[Senate Hearing 112-804]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 112-804

 
                             SENIOR HUNGER

                      AND THE OLDER AMERICANS ACT

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



                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                                   ON

        EXAMINING SENIOR HUNGER AND THE ``OLDER AMERICANS ACT''

                               __________

                             JUNE 21, 2011

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


      Available via the World Wide Web: http://www.gpo.gov/fdsys/





                  U.S. GOVERNMENT PRINTING OFFICE
82-326                    WASHINGTON : 2013
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001




          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
BERNARD SANDERS (I), Vermont
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
SHELDON WHITEHOUSE, Rhode Island
RICHARD BLUMENTHAL, Connecticut

                                     MICHAEL B. ENZI, Wyoming
                                     LAMAR ALEXANDER, Tennessee
                                     RICHARD BURR, North Carolina
                                     JOHNNY ISAKSON, Georgia
                                     RAND PAUL, Kentucky
                                     ORRIN G. HATCH, Utah
                                     JOHN McCAIN, Arizona
                                     PAT ROBERTS, Kansas
                                     LISA MURKOWSKI, Alaska
                                     MARK KIRK, Illinois
                                       

                      Pamela Smith, Staff Director

                 Lauren McFerran, Deputy Staff Director

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                 ______

                Subcommittee on Primary Health and Aging

                        BERNARD SANDERS, Vermont

BARBARA A. MIKULSKI, Maryland        RAND PAUL, Kentucky
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania   JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina         ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon                 LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island     MICHAEL B. ENZI, Wyoming (ex 
TOM HARKIN, Iowa (ex officio)        officio)

                Ashley Carson Cottingham, Staff Director

                Peter J. Fotos, Minority Staff Director

                                  (ii)




                            C O N T E N T S

                               __________

                               STATEMENTS

                         TUESDAY, JUNE 21, 2011

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health, 
  and Aging, opening statement...................................     1
Paul, Hon. Rand, a U.S. Senator from the State of Kentucky.......     3
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....     5
Hagan, Hon. Kay R., a U.S. Senator from North Carolina...........    49

                            Witness--Panel I

Greenlee, Kathy, Assistant Secretary, Administration on Aging, 
  U.S. Department of Health and Human Services, Washington, DC...     6
    Prepared statement...........................................     8

                          Witnesses--Panel II

Blancato, Robert, Executive Director, National Association of 
  Nutrition and Aging Services Program, Washington, DC...........    18
    Prepared statement...........................................    20
Gordon, Kenneth E., Executive Director, Area Agency on Aging for 
  Northeastern Vermont, St. Johnsbury, VT........................    25
    Prepared statement...........................................    27
Brown, Kay E., Director, Education, Workforce and Income 
  Security, Government Accountability Office, Washington, DC.....    29
    Prepared statement...........................................    31
Koren, Mary Jane, M.D., M.P.H., Vice President, Picker/
  Commonwealth Fund Long-Term Quality Improvement Program, The 
  Commonwealth Fund, New York, NY................................    38
    Prepared statement...........................................    39

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    AARP.........................................................    53
    Feeding America..............................................    55
    The Gerontological Society of America........................    60
    Hunger Free Vermont..........................................    60
    Meals on Wheels Association of America.......................    62
    An Overview of Senior Hunger in the United States, James P. 
      Ziliak & Craig Gundersen...................................    70
    Jeff Gordon, Inc., letter....................................    72

                                 (iii)



                             SENIOR HUNGER

                      AND THE OLDER AMERICANS ACT

                              ----------                              


                         TUESDAY, JUNE 21, 2011

                                       U.S. Senate,
                  Subcommittee on Primary Health And Aging,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:02 a.m. in 
Room 430, Dirksen Office Building, Hon. Bernard Sanders, 
chairman of the subcommittee, presiding.
    Present: Senators Sanders, Hagan, Franken, and Paul.

                  Opening Statement of Senator Sanders

    Senator Sanders. Good morning and welcome to a hearing of 
the Committee on Health, Education, Labor, and Pensions 
Subcommittee on Primary Health and Aging. Today's hearing is 
addressing a very important issue and I want to thank everybody 
for being here, especially our panelists.
    I don't have to tell anybody in this room that our country 
today faces some enormously serious problems, and one of them 
is that, in a time of severe recession, high unemployment, and 
increased poverty, how do we make certain that all of our 
people, especially the most vulnerable, those unable to take 
care of themselves, are able to maintain at least a minimal 
standard of living.
    In my view, the problem that we are discussing today, food 
security among seniors, is both a moral issue and it is a 
financial issue. So we're going to be going over both of those 
aspects of the problem this morning. From a moral perspective, 
it is clear to me that in this great Nation no one should go 
hungry, especially those who are old and frail and unable to 
take care of themselves. From a financial perspective, what is 
also clear--and we will hear testimony about this this morning 
from our panelists--is that investing in senior nutrition and 
in well-designed senior programs in general saves money. Let me 
repeat that: Saves money for the government, because when we do 
that, when we make sure that our seniors have adequate 
nutrition, among other things, at the end of the day those 
seniors are not going to be ending up in a emergency room, 
those seniors are not going to be ending up in a hospital when 
they should not be in a hospital, and in many cases they're not 
going to be ending up in a nursing home.
    I think one of the main points that I want to make this 
morning and we'll pursue with our panelists, is that investing 
in seniors, making sure that seniors have the nutrition that 
they need, is not only the right and moral thing to do; it is 
the financially smart thing to do.
    Today the situation in our country with regard to hunger 
among seniors is not anything that we should be proud of and is 
something that must be significantly improved. As the baby boom 
generation transitions into their senior years, an ever-
expanding number of our Nation's seniors grapple with issues of 
food insecurity and malnutrition. In fact, the hunger rates for 
lower income seniors have more than doubled in recent years.
    In the wake of the recession, there is a growing demand for 
both home-delivered and congregate meal programs, and there is 
evidence indicating that some of our poorest and most 
functionally limited seniors are simply not getting the 
nutrition they need.
    Sometimes here on Capitol Hill, in this beautiful room, it 
is hard to imagine that right now all over this country there 
are hundreds of thousands, if not millions, of seniors sitting 
alone, perhaps suffering from one or another degree of 
dementia, confused about the medications they are taking, not 
able to prepare the food that they need in order to take care 
of themselves. But that is a reality that is going on in our 
country and a reality that we as Americans have got to address.
    It is estimated today that 5 million seniors face the 
threat of hunger, 3 million seniors are at risk of hunger, and 
1 million seniors go hungry because they cannot afford to buy 
food. But in some cases it's not just money. In some cases it's 
having the transportation to get to the store. In some cases 
it's the ability to think through, when you're 85 or 90 and 
alone, what kind of food you need and how you purchase it.
    This issue is important again not only from a moral 
perspective, but from a financial one as well. Persistent 
hunger and malnutrition leads to multiple chronic diseases, 
resulting in extended hospital stays and premature nursing home 
placements. There are some studies out. They're not quite sure 
about what percentages of seniors today who are in nursing 
homes, and might not need to be in that expensive care, if they 
had good nutrition and somebody visiting them on a regular 
basis. That seems to me to be pretty dumb, not a good way to 
spend Federal money.
    Medicaid is paying for 70 percent of nursing home 
residents' care in this country. At a time when we face 
skyrocketing deficits, we must dedicate our efforts to funding 
and finding inexpensive preventative measures to deal with 
these issues. We, as a nation, do not do well with prevention. 
We waste huge sums of money by taking care of people at the 
end, at the end when they're in the hospital, when they're very 
sick, rather than keeping them from getting sick.
    In today's hearing we will also be discussing the simplest 
of common sense solutions, ensuring that older Americans have 
access to a prepared and nutritious meal. I have visited many 
senior centers in Vermont and I just want to thank--not just in 
Vermont, but all over this country, there are tens and tens of 
tens of thousands of volunteers who are driving their cars, 
delivering Meals on Wheels, taking care of seniors, doing all 
kinds of wonderful things as volunteers, and I want to make it 
clear that we are very, very appreciative of their efforts.
    Today we have a wonderful panel. We're going to take a 
comprehensive look at this issue, at the severity of the 
problem, what makes sense, common sense solutions to that 
problem. So I again want to conclude by thanking all of you for 
being here and thanking our panelists for the presentations 
they will shortly make.
    Now I'd like to introduce Senator Rand Paul.
    Senator Paul.

                       Statement of Senator Paul

    Senator Paul. Thank you, Chairman Sanders.
    As a physician who's cared for the elderly and impoverished 
patients, I have a very real and personal concern for those 
without the resources or the ability to provide for themselves. 
It would be a great burden and motivation on every American's 
heart that elderly individuals, however few, are in need. 
Ensuring that no senior citizen goes hungry is an important 
goal for our country. The consequences of malnutrition are 
devastating. In addition to personal hardships, senior hunger 
also costs taxpayers in the form of higher health costs.
    Unfortunately, it's not as simple as waving a magic wand of 
government and poverty's gone or hunger is gone. We've been 
doing this a long time, with some success and some failure. The 
Older Americans Act of 1965 was originally passed as part of 
LBJ's Great Society war on poverty. Since 1965 the Federal 
Government has invested over $51 billion in noninflation-
adjusted dollars in the Older Americans Act programs. We must 
ask ourselves, if government is capable of ending poverty for 
seniors why haven't we succeeded?
    We should ask if private charity is also capable of feeding 
the hungry and do government programs crowd out private 
charity? We should ask why we have 70 duplicate Federal 
programs for nutrition.
    Today we are focusing our discussion on senior hunger and 
nutrition services within the Older Americans Act. Nutrition 
programs make up $818 million out of the $2 billion spent on 
this program. We will be discussing multiple nutrition 
programs, including the congregate meals program, home-
delivered meals program, nutrition services incentive grants, 
etc. These programs are just a few of the dizzying array of 
Federal programs related to domestic food assistance.
    The GAO recently issued a report finding that there are 
over 70 duplicate programs, 70 duplicate Federal programs, 
dealing with nutrition. Eighteen of these duplicate Federal 
programs are primarily dealing with nutrition and six of these 
duplicate Federal programs are for seniors.
    We have a chart here that gives you an idea of how we do 
nutrition assistance. Like so much of government over the last 
several decades, we just add more to it. We've got program 
after program, a dizzying array, through this algorithm.
    We must ask, what if this program didn't exist tomorrow? 
Would people still get food from the government? Probably from 
69 other programs they'd get food. For example, what if we did 
food stamps, made the food stamps cover those that they're not 
covering, give the money to States, let the States administer 
it and get it to hungry people? It would be a heck of a lot 
simpler.
    The thing is that administration of programs, any program, 
is notoriously inefficient the farther it is away from the 
people. The closer it is to the people through the States, the 
more efficient the program is. We should feed hungry people, 
but we shouldn't feed people who have the resources to feed 
themselves. We should feed hungry people that private charity 
is not feeding, but we shouldn't feed hungry people that 
private charity is feeding.
    We should try not to duplicate ourselves? Why? Because we 
spend $2 trillion we don't have, so we're having to borrow 
money from China, borrow money from Japan, borrow money from 
Russia. The list goes on and on. We do not have unlimited 
resources, so we have to rethink what we've been doing for the 
last 50 years.
    We're in a big mess as a country. It doesn't mean we cannot 
help those who need help, but we should be helping only those 
who truly do need help.
    Are we advertising these services? How much money do we 
spend advertising? In my town there's somebody going all around 
the State, they're advertising in the newspaper. You know, if 
people need assistance, let them know where the assistance is, 
but do we have to promote the programs and have a promotional 
budget to promote the programs?
    But I think we need to simplify these things. As a whole, 
the government spent over $90 billion on food nutrition 
assistance in 2010. This isn't including Medicaid. We are 
spending an enormous amount of money and we need to spend it 
more wisely. We need to cut out the duplication.
    Meals on Wheels has a great history. My grandmother 
delivered Meals on Wheels to people for most of her adult life. 
When she could barely walk up the steps in Pittsburgh, she was 
still taking meals to others who she thought were less 
fortunate than herself.
    There are good programs, but we must ask how many of these 
programs can exist and might exist if we get the government out 
of their way. MIT researchers Jonathan Gruber and Daniel 
Hungerman have written an excellent paper finding that for 
every dollar of Federal spending, there was a corresponding 3 
percent reduction in charitable giving by the churches. Overall 
they found that government or Federal spending led to an 
overall 30 percent decline in charitable church giving.
    There are many great programs out there. For example, Wal-
Mart Foundation made a $2 billion commitment to hunger relief 
efforts in the United States through 2015, almost equal to 
these Federal programs.
    You have to ask yourself, if you had $100 who would you 
give it to? Would you give it to the Federal Government to say, 
``will you help some people with my $100,'' or would you give 
it to the Salvation Army or to a private charity that does a 
much better job, that's much more efficient, and gets people 
and does help people in your area, and you can go and see the 
help directly?
    You have to ask the difference also, is there a difference 
between charity, private charity, and the nobility of private 
charity, and then sort of the bureaucratic malaise of a 
transfer program that involves transferring wealth from one 
group to another.
    In the remarks that we will hear today, we will find out 
that only 13 percent of the people getting assistance from the 
OAA are said by the group who is making this determination, 
which may or may not be the most objective, that only 13 
percent of them would not be able to get this without OAA's 
assistance. In other words, 87 percent of them could, either 
through food stamps or through other programs or, since there 
really doesn't seem to be a financial indication for why you 
get this assistance, they could be affording to get their food 
on their own.
    The question is really, do we need duplicate programs? 
Should we not be trying to get rid of duplication at the 
Federal Government level? Should we not be simplifying these 
programs? Should we not be sending these programs back to the 
States so they can have better oversight, so we can have less 
bureaucrats in the middle, less overhead, and more efficient 
distribution of services?
    These aren't questions that are just philosophic questions. 
These are questions that have to and will have to be answered 
because we as a country are out of money and we cannot just 
keep adding on program after program.
    Thank you, Mr. Chairman.
    Senator Sanders. Thank you.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. I want to get to our witnesses and don't 
want to take too long, but make no mistake about it, the Older 
Americans Act saves money. It leverages money. It saves money. 
It allows seniors to stay in their homes who wouldn't otherwise 
be able to stay in their homes.
    So when we're talking about duplicative programs, Meals on 
Wheels and congregate dining aren't duplicative; they're part 
of the same program. Let's not get too confused here. I was a 
member of the Special Committee on Aging last Congress, and 
because I'm a member of the HELP Committee--I'd like to thank 
the chairman for holding today's hearing on this very important 
issue to Minnesota seniors and across the country, and the 
ability to participate--I'm not a member of this subcommittee, 
but I'm a member of the HELP Committee and I was a member of 
the Special Committee on Aging, and as such I asked my staff to 
start going around the State and doing listening sessions on 
the Older Americans Act, because I knew we were going to be 
reauthorizing it. And I personally have done six or seven. I 
did one this last weekend in Burnsville, MN, at a great place 
called Ebenezer Ridge's.
    I cannot tell you how important this is to those seniors. I 
would ask the Ranking Member, have you been to listening 
sessions with these seniors? Because--and I thank your 
grandmother for doing what she did. Your grandmother was 
volunteering.
    This is leveraging volunteers, and they are--Meals on 
Wheels is a wonderful program. I think we'll have witnesses 
speaking about what it costs to deliver Meals on Wheels. Your 
grandmother was probably reimbursed for travel.
    It is sometimes the only point of contact that these 
seniors have during the day and breaks their isolation and how 
many Meals on Wheels volunteers have found a senior in actual 
dire trouble and saved their lives?
    I love the volunteers that I've met in the listening 
sessions that I've done. I also loved the professionals who 
implement the program.
    What I'd like to emphasize is the actual savings that this 
program creates. There are seniors who are able to live in 
their homes as they would prefer, rather than have to go to a 
nursing home, and but for this program--but for Meals on 
Wheels, but for congregate dining, but for those who provide 
eldercare, many of whom are seniors themselves, like your 
grandmother, Senator Paul, who are very moving in their 
testimony, who say that this is a spiritual thing that they do, 
providing care for other seniors who need it--this is a program 
that saves and leverages money to save the Federal Government 
money, and it is a very successful program and I'm pleased to 
be participating in today's hearing.
    Senator Sanders. Thank you very much, Senator Franken.
    Now we're going to hear from our first witness. Kathy 
Greenlee is the Assistant Secretary for the Administration on 
Aging, U.S. Department of Health and Human Services. Assistant 
Secretary Greenlee served as Kansas's Secretary of Aging and 
State Long-Term Care Ombudsman. She also recently served on the 
board of the National Association of State Units on Aging.
    Ms. Greenlee, thank you very much for being with us this 
morning.

       STATEMENT OF KATHY GREENLEE, ASSISTANT SECRETARY, 
 ADMINISTRATION ON AGING, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                    SERVICES, WASHINGTON, DC

    Ms. Greenlee. Thank you, Chairman Sanders. It's good to see 
you again. I appreciate you holding the hearing. I also want to 
acknowledge Senator Paul. I'm very glad that your subcommittee 
is paying particular attention this morning to hunger, a very 
important subject.
    I would also like to say, ``hi'' to Senator Franken. I 
commend you. I know of the work that you've been doing in 
Minnesota as you've gone around the State to gather 
information, and I just want to thank you for that work as 
well.
    I appreciate the opportunity to testify at this hearing 
about hunger, the senior nutrition programs, and the Older 
Americans Act. The Older Americans Act plays a critical role in 
helping many of our most vulnerable seniors maintain their 
health, their well-being, and independence, avoiding more 
costly hospital or nursing home placement, as you mentioned, 
Senator Sanders.
    Hunger and food insecurity is a serious problem among many 
older Americans. Research that was sponsored by the Meals on 
Wheels Association found that nearly 6 million seniors faced 
the threat of hunger in 2007. We know that, through science-
based research, that adequate food and nutrition is vitally 
important for promoting health, decreasing the risk of chronic 
disease, maintaining functionality, and helping older adults 
maintain their independence at home and in their communities.
    The Older Americans Act nutrition programs have been one of 
the core elements of our national strategy for reducing food 
insecurity among the elderly for nearly 40 years. As you have 
mentioned, there are three different food programs that we 
administer at the Administration on Aging, three different 
strategies for dealing with senior hunger.
    One is the Congregate Nutrition Service. This provides 
meals in a group setting, such as senior centers. In my 
experience, many elected officials at every level are familiar 
with senior centers, have seen the valuable services that are 
provided, not just the food, but also other wellness and other 
activities, and companionship for seniors as they participate. 
In fiscal year 2009, more than 92 million meals were provided 
to nearly 1.7 million seniors in a congregate senior center 
setting.
    The second program is, of course, the home-delivered meals 
program. Some people know this as the Meals on Wheels program. 
Meals on Wheels is certainly a critical partner in our attack 
against senior hunger. There are also other home-delivered 
meals programs, and all of the meals programs that are 
providing to home-bound individuals do so to individuals who 
are home-bound due to illness, disability, or geographic 
isolation. The home-delivered meals is often the first in-home 
service that someone requests and serves as the primary access 
point to other critical home and community-based services.
    In fiscal year 2009, nearly 149 million home-delivered 
meals were delivered, 149 million, to more than 880,000 home-
bound individuals.
    Our third strategy and nutrition program, I think, is not 
as well known as the congregate meals or home-delivered. That's 
the Nutrition Services Incentive Program. This is an incentive 
program that is distributed based on performance the year 
before, number of meals served the year before. It gives the 
area agencies on aging and the meal providers access to 
commodities programs administered at the U.S. Department of 
Agriculture, either cash to purchase commodities or commodities 
themselves.
    It's important to note that our programs and the older 
adults who participate in these nutrition programs are low 
income, but income itself is not the only objective. It's not 
the only measure of need for nutrition services. We certainly 
target programs to people who are low income, but there are 
many seniors who are functionally impaired, meaning they can no 
longer drive to a grocery store, they can no longer physically 
carry their groceries, they can no longer see, they can no 
longer actually prepare the meal, which makes this program very 
different from a program that provides access to groceries. 
This is a program that provides access to prepared meals, 
because at some point many people can no longer cook for 
themselves. They have physical inability to prepare their own 
food.
    Our services through the Older Americans Act are targeted 
and they have always been meant to serve people who are older, 
poorer, more likely to live alone, more likely to be 
minorities, in poor health, in poor nutritional status, 
functionally impaired, and at higher nutritional risk.
    Our performance data indicates that the Older Americans Act 
programs are effective. Fifty-eight percent of congregate and 
ninety-three percent of home-delivered meal recipients say that 
the meals enable them to live in their communities longer. The 
majority of nutrition program recipients receive more than half 
of their total food intake for the day from our programs.
    As much as we love the nutrition program, I believe it's 
also important that in many instances nutrition alone is not a 
sufficient support. There are other individuals who need other 
kinds of support that we provide in order to help them maintain 
their health and stay out of hospitals and nursing homes.
    Older Americans Act programs help older Americans with 
severe disabilities remain independent. The programs are 
efficient and they build system capacity. For every Federal 
dollar the Older Americans Act funds, communities and States 
leverage nearly $3 in other funding.
    As a former Secretary of Aging in Kansas and finishing my 
second year as the U.S. Assistant Secretary for Aging, I have 
seen firsthand how these programs support the values we all 
share, supporting independence, maintaining health, helping 
people that are the most vulnerable among us, and providing 
respite care for families as they continue to take care of 
their loved ones.
    Chairman Sanders, I look forward to continuing to work with 
you as we talk about this program and other programs that we 
administer at the Administration on Aging, and to continue to 
engage with members of your committee as we talk about the 
reauthorization of the Older Americans Act.
    Thank you.
    [The prepared statement of Ms. Greenlee follows:]
                  Prepared Statement of Kathy Greenlee
    Thank you, Chairman Sanders, Ranking Member Paul, and members of 
the Subcommittee on Primary Health and Aging, for the opportunity to 
testify at this important hearing on hunger, senior nutrition programs 
and the role of the Older Americans Act (OAA) in helping some of our 
most vulnerable seniors maintain their health and well-being in their 
homes and communities, avoiding more costly hospital and nursing home 
care.
    Hunger and food insecurity is a serious problem among many older 
Americans. Research sponsored by the Meals on Wheels Association of 
America in 2008 found that nearly 6 million seniors faced the threat of 
hunger in 2007.\1\ Half of these at-risk seniors had incomes above the 
Federal poverty line. These individuals and households, at some time 
during the year, had difficulty providing nutritionally adequate and 
safe foods due to a lack of resources. Yet, study after study show that 
adequate food and nutrition is vitally important for promoting health, 
decreasing the risk of chronic disease, maintaining functionality, and 
helping older adults remain independent at home, and in their 
communities.
---------------------------------------------------------------------------
    \1\ ``The Causes, Consequences, and Future of Senior Hunger in 
America.'' James P. Ziliak, Ph.D., Gatton Endowed Chair in 
Microeconomics and Director of the Center for Poverty Research, 
University of Kentucky; Craig Gundersen, Ph.D., Associate Professor, 
Department of Human Development and Family Studies, Iowa State 
University. Sponsored by the Meals on Wheels Association of America. 
March 2008.
---------------------------------------------------------------------------
    OAA nutrition services programs have been one of the core elements 
of our national strategy for reducing food insecurity among the elderly 
for nearly 40 years. These vital community-based programs, which serve 
persons aged 60 and over, provide access to meals in a group setting or 
delivered to the home, a service that is not provided by other Federal 
nutrition programs.
    As currently authorized, OAA nutrition services programs include:

     Congregate Nutrition Services (Title III-C1): Provides 
funding for the provision of meals and related services in a variety of 
congregate settings, which help to keep older Americans healthy and 
prevent the need for more costly medical interventions. Established in 
1972, the program also presents opportunities for social engagement and 
meaningful volunteer roles, which contribute to overall health and 
well-being. In fiscal year 2009, more than 92 million meals were 
provided to nearly 1.7 million seniors in a variety of community 
settings.
     Home-Delivered Nutrition Services (Title III-C2): Provides 
funding for the delivery of meals and related services to seniors who 
are homebound due to illness, disability or geographic isolation. 
Established in 1978, home-delivered meals are often the first in-home 
service that an older adult receives, and serve as a primary access 
point for other home and community-based services. In fiscal year 2009, 
nearly 149 million home-delivered meals were provided to more than 
880,000 homebound individuals.
     Nutrition Services Incentive Program (NSIP) (Title III-A): 
Provides additional funding to States, Territories, and eligible tribal 
organizations that is used to provide meals. Funds are awarded to 
States and Tribes based on the number of meals served in the prior 
Federal fiscal year. States and Tribes have the option to purchase 
commodities directly from the U.S. Department of Agriculture with any 
portion of their award if they determine that doing so will enable them 
to better meet the needs of the older persons they serve.

    Although many of the older adults who participate in both the 
congregate and home-delivered programs are low-income, income alone is 
not an adequate measure of need for nutrition services. Many of the 
recipients of this assistance are functionally impaired, meaning that 
they may not be able to drive to a grocery store, carry their 
groceries, stand for even short periods of time, or they may have hands 
that are too affected by arthritis to prepare a meal. In other words, 
provision of groceries is not sufficient to eliminate food insecurity 
and hunger in this population.
    In sum, each year the OAA nutrition services programs help more 
than 2.5 million older adults, many of whom are functionally impaired 
and are at risk of serious health consequences, receive the meals they 
need to stay healthy and decrease their risk of disability.
    OAA Nutrition Programs Effectively Target Those With Special Needs. 
The OAA does not require that all people be served, nor is it means 
tested, but it does require that services be targeted. The OAA 
nutrition programs are generally targeted to those with the greatest 
levels of food insecurity, including those who are poor or near poor, 
socially isolated, functionally impaired, and in poor health. Serving 
Elders at Risk, a national evaluation of the Administration on Aging's 
(AOA) nutrition program clients, found that recipients of this 
assistance are older, poorer, more likely to live alone, more likely to 
be minorities, in poorer health and nutritional status, more 
functionally impaired, and at higher nutritional risk than older 
individuals in the general population.\2\
---------------------------------------------------------------------------
    \2\ Serving Elders at Risk--National Evaluation of the Elderly 
Nutrition Program, 1993-95, pp. 117-18.
---------------------------------------------------------------------------
    Based on data gathered through fiscal year 2009 and via the 2009 
National Survey of Older Americans Act program participants, we know 
the following about the participants in the OAA nutrition programs:

    For the home-delivered meals programs:

     4 percent are in poverty and 52 percent are at high 
nutritional risk;
     24 percent do not have enough money or food stamps to 
purchase enough food to eat;
     63 percent rely on their home-delivered meal for one-half 
or more of their total food for the day;
     17 percent report they choose between purchasing food and 
medications;
     55 percent of white, 63 percent of African-American and 38 
percent of Hispanic home-delivered meal participants report their 
health as fair to poor.

    For the congregate meals programs:

     34 percent are in poverty and 19 percent are at high 
nutritional risk;
     13 percent do not have enough money or SNAP benefits to 
purchase enough food to eat;
     58 percent rely on their congregate setting meal for one-
half or more of their total food for the day;
     27 percent of white, 38 percent of African-American and 26 
percent of congregate meal participants report their health as fair to 
poor.

    AOA's annual performance data further demonstrate that these 
programs are an efficient and effective means for helping seniors 
remain healthy and independent in their homes and in the community. 
Ninety-one percent of home-delivered meal clients rate service as good 
to excellent. In addition, the number of home-delivered meal recipients 
who have severe disabilities (those with three or more impairments of 
activities of daily living) totaled more than 357,000 in fiscal year 
2009. This level of disability is frequently associated with nursing 
home admission, and demonstrates the extreme frailty of a significant 
number of persons served by the home-delivered meals program.
    Additionally, data from AOA's 2009 national survey of elderly 
program participants show that the nutrition services programs are 
effectively helping seniors improve their nutritional intake and remain 
at home: 73 percent of congregate and 85 percent of home-delivered meal 
recipients say they eat healthier meals due to the programs, and 58 
percent of congregate and 93 percent of home-delivered meal recipients 
say that the meals enabled them to continue living in their own 
homes.\3\
---------------------------------------------------------------------------
    \3\ 2009 National Survey of Older Americans Act Participants. 
http://www.data.aoa.gov, select AGID.
---------------------------------------------------------------------------
    For the majority of program participants, the program provides more 
than one-half or more of their total food intake and enables them to 
continue living in their own homes.
    AOA continues to build upon the successes of the senior nutrition 
programs and further increase their effectiveness by implementing a 
multi-year, comprehensive evaluation. In addition to providing detailed 
information on how the nutrition programs currently operate at the 
State and local levels, the evaluation is designed to measure the 
programs' effects on food insecurity and hunger, social isolation and 
the health and well-being of program participants. AOA is working with 
the Centers for Medicare and Medicaid Services (CMS) to identify an 
appropriate comparison group of non-participants and measure healthcare 
utilization and cost. The evaluation will answer how and why program 
results are achieved.
    The OAA nutrition programs are a good investment in reducing food 
insecurity. To help address hunger and food insecurity among older 
Americans during the economic downturn, $100 million in funding was 
provided as part of the American Recovery and Reinvestment Act of 2009 
to the OAA senior nutrition programs. Since March, 2009, this 
supplemental funding has provided more than 22 million meals to help 
combat food insecurity among more than 1.1 million older Americans.
    The nutrition programs help to support family caregivers, who 
provide most of the care for older adults. The provision of a home-
delivered meal, which includes not only a meal, but also a mid-day 
contact, may allow a family caregiver to continue to work and provide 
care for a loved one in the morning before work and in the evening. 
Home-delivered meals provide a critical service as a part of a formal 
comprehensive and coordinated service system that individualizes care 
for older adults and their families.
    Congregate meals provide a daily social interaction that is also a 
gateway to volunteer opportunities and civic engagement, other home and 
community-based services, and a meal that promotes health and reduces 
the risk of chronic disease. Nutrition services are not simply access 
to food, but to a system that meets social service, health, and food 
security needs.
    Nutrition services are but one component of a larger system of both 
formal and informal supports authorized by the OAA that help older 
individuals maintain their health at home and out of hospitals and 
nursing facilities. In fiscal year 2009, nearly 11 million older 
Americans and their family caregivers have been supported through the 
OAA's comprehensive home and community-based system. These services 
include: transportation; case management; information and referral; in-
home services such as personal care, chore, and homemaker assistance; 
community services such as adult day care; support for family 
caregivers; protections against elder abuse; nursing home ombudsmen who 
serve as advocates for residents of long-term care facilities; legal 
assistance; pension counseling and assistance programs; prevention and 
reporting of waste, fraud and abuse in the Medicare and Medicaid 
programs, and a host of other supports that are tailored to meet 
individual needs.
    This nationwide network of community-based assistance complements 
medical and health care systems, helps to prevent hospital re-
admissions, provides transport to doctor appointments, and supports 
some of life's most basic functions, such as assistance to elders in 
their homes by delivering or preparing meals, or helping them with 
bathing.
    This assistance is especially critical for the nearly three million 
seniors who receive intensive in-home services, half a million of whom 
meet the disability criteria for nursing home admission but are able to 
remain in their homes, in part, due to these community supports. An 
analysis of the OAA's program data reveal that, through fiscal year 
2009 (the most recent year data are available), most indicators have 
steadily improved.

