[Senate Hearing 115-196]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-196

    AGING WITH COMMUNITY: BUILDING CONNECTIONS THAT LAST A LIFETIME

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                              MAY 17, 2017

                               __________

                            Serial No. 115-5

         Printed for the use of the Special Committee on Aging
         
         
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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina          KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee                RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina         JOE DONNELLY, Indiana
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska                CATHERINE CORTEZ MASTO, Nevada
                              ----------                              
                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director
                                CONTENTS

                              ----------                              

                                                                   Page

Opening Statement of Chairman Susan M. Collins...................     1
Statement of Ranking Member Robert P. Casey, Jr..................     3

                           PANEL OF WITNESSES

Lindsay Goldman, LMSW, Director, Healthy Aging, The New York 
  Academy of Medicine............................................     5
Meg Callaway, Project Director, Piscataquis Thriving in Place 
  Collaborative..................................................     7
Cathy A. Bollinger, Managing Director, Embracing Aging, York 
  County Community Foundation....................................     8
Anamarie Garces, Founding Member, Miami-Dade Age-Friendly 
  Initiative, Co-Founder and CEO, Urban Health Partnerships, 
  Miami, Florida.................................................     9

                                APPENDIX
                      Prepared Witness Statements

Lindsay Goldman, LMSW, Director, Healthy Aging, The New York 
  Academy of Medicine............................................    30
Meg Callaway, Project Director, Piscataquis Thriving in Place 
  Collaborative..................................................    47
Cathy A. Bollinger, Managing Director, Embracing Aging, York 
  County Community Foundation....................................    48
Anamarie Garces, Founding Member, Miami-Dade Age-Friendly 
  Initiative, Co-Founder and CEO, Urban Health Partnerships, 
  Miami, Florida.................................................    63

                  Additional Statements for the Record

Statement of Amy Schectman, President, Jewish Community Housing 
  for the Elderly, Boston Massachusetts..........................    66
Statement of the Altarum Center for Elder Care and Advanced 
  Illness........................................................    69

 
    AGING WITH COMMUNITY: BUILDING CONNECTIONS THAT LAST A LIFETIME

                              ----------                              


                        WEDNESDAY, MAY 17, 2017

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:30 a.m., in 
Room SD-562, Hon. Susan M. Collins, Chairman of the Committee, 
presiding.
    Present: Senators Collins, Rubio, Fischer, Casey, 
Blumenthal, Donnelly, Warren, and Cortez Masto.

    OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The hearing will come to order. Good morning. 
Thank you all for being here.
    As many of you are aware, originally this hearing had been 
scheduled for last week. Due to circumstances beyond our 
control, the hearing had to be postponed, and I very much 
appreciate our witnesses coming again or sending a 
representative when they could not do so to help us explore 
what is a very important issue.
    Isolation and loneliness can have serious, even deadly 
consequences, for the health and well-being of our nation's 
seniors. We examined this growing epidemic in a hearing that 
this Committee held last month, and we learned that isolation 
is associated with a greater incidence of depression, diabetes, 
and heart disease. In fact, the health risks of prolonged 
isolation are comparable to smoking 15 cigarettes a day. I must 
say that fact astonished me.
    Today, we are looking for solutions that will help to build 
a stronger sense of community, therefore leading to happier, 
healthier lives for older Americans.
    When the Senate Aging Committee was first established in 
1961, 9 percent of Americans were over age 65. Today, those 
older than 65 represent 15 percent of our population. By the 
year 2060, nearly one out of four Americans will surpass their 
65th birthday.
    The fastest-growing age group is what is called the 
``oldest old,'' those 85 years old and older. Today, we will 
explore ideas to connect seniors with communities to make home 
not only a better place to grow up, but also a better place to 
grow old.
    Most seniors want to live at home as long as possible. 
This, however, can pose challenges. Maintaining a home is an 
arduous task at any age and can be especially so for older 
adults. Snow may need to be shoveled. Repairs may need to be 
made. Windows may need to be replaced. The list is endless.
    As seniors age and in some cases develop chronic diseases 
that present mobility and other impairments, homes may need 
more significant modifications such as wider hallways to 
accommodate a wheelchair, grab bars in the bathroom, chairlifts 
for the stairs.
    Transportation is another key factor of an age-friendly 
community. Seniors need a way to get to the grocery store and 
doctors' appointments and to visit with friends or enjoy 
community events, especially once driving is no longer a safe 
option. Age-friendly communities often provide bus routes for 
seniors, volunteer driver programs, and other initiatives to 
help seniors go where they need and want to go.
    One key feature of age-friendly communities cannot be 
captured by infrastructure or policy but is part of our 
culture. In a 2007 report, the World Health Organization 
declared the development of age-friendly communities a global 
priority.
    One domain that stood out to me is the need for respect and 
inclusion for our seniors. In age-friendly communities, seniors 
are respected for their past and present accomplishments. They 
are included in community planning. They engage with younger 
adults and children. They are valuable and contributing members 
of society with a lifetime of experience to offer. Whether they 
are homebound or not, the community ensures that seniors are 
not left feeling isolated or left out.
    Respect and inclusion are an essential part of the spirit 
of the American democracy. Towns from the most rural to the 
most urban are responding to the needs of seniors, as we will 
learn today. Initiatives to create age-friendly communities 
have grown organically across the country. The national 
organization that provides support and tools is the AARP 
network of age-friendly communities.
    In Maine, our state motto is Dirigo, which means ``I 
lead,'' and I am very proud that Maine is leading the way.
    Of the 163 communities in the nation that have joined this 
network, 35 are in the State of Maine. We have communities such 
as Bethel and Biddeford, Eastport and Milo that are committed 
to becoming more welcoming to seniors. These 35 communities 
have each developed an action plan reflecting local needs. When 
the oldest and most rural state leads the way, it represents 
success for the entire nation.
    Our hearing today is especially fitting during Senior Corps 
Week. In Maine, 1,675 volunteers make significant contributions 
to communities through the state's nine Senior Corps programs. 
Senior companions, RSVP volunteers, and RSVP Vet to Vet connect 
seniors with communities. Senior service presents a promising 
solution to help combat isolation and promote a sense of 
community and a sense of service and mattering.
    Today, we will hear from four program directors who will 
describe initiatives under way in their communities to address 
the needs of their aging populations. You will notice that no 
two models are alike, and that is the beauty of this approach. 
Each is built from the ground up. Each is tailored and 
customized for seniors living in their communities. The factor 
that ties these programs together is a strong sense of 
community that includes and values all of our seniors.
    It is now my pleasure to turn to our Ranking Member, 
Senator Casey, for his opening statement.
    Thank you.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING 
                             MEMBER

    Senator Casey. Chairman Collins, thank you for holding this 
important hearing and also for working to reschedule it after 
it was postponed from last week, and I want to thank the 
witnesses for being here today.
    As many of you know, May is Older Americans Month, and this 
year, the slogan for Older Americans Month is ``Age Out Loud,'' 
a good slogan. So our hearing topic today, living--livable, I 
should say, communities fits nicely into the theme.
    Older Americans want to be out and about, aging out loud in 
their cities and their towns. They want to go to little league 
games or see a movie or work or volunteer, shop or interact 
with their neighbors. For this reason, I am pleased that 
experts from communities large and small, rural and urban are 
here to discuss how to design livable communities.
    I am particularly delighted to have a leader here today 
from my home State of Pennsylvania and in particular York, 
Pennsylvania. I will introduce Cathy later, but we are grateful 
for the work that she has done and the people of York County 
and the City of York. And I can confirm what a great community 
York is. I was just there not long ago, and we are grateful 
that she is with us.
    We should aim for every county across the country to be 
like York County. And I know that Chairman Collins talked about 
communities in Maine and how many of them are livable 
communities, so we should have a competition, I guess, to get 
as many signed up.
    What does it mean in practice? I guess that is one question 
some might be asking. What it means is that local officials are 
reorienting their thinking as to their plans for and their 
investment in a number of things: number one, home repair 
programs so that aging adults can maintain their households 
without great expense; second, accessory dwelling units so 
relatives can live with their families and retain their 
privacy; third, more and varied transportation options for 
those who are no longer able to drive; fourth, wide, slip-free, 
even-surface sidewalks and more time to cross the street at 
traffic signals--I think people at any age would want that--and 
simple solutions like a bench to sit on and wait for a bus.
    These strategies can make a big difference to a senior who 
wants to be active and engaged in their community, and these 
strategies can help make progress on the public health 
challenge of senior isolation. These strategies also make it 
possible to have towns and cities that are inclusive, as the 
Chairman said, that are cross-generational and are age- and 
income-friendly.
    I expect our witnesses today will also address the 
importance of neighborhoods that have a mix of older and 
younger residents and families from multiple socioeconomic 
levels.
    We know that inclusive neighborhoods are often the 
healthiest neighborhoods, and we also know that making our 
communities age-friendly will not be fully realized without 
partners at the Federal level.
    It is, in part, for this reason that I have joined my 
colleagues in urging President Trump to work with us on an 
infrastructure package, legislation to invest in our 
infrastructure.
    I am committed to ensuring states and localities have the 
resources necessary to invest in our cities and towns of the 
future, creating millions of jobs along the way.
    I look forward to hearing from our witnesses about how that 
investment would also significantly benefit older Americans and 
individuals with disabilities.
    Thank you, Madam Chair.
    The Chairman. Thank you very much, Senator Casey.
    We will now turn to our panel of witnesses. First, we will 
hear from Lindsay Goldman. Ms. Goldman is the director of 
Healthy Aging and the Center for Health Policy and Programs at 
The New York Academy of Medicine. She oversees age-friendly New 
York City and works to improve all aspects of city life for 
seniors.
    We will go from New York City to rural Maine with our next 
witness, who is one of my constituents, Meg Callaway. Ms. 
Callaway is the program director of the Thriving in Place 
Collaborative in Piscataquis County, where some of Maine's most 
rural communities are located. Meg works to provide critical 
services, such as food, housing, and caregiver support to older 
adults living in Piscataquis County by coordinating a network 
of existing local resources. She has nearly 25 years of 
experience in the Maine social service system and has worked 
extensively with Maine families, and I am delighted that she 
was able to return to participate today.
    I would now turn to our Ranking Member Casey to introduce 
our next witness.
    Senator Casey. Thanks very much.
    I am pleased to introduce Cathy Bollinger from Spring 
Grove, Pennsylvania, which is in York County, as I mentioned. 
She is the managing director of the York County Community 
Foundation Embracing Aging Initiative. With a collaboration 
made up of businesses, charitable groups, and government 
agencies, Cathy works to create livable communities for aging 
Pennsylvanians. This work includes improving housing, 
transportation, lifelong learning, arts and culture, and health 
and well-being for seniors in York County, Pennsylvania. 
Because of this innovative work, York is one of only six 
communities highlighted for its livable communities work by the 
National Association of Area Agencies on Aging. She has done 
this work for years, and we are grateful that she is here.
    Welcome to the Committee, Cathy. Welcome back. You were 
here last week as well. We look forward to your testimony.
    The Chairman. I am now pleased to turn to Senator Rubio, 
who will introduce our witness from the great State of Florida.
    Senator Rubio. Thank you. Thank you, Madam Chair, for 
holding this important hearing.
    I also want to take a quick moment to introduce Anamarie 
Garces from my home State of Florida and from my home City of 
Miami. She is a founding member of the Miami-Dade Age-Friendly 
Initiative, which works to improve the community life for older 
adults. Her organization works closely with a community that I 
know well, Little Havana in Miami, Florida, to improve the 
quality of life for seniors, and I am pleased that she is with 
us here today. I thank her for her good work. I look forward to 
her testimony.
    The Chairman. Thank you very much, Senator.
    Ms. Goldman, we will start with you.

