[Senate Report 105-36]
[From the U.S. Government Publishing Office]



105th Congress                                             Rept. 105-36
                                 SENATE  

 2d Session                                                    Volume 3
_______________________________________________________________________


 
                 DEVELOPMENTS IN AGING: 1996 - VOLUME 3

                               __________

                                A REPORT

                                 of the

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                              pursuant to

               S. RES. 73, SEC. 19(c), FEBRUARY 13, 1995

  Resolution Authorizing a Study of the Problems of the Aged and Aging





                 April 30, 1998.--Ordered to be printed


105th Congress                                             Rept. 105-36
                               SENATE

2d Session                                                     Volume 3
_______________________________________________________________________


                      DEVELOPMENTS IN AGING: 1996


                                VOLUME 3

                               __________

                                A REPORT

                                 of the

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                              pursuant to

               S. RES. 73, SEC. 19(c), FEBRUARY 13, 1995

  Resolution Authorizing a Study of the Problems of the Aged and Aging





                 April 30, 1998.--Ordered to be printed


                       Developments in Aging: 1996

                                Volume 3


                       SPECIAL COMMITTEE ON AGING

                  CHARLES E. GRASSLEY, Iowa, Chairman
JAMES M. JEFFORDS, Vermont           JOHN B. BREAUX, Louisiana
LARRY CRAIG, Idaho                   JOHN GLENN, Ohio
CONRAD BURNS, Montana                HARRY REID, Nevada
RICHARD SHELBY, Alabama              HERB KOHL, Wisconsin
RICK SANTORUM, Pennsylvania          RUSSELL D. FEINGOLD, Wisconsin
JOHN WARNER, Virginia                CAROL MOSELEY-BRAUN, Illinois
CHUCK HAGEL, Nebraska                RON WYDEN, Oregon
SUSAN COLLINS, Maine                 JACK REED, Rhode Island
MIKE ENZI, Wyoming
                   Theodore L. Totman, Staff Director
               Kenneth R. Cohen, Minority Staff Director


                         LETTER OF TRANSMITTAL

                              ----------                              

                                       U.S. Senate,
                                Special Committee on Aging,
                                              Washington, DC, 1997.
Hon. Albert A. Gore, Jr.,
President, U.S. Senate,
Washington, DC.
    Dear Mr. President: Under authority of Senate Resolution 73 
agreed to February 13, 1995, I am submitting to you the annual 
report of the U.S. Senate Special Committee on Aging, 
Developments in Aging: 1996, volume 3.
    Senate Resolution 4, the Committee Systems Reorganization 
Amendments of 1997, authorizes the Special Committee on Aging 
``to conduct a continuing study of any and all matters 
pertaining to problems and opportunities of older people, 
including but not limited to, problems and opportunities of 
maintaining health, of assuring adequate income, of finding 
employment, of engaging in productive and rewarding activity, 
of securing proper housing and, when necessary, of obtaining 
care and assistance.'' Senate Resolution 4 also requires that 
the results of these studies and recommendations be reported to 
the Senate annually.
    This report describes actions taken during 1995 and 1996 by 
the Congress, the administration, and the U.S. Senate Special 
Committee on Aging, which are significant to our Nation's older 
citizens. It also summarizes and analyzes the Federal policies 
and programs that are of the most continuing importance for 
older persons and their families.
    On behalf of the members of the committee and its staff, I 
am pleased to transmit this report to you.
            Sincerely,
                                     Charles E. Grassley, Chairman.


                   ITEM 1--DEPARTMENT OF AGRICULTURE

                              ----------                              


                  AGRICULTURAL RESEARCH SERVICE (ARS)

