[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                   EXAMINING THE OLDER AMERICANS ACT:
                   PROMOTING INDEPENDENCE AND DIGNITY
                           OF OLDER AMERICANS

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

                                 HEARING

                               BEFORE THE

            SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES


                         COMMITTEE ON EDUCATION
                               AND LABOR
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

              HEARING HELD IN WASHINGTON, DC, MAY 15, 2019

                               __________

                           Serial No. 116-23

                               __________

      Printed for the use of the Committee on Education and Labor

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

           Available via the World Wide Web: www.govinfo.gov
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                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
36-598 PDF                  WASHINGTON : 2020                     
          
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                    COMMITTEE ON EDUCATION AND LABOR

             ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

Susan A. Davis, California           Virginia Foxx, North Carolina,
Raul M. Grijalva, Arizona            Ranking Member
Joe Courtney, Connecticut            David P. Roe, Tennessee
Marcia L. Fudge, Ohio                Glenn Thompson, Pennsylvania
Gregorio Kilili Camacho Sablan,      Tim Walberg, Michigan
  Northern Mariana Islands           Brett Guthrie, Kentucky
Frederica S. Wilson, Florida         Bradley Byrne, Alabama
Suzanne Bonamici, Oregon             Glenn Grothman, Wisconsin
Mark Takano, California              Elise M. Stefanik, New York
Alma S. Adams, North Carolina        Rick W. Allen, Georgia
Mark DeSaulnier, California          Francis Rooney, Florida
Donald Norcross, New Jersey          Lloyd Smucker, Pennsylvania
Pramila Jayapal, Washington          Jim Banks, Indiana
Joseph D. Morelle, New York          Mark Walker, North Carolina
Susan Wild, Pennsylvania             James Comer, Kentucky
Josh Harder, California              Ben Cline, Virginia
Lucy McBath, Georgia                 Russ Fulcher, Idaho
Kim Schrier, Washington              Van Taylor, Texas
Lauren Underwood, Illinois           Steve Watkins, Kansas
Jahana Hayes, Connecticut            Ron Wright, Texas
Donna E. Shalala, Florida            Daniel Meuser, Pennsylvania
Andy Levin, Michigan*                William R. Timmons, IV, South 
Ilhan Omar, Minnesota                    Carolina
David J. Trone, Maryland             Dusty Johnson, South Dakota
Haley M. Stevens, Michigan
Susie Lee, Nevada
Lori Trahan, Massachusetts
Joaquin Castro, Texas
* Vice-Chair

                   Veronique Pluviose, Staff Director
                 Brandon Renz, Minority Staff Director
                                 ------                                

            SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES

                  SUZANNE BONAMICI, OREGON, Chairwoman

Raul M. Grijalva, Arizona            James Comer, Kentucky,
Marcia L. Fudge, Ohio                  Ranking Member
Kim Schrier, Washington              Glenn ``GT'' Thompson, 
Jahana Hayes, Connecticut                Pennsylvania
David Trone, Maryland                Elise M. Stefanik, New York
Susie Lee, Nevada                    Dusty Johnson, South Dakota
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on May 15, 2019.....................................     1

Statement of Members:
    Bonamici, Hon. Suzanne, Chairwoman, Subcommittee on Civil 
      Rights and Human Services..................................     1
        Prepared statement of....................................     3
    Comer, Hon. James, Ranking Member, Subcommittee on Civil 
      Rights and Human Services..................................     4
        Prepared statement of....................................     5

Statement of Witnesses:
    Archer-Smith, Ms. Stephanie, Executive Director, Meals on 
      Wheels of Central Maryland, Inc............................    13
        Prepared statement of....................................    15
    Ducayet, Ms. Patricia, LMSW, Texas State Long-Term Care 
      Ombudsman, Texas Health and Human Services.................    30
        Prepared statement of....................................    32
    Girard, Ms. Lee, Director, Multnomah County Aging, Disability 
      and Veterans Services......................................     7
        Prepared statement of....................................     9
    Whiting, Ms. C. Grace, J.D., President and CEO National 
      Alliance Caregiving........................................    22
        Prepared statement of....................................    24

Additional Submissions:
    Chairwoman Bonamici:
        ADRC Business Case: Final Report.........................    59
    Questions submitted for the record by:
        Chairwoman Bonamici 

        Schrier, Hon. Kim, a Representative in Congress from the 
          State of Washington....................................   106
    Responses to questions submitted for the record by:
        Ms. Archer-Smith.........................................   107
        Ms. Ducayet..............................................   109
        Ms. Girard...............................................   112
        Ms. Whiting..............................................   114

 
                   EXAMINING THE OLDER AMERICANS ACT:.
                       PROMOTING INDEPENDENCE AND
                       DIGNITY OF OLDER AMERICANS

                              ----------                              


                        Wednesday, May 15, 2019

                        House of Representatives

                   Committee on Education and Labor,

            Subcommittee on Civil Rights and Human Services

                            Washington, DC.

                              ----------                              

    The subcommittees met, pursuant to notice, at 10:18 a.m., 
in room 2175, Rayburn House Office Building. Hon. Suzanne 
Bonamici [chairwoman of the subcommittee] presiding.
    Present: Representatives Bonamici, Schrier, Hayes, Trone, 
Lee, Comer, Thompson, Stefanik, and Johnson.
    Also present: Representatives Scott, and Foxx.
    Staff present: Nekea Brown, Deputy Clerk; Ilana Brunner, 
General Counsel Health and Labor; Brutrinia Cain, HHS Detailee/
Health Fellow; Emma Eatman, Press Aide; Alison Hard, 
Professional Staff; Carrie Hughes, Director of Health and Human 
Services; Ariel Jona, Staff Assistant; Stephanie Lalle, Deputy 
Communications Director; Katie McClelland, Professional Staff; 
Richard Miller, Director of Labor Policy; Max Moore, Office 
Aide; Veronique Pluviose, Staff Director; Banyon Vassar, Deputy 
Director of Information Technology; Cyrus Artz, Minority 
Parliamentarian, Courtney Butcher, Minority Director of Member 
Services and Coalitions; Bridget Handy, Minority Communications 
Assistant; Amy Raaf Jones, Minority Director of Education and 
Human Resources Policy; Kelley McNabb, Minority Communications 
Director; Jake Middlebrooks, Minority Professional Staff 
Member; Casey Nelson, Minority Staff Assistant; Brandon Renz, 
Minority Staff Director; Mandy Schaumburg, Minority Chief 
Counsel and Deputy Director of Education Policy; Meredith 
Schellin, Minority Deputy Press Secretary and Digital Advisor; 
and Heather Wadyka, Minority Operations Assistant.
    Chairwoman BONAMICI. The Subcommittee on Civil Rights and 
Human Services will come to order. I note a quorum is present. 
This meeting will hear the testimony on examining the Older 
Americans Act, promoting independence and dignity for older 
Americans.
    Pursuant to committee rule 7c opening statements are 
limited to the Chair and ranking member. This allows us to hear 
from our witnesses sooner and provides all members with 
adequate time to ask questions.
    I recognize myself now for the purpose of making an opening 
statement.
    We are here today to examine the Older Americans Act, a 
critically important pillar of our efforts to improve the 
quality of life for older Americans and their families.
    In 1965, Congress passed the Older Americans Act, or OAA, 
to provide basic supports to aging Americans. Since then, 
Congress has repeatedly updated and strengthened the OAA in a 
bipartisan manner to fulfill its mission of helping more 
Americans live independently and age with dignity.
    OAA programs have been consistently successful, which has 
led to a gradual expansion of the services it provides. The Act 
now supports a range of community-based programs that target 
assistance to those who need it most.
    Of the many vital OAA programs, one of the most recognized 
is nutrition assistance offered through both congregate meal 
sites and home-delivered programs such as Meals on Wheels. 
OAA's nutrition assistance programs provide more than 900,000 
healthy meals to older Americans each day.
    OAA also supports elder justice activities and funds 
programs to prevent elder abuse. Additionally, the Act offers 
community service employment opportunities to low-income 
seniors, allowing them to access part-time work that both 
supports them economically and provides purpose and social 
engagement.
    OAA also provides family caregivers with much needed 
training, respite, and support. And based on my own experience 
caring for my 90-year-old mother, who has Alzheimer's, I can 
particularly appreciate the importance of the National Family 
Caregiver Support Program.
    Collectively, OAA programs serve about 11 million older 
adults, 3 million of whom regularly look to OAA services for 
basic needs. Importantly, OAA programs work together to make 
sure that aging adults retain independence and avoid costly 
institutionalized care for as long as possible.
    Despite the success of the Older Americans Act, in recent 
years our investment has not kept pace with inflation and has 
not recognized the rising number of older Americans and the 
challenges they continue to face.
    Although the population of Americans age 60 and over has 
grown more than 60 percent since 2001, OAA funding has only 
grown by roughly 20 percent. And, accounting for inflation, OAA 
funding has steadily declined by 16 percent.
    The disinvestment has weakened OAA programs at a time of 
growing demand for the services they provide. Nearly 1 in 10 
Americans over the age of 65 lives in poverty, and they are not 
getting the support they need. A 2015 Government Accountability 
Office study found that 83 percent of food insecure, low-income 
older Americans did not receive any meal services, and 2 in 3 
older Americans who struggle with daily activities received 
limited or no home-based care.
    As the number of older Americans continues to increase, 
Congress must strengthen our support for OAA's proven, long-
standing programs. We must recommit to providing basic services 
and compassionate care to vulnerable members of our 
communities.
    Not only is this the right thing to do, but the economics 
also make sense. OAA allows older Americans to delay or 
altogether avoid costlier care by promoting healthier--healthy 
behaviors, such as chronic disease management, and by providing 
the supportive services that allow seniors to age in place.
    That is the responsibility and the opportunity facing this 
committee and the 116th Congress. We are in a position to 
advance a reauthorization of the Older Americans Act that will 
allow millions of Americans across the country to age with 
dignity.
    This hearing is an important first step. Today, we will 
discuss the challenges facing older Americans, what OAA 
programs look like across the country, and how the OAA supports 
millions of seniors and their families.
    Today we are also continuing the law's tradition of strong 
bipartisan support. I was honored to be involved in the 2016 
reauthorization when both the House and Senate unanimously 
supported the legislation and I look forward to once again 
working with Ranking Member Comer, Ranking Member Foxx, and of 
course Chairman Scott, and all my colleagues on both sides of 
the aisle to advance a robust Older Americans Act 
reauthorization bill this year.
    Thank you to the distinguished witnesses for being here 
today. I look forward to this discussion.
    And I now recognize the distinguished ranking member for 
the purpose of an opening statement.
    [The statement of Chairwoman Bonamici follows:]