 STATEMENT OF LINDSAY GOLDMAN, LMSW, DIRECTOR, HEALTHY AGING, 
                THE NEW YORK ACADEMY OF MEDICINE

    Ms. Goldman. Good morning, and thank you, Chairwoman 
Collins, Ranking Member Casey, and members of the Aging 
Committee for the opportunity to testify today. My name is 
Lindsay Goldman, and I am the director of Healthy Aging at The 
New York Academy of Medicine.
    Established in 1847, the academy advances solutions that 
promote the health and well-being of people in cities 
worldwide. One of our current priority areas is healthy aging. 
The academy serves as the secretariat for Age-Friendly New York 
City, a public-private partnership with the city council and 
the mayor's office, working to maximize the social, physical, 
and economic participation of older people.
    Beginning in 2007, using the World Health Organization's 
eight domains of an age-friendly city, we conducted a 
comprehensive assessment of the city's age friendliness to 
identify barriers to engagement faced by older people 
throughout the course of daily life. The assessment included 
guided conversations with thousands of residents, roundtable 
discussions with hundreds of professionals, a literature 
review, and extensive mapping.
    In response to our findings in 2009, the mayor's office 
announced 59 initiatives across 13 city agencies to improve the 
quality of life for older adults and appointed a commission for 
an age-friendly New York City to encourage private 
organizations to become more inclusive. Nearly 10 years later, 
we remain deeply invested in this effort.
    We applaud the Committee's recognition of social isolation 
as a threat to public health. Through low- or no-cost 
solutions, Age-Friendly New York City works to optimize 
existing age-neutral assets that facilitate connections between 
the generations.
    Today, I will describe our strategies to increase 
walkability and access to public transit, to leverage public 
space and programming, and to maximize economic participation 
to prevent social isolation.
    There is considerable evidence that walking is associated 
with better physical and mental health, and the majority of 
older New Yorkers prefer to walk to destinations. However, 
older people reported challenges, like inadequate street-
crossing times, poorly maintained sidewalks, and lack of 
seating.
    The Department of Transportation, DOT, established the Safe 
Streets for Seniors Program to evaluate conditions in areas 
with high rates of senior pedestrian fatalities or injuries and 
implement mitigation measures such as extending street-crossing 
times, constructing pedestrian safety islands, widening curbs 
and medians, narrowing roadways, and installing new stop 
signals. Through this process, over 600 dangerous intersections 
have been redesigned, and senior pedestrian fatalities have 
decreased 16 percent citywide.
    DOT also installed over 1,500 new benches around the city, 
particularly near senior centers and housing, hospitals and 
health centers, commercial districts, and municipal facilities. 
In response to feedback that bus shelters often lack seating 
and felt unsafe, nearly 4,000 shelters have been redesigned 
with seating and transparent walls. Older people report 
increased mobility and new social connections as a result of 
these initiatives.
    While research suggests that participation in public space 
improves health and well-being through opportunities for 
physical and social activity, older people tend to spend more 
time engaged in solitary and sedentary pursuits, such as 
watching TV and reading.
    Older people in the neighborhood of East Harlem revealed 
that they did not use public pools because they were afraid of 
getting hurt during crowded general swim hours. In response, 
the Parks Department piloted senior-only swim hours at one pool 
in the morning when the pool was underutilized. The program was 
so popular, the Parks Department expanded it to 16 pools 
citywide and added water aerobics instruction.
    A preliminary evaluation indicated that older people who 
participated in water aerobics demonstrated greater lower body 
strength and flexibility than those who did not.
    Older people often have a limited catchment area for 
activity, so local businesses enable them to meet basic needs 
and to socialize. Local businesses also depend on older people, 
who account for nearly 50 percent of consumer spending, as 
loyal customers, yet older people often reported barriers, 
including accessibility, affordability, and lack of appropriate 
products and services.
    With input from the business community, the academy created 
the Age-Friendly Business Resource Guide to help businesses 
better attract and cater to an aging consumer base. We have 
educated 30,000 storefront businesses, catalyzing improvements 
such as the addition of seating in stores, more legible 
signage, and new senior discounts. A small study found that 
businesses that made age-friendly changes had higher average 
cash receipts than similar businesses that did not.
    As illustrated by these examples, planning processes to 
inform improvements to the built, social, and economic 
environment should engage older people as experts on their own 
lives. By leveraging evidence-based, age-friendly strategies 
such as universal design and active transit, Federal investment 
in infrastructure can facilitate independence, promote 
engagement, and build a sense of community.
    Additionally, Federal leadership and funding can help to 
reduce social isolation and maintain the health and well-being 
of older people through the provision of safe and affordable 
housing as well as better access to health care, 
transportation, healthy food, technology, and arts and culture.
    Thank you.
    The Chairman. Thank you very much for your very interesting 
testimony. Both Senator Casey and I were struck by that 
reduction in pedestrian fatalities, which is really 
extraordinary.
    Ms. Callaway.

   STATEMENT OF MEG CALLAWAY, PROJECT DIRECTOR, PISCATAQUIS 
                THRIVING IN PLACE COLLABORATIVE

    Ms. Callaway. Good morning, Chairman Collins, Ranking 
Member Casey, and members of the Senate Special Committee on 
Aging. Thank you so much for having us return to testify this 
morning. My name is Meg Callaway, and I direct the Thriving in 
Place Collaborative in Piscataquis County, Maine.
    Piscataquis has Maine's second oldest population, and we 
are the state's most rural region. We are actually one of only 
two frontier territories remaining east of the Mississippi 
River, with fewer than six people per square mile and a land 
mass slightly bigger than Connecticut. We are home to 17,000 
people and 27,000 moose.
    [Laughter.]
    Ms. Callaway. The Piscataquis County Thriving in Place 
Collaborative is one of nine aging-in-community projects that 
are funded through the Maine Health Access Foundation's 
Thriving in Place or TiP initiative. These projects convene 
partners, including municipal leaders, social service 
providers, health professionals, businesses, and volunteers to 
assess the regional needs of older and medically vulnerable 
adults and to implement strategies that help them to stay at 
home and connected in their communities.
    TiP projects improve the coordination of existing services 
and supports in rural communities, and by doing so, we increase 
access to critical resources, such as housing, food, 
transportation, socialization, health care, and very 
importantly, caregiver support. We do this by building 
relationships and by facilitating communication between older 
people and community organizations. Older volunteers are 
integral to our efforts. Their experiences and priorities shape 
all that we do.
    While all projects focus on keeping older adults connected 
to their communities, our approaches vary. The situational 
needs of older people living on the rocky coast can be 
different than those of seniors living in the deep woods of 
Maine, and their available resources also can be quite 
different.
    The success of the Thriving in Place Collaborative--
Initiative is largely due to the flexible funding that allows 
communities to build on their own strengths and to focus on the 
specific needs of their aging populations.
    For example, in Piscataquis County, a local farm provides 
fresh meals for seniors recovering from extended illness. 
Renovations are under way of an historic building that will 
house a senior center for independent adults and an adult day 
services program for older adults who need more support.
    We now have a central phone line that anyone can call for 
help with locating senior services, and when a caller has 
complex medical needs, we send a nurse to help put together a 
plan of care.
    With the help of AARP, we have stocked five local libraries 
with caregiver and aging resources, and volunteers provide 
social connection and fresh produce to homebound seniors 
through our local Senior Companion and Senior FarmShare 
program. We have a local volunteer hospice that provides 
respite for family caregivers.
    The Aroostook County TiP in northern Maine partners with 
their local nursing school and hospital to engage students in 
home-based assessments and discharge follow-up. Students review 
discharge instructions, provide pre-made meals, and review 
medications to assist seniors after a hospital stay. And this 
collaboration is yielding significant reductions in hospital 
re-admissions.
    TiP Downeast on the Blue Hill Peninsula has established an 
in-home visitor program and is bringing evidence-based health 
programs deeper into rural, coastal areas, again, reducing 
hospital admissions and institutionalization.
    TiP programs are educating their communities about care 
transitions and the importance of completing advanced care 
directives. As TiP aligns these and so many other essential 
resources, new, more efficient ideas for engaging older adults 
and reducing isolation continue to emerge. These projects are 
actively demonstrating the power of community to keep seniors 
healthy, connected in their communities, and truly thriving in 
the places they call home.
    Thank you.
    The Chairman. Thank you very much for your testimony.
    Ms. Bollinger.

 STATEMENT OF CATHY A. BOLLINGER, MANAGING DIRECTOR, EMBRACING 
            AGING, YORK COUNTY COMMUNITY FOUNDATION

    Ms. Bollinger. Chairman Collins, Ranking Member Casey, and 
members of the Special Committee on Aging, thank you for the 
opportunity to testify today. I am Cathy Bollinger, managing 
director of York County Community Foundation's Embracing Aging 
Initiative.
    Embracing Aging launched in the fall of 2013 with a release 
of a report we commissioned that identified how to make York 
County more age-friendly. The report led us to form committees 
to address the issues of attitudes around aging, community 
engagement, health and well-being, housing, and transportation 
and walkability.
    Our goal is to create a community that is a safe, 
welcoming, appropriate, and adaptable place to age. To 
accomplish this, we develop and implement strategies to improve 
attitudes around aging, so that we can care and understand 
about the needs and the perspectives of all ages. We also 
provide strategic leadership and advocacy to create more high-
quality, forward-thinking options to help older people live as 
they choose in their community.
    Located in south central Pennsylvania, York County is home 
to over 440,000 people. It has 72 municipalities. Ten percent 
of people of all ages live in poverty. Seventeen percent of our 
county's population is age 65 and older.
    Thirty-seven percent of our residents are age 50 and older. 
Over one-third of York countians age 65 and older struggle to 
meet their basic needs, forcing them to make difficult choices 
among things such as nutritious food, prescription medications, 
or adequate heating and cooling.
    Embracing Aging works collaboratively across sectors to 
effect social change. Most important is assuring that older 
people are around the table in the planning, implementing, and 
evaluation of programs and ideas.
    Building relationships with key stakeholders and sharing 
specific strategies to ensure public spaces, services, and 
policies are age-inclusive is important in creating a livable 
community. This is the reason we have awarded grants to support 
partnership planning, improve walkability, provide age-friendly 
seating, improve signage, and offer a free park-and-go shuttle 
for seniors attending local events.
    Helping older adults be proactive in creating their plan 
for aging in community is also important to age-friendly work. 
We created a program that teaches older people new strategies 
to examine their needs in housing, transportation, health, 
finances, and social interactions, and introduced them to 
services and programs to help them live longer and stronger in 
the place that they call home.
    We awarded grant money to an organization to grow its 
capacity, to provide home repairs and maintenance services to 
older adult homeowners without financial means, so they can 
remain living safely in their home.
    Assuring older people have employment opportunity helps 
create a livable community. We partnered with our local 
Economic Alliance to host employer industry forums to assess 
employers' interests in how best to recruit older workers and 
build an employment environment that works for employees of all 
ages. The results are the foundation for an age-friendly 
business designation program we are developing.
    As part of this work, we developed a program for employees 
entitled ``Embracing Aging: Challenging the Perceptions of 
Aging'' to increase understanding of older adults, and people 
across different generations, to help build a workforce that is 
more creative and productive, and more open and supportive of 
older customers.
    We are an aging society, and data demonstrates that each 
future generation will continue to live longer. The impact of 
this change has not yet been fully reflected in government 
policies affecting a community's infrastructure, Social 
Security, and Medicare. The heavy lifting to support the 
infrastructure necessary for this change must come from 
government.
    Specifically, we think funding for the following is key to 
improved livability: one, better transportation options, 
including improving walkability; two, incentives to address 
blighted properties and incentives to preserve and build more 
low-income and affordable housing with supported services 
proximate to transportation; and three, enhanced in-home 
community-based services and a health care plan that does not 
penalize older adults.
    Chairman Collins, Ranking Member Casey, and members of the 
Special Committee on Aging, thank you for the honor in sharing 
the work of York County Community Foundation's Embracing Aging 
Initiative, and thank you for your commitment to making America 
a great place to age.
    The Chairman. Thank you very much for your testimony.
    Ms. Garces.