Title and purpose statement of each program or activity which affects 
        older Americans
    Studies are conducted at the Jean Mayer USDA Human 
Nutrition Research Center on Aging (HNRCA) at Tufts University, 
Boston, Massachusetts, which address the following problems of 
the aging:
          1. What are nutrient requirements to ensure optimal 
        function and well being for a maturing population?
          2. How does nutrition influence the progressive loss 
        of tissue function associated with aging?
          3. What is the role of nutrition in the genesis of 
        major chronic, degenerative conditions associated with 
        the aging process?
    In addition, studies are performed at the Beltsville Human 
Nutrition Research Center (BHNRC), the Grand Forks Human 
Nutrition Research Center (GFHNRC), and the Western Human 
Nutrition Research Center (WHNRC) on the role of nutrition in 
the maintenance of health and prevention of age-related 
conditions, including cancer, coronary heart disease, 
hypertension, diabetes, neurological disorders, osteoporosis, 
and immunocompetence. Summaries of human nutrition research 
progress and a list of projects related to nutrition and the 
elderly are attached.
Brief description of accomplishments
    Researchers at the Jean Mayer USDA Human Nutrition Research 
Center on Aging (HNRCA) at Tufts University have made 
significant strides toward improving the quality of life for 
men and women as they age. These accomplishments show promise 
in delaying the onset of many age-related diseases and 
conditions.
    Immune Function. The decline in immune function during 
aging, which increases susceptibility to infection and risk of 
certain cancers, is modulated by protein, vitamin, and mineral 
intake. Recent research at HNRCA supports the role of vitamin E 
in enhancing immune response:
          Vitamin E supplementation enhanced T cell-mediated 
        immune function in healthy elderly; the optimal dose 
        was demonstrated to be 200 IU/day.
          Vitamin E supplementation also significantly 
        protected against exercise-induced oxidative damage and 
        promotes acute phase immune responses in healthy older 
        men.
    Bone Health. Osteoporosis occurs most frequently in 
postmenopausal white women and in the elderly. Approximately 20 
percent of American women suffer one or more fractures before 
age 65 and as many as 40 percent sustain fractures later in 
life. Almost 50 percent of these people will require long-term 
care services. Inadequate calcium and vitamin D intake can lead 
to bone loss and increased risk of osteoporosis. Research at 
HNRCA has shown that:
    Calcium absorption has a heritable component that is 
apparent at low but not at high calcium intake levels, 
illustrating an interaction between heredity and the nutrient 
intake. The HNRCA identified age-related changes in vitamin D-
independent calcium transport as a major determinant of 
intestinal calcium malabsorption during senescence. 
Supplementation with calcium and vitamin D to recommended 
levels reduced the rate of bone loss and the incidence of 
symptomatic fractures in healthy men and women age 65 and 
older.
    The HNRCA identified a negative role of high dietary 
calcium intakes on zinc homeostasis in the elderly. 
Specifically, high calcium intake reduced zinc retention, a 
finding of substantial relevance to consumers who self-
prescribe calcium supplements and may thereby put themselves at 
risk of zinc deficiency.
    Exercise, Body Composition, and Prevention of Frailty. 
Sarcopenia, the loss of lean body mass as one ages, strongly 
influences muscle strength and mobility and contributes to 
falls and frailty. Studies in this area have shown that:
          Home-based resistance exercise training improves 
        function and reduces Sarcopenia and frailty in the 
        elderly.
          Total body potassium content, a measure of lean body 
        mass, assessed by total body potassium (K-40) 
        measurements, declined at roughly 0.5-percent in muscle 
        per year without exercise and nutrition intervention.
          Percent body fat assessed by neutron inelastic 
        scattering increased with age for female volunteers 
        between the ages of 20 to 50 years and throughout adult 
        life for males.
          Elderly persons find it difficult to maintain a 
        constant body weight (some gain too much, others lose 
        weight) due to an impaired ability to regulate food 
        intake.
          Sarcopenia is associated with increased production of 
        several cytokines, but not with low growth hormone.
    Prevention of Cardiovascular Disease and Stroke. 
Cardiovascular disease is the leading cause of death in the 
United States. Coronary heart disease (CHD) increases with age 
and is responsible for approximately 24 percent of total U.S. 
deaths. Dietary changes, particularly reducing total and 
saturated fat and increasing soluble fiber intake is often the 
first step to attempt to reduce elevated cholesterol levels. 
Recently, the significant impact for vitamins C, E, and other 
antioxidant phytochemicals, and folate and vitamins B6 and B12 
has been investigated. Genetics are also a significant factor 
in disease risk.
    Additional ARS research results included:
    The carbon to oxygen ratio in tissue, measured by neutron 
inelastic scattering, is a measure of fat content. This method 
was validated against hydro densitometry and used to study the 
relationship between fat distribution patterns and risk for 
cardiovascular disease. Certain body fat distribution patterns 
are associated with increased risk for cardiovascular disease.
    Researchers identified a genetic influence on the over-
consumption of high fat diets that may help to explain why some 
individuals become obese.
    Consumption of hydrogenated oils were found to adversely 
impact plasma low density lipoprotein (LDL) cholesterol levels.
    Diets were developed that were adequate in essential fatty 
acids which reduce LDL cholesterol and promote weight loss.