 Prepared Statement of Hon. Suzanne Bonamici, Chairwoman, Subcommittee 
                   on Civil Rights and Human Services

    We are here today to examine the Older Americans Act, a critically 
important pillar of our efforts to improve the quality of life for 
older Americans and their families.
    In 1965, Congress passed the Older Americans Act, or O-A-A, to 
provide basic supports to aging Americans. Since then, Congress has 
repeatedly updated and strengthened OAA in a bipartisan manner to 
fulfill its mission of helping more Americans live independently and 
age with dignity. OAA programs have been consistently successful, which 
has led to a gradual expansion of the services it provides. The Act now 
supports a range of community-based programs that target assistance to 
those who need it most.
    Of the many vital OAA programs, one of the most recognized is 
nutrition assistance offered through both congregate meal sites and 
home-delivered programs such as Meals on Wheels. OAA's nutrition 
assistance programs provide more than 900,000 healthy meals to older 
Americans each day. OAA also supports elder justice activities and 
funds programs to prevent elder abuse. Additionally, the Act offers 
community service employment opportunities to low-income seniors, 
allowing them to access part-time work that both supports them 
economically and provides purpose and social engagement. OAA also 
provides family caregivers with much-needed training, respite, and 
support. And based on my own experience caring for my 90-year-old 
mother, who has Alzheimer's, I can particularly appreciate the 
importance of the National Family Caregiver Support Program.
    Collectively, OAA programs serve about 11 million older adults 3 
million of whom regularly look to OAA services for basic needs. 
Importantly, OAA programs work together to make sure that aging adults 
retain independence and avoid costly institutionalized care for as long 
as possible.
    Despite the success of the Older Americans Act, in recent years our 
investment has not kept pace with inflation and has not recognized the 
rising number of older Americans and challenges they continue to face.
    Although the population of Americans age 60 and over has grown more 
than 60 percent since 2001, OAA funding has only grown by roughly 20 
percent. And, accounting for inflation, OAA funding has steadily 
declined by 16 percent.
    This disinvestment has weakened OAA programs at a time of growing 
demand for the services they provide. Nearly one in ten Americans over 
the age of 65 lives in poverty, and they are not getting the support 
they need. A 2015 Government Accountability Office study found that 83 
percent of food insecure, low-income older Americans did not receive 
any meal services. And two in three older Americans who struggle with 
daily activities received limited or no home-based care.
    1
    As the number of older Americans continues to increase, Congress 
must strengthen our support for OAA's proven, long-standing programs. 
We must recommit to providing basic services and compassionate care to 
vulnerable members of our communities.
    Not only is this the right thing to do, but the economics also make 
sense. OAA allows older Americans to delay or altogether avoid costlier 
care by promoting healthy behaviors, such as chronic disease 
management, and by providing the supportive services that allow seniors 
to age in place.
    That is the responsibility and the opportunity facing this 
Committee and the 116th Congress. We are in a position to advance a 
reauthorization of the Older Americans Act that will allow millions of 
Americans across the country to age with dignity.
    This hearing is an important first step. Today, we will discuss the 
challenges facing older Americans, what OAA programs look like across 
the country, and how the OAA supports millions of seniors and their 
families. Today we are also continuing the law's tradition of strong 
bipartisan support. I was honored to be involved in the 2016 
reauthorization when both the House and Senate unanimously supported 
the legislation. I look forward to once again working with Ranking 
Member Comer, Ranking Member Foxx, Chairman Scott, and all my 
colleagues on both sides of the aisle to advance a robust Older 
Americans Act reauthorization bill this year.
    Thank you to the distinguished witnesses for being here today. I 
look forward to this discussion and now yield to the Ranking Member, 
Mr. Comer, for the purpose of an opening statement.
                                 ______
                                 
    Mr. COMER. Thank you, Madam Chairman, for yielding.
    Today's life expectancy in our Nation is at a historic 
high, which is great news and it means we need to be doing all 
we can to ensure that Americans have access to quality, timely 
services which allow them to live in their homes as long as 
possible.
    This hearing will help us better understand what might be 
done to ensure the law is aging as well as the people it saves.
    Since 1965 the Older Americans Act, or OAA, has governed 
the organization and delivery of services for senior citizens 
throughout the country. With more than 41 million Americans 65 
and older, the social and nutritional programs offered by OAA 
are critical to helping them maintain independence. The reach 
of this law is substantial and covers many aspects of elder 
care.
    In addition to well known programs like Meals on Wheels, 
OAA support services provided by more than 300 State, tribal, 
and native Hawaiian organizations and approximately 200,000 
local providers. Some of these services include nutrition 
programs, providing meals for senior citizens, schools, and 
churches, care to prevent the abuse, neglect, and exploitation 
of seniors, family care giver support systems, and community 
service employment opportunities for older Americans.
    These types of programs offer valuable assistance for 
American seniors and the Federal Government should continue to 
support them. I know that I do.
    As our committee considers reauthorization of OAA, I am 
confident that we can work together on bipartisan legislation 
to support our Nation's seniors through effective policy.
    I thank the witnesses for being here today and hope today's 
discussion will offer insights into how we can build upon OAA's 
flexible policies to promote consumer driven independent living 
for older Americans.
    Madam Chairman, I yield back.
    [The statement of Mr. Comer follows:]

Prepared Statement of Hon. James Comer, Ranking Member, Subcommittee on 
                    Civil Rights and Human Services

    Thank you for yielding.
    Today's life expectancy rate in our Nation is at a historic high, 
which is great news, and it means we need to be doing all we can to 
ensure that Americans have access to quality, timely services which 
allow them to live in their homes as long as possible. This hearing 
will help us better understand what might be done to ensure the law is 
aging as well as the people it serves.
    Since 1965, the Older Americans Act, or OAA, has governed the 
organization and delivery of services for senior citizens throughout 
the country. With more than 41 million Americans 65 and older, the 
social and nutritional programs offered by OAA are critical to helping 
them maintain independence.
    The reach of this law is substantial and covers many aspects of 
elder care. In addition to well-known programs like Meals on Wheels, 
OAA supports services provided by more than 300 State, Tribal, and 
Native Hawaiian organizations and approximately 20,000 local providers. 
Some of these services include: nutrition programs providing meals at 
senior centers, schools, and churches; care to prevent the abuse, 
neglect, and exploitation of seniors; family caregiver support systems; 
and community service employment opportunities for older Americans. 
These types of programs offer valuable assistance for America's 
seniors, and the Federal Government should continue to support them.
    As our committee considers a reauthorization of OAA, I am confident 
that we can work together on bipartisan legislation to support our 
Nation's seniors through effective policy. I thank the witnesses for 
being here and hope today's discussion will offer insights into how we 
can buildupon OAA's flexible policies to promote consumer-driven, 
independent living for older Americans.
                                 ______
                                 
    Chairwoman BONAMICI. Thank you very much to the ranking 
member.
    Without objection, all other members who wish to insert a 
written statement into the record may do so by submitting them 
to the committee clerk electronically in Microsoft Word format 
by 5 p.m. on May 29, 2019.
    I will now introduce our witnesses. I am honored to 
introduce Lee Girard, who is the director of Multnomah County 
Aging, Disability, and Veterans Services Division, the 
federally designated Area Agency on Aging, or AAA, from 
Multnomah County, Oregon, and the largest AAA in the State of 
Oregon. Multnomah County Aging, Disability, and Veterans 
Services Division serves approximately 40 percent of the 
State's caseload in long-term services and supports.
    The Division operates Older Americans Act programs, State 
funded programs, adult protective services, and Medicaid 
eligibility for long-terms services and supports for older 
adults, people with disabilities, and veterans. Lee has a staff 
of 465, with 10 community centers and 11 meal sites, reaching 
more than 136,000 consumers annually.
    Lee currently serves as the chair of the Oregon Association 
of Area Agencies on Aging, the member association representing 
the area agencies in the State of Oregon. She is also a board 
member of the National Association of Area Agencies on Aging, 
or n4a.
    We are going to come back to Ms. Archer-Smith.
    Next is Christina Grace Juno Whiting. She is the president 
and chief executive officer at the National Alliance for 
Caregiving, where she continues her tenure from previous roles, 
including chief operating officer and the director of strategic 
partnerships.
    Grace led the launch of the Caregiving in the U.S. 2015 
research study with AARP and directed the first national public 
policy study of rare disease caregivers with Global Genes.
    She has contributed to several national reports on 
caregiving, including Cancer Caregiving in the U.S., with the 
National Cancer Institute and Cancer Support Community, and 
Dementia Caregiving in the U.S., with the Alzheimer's 
Association.
    She is also a member of the American Society on Aging and 
the Gerontological Society of America.
    Next we have Patty Ducayet. She is a licensed master social 
worker. She became the State long-term care ombudsman at the 
Texas Department of Health and Human Services in January of 
2007. As the State long-term care ombudsman, Patty oversees 28 
local ombudsman programs, certifies and trains ombudsmen, and 
advocates for policy and legislative change to positively 
impact Texans living in nursing and assisted living facilities.
    Patty has served on the Board of the National Association 
of State Long-term Care Ombudsman Program since 2009, including 
serving as president from 2014 to 2018. She currently serves as 
chair of the Association's advocacy committee.
    Mr. Trone is not here, so. Mr. Trone was going to introduce 
Ms. Archer-Smith, but I am going to introduce her.
    She is from his home State of Maryland. Stephanie Archer-
Smith is executive director of Meals on Wheels of Central 
Maryland, a community based, nonprofit organization providing 
congregate and home-delivered meals and support services to 
individuals primarily age 60 and older through the Older 
Americans Act nutrition program in Baltimore City and County, 
as well as six surrounding counties.
    Ms. Archer-Smith has 35 years of experience working with 
vulnerable populations through the life cycle in private, 
public, and not for profit human services organizations. 
Stephanie has served on the board of directors for the 
Baltimore Homeless Services and was a contributing author to 
Journey Home, Baltimore's 10-year plan to end homelessness.
    We appreciate all of the witnesses being here today and we 
look forward to your testimony.
    Let me remind the witnesses that we have read your written 
statements and they will appear in full in the hearing record. 
Pursuant to committee rule 7d and committee practice each of 
you is asked to limit your oral presentation to a 5-minute 
summary of your written statement.
    Let me remind the witnesses that pursuant to Title 18 of 
the U.S. Code section 1001, it is illegal to knowingly and 
willfully falsify any statement, representation, writing, 
document, or material fact presented to Congress or otherwise 
conceal or cover up a material fact.
    Before you begin your testimony please remember to press 
the button on the microphone in front of you so it will turn on 
and the members can hear you. As you begin to speak the light 
in front of you will turn green. After 4 minutes the light will 
turn yellow to signal that you have 1 minute remaining. When 
the light turns red your 5 minutes have expired and we ask that 
you please wrap up.
    We will let the entire panel make their presentations 
before we move to member questions. When answering a question, 
please remember once again to turn your microphone on.
    I will first recognize Ms. Girard.