 STATEMENT OF ANAMARIE GARCES, FOUNDING MEMBER, MIAMI-DADE AGE-
     FRIENDLY INITIATIVE, CO-FOUNDER AND CEO, URBAN HEALTH 
                  PARTNERSHIPS, MIAMI, FLORIDA

    Ms. Garces. Chairman Collins, Ranking Member Casey, and 
members of the Aging Committee, thank you for the opportunity 
to testify before you today and for the work you are doing. My 
name is Anamarie Garces. I am a founding member of the Miami-
Dade Age-Friendly Initiative. I am co-founder and CEO of Urban 
Health Partnerships, one of the lead partners in the 
initiative.
    The Miami-Dade Age-Friendly Initiative is a collective 
impact effort focused on policy, systems, and environmental 
changes toward creating a community for all ages and ability, 
where older adults can stay active, engaged, and healthy with 
dignity and enjoyment. And it is led by a diverse group of 
partners, including AARP Florida, the Alliance for Aging, 
Health Foundation of South Florida, Miami-Dade County, Miami-
Dade Transportation Planning Organization, United Way of Miami-
Dade, and Urban Health Partnerships, along with an advisory 
committee and 50 key stakeholders and community members.
    Miami-Dade is the most populous county in Florida, with 2.6 
million people, more than 500,000 older adults above the age of 
60, and we expect that to increase to 800,000 by 2040.
    Miami-Dade has a diverse population. Sixty-seven percent of 
the county identifies as Hispanic, and most who are bilingual 
speak Spanish.
    Miami-Dade has identified age-friendly as an important 
approach to reducing social isolation and addressing how we can 
build a community that supports the wants and needs of older 
adults. It recently joined the AARP Network of Age-Friendly 
Communities, making it the fifth largest community in the 
country to join the network.
    The World Health Organization's domains of livability can 
be broken up into two categories: the built environment or the 
environment we can see and touch, such as housing, streets, 
parks, and infrastructure; and the social environment, such as 
the opportunities, support, and services that are available. 
Both are important and interdependent.
    Miami-Dade has focused on the built environment, first 
recognizing that if services or opportunities for social 
engagement are available, but residents do not have access or 
do not feel safe accessing them, it will isolate them from the 
resources and services that they need.
    Some of the age-friendly strategies that have been 
implemented in Miami-Dade include ensuring that all 
transportation policies have an older adult focus. The 
Comprehensive Development Master Plan, land use, and community 
health and design elements were considered with an older-adult 
lens. The long-range transportation plan has performance 
measures specifically to assess how well we are meeting the 
older adults needs.
    Miami-Dade parks have incorporated standards, programs, and 
facilities to engage older adults. The Housing Work Group 
supports the development of the Affordable Housing Trust Fund 
for Miami-Dade.
    Summits, workshops, events, town halls, and surveys have 
taken place, and the input received has translated into a 
robust action plan to guide our work.
    In 2012, our Safe Routes to Age in Place Project launched 
to empower older adults in Little Havana to recognize the needs 
and to identify changes to improve the safety within their 
neighborhood. Little Havana, or La Pequena Habana, was recently 
named a national treasure. It is a diverse neighborhood in 
Miami-Dade known for its Cuban-American heritage and is home to 
immigrants from across Central America and the Caribbean.
    The older adults engaged in the workshops, they led a CDC 
Healthy Aging Network walking audit, and they discussed 
themselves with elected officials and transportation agencies 
what they would like to see in their communities, and they 
advocated for the changes that would make them more able to 
access their daily needs.
    We also developed an advisory committee to provide input to 
the Florida Department of Transportation on the Little Havana 
Pedestrian Safety Study. The low-cost, high-impact built 
environment projects have exponential benefits for older 
adults.
    One tactic is shade. Utilizing a digital laser infrared 
thermometer temperature gun, it was determined that shaded bus 
stops were 10 to 20 degrees less hot or had lower surface 
temperature that non-shaded bus stops in Miami-Dade County. The 
average temperature in Miami on any given day is 82 degrees. 
Due to concrete and heat island effect that is created at bus 
stops without shade, older adults can experience temperatures 
of much more than 100 degrees while waiting at their stops. 
Research supports that shaded stops provide the sensation that 
individuals waited 10 minutes less than those at non-shaded 
stops.
    The Safe Routes to Age in Place Advisory Committee 
recommended an age-friendly business district, so we developed 
one. Older adults told us that once they had safer streets, a 
financial incentive, and places to go, they would be motivated 
to walk more. Initially, 25 businesses within only a quarter 
mile of their target location of where they lived provided 
purchasing incentives for older adults to walk every Tuesday to 
their stores. An age-friendly community is called ``age-
friendly'' and not ``senior-friendly'' because the strategies 
are not only good for older adults but for everyone, from the 
very young to the very old. The same curb cut or ramp that may 
be added to ensure a wheelchair can get onto a sidewalk is the 
same one that can help a parent push a child in a stroller. 
Each time added to a crossing signal, that can help ensure that 
an older adult or anyone will not lose their footing if they 
try to rush across the street too quickly.
    We need your continued leadership to ensure age-friendly 
livable communities are a priority in our cities, to help build 
the infrastructure that works for all ages and connects us to 
our resources and to our citizens, and to ensure aging 
continues to be the conversation in all aspects of decision 
making, and we build policies and plans for the future of our 
country.
    Thank you for the opportunity to testify today and to share 
some of the strategies Miami-Dade is using to connect the 
community and to plan for our aging population.
    I welcome your questions.
    The Chairman. Thank you very much for excellent testimony 
with so many good ideas, and I love that we have such a variety 
of communities represented here because it shows that these 
strategies can be effective, whether it is in a very large 
city, a bilingual area, the most rural community, a suburban 
community, no matter where people are living. And I really 
congratulate each of you for the work that you are doing.
    By the way, I could really relate to the issue of the time 
to cross the street. Having broken my ankle back in December, I 
quickly learned that unless I got there at the very beginning 
of the light changing, I did not have time to safely make it 
across the street in the early days of my injury, and it was a 
real eye-opener to me about what it is like not only for an 
older person who may be moving more slowly, but as our last 
witness just pointed out, a parent with a stroller. And so a 
lot of the practical things you are doing do help people of all 
ages but particularly our seniors.
    Ms. Goldman, I am curious as a result of your work if you 
found that attitudes are changing about aging.
    Ms. Goldman. I think that they are. I think that we still 
have a long way to go. If you have ever tried to purchase a 
birthday card for anyone over 50, you are aware of the bias 
that we contend with on a daily basis, some subtle, some not so 
subtle.
    But I think that what we have done is really tried to keep 
older people active and engaged in their communities for as 
long as possible, and by virtue of doing that, really promoting 
intergenerational contact. And it is only through that kind of 
contact that we challenge these stereotypes of aging and begin 
to really consider the aging of the population as a tremendous 
opportunity. So I think that having older people in parks, in 
restaurants, in theaters, in museums, and interacting with 
people of all ages, because generally they tell us they prefer 
to be in multigenerational environments, helps to connect 
people and helps people to realize exactly what an asset the 
older population is. They have very high rates of civic 
engagement and voting, high rates of volunteerism. They 
represent 70 percent of charitable donations. They serve as 
caregivers to children and older adults, enabling other people 
to continue working, and they are long-term, engaged residents 
of neighborhoods.
    The more we can ensure that our community assets are 
welcoming and accessible to people of all ages, the further we 
will go in challenging ageist stereotypes which contribute to 
lower levels of engagement and activity and higher levels of 
social isolation.
    The Chairman. Thank you.
    Ms. Callaway, you mentioned in your testimony that health 
care providers in your communities in Piscataquis County are 
critical in engaging with the older adults. Could you offer us 
any examples of how rural hospitals and other providers have 
repurposed their space or changed their activities to better 
engage and meet the needs of older residents?
    Ms. Callaway. Sure. Actually, our local hospital, Mayo 
Regional Hospital, has some grant funding from the Maine Health 
Access Foundation, which also funds the TiP, to reach out to 
people who are older and find out what some of their barriers 
are to health care. One recent forum revealed that a lot of 
people are having difficulty accessing dental care.
    Just by being at the table at these networks across the 
state, hospitals are helping to get the word out to their 
patients about the resources that are available in community, 
and I think that with more patient-centered models, more 
hospitals are aware of asking older people about their 
transportation, about their formal and informal supports, about 
whether they are struggling with caregiving. And they are also 
hosting events where they learn about transportation options.
    We have a local transportation provider that has been 
providing transportation for many years but has only recently 
started to focus on older people, and so they have gone with us 
to senior housing facilities and shared what it is they can 
provide. And they have signed people up so that people do not 
have to worry about whether they are in one program or another, 
and then they take them in a van on a ride to a local ice cream 
shop or to the local fossil museum to have the experience 
together. They get some social interaction with each other, and 
they learn that riding on this level of transportation is 
accessible and easy for them. And as a result of doing that, in 
one year they have increased ridership by 10 percent and 
actually added routes, which in our very small, very rural 
area, where it is hard to get from one place to another, is 
very significant.
    The Chairman. Thank you.
    Senator Casey.
    Senator Casey. Thank you, Madam Chair.
    I wanted to start with Cathy. Because you have been here 
two weeks in a row, I think I can call you by your first name. 
You made two trips. We are grateful for that, as well as our 
other witnesses.
    I guess I wanted to start with the issue of transportation, 
which has been mentioned obviously in a lot of the testimony. 
That is such a big component of the life of any community, and 
I guess in terms of just itemizing, if you had a wish list of 
improvements that could be made--and I would argue that the 
Federal Government should be a full partner in that. That is 
one of the highlights of my opening comments, which was that we 
hope--we hope that we can have a bipartisan infrastructure 
bill. A huge part of that, of course, would be transportation.
    So I guess in terms of the work that you have done in York 
County and in particular the Community Foundation, what would 
you identify if you had to list the priorities for 
transportation investments or improvements?
    Ms. Bollinger. Thank you Senator Casey for your question. 
As we know, people are living longer, and we also know that 
transportation is a key social determinant to health. And it is 
really hard for us to keep pace without federally funded 
dollars to support the infrastructure and to assist in 
identifying multi-modal innovative solutions. So smart 
planning, seed money is really important so that we can do 
demonstration projects that will help us be poised to support 
replicable and innovative projects and prepare for the rapid 
change happening in our communities.
    To share an example of this, the Central Pennsylvania 
Transportation Authority, which does business in York County as 
Rabbit Transit, received seed money from the Transit 
Planning4All Initiative, and this seed money was used to 
address barriers to accessibility for older adults and people 
with disabilities. And through this funding, Embracing Aging 
has partnered with Rabbit Transit in a program called ``3P 
Ride: More People, More Places, More Possibilities.''
    We did a lot of focus groups to really understand the 
barriers facing older adults and people with disabilities and 
have been working on solutions with this funding. So, for 
instance, we were able to add capital improvements to the 
transit enhancement plan to systematically address high 
frequently used transit stops that have been deemed a safety 
risk.
    We have expanded the hours and services for older adults so 
they can attend faith-based services over the weekend or go to 
neighboring counties. We have been able to provide additional 
runs to address major fixed-route crowding, and partner with 
volunteer transit providers such as Uber to help get 
individuals at risk of being late for appointments to and from 
where they need to.
    Smart planning and seed money for demonstration projects 
are priorities for changes in transportation infrastructure.
    Senator Casey. Cathy, I was also noticing in your testimony 
on page 7 under the topic or under the heading of 
transportation and walkability, which was a couple of 
fundamental changes that could be made, large and well-placed 
directional signs, lighted roadways, clearer road markings, 
brighter stop lights, and dedicated left-turn signals, I think 
we all like those.
    Ms. Bollinger. Yes. Yes, definitely.
    Senator Casey. Very practical.
    I guess the other thing is this dynamic where because older 
Americans in some communities might feel that they lack a safe 
and reliable way to get around, that is forcing some of them to 
move, can you speak to that issue?
    Ms. Bollinger. We do not know the full impact that lack of 
transportation has in York County. We do know that 23 percent 
of York countians are living alone. We know some of them have 
transportation challenges, such as 8 percent of households of 
people age 65 and older do not have vehicles.
    What we have done to start to address this issue is we 
partnered with the York County Planning Commission to have maps 
created of our county by municipality to show concentration 
areas of older adults living in the community, but we have 
different layers to it, so we can see older adults living in 
poverty, older adults living alone, older adults without 
transportation. And then layered on that are things like the 
fixed-bus routes, libraries, grocery stores, doctors' offices, 
senior centers, medical facilities, arts and culture venues, so 
that we can really begin to identify where the pockets of 
isolation are York County and begin working with municipalities 
to develop strategies to address them.
    Senator Casey. Thanks very much.
    I know I am out of time. I just want to highlight one piece 
of the research that the foundation did. You said on page 2, 
quote, ``If we removed age 55-plus employees from York County's 
workforce, 13,420 jobs would be vacant, and almost $1 billion 
would be removed from the economy.'' That is a remarkable 
impact, and I thought that was significant to highlight.
    Thank you, Madam Chair.
    The Chairman. Thank you.
    Senator Cortez Masto, we are delighted to have you with us 
today.
    Senator Cortez Masto. Thank you. Thank you, Madam Chair and 
Ranking Member.
    And I appreciate you coming back to talk with us. I am from 
Nevada, and so my first question is--really, I am going to 
follow up on the transportation, but, Ms. Callaway, I want to 
ask you this question. In Nevada, there are 17 counties. 
Fifteen of the counties are rural, and that is our challenge, 
is how do we get services, how do we get transportation, how do 
we address this issue in our rural communities to really bring 
the services that are necessary for some of our aging 
population.
    I am curious if you can address a little bit more what you 
have done in your rural communities and to spur that and help 
us identify areas where we can focus on more of these services.
    Ms. Callaway. One of the things we are very hopeful about 
is that as we are transitioning from funding from the Maine 
Health Access Foundation, we are working with AARP more and 
working more at the individual community level, so we have 
recruited town managers to support the work. And I think a lot 
of the increasing access comes down to the fact that everything 
in Maine is very personal, and the person from whom you learn 
about a resource is absolutely critical to whether or not you 
follow up on it.
    And the work we have done so far is quite regional. So we 