    Low plasma level of docosahexaenoic acid is a risk factor 
for dementia, as is an apoE-IV genotype. Both apoE and apoA-IV 
genotype determine responsiveness to LDL cholesterol lowering 
from diets restricted in saturated fat and cholesterol.
    Nutrient factors are the primary determinants of elevated 
total plasma homocysteine concentrations, commonly found in 
older Americans. Plasma homocysteine is inversely correlated to 
status and intake of foliate, vitamin B12 and vitamin B6 and 
directly proportional to the prevalence of carotid stenosis in 
the elderly subjects in the Framingham Heart Study.
    Cataract and Age-Related Visual Impairments. Visual 
impairment is common among older adults. In the United States, 
the prevalence of cataracts which impact vision is about 40 
percent of people over 75 years. Age-related macular 
degeneration is the primary cause of incurable blindness in the 
United States. Approximately 25 percent of people 65 years and 
older have signs of age-related maculopathy. There is a growing 
body of evidence that the onset of cataract and age-related 
macular degeneration can be retarded in many cases by behavior 
and nutrition factors.
    Clinical/epidermiologic studies suggest a protective effect 
of dietary vitamin C against cataract formation. Use of vitamin 
C supplements for 10 or more years was associated with an 80% 
lower prevalence of age-related lens opacities in women aged 
55-71 years. Use of supplements for less than 10 years was 
without significant effect.
    Cancer in the aging population. The total incidence of 
cancer each year is increasing for both men and women in the 
United States. It has been estimated that at least a third of 
cancer mortality is related to dietary factors. Research in 
this area has found that:
          Folic acid supplementation in human subjects who 
        harbor colonic polyps leads to an improvement in a 
        purported intermediary marker of colon cancer, DNA 
        hypomethylation of the colonic mucosa.
          The protection that fruits and vegetables provide 
        against disease, including cancer and cardiovascular 
        diseases and stroke has been attributed to their 
        antioxidant content. The total antioxidant capacity of 
        fruits and vegetables has been measured using the 
        automated oxygen radical absorbance capacity (ORAC) 
        assay. Adults who consumed of a meal containing 3400 
        mol Trolox equivalents of ORAC from spinach, 
        strawberries, red wine phenolics or vitamin C increased 
        serum ORAC by 10-15 percent indicating significant 
        absorption of antioxidant phytochemicals from these 
        food sources.
    Food and Diet Studies. Eating foods which are rich in 
vitamin K rapidly improves vitamin K status. Epidemiologic 
studies are underway to examine the relationship between 
vitamin K status and chronic diseases, such as cardiovascular 
disease and osteoporosis. In order to adequately assess dietary 
intake of the vitamin, scientists have developed and validated 
a comprehensive vitamin K food composition database.
    High prevalences of disability, diabetes, depression and 
obesity were found among a representative group of Hispanic 
elders in Massachusetts. Puerto Rican elders, had higher rates 
of these conditions than did other Hispanics or non-Hispanic 
whites. A food frequency questionnaire developed for this 
population found that their diets tend to be high in refined 
starchy foods and low in variety and micronutrients.
    The Framingham Heart Study revealed that diet patterns of 
subjects predicted blood folate, homocysteine, vitamin B12 
concentrations and bone status. Studies also indicated that:
          Fruits, vegetables and breakfast cereal appear to be 
        protective of folate and homocysteine status; vitamin 
        B12 supplements and fortified breakfast cereal appear 
        protective of vitamin B12 status; and potassium, 
        magnesium, and fruits and vegetables were significantly 
        associated with greater bone mineral density in elderly 
        men and women and with lower losses in bone mineral 
        density over time in elderly men.
    Long-term feeding of rats with a defined diet containing 
extracts of strawberries or spinach or high in vitamin E 
retarded the onset of several parameters of aging including; 
loss of brain cell receptor sensitivity, and cognitive 
behavior.
    Antioxidants Research Laboratory. The Antioxidants Research 
Laboratory works to understand the role of dietary antioxidants 
and factors such as drugs and exercise on free radical 
reactions and changes in oxidative stress status during aging.
    Oxygen free radicals generated during cellular metabolism 
and by certain lifestyle factors appear to play a critical role 
in the aging process and in the development of chronic diseases 
common among the elderly. Diets characterized by high intakes 
of foods rich in antioxidant vitamins and other phytochemicals 
are associated with better maintenance of physiologic function 
and a lower prevalence of many chronic diseases. An 
understanding of how antioxidants reduce oxidative stress 
status and impact the pathogenesis of chronic disease will 
enable us to improve health promotion and the treatment of 
chronic disease among other adults.
    Body Composition Laboratory. The Body Composition 
Laboratory evaluates the effect of nutrition on the dynamic 
interactions between the body's protein, water, fat and bone 
and studies the relationship of these changes to the aging 
process. This laboratory works to understand the mechanisms 
leading to loss of muscle mass with age, and develop 
appropriate interventions that reverse this decline; develop 
new techniques of measuring muscle mass accurately in vivo; 
develop and validate methods for assessing body composition and 
nutrition status of non-institutionalized elderly in 
epidemiologic studies; and evaluate the efficacy of anti-
cachexia and anti-obesity treatments.
    Calcium and Bone Metabolism Laboratory. The Calcium and 
Bone Metabolism Laboratory conducts research to improve the 