     OAA programs help older Americans with severe disabilities 
remain independent and in the community: One approach to measuring the 
value of OAA's programs is the newly developed nursing home predictor 
score. The components of this composite score are predictive of nursing 
home admission based on scientific literature and AOA's Performance 
Outcome Measurement Project (POMP) which develops and tests performance 
measures. The components include such items as percent of program 
recipients who are transportation disadvantaged and the percent of 
congregate meal individuals who live alone. As the score increases, the 
prevalence of nursing home predictors in the OAA service population 
increases, meaning AOA is reaching those most in need of help. In 2003, 
the nursing home predictor score of program participants was 46.57. In 
fiscal year 2009, this score increased to 61.0.
     OAA programs are efficient: The national aging services 
network--comprised of 56 State and territorial units on aging, 629 area 
agencies on aging, 246 Indian tribal and native Hawaiian organizations, 
nearly 20,000 direct service providers, and hundreds of thousands of 
volunteers--is providing high-quality services to the neediest elders, 
and is doing so in a prudent and cost-effective manner. AOA and the 
national aging services network have significantly increased the number 
of persons served per million dollars of OAA funding. Without 
controlling for inflation, OAA programs have increased efficiency by 
over 36 percent between fiscal year 2002 and fiscal year 2009, serving 
8,524 clients per million dollars of funding in fiscal year 2009 
compared to 6,103 clients served per million dollars of AOA funding in 
fiscal year 2002. This increase in efficiency is understated, since the 
purchasing power of a million dollars in 2009 is significantly less 
than in 2002 due to inflation.
     OAA programs build system capacity: One of the main goals 
of OAA program funding is to encourage and assist State agencies and 
area agencies on aging to concentrate resources in order to develop 
greater capacity, and foster the development and implementation of 
comprehensive and coordinated systems. This capacity-building at the 
State and community level is evidenced by the fact that for every 
dollar of Federal OAA funding provided, States and communities leverage 
nearly $3 in other funding from other sources.

    Taken as a whole, AOA's performance measures and indicators form an 
interconnected system of performance measurement akin to the three legs 
of a stool (efficiency, outcomes and targeting) holding up AOA's 
mission and strategic goals that include:

    1. Empowering older people, their families, and other consumers to 
make informed decisions about, and to be able to easily access, 
existing health and long-term care options;
    2. Enabling seniors to remain in their own homes with a high 
quality of life for as long as possible through the provision of home 
and community-based services, including supports for family caregivers;
    3. Empowering older people to stay active and healthy through Older 
Americans Act services and the preventative care benefits under 
Medicare;
    4. Ensuring the rights of older people and prevent their abuse, 
neglect and exploitation; and
    5. Maintaining effective and responsive management.

    As the former Secretary of Aging in Kansas, and now having the 
honor to serve as the U.S. Assistant Secretary for Aging and listening 
to individuals and families in a variety of settings, I have seen 
firsthand how the OAA reflects the American values we all share:

     Supporting freedom and independence;
     Helping people maintain their health and well-being so 
they are better able to live with dignity;
     Protecting the most vulnerable among us; and
     Providing basic respite care and other supports for 
families so that they are better able to take care of loved ones in 
their homes and communities for as long as possible, which is what 
Americans of all ages overwhelmingly tell us they prefer.

    For more than a year, we have received reports from more than 60 
listening sessions held throughout the country, and received online 
input from interested individuals and organizations, as well as from 
seniors and their caregivers, about the reauthorization of the OAA. 
This input represented the interests of thousands of consumers of the 
OAA's services. We continue to encourage ongoing input and discussions.
    During our input process we were consistently told that, as it is 
currently structured, the OAA is very helpful, flexible and responsive 
to people's needs. We also heard a few themes, I will mention two 
today:

    FIRST: Improve program outcomes by:

     Embedding evidence-based interventions in disease 
prevention programs;
     Encouraging comprehensive, person-centered approaches;
     Providing flexibility to respond to local nutrition needs; 
and
     Continuing a strong commitment to efforts to fight fraud 
and abuse.

    SECOND: Remove barriers and enhancing access by:

     Extending caregiver supports to parents caring for their 
adult children with disabilities;
     Providing ombudsman services to all nursing facility 
residents, not just older residents; and
     Using Aging and Disability Resource Centers as single 
access points for long-term care information to public and private 
services.

    Let me give three brief examples of areas we would like to discuss 
as you consider legislation:

     Ensuring that the best evidence-based interventions for 
helping older individuals manage chronic diseases are utilized. These 
have been effective in helping people adopt healthy behaviors, improve 
their health status, and reduce their use of hospital services and 
emergency room visits.
     Improving the Senior Community Service Employment Program 
(SCSEP) by integrating it with other seniors programs. The President's 
2012 budget proposes to move this program from the Department of Labor 
to the Administration on Aging at HHS. We would like to discuss 
adopting new models of community service for this program, including 
programs that engage seniors in providing community service by 
assisting other seniors so they can remain independent in their homes, 
while also continuing to support community organizations that rely on 
SCSEP participants for their valuable work contributions.
     Combating fraud and abuse in Medicare and Medicaid by 
making permanent the authority for the Senior Medicare Patrol Program 
(SMP) as an ongoing consumer-based fraud prevention and detection 
program--and by using the skills of retired professionals as volunteers 
to conduct community outreach and education so that seniors and 
families are better able to recognize and report fraud and abuse.
    The Older Americans Act has historically enjoyed widespread, 
bipartisan support. One of its great strengths is that it does not 
matter if an individual lives in a very rural or frontier area, or in 
an urban center--the programs and community-based supports it provides 
are flexible enough to meet the needs of individuals in diverse 
communities and settings. Based in part upon the extensive public input 
we received, we believe that the reauthorization can strengthen the OAA 
and put it on a solid footing to meet the challenges of a growing 
population of seniors, while continuing to carry out its critical 
mission of helping elderly individuals maintain their health and 
independence in their homes and communities. We look forward to working 
with this subcommittee as the reauthorization process moves forward.
    Thank you again, Chairman Sanders and members of the subcommittee 
for your leadership on these important issues and for your invitation 
to testify today. We look forward to working with this subcommittee as 
the reauthorization process moves forward. I would be happy to answer 
any questions.

    Senator Sanders. Ms. Greenlee, thank you very much for your 
testimony.
    Let me begin the questioning in two ways. No. 1, it seems 
to me that if we provide nutrition, if we provide 
socialization, if we are monitoring the well-being of people 
who are frail and elderly, that at the end of the day we save 
money by keeping people out of the emergency room, out of the 
hospital perhaps, out of nursing homes. Is that true?
    Ms. Greenlee. Yes, sir. Our evidence shows that to be true.
    Senator Sanders. Do you want to comment on that in general? 
Why does it in your judgment make sense to invest in these 
programs as a way in fact to save Federal money at a time of a 
huge deficit?
    Ms. Greenlee. Almost every person as they age will need 
supports of some sort to remain independent. The data shows 
between two-thirds and 75 percent of all of us will need help 
to stay independent. As I said in my testimony, often the first 
type of support that's requested is nutrition. But there are 
other supports that individuals need. By and far--by 
overwhelming evidence, the least expensive place to deliver 
services is in someone's home. People will need services. 
Staying in the home is least expensive.
    The Older Americans Act programs are far more effective and 

efficient than a Medicaid home and community-based waiver or 
very expensive congregate care, such as a skilled nursing home. 
They are a good investment. As you mentioned, it's also what 
people want. I think the fiscal policy and the people policy 
are aligned to support in-home services.
    Senator Sanders. Let me stay on that theme. My 
understanding is that there are many seniors who are in nursing 
homes today 
because they are not able to get the nutrition they need if 
they stayed at home. Is that your understanding?
    Ms. Greenlee. Senator, yes, but I'd like to qualify and 
expand your statement. As you said in your opening, lack of 
nutrition often leads to other chronic disabling conditions. 
What we find is that people who have multiple chronic 
conditions, disabling conditions, are more likely to enter a 
nursing home. It's a contributing factor among other 
contributing factors that leads to frailty and poor health, 
which is a predeterminant for nursing home admission.
    Senator Sanders. Let me ask you this. Can you give us a 
rough estimate as to how many seniors today as we speak are not 
getting the nutrition that they need?
    Ms. Greenlee. Senator, I've seen some recent studies that I 
could provide your staff--I think we have--that shows the 
amount of food insecurity varies by State, from as much as 12 
percent of seniors in a State to as little as 3 percent of 
seniors in a State. There are millions and millions--the 
numbers I have seen are 8 or 9 million--seniors who are without 
food, food insecure.
    But there are also increasing categories that expand from 
there, to people who have instability and inability to get 
food. There are many, many million seniors who don't have 
enough to eat or have access to the resources.
    Senator Sanders. Let me stop at that point. Senator Paul.
    Senator Paul. Thank you for your testimony, Ms. Greenlee. 
In your testimony you cite that only 13 percent of participants 
in the congregate meals program don't have enough money or food 
stamps to purchase enough food to eat. I guess the converse of 
that is 87 percent of the participants that you're helping 
already have enough money to buy their own food?
    Ms. Greenlee. Senator, we do find that the people who 
participate in congregate meals usually have more resources, 
are less frail. All of the people who participate, both home-
bound and in the congregate, are encouraged to provide 
contributions, and our total client contributions for the meals 
programs always exceeds on average more than the third program 
that I mentioned. $170 to $180 million a year we get from 
seniors themselves as we encourage them to participate, and 
most do.
    Senator Paul. Meals on Wheels originally was a private 
program?
    Ms. Greenlee. Not to my understanding, Senator. It was 
passed in the 1972 amendments to the Older Americans Act.
    Senator Paul. Actually, I think there were originally Meals 
on Wheels programs that were private and relied on private 
funding from churches and other groups. There was an example 
actually in the 1980s from the Twin Cities area, Meals on 
Wheels of Benton Harbor, MI. After operating for 4 years with 
small monthly deficits offset by charitable donations, the 
program was forced to close once a duplicate OA program 
siphoned off half of its clients. Meals on Wheels was operating 
on people paying for their meals and OAA came in with free 
meals and competed actually with the private Meals on Wheels 
program.
    I think there is some crowding-out phenomenon. The other 
thing is we all have sympathy for the elderly. I mean, we're 
all going to be old some day and we hope that there will be 
someone there to help us. Is part of your eligibility 
questioning--I guess income is not part of the eligibility?
    Ms. Greenlee. That's correct, it's not a means-tested 
program.
    Senator Paul. Eligibility is not dependent on whether any 
of your family members live near you? You don't ask them if 
their daughter lives down the street or anything like that?
    Ms. Greenlee. No, sir, I don't believe that's done.
    Senator Paul. I mean, I would think that the thing is that 
if three of your kids live in town and one's a doctor, one's a 
lawyer, and one's an accountant, maybe they ought to help you 
before the taxpayer helps you. These are just common sense 
things, if I ran a welfare program in my little town in 
Kentucky, that I would ask. I would also probably ask if you've 
got a million dollars in the bank.
    It's the same way when you go to a nursing home. Sure we 
have sympathy for people, but should the government be the 
first one lining up so the kids can get the million dollars 
that granddad has?
    So there's a lot of things. These questions have to be 
asked. You should ask, and if you want to help people who 
cannot help themselves by all means let's do it, but let's help 
them with one program. Let's not have program after program 
after program, and let's not have a program that helps 87 
percent of people who can help themselves. We can't afford it.
    Basically, this is a small program with regard to Federal 
programs, but it's still $818 million that we don't have. We've 
got to borrow it from somewhere. We've got to pay interest to 
China to borrow this money. It's not really a matter of whether 
or not we have sympathy. We all have sympathy. We just have 
different ideas of how to go about addressing the sympathy.
    While I want to help people, I want to also have programs 
that ask questions: Do you have money in the bank, do you have 
kids that could be doing this? And is the government replacing 
the idea of what families should do? Is government replacing 
the idea of what charities should do? These are fundamental 
questions and not idle questions, in the sense that we have to 
ask these questions because we're out of money.
    Do you have a comment?
    Ms. Greenlee. Yes, sir, I have a couple of comments, both 
with regard to your statement and your opening comment. Two 
things I would suggest as we talk about duplication and the 
value of this program, that I'd be glad to work with you on for 
consideration. Of the various Federal programs that provide 
food assistance to seniors, this is the only one that provides 
prepared meals. I think that's an important component to 
understanding the value of the program.
    The second observation that I have is that the structure of 
this program from the Federal level to the local level is very 
different from any other Federal program that I'm aware of. We 
have a very small Federal agency that administers money 
directly to the States and the territories, 250 tribal 
organizations, 650 area agencies on aging, providing services 
to thousands of providers and tens of thousands of volunteers. 
It's a pyramid, and the broad base is the community.
    The design of the Older Americans Act for this program and 
all the other services is community integration to support 
faith organizations and other local organizations. It was never 
designed to be an entire and overwhelming Federal response to 
nutrition, but an important component of a Federal ally, which 
is what I believe we have demonstrated that we are.
    Senator Sanders. Thank you, Senator Paul.
    Senator Franken.
    Senator Franken. Let me ask you about this, because again 
I've done a lot of listening sessions around the State of 
Minnesota and so many testified to the effect of this program 
in allowing people to stay in their homes. There are other 
parts of the Older Americans Act--respite care you mentioned, 
which is relieving a daughter who is taking care of a parent 
who is staying in the home and the daughter is taking care of 
her dad or her mom who is very old and would have to go into a 
nursing home were it not for the daughter taking care of her or 
him. And then there's respite care, like 4 hours a week of 
respite care that actually makes it possible for this child to 
do this. That keeps a parent out of a nursing home.
    I think that, Senator Paul, you should understand the 
leveraging here and what this does, what this program does, 
because if it weren't for this program we'd have to borrow more 
money from the Chinese.
    Let me ask you this. Would it be cost-efficient for the 
Older Americans Act to hire bureaucrats to track down daughters 
and sons who live within--what mile radius would it be 
effective? Would it be a 3-mile radius? Would it be a 5-mile 
radius? Would we have to put rules and regulations in order?
    How would you do that? Do you think that would be cost-
effective, if the Older Americans Act got into hiring a big 
bureaucracy to find out exactly how much each senior who is 
trying to stay in their home, what resources they had available 
to them? How would you do that?
    Ms. Greenlee. Senator, if I can make a couple of points. 
Eighty percent of the long-term care in this country is 
provided by the family. That has not ever changed. There are 
always family members around, at least for most people that are 
fortunate. Eighty percent have family support.
    The Older Americans Act was not designed to be a means-
tested entitlement program. It was always designed to be 
flexible and to provide only the services that an individual 
needed at that point in time and as they became more frail.
    We have met those targets. We have reached people who are 
older, who are poorer. We have reached a higher percentage of 
people of color than the average population and people in worse 
health. So we know that the targeting is effective, that we can 
get to the people for whom the services are best designed.
    We do not do a comprehensive assessment in order to give 
people eligibility for services. We target the services to the 
people who most need them instead.
    Senator Franken. Do you think other programs in the Federal 
Government can learn from the Older Americans Act and from what 
you guys do?
    Ms. Greenlee. Certainly, because I think this is a cost-
effective way to help provide supports. It's a light touch 
rather than a huge Federal program. It provides the supports 
that someone needs. We actually are the people who have always 
done house calls, who go to someone's home and make an 
assessment and give them just that amount of support.
    Senator Franken. Well, I so compliment what you do. I again 
believe that this is a program that saves the taxpayers money 
by leveraging what you do and by allowing seniors to stay in 
their home, which they want to do. And if not for your program, 
they wouldn't be able to.
    So I would only recommend to members of our body who aren't 
familiar with the Older Americans Act to do some research 
actually on the ground in their States, instead of relying on 
statistics provided for them by various groups, and to actually 
see this as it works on the ground, because I can't tell you 
how inspiring it is, not only to see the help that is provided, 
but to hear from those people who you are leveraging, the 
volunteers, what it means to them and how it keeps them 
involved--many of them are seniors--and what they get out of 
it.
    It is a program that is a pyramid and at the bottom is the 
community. And I want to thank you for your work.
    Ms. Greenlee. Thank you, Senator.
    Senator Sanders. Thank you, Senator Franken.
    Senator Paul.
    Senator Paul. I had one follow-up question. I think it's 
curious that only in Washington can you spend $2 billion and 
claim that you're saving money. Here's a thought: Perhaps the 
$2 billion we spend on OAA, if we subsumed that into another 
program and didn't spend it, that might be saving money. But to 
simply say that we're taking money and saving money that would 
be spent otherwise--I think the idea or notion that spending 
money in Washington somehow is saving money really kind of 
flies past most of the taxpayers.
    Now, what I would say, though, is that--or the question I 
actually have is, with food stamps can you buy these home-
delivered meals, Ms. Greenlee?
    Ms. Greenlee. I always think of food stamps as primarily 
buying groceries, but I'm understanding----
    Senator Paul. Apparently you can.
    Ms. Greenlee [continuing]. You can buy some home-delivered 
meals.
    Senator Paul. You can. The USDA fact sheet in your binder 
says that you can take food stamps and you can buy home-
delivered meals. So if the sole purpose of this is to have 
prepared meals and nobody else is providing them, we could 
privatize Meals on Wheels and let food stamps buy the thing and 
save $2 billion, and then we really would be saving money.
    Thank you.
    Senator Sanders. Let me just make a comment and maybe ask 
you a question. Senator Paul has suggested that only in 
Washington can people believe that spending money actually 
saves money. I think that is the kind of philosophy which 
results in us spending almost twice as much per person on 
health care as any other country on Earth. Because we have 
millions and millions of Americans who can't get to a doctor on 
time, some of them die, some of them become very, very ill. 
They end up in the emergency room, they end up in the hospital, 
at great cost, rather than making sure they have access to a 
doctor.
    The point is--and I think we have a bit of a difference 
here--I believe--I think Senator Franken has spoken to the 
fact--that prevention, keeping people healthy, taking care of 
their needs at home, does actually save money; and that if you 
deny those resources you're leaving a senior citizen home today 
alone, isolated, confused about medicine, not getting the 
nutrition they need, you know what happens to that person? That 
person collapses. That person ends up in emergency room, that 
person ends up in a nursing home, at much greater cost to the 
system.
    My own belief is, Ms. Greenlee, we have got to do a lot 
more. Our goal should be that no senior in this country goes 
hungry, that we do everything that we can to keep seniors out 
of nursing homes and in their own homes if that's what they 
choose by making sure that we have people visiting them, making 
sure they're doing well with their medications, making sure 
that they're getting the nutrition and the food that they need.
    I happen to believe that intelligently investing in the 
needs of our people does in fact save us substantial sums of 
money.
    Ms. Greenlee, yes.
    Senator Franken. I just want to say one thing. I want to 
make it very narrow, very narrow. Does the Older Americans Act 
save the American taxpayer money by allowing--and I'm going to 
say it as clearly as I can, because I don't think this is--I 
think Minnesotans understand this, and when I was in 
Minnesota--and again, I would urge any Senator who has their 
doubts about this to actually go to a senior center and 
actually go on the ground and ask about this.
    Here is my very precise question: Does the Older Americans 
Act save taxpayers money by allowing seniors to stay in their 
homes, as opposed to going to nursing homes?
    Ms. Greenlee. Yes, Senator.
    Senator Franken. Thank you. Do you want to expand on that?
    Ms. Greenlee. I guess my expanded answer would be that I 
believe the program from the very inception was designed to 
target outreach to individuals who were most at risk for spend-
down to Medicaid and most at risk for nursing home admission, 
and everything that we can do to help invest in the community 
and less expensive services, help people stretch their own 
assets, help people avoid Medicaid, is a wise investment, 
because once they receive Medicaid services, regardless of 
their setting, they're much more expensive.
    Senator Franken. Are there people in actual other places 
besides Washington, DC, that understand that, like in the 
States where this is administered?
    Ms. Greenlee. I think in Kansas we have figured that out, 
yes.
    Senator Franken. Yes. In Minnesota, too.
    Senator Sanders. Senator Paul wanted to make another 
comment.
    Senator Paul. I appreciate the great and very, I think, 
collegial discussion, and we do have different opinions. Some 
of us believe more in the ability of government to cure 
problems and some of us believe more in the ability of private 
charity to cure these problems.
    I guess what I still find curious is, though, that if we 
are saving money with the $2 billion we spend, perhaps we 
should give you $20 billion. Is there a limit? Where would we 
get to--how much money should we give you in order to save 
money? So if we spend Federal money to save money, where is the 
limit? I think we could reach a point of absurdity.
    Thank you.
    Senator Franken. I think you just did.
    Senator Sanders. I would suggest, Senator Paul, that when 
you have seniors in this country who are dealing with food 
insecurity who are not getting the nutrition that they need, my 
guess is that the government is wasting substantial sums of 
money by not taking care of those seniors, who will end up in 
emergency rooms, in hospitals, and in nursing homes.
    So you asked that question. My answer is I don't want to 
see one senior in this country go hungry. It's the morally 
right thing to do, and from a fiscally conservative point of 
view saving government money in my view, it is the right thing 
to do.
    Thank you very much for your testimony.
    Ms. Greenlee. Thank you. Thank you, Senators.
    Senator Sanders. If we can have our second panel.
    Let me thank all of the panelists for being with us. Each 
and every one of you are working hard on this issue and we 
appreciate the work that you do.
    Let's begin with Robert Blancato. Mr. Blancato is the 
executive director of the National Association of Nutrition and 
Aging Services Programs. Mr. Blancato is also the national 
coordinator of the Elder Justice Coalition and was appointed by 
President Clinton to serve as executive director of the 1995 
White House Conference on Aging. He was subsequently appointed 
to serve on the Policy Committee for the 2005 White House 
Conference on Aging.
    Mr. Blancato, thank you very much for being with us.

  STATEMENT OF ROBERT BLANCATO, EXECUTIVE DIRECTOR, NATIONAL 
     ASSOCIATION OF NUTRITION AND AGING SERVICES PROGRAMS, 
                         WASHINGTON, DC

    Mr. Blancato. Thank you, Chairman Sanders, Senator Paul, 
Senator Franken. Thank you for the opportunity to testify. My 
name is Bob Blancato, executive director of the National 
Association of Nutrition and Aging Service Programs.
    We appreciate this first hearing being focused on the 
nutrition programs, the largest and most visible in the Older 
Americans Act, serving 2.6 million older adults daily with more 
than 236 million meals each year. Next year we celebrate their 
40th anniversary. This year we want to see these programs 
strengthened, their dollars protected, and continue to achieve 
their three purposes: reduce hunger and food insecurity, 
promote the health and well-being of older individuals, and 
promote socialization to prevent isolation.
    Senior hunger is a growing reality. The Leadership Council 
of Aging Organizations estimates hunger among older people 
increased by 20 percent in the past decade. The Meals on Wheels 
Foundation says there were nearly 6 million seniors facing the 
threat of hunger in 2007. Feeding America estimates 3 million 
food-insecure older adults. The American Dietetic Association 
Journal notes 2.5 million older Americans are at risk of 
hunger. And an AARP paper notes that between 2006 and 2008 the 
number of poor and near-poor older adults, who did not know 
where their next meal would come from, doubled, from 5 to 10 
percent.
    The Older Americans Act is one solution as the largest 
national food and nutrition program specifically for older 
adults. One in ten in the congregate program today has more 
than three IADLs, which can be a precursor to a senior going 
hungry.
    The second purpose is to promote the health and well-being 
of older adults. The dangers of poor nutrition are well-
documented. Risks include premature nursing home admission and 
increased and longer stays in hospitals. Eighty-seven percent 
of older adults have one or more of the most common chronic 
diseases: hypertension, coronary heart disease, and diabetes. 
In those aged 45 to 64, diabetes alone more than triples the 
risk of nursing home admission. These three diseases can be 
prevented or treated through access to appropriate nutrition 
services. The Older Americans Act is one solution. Its meals 
must and do provide at least one-third of the dietary reference 
intakes for older adults. In about 60 percent of participants 
this meal is one-half or more of their total food for the day, 
and for minority older adults the percentage is even higher.
    Further, more than one-third of home-delivered meals 
participants today have three or more limits of activities of 
daily living, which is a precursor for nursing home placement. 
Each day they remain in the home-delivered program, we 
potentially save money in Medicare and Medicaid.
    The final purpose of this act is to promote socialization, 
to try and prevent isolation and loneliness.
    Nutrition programs run well because of the millions of 
hours of service provided by volunteers, which in turn produce 
savings. Almost 25 percent of seniors in the CSET program help 
other seniors, mostly in nutrition and senior center programs.
    But these programs are in tough shape today. Based on a 
survey we did, higher energy, especially gas, and food prices 
and loss of volunteers is causing cutbacks in services. Wayne 
County, MI, just started its first waiting list in 31 years. 
Fiscal year 2012 funding for nutrition programs must grow above 
fiscal year 2011 levels. If not, there will be real 
consequences involving our most vulnerable older adults.
    Let me offer a few recommendations for the reauthorization: 
A 5-year extension with sufficient authorization levels to 
allow the programs to meet current and future need. Let's add 
seniors susceptible to hunger into the targeting language which 
directs resources to the neediest older adults. Let's protect 
our nutrition dollars, rethink the existing transfer authority, 
since almost $40 million came out of nutrition for other 
services, some not related to nutrition. We cannot afford that 
any more.
    Let's enhance the current flexibility in how local 
decisions are made about funds used in the nutrition program, 
but preserve the integrity of the separate, congregate, and 
home-delivered meal program. Let's have a nutrition resource 
center to improve the work in the field. Let's provide greater 
access to fresh fruits and vegetables and greater flexibility 
for meal planning to reflect cultural considerations.
    Let's integrate the aging network, especially nutrition 
providers, into the community-based care transition programs 
that are evolving.
    Finally, let's increase the opportunities for communities 
to serve meals to seniors and children in community facilities.
    I have more in my written statement of recommendations. But 
let me put a face on this issue to close with. Theresa is 83 
years old. She went to a congregate program when she became a 
widow. She became a volunteer, has been in the program now for 
17 years. A 68-year-old man in the congregate program for 7 
years that has allowed him to stretch his dollars and still get 
prescription drugs that he needs. Mary at 92 is home-bound, has 
vertigo, and cannot stand up to cook, and she's been receiving 
home-delivered meals for 6 years. Claudette, age 67; her 
husband had a heart attack. Home-delivered meals for him allows 
her to continue to work.
    Mr. C was at San Antonio senior center since August 2010. 
He was well-dressed and engaged with others. Suddenly, a 
dramatic decline in his appearance. Staff asked and he admitted 
he was now homeless, living in his car. He was connected to 
adult protective services and now lives in an apartment, has 
gained 8 pounds, and has his friends and a safe haven.
    The Older Americans Act nutrition programs are all about 
value, to those it serves and to the volunteers who work in its 
program. An emerging value is how much it has and will save 
Medicare-Medicaid costs in the future.
    A final thought: The act enjoys a long and bipartisan 
history in this body and in the House. We hope it will 
continue. Take time to visit the nutrition programs in your 
State and see for yourself why this is such a good investment 
that provides countless returns.
    Thank you.
    [The prepared statement of Mr. Blancato follows:]
                 Prepared Statement of Robert Blancato
    Chairman Sanders, Senator Paul, thank you for the opportunity to 
testify before your subcommittee. My name is Bob Blancato and I am the 
executive director of the National Association of Nutrition and Aging 
Services Programs, NANASP. We are a national membership organization 
representing community-based providers of congregate and home-delivered 
nutrition services for the elderly as well as other professionals in 
the aging network.
    Our more than 600 members along with many others in the national 
aging network, including registered dieticians, appreciate your 
dedicating this first Older Americans Act hearing to the nutrition 
programs. They are the largest and most visible programs in the act. 
They operate in every State. They serve more than 2.6 million older 
Americans daily with more than 236 million nutritious meals served each 
year. A critical component--whether the meal is delivered to one's home 
or served at a congregate site--is the daily personal contact with the 
older adult.
    Nutrition services in the Older Americans Act include the 
congregate and home-delivered meals programs along with NSIP, the 
Nutrition Services Incentive Program. Congregate meal programs operate 
in a variety of sites, such as senior centers, community centers, 
schools, and adult day care centers. Besides meals, services include 
nutrition screening and education and nutrition assessment and 
counseling as appropriate. The program also presents opportunities for 
social engagement and meaningful volunteer roles, which contribute to 
overall health and well-being. Home-delivered meals provide meals and 
related nutrition services to older individuals that are homebound. 
Home-delivered meals are often the first in-home service that an older 
adult receives, and the program is a primary access point for the other 
home and community-based services. NSIP provides additional funding to 
States, Territories and eligible Tribal organizations that is used 
exclusively to purchase food, and may not be used to pay for other 
nutrition-related services or for State or local administrative costs. 
States may choose to receive the grant as cash, commodities or a 
combination of cash and commodities.
    Next year, we will celebrate the 40th anniversary of the signing 
into law of the Nutrition Program for the Elderly Act as the 1972 
amendments to the Older Americans Act. Our goal for the 2011 
reauthorization process is making the nutrition programs stronger, by 
protecting its Federal dollars and ensuring the programs address all 
three of its main purposes which are to:

    1. Reduce hunger and food insecurity;
    2. Promote the health and well being of older individuals by 
assisting them to access nutrition and other disease prevention and 
health promotion services to delay the onset of adverse health 
conditions resulting from poor nutritional health; and
    3. Promote socialization, community service and prevent isolation 
of older individuals.