have focused on service providers being more aware at a 
granular level about the kinds of transportation that are 
available and opportunities to volunteer to be a driver, but 
now getting to more the local community level is absolutely 
critical.
    One of the problems that we have in deep rural Maine is 
that alternatives to actually getting people physically to 
their destinations are not even available to us enough. We do 
not have enough broadband access.
    Senator Cortez Masto. Right.
    Ms. Callaway. There are great cutting-edge technologies 
that would allow for telehealth. We have a wonderful resource 
in a local geriatrician who does house calls. That is quite 
remarkable, but there is absolutely no succession plan for her. 
And she frequently talks about the fact that if you are in a 
busy medical practice, you do not think about the person who 
does not come to you, and attach to each of those who cannot 
get to a doctor's appointment are caregivers who themselves are 
very stranded and isolated and are providing 30 billion hours 
of uncompensated care.
    So if we were to be able to get the funding, not just to 
continue to coordinate what we have, but to really extend it 
through telehealth, I think that would be a critical resource.
    Senator Cortez Masto. And thank you because I think that my 
colleagues and I--and this is part of our infrastructure 
package. I think we have all identified the need for broadband 
throughout all of our communities because of the services it 
will bring and reach people that normally would not have access 
to those services.
    So thank you. I appreciate those comments.
    Ms. Callaway. Thank you.
    Senator Cortez Masto. Ms. Garces, I was curious, your 
conversation and your statements, because southern Nevada, 
Clark County, where Las Vegas is, that is probably about 70 
percent of the population, 2 million, and we have a very large 
Spanish-speaking immigrant population, so I appreciate your 
comments.
    I am curious. Did that create any special challenges for 
you, and what lessons can we in Las Vegas learn from how you 
approached and brought and talked about how we address services 
for the aging population in those Spanish-speaking communities?
    Ms. Garces. Thank you for your question.
    One of the lessons learned is that the Spanish population, 
documented or undocumented--or citizens or undocumented have 
very common threads through all of their cultures. Their 
language might be Spanish, but they maybe represent more than a 
dozen different countries within a small area, but family or 
the nuclear intergenerational households, those common threads, 
and understanding the context of that community, understanding 
the fabric of that community can help us in identifying what 
are the solutions needed to prevent isolation and to provide 
them the services that they need.
    So it would not have been--it was not necessarily a 
challenge in Little Havana. It was just something that was 
understood. It was a foundation that allowed us to then have 
the success that we were able to have.
    Another part or a lesson learned that I would like to share 
is ensuring that they are part of the process from day one, not 
only that we are listening to them to understand, but that they 
are the ones that will be able to help make the solutions and 
identify not only those needs for services and identify where 
they would like to go, but understanding what the root causes 
are of why they cannot get to those services or why they need 
those services and then working with them to co-design the 
solutions needed.
    Senator Cortez Masto. Thank you. I appreciate it, again, 
and thank you for having this hearing. I have to run to another 
meeting, but I so appreciate the conversation. Thank you.
    Ms. Garces. Thank you.
    The Chairman. Thank you very much for your testimony, and I 
want to second what you said about the importance of rural 
broadband. That is a huge issue in my state as well and should 
be part, as you indicated, of our infrastructure package, so 
thank you for bringing that up.
    Ms. Callaway, in your testimony, you mentioned that 
renovations are currently under way in an historic building in 
Dover-Foxcroft that will eventually serve as a senior center 
and perhaps offer adult day care services, respite care for 
caregivers. And we have discussed at our previous hearings that 
it is not just the older person who may be ill or disabled who 
can become isolated. It is the caregiver as well, and they can 
become overwhelmed with the responsibilities and absolutely 
exhausted from an endless series of 24/7 days. Can you discuss 
what services you envision could be offered in Dover-Foxcroft 
at this building if it is turned into an adult center?
    Ms. Callaway. Absolutely. The one most critical resource 
for caregivers is respite. A few hours to take care of one's 
own needs, with all the burden of care that families are 
carrying, is absolutely critical, and this is uncompensated 
care. In very rural Maine, people are torn between the demands 
of low-wage employment and the needs of their relatives, which 
can be quite intense.
    People are leaving marginally independent adults with 
dementia home alone, and if you can imagine what it must be 
like to go off to work and worry that your mother or your 
spouse might wander away or leave a burner on, that is quite a 
distraction, and that adds a tremendous amount of stress to 
daily living.
    So what we are hoping to provide at the senior--at the 
adult day services center is full medical care. So there will 
be nursing care. People will be able to have a few warm meals. 
They will be able to have--they will offer bathing and 
companionship for people, and that will free the caregivers up 
to participate in some of the programming through the senior 
center for independent adults. So whether that means taking a 
health class, Tai Chi, Qi Gong, or attending a support group, 
those are really critical resources.
    We also--anytime we have a forum where people can learn 
more about dementia care, people turn out for that in numbers 
that they just do not turn out for anything else.
    And we have been very successful in spreading the Savvy 
Caregiver Training Program, and we would hope to base that out 
of the senior center too, which is all about not only taking 
care of a loved one with dementia, but what it means to take 
good care of yourself.
    The Chairman. Thank you. That sounds just wonderful. What a 
great gift to the community that would be on so many fronts, 
and I have seen senior centers in communities in Maine who have 
made such a difference in getting people out of their homes and 
to socialize and enjoy one another's company. But your concept 
of combining the two, I think is really innovative and needed.
    Ms. Garces, I am intrigued by your effort to develop an 
age-friendly business district, where you convinced 35 
different businesses to offer incentives to seniors if they 
would walk to the business on Tuesdays, I think it was. And 
this is a great idea, in my view.
    I am curious how the program was started, whether 
businesses were eager to participate, or did you have to really 
sell them on this? And have the participating businesses 
reported benefits from participating?
    Ms. Garces. Thank you for the question.
    The 25 businesses that joined--how it began was because 
when the older adults expressed to the elected officials what 
they would like to see in their communities based on the 
walking audit that they had conducted, we asked them, ``Well, 
what else--what else--why would you want to walk?'' And they 
said, ``Well, if it was a purchasing incentive, a place to go, 
and the streets were safer, we would get there,'' and so the 
agencies and elected officials committed to making the streets 
safer. There were places to go within a quarter mile. A quarter 
mile is the distance that we felt older adults would feel 
comfortable. Usually, it is about a half mile, but for these 
older adults, they did not feel more than a quarter mile, they 
could really get there in walking distance and feel 
comfortable. And so that is how we decided to reach out to the 
businesses.
    And we originally looked at the New York model of modifying 
businesses for older adults to accommodate older adults, but in 
Miami, that in Little Havana, that did not seem possible with 
the urban core that we were working with. But what did seem 
possible was providing this purchasing incentive or this 
purchasing power to the older adults.
    In the pilot phase, it was very successful, more successful 
in some stores than others. Over 70 percent reported very 
successful, and almost 90 percent reported that it was 
successful in obtaining more customers. The ones that reported 
the most, that were the most successful, were those stores 
that--or those businesses that the older adults like to 
frequent the most for luxury. So beauty parlors were very 
popular if they wanted to access something. So those that were 
technology-based--and we are seeing a big gap in Miami-Dade for 
older adults with technology and trying to increase their use 
of technology, but those that were technology-based were not as 
frequently--or not as frequented by older adults on Tuesday 
mornings as those other stores. But the majority of stores did 
see that the business-friendly district was very successful.
    The Chairman. Thank you.
    Senator Warren.
    Senator Warren. Thank you, Madam Chair, and thank you again 
for having this hearing, very important subject.
    According to the latest research by the Joint Center for 
Housing Studies at Harvard University, because of low incomes 
and limited assets, about 4 million senior households are 
eligible for rental assistance, but only about a third of those 
who need this help can actually get it. The problem is that the 
housing simply does not exist, and because of this affordable 
housing shortage, a large majority of low-income senior 
households face paying more than half their incomes for rent or 
living in severely inadequate conditions or both of those.
    Now, there are a number of reasons for this shortage, but 
one of them is that in 2011, Congress cut off funding for the 
new construction in Housing and Urban Development's 202 
program, which provides housing to low-income seniors.
    So, Ms. Garces, you are the co-leader of the Miami-Dade 
County Age-Friendly Initiative. I know that you are an expert 
on public policy issues affecting seniors, including housing 
assistance. Can you explain a little bit about how the 202 
program works?
    Ms. Garces. Sure. Thank you for your question.
    The 202 program, or the HUD program that was established in 
1959, provides funding to private nonprofits in order to 
develop and operate housing and supportive services, and that 
is for very low- or extremely low-income seniors. What we are 
seeing now, more than 430,000 seniors are engaged or nationwide 
are living in those homes or in the program.
    In Miami-Dade, we have more than 7,000 units. The issue is 
the long waiting list. Many seniors are on these waiting lists, 
thousands and thousands, and many of them never are able to be 
removed from the waiting list.
    Another issue we are having, because construction, as you 
mentioned, Senator Warren, has not been granted or funded, has 
not been granted for new construction, when renewal to the 
contract for these properties comes up and there is--the market 
rate is soaring, such as in Miami, many of those properties, we 
face them going into market-rate value, and so we lose the 
affordable housing that we currently have for older adults to 
market-rate values.
    And in Miami-Dade, in particular, more than 50 percent of 
older adults are spending more than 30 percent of their income 
on housing.
    Senator Warren. So despite the fact that our population is 
getting older, as the Chair pointed out, the changing 
demographics in the country, and that we already have severe 
housing affordability crisis for seniors, Congress has not 
seriously funded new dedicated housing for seniors in more than 
5 years. Is that a fair statement?
    Ms. Garces. That is correct. Yes.
    Senator Warren. Now, the shortage of affordable housing is 
not only a problem individually for seniors. It is also a 
problem for our economy overall. When seniors spend more than 
they can afford on housing, then they are forced to cut back on 
other necessities, so they spend less money on transportation 
or food or health care. Reduced spending in these areas can 
cause depression, can trigger other health problems, which in 
turn can increase cost for taxpayers when seniors are forced to 
use more Medicaid or more Medicare services.
    So, Ms. Garces, cutting off funding to the 202 program may 
have saved Congress some money in the short run.
    Ms. Garces. Right.
    Senator Warren. But how do you see the costs when seniors 
cannot afford housing?
    Ms. Garces. Senator Warren, as you mentioned, when seniors 
cannot afford housing, they are forced to make very difficult 
decisions. They need to spend their limited or fixed income on 
transportation, on health care, on their time. They need to 
make decisions on how they will spend their time. There are 
costs on--that strain individually and on the society, on the 
community.
    We also are--the lack of affordable housing can lead to 
poverty and homelessness. What we are seeing now is that 
100,000 seniors are expected to be homeless by 2050 nationwide, 
and that is more than double the number that we had in 2010. 
And that is just part of the cost that we will face----
    Senator Warren. Yeah.
    Ms. Garces. [continuing]. With the shortage of affordable 
housing.
    Senator Warren. Thank you. I think that is a very serious 
warning.
    You know, the 202 program has been a lifeline for seniors 
in Massachusetts, where more than 13,200 seniors live in 
housing supported by this funding. The typical income of 
Massachusetts seniors living in 202 housing is between $12,000 
and $15,000 a year. Nonprofits such as the Jewish Community 
Housing for the Elderly in Massachusetts and LeadingAge are 
leading the charge to try to convince Congress to revive 
funding for projects under the 202 program.
    And as we start looking at the 2018 budget, I hope that 
members of the Senate Aging Committee will take a very close 
look at this and we might be able to work together to make sure 
that there is adequate funding, so that there is more housing 
available for our seniors.
    Thank you, Madam Chair.
    The Chairman. Thank you.
    Senator Casey.
    Senator Casey. Thank you, Madam Chair.
    I guess one of the questions we try to focus on at the end 
of a hearing, because you traveled a great distance to be here 
twice, is what you hope we would do. You can express it any way 
you want. You can express it, ``We hope you do the following.'' 
You can be a little more assertive and say, ``You should do the 
following.'' You could say, ``We will come back a third time if 
you do not do the following.''
    [Laughter.]
    Senator Casey. But I guess I want to give everyone an 
opportunity, starting with you, Ms. Goldman, to outline 
priorities.
    Obviously, two big topics are, as Senator Warren said, 
housing and obviously transportation, but what would you hope 
we would do just, say, in the next year? We have budget and 
appropriations debates coming up, and we might need some 
direction around here. So this is your opportunity if you can 
outline those for us, maybe just two. We would give you a third 
one if you need it.
    [Laughter.]
    Ms. Goldman. Thank you.
    So I think, first, consulting older people as to what they 
need from their communities is really key. They are experts on 
their own lives, and so we should ask them.
    Second, I would say ensuring that we create communities 
through investments in infrastructure that are welcoming and 
accessible to people of all ages and abilities, and I think 
housing is really key here.
    I just wanted to add to the conversation about the 202 
buildings. In New York, it is not just a question of 
affordability. It is also a question of accessibility, and so 
we have 45 percent of rental housing in New York City is walk-
up buildings. Right? But in those 202 buildings, 80 percent 
have elevators, and so what we see is when people are younger 
and they are able to navigate those walk-up buildings, it is 
fine. When they become older, when they become injured or 
suffer some mobility impairment, they can no longer navigate 
those stairs.
    In the 202 buildings, they have elevators, but 
unfortunately, there are 200,000 people on the waiting list for 
202 housing in New York City. That is from a recent study by 
LiveOn New York, a senior advocacy group.
    So I think that what you see is unnecessary or premature 
institutionalization and severe social isolation when people 
who just cannot get out of their homes because they are 
inaccessible. So I would highlight the importance of investment 
in the 202 program as well as I would agree with everything 
that has been said to this point about investment in public 
transportation, in active transit strategies that promote 
walking and safe use of roadways by bikers and pedestrians.
    And I think that just generally ensuring that we consider 
the needs of people as they age is going to be essential moving 
forward.
    Thank you.
    Senator Casey. Thank you.
    Ms. Callaway.
    Ms. Callaway. Well, I thank you for putting together a 
panel that really reflects the geographic diversity of the 
aging experience, and more than anything, I would ask you to 