scientific basis for understanding and establishing the intake 
requirements for calcium, vitamin D, and other nutrients that 
influence bone health in adult men and women. This requires an 
understanding of how demographic, endocrine, genetic, racial, 
seasonal, and physical factors influence bone mass and affect 
nutrient requirements. It also requires an understanding of the 
absorption and metabolism of these nutrients. In this clinical 
research laboratory, volunteers are recruited to participate in 
both long-term, randomized, placebo-controlled intervention 
trials as well as smaller, more intense, shorter metabolic 
studies.
    Energy Metabolism Laboratory. The Energy Metabolism 
Laboratory examines how body weight is normally regulated and 
why many people gain weight as they grow older. The importance 
of genetic and environmental factors in determining body 
composition and energy regulation, and quantifying optimal 
dietary energy requirements are under investigation. Whole-body 
physiology studies examine the importance of energy expenditure 
and energy intake in determining body fat gain during adult 
life. Hormonal and cellular investigations are also underway to 
identify the underlying metabolic cause of individual 
differences in body composition and energy regulation.
    Gastrointestinal Nutrition Laboratory. A major focus of the 
Gastrointestinal Nutrition Laboratory is to determine how aging 
and associated factors, such as medication use, effect the 
intestinal absorption and metabolism of micronutrients, 
including carotenoids. Human volunteers, experimental animals, 
and cell culture models are studied to investigate whether 
changes in the requirements for vitamins A, B6, B12, and niacin 
are warranted in aging. Research is conducted in elderly 
subjects with atrophic gastritis or hypochlorhydria, 
representing a sub-population of elderly at risk for impaired 
nutrient absorption and metabolism.
    The chemopreventive effects of carotenoids against cancer 
are also explored. The biologic activity of carotenoid 
metabolites in gene expression is examined as a mechanism to 
explain both chemopreventive (when present in low 
concentrations) and cancer promoting (when present in high 
concentration) properties. The functions of carotenoids in 
preventing light damage to the macula of the eye and in 
promoting intestinal immunity are studied in collaboration with 
other HNRC laboratories.
    Genetics Laboratory. The Genetics Laboratory studies 
reactive oxygen species produced by cellular metabolic 
reactions that have been implicated in the pathogenesis of 
numerous diseases including atherosclerosis, cancer and 
Alzheimer's disease. The laboratory focuses on the molecular 
mechanisms, by which reactive oxygen species are used as 
signaling molecules in the regulation of cellular function and 
gene expression. Interestingly, clinical and epidemiologic 
studies have, in some cases, indicated that antioxidant 
nutrients may be effective in disease prevention. Recently 
molecular and cellular approaches have demonstrated that 
reactive oxygen species and antioxidants can directly affect 
the cellular signaling apparatus, and consequently the control 
of gene expression. The new research provides the link between 
reactive oxygen species and antioxidant chemistries, and the 
mechanisms of disease processes and prevention.
    Laboratory for Nutrition and Vision Research. The 
Laboratory for Nutrition and Vision Research seeks to determine 
the primary causes of eye lens cataract and degeneration of the 
macula and to apply this knowledge to extend the useful life of 
these organs. Current clinical/epidemiologic approaches and 
laboratory tests aim to define adequate nutrient levels during 
various life stages which will ultimately result in delayed 
accumulation of damaged lens and retinal proteins and delayed 
lens opacification and age-related maculopathy. Human and other 
mammalian lens tissue, a variety of animal models, whole lenses 
in culture, and cultured lens epithelia cells are studied. 
Since the lens is primarily composed of protein, a significant 
effort is being made to understand interrelationships between 
aging, regulation of lens protein metalobism, protease function 
and expression, and nutrition.
    Lipid Metabolism Laboratory, Cardiovascular disease (CVD), 
including coronary heart disease (CHD) and stroke, remain the 
leading causes of death and disability in our society. In 
addition to age and gender, significant CHD risk factors 
include an elevated level of low-density lipoprotein 
cholesterol, a decreased level of high-density lipoprotein 
cholesterol, cigarette smoking, hypertension, and diabetes. 
Hypertension and age are significant risk factors for stroke. 
Dietary intake and exercise level have a significant impact on 
cardiovascular risk, as do genetic factors. The Lipid 
Metabolism Laboratory focuses on defining the 
interrelationships between lipoprotein metabolism and 
consumption of various dietary fatty acids, cholesterol another 
dietary constituents, genetics, and aging. Other studies are 
designed to identify lipid and lipoprotein abnormalities and 
genetic mutations associated with CHD, stroke, and dementia 
risk. Scientistsare developing nutritionally-adequate optimal 
diets for fatty acids, cholesterol, and other dietary constituents in 
the elderly to minimize the risk of CVD and dementia.
    Mineral Bioavailability Laboratory. The Mineral 
Bioavailability Laboratory examines the biochemical and 
physiologic basis for changes in absorption and utilization of 
minerals with aging and determines the effects of aging on 
mineral requirements in the elderly. Research focuses 
specifically on understanding calcium, zinc, and iron 
metabolism in the elderly, and the effects of nutrient and 
hormonal changes on the expression of genes that modulate 
mineral metabolism.
    Neuroscience Laboratory. Although the primary focus of a 
great deal of research in neuronal aging is directed to 
identifying the mechanisms involved in age-related 
neurodegenerative disease, e.g., Alzheimer's disease and 
Parkinson's disease, many of the neurologic deficits seen in 