    Before we look to the future, we find nutrition programs across the 
country confronting tough times because of this economy. A recent 
survey we did of our membership indicated that for any of them, either 
rising gas or food prices is causing cutbacks in services and is 
contributing to loss of volunteers. I was informed that Wayne County, 
MI was recently forced to start its first waiting list for home-
delivered meals in 31 years.
    It was only 2 years ago when the Older Americans Act nutrition 
programs received an additional $100 million from the ARRA bill when 
the programs were confronting these same challenges. We can readily see 
the challenges have not gone away. It is critical that fiscal year 2012 
funding for the OAA nutrition programs be allowed to grow from fiscal 
year 2011 levels or else there will be real consequences involving 
older and frailer adults.
    Returning to the purposes, the first of which is to reduce hunger 
and food insecurity, I testified at a Senate Special Committee on Aging 
hearing on this topic in March 2008. The crisis of food insecurity 
continues. The terms used to describe the crisis include hunger, food 
insecurity, food insufficiency and malnutrition. No matter what term is 
used, it is harmful to the older person it impacts.
    The Leadership Council of Aging Organizations (LCAO) estimates that 
hunger among older persons increased by 20 percent in the past decade. 
The Meals on Wheels Association of America Foundation states that as of 
2007, there are nearly 6 million seniors facing the threat of hunger, 1 
million more than in 2001. Another estimate from Feeding America 
indicates there are 3 million food insecure seniors in the United 
States. According to an article in the March 2010 Journal of the 
American Dietetic Association, about 2.5 million older Americans are at 
risk of hunger and 750,000 suffer from hunger due to financial 
constraints. A brief issued by the Food Security Institute of the 
Center on Hunger and Poverty at Brandeis University indicates that 
national estimates of food insecurity among older Americans range from 
5.5 to 16 percent. A more recent study on hunger among older adults in 
New York City done by the Council of Senior Centers and Services points 
to a 35 percent rate of food insecurity. Separate work done by the U.S. 
Department of Agriculture points to especially high rates among those 
ages 60 to 64. This is important since eligibility for Older Americans 
Act title III programs is 60. In addition, the USDA Food Insecurity 
Report found that 884,000 households with older persons living alone 
are food insecure and older persons living alone represents one of the 
fastest growing populations in our Nation.
    The important point is that while the Older Americans Act is not 
the only solution; it remains the largest national food and nutrition 
program specifically for older adults. Also, according to the American 
Dietetic Association (ADA), these programs reach less than one-third of 
older adults in need of its program and services. Those it reaches tend 
to live alone, tend to be minorities and tend to have two or more 
chronic health problems. These are all elements along with lack of 
transportation and living in food deserts of what are the common causes 
of hunger among older adults.
    In addition, according to AOA data, more than one out of every 10 
seniors served in the congregate program have more than three 
impairments of activities of daily living (IADLs) which can be a 
precursor to a senior going hungry since two of the most commonly 
reported limitations is the inability to cook meals or shop. The number 
climbs to over 70 percent for home-delivered meal program participants.
    A fundamental outcome of the reauthorization must be to better 
target the resources of the nutrition program to ensure it is reaching 
those older Americans most susceptible to hunger.
    What does hunger and food insecurity mean to our Nation and the 
Federal Government? It means that older adults who are malnourished and 
often isolated are more likely to end up with more expensive and 
unnecessary hospital and nursing home stays. It means more doctor 
visits, home health care and other services. It also means we are 
letting members of our greatest generation suffer in their golden 
years.
    The second purpose of the nutrition programs is to promote the 
health and well-being of older individuals to delay the onset of 
adverse health conditions which can lead to placement in nursing homes 
and long-term care facilities.
    Consider that 87 percent of older adults have one or more of the 
most common chronic diseases--hypertension, coronary heart disease and 
diabetes. According to a 2006 American Medical Association article, in 
those aged 45-64, diabetes more than tripled the risk of nursing home 
admission.
    According to the ADA, these three common chronic diseases are 
preventable or treatable in part through access to appropriate 
nutrition services including meals, nutrition screening and assessment, 
counseling and education.
    Again, the OAA nutrition programs are not the only solution but the 
meals it provides every day must provide at least one-third of the 
Dietary Reference Intakes for older adults.
    As we look to reauthorize the OAA, we should consider the potential 
cost savings that could be achieved for Medicaid and Medicare if we 
invest more in programs like the nutrition programs. According to the 
AOA 2009 State Program Reports on Home-delivered Meal Clients, the 
average percent of clients who have three or more ADL (Activities of 
Daily Living) impairments is 35.19 percent and in West Virginia and 
Iowa the percentage exceeds 80 percent. Having three or more ADLs is 
normally a precursor for being admitted to a nursing home. The 
difference in cost between a home-delivered meal and a day in a nursing 
home is dramatic. If we are able to keep these individuals in their 
homes, we will achieve genuine savings. An investment in the nutrition 
programs today most certainly can produce a strong return on the 
investment in terms of savings to Medicare and Medicaid in the future.
    The final purpose of the nutrition programs is the promotion of 
socialization of older individuals. When older adults tell us stories 
about the importance of the congregate nutrition program, they tell it 
in the context of the program providing nourishment for the body and 
the soul. One of the fastest growing segments of the older population 
is those who live alone. In fact, according to AOA, 48 percent of all 
women over the age of 75 now live alone. The OAA nutrition program 
provides seniors, especially those who live alone, with an opportunity 
to interact each day with other older adults. This can help to avert 
greater isolation and loneliness for these older adults.
    There are many other outstanding cost-savings outcomes from the 
Older Americans Act nutrition programs. The programs are targeted to 
the older person in their own communities. They rely very heavily on 
volunteers who commit millions of hours of service which mean millions 
of dollars in savings. In addition, the nutrition programs have a 
critically important relationship with low-income seniors employed by 
SCSEP (Senior Community Service Employment Program) which do their 
community service work in nutrition programs. In fact in the case of 
one of the larger national SCSEP contractors, Senior Service America, 
24 percent of all the community service hours were in service to the 
elderly with about half of these hours being provided to senior centers 
and nutrition programs.
    The programs provide more than just a meal. Programs include 
engaging and actionable nutrition education programs intended to 
educate and inform older adults on how best to ensure proper nutrition 
when they are not at the programs.
    This reauthorization is important to both strengthening the core 
service programs in the act as well as to modernize the act for the 
future. In addition to our call for a 5-year reauthorization of the act 
with sufficient authorization levels to allow the program to meet 
current and future needs, we recommend the following:

     Protect nutrition dollars. It is time to rethink the 
transfer authority currently in the statute. The authority has been a 
one-way street. Most all of the money transferred comes from one 
program, the congregate nutrition program. Based on fiscal year 2009 
data, more than $78 million was transferred out of the congregate 
program. Half of this went for the home-delivered meals program. We 
think that is appropriate so communities can direct their nutrition 
programs to where older adults need them. The other half went for title 
III B services. Some, but not all of these funds were used to support 
services not related to nutrition. That has to change. In these 
difficult fiscal times, we cannot afford to take $39 million in funds 
intended for nutrition and have them go elsewhere. Only services that 
relate directly to nutrition, including transportation or senior 
centers should be funded under the transfer authority. Otherwise the 
transfers between B and C should be eliminated entirely.
     As the Leadership Council of Aging organizations 
recommends, we should enhance the current flexibility in the allocation 
of senior nutrition program funding in local communities while 
preserving the integrity of the separate congregate and home-delivered 
meals programs.

    Additional recommendations, some of which are included in the 
Leadership Council of Aging Organizations (LCAO) 2011 OAA Consensus 
Document include:

     Building the link between nutrition and health, and 
establish a set aside of funds under title III D for nutrition-related 
evidence-based health promotion programs.
     Authorize a Nutrition Resource Center that will identify 
ways to increase cost-effective food and nutrition services in home and 
community-based social and long-term care systems serving older adults. 
We see this as a public private partnership.
     Better enforce existing law that State Units on Aging 
solicit the expertise of a registered dietitian and work to have more 
RDs on the staff of SUAs.
     Provide greater access to fresh fruits and vegetables 
through senior farmers markets, urban gardening and farm-to-table 
programs.
     Promote greater flexibility for meal planning including 
cultural considerations and preferences while maintaining current 
requirements on meal requirements being met.
     Look for and provide support for best practices in 
nutrition programs that have succeeded in recruiting and retaining 
first wave boomers who are at risk for malnutrition in addition to 
existing clientele.
     Invest in the opportunity to use title III C funds not 
only to serve the current population in need but also to transform 
congregate home-delivered nutrition services to meet the nutrition 
needs of the burgeoning numbers of older individuals seeking to remain 
healthy in their communities.
     Improve data collection in the title III C nutrition 
programs, particularly measures of unmet need, such as waiting lists. 
Currently, according to a report by the National Health Policy Forum, 
data on the unmet need for nutrition services are elusive and national 
data on waiting lists does not exist.
     Better recognize the essential role of transportation in 
the provision of nutrition services.
     Develop through language a stronger role for the nutrition 
programs to aid in the fight against elder abuse, especially in the 
areas of education, raising awareness and helping to detect and report 
elder abuse.

    In addition, NANASP supports:

     Aging and Disability Resource Centers (ADRCs)-nutrition 
screening questions and routinely making appropriate referrals for full 
nutrition assessments for those determined to be at nutritional risk.
     A study that can determine how many seniors who are served 
by the act are at risk of being institutionalized without the nutrition 
program, determine the savings to Medicaid and based on this evidence 
then direct a portion of the dollars saved to be reinvested in the OAA. 
It is possible that some of this information might be included in the 
ongoing evaluation of the nutrition programs being conducted by AOA. 
The exact parameters of this proposed study could await the release of 
the evaluation.
     Build the capacity of and funding for the Native American 
Nutrition Programs in order to better strengthen their ability to serve 
the complex and urgent needs of elders in Indian Country.
     In advance of the 2012 reauthorization of the Farm bill, 
consider conducting joint hearings with the Agriculture Committee on 
the nutrition programs in each act that benefit older adults and work 
for better coordination.
     Expand the definition of nutrition education to include 
screening, assessment and counseling and extend this education to 
caregivers of older adults served by the OAA.
     Finally, we recognize that one of the more promising 
elements of the Affordable Care Act is the Community Based Care 
Transitions Program to support community-based organizations partnering 
with eligible hospitals to help patients safely transition between 
settings of care. A commitment of $500 million was announced recently 
by HHS. We believe some of these community-based organizations should 
be from the existing aging network in programs which feature nutrition 
services which are viewed as being important to a successful transition 
of care from a hospital back to the community.

    We hope this subcommittee might consider a broader hearing that 
could examine approaches that could strengthen the aging network's 
future role, responsibility and resources in home and community-based 
care, especially through the Medicaid program.
    The success of the OAA nutrition programs is often best captured by 
what seniors themselves say. I have recently obtained a few of these 
stories either by visiting a program or through those sent in by NANASP 
members.
    This first story was provided by our NANASP President Paul Downey:

          San Diego, CA--Peggy Shannon, 63, was laid off from her job 
        as an administrative assistant during the economic downturn in 
        2008. It was the first time since she turned 16 that she was 
        without a job. Eventually her unemployment ran out forcing 
        Peggy to take early retirement (with penalty) which put her 
        income at about $850--below the Federal Poverty Level. She made 
        drastic cuts in spending and was having to choose between 
        paying for medications or food. Peggy was extremely worried 
        about having regular, nutritious, meals because of her severe 
        diabetes. The stress of the situation caused her to lapse into 
        a deep depression where she isolated herself in her apartment 
        and cried most of the time. Her deep pride and embarrassment 
        over her situation prevented her from reaching out to family 
        and friends.
          Finally, in desperation with her blood sugar at dangerous 
        levels, she came to Senior Community Centers for food after 
        reading an article about the agency's new Gary and Mary West 
        Senior Wellness Center. The center serves two meals per day, 
        365 days per year. Peggy began coming every day for the food 
        and to have her blood sugar levels checked by the facility's 
        nurse. Because of her limited income, Peggy was not able to 
        make the donation for the meals. She insisted on ``paying'' for 
        them by volunteering to assist with clerical work. That led to 
        her becoming an active member of the Civic Engagement program 
        where she mentors other seniors facing similar challenges. It 
        also connected her with one of the Senior Community Centers' 
        collaborative partners, San Diego State University, which 
        provides interns and faculty in the West Center. Peggy was able 
        to secure a job working 15 hours a week for SDSU.
          Peggy emphatically states that Senior Community Centers saved 
        her life and credits the meals for motivating her to come in 
        for help. This is a classical it is ``more than just a meal'' 
        story.

    Another story I was told by an I&R/A (Information and Referral/
Aging) specialist from Wayne County, MI when I presented at the annual 
conference of the Alliance of Information and Referral Systems (AIRS). 
She found a voicemail on a Monday morning from an 88-year-old man who 
had left the message on a Sunday. He said he needed food, had no 
friends or family and only had enough food to last the day. The 
response on Monday was to provide him with a chore worker who could go 
to the grocery store, but the man's condition worsened and an ambulance 
was called. The man ended up first in the hospital and after 3 days, a 
doctor's recommendation was to transfer the man to a skilled nursing 
home. According to the I&R/A specialist, if the man ``had access to 
this crucial service, he may have had a better chance at avoiding 
placement in a skilled nursing facility.''
    The I and R specialist also noted, ``Then to show how older people 
through voluntary contributions value the nutrition programs comes this 
hand written note just signed Meg.''

          I have been in rehab for 2 months after falling and 
        fracturing my hip so I have lost contact with the outside world 
        almost. My husband said he had 3 pickups but he did not give me 
        the paper that accompanied the delivery. If I have shortchanged 
        you on this check, I apologize and will catch up on the next 
        check.

    Another story provided by one of our members involved an 87-year-
old man who had normally called once a month for transportation 
services so he could come to town and pay his bills. On his most recent 
call he said ``I don't think I am long for this world.'' When asked 
why, the man said he was starving. He was invited to the congregate 
site and initially showed up weighing 109 lbs but standing 6 feet tall. 
He finally agreed to attend the center three times a week during which 
time he was advised of other benefits for which he might be eligible. 
According to the program director,

          ``The congregate meal program helped to improve the man's 
        nutritional health; however, it did much more by opening the 
        door to so many other benefits that will continue to benefit 
        him and help him to live independently. He is more than just 
        units of service provided and dollars spent. His life has been 
        forever changed.''

    I appreciate the opportunity to present this testimony and these 
testimonials on the value of the Older Americans Act and especially its 
nutrition programs. That is the story of this act throughout its 
history. It is about the value it provides to those it serves. It is 
about the value of the volunteers who work in the program and perhaps 
most importantly; it is about the value it represents to our present 
and future Federal budgets. The Older Americans Act enjoys a long 
bipartisan history in this body and in the House. We hope that can 
continue to allow a strong reauthorization bill to be enacted which 
does more than just extend the program but also modernizes it to meet 
today and tomorrow's needs.

    Senator Sanders. Thank you.
    Mr. Blancato. Thank you very much, Mr. Blancato.
    Our next panelist is Ken Gordon. I have known Ken for many, 
many years. Ken is the executive director of the Area Agency on 
Aging for Northeastern Vermont, what we call the Northeast 
Kingdom, which is in fact one of the most rural and lowest 
income areas in the State of Vermont.
    Ken serves on the boards of the Community of Vermont 
Elders, the Northeastern Vermont Regional Hospital, and the 
National Association of Area Agencies on Aging.
    Mr. Gordon, thanks very much for being with us.

STATEMENT OF KENNETH E. GORDON, EXECUTIVE DIRECTOR, AREA AGENCY 
      ON AGING FOR NORTHEASTERN VERMONT, ST. JOHNSBURY, VT

    Mr. Gordon. Thank you, Chairman Sanders, Ranking Member 
Paul, and members of the subcommittee, for the opportunity to 
testify today. I am honored to be able to speak on behalf of 
those who depend upon the senior meal programs authorized by 
the Older Americans Act and the thousands of staff and 
volunteers who make these programs possible.
    My name is Ken Gordon. I do serve as the executive director 
for the Area Agency on Aging for Northeastern Vermont. We're a 
small nonprofit organization serving older adults in Vermont's 
remote Northeast Kingdom. While the back country of Vermont is 
beautiful, it's a difficult place to grow old. The winters are 
harsh, food and fuel costs are high, and, like elsewhere in the 
country, senior hunger remains a vexing problem.
    The disturbing reality we face is that hunger is a growing 
problem among seniors, affecting nearly 6 million older adults 
each year. The seniors who are served by this program have 
worked hard throughout their lives. They've paid taxes, they've 
responded to the call for military service, they've volunteered 
in their communities, and they've made possible the quality of 
life that we all enjoy today. And now, at the end of their 
lives, they are struggling to make ends meet.
    Increasingly, we see many seniors being forced to choose 
between paying for food, fuel, rent, or prescription medicines. 
Seniors on fixed incomes are particularly vulnerable, as food 
is often the first expense to be cut when prices rise.
    In Vermont and across the country, Older Americans Act 
nutrition programs play a critical role in combating senior 
hunger. In 2008, the act's nutrition programs served over 240 
million meals to approximately 2.6 million older adults and 
family caregivers. These programs work well because they are 
collaborative in nature. Participants contribute according to 
their means. Donors provide supplemental funding. State and 
local governments match Federal dollars. Churches and other 
community groups allow the use of their facilities, and 
volunteers provide much of the labor that makes these programs 
so successful.
    One of our senior meal recipients, a 92-year-old widow and 
retired teacher from St. Johnsbury, VT, by the name of Maybell 
Peck, has described the home-delivered meals she received as a 
real lifesaver, and for many, many people across the country 
they are precisely that. Senior meals provide life-sustaining 
nutrition for hundreds of thousands of older adults each day. 
Without this service, many seniors would be left hungry and 
alone. Often these programs provide the only true meal of the 
day for many older adults.
    The volunteers and staff who deliver these meals also 
perform a valuable check-in service to ensure the safety of the 
senior and are sometimes the only human contact that the senior 
may have all day.
    It is absolutely critical that we invest in these programs 
as they serve as an important lifeline for some of the most 
vulnerable, isolated, and frail people living in our 
communities.
    Ms. Peck also told us that the meals give her a sense of 
power, and in many respects these meals do empower older adults 
to remain living at home. The programs help older adults and 
family caregivers to remain in control of their own lives. They 
help the Medicare and Medicaid programs to avoid the cost of 
unnecessary hospital care and nursing home placements, and they 
serve as the foundation upon which our Medicaid waiver home and 
community-based care programs rest. They also serve an 
important role in the management of chronic disease.
    While the Older Americans Act nutrition programs have made 
a meaningful difference in the quality of life for millions of 
older Americans, the programs face enormous challenges and are 
operating under extraordinary stress. Demand for these 
programs, particularly in the category of home-delivered meals, 
has grown significantly in recent years. Funding for these 
programs has not increased in relation to the sharp rise in 
food and fuel costs we have all experienced, nor has it 
reflected the increased demand that these programs are 
contending with.
    In response to these challenges, additional Federal support 
for the act's Federal nutrition programs is vital. Greater 
flexibility within the act to develop innovative approaches to 
service delivery and that provide the flexibility to address 
local priorities is also critical to sustaining these programs.
    Last, while the Older Americans Act nutrition programs 
address a critical need, in the view of many they represent 
something far more important. They reflect the sacred 
obligation that many of us learned early in our lives to honor 
and respect our elders. These are the people that made our 
lives possible and whose labor and sacrifice led to the quality 
of life that we all enjoy today. Collectively, we share in the 
obligation to ensure that our elders' basic needs are met and 
that our country's senior citizens are able to live their lives 
with the independence and dignity that all Americans deserve.
    Thank you.
    [The prepared statement of Mr. Gordon follows:]
                Prepared Statement of Kenneth E. Gordon
    Thank you Chairman Sanders, Ranking Member Paul and members of the 
Subcommittee on Primary Health and Aging for the opportunity to testify 
at today's hearing regarding the issue of senior hunger and the 
reauthorization of the Older Americans Act (OAA). I am deeply honored 
to be able to speak on behalf of both the older adults and family 
caregivers who depend upon the senior meal programs authorized by the 
Older Americans Act, and the thousands of staff and volunteers who make 
these programs possible throughout our country.
    My name is Ken Gordon. I have the privilege of serving as the 
executive director of the Area Agency on Aging for northeastern 
Vermont. We're a small, non-profit social service organization serving 
older adults and family caregivers in the far northeastern corner of 
the State, an area bordering Canada to the North, and the State of New 
Hampshire to the East. It's a rural and heavily wooded area that is 
home to about 10,000 senior citizens.
    While the back country of Vermont is beautiful, it's a difficult 
place to grow old. The winters are harsh, food and fuel costs are high, 
and public transportation is often lacking. And, like elsewhere in the 
country, senior hunger remains a vexing problem for older Vermonters. 
Despite the extraordinary progress we have made in this country over 
the past 75 years in combating poverty and poor health among older 
adults, we still face the startling reality that nearly 6 million 
seniors (or over 11 percent of all older adults) from across the United 
States face the threat of hunger each year.
    Unfortunately, hunger among senior citizens is a growing problem. 
According to the U.S. Census, senior hunger in Vermont and many other 
States has risen dramatically in recent years. Seniors at the greatest 
risk of hunger are individuals age 60-64 and those living alone in 
rural areas. Front-line providers are reporting even greater rates of 
food insecurity since the onset of the economic downturn because family 
members are less able to help.
    The seniors we serve come from all walks of life, both rich and 
poor. Aging has a way of humbling us all to the realities of birth, 
death and our short time on this earth. But the majority of the people 
we serve are older adults of modest means who have played by the rules. 
They've worked hard throughout their lives, paid taxes, responded to 
the call for military service, volunteered in their communities and 
made possible the quality of life we enjoy today. And now, at the end 
of their lives, they are struggling to make ends meet.
    Increasingly, as gasoline, home heating fuel and food prices 
continue to rise, we see many of the seniors we work with being forced 
to choose between paying for food, fuel, rent or prescription 
medicines. Seniors on fixed incomes are particularly vulnerable to 
price increases. Because food is often the most flexible part of a 
household budget, it is frequently the first expense to be cut when 
prices rise.
    Hard times are also forcing many of the seniors we work with to 
choose foods that have limited nutritional value in place of fruits, 
vegetables, whole grains, low fat dairy products and lean proteins. As 
we know, there are important consequences associated with the food 
choices we make, and this is particularly the case for older adults. 
Over 90 percent of seniors have one or more nutrition-related chronic 
conditions such as heart disease, diabetes, or high blood pressure that 
makes their food choices a critical factor to their health and well-
being.
    In Vermont, and across the country, Older Americans Act nutrition 
programs play a critical role in combating senior hunger. In concert 
with the Supplemental Nutrition Assistance Program (SNAP), food 
commodity programs, community food shelves and other initiatives, they 
form a hunger ``safety net'' for older adults and their families. In 
2008, the act's congregate and home-delivered meal programs served over 
240-million senior meals to approximately 2.6 million older adults and 
family caregivers. The Older Americans Act nutrition programs are 
extraordinarily popular among seniors because there is little, if any, 
stigma associated with them, and the eligibility determination process 
is straight forward and relatively easy to negotiate.
    As those of you who have visited the senior nutrition programs in 
the communities you serve already know, the programs work well because 
they are collaborative efforts that rely on a partnership between the 
individuals receiving services, families, private donors, the State and 
Federal Governments, faith-based organizations and the community at-
large. Participants are asked to contribute according to their means 
through a system of anonymous, voluntary contributions, and they do. In 
2009, seniors and their families in Vermont contributed more than 
$800,000 towards the cost of operating these programs. Private 
foundations and corporate donors regularly provide supplemental funding 
to support these programs, State and local governments provide their 
``match'' to Federal dollars, churches and other community groups lend 
their facilities to the cause, and volunteers provide much of the labor 
that makes these programs so successful.
    As an aside, I'd like to invite you all to visit the Area Agencies 
on Aging, senior centers and meal programs in your home communities, to 
learn for yourselves about these programs and to meet the individuals 
they serve.
    One of our senior meal recipients, a 92-year-old widow and retired 
homemaker from St. Johnsbury, VT, by the name of Maybell Peck, has 
described the home-delivered meals she received as a real ``life 
saver''. And for many, many people across the country, home-delivered 
meals are precisely that.
    Senior meals provide life-sustaining nutrition for hundreds of 
thousands of older adults each day. Without this service, many seniors 
would be left hungry and alone. Often, these programs provide the only 
true meal of the day for many, if not most, of those individuals 
participating in the program. The volunteers and staff who deliver 
meals also perform a valuable ``check-in'' service to ensure the safety 
of the senior, and are sometimes the only human contact that a person 
may have for long stretches of time. It is absolutely critical that we 
invest in these programs, as they serve as an important lifeline for 
some of the most vulnerable and frail people living in our communities.
    It is also important for policymakers to understand who is being 
served by these programs. In our case, the majority of those being 
served are older men and women, age 75+, who are living alone on very 
modest incomes. Many of these seniors are unable to drive, have 
disabilities, suffer from multiple chronic health conditions, and do 
not have the physical ability to shop or prepare a meal. Often, they 
literally have no other way to feed themselves, and are completely 
reliant upon this service in order to remain living at home.
    Mrs. Peck also told us that the meals she received gave her a sense 
of ``power,'' and in many respects these meals do empower older adults 
to remain independent and living at home. Senior nutrition programs 
help older adults and family caregivers to remain in control of their 
own lives, while helping the Medicare and Medicaid programs avoid the 
significant costs of unnecessary hospital care and nursing home 
placements.
    It's been said that an army marches on its stomach. And, to a large 
degree, the same can be said about our efforts to manage chronic health 
conditions and to provide seniors and people with disabilities with 
alternatives to nursing home care. The Older Americans Act senior 
nutrition programs form the foundation upon which our Medicaid Waiver 
home and community-based care programs rest and are essential to these 
programs' continued success. They are also an important part of the 
chronic care initiatives that have been initiated in recent years by 
the Centers for Medicare and Medicaid Services that have been proven to 
enhance the quality of life for those who participate in them and save 
taxpayer dollars, too.
                               challenges
    While the Older Americans Act nutrition programs have made a 
meaningful difference in the quality of life for millions of older 
Americans, the programs face enormous challenges and are operating 
under extraordinary stress.
    Demand for these programs, particularly in the category of home-
delivered meals, has grown significantly in recent years as the 
population ages, and a growing number of States turn to more cost-
effective and consumer-preferred home and community-based alternatives 
to nursing home care.
    Increasingly, because of the rising cost of living, seniors are 
less able to support these programs via their contributions. Declining 
participant contributions are the norm for most senior meal programs in 
the area we serve. A similar trend has been reported nationally.
    Funding for these programs has not increased in relation to the 
sharp rise in food and fuel costs in recent years, nor has it reflected 
the increased demand that these programs are experiencing as a result 
of the economic downturn. Additionally, providers in rural and frontier 
communities face particular challenges in the face of rising gasoline 
prices.
    In response to these challenges, continued Federal support for the 
Older Americans Act senior nutrition programs is critical. Additional 
funding to ensure the viability of these programs in the future as the 
number of older adults grows dramatically is essential to the well-
being and security of the Nation's older adults and family caregivers. 
Additional flexibility within the act to develop innovative approaches 
and that provides States and Area Agencies on Aging with the 
flexibility to address local priorities is also critical to sustaining 
these programs in the future.
    Lastly, while the Older Americans Act nutrition programs address a 
critical need, and they pay for themselves many times over in the form 
of avoided health care costs, in the view of many, these programs 
represent something more important. They reflect the sacred obligation 
that many of us learned early in our lives to honor and respect our 
elders. These are the folks who made our lives possible and whose labor 
and sacrifice led to the quality of life that we enjoy today. 
Collectively, we share in both the obligation and the responsibility to 
ensure that our elders' basic needs are adequately addressed, and that 
our country's senior citizens are able to live their lives with the 
independence and dignity that all Americans deserve.

    Senator Sanders. Thank you very much, Mr. Gordon.
    Our third witness is Kay Brown. Ms. Brown is a director in 
the Government Accountability Office's Education Workforce and 
Income Security Team. Throughout her 25-year career at GAO, Ms. 
Brown has focused on improving government performance in 
delivering benefits and services to low-income people and 
vulnerable populations.
    Ms. Brown, welcome.

