some in-home services can help you stay 
at home, you know, that is absolutely the model of the state 
PASSPORT Program and our local Senior Choices Program. It's--
That's where people want to stay; and it's less expensive to do 
it, so it's pretty much a no-brainer. So maybe that's where the 
Bush Administration's idea came from because it's obvious. It's 
less expensive to government, and it's what people want, and 
what we need to do is create a friendly system that makes it 
easy to access and gives people choices. And so I would hope 
that, you know, anyone would come to that same conclusion. 
That's why the PASSPORT Program is so popular. That's why our 
Senior Choices Program is popular. It provides a broad array of 
services that meet people's needs, and it's less expensive than 
going into a place where you don't want to be.
    Chairman Tiberi. Are other counties doing that, to your 
knowledge as well?
    Mr. Horrocks. Yes. Again, it's not universal; but there are 
many counties in Ohio that are doing that.
    Chairman Tiberi. Thank you.
    Mr. Bibler, in your written testimony, one of the things 
that you stressed that I have not seen both in Washington and 
our hearing in Texas or the hearing here is your focus on the 
prevention of elderly abuse. Can you talk to us and explain to 
us how elderly abuse prevention efforts are fragmented out 
there and how maybe we can do better in putting more focus on 
the need to prevent elderly abuse?
    Mr. Bibler. Well, I don't think there's enough attention 
given to it. As I stated in my written testimony and my oral 
testimony, too, we only have one adult protective services 
worker in our county to cover the entire county. This is one 
issue that in the 10 years I've been director of the aging 
program, it's probably been the one that has disgusted me the 
most in how our elderly people are treated, especially by their 
family members. We have many older adults who have children 
living within the same county that never come over to see them; 
you know, will not bring them a warm meal on the weekend and 
will not come over and socialize with them; and if it wasn't 
for our employees and volunteers going out and delivering the 
meal and providing personal care and homemaking services, they 
would not get that contact.
    A lot of it is probably more neglect than abuse, although, 
there are issues of abuse, as well, too, that we encounter; but 
the system is just so inundated that, you know--And the laws in 
the state of Ohio make it very difficult for Adult Protective 
Services to do their job; to go out and, you know, really help 
these folks out and also to bring the people to justice who are 
abusing or neglecting the elderly. And I think we just need to 
focus a little bit more of our attention to these folks.
    I consider the elderly and our youth the two age groups 
that really as a community and as a government we need to 
protect because they're vulnerable. And I don't think enough 
attention has been given to elderly abuse. You hear a lot about 
children and child abuse and what Children Services does in 
each of our communities, but not enough attention is given to 
the abuse and neglect of our elderly. And I think this is 
something we need to look at.
    Chairman Tiberi. Any thoughts of how we can do that through 
the Act, through the reauthorization of the Act?
    Mr. Bibler. Well, here again, it comes down, I think, to 
funding is a lot of it; also education. I don't think enough 
people are aware. When I go out and tell people about how our 
elderly are abused and neglected in our community, they are 
shocked to hear that. They don't realize there are so many 
indigent seniors living in our community. Because when you 
think of that, you think of the single parents with one income 
that, you know, don't have the money; but they don't realize 
their seniors don't either. So I think, you know, if there was 
some funding that could be made available to educate people 
about it, to make people aware of it, because it may be their 
neighbor; and they don't even realize it. Because we have 
become a society where we kind of stick to ourselves. Years ago 
you had neighborhoods where you would go out and talk with your 
neighbors and everybody knew who everybody was on the street. 
And I don't think we see that much anymore. And I think people 
need to know that it's out there. And if funding was available 
that could filter down to the states so that more people could 
be hired to go out and investigate incidents of abuse and 
negligent, it would certainly help out.
    Chairman Tiberi. I don't know if you could answer this or 
maybe Chuck. Are volunteers who deliver meals--Are they taught 
to look for signs of neglect?
    Mr. Bibler. Our employees and volunteers become very close 
to their clients. They will actually come in and have arguments 
with me about their clients. You know, ``These are my clients, 
and they some need help, and we're not doing enough.'' They 
become very attached to them. They become very defensive for 
them, and they will fight for them. So our employees--We do--As 
a matter of fact, just this past Tuesday we had the lady from 
Adult Productive Services in to speak at our staff meeting so 
that they would know what are things that they can look for, 
what are things that they can report, and who it is that they 
can report them to.
    Chairman Tiberi. Chuck, could you follow up on that?
    Mr. Gehring. I agree with Dave. And our folks are trained. 
But also I would point out, the Older Americans Act funds for 
our counties here come through the Central Ohio Area Agency on 
Aging. And that organization, which is lead by Cindy Farson, 
who's sitting right over here, their director, has assessors 
who go out and assess the clients; and they also have case 
workers who go out and case manage clients. So those folks are 
out there on a regular basis. There are also requirements with 
some of the funding that you visit clients on regular bases. 
OK? You have to go out and see them, which is a great thing, 
but not just with a volunteer but with somebody who's really 
trained to do it. But I can tell you the volunteers--We have 
such a quality group of volunteers as Dave does and a quality 
group of employees. If they think something is wrong, they 
can--Generally what will happen is they contact somebody else.
    Chairman Tiberi. Bob, any thoughts on that?
    Mr. Horrocks. Similar situation with our volunteers. 
They're the best eyes of the community. They get to know folks. 
They know when something's different, and they let somebody 
know, and we train them to do that. They do it anyway. But the 
counsel is involved with doing investigations for neglect, 
abuse, and exploitation. We take the complaints. And I will 
tell you that those situations are the worst ones we deal with, 
the most difficult to deal with. A lot of it is self-neglect; 
and unlike our other clients who are coming to us and families 
who are coming to us and sons and daughters who are coming to 
us asking for us and are very appreciative of what we're able 
to do, this group of people generally doesn't want help. And 
they don't want to see you coming because you're coming because 
a neighbor complained about the smell or because of you know--
If you're the daughter or son in the household and you're being 
accused of something, you don't want somebody coming into your 
house and investigating that. It takes a lot of time and a lot 
of energy. When I see the resources that we have in this state 
for this, it's ridiculous because this is the most time-
intensive stuff that we work on. And so I would underscore the 
need for funding for that program.
    Additionally, training for those folks that are going to 
see this out in the community; training for people that work in 
banks; training for people, you know, at the post office; fire 
fighters; police; sheriff's department. These folks all come in 
contact, and they need to be a lot more sensitive to some of 
the issues that are around them.
    Chairman Tiberi. Did you have a point on this?
    Ms. Ragan. A year ago, January, Director Lawrence and 
Attorney General Pitro put out the elder abuse task force 
study. Subsequent to that, in Ohio, Senate Bill 175 was 
introduced by David Goodman. It ran into some problems. What it 
would do--And maybe this can come from a Federal level down the 
state level. Some of your local officials said it was an 
unfunded mandate. What you need to have is uniformity. What 
we're looking for now in the reintroduction of the APS Bill is 
some uniformity within--in the case of Ohio, all 88 counties so 
that when they get a report of abuse, that there are particular 
steps that are followed so that if you're in Delaware or 
Franklin or Licking, it's addressed. If you're in Adams or 
Vinton and Appalachia, they're not addressed; and that it is 
not an unfunded mandate. I think that it would help all of the 
states--And I can only speak to Ohio. I think it would help a 
lot of states if there was some involvement through the Older 
Americans Act that would enable or--I hate to use the term 
``force''--force the states to have a uniform reporting 
condition in each one of them.
    Chairman Tiberi. Thank you.
    Ms. Ragan. Thank you.
    Mr. Hinojosa. Ginni, you were chosen to be part of the Ohio 
delegation to the 2005 White House Conference on Aging.
    Ms. Ragan. Yes, sir.
    Mr. Hinojosa. So you represent--you spoke for all Ohioans 
when you went to that conference. We've talked a lot about the 
difficulties of the transportation, the costs, the food; but we 
haven't talked at all about the rising costs in prescription 
medicine. And for these folks, senior citizens, that has become 
a very serious problem and our Medicare/Medicaid program that 
we worked on a couple years ago has not been able to give 
discounted medication to very low income families.
    Tell me, please, do you all work with some of the large 
companies like Pfizer or Merck in trying to get medication--
free medication or medication for maybe as low as $10.00 for 
those individuals who probably are receiving less than a 
thousand dollars a month from Social Security and very little 
help from Medicaid? What are you all doing with those big 
companies?
    Ms. Ragan. First of all, several years ago--the director is 
sitting here--We started--were able to get through the 
legislature the Golden Buckeye prescriptive drug program, which 
gave discounts on prescriptive drugs. We also have pharmacies 
such as--or pharmaceutical companies such as Pfizer, et cetera 
that you can get discounted drugs from or those at no cost at 
all, I know from working with nurses who are out in the field 
with the elderly and with Alzheimer's. Our program has saved 
millions and millions of dollars for our people. We had another 
program put in, which was called Ohio's Best RX, which applied 
not only to our elderly. When Medicare, Part D, came in last 
year--And we did a tremendous amount of educating on that. We 
feel with those citizens that have used it and have used the 
forms that were provided by CMS--The tools are in the tool box. 
They're there. If you use them--It is not a system that you 
can't possibly negotiate. You can very easily. In the beginning 
there was snafoos. But when you look at all of the help with 
Medicare, Part D--which we thank you gentlemen for--when you 
look at the Golden Buckeye prescriptive drug card, when you 
look at Ohio's Best RX, yes, I think Ohio has done a tremendous 
job in trying to help our citizens, especially our elderly, 
with getting reductions on their prescriptive drug medicines.
    Mr. Hinojosa. Well, from listening to you, you all have a 
much better handle on this problem than we do this Texas. We 
had a public hearing, and we talked about this specific 
problem, and we need to make big improvements like you just 
described. I brought this up because this magazine just came 
out a few days ago, the Fortune magazine that lists the top 500 
companies in our United States; and in the top 20, Pfizer is 
one of the most profitable. And the pharmaceutical industry 
reported this last year that out of every dollar that they 
brought in, in revenues, 15.7 percent--15.7 cents out of every 
dollar was profit. So they need to be in the forefront of some 
of the companies.
    When I asked the question earlier, ``Are we collaborating 
with big companies?'' Well, they, particularly Pfizer and 
Merck, should be brought to the table to be one of our partners 
in this program because in Texas, in south Texas, we really 
count on them to help us with these families, these individuals 
who are far below the national poverty level and that 
medication. And the cost of prescription medication is a 
serious problem. So I'll get off of that, but I did mention it 
because I just happened to be reading that magazine on my trip 
here to Ohio.
    I want to ask you a question, Ginni, on volunteers. Has the 
advisory committee tried to increase volunteers for program 
resources from other Ohio state programs or other Ohio 
services?