aging occur in the absence of neurodegenerative disease. In 
fact, these diseases are superimposed upon an already declining 
nervous system. These deficits may include decreases in both 
motor and memory functions which could, in many cases result in 
hospitalization and/or custodial care. Research has suggested 
that both the changes that occur in Alzheimer's disease and 
Parkinson's disease, as well as those in aging, may involve 
increases in vulnerability to oxidative stress. Research in the 
Neuroscience Laboratory is directed to toward identifying 
factors that increase vulnerability to oxidative stress with a 
view toward identifying nutrient antioxidant regimens to 
restore these behaviors or prevent their decline.
    Research in the Neuroscience Laboratory is directed toward 
determining the membrane and neurotransmitter receptor 
characteristics that increase vulnerability to oxidative 
stress, alter calcium homestatis, and ultimately, cell 
viability in neuronal aging. Studies examine the expression of 
the behavioral deficits in aging using assessments of cognitive 
and motor behavior. Other studies examine the effects of 
dietary supplementation with fruits and vegetables high in 
antioxidant activity, as well as other antioxidants on 
retarding to age-related cellular, neuronal, and behavioral 
deficits.
    Nutritional Epidemiology Program. The Nutrition(al) 
Epidemiology Program uses the epidemiologic approach and 
methods to investigate the role of nutrition in healthy aging. 
Epidemiology allows for the study of complex interactions 
between genetic, behavioral, and environmental factors in a 
community setting. It is also the bridge between basic science 
and public policy. This program identifies nutrition related 
factors that influence the progressive loss of physiologic 
function and genesis of the major chronic, degenerative 
conditions associated with aging, such as cardiovascular 
disease and visual impairment. Studies assess the possible 
modification of these nutritional relations by personal 
behavioral, and genetic factors. This information is used to 
assist in determining the nutrient requirements necessary to 
obtain optimal function and well being for a maturing 
population. The research focuses on identifying the 
determinants of nutrition status and intake in the elderly, 
relating nutrition status and intake to measures of health and 
well-being, and improving methodology for research relating 
nutrition and aging.
    Nutritional Immunology Laboratory. The Nutrition(al) 
Immunology Laboratory has demonstrated that increased 
production of suppressive factors free radicals, and enzymatic 
products of lipid peroxidation, such as PGE2, play an important 
role in the dysregulation of the immune response in older 
adults, which contributes to increased incidence of infectious, 
inflammatory, and neoplastic diseases. Antioxidant and 
prooxidant nutrients modulate immune and inflammatory 
responses. This laboratory investigates the role of dietary 
components (antioxidants and prooxidants in particular) and 
their interactions with other environmental factors in age-
associated changes of the immune and inflammatory responses. 
Research is designed to develop a means to reverse and/or delay 
the onset of these immunological and age-related changes by 
appropriate dietary modifications and to determine the 
molecular mechansim(s) by which antioxidant and prooxidant 
nutrients modulate immune cell functions. Methods are being 
developed to use the immune response as a biologically 
meaningful in determining specific dietary requirements.
    Nutrition, Exercise Physiology, and Sarcopenia Laboratory. 
The mission of the Nutrition, Exercise Physiology, and 
Sarcopenia Laboratory is to understand the interaction of 
nutrition, hormonal and immunological factors in sarcopemia 
(the loss of muscle mass and function with aging) and to 
develop new methods of reversing and preventing these losses. 
Studies are conducted in healthy humans, in animals, and in 
vitro experimental systems. Over the past decade this 
laboratory has demonstrated the safety and effectiveness of 
progressive resistance exercise training (strength training) in 
reversing sarcopenia and frailty. Current projects are designed 
to better understand the mechansims causing sarcopenia, 
including changes in various hormones and in the immune system 
with age, and how exercise and diet can improve or prevent 
these changes.
    Phytochemical Laboratory. The Phytochemical Laboratory 
investigates the bioavailability, metabolism, and potential 
health benefits of various phytochemicals with antioxidant 
activity. Specific antioxidants currently under investigation 
include vitamins C and E, and the flavoniod family of 
compounds, including flavones, flavanones, anthocyanins, etc. 
The Oxygen Radical Absorbance Capacity assay and various High 
Performance Liquid Chromatography methods are used to 
characterize these antioxidants. In vivo nutrition studies are 
conducted in human volunteers to asses biological activity and 
function.
    Vitamin Metabolism Laboratory. The Vitamin Metabolism 
Laboratory examines the relationship between aging and B 
vitamin status with emphasis on requirements and long-term 
effects of inadequate status. The relationship of plasma 
homocysteine levels to intake and status of the vitamins folic 
acid, B12, B6 and B2 and cardiovascular disease, thrombosis and 
stroke, cognitive dysfunciton, certain cancers e.g., breast, 
colorectal, prostate and cervical are studied. The polymorphic 
mutations in the gene encoding enzyme of folate metabolism such 
as the thermolabile methylenetetrahy-drofolate reductase 
mutation are under investigation. The epidemiologic component 
of this research is conducted with a variety of outside 
collaborators including the National Cancer Institute, Johns 
Hopkins School of Public Health, Harvard School of Public 
Health, Hadasah Hospitals and the Farmingham Heart Study. Basic 
laboratory research includes the development of new methods for 
the study of small human specimens and animal model studies.