remember that the experience of aging depends so much on your 
ZIP Code.
    And I think it is also very important to continue to listen 
to older people themselves when they speak up about what they 
most need and want and to remember that funding the 
infrastructure for all of the services under the Older 
Americans Act is absolutely critical.
    There are people for whom their Meals on Wheels contact is 
about the only contact they will have. Those are particularly 
important in rural areas. I would encourage funding for 
telehealth, increasing broadband access, so that in lieu of 
driving people to events, they can see their medical provider 
through telehealth.
    And I want to applaud Senator Collins for her efforts to 
support caregivers. With the rate of dementia that we see, no 
matter where you live, it is a very high rate of people who are 
struggling with cognitive decline, and the people who are 
caring for them desperately need support in order to avoid 
being isolated and becoming unwell.
    Thank you.
    Senator Casey. Thank you.
    Cathy?
    Ms. Bollinger. In addition to the things I outlined in my 
oral and written testimony, as well as the other items and 
strategies the panelists have been sharing, I would like to 
just end with sharing our definitions for when I said we want 
to create a community that is safe, welcoming, appropriate, and 
adaptable.
    A safe community is one that is deliberately accessible and 
inclusive to people of all abilities and mobility.
    A welcoming community is free of misconceptions about aging 
and has increased appreciation of the wisdom, experience, 
social influence, and economic impact of older adults.
    An appropriate community is one that refrains from one-
size-fits-all solutions; instead it has options that are based 
on function rather than a person's age.
    And adaptable means creativity and flexibility are applied 
to the products, goods, services, events, and opportunities to 
best meet the want and needs of older adults.
    I think keeping these definitions in mind is important for 
Creating livable communities.
    Thank you.
    Senator Casey. Thank you.
    Ms. Garces.
    Ms. Garces. Thank you for this opportunity. You do not 
often get asked that question, if we had a wish list, so I am 
going to take you up on that offer.
    Senator Casey. Sure.
    Ms. Garces. Okay. So every budget item that comes before 
you, every policy that comes before you, you all have a 
tremendous power to choose to look at it with a health lens, to 
choose to look at it with an older adult lens, to choose to 
look at it and is it okay for those that are young, is it okay 
for those that are older. May every policy, every budget item 
think how will this impact older adults.
    How will this impact me, yourself, in 20 years? Will you be 
able to live where you live today? Will your children be able 
to grow in the homes that they are working so hard to invest? 
We can barely afford to go to college and not have tremendous 
debts. How will we be able to live in an environment and be 
able to foster and grow with dignity and enjoyment?
    Please, the request is to ensure that older adults are 
considered and everyone, but intentionally considered in each 
one of those decisions.
    And the second request, since you allowed two, would be, as 
you were speaking about the infrastructure bill and for 
transportation and what the request will be for transportation, 
the request of what we were trying to do in Miami-Dade, because 
we are often asked these questions, is really ensuring that 
that silo of transportation--we are not looking at only how 
does transportation impact older adults, but how do public 
spaces, parks, housing, and transportation impact itself?
    When you make those decisions on infrastructure or make 
recommendations for budget items, will the Housing for 202 
program be close to transit? Will public spaces--will there be 
an X amount of green space for that older adult to engage with 
their neighbors to truly prevent isolation? Ensuring that there 
are not silos while you are creating that policy, that it is 
not just the infrastructure or the structure that you are 
creating or the sidewalk or the bike lane, but let it go to 
someplace. Let the older adult access all that investment. 
Leverage that investment to be able to have the greatest 
quality of life that they can possibly have.
    Senator Casey. That is great. Thank you very much.
    The Chairman. Thank you, Senator Casey. Those were great 
answers that you solicited from your final question.
    I chair the Appropriations Subcommittee on Transportation 
and Housing, so many of the recommendations I have heard today 
are particularly helpful to me.
    I do feel compelled to correct the record on the Section 
202 program, and I told Senator Warren, who had to leave, that 
I was going to do so. And I showed her some of the actual 
figures, because this is a program that is near and dear to my 
heart.
    It is true that there are unacceptable waiting lists, not 
only for the Section 202 program, but Section 8. Virtually, 
every federally assisted housing program that we have--and, 
indeed, 84 percent of HUD's budget goes just for renewing the 
existing programs that we have out there, not accepting new 
people, but just making sure that we are keeping people who 
already have the vouchers to live in these programs.
    So the fact is that in the omnibus bill for fiscal year 
2017 that we just passed, as I do a quick glance of all the key 
housing programs at HUD, we take the biggest increase to the 
Section 202 program for our seniors, and that was a 16.1 
percent increase. So I could not let the record be mistaken 
that we somehow slashed the Section 202 program. In fact, it 
got the biggest increase of any of the housing programs.
    It does not mean that there are not problems. It does not 
mean that there are not seniors on waiting lists. I would point 
out that seniors also qualified for Section 8 program. It is 
not only the Section 202 program. And I would like to see us do 
better in figuring out how can we house the vulnerable 
families, seniors, and others in our society. I think we have a 
lot of work to do in that area.
    But it is not true that Congress--and I knew it was not 
true because I chair that Subcommittee. It is not accurate to 
say that Congress slashed that program. In fact, it got the 
biggest increase of any of the housing programs that are the 
major housing programs in HUD.
    And our Subcommittee, I am proud to say, also has greatly 
increased funding to help deal with individuals who are 
homeless, and that is something that the idea of people not 
having a safe place to go at night is very troubling to me.
    So it is a 16 percent increase for the Section 202. We do 
need to do more. It is hard within the budget constraints, and 
when 84 percent of HUD's budget is just for renewing the 
existing programs, that does not give you a lot of flexibility. 
But we were able to find some new funding, and I did want to 
point that out.
    Ms. Bollinger, I just had one--since I did not get to ask 
you a question, I do have one question that I wanted to ask you 
before we wrap up the hearing, and that is about age-friendly 
workplaces.
    I am becoming increasingly concerned about individuals who 
lose their jobs between age 50 and 65 or even 62, where they 
might be able to take early retirement, not that that is 
necessarily a good decision. But they have a really hard time 
finding new employment, despite the wisdom, experience, and 
skills that they bring.
    And in addition, being able to work during that time period 
improves your economic status, and it helps solve the social 
isolation problem. So could you talk to us about the work that 
you have done in helping to educate employers, helping to 
update skills of employees, if necessary? I am really 
interested in that.
    Ms. Bollinger. Thank you for your question, Senator 
Collins.
    As I mentioned earlier, we did partner with the Economic 
Alliance to assess the receptivity of employers in York County 
across many different industry forums to see if they were 
interested in providing strategies to best recruit older adults 
and to really assure that they have meaningful employment. And 
that as they do want to transition or change maybe from a 
traditional 40-hour-a-week, there are is opportunities for 
them.
    I can share that the results of the assessment early on 
focused on the communication gap between the generations versus 
what employers could be doing to proactively assure they have 
meaningful recruitment and employment of older workers. This 
was very telling for us, especially because when we started the 
assessment, we asked them to think of their oldest worker and 
then to provide an adjective that describes that older worker. 
Every single person's adjective was one of the most, positive 
adjectives that there could be, and yet they were not doing 
anything to really be thinking about recruiting and maintaining 
older workers.
    So we are working on this, and will hopefully be reaching 
out to employers as the year goes by and into next year with 
pilot programs. We are trying to find partners to help 
implement some of the strategies, because we feel that if we 
can do that, then we can create some wins, and maybe other 
employers will come on board.
    So we are early on in our work with that, but thank you.
    The Chairman. That is terrific, and I hope you will keep us 
informed of your efforts. As the Senator representing a state 
where we have seen a lot of mill closures and people who have 
worked hard their whole life all of a sudden find themselves 
unemployed when they are 52 years old, it is really tough, and 
particularly in rural Maine where there may not be a lot of 
other opportunities for employment. So I am very, very 
interested in that.
    Senator Casey, did you have any closing words you would 
like to make?
    Senator Casey. Just I wanted to add one comment, that we 
are going to have a lot of debates about appropriation matters, 
and one that I am--one of many that I am concerned about is the 
LIHEAP program. I think the proposal by the Administration was 
to eliminate the Low-Income Home Energy Assistance Program--not 
cut, eliminate. We should probably have an award in Washington 
for the bad idea of the year. There would be a long list of 
things, I am sure, but that is one of the worst ideas I have 
heard in a long time.
    So I am hoping that the budget director slipped it in at 
the last minute and no one at the White House saw it and it is 
just a big mistake, but that is a particularly negative 
approach to a lot of these topics we talked about. So we are 
going to be paying very close attention to that.
    But I wanted to thank Chairman Collins for arranging this 
hearing and working to make sure that we got it rescheduled and 
thank our witnesses for your great work and bringing this to 
our attention, especially across the diversity that is 
represented by the witnesses and by the regions you come from 
and giving great testimony about a topic that not enough of us 
are focused on, which is how can we make better our communities 
by making them more livable, especially for those who fought 
our wars and worked in our factories and taught our kids and 
built the great American middle class and have done so much for 
us. We have got to make sure that we are giving them 
opportunities to have the chance to live in livable communities 
across the country, so we are grateful.
    The Chairman. Thank you very much, Senator Casey, for your 
participation in shaping this hearing and for working so 
closely with me.
    I want to thank all of our witnesses for testifying, and 
again, I want to apologize that due to circumstances beyond our 
control that you had to come back a second time. But it was 
terrific to hear your testimony.
    Like Senator Casey, the lesson for me today is it does not 
matter what the community is like, or where it is, or how big 
or how small it may be. There are strategies that can be 
employed to help us make sure that we are connecting our 
seniors with community, preventing isolation and loneliness, 
and taking advantage of the many--the volunteering and the many 
other services that our seniors can provide.
    I also thank you for the very specific ways you are doing 
that in your communities. It really shows you need different 
strategies in different places.
    Now, coming in right before I was gaveling the hearing to a 
close, but making it, which he would not have if I had not 
asked one more question, is Senator Blumenthal from 
Connecticut. We welcome you, and please proceed.
    Senator Blumenthal. Thank you, Madam Chair. I apologize for 
being late. As Senator Collins and Senator Casey know, the 
occupational hazard of being a U.S. Senator is you have to be 
in three places at one time or more, so I really appreciate 
your having this hearing and giving me this opportunity to ask 
just a couple of quick questions.
    Let me ask Ms. Callaway. I am a member of the Veterans 
Affairs Committee and also a father of two veterans, and I have 
urged the VA to expand Wi-Fi access in more of its health 
facilities, where I understand it has been lacking.
    In fact, in West Haven, at our facility there, it was 
lacking until I brought that absence to the attention of the 
Secretary, then Secretary McDonald, and Secretary Shulkin has 
been very helpful as well.
    So, as you know, Internet access can literally be a 
lifeline for people of all ages, most especially for our senior 
veterans. Any veteran undergoing treatment, they are isolated 
when they are in a VA hospital, often completely isolated from 
friends, family, support networks, and that kind of connection 
is very, very important.
    Can you tell us what kinds of increased Internet access and 
connections can be made available at the facilities where they 
are now lacking?
    Ms. Callaway. Well, I wish I had a more specific answer to 
your question, but I can get you some information about what 
our local economic development council is doing to seek 
additional funding for broadband access. That is a high 
priority. Particularly in Piscataquis County, we have a very 
high percentage of veterans in our area. But I will provide 
that.
    Senator Blumenthal. Any of the other witnesses want to 
comment on Internet access and how it can be helpful?
    Why don't we go left to right. Go ahead.
    Ms. Goldman. I think that Internet access is really 
critical for older people, both under ordinary circumstances 
and in disaster situations, where it is really useful to have 
access to a variety of modalities of communication. We saw this 
during and after Hurricane Sandy in New York, where older 
people did not have Internet access or the same kinds of 
devices that their younger counterparts had. They were more 
likely to rely on landlines, which failed, and as a result were 
unable to maintain situational awareness and access the 
resources that they needed following the storm.
    But just generally, I think that there is a digital divide 
that exists. It is not just in rural communities, but also in 
low-income urban areas, where we see that among people who are 
older, specifically over 75, Internet access drops off. People 
who are low income and have lower levels of education, as well 
as people of color, are also less likely to have Internet 
access, which puts them at a tremendous disadvantage 
increasingly digitized, whether it is government benefits or 
access to employment opportunities or the ability to stay 
socially connected with friends and family.
    So I would say that an investment in broadband and Internet 
accessibility is really critical for older people, though the 
focus is often on expanding access for children and families.
    Senator Blumenthal. Ms. Garces?
    Ms. Garces. I just wanted to add to that. I believe your 
question was how do we increase the ability to provide Internet 
or broadband to a larger group in----
    Senator Blumenthal. Exactly. My question was somewhat 
inartfully phrased, but based on the experience at the VA, my 
feeling is that broadband, Internet access should be made more 
widely available to all groups, including senior veterans who 
are often less likely to have that kind of access.
    Ms. Garces. Yes. And it also leads to de-isolation. So it 
is one of the preventative strategies for isolation, is to 
provide Internet access, and so looking at hubs, government 
hubs, hospitals, essential services that we have within our 
communities, and allowing them to expand their broadband or 
have some type of a membership that would be of low cost or 
that would allow access to those specialized populations could 
be a way to increase the strategy.
    Senator Blumenthal. Thank you. Thank you very much to all 
of you for being here today. Thank you.
    The Chairman. Senator Blumenthal, in all seriousness, thank 
you for making the effort to join the hearing. You have been a 
very diligent member of this Committee, and I appreciate your 
participation.
    Senator Blumenthal. Thank you.
    The Chairman. Again, I want to thank all of our witnesses 
today. I also want to thank our staff, which has worked hard on 
this issue and to bring us such excellent witnesses.
    With that, we will have 1 week for additional questions to 
be submitted to the record. You may get some from individual 
Senators who were unable to be here today, and I very much 
appreciate your participation.
    This hearing is now adjourned.
    [Whereupon, at 11:00 a.m., the Committee was adjourned.]