  STATEMENT OF LEE GIRARD, DIRECTOR, MULTNOMAH COUNTY AGING, 
                DISABILITY AND VETERANS SERVICES


    Ms. GIRARD. Chair Bonamici, Ranking Member Comer, and 
members of the subcommittee, I am Lee Girard, Director of 
Multnomah County Aging, Disability, and Veterans Services.
    Thank you for this opportunity to share our experiences and 
recommendations for the Older Americans Act as you work toward 
reauthorization.
    In Oregon, we have set forth in statute the values of 
independence, dignity, and choice as the foundation of our work 
in supporting older adults. These values are also foundational 
in the Older Americans Act. Area Agencies across the Nation 
have worked to build a strong and dynamic network of services 
and supports that allow older adults to have the kinds of 
choices we all wish for, living in the communities of our 
choosing in ways that are responsive to our diverse needs and 
preferences.
    When my agency conducted our last area plan community needs 
assessment we talked to almost 500 older adults from diverse 
communities across our county. The need for flexibility in 
planning local services was highlighted by the variety of needs 
that were raised in these community sessions. Based on these 
listening sessions, our agency has continued to prioritize 
expansion of services for older adults with the greatest 
economic and social needs, with particular focus on LGBT and 
racial and ethnic communities in our area.
    Oregon is no different than the national trend. We now 
enjoy a longer lifespan than previous generations. By 2025, it 
is estimated that 20 percent of Oregon's population will be age 
65 and over. Oregon's person-centered system prioritizes the 
needs of the individual to provide better care, lower costs, 
and a better quality of life for older adults and people with 
disabilities.
    Information and assistance and person-centered options 
counseling are foundational services within the Older Americans 
Act. As an individual finds that they need more help to remain 
independent, these services provide the support to meet that 
goal.
    Several recent studies in Oregon have demonstrated the 
impacts of this work. A recent business case study found an 
11:1 return on investment for these services. The benefits that 
were found included finding and keeping long-term services and 
supports and housing, helping with basic needs to remain 
independent, avoiding homelessness--which is a growing issue 
for older adults--preventing abuse, and averting falls and 
other debilitating situations.
    A second study also found a distinct correlation between 
avoiding preventable hospitalizations and the availability of 
Older Americans Act funded information assistance and options 
counseling services. These are significant numbers and 
demonstrate the high value and return on investment for the 
services provided via the Older Americans Act. Social 
determinants of health can influence up to 60 percent of an 
individual's health.
    The Older Americans Act funds health promotion programs, 
elder justice and abuse prevention, family caregiving support, 
and nutrition services. It really is this holistic approach 
that made the Older Americans Act truly ``ahead of its time'' 
when it was created in 1965.
    As you begin your work on reauthorization, we encourage you 
to consider important adjustments that could be made to the Act 
to bring it into this new era of services and supports. We also 
know that the needs of older adults' experiences can vary 
widely and be significantly impacted by a variety of factors 
and barriers. The Older Americans Act is founded on targeting 
services to individuals with the greatest social and economic 
needs. We ask that LGBT communities be specifically recognized 
as one of those populations to be targeted.
    Local flexibility is also a key program strategy for the 
Older Americans Act. This provision has enabled Area Agencies 
to meet the needs of their local communities in ways that makes 
the most sense with the most efficient use of funds.
    Supporting innovation and best practices must also be 
another key priority. The Aging Network continues to evolve 
through local planning and development efforts to expand a 
network of services focused on interventions that lower the 
overall cost curve in long-term care and healthcare.
    Finally, a commitment for bipartisan support to increase 
authorization levels as well as reauthorizing the Older 
Americans Act is absolutely necessary to meet the goals of the 
Older Americans Act going forward.
    I would like to thank you for your time today and would be 
happy to answer any questions later from the committee.
    Thank you.
    [The statement of Ms. Girard follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairwoman BONAMICI. Thank you for your testimony.
    And next I will recognize Ms. Archer-Smith for 5 minutes 
for your testimony.

STATEMENT OF STEPHANIE ARCHER-SMITH, EXECUTIVE DIRECTOR, MEALS 
              ON WHEELS OF CENTRAL MARYLAND, INC.


    Ms. ARCHER-SMITH. Good morning, Chairwoman Bonamici, 
Ranking Member Comer, and members of the subcommittee. Thank 
you for the opportunity to testify today.
    My name is Stephanie Archer-Smith and I am the executive 
director for Meals on Wheels of Central Maryland, a community-
based nonprofit that provides congregate and home-delivered 
meals through the Older Americans Act nutrition program.
    Each year we serve over a million nutritious meals; 800,000 
of those are delivered to the door of nearly 3,000 homebound 
seniors in Baltimore City and the surrounding counties. 
Federally supported senior nutrition programs like ours are 
leading the fight to improve senior health by combating hunger 
and isolation. This unique combination of nutritious meals, 
companionship, and other person-centered services is only made 
possible by the Older Americans Act.
    Title III-C of the Older Americans Act, the nutrition 
program, is the only Federal program designed specifically to 
meet both the nutritional and social needs of older adults in 
order to reduce hunger and food insecurity, promote 
socialization, and improve the health and wellbeing of older 
individuals. In 2017 the Older Americans Act delivered on that 
promise to 2.4 million seniors nationwide.
    The Older Americans Act nutrition program is perhaps the 
best example of the power of a successful public-private 
partnership. At Meals on Wheels of Central Maryland, the Older 
Americans Act funding we receive makes up 60 percent of our 
budget. The remaining 40 percent is comprised of private 
donations, other private and local government grants, and other 
healthcare partnership programs. We mobilize more than 1,800 
volunteers who provide over $2 million of in-kind contribution 
annually to support our daily operations.
    The reality of senior hunger and isolation in our country 
is sobering. In Maryland more than 140,000 seniors face the 
threat of hunger each day, often making difficult choices 
between eating properly or paying for medication. Nationwide 
nearly 9 million seniors struggle with hunger, and almost twice 
as many live alone, leaving them at risk for negative health 
outcomes associated with food insecurity, malnutrition, and 
social isolation. Feelings of loneliness in particular are 
associated with negative health effects comparable to smoking 
15 cigarettes a day.
    The economic burden associated with senior malnutrition 
costs $51 billion annually, while senior falls account for $50 
billion in medical costs. The good news is the infrastructure 
to address these consequences already exists through the Older 
Americans Act network. The majority of seniors receiving Older 
Americans Act nutrition services report that participating in 
the program helps them feel more secure and prevents falls, 
avoiding hospitalization and reducing healthcare costs. One 
year of Meals on Wheels services can be provided for the 
approximate cost of 1 day in the hospital.
    In Maryland the impact is clear. Ninety-four percent of our 
participants report increase food security, ninety-eight 
percent believe our services have extended the length of time 
they can remain living at home, ninety-four percent report that 
Maryland Meals on Wheels has improved their quality of life, 
and one hundred percent report better medication compliance.
    But it is best illustrated by the story of the seniors 
themselves. Frederick, who is a 69-year-old Navy veteran, lives 
alone in a mobile home in Harford County. He has been receiving 
Meals on Wheels since 2015 because of his limited mobility. 
Frederick also receives food for his dogs, who are always by 
his side when we deliver.
    During his annual home assessment, something all Meals on 
Wheels clients receive, it was discovered that he had a roof 
leak so severe that he was no longer able to use his bedroom 
and mold was growing. Our case management team immediately 
intervened, identifying resources for his roof replacement.
    Today Frederick enjoys his home free of leaks and dangerous 
mold due to a complete roof replacement, which was finished 
earlier this month at no cost to him.
    Ruth lives alone on a narrow street in Baltimore. During a 
big snow storm last winter she wondered how the mobility van 
that picks her up for dialysis would make it down her narrow 
street. Despite the snow, her Meals on Wheels volunteer was 
there. The Meals on Wheels team reached out to the police to 
ask for their help in getting Ruth safely to her treatment.
    Ruth shared her gratitude with me, stating ``I thought my 
life depended on dialysis, but that day my life depended on 
Meals on Wheels.''
    Were it not for Meals on Wheels these seniors would be 
hungry and alone and disconnected from their community. The 
unacceptable truth is that for these seniors we are unable to 
serve this is their reality.
    A 2015 Government Accountability report found that 83 
percent of low-income food insecure adults are not receiving 
the meals they need. We currently have 186 people waiting for 
space on the Older Americans Act funded program. How do you 
tell a senior who needs your help that you cannot help them?
    I urge this committee to keep a strong and on-time 
reauthorization of the Older Americans Act a priority and 
support local nutrition providers like me as we work tirelessly 
to meet the unmet needs of seniors today and in the future.
    Again, I thank you for holding this timely hearing during 
Older Americans Act month, and for the opportunity to testify. 
I stand ready to support this process in any way I am able and 
look forward to answering any questions you might have.
    [The statement of Ms. Archer-Smith follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairwoman BONAMICI. Thank you for your testimony.
    And I recognize Ms. Whiting for your 5 minutes for your 
testimony.