Human Nutrition Research Center on Aging--Research Projects Related to 
Nutrition and the Elderly

                                                           Funding Level
                                                             fiscal year
                                                                 dollars
Functional Capacity and Nutrient Needs of Aging--HNRC, 1/11/
    95-1/10/00. Objective: To examine the effects of increased 
    physical activity, body composition and diet on the 
    following: (1) Peripheral insulin sensitivity and glucose 
    metabolism; (2) Functional capacity and nutrition status 
    of the frail elderly; (3) Whole body and skeletal muscle 
    protein metabolism; (4) Total energy expenditure and its 
    relationship to physical activity level and body 
    composition...............................................   940,560
Function and Metabolism of Vitamin K and Vitamin K Dependent 
    Proteins During Aging--HNRC, 1/11/95-1/10/00. Objective: 
    Molecular, biochemical and functional assays of vitamin K 
    nutritional status and dietary tools for the assessment of 
    vitamin K intakes will be developed and validated. In vivo 
    studies with rats will determine dietary sources of 
    vitamin K and requirements related to the synthesis of 
    matrix gla protein (MGP). The effects of aging and gender 
    on the expression of MGP will be studied in relationship 
    to dietary sources of vitamin K (phylloquinone or 
    menadione) and vitamin K antagonists......................   904,769
Absorption & Metabolism of Phytochemicals: Enhancement of 
    Antioxidant Defense Mechanisms in Aging--HNRC, 10/1/96-9/
    30/99. Objective: Determine (1) extent of absorption and 
    metabolism of flavonoids in fruits and vegetables high in 
    antioxidant activity, (2) usefulness of Oxygen Radical 
    Absorbing Capacity (ORAC) assay as an indicator of 
    antioxidant capacity of fruits and vegetables and status 
    in animal models exposed to increased oxidative stress, 
    and (3) possible health related outcomes..................   370,184
Dietary Antioxidants, Aging, and Oxidative Stress--HNRC, 11/1/
    94-10/31/99. Objective: To determine the effect of 
    enhancing antioxidant status on oxidative status, immune 
    responsiveness, and other physiologic functions; 
    interactions between vitamin E, other dietary antioxidants 
    and/or polyunsaturated fatty acids; the effect of dietary 
    antioxidants on the generation of eicosanoid and cytokine 
    products and oxidized lipid, protein, and nucleic acid 
    targets; the value of measures of antioxidants and 
    oxidative stress status as biomakers of aging and health..   670,700
Regulation of Gene Expression in Nutrient Metabolism--HNRC, 1/
    11/95-1/10/99. Objective: The major areas being explored 
    are aimed at defining the molecular mechanisms which 
    contribute to metabolic dysfunction in diabetes and 
    obesity. Specifically, we are examining the role of 
    oxidants in nutrient and hormonal signal transduction and 
    gene expression. Secondly, we are exploring how aging 
    influences nutrient and hormonal signalling and gene 
    expression................................................   432,679
Mineral Bioavailability in the Elderly--HNRC, 1/11/95-1/10/00. 
    Objective: To define the dietary factors that influence 
    the bioavailability, requirements, and status of minerals, 
    especially Ca, Mg, Fe, and Zn in humans. To define the 
    relationship between restriction fragment length 
    polymorphisms in the vitamin D receptor gene and calcium 
    metabolism in humans. To define the mechanism of age-
    associated intestinal calcium malabsorption...............   610,334
Bioavailability of Nutrition in the Elderly--HNRC, 1/11/95-1/
    10/00. Objective: To study the bioavailability of water 
    soluble vitamins in the aging population and determine the 
    effect of aging on vitamin requirements. To examine the 
    basis for the absorption utilization and excretion of 
    water soluble vitamins from food in the maturing and 
    elderly population. To assess vitamin status and its 
    relationships to drug intake and chronic diseases. To 
    study the impact of subclinical vitamin deficiencies on 
    the integrity and function of body physiology.............   901,017
Dietary Assessment of Rural Older Persons--HNRC, 2/1/96-12/31/
    00. Objective: (1) Test dietary assessment methodologies 
    (24-hr phone recalls and written food records) in a rural 
    population of older persons; (2) seek confirmation of 
    dietary findings using doubly-labeled water and indirect 
    calorimetric procedures; and (3) correlate dietary 
    findings with biomarkers of nutritional status (i.e. 
    measures of visceral protein, folate, B12, pyridoxine, 
    homocysteine and iron). Investigate nutrition knowledge 
    and practices (use of dietary supplements and reduced 
    calorie foods) of rural older persons.....................   186,857
Maintaining Bone Health in the Elderly--HNRC, 11/1/94-10/31/
    99. Objective: We will define the intake of calcium and 
    vitamin D above which skeletal mineral is maximally 
    spared. This requires an understanding of how hereditary, 
    demographic, endocrine, and physical factors (e.g. race, 
    sex, age, years since menopause, weight, and activity 
    level) affect the absorption and utilization of these 
    nutrients. Race differences in bone metabolism will be 
    sought in an effort to understand why blacks have less 
    osteoporosis.............................................. 1,100,401
Dietary Effects on Neurological Function--HNRC, 10/1/96-9/30/
    99. Objective: Identify selected food components that 
    affect neurological function and determine their 
    mechanisms of action......................................   633,579
Lipoproteins, Nutrition and Aging--HNRC, 1/11/95-1/10/00. 
    Objective: Our objectives are to develop optimal diets in 
    terms of fat and cholesterol content which are effective 
    in reducing LDL cholesterol, as well as favorably 
    affecting other heart disease risk factors, to study 
    nutritional regulation of plasma lipoproteins in animals, 
    and to study the interrelationships between aging, 
    nutrition, genetics, and to examine ways to prevent diet-
    induced atherosclerosis, lipoproteins, and heart disease 
    risk in populations....................................... 1,285,299
Effect of Nutrition and Aging on Eye Lens Proteins, Proteases, 
    and Cataract--HNRC, 1/11/95-1/10/00. Objective: One-half 
    of the eye lens cataract operations and savings of over $1 
    billion would be realized if we could delay cataract by 
    only 10 years. We are attempting to use enhancement of 
    dietary antioxidants, such as vitamin C, and other 
    nutrients, such as carotenoids or tocopherol, to delay 
    damage to lens-proteins and proteases and to maintain 
    visual functions in elderly populations. This should delay 
    cataract-like lesions in eye lens preparations, cataracts 
    in vivo, and age-related maculopathy......................   958,286
Epidemiology Applied to Problems of Aging and Nutrition--HNRC, 
    1/11/95-1/10/00. Objective: To define diet and nutritional 
    needs of older Americans; to advance methods in 
    nutritional epidemiology; and to develop indices which 
    reflect nutrient intake and which predict health or 
    disease outcomes in aging populations..................... 1,316,167
Gastrointestinal Function and Metabolism in Aging--HNRC, 11/1/
    94-10/31/99. Objective: To delineate the pathways of 
    intestinal carotene metabolism, and to determine if any 
    metabolic intermediate can transactivate nuclear 
    receptors; to determine if beta-carotene or cryptoxanthin 
    can prevent gastric cancer in the ferret/model; to 
    determine relative bioavailabilities of different 
    carotenoid compounds in the human. To determine niacin 
    requirements in elderly humans. To study the effect of 
    antioxidants in gut immunity in young and elderly adults.. 1,684,467
Nutrition, Aging and Immune Response--HNRC, 11/1/94-10/31/99. 
    Objective: Investigate the role of nutrients and their 
    interactions with other environmental factors in age-
    associated changes of the immune response, to reverse and/
    or delay the onset of these immunological changes by 
    dietary modification and to use the immune response as an 
    index in determining the specific dietary requirements for 
    older adults.............................................. 1,033,933
The Role of Aging in Energy and Substrate Regulation and Body 
    Composition--HNRC, 1/11/95-1/10/00. Objective: To examine 
    the extent and causes of changes in energy metabolism, 
    energy regulation and body composition with aging, and to 
    investigate optimal values for dietary energy intake and 
    expenditure in the aging population. In particular, to 
    determine the (1) roles of genetic inheritance and 
    environment factors in the determining body fat content, 
    (2) extent to which changes in body fat and protein with 
    aging are inevitable, and (3) molecular regulation of 
    proteins involved in fat metabolism in adipocytes......... 1,879,726