     
      
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                                APPENDIX

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                      Prepared Witness Statements

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   Prepared Testimony of Meg Callaway, Project Director, Piscataquis 
            Thriving in Place Collaborative, Old Town, Maine
    Good afternoon Chairman Collins, Ranking Member Casey and members 
of the Senate Special Committee on Aging. My name is Meg Callaway, and 
I direct the Thriving in Place Collaborative in Piscataquis County, 
Maine.
    Piscataquis has Maine's second oldest population and it is the 
State's most rural region. It is one of only two frontier territories 
remaining east of the Mississippi River, with fewer than six people per 
square mile and a land mass the size of Connecticut. It is home to 
17,000 people and 27,000 moose.
    The Piscataquis Thriving in Place Collaborative is one of nine 
aging-in-community projects funded through the Maine Health Access 
Foundation's Thriving in Place (TiP) initiative. These grant-funded 
projects convene partners including municipal leaders, social service 
providers, healthcare professionals, local businesses, and volunteers 
to assess the regional needs of older and medically vulnerable adults 
and to implement strategies that help them to stay at home and engaged 
in their communities.
    These projects serve rural communities, increasing access to such 
critical resources as housing, food, healthcare, transportation, 
socialization, and caregiver support. They accomplish this by building 
relationships and facilitating communication between community agencies 
and organizations to improve the coordination of existing community 
services and supports. Older adult volunteers are engaged in all 
projects to ensure that their experiences and priorities shape the 
direction of TiP efforts.
    While TiP projects share the goal of helping seniors remain engaged 
in their communities, their approaches vary. The situational needs of 
older adults on the rocky coast can be different from those of seniors 
living in the deep woods of Maine. The resources available to them can 
also be quite different. The success of the Thriving in Place 
initiative is largely due to the flexible funding the grants provide 
for communities to build on their own strengths and focus on the unique 
needs of their senior populations.
    In Piscataquis County, a local farm provides fresh meals for 
seniors recovering from extended illness. Renovations are underway of 
an historic building that will house a senior center for independent 
older adults, and an adult day services program for seniors needing 
greater support. We now have a central phone number that anyone can 
call for help with locating senior services. When callers have complex 
medical needs, we offer them a home nursing visit to develop a plan of 
care. We have stocked local libraries with books and DVDs about aging 
and caregiving resources. Volunteers provide social connection and 
fresh produce to homebound seniors through our local Senior Companion 
and Senior FarmShare programs. Family caregivers receive respite 
services from our local hospice volunteers. In their down time, local 
emergency medical technicians check in on frail older patients.
    The Aroostook County TiP, in rural northern Maine, has partnered 
with their nursing school and hospital, engaging nursing students to 
provide home-based assessments and post-discharge follow up. They visit 
to review discharge instructions and medications as well as deliver a 
supply of pre-made meals to assist seniors following a hospital stay. 
This collaborative program is yielding significant reductions in 
hospital re-admissions.
    TiP Downeast has established an in-home volunteer visiting program 
on the Blue Hill Peninsula and is working to bring evidence-based 
health programs deeper into rural, coastal areas. Both strategies aim 
to reduce hospital admissions and institutionalization.
    Several TiP programs are educating their communities about the 
importance care transitions and completing advance care directives. As 
TiP aligns and promotes these essential resources, new more efficient 
ideas for engaging older adults and reducing isolation continue to 
emerge. These programs are actively demonstrating the power of 
community to keep seniors healthy, connected to their communities, and 
truly thriving in the place they call home.
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Prepared Testimony of Anamarie Garces, Founding Member, Miami-Dade Age-
Friendly Initiative and Co-Founder and CEO, Urban Health Partnerships, 
                             Miami, Florida
    Chairman Collins, Ranking Member Casey, and members of the Aging 
Committee, thank you for the opportunity to testify before you today 
and for the work you are doing. My name is Anamarie Garces, and I am a 
founding member of the Miami-Dade Age-Friendly Initiative 
(www.AgeFriendlyMiami.org) and am co-founder and CEO for Urban Health 
Partnerships, one of the lead partners of the initiative. The Miami-
Dade Age-Friendly Initiative is a collective impact effort focused on 
policy, systems, and environmental changes toward creating a community 
for all ages and abilities where older adults can stay active, engaged, 
and healthy with dignity and enjoyment. It is led by a diverse group of 
partners including AARP Florida, the Alliance for Aging, Health 
Foundation of South Florida, Miami-Dade County, Miami-Dade 
Transportation Planning Organization, United Way of Miami-Dade, and 
Urban Health Partnerships along with an advisory committee of over 50 
key stakeholders and community members.
    Miami-Dade is the most populous county in Florida and home to over 
2.6 million people. It is also home to the largest population of older 
adults age 60 and over in Florida, which is more than half a million 
people. That number is expected to rise by more than 50 percent to over 
800,000, by 2040. Miami-Dade is large and sprawling with a diverse 
population. 67 percent of the County identifies as Hispanic and most 
who are bilingual speak Spanish.
    Miami-Dade has identified age-friendly as an important approach to 
reducing social isolation and addressing how we can build a community 
that supports the wants and needs of older adults.
    It recently joined the AARP Network of Age-Friendly Communities, 
making it the fifth largest community in the country to join the 
network.
    The WHO domains of livability can be broken up into two categories, 
the built environment, or the environment we can see and touch, such as 
housing, streets, parks, and infrastructure; and the social 
environment, such as the opportunities, support and services, that are 
available. Both are important and interdependent. Miami-Dade has 
focused on the built environment first recognizing that if services or 
opportunities for social engagement are available, but residents do not 
have access or do not feel safe accessing them, it will isolate them 
from the resources and individuals that they need. Some of the age-
friendly strategies that have been implemented in Miami-Dade include:
Age-Friendly Policies in Transportation, Community Healthy and Design 
        and Land Use
      Ensuring older adults were included in policies and 
performance measures by updating Miami-Dade's Comprehensive Development 
Master Plan and Long Range Transportation Plan (LRTP). For example, the 
LRTP includes an objective to promote transportation improvements that 
provide for the needs of the elderly and disabled.
Age-Friendly Parks
      As a partner in the initiative, the Parks, Recreation & 
Open Spaces department helped identify and incorporate age-friendly 
parks standards in several parks in Miami-Dade.
      In addition to physical amenities and features in the 
parks, they also provide Active Older Adults programming. These include 
programs such as Enhance Fitness, the Walk4Life Walking Program, and 
Thai Chi Classes for older adults.
      A toolkit demonstrating physical amenities to ensure 
access, safety, and comfort within parks as well as evidence-based 
programs was produced.
Age-Friendly Awareness
      We hold summits, workshops, and events for community 
leaders, municipal staff and stakeholders on the importance of 
respecting and including older adults in planning housing, 
transportation, and parks projects.
Age-Friendly Neighborhoods and Streets
      In 2012, our Safe Routes to Age in Place project was 
launched to empower older adults in Little Havana to recognize their 
needs and identify changes to improve safety within their neighborhood. 
Little Havana, or La Pequena Habana, was recently named a national 
treasure. It is a diverse neighborhood in Miami-Dade known for its 
Cuban-American residents and is home to immigrants from across Central 
America and the Caribbean. Little Havana was chosen because of these 
factors and because it has a high proportion of older adults living in 
the area, a high proportion of households without a car, and a 
disproportionate number of pedestrian injuries in the area. 
Participants engaged in educational workshops, led a walking audit, and 
led a discussion with elected officials and transportation agencies to 
advocate for the changes they wanted to see. We also developed an 
Advisory Committee to provide input to the Florida Department of 
Transportation Little Havana Pedestrian Safety Study.
      Today, there is a lot happening in Little Havana toward 
safer, complete streets for everyone on a broader scale.
      There are specific built environment designs that impact 
the willingness and ability of older adults to get outside, interact 
with their community, and prevent isolation. Older adults struggle with 
sharing walkways with bicyclists. On busy corridors such as Calle 8, or 
8th street, in Little Havana, seniors expressed their concern with 
trying to walk or get out of their homes because they fear cyclists on 
sidewalks, participants said, ``Pasan a todo dan sin timbre or 
corneta.'' English translation: ``People pass at high speeds without a 
bell.'' Another adult added, ``De todas formas deben de ponerles a las 
bicicletas su propia linea porque aqui hay muchas personas que no oyen 
bien.'' English translation: ``By all means bicyclists should have 
their own lane since older adults have a hard time hearing.'' These 
features are currently being considered in the redesign of current 
thoroughfares in their community.
      Another important piece is access to transit. In a recent 
interview with a community resident, she said the Golden Passport was 
important to her family. When her elderly father came to the 
realization that he was no longer able to drive around Miami-Dade, the 
Golden Passport allowed him to give up his keys. Miami-Dade's Golden 
Passport program, provides free bus passes for adults 65+. Due to the 
program, he was able to get out and enjoy the last years of his life 
with dignity and support.
      Another aspect is shade. Utilizing a Digital Laser 
Infrared Thermometer Temperature Gun it was determined that shaded bus 
stops were 10-20 degrees less hot than non-shaded bus stops in Miami-
Dade County. The average temperature in Miami is 82 degrees year round. 
Due to concrete or a heat island effect that is created at bus stops 
without shades, older adults can experience temperatures of more than 
100 degrees, while waiting at their stops.
Age-Friendly Business
      The Safe Routes to Age in Place Advisory Committee 
recommended an Age-Friendly Business District, so we developed one. 
Older adults told us that once they had safer streets, a financial 
incentive, and places to go, they would be motivated to walk more. 
Initially, 25 businesses provided purchasing incentives for older 
adults to walk every Tuesday to their stores within a quarter-mile of 
the target location.
      A Toolkit was developed to help other communities and 
businesses implement age-friendly strategies.
Age-Friendly Survey and Action Plan
      Today, the Initiative is continuing its work by surveying 
and engaging the community to update its action plan and identify next 
steps.
    An age-friendly community is called age-friendly and not senior-
friendly because the strategies used are not only good for older 
adults, but for everyone, from the very young, to the very old. The 
same curb cut or ramp that may be added to ensure a wheel chair can get 
onto a sidewalk, is the same one that can make it easier for me to push 
my son in his stroller. Extra time added to a crossing signal can help 
ensure that an older adult, or anyone, won't lose their footing if they 
try to rush across the street too quickly.
    A walkable community with safe streets and places that people want 
to utilize is good for the economy, encourages active transportation 
and physical activity, empowers older adults to access resources, and 
offers more opportunities to socialize and engage with the community. 
This is a long-term approach to addressing isolation where the 
community is built or modified to facilitate access, engagement, and 
opportunity.
    We need your continued leadership to ensure age-friendly, livable 
communities are a priority in cities, to help build infrastructure that 
works for all ages and connects us to our resources and to our 
citizens, and to ensure aging continues to be in the conversation in 
all aspects of decision making as we build the policies and plans for 
the future of our country.
    Thank you for the opportunity to testify today and to share some of 
the strategies Miami-Dade is using to connect the community and to plan 
for our aging population. I welcome your questions.