    Ms. Ragan. Not being able to address all of them. With the 
advisory counsel, sir, the 12 of us that are appointed by the 
Governor, we send them back to their communities. We 
represent--I represent central Ohio. We send them back into 
their communities to get people involved with their senior 
centers, with their senior programs; and, of course, 
legislation and advocacy. I think through your local 
organizations such as your senior center that we are at here, I 
know mental health in Ohio--I know they look for volunteers all 
the time. I think a lot of us also are involved with nonprofits 
where we sit on boards where we volunteer a lot of time.
    Is it a statewide volunteer effort under any one tent? Not 
that I'm aware of. I think--Excuse me. Yes. In the Ohio 
Department of Aging, we do have the state ombudsmen, and they 
are from all around the state. When there is any complaint 
filed by any individual resident in a nursing facility or care 
facility, they are empowered to go in, to investigate and to 
follow-up with anything that they find in their investigation. 
They do a tremendous job, absolutely tremendous job.
    We just trained all of the state ombudsmen several weeks 
ago in dementia training, which was under our budget last year. 
And we have trained them all to look and see when they go in on 
a complaint if, in fact, there is cause and how to treat those 
complaints. But the ombudsmen do a tremendous amount of 
volunteer work. The rest of us--other than a statewide effort--
I'm not aware of one big, huge umbrella in this state.
    Mr. Hinojosa. Well, if I may suggest it to you, I have some 
young children, ages 10 and 12. And we have been trying to talk 
to them about learning how to give back to the community and 
learn to volunteer. And just in looking at what is required to 
get accepted into some of the high schools there in North 
Virginia where we live, they have to not just have good grades, 
they have to show that they are volunteers for programs like 
yours. And so we're beginning to introduce them to that.
    Last week they had Earth Day, and they worked all day 
Saturday in the rain and in the cold, and they picked up I 
don't know how many tons of trash and stuff. I said that's only 
one example.
    Your program is a wonderful one for teenagers if they could 
just be introduced. And if they don't know about it, it's our 
fault. We need to consider how we can work with the schools and 
the counselors. So that if somebody needs to put in some hours 
in the community as volunteers that they begin to get 
acquainted with what your needs are, and then we bring them in.
    I going ask another question of David. How can we in the 
reauthorization address this transportation problem that came 
up with three out of the five of you as a big concern, a big 
problem for you to get the job done?
    Mr. Bibler. What I think, as I had mentioned earlier, you 
know, one of the biggest issues that we face is the condition 
of our vehicles; and the fact that there is no longer state 
funding available. And that was an 80/20 match. So we could get 
a $40,000 wheelchair lift vehicle for $8,000. That has dried 
up. And that's a big concern of ours right now is how we're 
going to continue to replace those vehicles. And Licking County 
is the second largest county geographically in the state of 
Ohio. So we put a lot of vehicles--or a lot of miles on our 
vehicles as I mentioned earlier trying to get out; transport 
people to medical appointments; and also transport people to 
the meal sites, which is primarily what we do. So I think 
additional funding that could be available in that area would 
certainly help us there.
    And also as I mentioned, too, that there is some assistance 
available; and I had written down your suggestion of contacting 
the Bill and Melinda Gates Foundation for a program that would 
allow us to coordinate our transportation efforts because that 
would allow us to do more with the funds that we all have and 
could combine our resources to do that. And so that is 
certainly something, as well.
    But, you know, again, most of it comes down to funding; 
being able to make the resources available to us so that we can 
have the vehicles to go out. As I told many people, if you gave 
us funding for 20 additional vehicles, we still probably could 
not meet all the transportation demands of the seniors in our 
community, being mostly a rural county. We are very fortunate 
that we have a very good taxing program within our city of 
where folks living within the cities of Newark and Heath can 
get to most places they want within those boundaries. Whereas, 
the people in those outlying areas that have a difficult time 
getting to doctors' appointments, whether it's into our--into 
Newark or whether it's going to Columbus. We transport a lot of 
people to Columbus where many of the specialists in central 
Ohio reside and work. And so we transport a lot of people for 
them--a lot of people over to the Columbus area as well.
    Mr. Hinojosa. I thank you for those suggestions. We'll do 
everything we can to include those in the reauthorization.
    My last question is to Elise. Elise, do you have any 
recommendations for Pat and for me that we need to address in 
this report that we're going to be turning in for this public 
hearing that you consider to be your most important issue and 
concern that you want us to address?
    Ms. Geig. Well, definitely our top eight recommendations 
that you heard over and over again are our big priorities. I 
would have to say that definitely to reauthorize the bill. To 
reauthorize the Older Americans Act is a No. 1 priority. As 
everyone on the panel has said, increased funding for all of 
the titles and services to maintain those and to increase them 
is another priority. A lot of the titles and services have been 
maintained over the years--or services have been cut. 
Definitely we need those to be maintained or increased, 
definitely.
    Recommendations that we have as a department--We felt very 
strongly--We have several programs that we feel very strongly 
about. Our EDRCs we feel very strong about, a lot of the 
Federal initiatives, the consumer directed care, long-term care 
on both of the programs we're very proud of. A lot of the 
feelings I've talked about--Mr. Bibler talked about the APS and 
how that's been something that needs to be addressed and our 
ombudsman program has been very strong in Ohio. As Ginni has 
also acknowledged, that's a very strong voluntary program. So 
we do want to maintain title funding for that. I think all of 
our top eight recommendations are very, very strong 
recommendations; and we don't want any of those to be ignored.
    Mr. Hinojosa. Thank you.
    Mr. Chairman, I want to repeat that they have been 
excellent, our panelists have been excellent; and we--at least 
I feel that I have learned a great deal from you. And we'll 
commit to take that first and high priority of getting it 
reauthorized, to work closely with Chairman Tiberi and other 
members of our committee--subcommittee so we can report back to 
you that we got it done. Thank you.
    With that, I yield back.
    Chairman Tiberi. Thank you, Mr. Hinojosa, for coming out to 
Columbus and central Ohio today. And thank you to all the 
panelists. You got see a little glimpse of my colleague and my 
ranking member, and it's just a joy to work with him. He can 
use a soft glove and criticize corporate America at the same 
time while talking about how important it is for volunteers to 
be part of that solution and--with respect to his kids.
    It reminds me a little bit of when I was in college and my 
parents encouraged me to volunteer at a nursing home in our 
neighborhood where we grew up, and it was called Norfolk 
Terrace. I'm sure all of you heard of you have heard of Norfolk 
Terrace. And it--you know, it provided me, not having 
grandparents in the United States because they were all in 
Italy, the opportunity to interact with not only elderly but 
folks who obviously had some severe needs, many of whom did not 
have families; and it provided me a different perspective, 
which I think is very helpful to all of us, providing us 
different perspectives.
    And a great irony today is a good friend of mine from high 
school is now in that nursing home going through rehabilitation 
from a severe auto accident that he was in. It's now called 
Villa Angela. But, you know, how ironic life can be sometimes. 
But it really speaks to what the heart of what some of you see 
every day; and that this is complex--very important, but 
complex. And it requires so many different people, so many 
different organizations to be helpful and ultimately providing 
the goal of helping older Americans. I've got to tell you, if 
it was just as simple as Ruben and I agreeing, it would be 
reauthorized tomorrow. Unfortunately, not everybody has his 
disposition or the work--What's it called--the working 
environment together that we have to try to get things done. 
But we obviously both believe very strongly in trying to get 
this done as quickly as possible. So we're going to do 
everything within our power to reauthorize this and to make it 
as good as we can make it and get the bill reauthorized. I 
think that's ultimately our goal is to get it reauthorized.
    Mr. Hinojosa. Would the Chairman yield?
    Chairman Tiberi. Yes.
    Mr. Hinojosa. It reminds me that his Italian heritage and 
my Mexican heritage have something in common. My mother was 95, 
as I said earlier; and she taught us a lot of things. And her 
daughters and her daughters-in-law would often times ask her, 
``Well, what's your secret to be able to get to 94 and still 
remember so many things so many things and stories?''
    And she said that there were lots of things that she could 
accredit that to. One was doing the crossword puzzle and the 
other one was to work outside on her garden.
    And one of the daughters said--well, daughters-in-law said, 
``Well, Mama Marina, is there any truth that maybe a little bit 
of wine once in awhile.''
    And she said, ``Oh, no question about it. I keep my good 
red wines in the kitchen, and that's a necessity as is--I'm 
sure that has taken me to this age of 94.''
    So all I can say is that we'll just have to look at our 
Italian and Mexican cultures and find ways in which to get this 
top priority passed by reminding the other Members of the 
Congress that there is hope if we could just work together.
    Chairman Tiberi. I agree.
    Thanks for coming in. Thank you to the panelists. Again, 
your testimony has been invaluable for us as we move forward. 
While we won't get everything we want in this reauthorization, 
we will get as good a deal as we can get; and ultimately, the 
reauthorization of this act is obviously very, very important. 
So we'll do that.
    I want to thank the staff: Moira, Ricardo, Kate, and 
Angela, who is here from Washington but from Columbus. And 
we'll get to visit with her family this evening. And thank you, 
Lucy, as well, coming from Washington. Thank you for coming as 
well and making this official. And with that, I just want to 
thank all the witnesses, again; the audience that is here for 
their participation. And if there is no further business before 
us, the subcommittee stands adjourned.
    [Whereupon, at 4:38 p.m., the committee was adjourned.]
    [Additional statement from the National Council on 
Disability follows:]

        Prepared Statement of the National Council on Disability

    The National Council on Disability (NCD) is an independent federal 
agency charged with making recommendations to the President and 
Congress to enhance the quality of life for all Americans with 
disabilities and their families. The overall purpose of the NCD is to 
promote policies, programs, practices, and procedures that guarantee 
equal opportunity for all individuals with disabilities, regardless of 
the nature or severity of the disability; and to empower individuals 
with disabilities to achieve economic self-sufficiency, independent 
living, and integration into all aspects of society. The NCD is 
required by its authorizing statute to advise the Administration and 
Congress regarding laws and issues that affect people with 
disabilities.
    The NCD would like to submit the following executive summaries for 
the record of the Subcommittee on Select Education's April 28, 2006 
Field Hearing on the Older Americans Act. Attached please find the 
executive summary of our 2005 report, The State of Long-Term Services 
and Supports: Financing and System Reform for Americans with 
Disabilities, followed by the executive summary of our 2004 report, 
Livable Communities for Adults with Disabilities. Please note that a 
web-link for each complete report precedes its respective summary. A 
statement by Martin Gould to the Social Security Advisory Board 
describing the Long Term Services report has been included as an 
introduction to the subject matter. The Livable Communities report is 
accompanied by a brief excerpt from a press release. Information 
identical to the body of this email is attached as a Word document. 
Thank you.
The State of 21st Century LTSS: Financing and Systems Reform for 
        Americans with Disabilities, Remarks by Martin Gould to the 
        Social Security Advisory Board, January 31, 2006
    In 2005, the National Council on Disability (NCD) engaged in 
research regarding the nation's LTSS ``system'' because it grew 
increasingly concerned about the (a) lack of a coherent national long-
term services and supports (LTSS) public policy for all people with 
disabilities; (b) fragmented nature of service and support delivery 
systems, with uneven access and services provisions; and (c) LTSS costs 
of 22 percent or more of state budgets, which are fast becoming 
unsustainable. On December 15, 2005, NCD released The State of 21st 
Century Long-Term Services and Supports: Financing and Systems Reform 
for Americans with Disabilities (http://www.ncd.gov/newsroom/
publications/2005/longterm--services.doc). The following facts and 
conclusions are drawn from that report.