    STATEMENT OF C. GRACE WHITING, J.D., PRESIDENT AND CEO, 
                NATIONAL ALLIANCE FOR CAREGIVING


    Ms. WHITING. Thank you so much, Chair Bonamici and Ranking 
Member Comer, and members of this subcommittee. Chair Bonamici, 
thank you especially for sharing your own personal experience 
as a caregiver for your mother. We need champions like you on 
these issues.
    I appreciate the time today to talk about the Older 
Americans Act, Title III-E, National Family Caregiver Support 
Program.
    My name is Grace Whiting and I am the President and CEO of 
the National Alliance for Caregiving, a 501(c)(3) nonprofit 
organization dedicated to advancing family caregiving through 
research, innovation, and advocacy. We believe that OAA 
programs, including the National Family Caregiver Support 
Program, support our long-term care ecosystem in three key 
ways.
    First, healthcare providers rely on caregivers to fill gaps 
in care and Older Americans Act's programs help caregivers 
become better care providers.
    Second, employers who face productivity losses due to 
caregiving can use OAA programs as a resource to help 
caregivers who are in the work force.
    And, third, OAA programs can protect the health, wealth, 
and wellbeing of aging caregivers themselves.
    We believe that family caregiving is a public health issue. 
In national research with AARP we estimate that there are 
approximately 44 million people caring for older adults and 
people with disabilities across a lifespan. That is one in five 
Americans, roughly the same size as the population of the 
country of Argentina. And when supported, caregivers can 
improve the quality of care offered to individuals. They 
support activities of daily living, such as helping people eat 
and bathe, instrumental activities of daily living, such as 
managing finances, and more than half are conducting medical 
nursing tasks that would normally be provided through formal 
care providers. Activities like giving injections, tube 
feedings, catheters, and colostomy care, often without any 
prior education on how to do these activities and no prior 
support. Most help with transportation, which helps address 
social isolation and allows people to stay engaged in their 
communities longer. And we know that when supported, caregivers 
can improve the health of populations and reduce health system 
costs.
    When surveyed, program participants in the Administration 
for Community Living program, almost nine out of 10 caregivers 
said that these services help them to be a better caregiver, 
and more than half said that if they did not have the National 
Family Caregiver Support Program, the person they care for 
would be in a nursing home. In fact, if we replaced every 
caregiver in America with a direct care worker, it would cost 
our economy $470 billion a year. Health care providers are 
aware of this cost savings and emerging trends in managed care 
rely on caregivers to bridge gaps, to reduce health system 
costs, and to improve shared savings.
    In our written testimony we speak to the impact of 
caregiving on the work force, including an estimated $36.5 
billion a year in productivity losses to employers. Title III 
programs can help employers offset the cost of caregiving. For 
example, nutrition programs provide support when a caregiver 
may not be available to make dinner, senior centers offer an 
additional form of respite. Transportation support for seniors 
can make it possible for caregivers to use that time for other 
needs.
    As family size shrinks, the number of available people to 
care is shrinking too, meaning that we must act now to protect 
caregivers.
    More than half of the caregivers in America are 50 years 
old or older, 7 percent are 75 years old or older, and 
caregivers of adults with disabilities are aging too. Think, 
for example, of the aging parents of an adult child with Down 
Syndrome, or the aging wife of a wounded warrior from Desert 
Storm. Yet the current program only supports 700,000 
caregivers. Based on our prevalence estimate, this means that 
the current program serves only 2 percent of America's 
caregivers.
    One quick personal story before I end. About 6 years ago I 
had the honor of being invited to the White House for a 
ceremony to celebrate caregivers of veterans, the Hidden Heroes 
Initiative, led by former Senator Elizabeth Dole. And I was 
standing in the green room talking to this caregiver whose 
husband had been wounded in Iraq and I said I grew up in 
Louisiana, I went to High School in Mississippi, I never in a 
million years thought that I would be standing in the White 
House looking outside at the tourists. And she looked at me, at 
this celebration to honor the work that she was doing for her 
husband, in a room that most Americans are never going to have 
the chance to be able to stand in, and she said all I can think 
about is my husband back at his hotel room and whether he is OK 
without me. That is the type of person that this program 
serves, people who are too tired, too overwhelmed, and too busy 
to advocate for themselves. We know that family is the basic 
unit of society, and our society needs these families to 
survive.
    Thank you.
    [The statement of Ms. Whiting follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairwoman BONAMICI. Thank you for your testimony.
    And now I recognize Ms. Ducayet for 5 minutes for your 
testimony.