  COOPERATIVE STATE RESEARCH, EDUCATION, & EXTENSION SERVICE (CSREES)

                      Programs and Accomplishments

Title and purpose statement of each program or activity which affects 
        older Americans

    The Cooperative State Research, Education, and Extension 
Service (CSREES) in its mission advances research, extension, 
and higher education in the agricultural, environmental, and 
human sciences to benefit people, communities, and the Nation. 
As a major research and education arm of USDA, CSREES through 
its Land-Grant institution network has conducted educational 
and research programs that have benefited older persons, their 
adult children, and caregivers. The vision is for older persons 
to maintain and continue a quality lifestyle while aging; have 
a greater opportunity to be financially secure; experience 
positive human relations; and to have the knowledge necessary 
to access health care options.
    CSREES and its state partner institutions collaborate with 
a variety of national, state, and local organizations and 
agencies such as the American Association of Retired Persons, 
the National Association for Family and Community Education, 
the Administration on Aging, theArea Agencies on Aging, 
American Society on Aging, American gerontological Society, and State/
local departments of human/family services and health. This 
collaboration provides more well-coordinated programs for consumers and 
extends the resources of each collaborator to better serve the 
clientele.
    As a component of the CSREES National Initiative on 
Children, Youth, and Families at Risk, human and electronic 
networks are addressing targeted issues identified by 
professionals and user groups throughout the system. One of 
those networks, the National Network for Family Resiliency 
(NNFR), provides leadership for acquisition, development, and 
analysis of resources that foster family resiliency. Family 
resiliency is defined as the family's ability to cultivate 
strengths to positively meet the challenges of life. The NNFR 
brings together educators, researchers, agency personnel, 
families, advocates for families, and practitioners who share 
an interest in strengthening families that face multiple risks 
to their resiliency. Collaborators from CSREES and 42 Land-
Grant institutions share leadership for maximizing expertise, 
bringing research to bear on significant family issues, and 
guiding research based on evaluation of programs and practices. 
The network provides access to resources through multiple 
avenues including electronic media, training and education, and 
community development. Within the network, a special interest 
group has formed to address intergenerational issues. The work 
group is composed of 35 multi-state and multi-institutional 
members. Currently their focus is on ``grandparents raising 
grandchildren.'' An Internet web site is in development that 
will highlight resources for grandparents as primary caregivers 
and promotion of positive intergenerational relationships for 
educators and the general public.
    Through the Cooperative Extension System at Land-Grant 
institutions, administrators and specialists in such fields as 
aging/gerontology, housing, financial management, nutrition, 
health, human development, family life, community development, 
and the agricultural sciences; plus the county extension 
educators serving 3,150 counties have designed, implemented, 
and evaluated numerous programs in the field of aging/
gerontology. Below are highlights of these programs.

Brief description of accomplishments

                                georgia

    The University of Georgia Cooperative Extension Service 
produces a quarterly newsletter entitled, ``Senior Sense 
Putting Knowledge to Work for Older Georgians.'' The newsletter 
is distributed to 2,700 persons and is also available on the 
College of Family and Consumer Sciences web page, where it is 
accessed and read worldwide. Topics covered in the newsletters 
include health issues, financial management, and care giving 
tips.

                                 idaho

    In Idaho, the rapid growth in the numbers of elderly 
citizens has produced the need for more people trained with an 
understanding of aging development and a wide variety of 
approaches to serving the elderly. an Idaho extension/research 
specialist joined forces with a teaching/research colleague to 
develop an interdisciplinary minor in aging in the School of 
Family and Consumer Sciences at the University of Idaho. A team 
of professionals from academic programs in psychology, 
sociology, architecture, family and consumer sciences, 
communications, and a representative from the library developed 
a proposal and submitted it to the Idaho Board of Education. 
The program has been approved. A minor in Aging will be an 
important career complement to majors as the student develops 
expertise in a subject matter support area like aging.
    The University of Idaho Cooperative Extension Service (CES) 
and vocational education staff identified a need for additional 
trained home health aides by the year 2005. They discovered 
that 890 people were employed as aides in 1994 but by the year 
2005, 1244 would be needed to meet the demand. The CES and the 
Idaho Department of Vocational Education collaborated to plan a 
secondary and post-secondary program for Geriatric Home Care 
Aides. They compiled a curriculum to be used to train home care 
aides, piloted the program, established sites for student 
clinical experience and internships, and established a system 
for graduate placement. Upon completion of the program 
including the internship, the student will be eligible to take 
the examination for Certified Nurse Assistant certification. In 
Idaho, these positions command approximately $8.00 per hour and 
prepare people for a wide variety of career paths.

                                michigan

    Michigan State University Cooperative Extension Service is 
in a partnership with Blue Cross and Blue Shield of Michigan, 
Kirtland Community College, Michigan Rural Aging Institute, 
Office of Services to the Aging, Michigan Department of 
Community Health, and the Michigan Family Independence Agency 
to provide caregiver training that will prepare caregivers to 
improve the care provided to older persons. Annually 4,000 
caregivers of older adults are trained on such topics as 
financial and legal issues of older adults, dementia, 
understanding difficult behaviors, working with the frail 
elderly, and financial abuse of the elderly. The training is 
provided statewide using distance learning technology. 
Caregivers obtain certification for completion of the training.

                                missouri

    The Center on Aging Without Walls is a unique way to bring 
information on age-related issues to the University Outreach 
and Extension network, to the older adults of the State of 
Missouri, and the many caregivers who provide care for older 
citizens. The Center is a web site made possible through a 
partnership between the Center on Aging Studies at the 
University of Missouri-Kansas City and the University of 
Missouri Outreach and Extension. Care giving issues have been 
addressed in this initial phase of the web site. Topics covered 
include burdens and rewards, care giver resources, ethics, 
health concerns, family relations, and mental health. The web 
address is .