 STATEMENT OF KAY E. BROWN, DIRECTOR, EDUCATION, WORKFORCE AND 
INCOME SECURITY, GOVERNMENT ACCOUNTABILITY OFFICE, WASHINGTON, 
                               DC

    Ms. Brown. Chairman Sanders, Ranking Member Paul, and 
Senator Franken, I'm pleased to be here today to discuss our 
recent work on food insecurity among older adults and the 
nutrition programs available to assist them. These programs 
play a vital role in the health and well-being of one of our 
Nation's most vulnerable groups.
    I will cover two points: the prevalence of food insecurity 
and receipt of nutrition assistance; and second, the extent to 
which nutrition assistance programs show signs of inefficiency 
or overlap.
    First on food insecurity and receipt of assistance: About a 
fifth of low-income older adults, those with incomes of less 
than $20,000 per year, were food insecure in 2009. These adults 
were uncertain of having or unable to acquire enough food 
because they lacked resources. A smaller but still significant 
number had their eating patterns disrupted and their food 
intake reduced because they couldn't afford enough food.
    Some of these older adults received help to alleviate food 
insecurity, but many did not. For example, in 2008 only about 
11 percent reported receiving home-delivered or congregate meal 
services.
    Based on our work, we know that requests for elderly 
nutrition assistance have grown, particularly since the 
recession, and are expected to continue to grow. Requests for 
home-delivered meals are growing faster than those of 
congregate meals.
    For my second point, I'd like to step back and look more 
broadly at the network of the Nation's nutrition assistance 
programs. Last year the Federal Government spent more than $90 
billion on domestic food assistance programs to serve not only 
older adults, but other vulnerable populations as well. There 
are 18 different programs administered by three separate 
Federal departments. The benefits are delivered through a 
complex network of multiple State offices, local governments, 
and nonprofit organizations. These 18 programs emerged 
piecemeal over the last several decades to address a variety of 
needs, often to target benefits to specific groups at high risk 
of malnutrition.
    Having multiple food assistance programs has some benefits. 
The programs provide various points of entry to help increase 
access and provide a range of choices for recipients. However, 
this arrangement can also result in overlap among programs and 
inefficient use of resources, as similar people access similar 
benefits from different programs.
    For example, the elderly nutrition program, as we've heard, 
provides home-delivered and congregate meals primarily to 
individuals aged 60 and older. But low-income older adults can 
also access programs offering similar benefits that are 
administered by USDA. They might receive commodities from the 
commodity supplemental food program, the emergency food 
assistance program, or the senior farmers market program. They 
might receive meals through the adult and child care food 
program. And many are eligible for electronic benefits redeemed 
in authorized stores through the largest program, SNAP, which 
was formerly called food stamps.
    Most of the Nation's 18 programs each have their own 
specific and often complex administrative procedures that 
Federal, State, and local organizations must follow to receive 
funding. Further, program eligibility rules often require 
applicants who seek assistance from multiple programs to submit 
separate applications for each one.
    Finally, not enough is known about the effectiveness of 
many of these programs. Research suggests that participation in 
7 of the 18 programs, and that includes the elderly nutrition 
program and SNAP, is associated with positive health and 
nutrition outcomes consistent with the program goals. However, 
little is known about the effectiveness of the remaining 11 
programs because they have not been well-studied.
    In conclusion, many older adults benefit from these 
programs. However, given the growing demand and the current 
constraints on our Nation's resources, it is vital to take 
steps to ensure that benefits and services go to those most in 
need, as efficiently as possible, and through programs that we 
know work.
    We have made recommendations to HHS, focused on identifying 
those most in need, and to USDA, focused on improving 
efficiencies. But continued oversight will be critical.
    This concludes my prepared statement.
    Thank you.
    [The prepared statement of Ms. Brown follows:]
                   Prepared Statement of Kay E. Brown
    Mr. Chairman, Ranking Member Paul, and members of the subcommittee, 
we appreciate the opportunity to discuss our recent work on food 
insecurity among older adults and the nutrition assistance programs 
available to assist them, including nutrition assistance programs 
authorized under the Older Americans Act of 1965 (OAA).\1\ This work 
can help inform government policymakers as they address the needs of 
one of our Nation's most vulnerable populations while ensuring the 
efficiency and effectiveness of Federal programs given rapidly building 
fiscal pressures facing our national government. While the economy is 
still recovering and in need of careful attention, widespread agreement 
exists on the need to look not only at the near term but also at steps 
that begin to change the long-term fiscal path as soon as possible 
without slowing the recovery. Our recent work can help with this by 
identifying potential inefficiency and overlap among programs. At the 
same time, there is recognition that the services provided by the OAA 
can play an important role in helping older adults remain in their 
homes and communities. As the Congress takes steps to address the 
fiscal challenge, it will be important that these steps are balanced 
with efforts to ensure the health and well-being of older adults.
---------------------------------------------------------------------------
    \1\ Pub. L. No. 89-73, 79 Stat. 218 (codified as amended at 42 
U.S.C. 3001-58ff ).
---------------------------------------------------------------------------
    My testimony today is based on two recent reports, our April 2010 
report on domestic food assistance \2\ and our February 2011 report on 
the unmet need for services under the OAA.\3\ My testimony highlights 
key findings from each of these reports related to: (1) the prevalence 
of food insecurity and the receipt of nutrition services among older 
adults; and (2) the extent to which nutrition assistance programs show 
signs of inefficiency or overlap. This statement will discuss some of 
the challenges related to ensuring the most efficient provision of 
services, and suggest how better information could help policymakers 
address overlap and duplication among programs while ensuring those 
most in need have access to services.
---------------------------------------------------------------------------
    \2\ GAO, Domestic Food Assistance: Complex System Benefits 
Millions, but Additional Efforts Could Address Potential Inefficiency 
and Overlap among Smaller Programs, GAO-10-346, (Washington, DC: April 
15, 2010).
    \3\ GAO, Older Americans Act: More Should Be Done to Measure the 
Extent of Unmet Need for Services, GAO-11-237, (Washington, DC: 
February 28, 2011).
---------------------------------------------------------------------------
    To address the objectives, we drew upon our April 2010 report and 
our February 2011 report. In this work, we employed an array of 
methodologies including analysis of administrative data on program 
expenditures and participation and national self-reported data on food 
security status; a nationally representative survey of local agencies 
that administer nutrition assistance programs funded by OAA \4\; an 
analysis of studies on program effectiveness; a review of relevant 
Federal laws and regulations and agency documents; and interviews with 
relevant experts, Federal officials, and staff of local agencies. We 
conducted our work in accordance with generally accepted government 
auditing standards. Those standards require that we plan and perform 
the audit to obtain sufficient, appropriate evidence to provide a 
reasonable basis for our findings and conclusions based on our audit 
objectives. We believe that the evidence we obtained provides a 
reasonable basis for our findings and conclusions.
---------------------------------------------------------------------------
    \4\ We conducted a survey of 125 local agencies, with 99 agencies 
(79 percent) responding. The percentages cited from this survey are 
subject to margins of error no more than plus or minus 12 percentage 
points at the 95 percent confidence level.
---------------------------------------------------------------------------
    On March 1, 2011, we issued a report outlining opportunities to 
reduce duplication across a wide range of Federal programs raising 
attention to these issues.\5\ That report was prepared in response to a 
new statutory requirement that GAO identify and report annually on 
Federal programs, agencies, offices, and initiatives--either within 
departments or governmentwide--that have duplicative goals and 
activities.\6\ In that work, we also considered fragmentation and 
overlap among government programs or activities as these can be 
harbingers of unnecessary duplication. Fragmentation of programs exists 
when programs serve the same broad area of need but are administered 
across different Federal agencies or offices. Program overlap exists 
when multiple agencies or programs share similar goals, engage in 
similar activities or strategies to achieve them, or target similar 
beneficiaries. Unnecessary duplication of program services can occur 
when two or more programs are engaged in the same activities or provide 
the same services to the same beneficiaries, and this can in turn 
result in inefficient service delivery and unnecessary program costs. 
Reducing or eliminating duplication, overlap, or fragmentation could 
potentially save billions of tax dollars annually and help agencies 
provide more efficient and effective services. These actions, however, 
will require some difficult decisions and sustained attention by the 
Administration and Congress.
---------------------------------------------------------------------------
    \5\ GAO, Opportunities to Reduce Potential Duplication in 
Government Programs, Save Tax Dollars, and Enhance Revenue, GAO-11-
318SP, (Washington, DC: March 1, 2011).
    \6\ Statutory Pay-As-You-Go Act of 2010, Pub. L. No. 111-139, 21, 
124 Stat. 8, 29-30 (codified at 31 U.S.C. 712 note).
---------------------------------------------------------------------------
  in recent years nearly a fifth of low-income older adults were food 
   insecure and most did not receive assistance from meals programs 
                        despite increased demand
    Analysis of data from the Current Population Survey's (CPS) Food 
Security Supplement shows that in 2009, about 19 percent of households 
with adults ages 60 and over with low incomes--under 185 percent of the 
poverty line--were food insecure. These adults were uncertain of having 
or unable to acquire enough food because they lacked resources. In 
comparison, slightly less than 15 percent of all households were food 
insecure. A small but significant portion of households with older 
adults had very low food security in 2009--about 8 percent of those 
with households under 185 percent of poverty and about 14.5 percent of 
those with incomes under the poverty line. In these households, one or 
more household members' eating patterns were disrupted and their food 
intake reduced, at least some time during the year because they could 
not afford enough food. (See Figure 1.)


    Older adults can and do access a number of resources to help 
alleviate food insecurity; however, many low-income older adults likely 
to need assistance from meals programs did not receive it, according to 
2008 data. Through our analysis of information from the CPS, we found 
that in 2008 approximately 9 percent of an estimated 17.6 million low-
income older adults \7\ received home-delivered or congregate meals 
services including those provided by the OAA Elderly Nutrition Program: 
Home-Delivered and Congregate Meals Services (Elderly Nutrition 
Program) \8\ and other organizations such as churches or nonprofits.\9\ 
However, many more older adults did not receive these meals services, 
but likely needed them due to food insecurity, difficulties with daily 
activities, and/or limited social interaction, as shown in table 1.\10\
---------------------------------------------------------------------------
    \7\ Our analysis of meal program recipients and non-recipients was 
limited to those living in households below 185 percent of the poverty 
threshold because the CPS did not collect generalizable information for 
individuals with higher incomes. In addition to people age 60 and over, 
younger spouses living with people age 60 and over and people with 
disabilities of all ages in housing facilities occupied primarily by 
older people where congregate meals are served or who live with someone 
age 60 and over are also eligible for meals services through title III. 
42 U.S.C 3030g-21(2)(I). Our estimates of older adults who are likely 
to need meals services also include these additional individuals. An 
estimated 31 percent of people age 60 and over were below 185 percent 
of the poverty threshold.
    \8\ 42 U.S.C. 3030e and 3030f. Nutrition services authorized 
under Title III Part C of the OAA are designed to provide balanced and 
nutritious meals at home or in a congregate setting. Home-delivered 
meals, commonly referred to as ``Meals on Wheels,'' are typically 
provided to individuals who have health difficulties that limit their 
ability to obtain or prepare food. Congregate meals are served at a 
variety of sites, such as schools and adult day care centers, and serve 
older adults' social interaction needs, in addition to nutrition.
    \9\ The CPS asked seniors whether they received home-delivered or 
congregate meals, but did not specify the source of the meals.
    \10\ We aligned our definition of likely need with two of the three 
key purposes of the Elderly Nutrition Program as described in the OAA: 
(1) reducing hunger and food insecurity and (2) promoting 
socialization. 42 U.S.C. 3030d-21. Given available data, we could not 
estimate the number of older adults likely to need services based on 
the third purpose of promoting health and well-being. Unless otherwise 
noted, our estimates of low-income older adults likely to need or 
receive meals services have a maximum confidence interval of +/^3.2 
percentage points of the estimate.

 Table 1: Percentages of Low-Income Older Adults With Each Characteristic of Likely Need and Percentages Who Did
                                       and Did Not Receive Meals Services
----------------------------------------------------------------------------------------------------------------
                                                            Did not
                                                 Received   receive    Received     Did not   Received  Received
Characteristics of likely need     Have each      home-      home-    congregate    receive    either    neither
                                characteristic  delivered  delivered     meals    congregate   type of   type of
                                                  meals      meals                   meals      meal      meal
----------------------------------------------------------------------------------------------------------------
Food security:
  Food secure.................         81.4          3.3       96.7         5.7        94.3        8.3      91.7
  Food insecure...............         18.6          7.4       92.6         4.9        95.1       11.1      88.9
Number of impairments \1\:
  None........................         65.2          2.3       97.7         5.1        94.9        6.9      93.1
  One.........................         18.0          3.6       96.4         6.3        93.7        8.8      91.2
  Two or more.................         16.8         11.5       88.5         6.4        93.6       16.7      83.3
Social isolation \2\:
  Less isolated...............         31.8          2.5       97.5         6.1        93.9        7.9      92.1
  More isolated...............         41.4          5.0       95.0         5.0        95.0        9.0      91.0
  Missing \3\.................         26.8          4.5       95.5         5.8        94.2        9.7      90.3
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of 2008 CPS data.
\1\ To identify older adults likely to need meals programs based on potential difficulties preparing or
  obtaining food, we used four CPS questions that identified functional impairments, such as difficulty doing
  errands alone, serious difficulty walking or climbing stairs, or difficulty dressing or bathing.
\2\ We defined likely need for more social interaction as answering ``no'' to all of the questions in the CPS
  civic engagement supplement that asked about the older adult's participation in social activities. However,
  such survey data do not capture more qualitative aspects of an individual older adults' likely need for social
  interaction such as personality and individual preference. The data also do not allow us to identify
  individuals who may interact socially outside of organized groups and activities.
\3\ CPS questions related to social isolation were asked at a different time in the survey cycle than questions
  about receipt of meals services. Therefore, approximately 27 percent of the older adults with low incomes in
  our sample provided information about participation in meals programs, but not about participation in social
  groups. As a result, we could not measure whether they were more or less socially isolated.

    It should be noted that there are many reasons why older adults may 
not receive nutrition assistance through the Elderly Nutrition Program. 
They may not know about the available services, may not have access to 
services due to limited supply in their area, may receive informal 
assistance from family or neighbors, or may choose to remain self-
sufficient rather than request government benefits. In addition, some 
older adults may choose to participate in a separate program instead, 
such as the Supplemental Nutrition Assistance Program (SNAP), formerly 
known as Food Stamps, where they can purchase their preferred foods.
    Requests for Elderly Nutrition Program services have increased and 
demand will likely continue to grow. Through our survey of area 
agencies on aging (local agencies) conducted during the summer of 2010, 
we found that an estimated 79 percent of agencies had seen increased 
requests for home-delivered meals, and 47 percent had seen increased 
requests for congregate meals since the start of the economic downturn. 
Further, requests for OAA services are increasing as more seniors stay 
in their homes longer rather than move to assisted living facilities or 
nursing homes, according to agency officials. According to U.S. Census 
data, more than 9 million more Americans were 60 years and older in 
2009 than in 2000, and the Census Bureau projects that population group 
will continue to grow.
    Further, demand for Elderly Nutrition Program home-delivered meals 
is growing compared to congregate meals. In our 2010 survey, an 
estimated 22 percent of agencies reported they were generally or very 
unable to serve all clients who request home-delivered meals, compared 
to an estimated 5 percent of agencies who were generally or very unable 
to serve all clients who requested congregate meals. To adjust to these 
changes in requests for services, most State and some local agencies 
utilized the flexibility provided by the law to transfer OAA funds 
among title III programs.\11\ Agencies most commonly transferred funds 
from congregate meals to home-delivered meals or other title III 
services. Nationally, from fiscal year 2000 through fiscal year 2008, 
States collectively transferred an average of $67 million out of the 
congregate meal program each year (see Figure 2).
---------------------------------------------------------------------------
    \11\ OAA title III authorizes a supportive services and senior 
centers program that covers, for example, health, transportation, 
ombudsman, nutrition, and education services, as well as home-delivered 
and congregate meals programs. 42 U.S.C. 3030d. The OAA provides 
states with some authority to transfer Federal funding allocations 
among programs. A state may transfer up to 40 percent of allocated 
funds for the home-delivered meals programs to the congregate meals 
program, or vice versa, and the Assistant Secretary of Aging can grant 
a waiver for a State to transfer an additional 10 percent. 42 U.S.C. 
3028(b)(4). In addition, a state may transfer up to 30 percent of 
allotted funds for Part B support services (such as transportation and 
home-based care) to the meal programs and vice versa, and the Assistant 
Secretary may grant a waiver of the 30 percent limit. 42 U.S.C. 
3028(b)(5) and 3030c-3(b)(4).


  actions needed to reduce administrative overlap among domestic food 
                          assistance programs
    In part because food insecurity is a national problem that affects 
not only older adults but also many other vulnerable groups, the 
Federal Government spent more than $90 billion on domestic food 
assistance programs in 2010. This represents an increase of 
approximately 44 percent over 2008 spending, driven largely by 
increased spending on the SNAP. We identified 18 different Federal 
programs that provide nutrition assistance, programs that emerged 
piecemeal over the past several decades to address a variety of needs. 
Agency officials and local providers have indicated that the multiple 
food assistance programs work together and provide various points of 
entry to the system to help increase access to food for vulnerable or 
target populations at high risk of malnutrition or hunger. Those 
officials and providers told us that, since no one program alone is 
intended to meet a household's full nutritional needs, the variety of 
food assistance programs can help households fill gaps and address the 
specific needs of individual members. However, we have previously 
reported signs of overlap and inefficient use of resources in the 
delivery of benefits through these programs. In addition to the 
Departments of Agriculture (USDA), Health and Human Services (HHS), and 
Homeland Security (DHS) multiple State and local government and 
nonprofit organizations work together to administer a complex network 
of programs and providers.
    We have found that some of these programs, including those serving 
older adults, provide comparable benefits to similar or overlapping 
populations. For example, the Elderly Nutrition Program administered by 
the Administration on Aging (AOA), provides home-delivered and 
congregate meals primarily to individuals 60 years and older. 
Separately, other programs administered by USDA, including the 
Commodity Supplemental Food Program, targets a similar population, 
providing food to older adults, as well as women, infants and children 
who are also served by the Special Supplemental Nutrition Program for 
Women, Infants, and Children (WIC) program. In addition, individuals 
eligible for groceries through the Commodity Supplemental Food Program 
or services through the Elderly Nutrition Program may also be eligible 
for groceries through the Emergency Food Assistance Program and for 
targeted benefits that are redeemed in authorized stores through the 
largest program, SNAP. In fact, a recent AOA report conducted by 
Mathematica \12\ found that 7 percent of congregate meal recipients and 
16 percent of home-delivered meal recipients were also receiving SNAP 
benefits. The availability of multiple programs with similar benefits 
helps ensure that those in need have access to nutritious food, but can 
also increase administrative costs, which account for approximately a 
tenth to more than a quarter of total costs among the largest of these 
programs. In addition, our previous work has shown that overlap among 
programs can lead to inefficient use of Federal funds, duplication of 
effort, and confusion among those seeking services.
---------------------------------------------------------------------------
    \12\ Allison Barrett and Jody Schimmel, Mathematica Policy 
Research, ``Multiple Service Use Among OAA Title III Program 
Participants,'' September 2010 (Research Brief).
---------------------------------------------------------------------------
    We have found in previous work that despite the potential benefits 
of varied points of entry, program rules related to determining 
eligibility often require the collection of similar information by 
multiple entities.\13\ For example, an older adult might apply for 
congregate meals through the Elderly Nutrition Program at their local 
area agency on aging, electronic benefits through SNAP at the Health 
and Human Services office, and vouchers for fresh fruit and vegetables 
through the Senior Farmers' Market Nutrition Program at a local food 
bank. Most of the 18 programs have specific and often complex 
administrative procedures that Federal, State, and local organizations 
follow to help manage each program's resources. According to our 
previous work and State and local officials, rules that govern these 
and other nutrition assistance programs often require applicants who 
seek assistance from multiple programs to submit separate applications 
for each program and provide similar information verifying, for 
example, household income. This can create unnecessary work for both 
providers and applicants and may result in the use of more 
administrative resources than needed.
---------------------------------------------------------------------------
    \13\ GAO, Domestic Food Assistance: Complex System Benefits 
Millions, but Additional Efforts Could Address Potential Inefficiency 
and Overlap Among Smaller Programs, GAO-10-346, (Washington, DC: April 
15, 2010).
---------------------------------------------------------------------------
    Moreover, not enough is known about the effectiveness of many of 
these programs. Research suggests that participation in 7 of the 18 
programs--including the Elderly Nutrition Program and SNAP--is 
associated with positive health and nutrition outcomes consistent with 
programs' goals.\14\ For example, studies on the Elderly Nutrition 
Program found that the program increases socialization and may have a 
positive effect on food security. In addition, research suggests the 
program improves participants' dietary and nutrient intake--an outcome 
related to the program's goal of promoting the health and well-being of 
older individuals by assisting such individuals to gain access to 
nutrition and other disease prevention and health promotion services to 
delay the onset of adverse health conditions resulting from poor 
nutritional health or sedentary behavior. However, little is known 
about the effectiveness of the remaining 11 programs because they have 
not been well-studied.
---------------------------------------------------------------------------
    \14\ The other programs that show outcomes consistent with many of 
their program goals include: WIC, the National School Lunch Program, 
the School Breakfast Program, Nutrition Assistance for Puerto Rico, and 
the Special Milk Program.
---------------------------------------------------------------------------
    Agencies do regularly collect performance and other data on 
nutrition assistance programs but these data are not sufficient to 
determine program effectiveness and do not always provide all the 
information needed to effectively and efficiently manage their 
programs. Agency data show that the 11 less-studied programs provide 
food and nutrition assistance to millions of individuals and households 
each year--an outcome related to their goals--however, this alone does 
not demonstrate the overall effectiveness of these programs. Other 
data--such as on need and unmet need for services--could help agencies 
better target limited resources and more efficiently serve their target 
populations but agencies often do not have this information. For 
example, while the OAA requires AOA to design and implement uniform 
data collection procedures for States to assess the receipt, need, and 
unmet need for title III services,\15\ AOA does not provide 
standardized definitions or measurement procedures for need and unmet 
need that all States are required to use. Instead, AOA provides States 
with non-binding guidance on these issues and an assortment of tools 
and resources that they can use to evaluate need and limited 
information about measuring unmet need. States use a variety of 
approaches to measure need and measure unmet need to varying extents, 
but no agencies that we spoke with fully estimate the number of older 
adults with need and unmet need in their service area. Such information 
could help providers make informed decisions about serving those most 
in need as the number of older adults increases and resource 
constraints are likely to continue.
---------------------------------------------------------------------------
    \15\ 42 U.S.C. 3012(a)(26).
---------------------------------------------------------------------------
    In April 2010, we recommended that USDA, as the principal 
administrator of the Federal Government's food assistance programs, 
identify and develop methods for addressing potential inefficiencies 
among food assistance programs and reducing unnecessary overlap among 
its smaller food assistance programs while ensuring that those who are 
eligible receive the assistance they need. These methods could include 
conducting a study as a first step; convening a group of experts; 
identifying which of the lesser-studied programs need further research 
and taking steps to fill the research gap; or identifying and piloting 
proposed changes.
    Further, in February 2011 we recommended that, to help ensure that 
agencies have adequate and consistent information about older adults' 
needs and the extent to which they are met, the Secretary of Health and 
Human Services partner with other government agencies that provide 
services to older adults and, as appropriate, convene a panel or work 
group of researchers, agency officials, and others to develop 
consistent definitions of need and unmet need and to propose interim 
and long-term uniform data collection procedures for obtaining 
information on older adults with unmet needs for services provided from 
sources like title III.
    In addition to our specific recommendations to USDA and HHS, we 
have also noted in prior work that agencies can reduce program 
inefficiencies by broadening their efforts to simplify, streamline, or 
better align eligibility procedures and criteria across programs to the 
extent that it is permitted by law. Consolidating or eliminating 
overlapping programs also have the potential to reduce administrative 
costs but may not reduce spending on benefits unless fewer individuals 
are served as a result. More broadly, essential to all these efforts is 
collaboration among many entities. Achieving meaningful results in many 
policy and program areas, including food and nutrition services, 
requires some combination of coordinated efforts among various actors 
across Federal agencies with other governments at State and local 
levels and nongovernmental organizations.
                               conclusion
    In conclusion, as I have outlined in my testimony, opportunities 
exist to streamline and more efficiently carry out these important 
domestic food assistance programs. Specifically, addressing 
duplication, overlap, and fragmentation could help to minimize the 
administrative burdens faced by those entities--including States and 
localities as well as nonprofit organizations--that are delivering 
these programs' services. Such administrative burdens range from 
eligibility requirements and the application process to costs 
associated with carrying out the program and reporting requirements. 
Improving consistency among these various requirements and processes as 
well as considering how multiple agencies could better coordinate their 
delivery of programs could result in benefits both for those providing 
and those receiving the services. In addition, collection of adequate 
and consistent information about older adults' needs and the extent to 
which they are met could help providers make informed decisions about 
serving those most in need. It is particularly important to use 
resources efficiently given that the need for meals programs among low-
income older adults will likely continue to outpace available services 
given the growing older population and continued economic constraints.
    Careful, thoughtful actions will be needed to address issues 
involving potential duplication, overlap, and fragmentation among 
Federal programs and activities. These are difficult issues to address 
because they may require agencies and Congress to re-examine within and 
across various mission areas the fundamental structure, operation, 
funding, and performance of a number of long-standing Federal programs 
or activities. Continued oversight will be critical to ensuring that 
unnecessary duplication, overlap, and fragmentation are addressed.
    Thank you, Mr. Chairman, Ranking Member Paul, and members of the 
subcommittee. This concludes my prepared statement. I would be pleased 
to answer any questions you may have.
                                 ______
                                 
 Appendix I: Selected Federal Food and Nutrition Assistance Programs, 
                               by Agency


------------------------------------------------------------------------
                 Item no.                           Program Name
------------------------------------------------------------------------
USDA
  1.......................................  Child and Adult Care Food
                                             Program
  2.......................................  Commodity Supplemental Food
                                             Program
  3.......................................  Community Food Projects
                                             Competitive Grant Program
                                             \1\
  4.......................................  Food Distribution Program on
                                             Indian Reservations
  5.......................................  Fresh Fruit and Vegetable
                                             Program
  6.......................................  National School Lunch
                                             Program
  7.......................................  Nutrition Assistance for
                                             Puerto Rico
  8.......................................  School Breakfast Program
  9.......................................  Senior Farmers' Market
                                             Nutrition Program
  10......................................  Special Milk Program
  11......................................  Summer Food Service Program
  12......................................  Supplemental Nutrition
                                             Assistance Program (SNAP)
  13......................................  The Emergency Food
                                             Assistance Program
  14......................................  WIC
  15......................................  WIC Farmers' Market
                                             Nutrition Program
DHS Federal Emergency Management Agency
  16......................................  Emergency Food and Shelter
                                             National Board Program
HHS Administration on Aging
  17......................................  Elderly Nutrition Program:
                                             Home-Delivered and
                                             Congregate Nutrition
                                             Services
  18......................................  Grants to American Indian,
                                             Alaska Native, and Native
                                             Hawaiian Organizations for
                                             Nutrition and Supportive
                                             Services
------------------------------------------------------------------------
Source: GAO, Domestic Food Assistance: Complex System Benefits Millions,
  but Additional Efforts Could Address Potential Inefficiency and
  Overlap among Smaller Programs, GAO-10-346 (Washington, DC: Apr. 15,
  2010).
\1\The Community Food Projects Competitive Grants Program is
  administered by the National Institute of Food and Agriculture
  (formerly the Cooperative State Research, Education, and Extension
  Service, CSREES) of USDA. All other USDA programs listed above are
  administered by the Food and Nutrition Service. Community Food
  Projects Competitive Grants Program participation information is from
  CSREES Update: September 17, 2009, Office of the Administrator,
  CSREES, USDA.


    Senator Sanders. Ms. Brown, thank you very much.
    Our final witness is Dr. Mary Jane Koren, vice president 
for the Picker/Commonwealth Long-Term Quality Improvement 
Program at the Commonwealth Fund, a health policy foundation. 
Dr. Koren, an internist and geriatrician, began her career in 
geriatrics at Montefiore Medical Center, where she started the 
geriatrics fellowship program and was assistant medical 
director for the Montefiore Home Health Care Agency.
    Dr. Koren, thanks for being with us.