STATEMENT OF PATRICIA DUCAYET, LMSW, TEXAS STATE LONG-TERM CARE 
           OMBUDSMAN, TEXAS HEALTH AND HUMAN SERVICES


    Ms. DUCAYET. Thank you, Chair Bonamici and Ranking Member 
Comer, thank you to the subcommittee. It is my pleasure to 
testify today on behalf of the Texas State Long-Term Care 
Ombudsman Program.
    Title VII of the Older Americans Act authorizes State 
ombudsman programs to protect the health, safety, welfare, and 
rights of residents, people who live in nursing facilities and 
assisted living facilities.
    In Texas over 92,000 people live in a nursing home and over 
45,000 live in an assisted living facility. Last year we 
resolved 78 percent of our complaints that we received; that 
was over 16,000 complaints in the State of Texas. We did that 
through the use of 100 staff and over 400 volunteers in our 
program.
    Today you recognize the ombudsman program and the work we 
do to prevent abuse and protect residents' rights. And you see 
that as part of the system to protect independence and promote 
dignity. Many Americans don't think of an assisted living as a 
place where you can be independent, but it should be. And many 
Americans don't think of a nursing facility as a place where 
you can live a dignified life, but it must be.
    Our program volunteers and staff are onsite in facilities 
to the maximum extent possible, to ensure that residents have 
independence and to address instances of indignity. Essential 
elements of the ombudsman program include our confidentiality 
provisions, systems advocacy, resolving complaints, and 
preventing abuse and neglect. Confidentiality requirements are 
specifically outlined in the Act and include strict 
confidentiality of our ombudsman program records, so no 
resident identifying information can be released by our program 
without the permission of the person to which it pertains.
    Based on the problems we observe in facilities our program 
represents the interests of residents to decisionmakers in 
Congress, to the State legislatures, and to Federal and State 
agencies. We make recommendations and provide comments, which 
we call systems advocacy, and aim to improve quality of life 
and quality of care for residents, most of whom are Medicare 
and Medicaid eligible.
    In 2017, State ombudsman programs across the Nation 
investigated almost 200,000 complaints, complaints ranging from 
the use of chemical restraints to neglect to insufficient 
staffing in facilities. But the most common complaint we 
receive is about discharge. Because a nursing home is a 
person's residence, a resident has a right not to be discharged 
without cause. To protect this right, a resident can appeal to 
the State Medicaid agency and nursing homes are required to 
notify every resident and the ombudsman each time there is a 
discharge. Ombudsmen help residents who want to stay in their 
home file an appeal and represent them in a hearing. Ombudsmen 
also negotiate with the facility to find solutions that are 
other than discharge.
    So as an example, I want to share with you a brief story 
from Texas. A resident in a dementia unit was issued a 
discharge notice for being a threat to others. The resident had 
recently fallen, had limited mobility and vision, and had a 
diagnosis of dementia. The facility was discharging him for one 
incident of disrobing in public, which is a relatively common 
symptom of dementia. His guardian appealed the discharge, and 
while awaiting the hearing received a call at 6 p.m. on a 
Friday night from the nursing home informing the guardian that 
the resident had been discharged to a behavioral health 
hospital.
    The nursing facility refused to take the resident back. So 
the resident remained in this behavioral health hospital for a 
month before being transferred to a new nursing facility and 
living only 1 week longer.
    While the resident's case prevailed in the fair hearing, 
because it was an improper discharge, the result came too late 
to benefit him. So the guardian has given us permission to 
share his story to honor him and to inform you of the effects 
of improper discharge.
    To prevent abuse, neglect, and exploitation, ombudsmen 
train residents, family members, and facility staff on how to 
prevent, identify, and report abuse. Each onsite visit that we 
make also prevents abuse. And 2017 nationwide, ombudsman 
programs made over 29,000 routine visits for that purpose. 
Ombudsman programs also investigated over 5,000 cases of abuse, 
neglect, and exploitation in an assisted living facility and 
over 11,000 cases of abuse, neglect, or exploitation in a 
nursing home.
    Thank you for preserving the independence and dignity of 
older Americans across the continuum, thank you for recognizing 
that people who live in institutions and victims of abuse also 
need dignity and independence.
    On behalf of the Texas Ombudsman Program and my colleagues 
around the country, I want to thank you. Thank you for your 
support of the Older Americans Act and with it, ombudsmen will 
be here in the future and are here today to prevent harm and 
protect residents' rights.
    Thank you very much.
    [The statement of Ms. Ducayet follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairwoman BONAMICI. Thank you so much to each of our 
witnesses for your excellent and comprehensive testimony.
    Under committee rule 8a we will now question witnesses 
under the 5-minute rule. As chair I will go first and then 
yield to the ranking member. We will then alternate between the 
parties.
    And I yield myself 5 minutes.
    Ms. Girard, you discussed research that has been conducted 
in Oregon regarding the return on investment for OAA programs. 
I ask you unanimous consent to enter into the record the 2018 
report commissioned by the Oregon Department of Human Services.
    So how have you been able to achieve--you talked about an 
11:1 return on investment you mentioned. And based on this 
research and from your professional experience, are OAA 
programs a good investment for the Federal Government and the 
taxpayer?
    Ms. GIRARD. Yes, I would say that they are an excellent 
investment. The foundation for the return on investment that 
was studied in Oregon is really person-centered options 
counseling, and that really entails individuals who have been 
trained on how to do motivational interviewing and really 
person-centered care planning and work with individuals, meet 
with individuals, and really focus in on their long-term 
services and support needs, and really develop a very focused 
plan that is person-centered to what that person and individual 
needs and the very unique needs that they have.
    Through the study what we were able to do is actually do 
both a qualitative and quantitative analysis really looking at 
what were the outcomes that were gained for each individual. 
And then we used either State or national data around things 
like if we were shown that we were able to prevent future 
falls, we could--you can actually cost that out. You know what 
the cost is when somebody falls and breaks a hip and ends up in 
the hospital. And we were able to show that we were reducing 
hospital readmissions. We know what the cost of that is in our 
community.
    And then able to do other things like helping somebody to 
avoid homelessness. We know what the expense is for somebody 
being homeless. So doing that we were able to really show that 
this is a comprehensive service that really helps to connect 
people to just a wide variety of very person-centered services 
that results in a significant cost savings.
    Chairwoman BONAMICI. Thank you for that work. And 
continuing, Ms. Girard, you discussed tailoring your 
department's services and supports to meet the distinct needs 
of individuals from diverse communities, including the LGBT 
community. We know that LGBT older adults often face structural 
inequalities, including greater social isolation and higher 
rates of poverty. But they also encounter barriers to accessing 
culturally competent aging services and supports and in many 
cases are less likely to have supportive family members and 
more likely to face discrimination.
    So I want to ask you, and then I will ask the others, how 
does your department address the unique needs of the LGBT 
community and why should LGBT older adults be designated a 
population of greatest social need?
    Ms. GIRARD. Thank you, Chair Bonamici.
    One of the things that is really a challenge for us locally 
is that there are not really good data sources around what is 
the prevalence of folks that are LGBT in our community. And 
there is actually a fear for people reporting. So one of the 
things that we have done is we have a great network in our 
area,--we do, we actually participate in both regional and 
Statewide advocacy coalition to really raise awareness and to 
really try to identify what the needs are. And one of the 
things we really have done is we have actually met one-on-one 
with individuals in our communities. We have done things like 
we know that there are specific types of social events, so we 
actually go and meet. We went to a dinner party with a group of 
folks and really sat down and talked about what are the unique 
issues and needs that you are experiencing. And when we did 
some of that as part of our area plan, what we really found was 
that the needs do differ across different populations.
    Chairwoman BONAMICI. And what would the designation of 
greatest social need mean? And I am going to ask the others as 
well.
    Ms. GIRARD. I really think it helps to--one of the things 
that it does is it really focuses our area plan efforts. So we 
have to do--it makes us really reach out into the community, 
hear from communities, and then really be conscientious about 
how we program for those needs.
    Chairwoman BONAMICI. Thank you.
    Does anybody else--please weigh in on that issue. Ms. 
Whiting, did you have--
    Ms. WHITING. So I would second the recommendation that 
there needs to be more research. We know that there is 
approximately 9 percent of caregivers in America identified as 
LGBT and I have heard from the field that particularly people 
who are transgender sometimes feel that the people they care 
for get worse care from formal providers because of biases. So, 
for example, a gentleman who is transgender said that his 
mother received worse care in the nursing facility she was at 
because the staff was uncomfortable with him and his identity.
    So I think it is an area that needs more research. We had 
in our written testimony, included some recommendations for OAA 
reauthorization and one piece of that is to collect more data 
in particular on caregiving and these OAA programs broadly.
    Chairwoman BONAMICI. My time is expired, so I am going to 
ask the others--well, we will submit a question for the record.
    And I now yield to Dr. Foxx, the ranking member of the full 
committee for 5 minutes for your questions.
    Ms. FOXX. Thank you, Madam Chairman. And I want to thank 
our witnesses for being here today to discuss this important 
subject.
    Miss Girard, I was pleased to hear that you appreciate the 
value of local flexibility in the Older Americans Act. Can you 
give us some examples of the differences between services you 
provide to seniors in Portland versus some of the more rural 
areas of Oregon?
    Ms. GIRARD. Thank you, Representative Foxx.
    I think probably a really key example is the provision of 
transportation. We hear from older adults across Oregon that it 
is a significant need, but it looks very different in Portland 
than it does out in places like Ontario or Malheur County.
    In our area we have a robust transit system and we can 
purchase transportation services through that network. In rural 
counties, the AAA is the transportation network. So that is 
probably a really good example.
    Ms. FOXX. Great.
    This question is for all of you, and I will start on this 
end of the panel so you are not always last. One of the 
purposes of the Older Americans Act is to help people age 60 
and older maintain independence in the home. Why is this 
important and how does this goal potentially save taxpayer 
dollars? And do keep in mind there are four of you to answer, 
so.
    Ms. DUCAYET. Well, as the representative of providing 
services to people who live in an institutional setting, I will 
make my answer quick to you and say I know that people want to 
live in their home and prefer to. There will be a need 
continuously for long-term care facilities, but emphasis does 
need to be where people want to get their services at home.
    Ms. WHITING. I would say it is in the title of the hearing 
today, it is about dignity and independence. Our family sizes 
are getting smaller, we have got I think roughly one out of 
five Americans are over 60, and so we want people to be able to 
thrive and to be cared for by their families in the setting 
they choose.
    Ms. FOXX. Ms. Archer-Smith.
    Ms. ARCHER-SMITH. Yes, I would echo that the people that we 
work with want to stay--they want to stay in their home and in 
their communities, they want to age in place. It is more 
economical to age in your home and I would argue that 
intergenerational communities are stronger.
    Ms. FOXX. All right.
    Ms. GIRARD. In our community only 14 percent of people 
getting long-term services and supports are in a nursing 
facility. The Older Americans Act is the foundation of helping 
people identify and figure out what additional kinds of 
resources and services are available so that they don't have to 
rely on nursing facility services unless it is absolutely 
necessary.
    Ms. FOXX. And let me ask a clarifying question, because I 
have for years--I think, Ms. Archer-Smith, you mentioned that 
it is less expensive--one of you mentioned it is less expensive 
for people to remain in their homes. And I have also read over 
the years that people are healthier, more alert, and in 
better--generally in better health and better able to be 
involved with activities the longer they are able to stay in 
their home.
    I am sure there is associations with having the ability to 
do it, but also using the facility that you have while you are 
in your home. Does the research continue to show that?
    Any of you can respond.
    Ms. WHITING. Especially in Alzheimer's and dementia, where 
someone who is changing settings but might have mild cognitive 
impairment, it can be very hard for both that person and the 
family to continue to care for them.
    Ms. GIRARD. And I would just add that in Oregon, because we 
do have such a broad array for people that are often at the 
same level of need, we are able to show that people can 
function quite well at home and have pretty significant care 
needs as long as you have a system that supports them.
    Ms. FOXX. Great. Thank you all.
    I yield back, Madam Chairman.
    Chairwoman BONAMICI. Thank you, Dr. Foxx.
    I now recognize Representative Lee from Nevada for 5 
minutes for your questions.
    Ms. LEE. Thank you, Madam Chair, for hosting this important 
hearing on such an important issue.
    Having a father who passed away after spending 4 years in a 
nursing home and now dealing with a mother who is suffering 
from--is an assisted living facility and having experienced her 
struggles as a caregiver, I think that addressing these issues 
is incredibly important.
    I appreciate the question that Representative Foxx just 