What Do We Know About the Status of LTSS in America?
    LTSS is not just for seniors. Most LTSS data and definitions are 
based on people 65 and older. It's impossible for policy makers and 
researchers to accurately calculate current and future costs without a 
clear consensus as to who is to be covered by a LTSS system and how 
eligibility will be calculated.
    A growing senior population will need access to affordable LTSS. 
Today, twenty percent of people 65 and over will require assistance 
with at least one ADL and 50% will require assistance by age 85. By 
2045, people over age 65 who are in need of assistance with 2 ADLs will 
grow from 1.8 million to 3.8 million.
    The incidence of disability is rising for the younger population 
and the impact on future LTSS costs is unclear. Little data has 
forecast what this will mean for future LTSS costs and services. There 
is no aggregated data on the overall costs of LTSS using definitions 
(e.g., National Council on Disability) that includes transportation, 
nutrition, and housing.
    It is unclear what LTSS truly looks like for people under age 65 
across disabilities that are working and living in the community. There 
is little research on the disparities in LTSS needs and costs among 
diverse populations. The issues of poverty, lack of insurance and 
continued segregation from an affordable and consistent health care 
system will increase the future needs and costs for LTSS for diverse 
populations in the U.S. who are projected to make up 50 percent of the 
American population by 2050.
    The growth in Medicaid spending is unsustainable. The ability of 
states to respond to current and future LTSS needs is beyond their 
capacity and resources if health care costs continue to rise at double-
digit rates. Private long term care insurance is not designed for 
people under 65 years of age. Private long term care insurance targets 
individuals age 65 and older within specific disease categories. Over 
six million Americans own private long term care insurance and 50 
percent of the claims paid are for Alzheimer's and other forms of 
dementia.
    In understanding future LTSS costs, the role of care giving and 
workforce issues is unclear.
    Nearly 44 million American caregivers age 18 and over provide 
unpaid care to an adult age 18 or older. Six out of ten of these 
caregivers are employed while providing care, most are women age 50 or 
older. Paid direct care workers are in short supply. The turnover rate 
in nursing facilities is nearly 100%, while home care agencies have 
annual turnover rates between 40% and 60%.
    This nation faces major challenges to its LTSS workforce. LTSS 
workers who provide paid care are often without health insurance and 
other employee benefits and frequent turnover of staff occurs due to 
low wages and lack of benefits.
    There is no coordinated, comprehensive response to LTSS needs 
despite the diversity of challenges associated with varying types of 
disabilities. The current system of response to individual LTSS needs 
is dependent on state specific differences in coverage, resource 
allocation and targeted populations. In addition, Medicaid LTSS 
provided to a person in one state does not transfer to another state if 
that person moves. Additionally, current costs are not a customized 
response to individual needs.
    There is little political or public understanding of LTSS needs. 
Fifty-nine percent of Americans have given little or no thought at all 
to the issue of LTSS. Most Americans think of LTSS as long-term care 
for seniors with severe chronic disabilities who reside in nursing 
homes. This perception is a holdover from the 1960s when Medicaid and 
Medicare were first established and reflects a system of care that is 
outdated and no longer cost effective. Few Americans ever think of LTSS 
for individuals under the age of 65 with significant disabilities who 
are living and working in the community. Many people do not realize 
that there is no LTSS public policy for individuals of moderate to 
middle income whether over or under the age of 65. Despite the movement 
today to provide services and supports in the home and community, 
almost 70 percent of Medicaid resources for LTSS still supports 
individuals in nursing facilities or state institutions.
    There is fragmentation of the Federal system of LTSS. Depending on 
where you live, your age, your economic status, and the nature of your 
disability, you will face different options and levels of response to 
LTSS needs. Furthermore, there is no single federal program, federal 
agency, or congressional committee is charged with the responsibility 
for the management, funding, and oversight of LTSS; however, 23 federal 
agencies are actively involved in LTSS using a broad based definition.
    Policy makers are not asking the hard questions. Most exercises in 
forecasting future visions for long-term service and support policy do 
not address the hard questions: What services should be guaranteed to 
individuals who are unable to provide for themselves? What protections 
from catastrophic loss should be afforded? And, most importantly, who 
will pay?
    Consumers are not providing real solutions. Perhaps most alarmingly 
of all the findings, Americans with disabilities are not leading the 
LTSS policy discussion(s).
    Finally, no proposals have provided a total picture of what LTSS 
costs for people with lifelong disabilities would look like, and no 
studies exist that provide viable funding alternatives for a new 
system.
Conclusion
    It is imperative that our nation transform its LTSS programs, 
financing, and policies to promote and protect individual dignity and 
independence within the context of supportive families and communities 
and to circumvent the impending storm created by our growing 
demographic and economic challenges. If we are to achieve real change 
in our current system of LTSS, we will need to base the transformation 
on a: (a) broad definition; (b) fundamental set of operating 
assumptions that serve as the basis for real change to occur; and (c) 
series of action steps.
    A broad definition of long-term service and supports will reflect 
people's essential needs for maintaining a quality of life with maximum 
dignity and independence. Housing, transportation, nutrition, 
technology, personal assistance, and other social supports should be 
included in a definition of long-term services and supports.
    Furthermore, there are five operating assumptions that need to be 
addressed by policymakers who undertake any major effort intending to 
achieve meaningful change in LTSS. First, people who are elderly and 
people with disabilities both desire and deserve choices when seeking 
assistance with daily living in order to maintain their self-
determination, dignity and independence. Second, without significant 
reform, the current financing mechanisms, both public and private, will 
become unsustainable in the near future. LTSS must be affordable to all 
Americans regardless of income level and we must consider opportunities 
to leverage public and private support in new ways without 
impoverishing beneficiaries. Third, there is an opportunity with the 
changing demographic picture of the United States to explore the 
possibilities of a universal approach to the design and financing of 
supports that is responsive to individuals with disabilities both under 
and over the age of 65 without sacrificing individual choice and 
flexibility. Fourth, formal and informal care giving must be sustained; 
and family needs and workforce recruitment and retention challenges 
must be addressed. Fifth, the approach to quality must examine consumer 
direction and control of resources in addition to traditional external 
quality assurance mechanisms.
    Finally, we need to engage in a series of action steps and 
activities to make the transformation happen. These action steps 
include: Increase policymaker knowledge and understanding of public and 
private costs and benefits of LTSS for people with disabilities under 
age 65 and their families; design and implement an action plan to 
monitor and oversee states' activities to meet their ADA obligations as 
a result of the Olmstead Supreme Court decision; decouple eligibility 
for home and community-based waiver services from determination of 
nursing home eligibility; increase support for family members and 
others in their role as informal and unpaid caregivers for individuals 
with disabilities of all ages; improve the supply, retention, and 
performance of direct support workers to meet increasing demand; hold 
states accountable for rebalancing their system to increase home and 
community-based LTSS; explore possible relationships between private 
LTSS insurance products and publicly financed LTSS; and, improve 
consumer understanding, knowledge, and skills to develop a person-
centered plan and self-direct an individual LTSS budget.
    As the number of Americans requiring LTSS increases, the existing 
fragmented ``system'' will become increasingly incapable of being 
sustained. Without a dramatic change of direction, disaster is 
inevitable.
The State of 21st Century Long-Term Services and Supports--Financing 
        and Systems Reform for Americans with Disabilities
                                                 December 15, 2005.
    The complete version of this report can be found at: http://
www.ncd.gov/newsroom/publications/2005/longterm--services.doc
Executive Summary
            Introduction
    Long-term services and supports (LTSS) is not only an issue for 
older Americans but also for younger individuals with disabilities, and 
any LTSS financing and system reform efforts must consider both 
populations.
    The current LTSS system is funded primarily by state and federal 
programs. More specifically, Medicaid is the primary payer of LTSS in 
this country. Medicaid paid for 45 percent of the $137 billion this 
country spent on LTSS in FY 2000. Yet, despite the amount of money that 
state and federal programs are allocating to LTSS, individuals and 
their families still pay out of pocket for nearly one-third of LTSS 
expenses.
    Although the population of people who have disabilities and people 
who are elderly has indicated a preference for receiving LTSS in home- 
and community-based settings, a federal institutional bias exists. 
Presently, about 1.6 million people live in nursing homes, group homes, 
and other institutional facilities. At the same time, there are about 2 
million to 2.4 million people on waiting lists or in need of some type 
of LTSS.
    Options for LTSS are emerging. Aging and disability advocates are 
working with the health care industry to create a continuum of care, 
including such services as assisted living, adult day services, and 
home care. Governors have creatively used the Medicaid waiver process 
to increase home- and community-based services for people who are 
elderly and people with disabilities.
    Although financing is the cornerstone of the LTSS issue, other 
issues are critical in building an adequate, seamless, and effective 
LTSS system to meet the increasing needs of aging baby boomers and the 
increasing numbers of individuals with disabilities who have LTSS 
needs. These issues include supporting family caregivers, addressing 
workforce shortages, improving the quality of LTSS services, and 
improving access to transportation and housing.
    Recognizing, in particular, that the impending age wave of baby 
boomers will significantly increase the demand for LTSS in the coming 
decades, the National Council on Disability was interested in 
researching the issues of LTSS financing and systems reform. This 
report addresses those issues.
    The development of long-term services and supports (LTSS) 
comprehensive policy will define the future economic independence of 
Americans with disabilities. Changing demographic and economic trends, 
here and abroad, will demand that the United States retool its 
programmatic and financial infrastructure to protect and promote 
individual dignity and independence of all Americans with disabilities. 
The development of sustainable and affordable LTSS public policy for 
the 21st century-funded through a unique combination of individual 
contributions, innovative private sector assistance, and public 
support-will provide a new security for Americans with disabilities to 
work and live independently. Although 20th century advances 
revolutionized the concept of health care and longevity for many 
Americans, increasing life expectancy by 30 years, they fell short in 
providing an affordable LTSS public policy for both the medical and 
nonmedical services and supports needed by many working Americans with 
disabilities. The United States is a world leader in extending life and 
eradicating disease, but it has failed to develop an LTSS public policy 
that truly integrates disability as a natural part of the human 
experience.
    Few Americans think of LTSS for individuals under the age of 65 who 
are living and working in the community with significant disabilities. 
Many people do not realize that there is no LTSS public policy for 
individuals of moderate to middle income, whether over or under the age 
of 65. Private insurance is available for long-term care that, on 
average, is capped at a specific dollar amount, provides coverage for 
about three years, and is geared toward services and supports that 
cater to diseases of aging and not the needs of everyday working 
Americans with disabilities.