  STATEMENT OF MARY JANE KOREN, M.D., M.P.H., VICE PRESIDENT, 
PICKER/COMMONWEALTH FUND LONG-TERM QUALITY IMPROVEMENT PROGRAM, 
              THE COMMONWEALTH FUND, NEW YORK, NY

    Dr. Koren. Thank you, Mr. Chairman, for inviting me to 
testify today. I'm Dr. Mary Jane Koren and as a geriatrician I 
have made many home visits to patients living in the Bronx. In 
my experience, these nutritional programs, those supported by 
Title III C of the Older Americans Act, are undoubtedly some of 
the most cost-effective interventions yet devised to combat 
nutrition and hunger in seniors, keeping them healthier, 
longer, so they stay out of hospitals, they stay out of nursing 
homes, and they remain in their own homes.
    Let me tell you why this is the case. Against a backdrop of 
physiologic changes associated with aging--such as the anorexia 
of aging, poor dentition, difficulty swallowing--there are 
multiple medical conditions that compromise an elder's ability 
to maintain nutritional status. Older adults have multiple 
chronic conditions, such as diabetes, depression, heart 
failure, kidney disease, and arthritis. Fifty percent of people 
over the age of 65 have two to four chronic conditions. 
Likewise, the prevalence of dementia rises with age, affecting 
almost half of those 85 years or older.
    The interplay of these factors, both physiologic and 
pathologic, means that many seniors experience often 
insurmountable odds with shopping and meal preparation. They're 
at high risk for hunger and consequently high users of health 
care services.
    Social issues also play a major role in hunger and food 
insecurity for elders with limited means and forces them to 
choose between buying food and paying the rent. Further, as I 
can attest from my own experiences making home visits in the 
South Bronx, many elderly patients are reluctant to leave their 
own apartments. They've learned the hard way that the denizens 
of that urban jungle view them as easy prey. Others of my 
patients were just as trapped at home when they could no longer 
drive. All too often, my patients were subsisting on a protein-
deficient tea and toast diet.
    As a geriatrician, I can tell you that hunger only makes 
things worse and drives up health care costs. Yet a low-cost 
simple intervention such as home meal delivery or congregate 
meals can reduce hospitalization and delay nursing home 
placement, thus significantly lowering the costs of what is 
otherwise an extremely high-cost population and a major driver 
of health expenditures.
    Why are these programs effective? When older people don't 
eat enough good food, bad things happen. Research findings show 
that undernutrition causes any or all of the finding: muscle 
wasting, pressure ulcers, apathy, increased susceptibility to 
infections, anemia, delirium, increased frailty, functional 
decline, and fall. Any one of these negative health outcomes 
have enormous implications for service utilization.
    Take falls. A third of people over 65 and a third of them 
suffer moderate to severe injuries from falls, leaving them 
disabled or unable to live independently. In 2000 the health 
care costs of falls exceeded $19 billion. Malnourishment 
increases the rate of falls and it worsens the outcomes. We 
know from research and from experience that providing 
nutritional support to vulnerable elders works.
    If home-delivered and congregate meal programs could save 
even a fraction of what falls cost Medicare and Medicaid, 
they'd pay for themselves. Multiply that by the costs of 
treating all these other health consequences of hunger and the 
value of these programs is off the chart.
    Not only that, people really love these programs, because 
they not only provide something to eat, they provide a reason 
to eat. Make no mistake, social isolation kills people, too. 
The socialization provided by these programs is a godsend for 
those who've outlived their friends and who because of illness, 
frailty, and dysfunction their life has been reduced to a 
couple of rooms.
    This happened to my father. After a head injury in a car 
accident, he couldn't drive, he couldn't shop, and he couldn't 
do much in the way of meal preparation for himself. All he knew 
is he wanted to stay home. Meals on Wheels played a critical 
role in keeping him in his own home for the last years of his 
life. The volunteer's visit was the high point of his day.
    Meals on Wheels also helped me, too, as his long-distance 
caregiver. They became my early warning system. Time and again, 
they alerted me to a problem before it was escalated to a 
catastrophe.
    The bottom line is these programs help seniors stay 
healthier, which keeps them out of emergency rooms, decreases 
the rate of hospitalization, shortens lengths of stay and re-
admissions, and keeps them out of expensive nursing homes.
    In conclusion, I would make several recommendations for 
things that might be done at the Federal level. First, I would 
urge not only the reauthorization of funding for title III 
nutrition programs, I would strongly suggest they be expanded. 
They work.
    I would also advise there be support for demonstrations, 
pilots, and applied research on how the programs could better 
serve our diverse population, and test creative strategies for 
improving outcomes even further.
    Third, I would recommend that the requirements for the 
nutrition programs should ensure the caloric adequacy and key 
nutrients in meals. For many seniors these meals are their main 
source of daily food intake. Target specific highly vulnerable 
groups for receipt of enhanced services. Tailor the programs' 
services to increase its effectiveness for people with 
particularly high burdens of illness. Enhance the nutritional 
education and counseling given to caregivers and to their 
patients, and give the program the flexibility it needs to 
better accommodate regional and ethnic food preferences and 
improve palatability and taste.
    I thank you for your attention and for providing the 
opportunity of addressing the committee.
    [The prepared statement of Dr. Koren follows:]
          Prepared Statement of Mary Jane Koren, M.D., M.P.H.
    Thank you, Mr. Chairman, for inviting me to testify today. I am Dr. 
Mary Jane Koren and a geriatrician by training. Most of my career has 
been devoted to serving the elderly, particularly those with serious 
chronic conditions. I have taken care of residents living in nursing 
homes, made home visits as the assistant medical director of the 
Montefiore Home Health Agency to patients living throughout the Bronx 
and later was appointed to be the director of New York State's Bureau 
of Long Term Care Services. Currently, I am vice-president at the 
Commonwealth Fund, an independent private foundation working toward a 
high performing health system which is located in New York City. The 
grant-making program I manage is aimed at improving long term services 
and supports particularly for people covered by both Medicare and 
Medicaid, also called the ``dual eligibles'', and for those 
transitioning from one level of care to another.
    No matter which hat I'm wearing--geriatrician, policymaker or 
grantmaker--my goal has been, and is, to help frail older adults 
maintain their independence and well-being. The program I would speak 
to today, Title III-C of The Older Americans Act, Nutrition Services, 
is probably one of the simplest, yet most effective programs yet 
devised to help low-income seniors stay in their homes and stay out of 
hospitals and nursing homes. You have heard today from both Federal and 
State policymakers and from those who administer these programs. I will 
therefore try to give you a somewhat different perspective. Based on my 
professional background and front-line experience caring for elderly 
patients I'll briefly cover four areas: First, I'll say a bit on 
exactly why hunger, or under-nutrition, is so common in this 
population; second, talk about the consequences of under-nutrition both 
for patients and for rising health care expenditures; third, describe 
how home delivered and congregate meals can help low-income seniors, 
their families, health care providers and policymakers, especially in a 
time of constrained resources; and lastly, make several recommendations 
to strengthen these programs.
    First, some information about aging: because of the way our bodies 
age, older people have a heightened risk of ``hunger''. The aging 
process itself predisposes a person to under-nutrition--
physiologically, it's a stacked deck. These physiologic changes make it 
extremely difficult for even healthy older adults to stay well 
nourished. Here are some examples. There is what's termed the 
``anorexia of aging'', a natural phenomenon in which the desire for 
even adequate quantities of food declines commensurate with the decline 
in physical activity seen in the very old. This means that seniors 
don't feel as hungry as you or I do at meal times and so there is the 
tendency to only eat a little bit or even to skip a meal. Compounding 
that, stomachs ``shrink'', or become less compliant, as people age so 
they feel ``full'' faster. This sensation of satiation is further 
mediated by the release of such hormones as cholecystokinin, leptin and 
dynorphin which act both on the brain and on the gut. The senses of 
smell and taste likewise diminish with age--food loses its savor making 
meals less interesting and enjoyable so people tend to eat less. Oral 
problems, such as poor dentition, ill-fitting dentures, or decreased 
saliva production are common in old age which can make eating a misery. 
It has been estimated that dental problems alone may decrease food 
intake by up to 100 kcal/day--not a lot, perhaps, for 1 day but 
cumulatively, over weeks and months, enough to cause an insidious and 
inexorable loss of weight.\1\ Swallowing problems, or dysphagia, can 
make mealtimes a source of stress, not enjoyment. People who've 
experienced difficulty swallowing may be reluctant to eat very much or 
be very selective about what they try to eat because of their fear of 
choking. In addition, older adults don't get as thirsty as young 
people, which, especially in hot weather or for people with congestive 
heart failure on diuretics, can cause dehydration with its serious 
complications including dizziness, delirium and falls.\2\ In a word, 
the aging process itself sets the stage for inanition or energy-protein 
malnourishment.
---------------------------------------------------------------------------
    \1\ ``Nutrition'' ch2, p9. Merck Manual of Geriatrics, Second 
Edition, (Whitehouse Station, NJ: Merck & Co., Inc. 1995).
    \2\ Up to 2 percent of falls in elderly patients result in hip 
fractures and up to another 5 percent result in other fractures. These 
types of injuries account for about 5 percent of hospitalizations for 
patients over 65 years old. About 5 percent of elderly hip fracture 
patients die while hospitalized, while overall 12-month mortality 
ranges from 12 to 67 percent. See N. Alexander, ``Falls'' in Merck 
Manual of Geriatrics, Third Edition. (Whitehouse Station, NJ: Merck & 
Co., Inc. 2000).
---------------------------------------------------------------------------
    On top of this, there are a whole host of medical problems and 
social issues common to low-income older adults that further compromise 
an elder's ability to maintain optimum nutrition. Far and away the most 
common cause of under-nutrition is depression. Research has shown that 
depressive symptoms are associated with insufficient food intake and 
nutritional deficiencies, especially in poor elderly people living at 
home \3\ because of loss of appetite, diminished enjoyment of food, 
difficulty with food preparation and consumption of a less varied 
diet.\4\ A vicious circle gets started where depression leads to poor 
intake, which worsens depressive feelings, and so on. It can be a hard 
circle to break especially in the homebound elderly who tend to become 
lonely, withdrawn and apathetic. One study, for example, found that 
depressive symptoms, which were more common among women in the study, 
were linked with diminished mobility and social interaction.\5\ I would 
also note that social isolation is one of the major risk factors for 
elder abuse, most commonly perpetrated by family members.\6\ 
Encouraging those delivering meals to look for signs of elder abuse 
would help enormously in the detection of what's often a hidden problem 
and in getting help for an elder, who may have no other contact with 
people outside the home.
---------------------------------------------------------------------------
    \3\ German L, Kahana C, Rosenfeld V, Zabrowsky I, et al. 
``Depressive symptoms are associated with food insufficiency and 
nutritional deficiencies in poor community-dwelling elderly people.'' J 
Nutr Health Aging. 2011; 15(1):3-8, cited in Morley JE. 
``Undernutrition: a major problem in nursing homes.'' J Am Med Dir 
Assoc. 2011 May; 12(4):243-6. Epub 2011 Mar 23.
    \4\ Sharkey JR, Branch LG, Zohoori N, Giuliani C, et al. 
``Inadequate nutrient intakes among homebound elderly and their 
correlation with individual characteristics and health-related 
factors.'' Am J Clin Nutr. 2002 Dec; 76(6):1435-45.
    \5\ Penninx BW, Leveille S, Ferrucci L, van Eijk JT, et al. 
``Exploring the effect of depression on physical disability: 
longitudinal evidence from the established populations for 
epidemiologic studies of the elderly.'' Am J Public Health. 1999 Sept; 
89(9):1346-52, cited in Sharkey JR, Branch LG, Zohoori N, Giuliani C, 
et al. ``Inadequate nutrient intakes among homebound elderly and their 
correlation with individual characteristics and health-related 
factors.'' Am J Clin Nutr. 2002 Dec; 76(6):1435-45.
    \6\ ``Who Are the Abusers?'' National Center for Elder Abuse, 
Administration on Aging. Accessed June 17, 2011 http://
www.ncea.aoa.gov/NCEAroot/Main_Site/FAQ/Basics/Abusers.aspx.
---------------------------------------------------------------------------
    In addition to the impact of depression on food intake, older 
people have multiple chronic conditions, such as diabetes, heart 
failure, kidney disease, stroke and arthritis. The prevalence for those 
over age 65 of two to four chronic illnesses is about 50 percent. For 
those over age 75 almost 20 percent have five or more chronic illnesses 
\7\ which take a huge toll on normal function, including even basic 
actions like being able to stand or lift things which compromises the 
ability to shop, prepare a meal and sometimes even the ability to eat. 
The presence and perceived effect of individual diseases and conditions 
on daily activities is termed the ``the burden of disease'' \8\--and 
the more illnesses a person has, the higher that ``burden'' becomes. 
When people don't feel well, appetite is often the first thing to go 
which leads to insufficient energy-protein intake and weight loss.
---------------------------------------------------------------------------
    \7\ ``Chronic Care: A Call to Action for Health Reform.'' AARP 
Public Policy Institute. Accessed June 17, 2011 http://assets.aarp.org/
rgcenter/health/beyond_50_hcr.pdf.
    \8\ Ibid. 4
---------------------------------------------------------------------------
    But treating people's illnesses may actually worsen the situation 
as far as nutrition is concerned. National surveys show that more than 
9 of 10 older adults are taking prescription medications. According to 
the National Health and Nutrition Examination Survey, 64 percent of 
adults ages 60 and older are taking three or more prescription drugs 
per month. Almost 40 percent are taking five or more prescription 
medications per month \9\--and that's the average! In a population with 
such a high burden of illness, the likelihood that people will be on 
multiple medications is all but certain. Some drugs, like digitalis, a 
common medication for those with heart problems, directly suppress 
appetite. Others, like medications for arthritis or antibiotics, can 
cause stomach upset.
---------------------------------------------------------------------------
    \9\ Gu Q, Dillon CF, Burt VL. ``Prescription Drug Use Continues to 
Increase: U.S. Prescription Drug Data for 2007-8.'' NCHS Data Brief. 
2010 Sept; (42):1-8. Accessed June 17, 2011. http://www.cdc.gov/nchs/
data/databriefs/db42.pdf.
---------------------------------------------------------------------------
    Then, there is another group of medications that can cause 
malabsorption, i.e. the medicines inhibit the uptake of nutrients from 
the intestinal track.
    Another disease that is a major factor in under-nutrition in the 
elderly is dementia, a slowly progressive disease found in almost 50 
percent of people over the age of 85. It is the fifth leading cause of 
death for those over 65.\10\ Data shows that it strikes women with far 
greater frequency than men, with \2/3\ of the cases being women, who 
according to census data are far more likely than men to be poor and 
live alone. So here we have people who may not feel hungry, who may 
quite literally forget to eat and, even if they do remember, may be 
unable to figure out how to prepare even the most rudimentary of meals. 
In this all too common scenario the probability of admission to a 
nursing home rises exponentially. Yet a low cost, simple intervention 
such as home meal delivery or congregate meals can reduce 
hospitalization and delay nursing home admissions thus significantly 
lowering the costs of what is otherwise an extremely high cost 
population and a major driver of health care expenditures.
---------------------------------------------------------------------------
    \10\ ``2011 Alzheimer's Disease Facts and Figures, Fact Sheet.'' 
March 2011, p1-2. Accessed June 17, 2011 http://www.alz.org/
documents_custom/2011_Facts_Figures_Fact_Sheet.pdf.
---------------------------------------------------------------------------
    Aside from these common medical problems however there are many 
social factors that play a vital role in the health and well-being of 
the elderly. Compared to the under 65 population, almost 9 percent of 
the elderly live at or below poverty.\11\ Data from numerous studies 
shows that poverty and hunger go hand in hand in the elderly. This is a 
problem that will only get worse. A recent survey by AARP's Public 
Policy Institute \12\ reported that one quarter of those surveyed who 
were ages 50 and over, said they had already exhausted all their 
savings during the recession and over a third who were having 
difficulty making ends meet had to stop or cut back on saving for 
retirement. Food insecurity is a problem that will grow as more and 
more old people are faced with having to choose between food, rent or 
medicine. Addressing hunger through title III's nutrition programs will 
help seniors stay independent in their own homes.
---------------------------------------------------------------------------
    \11\ ``A Profile of Older Americans: 2010'', p. 1. Administration 
on Aging (AOA), U.S. Department of Health and Human Services. Accessed 
June 17, 2011 http://www.aoa.gov/aoaroot/aging_statistics/Profile/2010/
docs/2010profile.pdf.
    \12\ ``Recovering from the Great Recession: Long Struggle Ahead for 
Older Americans.'' May 2011, p. 3. Sara E. Rix, AARP Public Policy 
Institute. Accessed June 17, 2011. http://assets.aarp.org/rgcenter/ppi/
econ-sec/insight50_recovering.pdf.
---------------------------------------------------------------------------
    Physical disability, frailty and dementia separately and in 
combination mean that many seniors experience difficulty with shopping 
and meal preparation. For example, people who've ``aged in place'' 
either in rural or suburban areas may find themselves living miles from 
a grocery store and, unable any longer to drive, dependent on the good 
will of neighbors, friends or relatives to get out to shop for food. 
Even in areas with reasonably good public transportation, buses and 
subways may be difficult for the frail and disabled especially if 
trying to lug groceries or maneuver a small shopping cart. Furthermore, 
as I can attest from my own experiences making home visits in the South 
Bronx, many patients are afraid to venture beyond their apartments. 
They learned the hard way that denizens of the urban jungle saw them as 
``easy prey''. I cannot tell you how many of my patients ended up 
defaulting to a ``tea and toast'' diet, essentially devoid of 
nutritional benefit because they were trapped in their own apartments 
and couldn't or wouldn't risk a trip to the store for food. For them, 
meals on wheels was central to their survival.
    But does ``under-nutrition'' or ``hunger'' really matter? 
Absolutely--and here's why. Under-nutrition leads to any one of several 
types of nutritional deficiencies. Whether it's not enough calories to 
maintain weight, insufficient protein to maintain muscles and other 
vital organs or deficiencies of vitamin and micronutrients, such as 
zinc, unless older people eat enough ``good food'' bad things happen. 
These include:

     Weight loss--and at least two longitudinal studies suggest 
that weight loss in later life predicts mortality \13\;
---------------------------------------------------------------------------
    \13\ ``The Role of Nutrition in Maintaining Health in the Nation's 
Elderly: Evaluating Coverage of Nutrition Services for the Medicare 
Population.'' 2000, p. 67. Institute of Medicine. National Academy 
Press. Washington, DC.
---------------------------------------------------------------------------
     Skin problems, such as the development of pressure ulcers 
and decreased wound healing, especially of the skin tears that are such 
a common occurrence with the papery skin seen in the oldest old. 
Unhealing wounds leave people vulnerable to infections of the 
surrounding skin, soft tissues and underlying bone;
     Loss of muscle mass, or sarcopenia, causes loss of 
strength and function which predisposes to increased falls leading to 
hospitalization, nursing home placement and death \14\;
---------------------------------------------------------------------------
    \14\ Fielding RA, Vellas B, Evans WJ, Bhasin S, et al. 
``Sarcopenia: an undiagnosed condition in older adults. Current 
consensus definition: prevalence, etiology, and consequences. 
International working group on sarcopenia.'' J Am Med Dir Assoc. 2011 
May; 12(4):249-56. Epub 2011 Mar 4.
---------------------------------------------------------------------------
     Suppressed immune function, which makes people more 
susceptible to infections and less able to mount a defense against 
otherwise minor infections;
     Fatigue which exacerbates depressive symptoms and saps any 
energy an individual might have to stay engaged with their communities 
and wider social network;
     Increased frailty, which has been described as loss of 
physiologic reserve that increases the risk of disability, which is a 
sort of precursor state to being dependent on another individual to 
compensate for functional deficits \15\;
---------------------------------------------------------------------------
    \15\ Buchner DM, Wagner EH. ``Preventing frail health.'' Clin 
Geriatr Med. 1992 Feb; 8(1):1-17, cited in Rockwood K, Fox RA, Stolee 
P, Robertson D, et al. ``Frailty in elderly people: an evolving 
concept.'' CMAJ. 1994 Feb 15; 150(4):489-95.
---------------------------------------------------------------------------
     Functional decline and impairment, which means people have 
trouble with their own personal care, e.g. bathing, as well as things 
like ambulation, thus increasing the risk of falls and gradual loss of 
the capacity to independently manage routine household tasks such as 
grocery shopping and meal preparation;
     Higher complication rates and more severe complications 
from underlying chronic conditions or acute inter-current illnesses, 
such as pneumonia, and longer lengths of stay when hospitalized;
     Depression, loneliness and sometimes a condition known as 
pseudodementia;
     Falls which may arise from altered function brought about 
by any number of vitamin deficiencies such as Hypovitaminosis D, 
Vitamin B12 deficiency or from unrecognized dehydration;
     Delirium, which even when transient, has been shown to 
have long-term sequellae;
     Anemia from deficiencies of B6 (sideroblastic anemia) or 
B12 (megaloblastic anemia) which leaves people feeling exhausted and 
can even worsen heart failure.

    Any of these negative health outcomes have enormous implications 
for service utilization. For example, as was mentioned above, many of 
the consequences of malnutrition increase the risk of a fall. Already, 
according to the CDC \16\:
---------------------------------------------------------------------------
    \16\ ``Costs of Falls Among Older Adults.'' Centers for Disease 
Control and Prevention. Accessed June 17, 2011, http://www.cdc.gov/
HomeandRecreationalSafety/Falls/fallcost.html.

     One in three adults 65 and older falls each year.\17\ \18\
---------------------------------------------------------------------------
    \17\ Hausdorff JM, Rios DA, Edelberg HK. ``Gait variability and 
fall risk in community-living older adults: a 1-year prospective 
study.'' Arch Phys Med Rehabil. 2001 Aug; 82(8):1050-6.
    \18\ Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, et al. 
``Preventing falls among community-dwelling older persons: results from 
a randomized trial.'' Gerontologist. 1994 Feb; 34(1):16-23.
---------------------------------------------------------------------------
     Of those who fall, 20 percent to 30 percent suffer 
moderate to severe injuries that make it hard for them to get around or 
live independently and increase their chances of early death.\19\
---------------------------------------------------------------------------
    \19\ Alexander BH, Rivara FP, Wolf ME. ``The cost and frequency of 
hospitalization for fall-related injuries in older adults.'' Am J 
Public Health. 1992 Jul; 82(7):1020-3.
---------------------------------------------------------------------------
     Older adults are hospitalized for fall-related injuries 
five times more often than they are for injuries from other causes.\20\
---------------------------------------------------------------------------
    \20\ Ibid. 19.

---------------------------------------------------------------------------
    These statistics translate into real money:

     In 2000, the total direct cost of all fall injuries for 
people 65 and older exceeded $19 billion: $0.2 billion for fatal falls, 
and $19 billion for nonfatal falls.\21\
---------------------------------------------------------------------------
    \21\ Stevens JA, Corso PS, Finkelstein EA, Miller TR. ``The costs 
of fatal and nonfatal falls among older adults.'' Inj Prev. 2006 Oct; 
12(5):290-5.
---------------------------------------------------------------------------
     By 2020, the annual direct and indirect cost of fall 
injuries is expected to reach $54.9 billion (in 2007 dollars).\22\
---------------------------------------------------------------------------
    \22\ Englander F, Hodson TJ, Terregrossa RA. ``Economic dimensions 
of slip and fall injuries.'' J Forensic Sci. 1996 Sept; 41(5):733-46.
---------------------------------------------------------------------------
     In a study of people age 72 and older, the average health 
care cost of a fall injury totaled $19,440, which included hospital, 
nursing home, emergency room, and home health care.\23\
---------------------------------------------------------------------------
    \23\ Rizzo JA, Friedkin R, Williams CS, Nabors J, et al. ``Health 
care utilization and costs in a Medicare population by fall status.'' 
Med Care. 1998 Aug; 36(8):1174-88.

    If home delivered services and congregate meal programs could 
reduce by even a fraction of what just this one preventable event costs 
the health care system, the program would pay for itself. Multiply that 
by the number of items in the list above and the value of these title 
III-C Nutritional programs is manifest. Especially since we know, from 
research studies and from experience, that providing nutritional 
support to vulnerable elders works. For example, in one study 
nutritional support of malnourished elderly individuals after a 
hospitalization actually improved their function.\24\ Translation? It 
reduced the likelihood of nursing home placement.
---------------------------------------------------------------------------
    \24\ Neelemaat F, Bosmans JE, Thijs A, Seidell JC, et al. ``Post-
discharge nutritional support in malnourished elderly individuals 
improves functional limitations.'' J Am Med Dir Assoc. 2011 May; 
12(4):295-301. Epub 2011 Feb 11.
---------------------------------------------------------------------------
    This discussion would not be complete however without asking what 
the impact of these programs is for the elderly themselves. Ensuring 
that old people have a balanced, nutritionally complete diet, can 
reverse many of the consequences of malnutrition or outright prevent 
them. People feel better, stronger, and more able to care for 
themselves. Which is good. However the other real ``take away'' is that 
the importance of these programs transcends food--they not only give 
people something to eat, they give people a reason to eat. They are a 
life-line out to the community for low-income older people whose world 
has often been reduced to a couple of rooms due to frailty, illness and 
dysfunction. The nutrition programs are a source of socialization which 
is so often missing for the old. Knowing that someone's coming by is 
often the only reason for them to get out of bed. Forming a 
relationship with the person delivering the meal so they have someone 
to talk to or getting out to a lunch program where they'll see friends 
a couple of times a week is as important as the food itself.
    I saw this with my father. He received home delivered meals after 
an automobile accident at age 82 left him with a traumatic brain 
injury. He could no longer drive, his higher executive functions were 
impaired and gradually his short-term memory eroded but his desire to 
live in his own home stayed strong. I live 75 miles away from where he 
lived and don't own a car. I can assure you that had he not had Meals 
on Wheels, which came by 5 days a week, he would have been in a nursing 
home for the last 14 years of his life. I also know how much he valued 
the volunteer's visit, which was the high point of his day. That 
volunteer was his audience for an all too brief but important few 
minutes a day, relieving some of the tedium and loneliness of his life 
out there in his house in the country.
    Meals on Wheels did something for me too in my role of long 
distance caregiver: it was my early warning system if something was 
going wrong. Over the course of several years I'd get a call that 
either he appeared bruised from having fallen, or ``wasn't himself '' 
or the heat didn't seem to be working. Meals on Wheels were my eyes: 
they got to know my father and alerted me about ``a problem'' before it 
became ``a catastrophe''.
    The bottom line is title III-C funds are amazingly effective at 
helping seniors help themselves by feeding not only the body but the 
person. Having social connections and having enough to eat fulfills 
several basic human needs and keeps people healthier, longer. Healthy 
people, even when they are very old, don't need and don't use as many 
health care services as sick people do. Without a strong program of 
home delivered meals and congregate dining the really big ticket items 
go up: more trips to the emergency rooms, more frequent 
hospitalizations with longer stays, more re-admissions, and more years 
in a nursing home.\25\ As a nation, it behooves us to start spending 
smart. Providing funding for these programs is the way to do just that. 
Nutritional programs are low cost solutions for high cost problems.
---------------------------------------------------------------------------
    \25\ Yang Y, Brown CJ, Burgio KL, Kilgore ML, et al. 
``Undernutrition at baseline and health services utilization and 
mortality over a 1-year period in older adults receiving Medicare home 
health services.'' J Am Med Dir Assoc. 2011 May; 12(4):287-94. Epub 
2010 Oct 27.
---------------------------------------------------------------------------
    In conclusion I would make several recommendations for things that 
can be done at the Federal level. First, I would urge not only the 
reauthorization of funding for the nutritional programs covered under 
Title III-C of the Older American's Act, I would suggest they be 
expanded. The elderly use more health care services than any other age 
cohort and the low-income elderly, or dual eligibles, even more so. 
Therefore, while there is no single ``silver bullet'' to rein in costs 
for Medicare these title III programs come about as close as you will 
ever get to a simple, low-cost, low-tech intervention that's very 
popular with patients and their families with an incredible pay back. 
Second, I would advise that there be support for demonstrations, pilot 
programs, evaluations and applied research aimed at better 
understanding the needs of the populations served and testing creative 
strategies for improving outcomes. Third, I would recommend that 
certain elements of the program be strengthened to make it even more 
cost-effective. Specifically, the requirements for the Nutrition 
Programs under the Older American's Act should:

     Ensure the nutritional completeness and adequacy of key 
nutrients in delivered or served meals. For many seniors these meals 
are their main source of daily food intake. Therefore, they need to 
have sufficient calories, high quality protein from meat, fish or 
poultry, green, leafy vegetables and fresh fruit. Research has shown 
that nutritional supplements are unnecessary if people are eating a 
well-balanced diet.
     Target specific highly vulnerable groups, such as women, 
African-Americans and the homebound for receipt of enhanced services.
     Tailor the program's services to increase effectiveness 
for people with particularly high burdens of illness or high energy 
(caloric) requirements, such as those with Parkinson's Disease, who 
burn through calories because of tremors.
     Include nutritional education and counseling to patients 
and caregivers.
     Give the program flexibility to accommodate regional, 
ethnic and racial food preferences and improve palatability and taste.

    I thank you for your attention and providing the opportunity of 
addressing the committee.