asked about the benefits the tax benefit and financial benefit 
of allowing people to age in place.
    I wanted to ask Ms. Girard, you know, as we know, these 
supportive services and preventative health programs are 
essential for older Americans in need of care. And in Nevada, 
my home State, $3.5 million went to support that.
    Can you please elaborate on how home healthcare services 
can serve as preventive healthcare for older Americans?
    Ms. GIRARD. Yes. We have had--In Oregon we have had a 
foundation of both State and Older Americans Act funded in-home 
service supports for older adults since 1981. Well, the Older 
Americans Act actually before that. And we have been able to 
show that it really helps people to avoid further decline, it 
helps them to avoid spending down to have to go on Medicaid and 
use more expensive Federal supports, and actually keeps them 
more engaged in their communities.
    Ms. LEE. Thank you.
    Miss Whiting, one of your recommendations was to develop a 
national resource center for caregiving. Can you explain what 
the benefit of establishing that would be?
    Ms. WHITING. Absolutely. And that recommendation builds on 
some of the language in the RAISE Family Caregivers Act that 
was enacted last year, which talks about finding efficiencies 
between different Federal agencies. So, for example, there is 
the VA Caregiver Support Program, there is the National Family 
Caregiver Support Program under Older Americans Act, there were 
supports across CMS, looking at different types of caregiver 
supports within Medicaid and community-based service models.
    So the idea here is let us put all that information in one 
place and make it more efficient for caregivers to navigate 
across these different centers, as well as identify other 
community-based supports that might be available to families 
across the country.
    Ms. LEE. Yes that--Speaking from a personal point of view, 
my father broke his hip and because of Medicare requirements 
and Medicaid requirements, was really forced--you know, they 
quit--we quit rehab, which led him to unfortunately go into a 
nursing home. So I find that sort of looking across all of 
these issues and doing as much as we can to keep someone in 
home is really important.
    So I look forward to working with you on that.
    I wanted to turn real quickly to nutrition. In Nevada 
80,000 older Americans were deemed to be food insecure in 2016. 
Estimated by 2025 17,000 more older Nevadans will need 
nutrition services than those today, totaling almost 100,000 
older Nevadans.
    And we all know the great work that Meals on Wheels 
accomplishes carrying out home-delivered services.
    I would like to ask Ms. Archer, can you please speak a 
little bit about the other option, congregate nutrition option, 
and how it is important to fulfilling the social needs of many 
of our older Americans?
    Ms. ARCHER-SMITH. Yes, thank you.
    The congregate meal program as I see it, it is kind of a 
continuum of service. So the congregate meal program is really 
good for people who might be able to get to it, either they 
have transportation provided for them or they are still a 
little bit more mobile. So they don't quite need the home-
delivered meal program yet. So it is a good continuum of 
service. That opportunity to socialize with your peers is 
invaluable. And what often happens is they come for the meal 
and then they engage in other programs and other activities 
that will keep them healthier, more mobile, stronger, things 
like that. So it is a really important part of the continuum of 
service.
    Ms. LEE. Great.
    I will yield the rest of my time. Just thank you all for 
the important work you do.
    Chairwoman BONAMICI. Thank you for your questions. And as I 
am yielding to Ranking Member Comber, I want to encourage all 
of my colleagues to do what I have done, which is to deliver 
Meals on Wheels and to visit a congregate meal site, because I 
think you will really appreciate everything that happens there.
    And now I yield to Ranking Member Comer for 5 minutes for 
your questions.
    Mr. COMER. And I agree with that, Madam Chair. I have done 
that as well.
    Miss Ducayet--did I pronounce that right? I am from rural 
Kentucky, it is hard for me to pronounce a name like that, but 
so glad you are here. You mentioned the importance of 
flexibility in the location of a State long-term care ombudsman 
program. Can you expand on what factors might play into this 
decision?
    Ms. DUCAYET. Thank you for the questions. And, yes, I know 
I have a difficult last name and career name as well--it is 
hard to pronounce.
    Yes, so we are in, in Texas, the State unit on aging, a 
pretty traditional setting for the State Ombudsman Program. And 
we coordinate with the Area Agencies on Aging in our State to 
deliver ombudsman services locally. That is a fairly standard 
practice in many States, but not all States operate in the same 
manner, and they do so successfully. The flexibility is needed 
because of different State structures and the different jobs 
that are done in a State unit on aging, or in an Area Agency on 
Aging, because ombudsman programs need to be free of any 
conflicts of interest so that we are sure we are assured that 
we are serving the needs of the resident first and foremost and 
that none of our work is compromised by the location that we 
operate within.
    And so my placement within my State agency, for example, 
ensures that I have independence from other functions that are 
performed by the State Medicaid agency, for example. And it 
works very well for us.
    Mr. COMER. Great.
    Ms. DUCAYET. Thank you.
    Mr. COMER. Great.
    Miss Girard, how do the agencies on aging, senior citizens, 
and other providers of elderly services work together to 
deliver services?
    Ms. GIRARD. I think the foundation is we start with our 
area plan. Every Area Agency on Aging needs a robust area plan 
that really engages all of the community. And then we actually 
in our area have an aging and disability resource connection 
network, and so we really are able to have a no wrong door 
system. We fund a wide variety of services out in community-
based organizations, some of which are culturally responsive, 
some are culturally specific, and it is really that aging and 
disability resource connection network that allows the 
consumer--it doesn't really matter where they show up, we are 
going to be able to help them.
    Mr. COMER. Great.
    This question is for everyone on the panel. As Ms. Foxx 
said, we have limited time, but are there any provisions in the 
current law or regulations that are particularly burdensome to 
your efforts that we in Congress need to address this year? Can 
anyone think of anything?
    Well, I will--before I yield back I will say this, of all 
the government programs that I am aware of, and there are many, 
in my opinion in my district there is nothing more popular that 
Meals on Wheels. Very popular district and anytime there is 
mention of potential cuts to that we get a lot of calls and 
messages in my office on that. So I appreciate everything that 
you all do and we look forward to working with you as we 
continue to try to make life better for you and for the great 
people that you serve.
    Madam Chairman, I yield back.
    Chairwoman BONAMICI. Thank you very much, Mr. Comer.
    I now recognize Representative Hayes from Connecticut for 5 
minutes for your questions.
    Ms. HAYES. Good afternoon, everyone, and thank you for 
having this very important hearing and for you all coming here.
    I am struggling a little this morning because I have this 
lovely binder with these prepared questions and all I can think 
about is my grandma right now. And so I really have to shift 
gears and just go in a different direction just for a minute, 
if you would indulge me.
    I was raised by my grandmother. My mom struggled with 
addiction and my grandmother raised my brother and I, and 
really was the backbone of our family. And I would say that, 
you know, this is over 30 years ago, but in my experience, 
recently as a teacher and even seeing it every week in my 
church, there are so many aging adults who are over 60 who are 
now raising their grandchildren. So I know we are talking a lot 
about, you know, our elderly community receiving care, but 
there are so many of them that are still giving care.
    So I guess what I want to first start with, the Senate held 
a similar hearing last week and they talked about the National 
Family Caregiver Support Programs.
    I guess, Ms. Whiting, has the opioid crisis impacted the 
rate of aging Americans, especially grandparents, who are 
having to be the de facto guardians and in fact raising their 
grandchildren?
    Ms. WHITING. Thank you for the question. It is incredibly--
something that has been on our minds as we look out at the 
field and we interact with people, that the rate of substance 
abuse--even I would say other populations, such as military 
veterans where you have wounded warriors coming home and they 
are not able to care for their own children and so sometimes 
their parents take on care of those minor children. So I think 
you have hit on something that is critically important and, of 
course, is recognized within the Older Americans Act program 
overall.
    I would say that some have proposed flexibility in allowing 
States to, you know, put some of the caregiver funding into the 
kinship care, the grandparents raising grandchildren. We would 
just encourage you to think about expanding authorization and 
appropriations for the program as a whole, because there are 
many people over 50 who are also caring for other adults and 
kids with disabilities.
    Ms. HAYES. Thank you. And I think that is exactly where I 
was going, because currently there is a proposed 10 percent cap 
on the NFCSP programs that fund older adults caring for 
children in this country. And I don't want to us to get caught 
up addressing one problem, but not addressing the flip side of 
that problem because fast forward 30 years and the same 
grandmother who I just told you was the backbone of our family 
went through stages of dementia, Alzheimer's, hospice, at home 
in bed. My aunt didn't leave the house for a year because she 
had to take care of my grandmother.
    So I want to make sure that we are addressing all aspects 
of this problem. It is not just about providing nutrition and 
supports and getting health care services, but really the 
entire family is affected when this happens. You know, whether 
they are the children, who now the only reliable person in 
their life can no longer care for them, or the adults who are 
now tasked with caring for their parents and have to put their 
careers on hold, their families, their lives on hold.
    So I guess my question for--and this is the same thing that 
everyone here has kind of said--how can we provide supports 
to--what is it that we need to be asking for when we are 
legislating programs to ensure that we are touching all of 
those needs and not just pinpointing one area? Because I 
recognize how broad those things are.
    Ms. DUCAYET. Thank you for the question and your personal 
story.
    One thing that occurs--
    Ms. HAYES. Everything is personal here, I swear.
    Ms. DUCAYET. One thing that occurs to me is the need for 
person-centered services. And the Older Americans Act actually 
does an incredible job of emphasizing that. But I think there 
is always room for improvement in terms of how we coordinate 
those person-centered services across the different Older 
Americans Act services. So that is something I would recommend 
to look at and see if that is a point where we could improve 
upon.
    Ms. WHITING. I would also just thank you for your personal 
story and for talking about that. My grandmother had dementia 
and my aunt was her primary caregiver, and it was very 
difficult for her to access services because some of the 
restrictions in these laws around ages. So, for example, in the 
caregiver program, you know, it is caring for people over 60 
and then caring for people with dementia of any age. And it is 
sometimes difficult for people to understand how those programs 
could be administered. So that is an area where, you know, 
thinking about how the program aligns and making sure people 
understand at the State level how the program can be 
administered.
    Ms. HAYES. Thank you, Madam Chair. That is all I have.
    Chairwoman BONAMICI. Thank you very much, Representative.
    I now recognize Representative Thompson from Pennsylvania 
for 5 minutes for your questions.
    Mr. THOMPSON. Chairwoman, thank you so much. Thank you for 
this session. As someone who worked a career for almost 30 
years serving mostly older adults, therapists, previously a 
licensed nursing home administrator, the Older Americans Act is 
incredibly important.
    I was pleased when a few years back here we did the last 
reauthorization, we made some really good improvements, tried 
to focus on some of the chronic and disabling conditions, did 
some investment in our senior centers. A lot of good things. 
But this is the reason we do periodic reauthorizations, so we 
make sure that we are always getting it better and getting it 
right.
    And thank you for what each of you do and the perspectives 
that you bring here. You know, one of the covered--and this was 
mentioned briefly--one of the covered populations under the 
Older Americans Act obviously are those who are living with 
Alzheimer's disease. I experienced that. My mother lived with 
Alzheimer's for 10 years. It stole her identity, her memories, 
and then her life eventually. You know, these individuals 
receive the vital care and assistance needed to help maintain 
their independence. However, there is an estimated 200,000 
Americans under the age of 60 that are now living with 
Alzheimer's disease, or more commonly referred to as early 
onset Alzheimer's. Kind of an area I worked on when I practiced 
rehabilitation.
    Now, those with early onset Alzheimer's face difficult 
challenges when it comes to family and work and finances. 
Things kind of compound. It is almost like an accelerated aging 
to some extent.
    So starting with Ms. Whiting, you know, what are your 
thoughts as we look forward to reauthorization--and I know that 
we have got an age group of 60 that we define with the Older 
Americans Act, but quite frankly, when you look at things like 
Medicare, we do make accommodations for certain disabling 
conditions, end State renal disease--there may be more--you 
know, where folks are younger than that normal eligibility age. 
Any thoughts on what we should do in terms of early onset 
Alzheimer's? Any revisions or thoughts for changes as a result 
of the next reauthorization of the Older Americans Act?
    Ms. WHITING. So under the current Family Caregiver Support 
Program my understanding is that if you are caring for someone 
with Alzheimer's or related dementias of any age that you can 
receive services. But I would say when we look at other places 
in the Federal Government where they are providing support to 
caregivers, this is an area that is definitely underserved.
    So, for example, there is an estimated 5.5 million people 
caring for military veterans and the support for those programs 
is over $1 billion. Likewise, with Alzheimer's and dementia, 
you know, that community was able to reach an appropriation and 