    Ninety percent of Americans do not have long-term care insurance, 
and many do not have the financial savings to cover the costs of aging. 
Few insurance products are available that cover the costs of providing 
services and supports targeted for individuals and families challenged 
with lifelong disabilities under age 65. A recent actuarial study found 
that Americans at age 45 are more likely to become disabled than to 
die, and yet we continue to insure against loss of life rather than 
against the risk of disability. There are no risk pools or insurance 
products designed to supplement the additional costs associated with 
living and working with a lifelong disability. There is little research 
or data that accurately captures what this means for planning the 
financial future of an individual born today with a lifelong 
disability.
    Disability prevalence is rising in the under-age-65 population and, 
although it has decreased slightly for seniors, it will begin to rise 
sharply as the current senior population of 34 million doubles over the 
next 20 years. Inherently, most Americans think of LTSS as long-term 
care for seniors in nursing homes with severe chronic disabilities. 
This bias is a holdover from the 1960s, when Medicaid and Medicare were 
first established, and reflects a system of care that is outdated and 
no longer cost-effective. Although the movement today is to provide 
services and supports in the home and community through an array of 
waivers, more than 50 percent of Medicaid resources for LTSS continue 
to support individuals in nursing facilities or intermediate care 
facilities for the mentally retarded (ICF/MRs).
    In 2001,\i\ the United States spent $1.24 trillion (or about $5,500 
per person) on personal health care services, with 12 percent (or 
$151.2 billion) spent on LTSS. Although 70 percent of the 53 million 
Medicaid beneficiaries are children and mothers, more than half of the 
$276.1 billion spent in 2003 was for populations who are aging (15 
percent) and with disabilities (15 percent). The predominant disability 
populations receiving Medicaid LTSS are those with mental retardation 
and developmental disabilities (MR/DD) and low-income seniors who rely 
on both Medicaid and Medicare. Between 9 million and 12 million 
Americans need help with activities of daily living (ADLs) and 
instrumental activities of daily living (IADLs), and 3.5 million are 
under 65 years of age. The literature also reports that 25 million 
individuals with chronic severe disabilities under age 65 are probably 
in need of some LTSS, but these individuals are often not counted or 
found eligible because of income or family assets, or they fall outside 
the realm of traditional functional assessments that use ADLs and IADLs 
as measurements. There is also confusion about what definition of 
disability should be used to assist policymakers in studying LTSS 
needs. Finally, LTSS are not portable and are highly dependent on the 
fiscal and budgetary priorities and obligations of each state.
---------------------------------------------------------------------------
    \i\ O'Shaughnessy, C. (2003). Long-Term Care Chart Book: Persons 
Served, Payers and Spending. Congressional Research Service: The 
Library of Congress (RS21518). P. 3
---------------------------------------------------------------------------
    In addition, about one-fifth of the U.S. population is uninsured or 
underinsured, with more than 18,000 American lives lost each year 
because of gaps in insurance coverage, at an economic cost between $65 
billion and $139 billion annually from premature death, preventable 
disability, early retirement, and reduced economic output. Rising 
double-digit inflation costs for health care continue to confound state 
and federal efforts to reign in overall health and LTSS spending. The 
probability of sustaining future promises to current social policy and 
its beneficiaries is low if the demographics are correct: Fewer workers 
will mean lower payroll contributions and less money available to fund 
past and future commitments. The research suggests that the problem is 
beyond incremental reform and requires immediate attention.
    A ``rich picture'' methodology was used to introduce the problem 
this report addresses. The picture captures the current health care and 
LTSS system. The field of management often uses a rich picture systems 
methodology, that is, ``an innovative tool that encapsulates knowledge 
relevant to strategic reform.'' For the disability field, the use of 
the rich picture allows people with intellectual impairments and other 
cognitive challenges to grasp the essence of the research through a 
visual representation and dialogue. The picture and narrative relied on 
the review of primary and secondary research documents; one-on-one 
open-ended interviews with key stakeholders in the disability, long-
term care, and health care fields; review of congressional records and 
attendance at a number of hearings; and the convening of a national 
expert advisory panel on LTSS.
    The setting for the rich picture is the ocean, with the current 
LTSS and health care ship heading toward an iceberg that represents the 
barriers and challenges to systems reform. The cast for this rich 
picture provided the substantive descriptions and main body of research 
and analysis about the barriers and challenges of navigating through 
the current system of LTSS. The presentation of the research in this 
format was purposeful so that the reader and the researcher could begin 
the voyage together with a snapshot of the problem. It was intended 
that a new picture would emerge as the researchers integrated the 
findings from the other chapters of the research. The final picture is 
a new ship, ``AmeriWell,'' that is designed to provide LTSS for all 
Americans regardless of income or category of disability through 
innovative funding from individuals and families, the private sector; 
and the Federal Government. AmeriWell will delink aging and disability 
populations from both Medicaid and Medicare that require LTSS to form a 
new LTSS program that provides services and supports to middle-and low-
income Americans with disabilities.
    The purpose of this research is to produce new knowledge and an 
understanding of current experience with and the future need for 
affordable LTSS for people with disabilities. The following findings 
provide a broad overview of the four areas researched for this report. 
Chapter recommendations are provided here in brief, but a detailed 
summary is available in chapter 6. All footnotes and references can be 
found in the original text, except where otherwise noted.
Findings
            1. Little Political or Public Understanding of Current and 
                    Future LTSS Needs (Chapter 1)
    A. There is little public or political interest in putting LTSS 
onto the national agenda, although state Medicaid spending represents 
22 percent of overall state budgets and is fast becoming unsustainable.
    B. Fifty-nine percent of Americans have given little or no thought 
to the issue of LTSS and the costs associated with aging or disability.
    C. Most Americans do not understand the current system of LTSS, how 
it is funded, or who is eligible for services. Many people do not 
understand that Medicaid is the primary provider of LTSS for all 
populations-both young and old-and that eligibility is income 
sensitive.
    D. The development of affordable LTSS is the missing link in making 
work a reality for many Americans with disabilities.
            2. Fragmentation of Federal System of LTSS (Chapter 1)
    A. There is no single federal program or federal agency charged 
with the responsibility for management, funding, and oversight of LTSS 
at home and in the community. More than 20 federal agencies and almost 
200 programs provide a wide range of assistance and services to people 
with disabilities.\ii\
---------------------------------------------------------------------------
    \ii\ Finding added and not part of main body of research. 
Government Accountability Office. (June 2005). Federal Disability 
Assistance: Wide Array of Programs Needs To Be Examined in Light of 
21st Century Challenges. Washington, DC: GAO (GAO-05-626). P. 5.
---------------------------------------------------------------------------
    B. There is no single entry point at a community level for 
individuals with disabilities and seniors to learn about and access 
service and support options.
    C. There are multiple federal programs with varying policy 
objectives that embrace the values of consumer choice and independence 
in daily living, but there is no comprehensive, integrated delivery 
system that provides portability across states.
            3. Policymakers Continue to Avoid the Hard Questions 
                    (Chapter 1)
    A. Twenty years of research and exercises in forecasting future 
visions for LTSS have failed to answer the following questions: What 
services should be guaranteed to individuals unable to provide for 
themselves? What protections from catastrophic loss, financial or 
otherwise, should be afforded, and, most important, who will pay? How 
is the current LTSS policy working, and does it meet the needs of 
today's population with disabilities?
            4. Favorable Court Decisions Post-ADA for Future LTSS 
                    (Chapter 1)
    A. Positive forces for change began with the passage of the 
Americans with Disabilities Act (ADA) in 1990; they were followed by 
the Supreme Court decision in Olmstead in 1999 and the subsequent 
Administration actions in 2000, and continued to the present. They 
provide a platform to support policy and program changes for a long-
term support system that embraces consumer choice to live in the least-
restrictive environment at home and benefit from community 
participation.
            5. Future of LTSS Formal and Informal Workforce Unclear 
                    (Chapter 1)
    A. Population demographic changes because of aging, reduced 
fertility rates, increased women in the workforce, and changing family 
makeup predict there will be fewer unpaid family workers and an 
increased demand for paid workers.
    B. The role of government in addressing the challenges of the 
current formal and informal workforce is unclear.
    C. The majority of LTSS workers providing paid care are often 
without health insurance and other employee benefits and experience 
frequent job turnover.
            6. LTSS Policy Not Just for Seniors (Chapter 2)
    A. Most data for LTSS favors individuals age 65 and older with 
diseases of aging. Policymakers and researchers need accurate data to 
calculate current and future LTSS utilization and costs to develop a 
clear consensus as to who is to be covered by an LTSS system and how 
eligibility will be calculated.
            7. Disability Definitions Need Clarification (Chapter 2)
    A. Disability definitions range from a medical diagnostic approach 
to a functional assessment approach that uses ADLs and IADLs. There is 
no aggregated data on the overall costs and utilization rates using the 
NCD/AARP definition for LTSS that includes transportation, nutrition, 
and housing.
    B. There are 38 million people under age 65 reporting some level of 
disability and, of this Group, 25 million have a specific chronic 
disability; however, many of these individuals are not eligible for 
LTSS.
    C. Using the functional definition of disability based on ADLs and 
IADLs, the estimated population in need of LTSS under age 65 ranges 
from a conservative figure of 3.5 million to more than 10 million.
            8. Future Demographic Trends Predict That Many Americans of 
                    All Income Levels Will Need Access to Affordable 
                    LTSS (Chapter 2)
    A. Regardless of the definition of the target population, there is 
clear and undisputable data that the number of people over age 65 with 
ADL and IADL limitations is growing and will double by 2030.
    B. Twenty percent of people age 65 and over will require assistance 
with at least one ADL and 50 percent will require assistance by age 85. 
The number of people in need of assistance with two ADLs will grow from 
1.8 million to 3.8 million by 2045.
            9. Disability Rates Declining for Seniors and Impact on 
                    Future LTSS Utilization and Costs Is Unclear 
                    (Chapter 2)
    A. The rate of disability has declined in the 65-and-older 
population, mostly for IADLs. It is less clear whether this decline is 
due to health improvements or environmental changes because of 
increased technology for durable medical equipment, including assistive 
technology. However, the rate of disability for individuals 85 years 
and older is expected to rise as this population triples over the next 
30 years.
            10. Disability Rates Rising for Individuals Under Age 65 
                    and Impact on Future LTSS Utilization and Costs Is 
                    Unclear (Chapter 2)
    A. The rate of disability for individuals under age 65 is rising in 
diabetes, obesity, and mental illness. Little data is available that 
accurately predicts how this will impact future LTSS utilization, 
costs, and service delivery.
    B. It is unclear what LTSS truly looks like for individuals under 
age 65 across disabilities and specific age groups for those working 
and living independently. The research shows that individuals under age 
65 are heterogeneous and have specific needs according to gender, age, 
and type of disability that are quite different from individuals over 
the age of 65.
            11. Individuals Under Age 65 Receive Less Personal 
                    Assistance and Are More Likely To Be Nonwhite 
                    (Chapter 2)
    A. Individuals with two or more ADL limitations and personal 
assistance needs under the age of 65 estimated a shortfall of 16.6 
hours of help per week and were more likely to be nonwhite, female, and 
living alone.