    Senator Sanders. Dr. Koren, thanks very much for your 
testimony.
    Let me begin the questioning with Ken Gordon. Ken, you live 
and I used to live years ago in one of the most rural parts of 
a rural State. We got a lot of snow in the wintertime. People 
are isolated. Talk for a moment about the impact of Meals on 
Wheels among elderly, frail people in a very rural part of 
America?
    Mr. Gordon. They are incredibly important to people's well-
being. Social isolation is in fact a huge problem, particularly 
so in rural environments, where there's little social 
interaction, and apartment buildings or other settings. So not 
only do they provide essential nutrition for individuals who 
may have difficulty being able to travel to a senior center or 
to a grocery store to pick up food, but they help on the social 
end as well.
    Senator Sanders. Thanks.
    Dr. Koren, let me ask you a question. I read your testimony 
with great interest, and I think the thrust of what you are 
saying, which I would like you to elaborate on, is that if 
seniors are not getting the nutrition that they need, in a 
dozen different ways it ends up costing us as a society and 
costing the government substantially more money to address 
needs that result from lack of nutrition.
    Do you want to elaborate on that point, please?
    Dr. Koren. Yes. As I mentioned, there are a lot of 
physiologic problems with aging and also medical conditions. 
But undernutrition, malnutrition, causes in and of itself even 
further conditions. As I mentioned, you have muscle wasting, 
which causes people to be weak. They fall more. You have--
    Senator Sanders. So you're saying--I'm sorry to interrupt 
you--is that people who do not have adequate nutrition are more 
likely to sustain injuries falling?
    Dr. Koren. Yes.
    Senator Sanders. And what is the cost of taking care of 
people who fall?
    Dr. Koren. The 2000 costs were $19 billion.
    Senator Sanders. Let me just mention. That's falls.
    Dr. Koren. That's falls; it's a single condition.
    Senator Sanders. The cost of this entire bill that we're 
talking about nutrition and nonnutrition, is $2 billion, 
compared to $19 billion addressing just the issues relating to 
falls.
    Please continue.
    Dr. Koren. The $19 billion was in 2000. The estimated costs 
for falls in 2020 is $54 billion. The costs for this are going 
up. So even that one condition alone, which is worsened by the 
other problems that come with malnutrition--anemias, 
depression, and wasting of muscles--all of these things are 
things that can be prevented, and they also make the underlying 
medical conditions far worse for people. So it worsens things.
    For example, anemia can worsen heart failure. That's one of 
the major drivers of health costs in this country today, is 
caring for people with congestive heart failure. So the 
interplay of the problems that occur from undernutrition make 
underlying medical conditions far worse.
    Senator Sanders. Mr. Blancato, say a few words, if you 
will, about the unmet need in this country? What we've heard 
from Dr. Koren is that in fact as a nation we are unnecessarily 
spending many, many billions of dollars because seniors are 
incurring a number of illnesses and problems because of poor 
nutrition.
    Could you tell us what you perceive to be the unmet needs 
in terms of nutrition and seniors?
    Mr. Blancato. I think a lot of it is reflected in the 
numbers that we provided in the statements about the number of 
food-insecure people, that could range between 3 and 6 million, 
the 87 percent of older people who have those common three 
chronic diseases. The one on diabetes in particular stood out 
as one that indicates that for them they have a three times 
higher rate of being placed in nursing homes.
    Again, the idea with the Older Americans Act was to catch 
the problem early, to find when the person was assessed as 
being at risk and potential institutionalization it was because 
of many reasons, and because of nutritional needs. So the idea 
of the intervention early was intended to save the dollars that 
are down the road.
    I think that this program has proven itself over and over 
again through the work that's been done and, as pointed out by 
the GAO, by the evaluation that is done of this program on a 
regular basis to ensure it's meeting its goals.
    Senator Sanders. Thanks very much.
    Senator Paul.
    Senator Paul. Thank you, Senator Sanders.
    I still can't get over how we're going to spend more money 
and we're going to save money by spending more money. This idea 
that for some--people are going to get less injuries from their 
falls. Dr. Koren just said people are still falling and their 
costs are rising. The rising nutritional costs, all the 
statistics seem to show that we're getting worse, not better. 
We're spending more, not less.
    If we're going to make this argument that somehow providing 
nutrition is going to make the injuries less from falling, 
shouldn't we have some data? It sounds like the data argues the 
opposite. The data argues we're spending more on injuries from 
falls as a percentage, we're spending more on nutrition as a 
percentage, we have more problems, not less problems.
    You have to have data that proves your points. You have to 
argue somehow that we are making progress, that we're saving 
money. You can't just say that we're going to spend $2 billion, 
why not spend $4 billion or why not spend $10 billion to save 
more money? You have to prove what we're actually asserting.
    Now, one of the things I was curious about--I don't have 
arguments against Meals on Wheels. I like Meals on Wheels. I do 
have an argument against a multimillionaire getting Meals on 
Wheels. I do have a question in my mind when Dr. Koren says her 
father benefited from it. I have no question her father 
benefited from it, but my question is should a guy or a fellow 
working at McDonald's be paying taxes to provide Meals on 
Wheels for the father of a physician? Is there not anybody else 
who has that question, whether or not we should target people, 
those who are in need or whether everybody--does Warren Buffett 
need Meals on Wheels? If Warren Buffett's father or his 
daughter lives nearby, do they need Meals on Wheels? Should we 
not ask these questions, whether or not there is someone else 
to provide or what the means of the people are before we give 
these programs? We don't have unlimited programs.
    I really think there are questions about this. I guess my 
question to Dr. Koren would then be, if the health care costs 
related to falls, are going up, how is that an argument that 
nutrition is somehow helping the health care costs related to 
falls?
    Dr. Koren. One of the reasons that costs are going up are 
there are more old people. But another reason is that what 
nutrition can do is slow the trend. What we want to do is not 
eliminate every fall--that will never happen--but what you want 
to do is slow the rate of falls and decrease the incidence of 
falls, which can happen from better nutrition.
    I also want to improve the odds of a better outcome if 
people fall. And if malnourished older people fall, they're 
going to stay in the hospital longer and they're going to end 
up in a nursing home.
    Senator Paul. But basically you'd have to look at some 
statistics. And we aren't talking about numbers here; we're 
talking about percentages. So you'd have to look at percentage 
of old folks getting hip fractures and tell me you're getting 
less hip fractures because you're feeding them better through 
these poverty programs. I think you'll find those statistics 
don't exist.
    Most every group that comes up here wants to tell us how 
much worse the problems are because they can get more money 
because the problems are worse. I don't see anybody coming 
forward to any of these committees saying, ``oh, the problems 
are getting better, the war on poverty is really working, we 
have less poverty now.''
    We're not looking at numbers, raw numbers. Everybody 
understands the population's growing. But if you look at 
percentages, what everybody who comes before the committee 
says: ``Things are worse, things are worse; give us more 
money.'' Well, things are worse; what happened to the money we 
already gave you?
    We have 70 programs doing the same thing. I think we need 
to ask the question, how do we get rid of duplicate programs? 
My question to Ms. Brown would be: Do you have any suggestions 
for how we would get rid of duplicate programs in nutritional 
assistance? Thank you.
    Ms. Brown. Just for the record, we're not recommending 
there be a change in any single program. We are, in view of the 
dire fiscal condition of the country, suggesting that we need 
to step back and look across the number of different programs 
that we're offering right now and see if we can find ways to 
increase the efficiencies, especially as we expect the demand 
to grow.
    It's not a simple issue, and all of these programs were 
created because there was some kind of need. If we were to step 
back and look across the programs, the things that we would 
have to keep in mind are what any effects of any change would 
be on the recipients and those who need the services and also 
what the cost-effectiveness would be.
    The actual decisions about how programs would be changed, 
combined, many different options, would be policy decisions.
    Senator Sanders. Thank you.
    Senator Franken.
    Senator Franken. Ms. Brown, Senator Paul asked for actual 
research. It sounds like you have done research on the Older 
Americans Act, the nutritional programs in that. Is that true?
    Ms. Brown. With the 18 programs that we identified that 
existed ought to provide nutrition, we looked at each of those 
programs to see what kind of research was available to tell us 
whether the programs achieved their goals, the specific goal of 
the program. For 11 of the programs, there wasn't enough 
research; and for the remaining, there was research and, yes, 
this program, the senior nutrition program, is one of the ones 
that is achieving its goals.
    Senator Franken. So by achieving its goals, do you mean 
that it saves money and that by providing these nutritional 
programs, it allows people to stay in their homes and therefore 
cuts the costs to the taxpayer in what we would pay and to 
everyone in terms of what they pay in terms of going into 
nursing homes?
    Ms. Brown. When I say that they met their goals, we looked 
at the explicit goals of the program as they're laid out in the 
law and in the regulations. The two most clear are related to 
food insecurity, and there is some evidence that these programs 
help address food insecurity, and the other is to address 
isolation of older adults, and there's some evidence that the 
programs have an effect on that, too.
    Senator Franken. Mr. Gordon, the clear inference of those 
results would be the ability to stay out of nursing homes, 
wouldn't it, and be able to stay at home, if you reduce 
isolation and increase nutrition?
    Mr. Gordon. Yes, Senator, we see evidence of that every 
day.
    Senator Franken. Now let me ask you this. Senator Paul had 
questioned how only people in Washington could see the 
relationship between spending money in that way and that 
actually spending money could save money. Do people in Vermont 
see that relationship, because people in Minnesota do and we've 
learned that people in Kansas do. So it's not only in 
Washington, is that correct?
    Mr. Gordon. That's correct. The Vermont legislature and 
several Vermont governors have also recognized that 
relationship.
    Senator Franken. Let me ask you this, too. Senator Paul 
brought up the idea of Warren Buffett being a recipient of 
Meals on Wheels. I think that's very unlikely. But he makes the 
point that there are probably some people who in some way or 
another could either contribute to the Meals on Wheels. And 
some people do, right, or the congregate dining? Some seniors 
do, right?
    Mr. Gordon. Correct.
    Senator Franken. OK. But I think what he's suggesting is 
that if we do this program at all, and since Ms. Brown seems to 
say that it achieves its goals, if we do this program at all, 
what he is I think suggesting is that the Older Americans Act 
set up a large bureaucracy to determine whether any recipient 
of either congregate dining or Meals on Wheels has a little bit 
too much money to qualify.
    He also talked about absurdity. Do you think that it would 
be absurd to set up that kind, really in a cost-benefit 
analysis, to set up a vast bureaucracy to make sure that Warren 
Buffett doesn't take too much advantage of the Meals on Wheels 
program?
    Mr. Gordon. Well, the intent----
    Senator Franken. Is that absurd?
    Mr. Gordon. In my mind, yes. As I understand it, the intent 
of Congress was that this program not be means-tested. I can 
also tell you that we worked carefully with individuals to talk 
about family supports and how family can help them remain 
independent in the community, and that's a part of our work 
with every senior that we engage.
    Senator Franken. Ms. Brown, I was a little confused, 
because you talked about 18 different programs and Senator Paul 
talked about 70 programs. Do you have any idea--I know the 
Senator has left, but do you have any idea where that 
discrepancy comes from?
    Ms. Brown. Yes, Senator. When we started our work to review 
all the domestic nutrition assistance programs, we went through 
the catalogue of many, many Federal programs. First we 
identified any programs that could provide food assistance or 
provided funding that would support food assistance. After we 
identified those 70, then we narrowed it down to those 18 
programs that existed solely to provide nutrition assistance. 
And looking at the available research and the administration of 
those 18 programs was plenty for us to do.
    Senator Franken. Thank you.
    Thank you, Mr. Chairman.
    Senator Sanders. Thank you, Senator Franken.
    Senator Hagan.

                       Statement of Senator Hagan

    Senator Hagan. Thank you, Mr. Chairman. I really appreciate 
you holding this hearing today. In my State of North Carolina, 
we have an aging population. In fact, the 65-year-old 
population is expected to double in the next 20 years to 2.1 
million people. Currently close to 30 percent of the seniors 65 
and older are living alone and 25 percent of those have an 
income between 100 to 200 percent of the poverty level.
    I know that the congregate and the home-delivered meals 
provided to our seniors, particularly our low-income seniors, 
really provide the vital nutrition to keep them alive. It's a 
very important program to millions of elderly people across the 
country, so I appreciate you holding this hearing.
    Mr. Blancato, you spoke of cutbacks in services and 
volunteers because of rising gas prices and food prices. Can 
you explain in more detail how the nutrition programs that rely 
on volunteers and provide also more information on the impact 
that such cutbacks in services have on seniors trying to access 
these programs.
    Mr. Blancato. Yes, Senator. Thank you. I point out, I have 
a brother who's aging in Winston-Salem, so he's in one of your 
populations there.
    The volunteers are impacted by the rising cost of gasoline 
in their ability to provide their volunteer service when the 
prices go up and end up having them being unable to continue to 
do volunteer work. So they are cutting back on their volunteer 
hours in these programs.
    We did a survey, and I'd be happy to share it for the 
record, but some of the things we learned were that programs 
ought to be cut back, the number of meals would have to be 
scaled back, waiting lists would start for people who applied. 
This is all because of rises in gas prices, food prices, 
particularly the food that's most important that's provided 
daily in these programs--beef and meat and bread and things of 
that nature.
    We're finding that the responses we're getting from our 
members run the gamut of what these cutbacks are really doing 
for their day-to-day services.
    Senator Hagan. I've been hearing that a lot, too, with 
rising gas prices, that the volunteers can't afford it.
    Mr. Gordon, in your testimony--and I know it was brought up 
already, too--we talked upon the issue about seniors who live 
in rural areas. North Carolina has a large population in the 
rural areas and many of them, according to your testimony, are 
at the greatest risk of hunger. Can you discuss some of the 
solutions that would target this vulnerable population?
    Mr. Gordon. It's a challenging area because of the 
logistics and the miles that need to be traveled. One of the 
promising areas of practice that we've begun to see around the 
country is merging our senior meal programs with the local food 
movement. We're seeing more and more attention being paid to 
growing food locally, to rely on local agricultural economies 
and distribution systems that are a part of that. I think 
particularly in rural communities, that is a solution to look 
for as we move forward.
    Senator Hagan. Thank you.
    Dr. Koren, in your testimony you make some recommendations 
for strengthening the nutrition programs. In particular, you 
recommend that we ensure the nutritional completeness and 
adequacy of key nutrients in delivered or served meals. Can you 
speak to the current nutritional components of the meals? I'm 
just curious, who determines the caloric, the macro and the 
micronutrient content of the meals, and does it vary State by 
State?
    Dr. Koren. I can't give you the exact statistics. I do have 
them in some of the materials I used to prepare my testimony. 
You also might be able to find that from Ms. Greenlee. Usually 
it is my understanding that the delivered meals provide about 
one-third of the recommended daily allowances for proteins, 
calories, and nutrition. But as I said, these meals are very 
often the primary food intake for people during the day.
    Also, with some of the cutbacks it's been harder to have 
high quality protein, such as meat, fish, poultry, and so 
forth, and also to have green, leafy vegetables and fresh 
fruits, which are really key for delivering the kinds of 
nutrients that elderly people need.
    Senator Hagan. So what is your recommendation on how to 
address that?
    Dr. Koren. I think some of the ideas that we've heard from 
Mr. Gordon, and also to really look carefully at these programs 
and see, are there ways of enhancing these. There have been 
questions about the provision of nutrient supplements, vitamin 
pills, things like that, with people. But also, if we can sort 
of think about these programs and enhance them so that the food 
itself is nutritious and can really deliver the kind of 
nutrient content that people require.
    Mr. Blancato. Senator Hagan, if I may, there's another 
point, too, and that is if we more closely enforce the 
provision of the law now that allows for consultation with 
dieticians with the nutrition programs, I think that would also 
address that issue, and we should look at that.
    Senator Hagan. Thank you.
    Ms. Brown, in your testimony you discuss how some seniors 
might receive assistance through the alternative means other 
than the elderly nutrition program. You mentioned that some 
seniors might choose to participate instead in the Supplemental 
Nutrition Assistance Program, or SNAP. Did you look at why some 
seniors might choose SNAP over the elderly nutrition program 
and, if so, what were the reasons?
    Ms. Brown. I think the specific thing with SNAP is that 
because it's an electronic benefit transfer, you can swipe a 
card in a supermarket, and you have the option to buy the food 
that you prefer and what you'd like to have. I think that's the 
main thing. There are people who also participate in the 
congregate meals or home-delivered meals and SNAP.
    Senator Hagan. Are there restrictions on what they can 
purchase with the SNAP card, the SNAP benefit?
    Ms. Brown. Yes, there are, and it's just primarily nonfood 
items, no alcohol, tobacco, that kind of thing.
    Senator Hagan. You also discuss that the GAO found overlap 
in these 18 nutritional programs for seniors run by the USDA, 
HHS, and DHS. However, when I look at the list of these 18 
programs, some of the programs don't appear to be geared toward 
the elderly. For example, the school breakfast program and the 
national school lunch program. Do all 18 of these programs that 
you've cited have an elderly component, and if not which of the 
18 could realistically be coordinated to ensure that services 
are provided for seniors needing nutritional assistance?
    Ms. Brown. I can explain the 18. That work was done at a 
request to look at the total domestic nutrition assistance 
programs in the United States.
    Senator Hagan. Not just for the elderly?
    Ms. Brown. Correct. Then for this testimony we stepped back 
and highlighted the ones that we know are available to the 
elderly. I can tell you, there's the commodity supplemental 
food program, the child and adult care food program. There's an 
emergency food program that provides commodities, and several 
others which I'd have to find.
    Senator Hagan. Thank you, Mr. Chairman.
    Senator Sanders. Thank you, Senator Hagan.
    Let me conclude the hearing by, first, thanking all of the 
panelists for excellent presentations without exception; and 
second of all, saying that I think that this discussion that 
we've had this morning raises a very fundamental issue about 
this country. Today in America we have the most unequal 
distribution of wealth and income of any major country on 
Earth. Some people are doing phenomenally well, a lot of people 
are doing very, very badly economically, and those numbers are 
growing.
    We've got to address that issue from a moral perspective, 
what do we do when millions of senior citizens do not get the 
nutrition that they require. Are we happy with that as a 
nation?
    The second issue--and I think Dr. Koren went into that at 
some length--is whether or not that is good economics, whether 
it makes sense that at a time when health care costs are 
escalating and we spend much, much more per person on health 
care than any other industrialized Nation on Earth, and that 
maybe one of the reasons is that we do a pretty bad job in 
terms of prevention in general, and maybe it does not make a 
whole lot of sense to see increased costs, health care costs, 
because of excessive emergency care utilization, nursing home 
utilization, hospital utilization, because people are not 
getting the nutrition they need.
    Is that good economics? I think not. So that's where we 
are, and I want to thank you all for commenting on this issue 
and for your excellent presentations. Thank you very much.
    The hearing is now adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                       Prepared Statement of AARP
    AARP is a nonprofit, nonpartisan organization with a membership 
that helps people 50+ have independence, choice and control in ways 
that are beneficial and affordable to them and society as a whole. We 
appreciate this opportunity to offer some preliminary ideas on the 
reauthorization of the programs and services of the Older Americans Act 
(OAA), pending formal legislative language. Our interest is to ensure 
that the act maintains critical service and information roles, and 
promote greater responsiveness to the needs of mature and older 
Americans, including those facing nutritional risk aggravated by 
advancing age.
    Today nearly 6 million older Americans experience hunger and this 
number will only increase as the aging population grows. Between 2006 
and 2008, the percentage of poor and near-poor elderly struggling with 
hunger or lacking sufficient nutrition and food resources more than 
doubled--from 4.7 percent to 10.1 percent. It is projected that by 
2025, this number will reach 12.6 million Americans 50+, or 14.9 
percent of this population. Based on recent studies, more than 5 
million seniors, or 11.4 percent of all seniors, experienced some form 
of food insecurity in the mid-2000s, and the number is increasing. 
Further, a recent study by NASAUD and the AARP Public Policy Institute 
reported that although demand for meals has increased substantially 
since the beginning of the recent recession, State funding for these 
programs has not kept pace and in several areas has decreased. The 
dimensions of the senior hunger problem are clearly growing as 
solutions appear to evade the grasp of our policy reality.
    In this period of economic downturn, AARP is most concerned that 
programs, authorities and partnerships that have already proven 
effective in meeting the needs of vulnerable older Americans be 
maintained and strengthened. We believe that older persons would be 
best served if Congress works expeditiously to reauthorize the program, 
with only minor changes in existing programs to improve efficiency. As 
related to combating senior food insecurity and nutritional risk, AARP 
believes that better coordination of existing OAA nutrition programs 
with other Federal, State and local programs holds great promise and 
merits the support of the Administration and Congress.
   i. reinforcing capacity for delivery of home and community-based 
                           nutrition services
    Helping people to grow older in their communities with independence 
and dignity is a bedrock goal of the Older Americans Act. All too 
often, advancing age and increasing frailty threaten the ability of 
older persons to remain healthy, nutritionally secure and independent 
in their own homes. The fear of having to enter a nursing home due to 
vulnerabilities aggravated by nutritional risks and other aging-related 
circumstances weigh heavily on the minds of many older persons and 
their families.
    AARP is open to potential new initiatives that complement existing 
caregiver and service programs with innovative and effective approaches 
to expanding nutrition program access through the existing and evolving 
network of home and community-based nutrition services. Newly adopted 
nutrition initiatives, however, often require additional funds be 
provided through the annual OAA appropriations process. AARP urges that 
no OAA nutrition or other OAA services activities be sacrificed to pay 
for new programs. This would require real commitment and creativity 
given Federal budget constraints. In the past, OAA has not 
traditionally received significant new increases in funding.
    Over the past two decades, States have made great strides in 
improving the nutrition options for nutritionally at-risk older 
persons, especially for those who want to remain in their own homes and 
communities for as long as possible. However, the weak economy has 
reduced funding availability and has forced reductions or elimination 
of nutrition services in many instances for our members and other older 
Americans. Advocates in States across the country are working to 
preserve access to vital nutrition services for older adults in these 
tough economic times and to prevent or minimize the potential harmful 
impacts that cuts in services or benefits could have on these 
individuals. Successful State delivery strategies that AARP could 
support may include:

     better coordination of Federal and State nutrition program 
funding (e.g., State-only funded programs, USDA nutrition programs, and 
public-private nutrition initiatives) with the existing network of OAA 
nutrition programs and other OAA home and community-based services;
     streamlining administrative operations that will permit a 
designation of central points of coordination for nutrition services 
for seniors; and
     adopting nutrition assessment and eligibility management 
practices that allow targeting of resources to the persons most in 
need, especially those traditionally underserved. Aging and Disability 
Resource Centers (ADRCs) might be a source of help in providing 
individuals and their families with one-stop nutrition information and 
other assistance to enhance coordination of the range of home and 
community services.