authorization level to support it.
    I think the other piece, though, is just looking at 
research and where is it that we don't know what we don't know.
    Mr. THOMPSON. And there was an early onset bill that has 
been introduced in the House and the Senate that I think would 
be perfect to incorporate into any future Older Americans Act 
reauthorization.
    I want to kind of revisit just briefly, to anyone that 
wants to comment further, on the whole issue of just everywhere 
I go, you know, obviously the public health crisis of our 
lifetime is substance abuse. Maybe it is opioids, maybe it is 
crack, maybe it is prescription drugs--it changes based on a 
host of factors, but it is the underlying substance abuse. And 
a tremendous number of--I don't want to call them older adults 
because I put myself in that category of, you know, 
grandparents who find themselves now back in a primary care 
role. And there is a reason we have our kids when we are 
younger, we have the endurance for it. And when you, you know, 
assume those roles say in your 50's and 60's and 70's, it is a 
challenge.
    And I heard some general responses, but are there any 
concrete, any specific at this point recommendations that you 
would have for--I am not one that just likes to throw money 
into a program and hope that good people do good things, I like 
to have clear direction. And maybe it is more study that we 
need to do to figure out what are the supports that folks--I 
guess technically it would be 60 and older because the Older 
Americans Act, of how can we help those grandparents that find 
themselves in a parenting role once again?
    Ms. GIRARD. I think That is a really, really great 
question. There are--I think there are some really good 
evidence-based programs that some communities are really 
starting to utilize that are helping to destigmatize and bring 
resources for older adults who are experiencing many behavioral 
health issues, including substance use disorders, because they 
are often co-occurring with other issues. And I know in our 
State we have actually been looking at studying what some of 
the barriers are for people getting the support that they need. 
And it is actually more challenging for somebody that is older, 
somebody 65 and older to get the supports that they need 
because of issues around how Medicare is structured. So if we 
can be looking at ways that we can use evidence-based programs, 
that we can use peer supports, where peers can actually support 
other people that are going through the same thing, I think 
that would be excellent.
    Mr. THOMPSON. Thank you, Madam Chair.
    Actually, let me just say if any other witnesses have any 
thoughts on inputs or specific strategies, if you wouldn't mind 
forwarding to the committee. I think that would be very 
helpful, how do we help these grandparents who find themselves 
in--
    Chairwoman BONAMICI. Yes, Representative Thompson, if you 
put that in writing as a question for the record we will make 
sure that happens and we have a full record.
    Thank you.
    I now recognize Representative Trone from Maryland for 5 
minutes for your questions.
    Mr. TRONE. Thank you, Madam Chairman. Thank you all for 
coming out today. This is a really important subject.
    I want to talk a little bit about social determinants of 
health, SDOH. It is a new term in health. I wasn't that 
familiar with it whatsoever. For the Older Americans Act, has 
been way ahead of the curve in recognizing the importance in 
addressing the social determinants of health through community 
interventions. Category under the SDOH that is starting to get 
more attention is loneliness and social isolation. It is a 
growing concern and one that has serious health consequences.
    A 2010 study at Brigham Young University found that 
loneliness can shorten a person's life by 15 years. Another at 
Rush University found connection between loneliness and a whole 
wide range of health problems, especially increased risk of 
Alzheimer's.
    So Ms. Archer-Smith, first of all I want to thank you again 
for coming out. You are a--You work in my district in 
Montgomery County, so it is great. You serve over 40,000 
seniors throughout Maryland, and we really appreciate the help 
with Meals on Wheels. But a quarter of our seniors are living 
alone. And, you know, I know the fantastic volunteers are 
serving many of these seniors nutrition, and that is the only 
human interaction they get often, and those connections are so 
important to have during the day.
    So you spoke about the benefits of home-delivered meals and 
reducing isolation among these homebound adults. Can you share 
some examples of individuals who particularly benefit from 
social contact provided by the program and how this program is 
doing more than just substance, but performing other duties on 
isolation?
    Ms. ARCHER-SMITH. Yes, and thank you for the question.
    So I can give countless examples of volunteers who tell us 
about the person who they wait for the end of the route so that 
they can spend more time with them, play cards with them, talk 
with them about, you know, what is in the news.
    I can share with you a personal experience that was in my 
written testimony of a woman named Doreen who was 92 years old 
and lived alone. And I actually delivered to her personally. I 
was covering for someone and I liked to do that periodically 
to, you know, engage with our clients. And she didn't know me 
when I came in, but her face was so excited to see me and her 
eyes lit up so, you know, so wide and she wanted to know 
everything about me, what was my name and what did I do at 
Meals on Wheels and why was I there today and where was her 
other volunteer. And those are the questions. She was just 
hungry for someone to talk to. And I think is true of many of 
the people that we serve, but many of the things that we do, we 
call ourselves more than a meal because we are delivering more 
than just a meal, and that goes beyond that interaction with 
the volunteer. We also have other services that act as other 
touch points for them. So if it is a companion visit or if it 
is a phone pal, or something like that. That is another touch 
point. If it is someone to help them with some grocery shopping 
and household things that we don't deliver, those are other 
touch points and those are opportunities for them to interact 
more. And we have many, many stories of people who receive our 
full offering of services.
    Mr. TRONE. Yes, I was with a friend of mine last night, he 
has worked with Meals on Wheels for probably four or 5 years 
and he had a lot of similar stories about, you know, saving one 
person toward the end of the route to spend some time with them 
and one-on-one, and that made their day.
    So I think it is really great work that you guys are doing.
    What are the limitations that you are facing right now to 
be able to cover everybody appropriately, and, you know, what 
are the barriers?
    Ms. ARCHER-SMITH. So the barriers obviously are the 
funding. I mean, you know, that is the easy answer. But, you 
know, there are so many other things that our clients need. So 
being able to create those services and a plan for them that is 
unique to their individual needs is important. So being able to 
be creative about how we can deliver those services, whether it 
is grocery shopping through volunteers or companion visits, or 
whether it is professional case management and care 
coordination services.
    Mr. TRONE. And what is your volunteer stream? Do you have 
an adequate number of volunteers?
    Ms. ARCHER-SMITH. We have an aging group of volunteers, so 
we have some very, very loyal volunteers that have been with us 
for many, many years. And so we are able to recruit a lot of 
volunteers by way of word of mouth because they are so loyal to 
us and they tell their friends about it.
    But we are struggling to keep volunteers with growth. So 
there needs to be a more intentional approach with that, which 
we are addressing.
    Mr. TRONE. Well, it is very rewarding work. Thank you.
    Ms. ARCHER-SMITH. Thank you.
    Chairwoman BONAMICI. Thank you, Mr. Trone.
    I now recognize Mr. Johnson from South Dakota for 5 minutes 
for your questions.
    Mr. JOHNSON. Thank you, Madam Chair.
    Ms. Ducayet, maybe start with you. Of course, as we talk 
about reauthorizing the Act we want to make sure that it is 
well positioned for the future. I feel like I have read in a 
number of different places that number of older Americans, 
seniors, will double like in the next 30 or 40 years. And I 
think despite our best efforts to help people age in place, I 
assume that will mean a lot more folks who will call nursing 
homes, long-term care facilities, home.
    No. 1, is my assumption right about the data from what you 
know?
    And then, No. 2, will that place a burden on the 
ombudsman--ombudspeople across the country?
    Ms. DUCAYET. Thanks. Yes. So absolutely we know that the 
numbers are really skyrocketing in terms of our aging 
population, and that is going to affect our need for long-term 
care facilities.
    Where we are really seeing the biggest boom, and it has 
really been happening for decades now, is in assisted living 
facilities. If we can make those affordable everywhere, and 
that is a big question in all States, then people will choose 
assisted living facilities instead of a nursing home if they 
could at all possibly have it. It gives you more freedom and 
independence. It is less expensive to provide services in that 
setting. That boom has completely overwhelmed our ombudsman 
programs across the country.
    And so we hope to see a new appropriation for us to serve 
people in assisted living facilities, frankly because we have 
never seen that given to us in reauthorizations before and we 
have been very overwhelmed by the addition of assisted living 
facilities to our responsibilities.
    Mr. JOHNSON. Yes, of course, resources are a big part of 
the equation. I mean nationally do we see a change in how 
services are deployed in a way that provides for more 
efficiency or effectiveness in meeting the mission?
    Ms. DUCAYET. Well, I think big States like mine tend to use 
localized services and don't have a State operation hub for all 
services to be provided, and that makes sense for us to have 
localized offices of our program so that we can get to the 
residents quickly and visit facilities frequently. We need to 
use volunteers and we are allowed to use volunteers. That is a 
cost savings to the government. Our volunteers do a lot for our 
program, but our volunteer work force is aging as well and that 
has been a challenge for us too as we need to replenish those 
services.
    So another thing that would help the ombudsman program with 
volunteers is to be able to recognize the role of the volunteer 
more specifically in the Act, be able to reimburse volunteers 
specifically for mileage costs and training costs that are 
associated with it. Because volunteers save money for the Older 
Americans Act, but it isn't entirely free to have a volunteer 
in your program either. You have got to have a well trained 
force.
    Mr. JOHNSON. So I just want to make sure I am tracking, 
more specific language making it clear that those volunteer 
expenses could be reimbursed as a part of the program would be 
helpful?
    Ms. DUCAYET. Yes, yes. Yes, it would.
    Mr. JOHNSON. Okay, very good.
    So then, Ms. Whiting, as we look at--we talked about aging 
in place, and I thought you did a nice job of outlining the 
value proposition. When we have effective caregivers that 
allows people to maybe put off going to a long-term care 
facility or assisted living.
    So a similar question, if we have this many more older 
Americans in the future, and you mentioned that we are only 
providing supports to 2 percent of the caregivers out there, 
are there ways that we should be looking nationally to deploy 
services in a different way that can help meet the goals, meet 
the mission?
    Ms. WHITING. I think, Congressman, the ultimate goal here 
is that we would have people taking care of each other and we 
would be fostering that, not just through the appropriations 
process and expanding the program, but just to bring to your 
attention the RAISE Family Caregivers Act advisory council has 
yet to meet and it is on a 3-year sunset and will end in 2021. 
And that council, you know, proposes an opportunity to examine 
those exact kind of questions. And so we would encourage you to 
think about extending the life of that so we can actually get a 
plan that has employers, providers, older Americans, and others 
putting in what they really need, and where there could be more 
efficiencies in the system.
    I think the other piece of this is--if I can respectfully 
call it the Golden Girls model--where we have peers living 
together because increasingly we have younger generations of 
caregivers who are not having as many kids, they are more 
isolated, and so how can we help people age in healthy ways, 
using things like respite and senior centers and these other 
types of OAA programs so that they can care for each other as 
peers.
    Mr. JOHNSON. Yes. So and then Ms. Archer-Smith, Ms. Girard, 
I just wanted to give you an opportunity briefly to comment on 
anything it is we are talking about, increasing number of 
seniors and if there are different deployment mechanisms to 
provide supports, allow for aging in place. Any other thoughts?
    Ms. GIRARD. Well, I don't know if it is an opportunity, it 
is definitely a challenge. One of the things that families need 
is they need respite care and they actually often can be a 
better caregiver if somebody else is coming in to do 
caregiving, like giving somebody a bath. And what we are really 
experiencing is a challenge in the availability of the work 
force.
    So I think work force development for people so that there 
are people that view this as a viable option for them for 
employment would be really, really beneficial. And I know that 
there are both many State and national efforts looking at work 
force issues, but that is going to be a big one.
    Mr. JOHNSON. Thank you very much.
    Madam Chair, I yield back.
    Chairwoman BONAMICI. Thank you very much.
    I now recognize Representative Stefanik from New York for 5 
minutes for your questions.
    Ms. STEFANIK. Thank you, Chairwoman, and thank you to our 
panelists for being here today on such an important topic.
    I represent New York's 21st district, which is one of the 
most rural districts on the East Coast, but it is also one of 
the most aged districts if you look at the percentage of 
seniors that I represent. So your programs and the great work 
that you do has a direct impact on my constituents.
    I wanted to followup on Mr. Thompson's line of questioning 
related to Alzheimer's. As we know, there are approximately 
200,000 Americans suffering from early onset Alzheimer's 
disease and too often people living with this disease in their 
30's, 40's, and 50's can have young children, new homes, or 
growing careers. They are shut out of vital services just 
because they are young and the disease hits them earlier.
    Alzheimer's forever changes people's lives. It has impacted 
my family and we have heard from stories on both sides, both 
individuals in the audience here today, witnesses, as well as 
Members of Congress who have been impacted. I introduced the 