    B. Paid personal assistance services go primarily to people 65 and 
older, and working-age people 65 and under rely more on unpaid personal 
assistance services.
            12. Increased Life Expectancy for People with Lifelong 
                    Disabilities and Its Impact on LTSS Utilization and 
                    Costs Unstudied (Chapter 2)
    A. Individuals with lifelong disabilities, such as Down syndrome, 
cerebral palsy, and mental retardation, are living longer and the 
impact on utilization of LTSS services and future costs is unclear from 
the current literature.
    B. It is unclear what future services and supports, including 
access to housing, transportation, and nutrition, will be in most 
demand for people under age 65 with lifelong disabilities living and 
working in the community.
            13. LTSS Needs Among Minority Populations and Impact on 
                    Future Utilization and Costs Needs Study (Chapter 
                    2)
    A. Black children are 13 percent more likely than white children to 
have a reported ADL limitation. A recent Government Accountability 
Office study confirmed that the black population has higher disability 
rates and lower lifetime earnings and shorter life expectancies than 
whites.
    B. The issues of poverty, lack of insurance, and continued 
segregation from affordable and consistent health care will increase 
the future needs and costs for LTSS for minority nonwhite populations 
in the U.S., which are projected to make up 50 percent of the American 
population by 2050.
            14. Growing Prevalence of Mental Illness and Its Impact on 
                    Future LTSS Utilization and Costs Unknown (Chapter 
                    2)
    A. The prevalence of chronic disease and deaths caused by 
noncommunicable disease in the United States between 1990 and 2020 will 
increase from 28.1 million to 49.7 million, an increase of 77 percent.
    B. Mental illness will rank number two after heart disease and 
replace cancer by 2010 as having a greater impact on death and 
disability. Medicaid is the principal public payer for mental health 
services and represents 36 percent of the $48 billion in spending. It 
is unclear what the future LTSS needs and costs will be for people with 
mental illness.
            15. Medicaid LTSS Not Designed to Support Growing Need of 
                    Middle-Income Population (Chapter 2)
    A. The current system of LTSS is designed for low-income 
individuals and is unsustainable under the current system of health 
care that has expanded Medicaid options to provide services and 
supports to an array of middle-income and uninsured individuals.
    B. There are 57 million working-age Americans between 18 and 64 
with chronic conditions such as diabetes, asthma, or depression, and 
more than one in five (12.3 million) live in families that have 
problems paying medical bills. Many are not eligible for LTSS services 
because they have assets above prescribed limits.
    C. The number of chronically ill people with private insurance who 
spend more than 5 percent of their income on out-of-pocket health care 
costs increased by 50 percent, to 2.2 million people, in 2003.
    D. The impact on LTSS costs are unclear for 6.6 million individuals 
with chronic care needs who are uninsured and go without needed care 
(42%), delay care (65%), or fail to get needed prescriptions (71%), but 
they will impact future need and costs without timely intervention.
            16. Growth in Medicaid Spending Is Unsustainable (Chapter 
                    2)
    A. Eligibility and service pathways to state Medicaid programs have 
expanded to meet the growing needs of 53 million low-income, middle-
income, and uninsured acute care and LTSS beneficiaries, and reflect 
the growing challenges of economic downturns, increased health 
premiums, increased longevity, a low savings rate, and slower wage 
growth.
    B. Twelve percent of $329 billion combined state and federal funds 
in 2005 was spent on LTSS.\iii\
---------------------------------------------------------------------------
    \iii\ Medicaid Reform A Preliminary Report from the National 
Governors Association. June 15, 2005.
---------------------------------------------------------------------------
    C. Seven million individuals are dually eligible for full Medicare 
and Medicaid benefits and another 1 million receive assistance with 
copays and deductibles; combined, this represents 42 percent of all 
Medicaid expenditures.
    D. The ability of states to respond to current and future LTSS 
needs is beyond their capacity and resources as long as health care 
costs continue to rise at double-digit rates.
            17. Two-Thirds of Medicaid Spending for Optional and Not 
                    Mandatory Service (Chapter 2)
    A. Two-thirds of Medicaid spending is for population groups and 
services technically defined as optional, and 90 percent of all long-
term care Medicaid services are optional. It is unclear how vulnerable 
people with disabilities are, with the majority of their services and 
funding falling under optional categories.
    B. Seventy-five percent of home- and community-based services 
(HCBS) waivers are for people with MR/DD and are used to purchase LTSS. 
The other 25 percent are used for people with physical disabilities and 
older people. There are three small waiver programs that serve 
individuals with a primary diagnosis of mental illness, accounting for 
0.2 percent of HCBS waiver expenditures. Further research is needed to 
explore the LTSS needs of the 25 percent population using HCBS.
            18. Medicaid Administrative Costs Need Further Research 
                    (Chapter 2)
    A. Research is needed to further determine whether Medicaid 
administrative costs meet the federal basic guidelines that ``costs be 
allowable, reasonable, and allocable for reimbursement under Federal 
awards.''\iv\
---------------------------------------------------------------------------
    \iv\ Finding added and not part of main body of research. Refers to 
Office of Management and Budget Circular A-87 that establishes cost 
principles for federal grants to state governments. April 2005. 
Department of Health and Human Services: Office of the Inspector 
General. Review of the Oklahoma Department of Human Services' Medicaid 
Administrative Costs. A-06-03-00046.
---------------------------------------------------------------------------
            19. Many Uninsured Americans Are Working (Chapter 2)
    A. Forty-nine percent of the 45 million uninsured Americans are 
either self-employed or work for companies with fewer than 25 
employees.
    B. More than 50 percent of low-income employees of small firms with 
incomes below 200 percent of the federal poverty level are uninsured.
    C. More than 2 million health care paraprofessionals report wages 
below the poverty line, do not work full time, and do not receive 
benefits.
            20. Long-Term Care Insurance Designed Mostly for Seniors 
                    and Not Individuals Under 65 with Disabilities 
                    (Chapter 2)
    A. Private LTSS insurance is targeted to individuals age 65 and 
older and often to specific disease categories. One insurance company 
reported that more than 50 percent of its LTSS insurance claims paid 
are for Alzheimer's and other forms of dementia.
            21. Risk of Disability Is Higher Than Premature Death at 
                    Age 45 (Chapter 2)
    A. The risk of disability is higher than premature death and is 
higher for older people than younger, and females are more likely to 
become disabled than males. A 45-year-old individual earning $50,000 
per year and suffering a permanent disability could lose $1,000,000 in 
future earnings.
    B. The public overestimates the help that is available from public 
disability insurance programs-Social Security Disability Insurance 
(SSDI) and other state-mandated, short-term programs. Workers 
compensation benefits cover only disabilities caused by injury or 
illness arising on the job-only an estimated 4 percent of disabilities.
            22. Congress Needs Research on the Current and Future 
                    Utilization and Costs of LTSS for Individuals Under 
                    Age 65 and Their Informal Workforce (Chapter 2)
    A. Congress needs sufficient data on LTSS costs and utilization for 
individuals across the spectrum of disabilities under age 65 to develop 
a sustainable and affordable LTSS policy.
    B. Congress needs sufficient data that responds to the demographics 
that predict a decrease in the current population of informal 
caregivers (valued at $200 billion a year) and the impact of this trend 
on the development of a future LTSS workforce.
    C. Research is needed on the different public and private cost-
sharing scenarios that focus on the under-age-65 population with 
disabilities and the relationship between public financing and private 
insurance to develop affordable products that insure against future 
risk of developing or being born with a disability.
            23. Changing Global Demographics and Economic Impact on 
                    Future LTSS Policy Unclear (Chapter 2)
    A. The global economic picture and changing demographics, in 
addition to the current U.S. federal budget deficit, raise new 
questions about the sustainability of current entitlement and social 
programs and their impact on beneficiaries with disabilities.
    B. Current state and federal budget deficits and funding priorities 
jeopardize a patchwork system of services and supports that do not meet 
the current needs of the target population, let alone those projected 
into the future.
            24. Role of Caregiving and Workforce Issues in 
                    Understanding Future LTSS Costs Unclear (Chapter 2)
    A. 44.4 million American caregivers age 18 and over provide unpaid 
care to an adult age 18 or older. Six out of 10 of these caregivers 
work while providing care; most are women age 50 years or older.
    B. Jobs for nurses' aids are expected to grow by 23.8 percent, 
while the employment of personal care and home health aides may grow as 
much as 58.1 percent between 1998 and 2008.
    C. It is unclear how many workers (the ``gray market'') are hired 
and supervised by consumers who pay for their own care, although the 
numbers are thought to be substantial.
    D. Direct care workers (3.1 million) are in short supply and have 
nearly a 100 percent turnover rate in nursing facilities; home care 
agencies have annual turnover rates between 40 and 60 percent.
    E. Direct care workers have low median hourly wages of $9.20 an 
hour and one-fifth (far more than the national average of 12 to 13 
percent) earn incomes below the poverty level; 30 to 35 percent of all 
nursing home and home health aides who are single parents receive food 
stamps.
            25. LTSS Not Portable Across States (Chapter 2)
    A. LTSS are not portable and cannot be moved with an individual 
from state to state, and current LTSS costs are not a customized 
response to individual needs.
    B. Current costs reflect matching an individual's circumstances to 
available services and supports, based on federal eligibility criteria, 
with degrees of consumer choice and direction that vary based on the 
state in which the individual lives.
    C. The fiscal health of each state (and its ability to provide the 
necessary match to draw upon federal Medicaid resources) determines the 
scope and array of the current LTSS system for low-income Americans 
with disabilities and seniors.
    D. The personal assistance service needs of an individual in 
California could be similar to someone living in Mississippi, and yet 
the availability of services and funding may vary dramatically.
            26. LTSS Public Policy Is Necessary to Increase Positive 
                    Employment Outcomes for People with Disabilities 
                    (Chapter 2)
    A. It is unclear how Americans with lifelong disabilities under age 
65 can become self-sufficient and economically independent through work 
and build careers without substantial LTSS reform that allows asset 
growth and more innovative public-private support for LTSS.
    B. It is unclear how Americans with or without disabilities will 
provide for their own health care and LTSS in the future without 
changes in savings behavior and the development of insurance products 
that protect against the risk of disability.
            27. External Advisor and External Policymaker Findings for 
                    LTSS Action Similar to State Findings (Chapter 3)
    A. Similar to the state findings, the advisory group encouraged 
moving any LTSS policy discussion away from the current medical status 
and disability type to a standardized assessment process to evaluate 
functional needs related to ADLs and IADLs.
    B. There is a need to reevaluate financial eligibility criteria and 
develop an expanded benefits menu that organizes service options from a 
presumption of individual preference for remaining at home and in 
community settings. The panel, without describing benefits coverage in 
detail, recognized that different people have different needs. As a 
result, the benefits coverage based on functional assessment must be 
flexible, individualized, and comprehensive. Nursing home level of care 
should be shifted from an entitlement status to an option of last 
resort.