    AARP also believes, however, that it is preferable to retain the 
current separation between the assessment of eligibility and the actual 
provision of nutrition services, so that the agency that conducts 
eligibility assessments does not have a financial interest in the type 
and amount of services authorized. Any potential and actual conflicts 
of interest by agencies authorizing or providing services should be 
avoided to ensure that older adults receive the services they need.
    The use of existing authorities under the OAA could also be 
explored to enhance nutrition and other community-based services under 
the Older Americans Act. Some examples could be the use of volunteers, 
support for innovative and proven intergenerational programs, and 
partnerships with National and State Title V Grantees to increase 
opportunities for Senior Community Service Employment Program enrollees 
to participate in the delivery of nutrition services.
    The aging network should consider where it can add real value and 
provide assistance to older adults at nutritional risk or experiencing 
food insecurity by leveraging partnerships and exploring new 
opportunities and coordination with Federal, State, local or public-
private programs and initiatives, especially if there is evidence-based 
data to support such efforts.
                ii. targeting of oaa nutrition services
    Administration of the programs and services provided under the OAA 
is more critical in these days of austere budgets than ever before. It 
is important to direct resources to areas that achieve the most impact 
while aiming to meet the goals of the act. Toward this end, the AARP 
supports uniform data collection procedures and definitions that permit 
evaluation of program effectiveness, especially regarding gaps in 
service to rural, frail, low-income and minority older persons. This is 
critical for addressing those elders who are food insecure and 
nutritionally at risk.
    Years of studies show pockets of under-service to certain older 
populations by the programs of the act. The Administration on Aging 
(AOA) has improved its ability to collect participant data in recent 
years. However, there are not adequate measures of the unmet need for 
services. Broadening the rigor and scope of data collection for title 
III nutrition programs could help demonstrate their impact on special 
populations and should be pursued. Toward that end, AARP continues to 
be concerned about the potentially harmful effect of mandatory cost 
sharing because of its undetermined impact on food insecure and 
nutritionally at-risk elders in target communities.
    For many years, AARP has advocated targeting OAA services to 
persons with the greatest social and economic need and, in particular, 
to low-income, older minorities. AARP continues to strongly support 
retention of the targeting provisions of the act. The flexible nature 
of the OAA programs is one of its strengths because it helps to garner 
broad public and political support. However, historically there have 
been problems in achieving adequate service delivery to older minority 
individuals. It is critical that new participation data collected by 
AOA be disseminated, so that the adequacy of current nutrition service 
delivery to older minorities can be evaluated. By tracking results, it 
is possible to ensure that more funding goes to those programs that 
achieve the best results with the targeted populations. Better tracking 
would also enhance ability to assess delivery of nutrition services to 
other underserved target populations, such as rural elders, and enable 
more effective allocation of OAA nutrition dollars.
           iii. aarp and aarp foundation anti-hunger efforts
    As such, AARP and its affiliated charity, AARP Foundation, are 
making a long-term commitment to help older Americans get nutritious 
food on the table so they will no longer have to make the devastating 
choice between basic needs like food and prescription drugs or food and 
housing. Drive to End Hunger is a national multi-year initiative 
designed to provide solutions to feed people today and prevent hunger 
among older Americans tomorrow.
    Drive to End Hunger aims to build national awareness about the 
issue of hunger among 50+ individuals. One platform for this is AARP's 
sponsorship of four-time NASCAR Sprint Cup Series Champion Jeff 
Gordon's No. 24 Drive to End Hunger Chevrolet. As part of this 
collaboration, Gordon and Hendrick Motorsports are engaging the NASCAR 
fan base, corporations, and charitable organizations through track 
engagement events across the country. AARP and AARP Foundation have 
also created a new online resource--www.drivetoendhunger.org--where 
anyone interested in learning more about the issue of hunger among 
older Americans can obtain information on the causes and consequences 
of hunger, as well as access resources to help eligible persons receive 
assistance.
    Drive to End Hunger aims to provide short-term support to people in 
need and to organizations serving the 50+ low-income segment, such as 
food banks, food pantries, and home meal service providers. AARP 
Foundation support comes in the form of both food and monetary 
donations. In only 6 short months since AARP and AARP Foundation 
launched Drive to End Hunger, we have provided the equivalent of 2.18 
million meals to local service providers in Alabama, Arizona, 
California, Colorado, Florida, Kansas, Michigan, North Carolina, 
Pennsylvania, South Carolina, Tennessee, and Virginia.
    Drive to End Hunger aims to increase participation in the 
Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) 
by utilizing AARP State Offices, volunteers, partners and existing AARP 
Foundation program infrastructure to educate and enroll eligible older 
Americans. While over 7 million 50+ individuals are eligible to receive 
benefits, only one-third are currently enrolled in the program. 
Participation in SNAP is low for many reasons including, but not 
limited to, misinformation about eligibility criteria, complexity of 
the application for benefits, and stigma associated with receiving 
public assistance. Not only will SNAP enrollment help nourish older 
Americans, increased participation will also help boost local economies 
as every $5 in SNAP benefits expended, generates $9.00 in local 
economic activity.
    Drive to End Hunger aims to develop sustainable solutions to 
hunger. Next month, AARP Foundation will launch a grant program and 
offer $1 million to fund projects that address the food needs of older 
adults experiencing hunger and focus on improving food access, 
adequacy, affordability, and appropriateness for 50+ Americans. State 
and local governments as well as national and community-based 
organizations will be eligible to apply.
    Drive to End Hunger aims to further thought leadership and research 
on hunger, paying particular attention to key research gaps that could 
lead to systemic solutions for 50+ older Americans.
                               conclusion
    Again, AARP appreciates the opportunity to address the critical 
issue of senior hunger, especially in the context of the OAA 
reauthorization as the Nation experiences a rapidly expanding older 
population. AARP believes that the economic climate demands a very 
targeted and reasonable approach to addressing the nutrition needs of 
older persons under the act while laying a foundation on which to build 
and direct future nutrition investments when the opportunity permits. 
We look forward to working with the groups in the aging network, 
Congress and the Administration to advance the interests, independence, 
and well-being of older Americans during this reauthorization process.
                 Prepared Statement of Feeding America
                              introduction
    Chairman Sanders, Ranking Member Senator Paul, and members of the 
U.S. Senate Committee on Health, Education, Labor, and Pensions, 
Subcommittee on Primary Health and Aging, thank you for the opportunity 
to submit this statement for the record on behalf of Feeding America 
and for holding this hearing. We look forward to hearing testimony from 
the witnesses and from committee members on the issue of senior hunger 
as well as the upcoming reauthorization of the Older Americans Act, 
particularly its impact on nutrition policies that impact the health 
and welfare of our Nation's increasing numbers of seniors.
    Feeding America is the Nation's leading domestic hunger-relief 
charity with a network of more than 200 food banks serving all 50 
States through over 61,000 local food assistance agencies. Feeding 
America food banks, as well as the food assistance agencies they serve, 
rely on a variety of public and private funding streams to feed 37 
million Americans, one out of eight, every year.
    During the worst economic downturn since the Great Depression, the 
number of American families struggling to make ends meet has increased 
significantly. Data being reported by the Federal Government mirrors 
what food banks across the country are seeing. In November 2010, the 
U.S. Department of Agriculture (USDA) released a report showing that 
more than 50 million Americans were at risk of hunger during the 2009 
calendar year. This number was an increase of nearly 14 million people 
since the economic recession began in 2007. With unemployment still 
hovering near 9 percent, the need for food assistance continues to grow 
and food banks continue to be pressed to meet the need in their 
communities. Last year, 37 million people, including 14 million 
children and nearly 3 million seniors, received emergency food 
assistance through the Feeding America network. This represents an 
increase of 46 percent since 2006.
    Many Feeding America food banks offer programs designed to meet the 
special nutritional needs of certain segments of the population, 
including children and seniors. Currently, 116 Feeding America food 
banks offer senior programs. The Federal Commodity Supplemental Food 
Program (CSFP) and the private Brown Bag (Food Box) delivery program 
are the most common program models. Combined, these programs account 
for 61 percent of the senior programs operated in the network and 87.6 
percent of the food distributed by senior programs. The other program 
models that food banks operate include senior home delivered meals and 
targeted mobile pantries. In total, more than 86.5 million meals are 
provided to seniors through these programs.
            the great recession, senior poverty, and hunger
    According to the U.S. Census Bureau, there are currently 38 million 
individuals in this country aged 65 and older. As the Baby Boom 
generation continues to age, this number is projected by the U.S. 
Department of Health and Human Services' Administration on Aging to 
increase by one-third by 2020, reaching nearly 55 million individuals. 
And, by 2030, the number of Americans aged 65 and older is projected to 
grow to 70 million people. At that time, seniors will comprise nearly 
one out of every five Americans.
    While the challenge that the aging of the Baby Boom generation--
those born between 1946 and 1964--would place on nutrition assistance 
programs has long been anticipated, the prolonged recession and its 
adverse impact on older American's financial security has made the 
challenge of meeting increased need more urgent. In addition to 
significant declines in retirement nest eggs, according to a 2009 
report by the Urban Institute, about 2 million adults age 55 or older 
were unemployed in August 2009, double the number in that age group who 
were unemployed just prior to the recession. Additionally, according to 
AARP, the average duration of unemployment rose for older job seekers 
from 20.2 weeks at the beginning of the recession to 29.9 weeks at the 
end. Moreover, the percentage of adults age 55 or older who were among 
the long-term unemployed (27 or more weeks out of work) rose from 23 
percent at the beginning of the recession to 38 percent at the end.
    Health and housing costs are a strain on the budgets of low-income 
older Americans, making it extremely difficult to afford other basic 
necessities such as food. According to a 2010 Feeding America study, 30 
percent of client households with seniors indicated that they have had 
to choose between food and medical care and 35 percent had to choose 
between food and paying for heat/utilities. Providing low-income 
seniors with nutrition assistance allows them to stretch their food 
budget and eases the burden of having to choose between buying food or 
other necessities, such as medicine and rent.
    Currently, one in six persons aged 65 and older lives in poverty, 
and another nearly one in three lives in near poverty. This is 
extremely troublesome given that seniors living below or near the 
poverty line are more likely to be at risk of food insecurity, and 
therefore at risk from the serious health consequences of not having 
proper nutrition. The prevalence of food insecurity among older 
Americans is a serious and growing problem in America. Given that the 
number of food insecure seniors is projected to increase by 50 percent 
in 2025, the demand for nutrition services among older Americans will 
continue to increase in the coming decades.
    It is particularly important that we address the nutritional needs 
of food insecure seniors. According to analysis of data from the 1999-
2002 National Health and Nutrition Examination Survey, seniors over the 
age of 60 who are experiencing some form of food insecurity are 
significantly more likely to have lower intakes of major vitamins, 
significantly more likely to be in poor or fair health, and more likely 
to have limitations in activities of daily living. Additionally, 
adequate nutrition is essential for preventing and managing chronic 
medical conditions. Without the proper nutrients seniors are at risk of 
the following: deterioration of existing health conditions, increased 
disability, decreased resistance to infections, lengthening of hospital 
stays, deteriorating mental health, increased risk of underweight, and 
at risk for diabetes.
    As the number of older Americans living in poverty and facing food 
insecurity continue to increase as a result of the fallout from the 
prolonged and severe recession, it is critical that we ensure that 
these seniors have access to the food they need to maintain a healthy 
lifestyle. While there are many effective programs working to address 
senior hunger in local communities across this country, there is still 
an unmet need that must be addressed. A report issued in February 2011 
by the General Accountability Office (GAO) estimates that only 10 
percent of low-income seniors that were food insecure in 2008 received 
meals through congregate or home delivered meal programs. As this 
report shows, it is critical that we not only fill these current gaps, 
but also proactively prepare to meet the future increased demand for 
nutrition services among the senior population.
    federal nutrition/food assistance programs and feeding america 
                            recommendations
    Feeding America's emergency food assistance and other targeted 
efforts to fill the gaps in nutrition services for low-income, older 
Americans cannot do the job alone. Instead, these charitable efforts 
are complimented by several key Federal food assistance programs, 
including: the Elderly Nutrition Program, the Supplemental Nutrition 
Assistance Program (SNAP, formerly known as food stamps), the Commodity 
Supplemental Food Program (CSFP), and The Emergency Food Assistance 
Program (TEFAP). These Federal programs are each a critical component 
in helping to ensure that food assistance reaches all seniors across 
the continuum of need--from seniors who are not homebound and can cook 
or access meals to seniors who are homebound and can cook to seniors 
who are homebound and can't cook. Different interventions are required 
to reach seniors throughout this continuum of need, and the 
continuation of each of these valuable programs helps to ensure that 
low-income seniors in need of food assistance continue to have access 
to healthy foods no matter where they are located on this continuum. 
And, while each of these programs is effective at helping to combat 
senior hunger, each could be expanded and improved to better meet the 
needs of an increasing number of food insecure seniors and fill the 
gaps in food assistance.
    Elderly Nutrition Program: The Elderly Nutrition Program, 
administered by the Department of Health and Human Services Agency on 
Aging (AOA), is a compliment to the broader nutritional safety net 
programs for low-income seniors administered by the USDA. The Elderly 
Nutrition Program is designed to: reduce hunger and food insecurity, 
promote socialization of older individuals including meaningful 
volunteer roles, and promote the health and well-being of older 
individuals and delay adverse health conditions through access to 
nutrition and other disease prevention and health promotion services.
    The nutrition program for seniors operated by the Agency of Aging 
is delivered in two ways, through congregate feeding sites and through 
home-delivery. According to the AOA, in fiscal year 2008, Congregate 
Nutrition Services provided more than 94.8 million meals to more than 
1.6 million seniors in a variety of community settings while Home-
Delivered Nutrition Services provided 146 million meals to more than 
909,000 individuals. These nutrition services help millions of older 
adults receive the meals they need to stay healthy and be food secure.
    Recommendations for the Older Americans Act: As the boomers retire 
and more Americans are living longer, it will be critical to ensure 
that seniors have access to the food and nutrition they need to 
maintain a healthy lifestyle. According to a report published by the 
American Dietetic Association, nutrition is one of the major 
determinants of successful aging. Food is not only critical to a 
senior's physiological well-being but also contributes to their social, 
cultural, and psychological quality of life. In addition, research from 
the Centers for Disease Control and Prevention (CDC) has shown that 
behaviors such as eating a healthy diet, taking part in physical 
activity, and not using tobacco are more influential than genetic 
factors in helping individuals avoid the deterioration associated with 
aging.
    Unfortunately, current levels of funding provided to AOA through 
the Older Americans Act are not sufficient to meet the increasing 
demand for senior nutrition. In order for the AOA to continue serving 
seniors in need of food and nutrition assistance, Feeding America 
recommend that Congress increase funding for these critical Nutrition 
Services programs. Additionally, to ensure that food insecure seniors 
participating in the Nutrition Services programs are better able to 
access other Federal food assistance programs available to them, 
Congress should consider requiring the dissemination of materials about 
other Federal food assistance programs.
    Supplemental Nutrition Assistance Program (SNAP): While Feeding 
America food banks and the 61,000 local agencies we support--including 
food pantries, soup kitchens, and emergency shelters--are often the 
first place older Americans turn to for emergency food assistance when 
they fall on hard times, the Supplemental Nutrition Assistance Program 
(SNAP) administered by the USDA is the cornerstone of the nutrition 
safety net. SNAP helps ensure struggling Americans have adequate 
resources for food until their household economic conditions stabilize 
and improve. In addition to providing emergency food assistance, many 
of our food banks conduct outreach to inform clients about their 
potential eligibility for SNAP and connect them with the long-term 
benefits they need. Incorporating SNAP application assistance and/or 
outreach into other senior food programs provides food banks with a 
venue to discuss the benefits of SNAP, dispel myths about the program, 
and assist seniors with the SNAP application process.
    SNAP is the Nation's largest Federal nutrition program, providing 
over 44 million participants with monthly benefits in the form of an 
electronic benefit (EBT) card that they can use like cash at most 
grocery stores to ensure access to an adequate diet. Nearly 80 percent 
of SNAP households include a child or an elderly or disabled person.
    SNAP benefits can be redeemed at any of the more than 200,000 
retail stores nationwide that are authorized to participate in the 
program. Almost 80 percent of SNAP benefits are redeemed within 2 weeks 
of receipt, and 97 percent are spent within a month. Because the 
benefits can be quickly and efficiently delivered to recipients via EBT 
cards, and recipients are likely to spend the benefits quickly, many 
economists view SNAP as one of the most effective forms of economic 
stimulus during an economic downturn. The USDA estimates that every 
$1.00 spent on SNAP benefits generates $1.79 in local economic 
activity.
    SNAP is an important resource that helps low-income seniors buy the 
food they need to maintain a healthy lifestyle. However, the SNAP 
participation rate among eligible seniors is much lower than the 
general population. According to the USDA, in 2008 a little over one-
third of eligible seniors participated in SNAP, compared to about two-
thirds of the eligible general population.
    Many seniors, especially those that are in need of assistance for 
the first time, are not aware of SNAP and the application process can 
be confusing for older Americans. According to a survey conducted by 
USDA's Economic Research Service, misinformation and confusion about 
the program's eligibility rules and benefit levels was cited as a major 
reason eligible seniors chose not to apply for SNAP benefits.
    Other seniors may choose not to apply for SNAP due to the perceived 
stigma associated with the program. According to the same Economic 
Research Service survey, many seniors felt that participation in SNAP 
might be degrading or embarrassing if others in their families or 
communities found out they were receiving SNAP benefits. Additionally, 
some seniors who had worked most of their lives and had never needed 
government assistance felt that asking for help from the FSP was a sign 
of failure or weakness.
    Recommendation to Improve Access and Participation: Congress should 
continue to strengthen SNAP's ability to meet need by breaking down 
access and participation barriers. Not all seniors who are eligible for 
SNAP participate in the program, because of stigma, misinformation 
about eligibility and potential benefits, or cumbersome enrollment 
procedures. While SNAP has made steady improvement in senior 
participation rates over the last several years, still only about one-
third of those eligible are served. Continued outreach is needed to 
make sure all who are eligible and in need of assistance are informed 
of and enrolled in the program.
    Congress should take steps to improve program education and 
outreach targeted to seniors, streamline the application and 
eligibility-determination process, and increase coordination with SNAP 
across other programs serving seniors. For example, categorical 
eligibility has been shown to both improve program access while at the 
same time allowing States to reduce administrative costs and simplify 
administration. Congress should strengthen categorical eligibility and 
encourage States to take advantage of the expanded option.
    Commodity Supplemental Food Program (CSFP): Administered by USDA, 
the Commodity Supplemental Food Program leverages government buying 
power to provide nutritionally balanced food packages to more than 
604,000 people, most of whom are low-income seniors 60 years or older 
in 39 States, 2 tribal organizations, and the District of Columbia. For 
many of these seniors, CSFP may be the only nutrition assistance 
program readily accessible to them.
    CSFP is an efficient and effective program. While the cost to USDA 
to purchase commodities for this package of food averages $20 per 
month, the average retail value of the foods in the package is $50. For 
the seniors participating in this program, CSFP provides more than just 
food and nourishment, it also helps to combat the poor health 
conditions often found in seniors who are experiencing food insecurity 
and at risk of hunger. CSFP food packages are specifically designed to 
supplement needed sources of nutrients typically lacking in 
participants' diets like protein, iron, zinc, and vitamins B-6 and B-
12. CSFP plays an important role in addressing the nutrition needs of 
low-income seniors.
    Despite the clear benefits of CSFP to low-income seniors and the 
long waiting lists that many States have of seniors who need this 
program, H.R. 2112, the fiscal year 2012 Agriculture Appropriations 
bill, has targeted CSFP for deep cuts. While this program will require 
a funding level of $176.8 million in fiscal year 2012 in order to 
sustain the current caseload, H.R. 2112 proposed cutting funding for 
this program by $38 million. As a result, if a cut of this magnitude 
were to be enacted, an estimated 150,000 low-income seniors would 
immediately be dropped from this vital program. Although the $20 
monthly CSFP food package may not seem like much, to a low-income 
senior it can mean the difference between putting food on the table and 
not having enough to eat.
    Recommendations for CSFP: Recognizing the role that this program 
plays in the lives of vulnerable, low-income seniors, Feeding America 
recommends that this program be reauthorized in the 2012 Farm bill and 
expanded to all 50 States. Additionally, Feeding America recommends 
that the income threshold for seniors wishing to participate in CSFP be 
raised to 185 percent of the Federal Poverty Line, bringing it in line 
with the threshold already applied to women and children participating 
in this program. Further, Feeding America recommends that the Senate 
provide $181.8 million for CSFP in fiscal year 2012 to maintain current 
caseloads and allow CSFP to expand into six additional States with 
USDA-approved State plans (Connecticut, Hawaii, Idaho, Maryland, 
Massachusetts and Rhode Island).
    The Emergency Food Assistance Program (TEFAP) Commodities: TEFAP is 
a means-tested Federal program that provides food commodities at no 
cost to low-income Americans in need of short-term hunger relief 
through organizations like food banks, pantries, soup kitchens, and 
emergency shelters. Healthy and nutritious food commodities provided 
through TEFAP are essential resources that enable Feeding America food 
banks to meet the need in their communities.
    TEFAP commodities currently account for approximately 25 percent of 
the food moving through Feeding America food banks nationwide. In most 
instances, local food banks supplement TEFAP commodities with privately 
donated foods to extend TEFAP program benefits beyond the budgeted 
amount for the program. As the unprecedented demand for food continues 
at food banks across the country, TEFAP commodities are essential for 
the provision of a steady emergency food supply. However, the level of 
commodities USDA provides is projected to drop off in fiscal year 2011 
and fiscal year 2012.
    In fiscal year 2010, TEFAP provided approximately $655 million 
worth of nutritious foods to low-income Americans. This figure includes 
commodity purchases mandated by the 2008 Farm bill as well as bonus 
commodity purchases that were appropriated for in fiscal year 2010 
Agriculture Appropriations and those bonus purchases made by USDA when 
necessitated by market conditions.
    In fiscal year 2011, even as the need for food assistance remains 
at unprecedented levels, the agricultural markets remain very strong. 
As a result, there is little need for USDA to intervene in the markets 
to make additional bonus commodity purchases. Without additional bonus 
purchases in fiscal year 2011, TEFAP spending levels will fall by about 
45 percent to approximately $360 million. This $295 million decrease in 
TEFAP commodity spending for fiscal year 2011 will significantly impact 
efforts to address the growing need for emergency food assistance 
throughout the country. Without additional funding for commodities, too 
many seniors who rely on the commodities they receive from emergency 
food distributions may go without adequate access to the nutritious 
foods they need.
    Recommendation for Increasing the Supply of Emergency Food: With 
agriculture commodity markets projected to remain strong in the coming 
years thereby driving a marked decline in the availability of bonus 
TEFAP commodities, Feeding America recommends that the amount of annual 
funding for mandatory TEFAP purchases be increased in the 2012 Farm 
bill. In addition, with respect to TEFAP commodities available in 
fiscal year 2011, Feeding America recommends that members of the 
committee make a request to the Secretary of Agriculture that he use 
his administrative authority to direct funds for the purchase of 
additional TEFAP commodities this fiscal year.
                               conclusion
    As the committee begins to engage in debate on the reauthorization 
of the Older Americans Act, we greatly appreciate the opportunity to 
submit testimony today on behalf of Feeding America, our over 200 
member food banks, and the 37 million Americans our food banks fed last 
year. For a growing number of Americans--including more than 3 million 
seniors--food banks are truly the first line of defense, and many times 
the only resource standing between them being able to put food on the 
family dinner table or going to bed with an empty stomach. However, our 
food banks and the charitable food assistance network cannot meet the 
needs of these families alone. It is only through our partnership with 
the public sector and the sustained support the Federal Government 
provides through programs like SNAP, CSFP, TEFAP, and congregate and 
home delivered meals that we can make real strides in the fight against 
hunger.
      Prepared Statement of The Gerontological Society of America
    The Gerontological Society of America (GSA) is the Nation's oldest 
and largest interdisciplinary organization devoted to research, 
education, and practice in the field of aging. The primary purpose of 
the Society--and its 5,400+ members--is to advance the study of aging 
and disseminate information among scientists, decisionmakers, and the 
general public. GSA would like to thank the HELP subcommittee on 
Primary Health and Aging for hosting a hearing on the important topic 
of nutrition for older adults, and the fundamental role of nutrition 
programs in the Older Americans Act.
    The Older Americans Act oversees congregate and home-delivered 
meals that bolster nutrition in older adults, allowing them to live 
healthily and age in place within their communities. According to the 
2005 White House Conference on Aging final report, physical changes 
that take place during aging can result in different nutritional needs, 
contributing to decreased food intake, unintentional weight loss, 
malnutrition, and/or obesity. These changes can lead to chronic 
diseases, such as diabetes and heart disease that ultimately cause 
individuals to seek costly hospital stays and placements in nursing 
homes. The cost of 1 day of hospitalization would more than cover the 
cost for an older person to receive 365 days of home-delivered meals. 
With this preventative approach, Older Americans Act nutrition programs 
not only provide crucial services to older Americans, but represent an 
important investment in keeping older adults healthy and costs down.
    Although organizations like the Meals on Wheels Association of 
America (MOWAA) collect data on the services they provide and self-
reported outcome measures, more research needs to be done on the need, 
current services, and outcomes. GSA supported the Leadership Council of 
Aging Organizations (LCAO) 2011 OAA Consensus Document, including the 
following recommendations for evidenced-based research:

    1. Improve data collection in the title III C nutrition programs, 
particularly unmet need, such as waiting lists. Currently, according to 
a report by the National Health Policy Forum, data on the unmet need 
for nutrition services are elusive and national data on waiting lists 
does not exist.
    2. Look for and provide support for best practices in nutrition 
programs that have succeeded in recruiting and retaining first wave 
boomers who are at risk for malnutrition in addition to existing 
clientele.

    In addition to improving the research on older adult nutrition, GSA 
supports strengthening the volunteering component of Older Americans 
Act nutrition programs. Roles for volunteers of all ages can include 
delivering meals, providing nutrition counseling, and organizing 
education activities or congregate meals. Benefits of engagement for 
older adults include self-reported quality of life, lower rates of 
dementia, reduced risk of depression, improved recovery from illness, 
and reduced mortality. Continuing to develop the connection between 
volunteering and older adult nutrition helps both groups, and reduces 
the cost burden on agencies.
    The Gerontological Society of America recognizes the importance of 
nutrition for older adults, and the great work accomplished by Older 
Americans Act programs to keep older adults healthy and in their 
communities. Every year, GSA hosts an Annual Scientific Meeting that 
brings together more than 3,500 top researchers in the field of aging 
for over 400 scientific sessions. The theme of GSA's 2011 meeting is 
``Lifestyle Leads to Lifespan.'' Indeed, this year's program includes a 
public policy symposium, developed in partnership with the Tufts 
University USDA Human Nutrition Research Center on Aging, focused on 
the critical role nutrition plays in healthy aging. Once again, thank 
you for making this topic a priority.
               Prepared Statement of Hunger Free Vermont
    Hunger Free Vermont, formerly the Vermont Campaign to End Childhood 
Hunger, is an education and advocacy organization with the mission to 
end the injustice of hunger and malnutrition for all Vermonters. 
Incorporated in 1993, we are a statewide nonprofit organization 
dedicated to hunger prevention through expanding access to nutrition 
programs that nourish Vermont's children and families. Hunger Free 
Vermont committed to expanding advocacy efforts to the senior community 
in 2010 in response to low participation among seniors in Federal 
nutrition programs, and the increase in senior hunger and malnutrition 
in Vermont.
    Vermont is considered the ninth hungriest State in the Nation, 
because we have seen a sharp rise in the more severe form of hunger 
known officially as ``very low food security.'' When asked about the 
causes of such an increase, Hunger Free Vermont points to Vermont's 
particular challenges as a State: relatively low incomes coupled with 
high housing and heating costs, plus the added burden of transportation 
costs as the most rural State in the country.
    At the same time, Vermont's older population is growing at a rapid 
pace; the fastest growing segment of the population is now 85 years and 
older with projections for 2030 showing a 149 percent increase over 
2000 census numbers. While the cost-of-living, particularly housing, 
food and fuel in Vermont, continue to rise, seniors on fixed incomes 
struggle to afford the necessities. Food tends to be the most flexible 
item in the household budget and is often cut first when funds are 
limited, particularly as seniors' appetites and desires to cook are 
waning. From our experiences working with front lines service 
providers, Hunger Free Vermont has come to understand that senior 
hunger is a very real problem in our State.
    Seniors are more likely to be at risk of hunger if they are living 
near or below the poverty line, between the ages of 60 and 64, 
divorced, separated, or living with a grandchild, or are a renter. Good 
nutrition is critical to maintain health and independent living when 
aging. Food insecurity and hunger have serious consequences on the 
health and well-being of elders. Seniors experiencing food insecurity 
are significantly more likely to have lower intakes of calories and 
major nutrients, significantly more likely to be in poor or fair 
health, and more likely to have limitations in activities of daily 
living. All these direct results lead to a sicker, less independent and 
less economically stable aging population.
    The 2010 USDA Food Security Report revealed that 14 percent of all 
Vermont households are food insecure. Food insecurity is defined as the 
lack of access to enough food to fully meet basic needs at all times 
due to lack of financial resources. Multiple national organizations, 
such as the Meals on Wheels Association, the AARP Foundation and 
Feeding America have documented an increase in senior food insecurity 
across the country. We see the effects of this increase in Vermont 
every day as usage of Federal nutrition programs rises and agencies 
report of more clients' in need of food.

     11,115 seniors ate meals at congregate meal sites in 2010, 
a 2 percent increase in meals and 8 percent increase in participants 
from 2009.
     736,514 meals were delivered to 4,357 seniors' homes in 
2010, a 5 percent increase in meals served from 2009.
     In 2010 there were over 5,000 calls to the statewide 
Vermont Senior Helpline regarding help with food and nutrition.
     Agencies on Aging report that they are seeing more people 
eating alone, and more young seniors (age 60-64) signing up for home 
delivered meals.
     While many home delivered meal programs request a 
suggested donation, programs often average a much smaller donation 
amount (for example, the suggested donation in the Lamoille Valley is 
$3 per meal; the average donation received is $.90 per meal).
     Agencies on Aging and Vermont Kin as Parents report that 
there are more grandchildren living with grandparents, and because 
financial support for kin is limited, delivered meals are sometimes 
being given to the children rather than the elders.

    Given the challenge of rising senior hunger in Vermont, the 
nutrition programs within the Older Americans Act are increasingly 
important as part of the social safety net to help seniors remain 
healthy and independent. In working with our partners across Vermont, 
Hunger Free Vermont sees the following challenges in reaching seniors 
in need via congregate and home delivered meal programs:

     Funding: Funding is limited and meal programs must do 
significant fundraising to be able to continue serving seniors at their 
current capacity. Nutritional meals cost much more to make than the 
Federal reimbursement provides. Agencies report that as seniors live 
longer, they are now serving multiple generations in their meal 
programs, from 60 years to 100-plus, presenting new challenges for 
serving meals, especially as more seniors have special diets and 
changing health needs. Transporting meals throughout rural Vermont is 
expensive, especially as gas prices continue to rise. Some programs 
risk losing their drivers unless they offer a mileage reimbursement or 
stipend.
     Access: Due to limited funding and capacity, congregate 
meal programs in Vermont are dispersed geographically and rarely serve 
meals more than a couple days a week. Seniors need access to good 
nutrition every day no matter where they live. Even in locations where 
meals are served daily, without low-cost public transportation options, 
seniors have difficulty accessing these meals.
     Structure: A one-size-fits-all prepared meal may not be 
the most cost-effective or flexible source of nutrition for every 
senior in need. In order to qualify for home delivered meals, a senior 
must be homebound, unable to cook, and/or nutritionally at risk. For 
some seniors, the problem is not inability to cook, but rather they are 
homebound due to loss of ability to drive or access public 
transportation. For others the issue is limited income; they need food 
but not necessarily a hot prepared meal.
    It is critical that the nutrition programs that serve food to 
insecure older Vermonters are able to do so both efficiently and 
effectively. These nutrition programs play a pivotal role in ensuring 
that seniors are able to live and age successfully and independently in 
their own homes and communities. By investing in proven, cost-effective 
programs now, Congress can ensure that seniors' nutritional needs are 
met, health care costs are reduced, and tax payer dollars are used 
wisely well into the future.
    Given the on-the-ground realities in Vermont, Hunger Free Vermont 
recommends the following improvements to congregate meal and home 
delivered meal programs:

     Increase Funding for Good Nutrition: Increased funding for 
both congregate meal programs and home delivered meal programs will 
allow programs to serve high quality meals to more food insecure 
seniors. As food and fuel prices continue to rise, additional funding 
will allow meal programs to meet the bottom line and meet the need.
     More Flexibility to Serve More: A more flexible home 
delivered meal program will allow funds to be used more efficiently and 
effectively while serving more seniors. Programs will have options for 
kinds of foods to be delivered and in what form (for example, as 
groceries or as prepared meals) to stretch funds and maintain 
independence as much as possible while still meeting the needs of 
seniors.

    In conclusion, to emphasize the importance of these programs, we 
will share a quote from one local advocate who visited a senior in 
rural Vermont. She said that,

          ``This senior had only one squash in her house and no money 
        in her bank account with 2 weeks to go before receiving her 
        next Social Security payment. Without access to the available 
        services and programs, such as 3SquaresVT, home delivered 
        meals, congregate meals and commodity boxes, she and many other 
        seniors in Vermont would go hungry.''

    Thank you for the opportunity to submit this statement for the 
record. Hunger Free Vermont looks forward to the successful 
reauthorization of the Older Americans Act as we work towards the day 
when Vermont is hunger free.
      Prepared Statement of Meals On Wheels Association of America
    Chairman Sanders, Ranking Member Paul and members of the 
subcommittee. The Meals On Wheels Association of America (MOWAA) 
commends you on beginning your hearings related to the reauthorization 
of the Older Americans Act by focusing on senior hunger in America and 
on the role of Older Americans Act (OAA) Senior Nutrition Programs 
(SNPs) in addressing it. We thank you for the opportunity to present 
testimony for your consideration as you work to improve the OAA's 
effectiveness in delivering needed nutrition services to those seniors 
who otherwise would not have access to nutritious food.
    The Meals On Wheels Association of America (MOWAA) is the oldest 
and largest national organization representing local, community-based 
Senior Nutrition Programs--both congregate and home-delivered (commonly 
referred to as Meals On Wheels)--and the only national organization and 
network dedicated solely to ending senior hunger in America. While we 
have traditionally used and continue to use the term ``community-
based'' to describe these programs, it is important to understand that 
the community has a much greater role in them than simply being the 
location in which these SNPs operate. It is more accurate to call these 
individual programs not only community-based but also community-
focused, -reliant, -reflective, -informed, -supported, -dependent and -
directed. So when MOWAA employs the term ``community-based'' we intend 
for it to carry all those meanings, and we believe the concept is an 
important one. Each SNP is unique, and while they all comply with 
certain uniform OAA-prescribed standards as related to things like the 
nutritional content of meals, for example, there is tremendous 
diversity among programs from community to community and State to 
State. This is the strength of our network, and it is one of the 
characteristics that distinguishes Senior Nutrition Programs from the 
majority of so-called Federal or federally funded food or feeding 
programs with which SNPs are often associated. In fact, there are more 
differences between SNPs and those programs than there are 
similarities. As the name SNP implies, these programs--which are also 
often referred to as senior meal programs--are nutrition programs that 
provide complete, well-balanced meals; and many of those meals are 
delivered to the homes of individuals who need them. Food programs are 
not necessarily either nutrition programs or meal programs. Again, the 
distinction is significant.
    Another hallmark of SNPs, which separates them from other Federal 
food programs, is that they are strong public-private partnerships. 
SNPs could not exist and operate without the majority of their funding 
coming from other, diverse sources, such as States and localities, 
foundations, corporations, individual donors and clients themselves or 
their families. The Administration on Aging (AOA) often notes that 
every $1 of Federal support made available through OAA leverages 
another $3.35 from other sources. As impressive, and distinctive from 
other food programs, as that figure is, we believe it significantly 
underestimates the leveraging power of these Federal funds. It fails to 
take into account the monetary value of the free labor contributed by 
the vast volunteer army--numbering between 800,000 and 1.7 million 
nationwide--as well as the donation of the use of personal vehicles to 
deliver meals. In an effort to calculate this additional value, we 
interviewed MOWAA Members representing rural, suburban and urban and 
small, medium-sized and large SNPs to derive the average per meal value 
of volunteer labor. We used $10 an hour, about half of the generally 
accepted value as calculated by the Independent Sector ($21.36 for 
2010). We also assumed that volunteers drove an average of 2 miles per 
meal delivery on average, again deliberately under estimating the 
distance. Using these numbers we found that volunteer labor and vehicle 
usage (calculated at $0.50 per mile) contributed about $2.75 for each 
home delivered meal. In fiscal year 2009, when 149 million meals were 
provided, that equates to additional leveraged, non-Federal funds of 
almost $410 million. Again, we stress that this grossly underestimates 
the actual value of the volunteer labor contribution and does not even 
take into account such labor associated with meals served at congregate 
sites.
    Not all MOWAA Member programs throughout the United States receive 
OAA (Title III) funds. There are numerous programs nationwide that are 
entirely privately funded. These programs work in many, if not most, 
communities side-by-side with their peers partially title III-funded 
programs; and the relationship is a symbiotic one. Both types of 
programs acknowledge the value and necessity of the other and both are 
necessary to the community's goal of providing meals to all the seniors 
who need them. Some of the private programs are also ``private pay,'' 
which means simply that clients who can afford them must pay for their 
meals; other private programs operate in the same way that title III 
programs do, often utilizing a sliding scale based on self-declared 
income and suggesting a voluntary contribution from clients. Where both 
types of programs exist, they clearly complement each other and expand 
the community's ability to provide nutrition services to seniors in 
need. But the reality is that not all communities have such private 
programs, for a variety of reasons, including the location and size of 
the community and the lack of human and financial resources to sustain 
any regular, appropriate and reliable nutrition services.
    Another critical distinction between OAA SNPs and Federal food 
programs is that OAA programs are not means-tested. The criteria is 
need, and that is, as it should be, much broader than income alone. 
Need can include disability or frailty or immobility or inability to 
carry out the Activities of Daily Living or social isolation. More and 
more we are witnessing the emergence of food deserts--that is, 
communities where there is not one single food source other than the 
SNP--even in those rural areas that once were the Nation's food basket. 
Lack of access to food and lack of ability to obtain it certainly 
constitute need. And if the need gaps, regardless of their cause, are 
not addressed, then seniors are hungry.
    MOWAA's mission, which is shared by our MOWAA Member programs, is 
clear and straightforward--``to end senior hunger by 2020.'' Our 
singular vision is driven by conviction. It is also compelled by the 
tragic fact that the number of seniors facing the threat of hunger in 
this great land is not only unacceptably high, but also--and this is 
despite the heroic efforts of some 3,500 senior nutrition programs 
funded through the Older Americans Act and their private peers--it is 
growing. Yes, growing. MOWAA believes that several factors account for 
this increase in senior hunger and hunger risk. Some of them are 
frequently discussed . . . like the significant growth in the number of 
individuals age 60 or older, fueled by the Baby Boom; or ever-
increasing costs of food and gasoline; or the state of the economy in 
general. Like SNPs themselves, this subcommittee has no control over 
these. But there are other factors that you can mitigate. Some of these 
``controllable'' are factors that, MOWAA believes, may be unintended 
consequences of the Older Americans Act in its current state. Let me 
reiterate what I just said, because it may be both a new concept and a 
provocative one: the current structure of the Older Americans Act may 
be contributing unintentionally to the rise of hunger risk among 
seniors in America.
    We can back up that bold statement not with emotion and anecdote, 
but with data. Then we will propose changes to the Older Americans Act 
that MOWAA is convinced will enable Senior Nutrition Programs across 
the United States to serve more meals to more seniors. Doing so will 
begin to shift the trend, even if only incrementally, toward fewer, not 
more, hungry seniors. The two major recommendations that we will put 
forth are simple, and are simply designed to reduce hunger risk among 
our Nation's vulnerable elderly.
    Before we describe them, we want to articulate some assumptions, 
which we trust can be universally accepted:

    1. Food is a basic necessity;
    2. There is a direct, and scientifically demonstrable, relationship 
between nutrition and health;
    3. Good nutrition contributes to the prevention, treatment and/or 
delay of onset of many of the most common chronic medical conditions in 
the elderly, such as hypertension, diabetes, and obesity, for example; 
and
    4. Hunger is a disease, and we have the cure for it today.