Younger Onset Alzheimer's Act this year, that was the 
legislation Mr. Thompson was referencing, that would amend the 
Older Americans Act to ensure the availability of programs and 
services for those impacted by Alzheimer's by allowing patients 
younger than 60 to access them.
    So my question, Ms. Whiting, this legislation would allow 
the National Family Caregiver Support Program and the Long-term 
Care Ombudsman Program to serve this population, but can you 
shed more light on how expanding these programs to those under 
the age of 60 would greater support family caregivers, 
especially those in the work force or those caring for young 
children? I am really interested in the caregiver piece aspect 
of this.
    Ms. WHITING. Thank you for that question.
    I think Alzheimer's is probably one of the biggest threats, 
for lack of a better word, facing us. In particular for 
caregivers, we know from research that it impacts their health, 
it impacts their ability to stay engaged in the work force, and 
we know that employers are starting to think about the impact 
of Alzheimer's. So actually in Kentucky the ranking member's 
home State, the Louisville Healthcare CEO Council has been 
trying to come up with business solutions for caregivers at 
work.
    I think where Older Americans Act programs can be most 
helpful to people with Alzheimer's, one would be respite, 
expanding the availability of respite. The second is, you know, 
really being a State laboratory to test Alzheimer's 
interventions that work. So, for example, the REACH 
intervention is an amazing intervention in New York, Mary 
Mittelman's program that she has done, hospital to home, that 
helps educate caregivers at discharge is also an excellent 
program. So thinking about how the AAA network can test that in 
different types of communities and then use that to spread 
those best practices.
    Ms. STEFANIK. Thank you.
    Ms. Girard, I wanted to followup on your recommendation 
about work force development when it comes to caregivers. The 
issue of caregivers is something that not only I have engaged 
on this committee, but also on the House Armed Services 
Committee when it comes to military caregivers. There was a 
program through the VA for military caregivers, but they did 
not anticipate just how many applications there would be. So it 
was underestimated.
    You talk about work force development specifically for 
caregivers. What can we do to ensure that we have a trained, 
qualified, and well paid work force when it comes to 
caregiving?
    Ms. GIRARD. That is a really great question as far as what 
kind of infrastructure is needed. I think we need to be looking 
at making sure that it is seen as a viable career, that it pays 
a living wage. That can be a challenge where sometimes the in-
home caregivers are actually receiving public benefits. So the 
more we can promote a living wage for folks where they might be 
able to get some benefits.
    I had the opportunity to be on our Oregon Home Care 
Commission and they really have developed Statewide a strategic 
plan. So I think encouraging communities to develop strategic 
planning that really looks at their work force and how they can 
really boost it, because really we are funding that work force 
in our area through both Medicaid, through State funds, and 
Older Americans Act funds. And it impacts really all the 
individuals getting those services. So it is a real vital 
thing.
    Ms. STEFANIK. Absolutely. Any other feedback on those 
questions from other panelists? Ms. Archer-Smith?
    Ms. ARCHER-SMITH. Yes. I would just encourage the 
reauthorization at levels that help meet the unmet need, 
because when you are providing the meal for the person with 
Alzheimer's, you are supporting that caregiver. When you are 
bringing other resources into the home, you are supporting that 
caregiver.
    We have stories, of you know, people that we have been able 
to help navigate a very complicated system of resources that 
are out there. And without the support of a case manager or a 
client support specialist, they may not have known how to get 
that, those extra hours of in-home care that they were eligible 
for. So making sure that we are meeting the unmet need is 
serving both the participant and the caregiver.
    Ms. STEFANIK. Thank you.
    My time has expired.
    Chairwoman BONAMICI. Thank you. I now recognize the 
chairman of the full committee, Representative Scott from 
Virginia, for 5 minutes for your questions.
    Mr. SCOTT. Thank you.
    Miss Whiting, I wanted to followup on one of the things you 
talked about, respite care. Can you talk about the value of 
respite care, both to the senior and to the caregiver?
    Ms. WHITING. Absolutely, and thank you for the question.
    So respite care is one of those evidence-based benefits 
that we know improves the ability of the caregiver to actually 
be a provider of care and it provides the individual who is 
receiving care a chance to essentially take a break. I mean one 
of the challenges is we think about caregiving in these real 
tactical terms, but there is research coming out that shows 
that if you are going to improve the relationship and the way 
that the caregiver and recipient communicate with each other, 
you cannot only improve the health of the older person or the 
person with disabilities, but you can improve the health of 
that caregiver as well.
    So being able to give people a break from each other and a 
chance to just be the sister, the wife, the brother, the 
friend, has a tremendously positive benefit on families.
    Mr. SCOTT. Thank you.
    Ms. Girard, you talked about the cost of caregiving. Is it 
realistic to think that you could provide funding for 
caregivers without subsidy?
    Ms. GIRARD. Well, I do know a good example. I am probably 
actually a good example because I am doing caregiving for my 
father. He lives about 30 miles from me and I have been 
searching for a caregiver that I am willing to pay in my 
community and I can't find anybody. So it is a struggle. I mean 
there are many families who are willing to cover the cost of 
that, and especially when you look at a return on investment of 
they get a break if you can have somebody come in 5 hours a 
week to just do some of the really heavy work.
    So I think looking at how we can encourage families to do 
that, individuals to do that. But then also I do think we have 
to look at a bit of a safety net for people that really can't 
afford to pay for caregiving and if you look at the return on 
investment.
    Mr. SCOTT. If you are going to pay the caregiver a living 
wage, most of the seniors can't pay someone else a living wage 
because they are hardly making it themselves.
    Ms. GIRARD. That is true. So that is where really we do 
have to subsidize that. But if you look at the cost of the in-
home caregiving and compare it to the cost of either a 
community-based care, like assisted living or a nursing 
facility, it is still much, much cheaper. We have some State 
funded programs where it is really only costing the State, and 
Older Americans Act actually, about $300 a month. But if that 
person was in an assisted living, it would be probably $3,000 a 
month. And if they were in a nursing home it would be closer to 
$6-8,000 a month. So if you look at it that way, it is actually 
very cheap.
    Mr. SCOTT. Thank you.
    The Older Americans Act supports a number of evidence-based 
health interventions. Ms. Girard, one of these is fall 
prevention, where evidence shows that fall prevention programs 
can reduce problems. Can you say a word about that?
    Ms. GIRARD. Yes. For our Area Agency on Aging we look at 
the development of those programs at multiple levels. We 
participate in a network that includes us, it includes public 
health, it includes health care providers, and it includes our 
community partners, like our nutrition programs. We develop a 
plan in our area and then we look at different ways that we can 
all pool funding to start really developing a network of fall 
prevention programs, evidence-based fall prevention programs. 
And some of the funding is coming from Older Americans Act, but 
some of the funding is coming from other sources. And we really 
try to embed it in local community-based organizations because 
then it is more likely to get out to the folks that actually 
need it.
    Mr. SCOTT. When you talk about evidence-based, do the fall 
prevention programs prevent falls?
    Ms. GIRARD. Yes, the evidence-based--they have been 
studied, they have been compared to control groups where people 
have not been getting the program, and has shown a really 
significant return in reduction of falls. And I know that in 
our area falls is actually, for older adults, one of the 
biggest disease injury kind of issues in our county.
    So it is something that our whole health network is really 
looking at.
    Mr. SCOTT. Thank you.
    And, finally, Ms. Ducayet, can you say a word about the 
ombudsman model addressing problems of elder abuse?
    Ms. DUCAYET. Yes, thank you. So I would say that our model 
includes surprise visits, frequent visits to facilities where 
our eyes and ears are in those buildings. And I think that 
absolutely prevents abuse. It is something different far and 
away from a regulatory function that is there to cite a 
facility and bring them into compliance. Our focus is on the 
resident and being person-centered and finding a resolution 
that the resident wants and seeks to feel safe and secure after 
abuse, neglect, or exploitation.
    I think those are really key factors. We resolve 73 percent 
of complaints to the satisfaction of the resident or the 
decisionmaker of the resident every year.
    Mr. SCOTT. Thank you.
    Ms. DUCAYET. Thanks.
    Mr. SCOTT. Thank you, Madam Chair.
    Chairwoman BONAMICI. Thank you, Mr. Chairman.
    And I see no other members.
    I want to remind my colleagues that pursuant to committee 
practice, materials for submission for the hearing record must 
be submitted to the committee clerk within 14 days following 
the last day of the hearing, preferably in Microsoft Word 
format. The materials submitted must address the subject matter 
of the hearing. Only a member of the committee or an invited 
witness may submit materials for inclusion in the hearing 
record. Documents are limited to 50 pages each. Documents 
longer than 50 pages will be incorporated into the record via 
an internet link that you must provide to the committee clerk 
within the required timeframe, but please recognize that years 
from now that link may no longer work.
    So, again, I want to thank the witnesses for their 
participation today. What we have heard is incredibly valuable 
and I know members of the committee may have some additional 
questions for you. We ask the witnesses to please respond to 
those questions in writing. The hearing record will be held 
open for 14 days to receive those responses.
    And I remind my colleagues that pursuant to committee 
practice, witness questions for the hearing record must be 
submitted to the majority committee staff or committee clerk 
within 7 days. Questions submitted must address the subject 
matter of the hearing.
    I now recognize the distinguished ranking member for his 
closing statement.
    Mr. COMER. Thank you, Madam Chairman. And I just want to 
again thank the witnesses for being here today and thank you 
for everything that you do in the people that you serve. Your 
knowledge and experience and testimony today will help us 
better serve older Americans as we move forward.
    It is crucial that we hear from people on the front lines, 
like yourselves, and I think this committee hearing has been 
very beneficial to us. We must acknowledge the challenges 
facing the Older Americans Act given the rapidly growing senior 
population and constraints of a limited Federal budget.
    As we explore ways to further empower seniors, we must 
enhance coordination within the program to effectively serve 
those with the greatest social and economic needs. A critical 
aspect of this is maintaining and strengthening the local 
flexibilities within the law to meet the needs of individual 
communities.
    We have the opportunity today to begin the committee's 
process of improving the law to better provide care for older 
Americans.
    Again, thank you for being here today and I look forward to 
working with you in the future.
    Madam Chairman, I yield back.
    Chairwoman BONAMICI. Thank you.
    I now recognize myself for making a closing statement.
    Thank you, again, to the witnesses for providing such 
insightful testimony. And I think I also want to thank my 
colleagues who shared--and you heard the intensely personal 
stories--because this is an issue that affects us all and 
affects our constituents.
    People in the United States of America should be able to 
retire and age with dignity. And by passing the Older Americans 
Act in 1965, Congress did make a commitment to provide 
Americans the support they need to age independently in their 
homes and communities for as long as possible. And today, as 
our witnesses testified, the Older Americans Act programs 
empower millions of adults every day to remain independent 
while avoiding or significantly delaying costly 
institutionalized care.
    The population of older Americans continues to grow, but 
unfortunately commitments--investments by Congress in OAA 
programs have not sufficiently kept pace. And this has reduced 
our ability to meet the increased demand for these effective 
and widely used services.
    Just Monday at home in Oregon I heard about an 80-year-old 
woman who was living in the back seat of her car. And I think 
far too many Americans continue to live in poverty across our 
districts, face discrimination, face barriers to basic 
necessities in part because OAA programs are underfunded and 
not well enough supported.
    So today's hearing has underscored our responsibility. We 
can help stop this cycle of disinvestment which is eroding the 
original purpose of the Older Americans Act and creating 
additional challenges for too many older Americans, and 
actually costing us more in higher cost care.
    As this committee considers the OAA reauthorization I hope 
we can work together so its programs have the support and 
resources needed to provide essential services and 
compassionate care to all aging Americans.
    Just 3 years ago both parties came together in each chamber 
of Congress to reauthorize and improve the OAA programs. Today, 
I appreciate my colleagues joining me in renewing that 
commitment to honoring the promise made to older Americans more 
than a half a century ago. By continuing the Older Americans 
Act tradition and bipartisan support we can make clear that 
this committee and this Congress will continue to stand up for 
older Americans.
    So thank you, again, to the witnesses for being here. I 
look forward to working with you and all of my colleagues on 
both sides of the aisle as we move forward.
    And if there is no further business, without objection, 
this committee stands adjourned.
    [Additional submission by Chairwoman Bonamici follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    [Questions submitted for the record and their responses 
follow:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    [Whereupon, at 11:49 p.m., the subcommittee was adjourned.]

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