    C. The system should offer more consumer choice and direction in 
determining needs, creating a service plan, and directing and managing 
provider selection and service delivery.
    D. The system should provide incentives to support and encourage 
family caregiving, and consider tax incentives to help defray expenses 
of dependent care for LTSS.
    E. Federal authorities should agree on key outcomes and a 
measurement system. Shared information and data collection and analysis 
across agencies in multiple settings should help improve understanding 
of cost-effectiveness based on different service delivery models. 
Performance outcomes should focus on wellness, productivity, inclusion, 
and independence.
    F. The cost should be spread across all wage earners over a 
lifetime as part of a social insurance financing framework. Similar to 
the approach of social security and Medicare, individual needs will 
vary over a life span.
    G. The system should decouple eligibility for benefits from current 
requirements of impoverishment for individuals and families.
    H. The system should provide support and incentives to encourage 
family support and informal caregiving to be balanced with public 
funding and responsibility. Key outcomes should be defined on an 
individual and systems level that focuses on wellness, productivity, 
inclusion, and independence.
            28. Selected State Strategies for LTSS Are Promising 
                    (Washington, Vermont, Minnesota, Texas, and 
                    Indiana) (Chapter 4)
    A. States have ongoing, intensive, comprehensive planning processes 
that involve a full range of stakeholders-from state officials to 
providers to advocates and people with disabilities themselves-and the 
commitment and support of the governor and legislature.
    B. Planning includes realistic accounting of the state's fiscal 
situation, availability of federal money, community partnership 
building, implementation of cost-limited regulatory changes, and 
benchmark settings to measure results.
    C. States are experimenting with merging, consolidating, and 
combining nursing home and HCBS dollars to better allocate funds 
according to the needs of people with disabilities and developing 
single-point-of-entry systems at the local level to encourage easier 
access to LTSS.
    D. States are experimenting with global budgeting that allows 
budgeting practices to blend (to some degree) institutional care and 
HCBS dollars and allows states the flexibility to respond to the 
preferences of people with disabilities to remain at home or in the 
community.
    E. States are broadening HCBS to allow greater numbers of people 
with disabilities the opportunity to direct their own care (for 
example, hiring, training, and supervising their workers).
            29. States Are Living Laboratories for Future LTSS Policy 
                    Development (Chapter 4)
    A. The Olmstead decision stimulated executive and legislative 
review of the current system of service delivery, unmet needs of target 
populations, and where the dollars are being expended.
    B. Cross-agency planning is most effective when the consumer 
stakeholder voice is included as part of the process to develop 
recommendations for systems reform.
    C. Structural changes have involved substantial reorganization to 
an umbrella department for multiple target populations with long-term 
support and service needs.
    D. Expanded use of Medicaid waivers is common to broaden benefits 
and LTSS to subpopulations.
    E. The most restrictive policy most frequently identified was the 
Medicaid institutional bias.
    F. There remains confusion in the use of language regarding long-
term care and LTSS.
    G. All selected states have waiting lists for specific target 
subpopulations, although states may limit services and operate the 
waiver on less than a statewide basis.
    H. Current budget challenges at a state level have compelled states 
to reexamine the balance between public and private responsibility for 
LTSS, evaluate approaches to target individuals based on an assessment 
of level of need, and seek to identify strategies that encourage 
coverage of supports through some type of insurance coverage and other 
private sector resource sharing.
            30. Local and Individual Strategies for LTSS Require Fresh, 
                    Creative Thinking That Reanalyzes the Use of Public 
                    and Private Resources (Chapter 5)
    A. There is growing recognition that a fundamental shift in values 
is occurring as states move LTSS to the community and home and out of 
the institutions. Individuals with disabilities are being provided with 
more choices to live independently.
    B. New housing models with cooperative organizational structures 
are providing a realignment of service and financial relationships at 
an individual and community level and recognize the importance of 
consumer choice and direction.
    C. New economic models for managing assets include pooled trusts, 
supportive corporations, time banks, and child trust funds, and raise 
important questions about public versus private responsibility to 
create and manage a social safety net for individuals deemed in 
greatest need of long-term support.
Recommendations for Incremental and Clean Slate Reform (See Chapter 6 
        for full text and implementation lead for each recommendation)
            1. Increase Policymaker Knowledge and Understanding of 
                    Public and Private Costs and Benefits of LTSS for 
                    People with Disabilities Under Age 65 and Their 
                    Families (Chapter 5)
    A. The lack of data that presents a complete and accurate picture 
of the costs for LTSS for families with children or adults with 
disabilities was a key finding by NCD researchers. Despite multiple 
studies by the Congressional Budget Office (CBO) and other federally 
sponsored research centers on the costs of long-term care for seniors, 
the population under age 65 with disabilities has not been a priority. 
The traditional definition of long-term care identified acute care 
needs as well as nonmedical services and supports for seniors. Today's 
definition of long-term care has changed to reflect the ongoing growth 
and integration of disability into mainstream culture. LTSS for people 
65 years and younger is about many nonmedical services and supports, 
such as personal assistance, assistive technology, financial 
management, housing, transportation, and nutrition. How people are 
assisted in compensating for loss of ADLs will define their future 
earnings potential and economic independence.
            2. Design and Implement a Multifaceted Action Plan of 
                    Monitoring and Oversight of State Activities to 
                    Meet Their ADA Obligations as a Result of the 
                    Olmstead Court Decision (Chapter 5)
    A. The Olmstead Supreme Court decision in 1999 provides important 
legal support for states' current efforts to rebalance their LTSS 
systems toward home- and community-based settings. The Administration, 
through an Executive Order and grant activities, has taken seriously 
the Court's decision and mandated a state planning process to improve 
and expand community-based choices for people with disabilities. More 
than $200 million has been awarded by the Centers for Medicare and 
Medicaid Services (CMS) to states on a competitive basis to promote 
system changes. Despite these efforts, litigation continues to expand 
in class action suits. In more than 25 states, individuals with 
disabilities have been frustrated with the pace of change and the slow 
movement of funding away from nursing homes and institutional settings 
to communities.
    B. The Office for Civil Rights at the Department of Health and 
Human Services (HHS) and the Justice Department have the responsibility 
to monitor and oversee Olmstead state plan implementation. As both 
agencies have done on numerous occasions in the past related to ADA, 
there is an opportunity to be proactive and design and implement an 
action plan that evaluates individual state efforts to meet the 
Olmstead community imperative mandate. Each state should be rebalancing 
its financing, reducing the number of individuals with disabilities 
residing in nursing homes, diverting others from entering nursing 
homes, and putting in place the infrastructure for expanded HCBS for 
individuals with disabilities.
            3. Decouple Eligibility for Home- and Community-Based 
                    Services Under an HCBS Waiver from a Determination 
                    of Nursing Home Eligibility (Chapter 5)
    A. It is necessary to remove the institutional bias in the Medicaid 
program to give Medicaid beneficiaries greater choice in how financial 
assistance is provided to cover a range of LTSS. The clear majority of 
stakeholders recognized the overwhelming consumer preference for HCBS. 
Two complementary options deserve immediate attention from Congress and 
bipartisan support.
    B. The first option is to shift the HCBS program from its current 
waiver status to a state plan requirement. Eligibility would be 
delinked from nursing home eligibility and states would receive an 
increased federal match under their state cost-sharing agreement for 
services provided in this category as part of their Medicaid 
reimbursement for authorized expenditures. CMS would set guidelines for 
a functional assessment process and minimum threshold of services to be 
covered, including personal assistance services.
    C. The second complementary option would be that federal funding 
follows the person from a nursing home to a community setting as part 
of a person-centered plan and self-directed budget. The Money Follows 
the Person (MFP) option would continue for a three-year period to help 
support successful community transition. Both options are currently 
part of legislative proposals before Congress. MFP and the Medicaid 
Community Attendant Services and Supports Act (MiCASSA) deserve to be 
the focus of hearings before the end of the year.
            4. Increase Support for Families and Significant Others in 
                    Their Role as Informal and Unpaid Caregivers for 
                    Individuals with Disabilities Over and Under the 
                    Age of 65 (Chapter 5)
    A. Eligibility for LTSS and the scope and intensity of covered 
services varies significantly from state to state. States have 
considerable discretion in determining who their Medicaid programs 
cover. Despite state variability in criteria for Medicaid eligibility 
and scope of benefits, in all states, individuals with disabilities are 
dependent on informal caregivers, including parents, family members, 
and significant others. The estimated benefit of informal caregiving 
exceeds $200 billion annually. Services should be designed to support, 
not supplant, the role of the family and actions of informal 
caregivers. Increased support for informal caregiving could be achieved 
through implementation of a complementary set of recommendations. There 
is a need to address the lack of portability from state to state for 
Medicaid LTSS.
            5. Improve the Supply, Retention, and Performance of Direct 
                    Support Workers to Meet Increasing Demand (Chapter 
                    5)
    A. As part of the Olmstead guidance, CMS should issue an advisory 
letter to state Medicaid directors directing corrective action to 
achieve parity of compensation across the environments where direct 
support workers are located.
    B. CMS should continue to fund demonstration projects to allow 
states to test innovative strategies to improve the recruitment, 
supply, retention, and performance of direct support workers.
    C. Funding should be authorized for collaborative demonstration 
projects between the U.S. Departments of Labor and HHS that promote 
collaboration between community colleges and disability-related 
organizations to develop a high-quality set of competencies to be 
taught in a new support worker certificate program that expands 
supplies of quality workers to meet market demand in home- and 
community-based settings.
    D. Worker cooperatives should be piloted and tested with the 
assistance of the Departments of Agriculture, Labor, and HHS to explore 
improved consumer-caretaker relationships.
            6. Mandate Coordination and Collaboration Among Federal 
                    Agencies to Align Public Policy and Transform 
                    Infrastructure to Be Responsive to Consumer Needs 
                    and Preferences for a Comprehensive System of LTSS 
                    (Chapter 5)
    A. Although Medicaid and Medicare dominate the landscape of funding 
authorities for LTSS, NCD researchers documented the complexity and 
fragmentation of multiple systems with different rules of eligibility 
and lack of information on access to and availability of resources. The 
fragmentation and coordination challenges carry over from the executive 
to the legislative branches of government, in which different 
committees in the Senate have different controlling authority than 
committees in the House of Representatives. Although Program Assessment 
Rating Tool (PART) reviews by the Office of Management and Budget (OMB) 
are incorporating common performance measures across agencies and 
programs, there is no focus on cross-department and agency 
collaboration. The nature of LTSS requires more than 200 programs and 
20 agencies to improve their coordination of resources at the community 
level, where they will benefit the end-user. No single recommendation 
can respond to this significant challenge. NCD recommends that the 
appropriate agencies and congressional committees implement the 
following set of recommendations:
     Hold congressional hearings to evaluate possible options 
for improvement of multiple department collaboration to provide access 
to information and supports and services to meet the long-term needs of 
people with disabilities under and over age 65.