    If we agree on those four fundamental points, then we hope that we 
can agree that the Older Americans Act should be one of the primary 
vehicles through which we deliver the cure to the deleterious disease 
called hunger--and prevent so many other diseases as well. We hope the 
subcommittee will agree that specific changes need to be made to the 
act during reauthorization in order to enable America to move more 
effectively and deliberately toward the eradication of senior hunger.
    Let us provide brief background about the basis for MOWAA 
recommendations for change, as well as the data sources that support 
those recommendations. We have based our recommendations on data, 
because data are impartial and in this case tend to be extraordinarily 
straightforward. In 2007 the MOWAA Foundation commissioned outstanding 
researchers from the University of Kentucky's Center for Poverty 
Research and Iowa State University to conduct a study entitled ``The 
Causes, Consequences and Future of Senior Hunger in America.'' That 
groundbreaking study was released at a hearing of the U.S. Senate 
Special Committee on Aging in March 2008. The findings were helpful to 
our understanding of the extent of senior hunger in the United States. 
They were also discouraging. The researchers found that in 2001, 1 in 9 
seniors, or 5 million older individuals, faced the threat of hunger.
    The next year we engaged the same researchers again and asked them 
to update the national study with 6 additional years of data, as well 
as to give us a state-by-state look at the incidence of senior hunger 
in America. The second study was released in November 2009 at a 
briefing of the House Hunger Caucus. To say that those findings were 
dispiriting is an understatement. They were, and are, morally 
unacceptable. By 2007, there had been a 20 percent increase in the 
number of seniors facing the threat of hunger, with the number growing 
from 5 to 6 million seniors.
    What is the relevance of this to the reauthorization of the Older 
Americans Act? Taken in isolation, probably nothing. Put in a context, 
quite a lot. MOWAA took the state-by-state data from the study and then 
overlaid specific program information and results taken from the 
National Aging Program Information System (NAPIS). This NAPIS data is 
available on the AOA Web site.
    Here is what we found. In fiscal year 2007, the year that 
corresponds with the study's hunger numbers, 21 of the top 25 Senior 
Hunger States--that is, those States with the highest rates of senior 
hunger--transferred funds from title III C, senior nutrition, to title 
III B. By contrast, only 12 of the bottom 25 Senior Hunger States made 
such transfers. In fiscal year 2008, 17 of the top 25 senior hunger 
States increased the amount of funds transferred from title III C 
nutrition to unspecified title III B services; and in fiscal year 2009, 
16 of the top 25 senior hunger States again increased the transfer from 
nutrition [see Appendix I].
    MOWAA believes the evidence is compelling and clear. Allowing 
transfer of funds from title III C to title III B is having a serious 
adverse impact on the health and well-being of vulnerable seniors 
across this great land. It must be stopped. MOWAA's first 
recommendation for reauthorization is to eliminate the authority to 
transfer funds from title III C to title III B. This is not a new 
position for MOWAA, but it is one for which we are advocating with 
renewed vigor--because what was once a surmise is now a fact, clearly 
supported by the data.
    In the past those groups that opposed this anti-transfer 
recommendation primarily raised two arguments against it. The first was 
that the amount of transfer nationally had remained relatively constant 
over time. We did not understand the relevance of that statement; even 
if it were relevant, it is no longer true. Over the course of the most 
recent 4 years for which we have data, net transfers into title III B 
from III C have grown significantly from approximately 9.6 percent, or 
just over $33 million, to about 13.4 percent or nearly $48 million [see 
Appendix II]. That is real growth and that lost nutrition funding could 
have furnished hundreds of thousands of additional meals at a time when 
hunger risk is growing.
    This trend of increasing transfer should be alarming to Congress, 
because both the House and the Senate are on record in report language 
as strongly warning States, particularly those with high incidences of 
senior hunger, not to transfer funds from nutrition to other services 
as long as needed for nutrition services existed. Below is an excerpt 
of House Report 109-493. That document is the only source by which to 
determine legislative intent, as the Senate bill was pre-conferenced 
with the House, so that there were no Senate or Conference Reports. The 
House Report reads in part:

          ``The committee cautions States from transferring funds from 
        nutrition services to non-nutrition supportive services unless 
        such transfers support, facilitate, or foster participation in 
        senior nutrition programs. In particular, States with a high 
        prevalence of food insecurity are strongly discouraged from 
        diverting funding provided for food services to non-food 
        expenditures and should do so only as a last resort. Further, 
        the committee strongly encourages States to use general and 
        administrative dollars provided in the specific line item or 
        category for which the funds were intended. The committee 
        believes strongly that . . . title III C dollars should not be 
        used by States to pay the administrative cost associated with 
        managing title III B services.''

    Clearly the committee's ``caution'' was not taken seriously by the 
States and in fact, many States' actions were in diametric opposition 
to the House's intent. The following year, the Senate expressed its 
agreement with the House authorizing committee's warning by adopting 
report language to accompany the Senate's Departments of Labor, Health 
and Human Services, Education and Related Agencies appropriation bill 
(Senate Report 110-107). That language read:

          ``The committee is aware that proper nutrition is essential 
        to the health and wellness of older Americans. A healthy diet 
        can prevent weakness and frailty, improve resistance to illness 
        and disease, and lead to better management of chronic health 
        problems. All of these in turn lead to greater independence and 
        quality of life for older persons. The recent reauthorization 
        of the Older Americans Act recognized the important role that 
        nutrition plays in promoting the health and well-being of 
        seniors. In addition to reducing hunger and promoting 
        socialization, the nutrition services program was reauthorized 
        with the purpose of assisting older Americans in accessing 
        nutrition and other disease promotion services that can delay 
        the onset of adverse health conditions. The act also added 
        greater emphasis on nutrition education, nutrition counseling 
        and other nutrition services. Despite increased recognition of 
        nutrition's importance to the health and well-being of our 
        seniors, the funding level for the nutrition services program 
        has stagnated in recent years, while at the same time the 
        population of older Americans continues to increase. The 
        committee notes that the number of meals provided under the 
        nutrition services program has declined by more than 8 percent 
        from fiscal years 2000 to 2005. The committee is aware that 
        flat funding, along with higher food and transportation costs, 
        has forced many programs to implement waiting lists and 
        consolidate meal sites in order to cut costs. The committee 
        hopes that the funding increase provided will help alleviate 
        the fiscal strain affecting these programs and will allow them 
        to continue to provide meals services that are essential to our 
        seniors. The committee recognizes that the recent 
        reauthorization of the Older Americans Act (Public Law 109-365) 
        continues to allow States to transfer funds between title III 
        B, which funds supportive services, and title III C, which 
        provides funding for nutrition services. While such transfers 
        have remained relatively stable over time, amounting to 
        approximately $35,000,000 per year transferred from nutrition 
        programs to supportive services, the committee is concerned by 
        the decrease of funds available for nutrition services. The 
        committee believes that the specific funding increase provided 
        for nutrition services in this bill should be used to directly 
        support, facilitate, or foster nutrition programs, and should 
        not be transferred for non-nutrition-related supportive 
        services.''--[emphasis added]

    Opponents to our proposal will likely attempt to argue that the 
transfer of funds have, in fact, been used to ``support, facilitate, 
foster nutrition programs.'' But that argument is in no way supported 
by the facts. There is not a shred of evidence to corroborate the fact 
that in fiscal year 2009 $48 million was spent on such activities. In 
fact, the data clearly show that was not the case. The single largest 
expenditure within the title III B spending is for a category entitled 
``Other Services.'' Other services do not include transportation, 
assisted transportation, nutrition education, nutrition counseling or 
case management.
    These activities all have their own discrete line items. AOA data 
gathered through the National Aging Program Information Services 
(NAPIS) system shows that the Federal portion title III B expenditures 
for ``Other Services'' in fiscal year 2008 was greater than $105 
million. Federal spending on title III B transportation and assisted 
transportation combined was less than $72 million. By fiscal year 2009 
Federal spending had risen to more than $110 million for other 
services, while spending for the two transportation lines remained 
relatively stable at just over $72 million. The most disturbing element 
of this transfer and spending activity is that the AOA data show 
absolutely no service units and no persons served attached to this 
``Other Services'' spending. That data, either persons or units or both 
(as is the case with meals), is recorded for every other category of 
title III spending. We should not have to imagine where and how that 
money is being spent, but we can be certain that it is not ``to 
directly support, facilitate, or foster nutrition programs'' [see 
Appendix III].
    The voluntary compliance regarding the use of nutrition funds to 
furnish nutrition services that the Congress has sought in the years 
since the last OAA reauthorization simply has not materialized. To the 
contrary, the opposite has occurred. The result has been increasing 
numbers of vulnerable older persons going without the meals and 
nutrition support they need to age healthily, prevent or improve 
chronic illness, recover from acute illness, avoid 
institutionalization. More have suffered hunger or faced its threat. It 
is time to stop the funding hemorrhage from title III C nutrition 
funds. We appeal to you, on behalf of the thousands of SNPs across 
America and the more than 6 million seniors needing services, to amend 
the Older Americans Act to prohibit the transfer of funds from title 
III C to title III B. It is a simple change that could have a 
monumental impact of the health and well-being of our seniors as well 
as a positive impact on the bottom line of the Federal budget. We will 
address that point in more detail below, after we offer MOWAA's second 
major reauthorization recommendation.
    MOWAA's second recommendation for changes in the OAA is also 
related to the issue of transfer. We propose the consolidation of 
titles III C 1 and III C 2 into a single title III C. This would 
eliminate the administrative burdens of intra-section transfers. 
States, Area Agencies on Aging and Senior Nutrition Programs could more 
easily direct nutrition dollars to areas of greatest need. There would 
be no change in what entities are eligible for funding, who could 
receive services, how clients are served, etc. Both congregate and 
home-delivered meal programs would continue to have access to these 
dollars, and the process of directing them where they need to go would 
be simplified. The administrative burden would be significantly reduced 
and time and energy could be directed to the provision of services.
    The adoption of these two recommendations would entirely eliminate 
transfer within the act by removing the only two provisions that allow 
it. MOWAA believes this change would benefit not only nutrition 
programs but also every other program and service funded under title 
III. It dispels long-held myths associated with transfers that have 
held us all captive--namely, that the resources provided to programs 
under the act have been sufficient, and that transfer authority allows 
States and localities to direct surplus funds from one service to 
another. There are no surpluses.
    Our first assumption, among the four principles we articulated 
earlier, was that food is a basic necessity. We believe that it is our 
moral imperative as a nation to make this basic necessity accessible 
and available to every citizen who needs it, particularly those who are 
vulnerable. We hope that this subcommittee agrees with that principle 
and trust that you do, judging from your decision to hold the first of 
your reauthorization hearings on the issue of senior hunger. As the 
architects of the legislation that governs SNPs you have the ability to 
profoundly improve the lives of those individuals who depend on us, and 
their communities, for the vital life supports. We know that Congress 
faces extraordinarily difficult decisions relating to spending and that 
the deficit must be addressed. We also know that this subcommittee has 
the power to direct millions of ``additional'' dollars to providing 
nourishing meals to seniors in need without spending 1 additional cent. 
That, we believe, should be an easy choice in this time of fiscal 
austerity. Had transfer from title III C to title III B been 
statutorily prohibited in fiscal year 2009, those $48 million of 
nutrition funds that were siphoned off for other services would have 
been available to provide a basic necessity to those in need. 
Ethically, it is the right thing to do. Practically, it makes eminently 
good sense.
    Our second and third assumptions focused on the connection between 
nutrition and health. They are indisputably linked. Good nutrition 
promotes and supports good health. Poor nutrition on the other hand 
leads to poor health, and poor health is extremely costly not only in 
personal terms for the individuals who suffer from it but also for the 
Nation and our economy. If we leave frail seniors languishing in their 
homes without proper nutrition, their health will inevitably fail. If 
they survive, they will end up hospitalized or institutionalized at a 
cost to the government that far exceeds the cost of providing adequate 
funds to Senior Nutrition Programs to enable them to furnish seniors 
meals in the homes and other settings. Senior Nutrition Programs can 
provide meals for nearly a year for roughly the cost of one Medicare 
day in the hospital. MOWAA can quantify, using actual health spending 
data, the savings that can accrue when seniors receive nutritious meals 
immediately following a hospital stay for an acute condition.
    Our evidence in this regard is based on 2006 data (in 2006 dollars) 
from a special project that MOWAA carried out in partnership with a 
major national insurance company. The findings were presented in 
December 2006 in Washington at a Leadership Summit sponsored by AOA. 
Through the special partnership, the private insurer's Medicare 
Advantage patients in select markets across the United States were 
offered without additional cost to the enrollees 10 nutritionally 
balanced meals, delivered by local Meals On Wheels programs, 
immediately following discharge from the hospital for an acute 
condition. Participation in the program was purely voluntary, and those 
individuals who chose to receive the service were typically sicker than 
those who declined it. Despite this fact, the insurance data show that 
those seniors who received just 10 meals had first month post-discharge 
health care costs on an average of $1,061 lower than those seniors who 
did not. The beneficial affects were also lasting. The third month 
after receiving those meals, the average per person savings to the 
insurer were $316.
    Individuals who did not receive meals had both more inpatient 
hospital days and more inpatient admissions per 1,000 than those who 
did receive meals. According to PricewaterhouseCoopers, preventable 
hospital re-admissions cost the Nation approximately $25 billion each 
year. One out of every five Medicare patients discharged from a 
hospital is re-admitted within 30 days at an annual cost to Medicare of 
$17 billion. Given these facts, providing adequate funds for Senior 
Nutrition Programs can only be regarded as a strong and demonstrable 
value proposition.
    Let us suppose that slightly less than 5 percent of traditional 
Medicare enrollees, or about 1.8 million seniors, received those 10 
meals after an acute illness. And let us suppose that providing meals 
for those seniors achieved only half the savings, that is, $688, that 
the Medicare Advantage insurer realized. That still would amount to 
savings to Medicare of approximately $1,238,400,000. The cost to the 
Federal Government of furnishing those meals would be less than 
$500,000. Simple subtraction makes clear the savings: $1,237,900,000. 
Is our scenario here hypothetical? Yes. Is it based on real world data 
and real life experience. Yes. Does furnishing vulnerable seniors meals 
make good fiscal sense and actually save Federal dollars? Absolutely 
Beyond that, from a human and humane perspective, and from the 
perspective of the value of individuals and their liberty--principals 
on which this Nation was founded and for which it still stands--it is 
the acceptable and right thing to do.
    All this leads to our principle No. 4, namely that hunger is a 
disease and one for which we have a cure today. Meals On Wheels and 
other SNPs throughout the United States deliver that cure to hundreds 
of thousands of seniors everyday. But, with additional resources, they 
could reach more. In closing, we ask you to give careful and serious 
consideration to the two primary recommendations that we presented to 
you today. We have others, but we believe that making these two 
relatively simple changes to the Older American Act are the place to 
begin our collective effort of reducing senior hunger and improving 
America's elders physical and emotional health at the same time that we 
improve our Nation's financial health.
    We thank you for your attention to this most critical issue and 
express our appreciation once again for the opportunity to present 
testimony to the subcommittee.



    In fiscal year 2007, of the top 25 senior hunger States, 21 
transfer funds from nutrition (title III C) to title III B. Of the 
bottom 25 senior hunger States, only 12 transfer funds from nutrition 
(title III C) to title III B. In fiscal year 2008, 17 of the top 25 top 
senior hunger States increased the amount of funds transferred from 
nutrition (title III C) to title III B. In fiscal year 2009, 16 of the 
top 25 senior hunger States increased again the amount of funds 
transferred from nutrition (title III C) to title III B.





    An Overview of Senior Hunger in the United States--June 13, 2011

   (By James P. Ziliak--University of Kentucky; and Craig Gundersen--
                        University of Illinois)

    Food insecurity is one of the leading public health challenges 
facing the United States today. In 2009 alone, over 50 million 
Americans lived in food insecure households, i.e., households that were 
uncertain of having, or unable to acquire, enough food for all 
household members because they had insufficient money and other 
resources for food. The experience of food insecurity manifests itself 
across the life-span in the United States. In recent years, increased 
attention has been paid to the experience of senior Americans and, in 
this overview, we consider the extent and determinants of food 
insecurity among senior Americans, the health consequences associated 
with food insecurity, and the influence of the recent economic 
downturn. This overview is based on our research reported in Ziliak, 
Gundersen, and Haist (2008), Ziliak and Gundersen (2009), and Gundersen 
and Ziliak (2011).\1\
---------------------------------------------------------------------------
    \1\ Funding for the research in Ziliak, et al. (2008) and Ziliak 
and Gundersen (2009) was made possible by a grant from the Meals On 
Wheels Association of America Foundation and, in Gundersen and Ziliak 
(2011), by a grant from the Merck Foundation.
---------------------------------------------------------------------------
    The extent and determinants of food insecurity among seniors. Based 
on data from the Current Population Survey (CPS), a nationally 
representative survey of over 50,000 households per year, we have 
characterized the extent of food insecurity among seniors over the past 
decade. The CPS contains the Core Food Security Module (CFSM), which is 
the data used to characterize food insecurity in the annual report from 
the USDA (Nord, et al, 2010). On average, between 2001 and 2009 about 3 
million seniors were food insecure in any year. Along with those 
experiencing food insecurity, another 2.9 million seniors are 
marginally food secure, i.e., they are experiencing some level of food 
hardship, albeit not enough to be fully food insecure.
    Insofar as food insecurity is closely tied to economic constraints, 
it is not surprising that certain groups of seniors are at greater risk 
of food insecurity. In particular, seniors with limited incomes, 
African-Americans, Hispanics, never-married individuals, renters, and 
younger seniors are all more likely to be food insecure. One other 
group that is at especially high risk of food insecurity are seniors 
raising grandchildren. We find that households with a grandchild 
present are on average about two and a half times as likely to be food 
insecure as households without a grandchild present.
    Along with income and demographic characteristics, there is a great 
deal of geographic diversity across the United States in food 
insecurity rates. This diversity is evident in Figure 1 which displays 
food insecurity rates for all 50 States plus the District of Columbia. 
The range of food insecurity rates is enormous from 1.6 percent in 
North Dakota to a rate over 7 times higher in Mississippi (12.5 
percent).


    While certain groups of seniors are at greater-risk of food 
insecurity and there are States with especially high rates of food 
insecurity, food insecurity cuts across the income spectrum. For 
example, over 50 percent of all seniors who are at-risk of hunger have 
incomes above the poverty line. Likewise, it is present in all 
demographic groups. For example, over two-thirds of seniors at-risk of 
hunger are white.
    The consequences of food insecurity among seniors. The mere 
existence of food insecurity among seniors is of concern to 
policymakers and program administrators in the United States. What 
makes food insecurity among seniors an even more pressing concern is 
that it may lead to numerous negative health outcomes. We examined 
whether or not food insecurity does lead to worse health outcomes among 
seniors through the use of data from the 1999-2006 waves of the 
National Health and Nutrition Examination Survey (NHANES), a nationally 
representative data set with numerous questions on health and nutrition 
outcomes.
    Controlling for other factors, we found that, as in the general 
population, food insecure seniors have worse health outcomes than food 
secure seniors. With respect to nutrient intakes, food insecure seniors 
are significantly more likely to have lower intakes of energy and major 
vitamins. The effects are very strong; for example, across all the 
measures, the effect of being marginally food insecure is over twice as 
large (and generally much larger) than a move in income from one-to-two 
times the poverty line. With respect to broader measures of well-being 
food insecure seniors are significantly more likely to report being in 
poor or fair health and report limitations in activities of daily 
living (ADL). For the latter, the effects are especially strong--for 
example, being marginally food insecure is roughly equivalent to being 
14 years older.
    Recent changes in food insecurity among seniors. The recent 
economic downturn has been associated with unprecedented increases in 
the extent of food insecurity among seniors in the United States. As 
seen in Figure 2, derived from Ziliak and Gundersen (2011), across all 
three measures there was an increase of over 30 percent in food 
insecurity from 2007 to 2008. While food insecurity rates did decline 
somewhat from 2008 to 2009 for seniors, in comparison to earlier in the 
decade, the proportions of food insecure seniors are markedly higher. 
And for the more vulnerable group of seniors raising grandchildren, 
food insecurity continued to rise through 2009. Overall, then, by 2009, 
23 percent more seniors were marginally food insecure, 37 percent more 
were food insecure, and an astonishing 88 percent more were very low 
food secure. Translating into estimates of the numbers of seniors 
involved, by 2009 7.5 million seniors were marginally food insecure, 
and of those 4 million were food insecure and 1.4 million were very low 
food secure. Despite another decade of efforts to address food 
insecurity among seniors, the scale of food insecurity remains 
stubbornly high.


                               References
Nord, M., A. Coleman-Jensen, M. Andrews, and S. Carlson. Household Food 
    Security in the United States, 2009. U.S. Department of 
    Agriculture, Economic Research Report 108. 2010.
Ziliak, J. and C. Gundersen. A Portrait of Food Insecurity in 
    Multigenerational Households: Part 1. Technical Report submitted to 
    the Merck Foundation. 2011.
Ziliak, J. and C. Gundersen. Senior Hunger in the United States: 
    Differences across States and Rural and Urban Areas. Technical 
    Report submitted to the Meals on Wheels Association of America. 
    2009.
Ziliak, J., C. Gundersen, and M. Haist. The Causes, Consequences, and 
    Future of Senior Hunger in America. Technical Report submitted to 
    the Meals on Wheels Association of America Foundation. 2008.
                                 ______
                                 
                                  Jeff Gordon Inc.,
                                             June 20, 2011.
Hon. Bernard Sanders, Chairman,
Subcommittee on Primary Health and Aging,
428 Dirksen Senate Office Bldg.,
Washington, DC 20520.

    Dear Chairman Sanders: It's an honor to be invited to speak before 
the committee--what a great opportunity to share all the work we are 
doing in NASCAR. Unfortunately, I am not able to travel to Washington, 
DC on the requested date due to other obligations previously scheduled.
    Below, please see information detailing the 2011-13 program. In 
addition to our objectives, we have partnered with International 
Speedway Corporation (ISC), the owners of Daytona International 
Speedway, and other tracks we race at to donate left over event food to 
local food banks.
    Concord, NC (Oct. 27, 2010)--Hendrick Motorsports and four-time 
NASCAR Sprint Cup Series champion Jeff Gordon have teamed with AARP and 
AARP Foundation on the Drive to End Hunger (www.DriveToEndHunger.org), 
an unprecedented 3-year initiative to address the growing problem of 
hunger among older Americans, including 6 million over the age of 60. 
Drive to End Hunger will be the majority sponsor of Gordon's No. 24 
Hendrick Motorsports team in 2011, 2012 and 2013, with primary paint 
schemes in 22 Sprint Cup races annually. The No. 24 Drive to End Hunger 
Chevrolet, which will be unveiled at a later date, will race in the 
next three Daytona 500 events.
    ``This is a truly unique opportunity to help people, and it's a 
completely new, cause-driven approach to sponsorship,'' said Gordon, 
39, winner of 82 career Sprint Cup races.

          ``Every single day, millions of older Americans arc forced to 
        make a choice between food, medicine and utilities. It's going 
        to be a team effort, and it's not going to be easy, but we can 
        solve this problem.''

    With Gordon as its spokesperson, Drive to End Hunger will help the 
millions of older Americans who are facing hunger across the United 
States. The effort will engage the NASCAR fan base, corporations and 
charitable organizations via a text-to-donate program; activation at 
racetracks across the country; further research on the causes and 
consequences of hunger in older Americans; and an innovative national 
grant program that will provide resources to address the problem at a 
local level.
    Donations from Drive to End Hunger will benefit the hunger programs 
of AARP Foundation.
    ``Hunger is a hidden problem that millions of older Americans are 
battling silently. In fact, between 2006 and 2008, the percentage of 
seniors struggling with hunger more than doubled,'' said Jo Ann 
Jenkins, AARP Foundation president.

          ``NASCAR fans are among the most charitable, community-minded 
        sports fans in the country, and they have a track record of 
        commitment. With the help of Jeff and the Hendrick team, we 
        will make the most of this unprecedented opportunity to end the 
        struggle that so many older Americans have with hunger.''

    Drive to End Hunger will build on the hunger initiative launched 
earlier this year by AARP Foundation, including volunteer-led food 
drives, individual and corporate fundraising campaigns, and online 
hunger resources at www.aarp.org/hunger.

          ``It's exciting to see a new organization engage with our 
        sport and our fans through such an innovative approach,'' said 
        Rick Hendrick, owner of Hendrick Motorsports. ``Having seen 
        firsthand what the NASCAR community is capable of 
        accomplishing, I know the program will help a lot of people in 
        our country who desperately need it. Success ultimately will be 
        measured by how many lives we can impact, and that's a truly 
        unique and special opportunity for everyone involved.''

    Darlington, SC--Four-time NASCAR Sprint Cup Series Champion Jeff 
Gordon, International Speedway Corporation's (``ISC'') Chief Executive 
Officer Lesa France Kennedy and Darlington Raceway President Chris 
Browning today announced that, on behalf of Drive to End Hunger, 
Americrown, ISC's food and beverage concessions operator, will donate 
all extra food items from the NASCAR Sprint Cup Series races it 
services to the local food bank that serves the race track area.
    Drive to End Hunger is AARP and AARP Foundation's national effort 
to end hunger for older Americans. Donations are expected to include 
breads, produce and other food items and will be prepared for delivery 
by Americrown on Mondays following ISC's NASCAR Sprint Cup Series 
races.
    ``This commitment is a huge opportunity to help people who are 
struggling with hunger in the communities around the ISC tracks,'' 
Gordon said.

          ``Fifty-one million Americans struggle with hunger and six 
        million of them are over 60. This is a problem that if we all 
        work together, we can solve. We're really thrilled that ISC has 
        joined us in this important fight.''

    ``Providing food to those who need help is a cause that positively 
impacts each community in which we operate,'' said France Kennedy.

          ``We are privileged to collaborate with Jeff Gordon and 
        AARP's Drive to End Hunger effort. Through our collective 
        efforts, we can make a difference in the lives of many in 
        need.''

    Today's announcement follows ISC's donations at Daytona 
International Speedway of more than 7,000 pounds of excess food to the 
Second Harvest Food Bank of Central Florida following the 2011 Daytona 
500; Talladega Superspeedway, which donated the extra food from its 
Aaron's Dream Weekend to the Community Food Bank of Central Alabama; 
and Richmond International Raceway Central which donated to the Central 
Virginia Food Bank.
    ``We are pleased that Darlington Raceway, through AARP's Drive to 
End Hunger, can make a significant difference for people in our 
community,'' Chris Browning said.

          ``In South Carolina alone, more than 22 percent of people 
        reported not having enough money to buy food in the last year. 
        Almost 10 percent of seniors in South Carolina are at risk of 
        hunger. Particularly in these economic times, we want to do 
        everything we can to support the folks in communities around 
        ISC tracks. They are important to us, they are important to the 
        sport, and solving this problem should be important to everyone 
        in America.''

    Donations will be made at these ISC tracks for the remainder of the 
2011 NASCAR Sprint Cup season, including:

    Daytona International Speedway (Daytona Beach, FL)--July 2d--Coke 
Zero 400; Homestead-Miami Speedway (Homestead, FL)--November 20th--Ford 
400; Kansas Speedway (Kansas City, KS)--June 5th--STP 400; and October 
9th--Hollywood Casino 400; Martinsville Speedway (Ridgeway, VA)--
October 30th--TUMS Fast Relief 500; Michigan International Speedway 
(Brooklyn, MI)--June 19th--Heluva Good! Sour Cream Dips 400 and June 
19th--Michigan 400; Phoenix International Raceway (Avondale, AZ)--
November 13th--Kobalt Tools 500; Richmond International Raceway 
(Richmond, VA)--September 10th--Last Race to Make the Chase; and 
Watkins Glen International (Watkins Glen, NY)--August 14th--Heluva 
Good! Sour Cream Dips at The Glen.
    Once again, I would like to thank you for this opportunity.
            Sincerely,
                                               Jeff Gordon.

    [Whereupon, at 11:36 a.m., the hearing was adjourned.]