      
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                  Additional Statements for the Record

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Statement of Amy Schectman, President, Jewish Community Housing for the 
                     Elderly, Boston, Massachusetts
    Thank you to the Senate Special Committee on Aging for holding a 
hearing on ``Aging With Community.'' Given the focus of your last 
hearing, you are well aware of the fact that loneliness has been firmly 
identified as the biggest public health hazard to older Americans, and 
community is the best antidote to loneliness ever invented. That's why 
Jewish Community Housing for the Elderly (JCHE) is so committed to our 
model of aging in community--our mission is that every older person has 
this opportunity to live a full life of connection and purpose in a 
dynamic, supportive environment.
    I want to emphasize how housing that's broadly affordable is the 
key component to age-friendly communities.
    JCHE builds, owns, manages and provides direct services in 1,200 
apartments across four campuses in eastern Massachusetts. We offer a 
rich array of programs and services so that everyone can find a way to 
connect to community, and do it with a laser-sharp focus on 
affordability. The median income in our properties is $10,473 per year.
    Our high quality housing with supportive services creates high 
functioning healthy senior communities and connected lives in a way 
that no other interventions can possibly achieve.
    A walk down the hallways of any JCHE housing will convince even the 
biggest sceptic. From first thing in the morning through quite late at 
night, folks gather in welcoming spaces to chat, participate in fitness 
activities together where they spur each other on, argue about current 
events constructively, volunteer with children from nearby schools, 
participate in life-long learning opportunities and write memoirs and 
notes to grandchildren in our computer centers. No one ever needs to 
feel lonely, and for those for whom making the initial contact is hard, 
our staff helps them find the right connection opportunity in our 
residences and out in the wider world.
    With housing the centerpiece of community building, affordability 
is essential. According to Harvard University's Joint Center on Housing 
Studies, severely housing-cost-burdened households spend 70 percent 
less on health care needs and 40 percent less on food than those living 
in affordable housing. Poor nutrition and lack of preventative health 
care have been shown to increase public expenditures dramatically but 
ineffectively. For this and other reasons, Harvard concluded that 
``housing is the linchpin of well-being for older adults'' and argues 
that making sure we have enough and appropriate housing takes on an 
urgency for the Nation as a whole. The Bipartisan Policy Center, in 
their Housing Commission report, argues for a system in which elders at 
or below 30 percent of area median income are guaranteed access to 
housing assistance [subsidies] and that in addition the Federal 
Government provide funding for short-term emergency housing 
stabilization assistance for those with incomes between 30-80 percent 
of area median.
    Supportive senior housing also provides opportunities for community 
and social connections to seniors in our neighborhood and gives them 
access to the expertise of our staff and programs offered. For example, 
at JCHE we invite community members to attend a variety of offerings at 
our sites, including many of our life-long learning lectures and 
intergenerational programs. Because all of our buildings are fully 
accessible and dementia-friendly, everyone is able to enjoy our 
offerings.
    The challenge we face and that America faces is the amount of need 
for stable homes and community versus our supply. We currently have a 
waiting list of 1,779 households for 1200 apartments with very slow 
turnover (given our emphasis on supports, we only lose 3 percent per 
year of our residents to nursing home placements despite the fact that 
38 percent are over the age of 85 and 17 percent are over 90). The 
waiting list would be longer if so many weren't so discouraged when 
they hear the length of the wait.
    And yet the most effective and efficient Federal housing program 
has been starved of new development funds for the past 5 years. The 
Section 202 housing program allowed us to build and staff high quality 
housing where seniors earning up to 80 percent of area median could pay 
only 30 percent of their income in rent. Consequently, the production 
of new affordable senior housing has slowed dramatically at the very 
time in our nation's history when the need is rising rapidly and age-
friendly communities are emerging as a priority.
    A few anecdotes illustrate the way a stable home in a supportive 
environment is a centerpiece for social connection and community 
building for seniors:
Betty
    ``These days, I'm feeling happy. I think it has something to do 
with the 200 neighbors I have at JCHE,'' Betty suggests.
    After undergoing surgery to remove melanoma from her face, Betty 
was worried about how her neighbors would react to the scars from the 
surgery. She dreaded having to explain what happened every time she ran 
into someone.
    To her relief, her neighbors, many of whom have had their share of 
health troubles, were as compassionate and understanding as she could 
have hoped.
    ``People didn't dwell on the bandages but they did surround me with 
kindness,'' Betty says. One neighbor asked what she could do to help, 
to which Betty replied, ``just smile.''
    Another neighbor gave her a book written in large print that Betty 
could read even with bandages partially obscuring her eyesight. A 
neighbor stopped by with bread, and someone else came with dessert. A 
resident who had just moved in and wasn't even unpacked yet, arrived at 
her door with blueberry pancakes.
    Betty's best friend at JCHE, Sylvia, accompanied Betty to her post-
operative visit. When she found out Betty was cancer free, she cried as 
only a soul mate can upon receiving such good news.
    ``It was an ordeal,'' Betty admits. But through it all, ``I never 
felt alone. The community was there for me in all the ways that 
matter.''
Selma
    ``When I say that I never exercised before I came to JCHE, I am not 
exaggerating,'' Selma laughs.
    Selma was that kid in high school who always skipped gym class, and 
never dreamed that one day she would become an exercise maven.
    Then a few years ago, Selma felt like she was coming apart. First, 
she broke her shoulder. Then, she suffered back fractures. One day, the 
pain in her legs was so severe that she could barely move.
    That's when her physical therapist suggested that JCHE's exercise 
program is exactly what she needed to regain her strength.
    So Selma became acquainted with our fitness center, and started 
receiving personalized instruction from our staff.
    She began exercising 5 days a week without having to leave her 
building.
    ``I was amazed by the results. I felt healthier and more alive. At 
87!'' she exclaims. Then Selma had a bit of a setback after she fell 
trying to step on a curb.
    ``It really shook me up. I was so nervous about curbs and stairs 
that I stayed at home all the time.''
    Selma quickly realized that staying at home wasn't making her any 
healthier, and so as difficult as it initially was, she returned to the 
gym.
    Our fitness staff instructor, Stacy, understood that Selma was 
scared to start exercising again and risk re-injury, so she designed a 
custom training regimen that helped Selma slowly regain her confidence 
and overcome her fear.
    ``We started by stepping up on a treadmill that wasn't moving. Then 
I moved on to stairs. Eleven months later, with Stacy's encouragement, 
I am regaining my confidence.''
    ``I know it's what's keeping me alive,'' Selma admits.
    [Each JCHE site has a fitness center with senior-friendly exercise 
equipment where fitness staff, including bilingual staff, provide 
personalized instruction. Understanding the risks that seniors face by 
falling, JCHE has an integrated falls prevention program that combines 
strength and balance exercises with assistance from JCHE's maintenance 
department to help residents reduce the occurrence of falls in their 
apartments.]
Simon and Malka
    Simon and Malka arrived to the U.S. 25 years ago from St. 
Petersburg (formerly Leningrad), Russia to reunite with their son, who 
had immigrated a few years earlier.
    ``We were excited about our new adventure, but were also anxious. I 
left a very respected position, and we were not sure what was ahead,'' 
Simon recalls.
    Simon asked his son to find a home for them that would ease their 
anxiety and facilitate such a major lifestyle change. Their son found 
JCHE.
    Right from the start, Simon and his wife participated in the wide 
array of programs available at JCHE. They quickly became part of a 
community. They attended classes, concerts and holiday celebrations.
    ``There were so many opportunities at JCHE that our lives felt 
active and productive,'' Simon says.
    When Simon's wife fell ill, Simon, then 87 years old, was grateful 
for the medical services JCHE arranged. The medical professionals who 
visited his wife were reliable, kind, and attentive to all her needs.
    ``JCHE made sure that my wife is comfortable and that gives me some 
room to breathe.''
    Had it not been for the love and care Simon and his wife found at 
JCHE--had they been living in relative isolation outside of a vibrant 
community--Simon believes his wife would have ended up in a nursing 
home. JCHE made it possible for the couple to remain together--an 
unbelievable blessing.
    ``My wife and I have taken care of each other for many, many years. 
If we lived somewhere else, she would be in a nursing home away from me 
just at the time in our lives when being together is most important.''
Sari
    Sari never had the benefit of formal education as she spent all of 
World War II in hiding in a basement to escape the Nazis. When she 
moved to the U.S. she needed to start working immediately; she always 
thought of herself as somehow lesser because of her lack of education.
    Nevertheless, every Tuesday for the past 8 years, Sari rode JCHE's 
van with her neighbors to the Everett Elementary School in Dorchester. 
For 3 hours, they practice reading with third, fourth and fifth graders 
to help the kids improve their reading skills.
    It's part of our Generations Together program that encourages 
residents and young people, ranging in age from preschoolers to college 
students, to develop relationships that are mutually beneficial.
    Right from the start, Sari knew she would love this program. She 
built meaningful connections with the students, who opened up to her 
about their families and told their parents about Sari.
    ``I'll never forget when one of the boys flew down the stairs, 
holding a picture of his dad who lived far away. It made me feel so 
special that he wanted to show me a photo of someone so important to 
him,'' Sari recalls fondly.
    ``A while ago, I overheard my daughter speaking on the phone with 
one of her friends. I heard her say something about her 90-year-old 
mother and something about tutoring. It took me a minute to realize 
that she was speaking proudly and she was speaking about me. I don't 
need to think of myself only as an immigrant who never went to college. 
I'm a tutor. My work is important and I do it well.''
Audrey
    ``Helping others has always given my life meaning,'' explains 
Audrey.
    As a doctor in her native Shanghai, China, Audrey treasured the 
opportunities to assist her patients. When she and her husband moved to 
JCHE, she discovered many ways to volunteer and give back to the 
community.
    But volunteering came to a screeching halt when Audrey was 
diagnosed with cancer.
    ``My prognosis was good, but my attitude was not,'' Audrey 
confesses.
    As is common for cancer patients, the feeling that she was running 
out of time took a physical and emotional toll on Audrey. She rarely 
left her apartment, in part because she felt that she needed to 
conserve her energy.
    ``But withdrawing only made me feel sick and lonely,'' Audrey 
recalls.
    Then, something happened. Audrey started to pay close attention to 
her neighbors and noticed that all the seniors at JCHE--much like 
people in all walks of life--were carrying one burden or another. But, 
unlike her, they didn't disengage from their neighbors; instead, they 
were active and appeared to thrive, regardless of whatever health 
ailments or personal setbacks they encountered.
    ``This is a very positive environment. With the encouragement of 
staff, I began to reconnect.''
    Today, Audrey is one of the most active members of the JCHE 
community. She helps her neighbors with translations, volunteers in our 
Chinese library and serves on the tenant council. Audrey enrolled in a 
program that helps Tufts medical students learn to communicate with 
older patients, and she even started a new program that brings in 
medical professionals to JCHE to share health information in Cantonese 
and Mandarin.
    She feels engaged, hopeful, and above all, she feels like her life 
once again has purpose.
    ``JCHE is a very special place. It inspires people to approach life 
positively, put their burdens aside and really live life!''
Sarah, Resident Service Coordinator
    For four years, JCHE's Resident Service Coordinator, Sarah, worked 
with Linda, a resident for whom JCHE had proved to be an absolute 
lifeline.
    ``That's what makes working at JCHE so rewarding for me,'' Sarah 
says.
    Linda had struggled with serious mental health issues throughout 
her life. She suffered abuse as a child and has long lost all contact 
with family. She has been homeless. Tragically, she calls the last 
place she lived, `The Heartbreak Hotel'.
    Not surprisingly, when Linda moved in four years ago, she needed a 
lot of help. She had no material possessions, so we helped her secure a 
bed and other basics. We connected her with doctors and arranged 
transportation. We talked and talked with her to orient her to life 
here.
    Slowly but surely, this support strengthened Linda's ability to 
take care of herself. Now she checks in every day, but mostly for a 
friendly chat. She has made friends and is active in many of the 
programs and activities JCHE offers.
    When Linda first arrived at JCHE, Sarah admits she was concerned 
that Linda was the person that others would cross a room to avoid.
    But that just wasn't the case.
    ``JCHE is a very strong community and Linda has a place within that 
community,'' Sarah emphasizes.
    Linda, who had so often been given the cold shoulder, has found 
that at JCHE, she is welcomed and warmly embraced.
    ``I'm so proud to work here and know that I can be part of a wide 
and strong safety net for folks who rely on it to maintain their health 
and dignity.''
Estelle
    ``I am 93, but I feel just the way I did 30 years ago,'' Estelle 
asserts.
    Estelle lived in Florida for many years, but after her husband 
passed away and her eyesight began to decline, Estelle decided it was 
time to move to Boston to be near her daughter.
    ``I'm not sure what I expected before I moved in, but I never 
expected to still be growing and learning.''
    The emphasis on lifelong learning is a centerpiece of life at JCHE. 
We offer a diverse array of opportunities for seniors to develop new 
skills, take up new hobbies, and pursue their passions.
    Estelle admits that one of her concerns about moving to Boston was 
not wanting to be a burden to her daughter--especially with her poor 
eyesight. ``At JCHE, I don't worry about being a burden to her, because 
of the unbelievable around-the-clock support I receive.''
    Estelle takes a Spanish class in her building. It's challenging, 
but she's sticking with it.
    ``Someone asked me what I would say is someone said you can't learn 
anything at age 93. Well, I told her, I guess I am proving them 
wrong!''