     Require the Department of Housing and Urban Development 
(HUD) and HHS to document current efforts and future plans to improve 
and expand the availability of affordable, accessible housing that is 
coordinated with services/supports, when needed. Establish an 
Interagency Council on Meeting the Housing and Service Needs of Seniors 
and Persons with Disabilities.\v\ (See chapter 6 for a description of 
the full role of the council.)
---------------------------------------------------------------------------
    \v\ Language added to U.S. Senate Bill, 109th Congress-S.B. 705 to 
include people with disabilities: Establish an Interagency Council on 
Meeting the Housing and Service Needs of Seniors, April 5, 2005, to 
include people with disabilities.
---------------------------------------------------------------------------
     Add to the PART performance criteria indicators that will 
evaluate documented outcomes from intra-agency and cross-agency 
collaboration to meet LTSS needs of people with disabilities. Consider 
possible financial incentives for agencies that document valued 
outcomes from LTSS system collaboration. Report annually to Congress on 
individual agency performance in this area.
     Issue a new Executive Order charging CMS to chair a time-
limited workgroup (six months) on LTSS that includes representation by 
HUD, HHS, the Social Security Administration (SSA), and the Departments 
of Education, Labor, Justice, Transportation, Treasury, and Agriculture 
to identify policy barriers and facilitators to an improved 
comprehensive, coordinated system of LTSS for people with disabilities 
under and over age 65 that maximizes interagency collaboration, 
promotes consumer direction, and increases consumer choice and access 
to affordable supports and services in home- and community-based 
settings.
            7. Improve and Hold States Accountable for Rebalancing 
                    Their Systems to Support LTSS (Chapter 5)
    A. Study states that are having success with a global budgeting 
approach to move their LTSS system from an institutional bias to be 
anchored by HCBS and home- and community-based supports.
    B. Develop a template in consultation with states to be used to 
evaluate and measure current expenditures for LTSS in institutional 
versus home- and community-based settings. Such a template would be 
developed jointly by CMS and CBO to allow for consistent, comparative 
benchmarking from year to year within and among states.
            8. Increase Understanding of the Possible Relationship 
                    Between an LTSS Insurance Product and Publicly 
                    Financed LTSS (Chapter 5)
    A. Congressional interest remains high to understand and explore 
further the possible relationship between the current market for long-
term care insurance products and a reduced dependence on Medicaid and 
Medicare for long-term support needs. With the growing cost of Medicaid 
and Medicare documented by NCD researchers, there is growing interest 
in forging a new level of partnership with the insurance industry that 
explores both the expansion of product options and the possible cost 
savings to the public system. For people with disabilities under age 
65, no such insurance product yet exists, and little is known about the 
risk factors in terms of potential utilization by the target population 
and how to achieve affordable pricing. Even with the adoption of 
several of the other major recommendations proposed in this report, it 
is unlikely that a revised Medicaid program will ever meet the needs of 
all people who are seeking LTSS.
    B. Conduct a feasibility study of possible new insurance products 
and options regarding relationship to the Medicaid program to evaluate 
possible strategies to partner an LTSS insurance product with 
supplementary Medicaid coverage for people with disabilities under age 
65. Consider price, benefit coverage, caps in coverage, and eligibility 
for Medicaid LTSS, and project market demand and needed incentives to 
share risk among stakeholders: the government, the consumer, and the 
insurance industry. The possible collaboration would include the 
assistant secretary for planning and evaluation (APSE) at HHS, CMS, and 
a private insurer.
    C. Pilot test such a product or products to evaluate cost benefits 
to all critical stakeholders. Such a pilot must recognize that LTSS 
must be individualized to accommodate the needs and desires of the 
individuals receiving assistance and that the services and supports 
must reflect consumer preference for noninstitutional settings. Such an 
insurance product must achieve several objectives: It must be 
affordable, flexible, responsive to consumer needs and preferences, and 
sustainable over time with federal oversight.
            9. Improve Consumer Understanding, Knowledge, and Skills to 
                    Develop a Person-Centered Plan and Self-Direct an 
                    Individual Budget (Chapter 5)
    A. The Cash and Counseling Demonstrations and the Independence Plus 
Waivers have produced early positive findings of increased consumer 
satisfaction with the self-direction of individual budgets, the 
selection of support providers, and increased choice in development of 
person-centered plans. Individuals with disabilities and their families 
should be given the opportunity to plan, obtain control, and sustain 
the services that are best for them in preferred home- and community-
based settings. For people with disabilities who have been given few 
choices in the past regarding services and supports and service 
delivery options, consumer self-direction requires information, 
education, and training to build the critical skills needed to make 
informed decisions.
    B. Access to information about service options, streamlined 
procedures for determining eligibility for various public benefits, and 
new infrastructure will need to be developed to assist with 
programmatic and financial management.
    C. Recommendations that recognize the principles of individual 
self-direction and responsibility for prudent and effective management 
of public resources are critical to the development of the LTSS system 
of the future.
    D. The system should continue to provide competitive grants that 
establish Aging and Disability Resource Centers (ADRCs) in all 50 
states that provide one-stop access to information and individualized 
advice on long-term support options, as well as streamlined eligibility 
determinations for all publicly funded programs.
    E. The system should establish, with funding from CMS, a National 
Resource Center on Consumer Self-Direction that identifies and 
disseminates best practice information on person-centered plan 
development, self-directed management of individual budgets, and 
examples of multiple funders combining funds within an individual 
budget to achieve common negotiated performance objectives.
    F. The system should require states, as part of their HCBS waiver 
implementation, to provide education and training to eligible Medicaid 
beneficiaries on effective and meaningful participation in person-
centered planning, management of individual budgets, and negotiation 
with service and support providers.
    G. The system should establish a cross-agency workgroup that 
involves CMS, the Administration on Aging (AOA), SSA, the 
Administration on Developmental Disabilities, HUD, the Office of 
Special Education and Rehabilitative Services at the Department of 
Education, and the Department of Labor to accelerate options for states 
to bundle and/or braid public funds within a self-directed individual 
budget with streamlined and accelerated eligibility procedures.
            10. Continue to Educate People with Disabilities, Their 
                    Families, and Other Critical Stakeholders About 
                    LTSS Challenges in Public Policy and Practice and 
                    Document Further Consumer Needs, Costs, and 
                    Preferences for a Comprehensive, Accessible, and 
                    Affordable System (Chapter 5)
    A. This report documents the current crisis and the impending 
``perfect storm.'' It is a complex and confusing picture, not easy to 
grasp and even more difficult to change as we move forward. NCD must 
continue to put the spotlight on the critical set of challenges that in 
the next 20 years may touch more than half the population of our 
country. For people with unmet LTSS needs today, NCD must continue the 
public education process through outreach activities and direct 
discussion with the disability community and policymakers.
    B. A series of audio conferences and a national summit of key 
leaders and stakeholders should be held to continue to document the 
findings and build consensus on possible policy and practical 
solutions.
Recommendations for Clean Slate Reform: Year 2049 (See Chapter 6 for 
        full text and implementation leads and future model)
            1. AmeriWell is a Prefunded, Mandatory, Long-Term Services 
                    and Support Model That Provides All Americans of 
                    Any Age with Coverage from Birth Based on Criteria 
                    of Risk and Functioning, and Not Category of 
                    Disability (Chapter 6)
    A. AmeriWell delinks LTSS from Medicaid and Medicare, creating its 
own governing agency, regulations, oversight, and congressional 
committee.
    B. The contributions of individuals and families, the private 
sector, and the Federal Government fund AmeriWell. A ``penny pool'' is 
established through private stock transactions to supplement LTSS costs 
for impoverished and vulnerable Americans previously served under 
Medicaid and Medicare.
    C. Medicaid remains a primary safety net for mothers and children. 
Medicare continues to provide its health and acute care and limited 
home services to individuals 65 and older who are not Medicaid eligible 
or on SSDI.
Livable Communities Report
            From NCD's November 2005 News Release:
    In 2004, NCD published its Livable Communities report. This report 
vividly showed how a variety of programs must work together efficiently 
in order to achieve a high quality of life for those they intended to 
benefit. As NCD's work and common experience make clear, it is no 
longer possible to look at housing in isolation from transportation, at 
employment separately from health care, or at income supports in old 
age apart from long-term services and non-cash supports. The challenge 
is to shape this growing awareness into processes that will fulfill the 
promise of coordinated planning and programming.
Livable Communities for Adults with Disabilities
    Publication Date: December 2, 2004.
    The complete version of this report is available at: http://
www.ncd.gov/newsroom/publications/2004/LivableCommunities.htm
Executive Summary
    For the promise of full integration into the community to become a 
reality, people with disabilities need safe and affordable housing, 
access to transportation, access to the political process, and the 
right to enjoy whatever services, programs, and activities are offered 
to all members of the community at both public and private facilities.
Introduction
    Communities in the United States are faced with increasingly 
difficult decisions about how to plan for change, and increase and 
improve the quality of life for adults with disabilities as well as 
elders who may develop disabilities as they grow older. People are 
living longer lives today than ever before and the population of people 
aged 65 and older is growing rapidly. By 2030, one in five people in 
the United States will be over the age of 65. Currently, more than 4.7 
million Americans aged 65 years or older have a sensory disability 
involving sight or hearing, and more than 6.7 million have difficulty 
going outside the home. As the population of elders grows, it is likely 
that the number of people aged 65 and older with disabilities also will 
grow, particularly among those 75 years of age and older.
    Adults with disabilities and elders want to live in their own homes 
as independently as possible for as long as possible. People want to 
live in supportive communities that encourage independence and a high 
quality of life. To facilitate independence, people often need the same 
kinds of services. In addition, people want to remain contributing 
members of the community. It makes sense, therefore, for the disability 
community and aging network--groups that traditionally work 
separately--to collaborate, align goals, and share resources to address 
the challenges and opportunities ahead.
    As the demographic profile of the United States changes, there will 
be an increased need for livable communities that support the needs and 
aspirations of people with disabilities and older adults. To meet this 
demand, three factors must be considered: (1) the elements of a livable 
community; (2) existing examples of livable communities in the United 
States today that can serve as models for others; and (3) how these 
communities develop and sustain livability features.
Framework of a Livable Community for Adults with Disabilities
    ``Livable community'' is a fluid term whose definition may change 
depending on the context and such considerations as community capacity, 
organizational goals, and the needs and desires of particular groups of 
citizens. For the purposes of this report, a Framework of a Livable 
Community for Adults with Disabilities was constructed to define the 
elements that need to be in place for a community to be considered 
livable for people with disabilities. It is clear, however, that the 
elements that make a community livable for people with disabilities 
make it a livable place for all members of the community. Thus, in 
improving its livability for one particular group of constituents, the 
community actually accomplishes considerably more.