www.jche.org
                               __________
      Statement of the Altarum Institute Center for Elder Care & 
                            Advanced Illness
    Chairman Collins and Ranking Member Casey, congratulations on a 
fine hearing highlighting strategies that enable tens of millions of 
older Americans to age in their own communities, whether urban, rural 
or suburban. The Center for Elder Care & Advanced Illness (CECAI) is a 
research organization, working in the public interest, which focuses on 
designing, implementing and scaling policy solutions that address the 
health and social services challenges facing the U.S. today. We focus 
particularly on cost-effective changes and adaptations that are needed 
to ensure that all of us can live comfortably and meaningfully in old 
age--either at home or another setting of choice--and at a sustainable 
cost to our families, to the community, and to taxpayers.
    The astonishing health care advances made during the 20th century 
and the early part of this century have provided us with a tremendous 
gift: the opportunity to live longer lives. Along with this comes the 
responsibility of helping our communities and our care systems adapt to 
be able to deliver a different mix of support--less aggressive 
``curative'' care and a greater emphasis on supportive services that 
allow people to live as independently as possible. This shift toward 
community care will soon become the norm for one-fifth of the 
population: In 13 years, all baby boomers will have reached the age of 
65, and the number of ``old-old'' people over the age of 85 will more 
than triple,\1\ from 4 million to 18 million by 2050. In fact, if we 
live to advanced old age, most of us will need assistance during our 
last few years.\2\ A chief challenge, therefore, is to devise ways in 
which supportive services can be expanded in communities across the 
country.
---------------------------------------------------------------------------
    \1\ Ortman JM, VelkoffVA, Hogan H. An Aging Nation: The Older 
Population in the United States. Washington, DC: U.S. Census Bureau. 
2014. https://www.census.gov/prod/20l4pubs/p25-1140.pdf.
    \2\ Favreault M, Dey J. Long-Term Services and Supports for Older 
Americans: Risks and Financing. Washington, DC: Office of the Assistant 
Secretary for Planning and Evaluation. 2016. https://aspe.hhs.gov/
basic-report/long-term-services-and-supports-older-americans-risks-and-
financing-research-brief.
---------------------------------------------------------------------------
    The Aging Network--comprised of 53 publicly chartered State Units 
on Aging, more than 600 Area Agencies on Aging, American Indian, Alaska 
Native and Native Hawaiian tribal organizations, and tens of thousands 
of community-based organizations--provides the bulk of the social 
services and supports that older adults need to remain in their 
communities. Primarily funded by the Older Americans Act (OAA), the 
Aging Network meets a range of health-related needs by providing home-
delivered meals, subsidized transportation, personal care, evidence-
based health promotion and disease prevention, long-term care ombudsman 
and elder justice services, respite care and other services for family 
caregivers, and employment programs for older workers. While a growing 
body of research is demonstrating that these cost-effective services 
improve health care outcomes, \3\ \4\flation-adjusted deg.unding for 
the OAA continues to decline--even as the number of seniors rises.
---------------------------------------------------------------------------
    \3\ Thomas KS, Dosa D. More than a meal: Results from a pilot 
research study. For Meals on Wheels America. 2015. Retrieved from 
http://www.mealsonwheelsamerica.org/theissue/research/more-than-a-meal.
    \4\ National Council on Aging. National Study of the Chronic 
Disease Self-Management Program: A Brief Overview. http://www.ncoa.org/
assets/files/pdf/center-for-healthy-aging/National-Study-Brief-
FINAL.pdf.
---------------------------------------------------------------------------
    At this juncture, many older adults with functional limitations 
face lengthy waiting lists for basic supports needed for independence, 
including home-delivered meals, subsidized transportation and housing 
adaptations. Services that are needed frequently or on a daily basis, 
such as personal care, are often available only to those who have the 
means to pay out of pocket--or to those whose incomes and assets are 
low enough to qualify for Medicaid. This is why many middle-class 
seniors find themselves spending down their lifetime financial 
resources until they are eligible for Medicaid.
    In addition to unnecessarily impoverishing seniors, another poor 
outcome associated with the shortage of community services is over-
utilization of hospitals and emergency room care by Medicare 
beneficiaries who have chronic conditions and functional limitations. 
In these settings, too many wind up receiving high-cost medical 
interventions that will yield little net benefit in their remaining 
lifetimes. A large body of research has established that there is a 
considerable amount of low-value, wasteful spending in Medicare in the 
frail elderly population.\5\ We urge policymakers at all levels of 
government to more closely examine how low-cost community services can 
successfully support seniors and lower health care costs through 
delaying or preventing excessive hospitalizations and ER visits, and to 
encourage reinvestment of some of these savings for enhancement of 
supportive services. With thoughtful leadership, enhanced flexibility 
and excellent oversight, this shift is entirely possible. Most readily, 
it can be accomplished through an expansion of the Program of All-
Inclusive Care for the Elderly (PACE), or through appropriately adapted 
Accountable Care Organizations or managed care organizations.\6\
---------------------------------------------------------------------------
    \5\ Schwartz AL, Landon BE, Elshaug AG, Chemew ME, McWilliams M. 
Measuring Low-Value Care in Medicare. JAMA Intern Med. 
2014;174(7):1067-1076. doi: 10.1OOl/jamaintemmed.2014.1541.
    \6\ Lynn J. MediCaring Communities: Getting What We Want and Need 
in Frail Old Age at an Affordable Cost. Washington, DC: Altarum 
Institute. 2016. Available at http://medicaring.org/book/.
---------------------------------------------------------------------------
    In addition, communities can do more to organize local volunteers 
willing to help older adults age in place with dignity, engagement, and 
meaning. Accomplishing this on a wide scale requires recognition at the 
national level--in the form of an initiative announced by the 
Department of Health and Human Services or the White House, or 
introduction of legislative policy to create locally chartered 
``Caregiver Corps'' across the country. Policy to do this was 
introduced by Ranking Member Casey in 2014, and a similar bill in the 
House of Representatives has been sponsored by Rep. Lujan-Grisham of 
New Mexico. Both bills aim to organize volunteers of all ages who are 
willing to provide practical assistance (though not personal care) and 
companionship to older adults. In doing so, volunteers would provide 
respite for family caregivers, supplement the assistance provided by 
home care aides, and create connections between generations.
    As the U.S. age wave gathers momentum, thoughtful steps can also be 
taken to boost the Older Americans Act (OAA). With this bipartisan 
statute up for reauthorization in FY 2020, the 115th Congress has an 
opportunity to hold hearings on possible targeted improvements. For 
example, consideration could be given to assessing resources and 
outcomes in relation to the number of older adults receiving services 
and to those who qualify for services but are wait-listed.
    CECAI appreciates the opportunity to provide input on aging with 
community. While it is clear that all communities have unique assets 
and strengths that they can draw upon to improve care for their older 
residents--neighbors, friends, parents, spouses and colleagues--
available resources in the form of existing programs, workforce, local 
economic and cultural factors, and other infrastructure and assets will 
necessarily vary. With careful planning, however, many of the changes 
that every community needs to make can be spearheaded by energetic 
advocates organizing at the local level, working alongside leaders and 
stakeholders who are committed to identifying and mitigating service 
supply shortages and to improving quality and reliability. We are 
delighted to submit these comments and would welcome an opportunity to 
assist the Senate Special Committee on Aging in any way to improve 
aging with community.
  

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