    The Framework of a Livable Community for Adults with Disabilities 
is inspired, in part, by a similar framework developed for the 
AdvantAge Initiative, a project that helps communities measure and 
improve their ``elder-friendliness.''2 It was informed further by 
research on the concept of livability, results of recent surveys of 
people with disabilities, countless interviews with key informants and 
people with disabilities, and a focus group session involving people 
with disabilities aged 30 and older in Washington, D.C. Similar themes 
emerged from each of these activities and were synthesized into the 
framework. Thus, a Livable Community for Adults with Disabilities is 
defined as one that achieves the following:
     Provides affordable, appropriate, accessible housing
     Ensures accessible, affordable, reliable, safe 
transportation
     Adjusts the physical environment for inclusiveness and 
accessibility
     Provides work, volunteer, and education opportunities
     Ensures access to key health and support services
     Encourages participation in civic, cultural, social, and 
recreational activities
    Within each of these six areas, a livable community strives to 
maximize people's independence, assure safety and security, promote 
inclusiveness, and provide choice.
    While no one community in the United States has addressed all six 
of these livability goals to equal degrees, many states, counties, and 
local communities have made extraordinary improvements in their 
livability for people with disabilities in one or even several of these 
areas. Their experiences and achievements can serve as inspiration and 
provide replicable ``best practices,'' which other communities can 
emulate as they strive to become more livable.
Strategies and Policy Levers
    Community efforts profiled in this report have employed a variety 
of strategies and policy levers to (1) expand access to affordable 
housing, transportation, and employment opportunities; (2) make the 
built environment more accessible; (3) reconfigure health and support 
service delivery systems to be more in line with the needs of people 
with disabilities; and (4) promote the social and civic engagement of 
these communities.
    Nearly every initiative included in the report has depended, to one 
degree or another, on strategic partnerships that have worked together 
to achieve the following goals: (1) leverage resources, (2) reduce 
fragmentation in the service delivery system, (3) address consumers' 
needs in a coordinated and comprehensive manner, (4) provide choice, 
and (5) implement policies and programs that help people remain 
independent and involved in community life. To maximize the potential 
for success, communities should use one or more of the following 
strategies and policy levers as well as develop all-important 
partnerships. These strategies and policy levers can and should be used 
at every level of government--including federal, state, county, and 
local--to affect change in any of the areas included in the Framework 
of a Livable Community for Adults with Disabilities:
     Consolidate administration and pool funds of multiple 
programs to improve ease of access to, and information about, benefits 
and programs for consumers. This strategy is used to streamline 
operations, eliminate redundancies, and leverage resources.
     Use tax credits and other incentives to stimulate change 
in individual and corporate behavior and encourage investment in 
livable community objectives. This strategy is often used to stimulate 
affordable housing development, reduce tax burden on individuals, urge 
employers to hire people with disabilities, and encourage the private 
sector to make their businesses more accessible to elders and people 
with disabilities.
     Provide a waiver or other authority to help communities 
blend resources from multiple public funding streams to provide and 
coordinate different services. This is a common policy lever in the 
provision of coordinated health care and support services, allowing 
agencies to blend funding streams, increase the availability of home- 
and community-based services as an alternative to institutional care, 
and support comprehensive and consumer-directed care.
     Require or encourage a private sector match to leverage 
public funding and stimulate public-private sector partnerships. 
Several of the community initiatives profiled in the report depend on 
monetary or in-kind contributions from the private and nonprofit 
sectors for their continued existence.
    In addition to these strategies and policy levers, successful 
community initiatives often depend on the ingenuity and persistence of 
community members who are able to mobilize resources, generate 
excitement, and stimulate action in their communities on behalf of 
people with disabilities and the elderly.
Lessons Learned and Recommendations
    A number of lessons can be gleaned from the community initiatives 
described in this report, many of which can serve as recommendations to 
other communities that are planning to make greater livability a 
priority issue in their locales.
Provide Affordable, Appropriate, Accessible Housing
    People with disabilities, including the focus group participants, 
say that satisfaction with housing arrangements is the determining 
factor for remaining in or moving from their communities, and this 
satisfaction depends on two key factors: housing affordability and 
accessibility. ``With stable housing, people with disabilities are able 
to achieve other important life goals, including education, job 
training, and employment.'' 3 According to the Public Policy 
Collaboration, however, people with disabilities ``face a crisis in the 
availability of decent, safe, affordable, and accessible housing,'' 4 
and those with low incomes are the most likely to be affected by this 
shortage. One estimate says that as many as 1.8 million people with 
disabilities who receive Supplemental Security Income (SSI) benefits 
have severe housing problems.5
    Model community efforts profiled in this report, which have 
expanded homeownership and rental housing options for people with 
disabilities, have developed strong partnerships and collaborations 
between the affordable housing system and the disability community. 
These relationships ensure that the housing created will meet the needs 
and preferences of people with disabilities and/or elders. Additional 
priority action steps in the area of housing include the following: (1) 
providing incentives for developers to maintain existing affordable 
housing units and/or increase such stock; (2) providing tax credits to 
help individuals with disabilities and seniors remain in the homes 
where they currently live; and (3) expanding awareness and encouraging 
incorporation of universal design and accessibility features into 
existing or new housing stock.
Ensure Accessible, Affordable, Reliable, Safe Transportation
    According to the 2003 National Transportation Availability and Use 
Survey, about one in four individuals with disabilities needs help from 
another person and/or assistive equipment, such as a cane, walker, or 
wheelchair, to travel outside the home. Nearly 6 million people with 
disabilities have difficulty getting the transportation they need, 
because public transportation in the area is limited or nonexistent, 
they don't have a car, their disability makes transportation difficult 
to use, or no one is available to assist them. The survey also found 
that more than 3.5 million people in the United States never leave 
their homes, and more than half of the homebound are people with 
disabilities. Of these, more than half a million indicate that, because 
of transportation difficulties, they never leave home.6
    Providing accessible, affordable, reliable, and safe transportation 
is an enormous challenge to communities. To address this challenge, 
some states and counties have been thinking systemically. Priority 
action steps in the area of transportation include the following: (1) 
creating ``coordinated transportation systems'' that combine all the 
disparate transportation services and funding streams into one system 
that is more efficient, cost-effective, and universally accessible; (2) 
computerizing and centralizing dispatch systems to make on-demand 
transportation more efficient and less frustrating for consumers; and 
(3) exploring the use of new technology to help people with 
disabilities and the elderly navigate their community's thoroughfares 
and transportation options.
Adjust the Physical Environment for Inclusiveness and Accessibility
    Since the passage of the Americans with Disabilities Act (ADA), 
noticeable accommodations have been made in communities large and small 
to improve access for people with disabilities. In most communities, 
however, expanding access to the physical environment is still a work 
in progress. One of the greatest obstacles to improving access for 
people with disabilities is the expense associated with altering the 
built environment and making other needed accommodations. In addition 
to cost, in larger cities or towns, the sheer volume of work to be done 
causes delays in making necessary changes. In older communities where 
there are many historic structures that need to be retrofitted for 
accessibility, conflict sometimes arises between preservationists and 
disability advocates. An equally significant obstacle is lack of 
awareness among the public about the difficulties people with 
disabilities face as they try to negotiate the physical environment.
    Fortunately, there are many resources available at all levels of 
government to help communities address these and other obstacles to 
accessibility. Priority action steps in this area include the 
following: (1) increasing awareness among community members by 
providing them with sensitivity training so that they can experience 
first-hand the access problems people with disabilities face; (2) 
educating city planners and public officials about how lack of access 
affects elders and people with disabilities and what they can do as 
professionals to improve the situation; (3) advocating for variances to 
zoning ordinances to accelerate improved access to the built 
environment.
Provide Work, Volunteer, and Education Opportunities
    A fundamental principle of Title I of ADA is that people with 
disabilities who want to work and are qualified to work must have an 
equal opportunity to work. However, unemployment among people with 
disabilities remains unacceptably high. The 2004 National Organization 
on Disability (N.O.D.)/Harris Survey of Americans with Disabilities7 
shows that working-age adults with disabilities are half as likely as 
working-age adults without disabilities to be employed (35% versus 
78%), and people with severe disabilities are less likely to be 
employed than those with slight disabilities (21% versus 54%).
    Priority action steps to increase employment opportunities for and 
encourage the hiring of people with disabilities include the following: 
(1) using technology to facilitate education and training programs, to 
provide telework opportunities, and to match qualified job candidates 
with employers; (2) increasing awareness among community members about 
the value of employing people with disabilities; (3) setting an example 
by hiring people with disabilities for positions within government 
agencies; (4) helping businesses make reasonable accommodations for 
employees with disabilities by providing them with needed funding and/
or technical assistance; and (5) removing any remaining disincentives 
to work, such as the potential loss of health care, SSI, or other 
entitlements.
Ensure Access to Key Health and Support Services
    Results of a survey by the Henry J. Kaiser Family Foundation reveal 
that, despite their well above average use of health care services, 
individuals with disabilities face greater barriers to health care 
access than does the rest of the population.8 People with disabilities 
have trouble finding doctors who understand their disabilities and are 
less likely than the general population to receive the range of 
recommended preventive health care services. In sum, people with 
disabilities face a fragmented health care delivery system that does 
not respond to their wishes or needs.
    Priority action steps in the area of health care include the 
following: (1) designing health care systems that are consumer directed 
and provide care coordination to ensure that the right kind of care is 
provided to beneficiaries; (2) allowing ``money to follow the person'' 
to the most appropriate and preferred care setting to create a more 
equitable balance between institutional and community-based services, 
eliminate barriers to care, and provide consumers with choice over the 
location and type of services provided; (3) integrating the delivery of 
acute and long-term care services to provide ``seamless'' high-quality, 
consumer-centered, and continuous care across settings and providers, 
and (4) providing support services that are linked to housing to 
increase the availability and efficiency of service provision.
Encourage Participation in Civic, Cultural, Social, and Recreational 
        Activities
    According to the 2000 N.O.D./Harris Survey of Community 
Participation, overall, ``people with disabilities feel more isolated 
from their communities, participate in somewhat fewer community 
activities, and are less satisfied with their community participation 
than their counterparts without disabilities.'' 9 The survey attributes 
the lower rates of participation among people with disabilities, in 
part, to lack of encouragement from community organizations. A 
community can hardly be called livable for people with disabilities if 
the people are not involved in the community's civic, cultural, or 
social activities.
    The survey results suggest that it is not enough for community 
organizations to simply offer activities and provide information about 
them to people with disabilities. Thus the priority steps in this area 
include the following: (1) encouraging community organizations to 
actively reach out to people with disabilities to include them in 
activities, and (2) ensuring that people with disabilities have access 
to all of the opportunities that are offered to other members of the 
community.
    It is reasonable to assume that communities will always face 
financial and structural obstacles to becoming more livable for people 
with disabilities. Intangible obstacles, like the public's lack of 
awareness and understanding of the difficulties people with 
disabilities face in their communities on a daily basis, are perhaps 
even more pervasive and difficult to overcome. But, as the community 
examples in this report illustrate, where there is political will, 
there are many possible, creative ways to surmount obstacles that 
prevent communities from being more livable for us all.


                                 
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