                                new york

    A Cornell University program that has young people and 
senior citizens interacting in ongoing activities has become a 
national model. A detailed handbook for group leaders who want 
to replicate the program is available nationally. Geared for 
children ages 9 to 13, but easily adaptable for other ages, 
Project EASE--Exploring Aging through Shared Experiences--is 
ideal for groups of scouts, 4-H groups, religious youth groups, 
after-school programs and other youth organizations. It can 
also be utilized in the classroom. The project is based on 
current research on the effectiveness of intergenerational 
programs to develop activities and projects that youth and 
senior citizens can share for mutually satisfying, meaningful 
and goal oriented interaction. Three years in development, 
Project EASE has been field tested and evaluated by more than 
70 4-H clubs in New York, involving about 600 participants. The 
youth and seniors may plan a joint community service project in 
which children and elders work together on an activity that the 
community will value; shared group activity projects that both 
groups enjoy but are not community service; and one-on-one 
programs, in which each youth is paired with a senior in 
activities such as arts and crafts, sharing oral histories, 
grooming pets, playing board games, etc. This project is 
supported in part with grants from the Charles Stewart Mott 
Foundation, the Public Welfare Foundation, and the College of 
Human Ecology at Cornell.
    In another innovative program, Cornell University 
researchers, Cooperative Extension Service faculty, and State/
local volunteers, and community agencies are addressing housing 
options for senior citizens. Twenty counties in New York have 
provided multi-faceted educational programs about community-
based housing options for the elderly for both professionals 
and the public. Professionals, housing and human service agency 
staff, municipal officials, and residents have new capacity to 
respond to the housing needs of an increasing older population. 
As a result of this project, they are knowledgeable about low-
cost community-based housing options such as shared housing, 
accessory apartments, and elder cottages. As a result of 
Cornell's research and extension outreach, state legislation 
was passed to provide capital funding for the creation of these 
new types of housing units. Municipal land-use and zoning 
regulations have been changed to permit the development of this 
housing in approximately 25 communities. Technical assistance 
is provided to attorneys and community planners about zoning 
and land-use regulations. There are now 12 shared living 
residences in communities throughout the State. A not-for-
profit organization has received $375,000 from the State to 
develop and operate an elder cottage lease program for low-
income elderly.

                             north carolina

    The North Carolina Aging with Gusto program has been 
adopted in more than half of North Carolina's 100 counties. 
This program is believed to be unique nationally because it 
focuses on the positive aspects of aging in how to achieve 
optimum financial, physical, and mental well-being in later 
years. Older adults learn how to prepare for and cope with 
problems related to finances, legal issues, health, care 
giving, housing and self-care. Recent figures suggest that the 
program has reached more than 35,000 people directly.
    North Carolina Cooperative Extension Service (CES) and the 
North Carolina Division of Aging have collaborated to pilot a 
new approach by distributing nutrition education materials with 
the Meals on Wheels food deliveries. This is one way to reach 
home-bound elderly that are especially difficult to reach and 
who are at greater risk of malnutrition and chronic disease. 
Sixteen different learn-at-home lessons have resulted in 
positive changes in the stages of change for fruit and 
vegetable consumption as evidenced in the pre- and post-test 
from 177 participants in five counties.
    To address another important issue for seniors, North 
Carolina CES and the North Carolina State Attorney General's 
Office worked together to educate older adults about consumer 
scams. In one county, 785 seniors were reached with 80 percent 
reporting they would be more cautious about telephone and mail 
solicitations and 77 percent stated that the program motivated 
them to change some of their consumer practices such as avoid 
sharing credit card information on the telephone, making 
financial donations to known charities and organizations, and 
checking on offers that are ``too good to be true.''

                                 Oregon

    Oregon State Cooperative Extension Service (CES) has a 
grant to study Behavioral Changes in Dementia Patients; 
Relationships to Caregiver Well-Being. Currently data is being 
collected on caregivers to Alzheimer's patients. The goal of 
the research is to expand the understanding of later life care 
giving to dementia patients and its consequences on caregivers' 
mental and physical health. Extension curricula will be 
developed as a result of this research.
    Dissemination of research-based information is the hallmark 
of the Cooperative Extension System. A network of professional 
educators provide such information in community-based settings. 
For example, Oregon State University is in a four university 
consortium to provide geriatric education with a special 
emphasis on reaching rural areas. A grant from the Geriatric 
Education Center Training Grant, Department of Health and Human 
Services, Public Health Services makes this program possible. A 
special focus is on reaching rural health care professionals to 
update and expand their knowledge of geriatric health issues. 
Oregon CES has disseminated 13 health guidelines for consumers 
relevant to older populations to 2,700 English and over 625 
Spanish consumers. In addition, Extension sponsored four 
teleconferences on a variety of women's health issues in later 
life with satellite downlinks in 27 sites throughout the State.

                              Pennsylvania

    Pennsylvania State University Cooperative Extension Service 
(CES) has a preventive health program for people over age 75 
and their family caregivers. The program provides independent 
living through lifestyle changes, nutrition, and regular 
exercise. Developed in rural Pennsylvania in Tioga, Bradford, 
Sullivan, and Susquehanna counties, this program reaches an 
extremely high-risk population. Ninety percent of the 
participants had annual household incomes below $20,000, and 84 
percent had only a high school or less education. High 
percentages had nutrition risk, low levels of physical 
activity, and losses in daily living activities. This program 
will be expanded statewide.
    Pennsylvania CES has also provided a program entitled 
``Medicare Managed Care: What Does It Mean for You?'' More than 
190 senior citizens and health care professionals in Centre 
County, Pennsylvania, participated. The six sessions were 
organized by Penn State's College of Agricultural Sciences and 
the Pennsylvania Office of Rural Health, in collaboration with 
Centre County CES, American Association of Retired Persons, 
Centre County Office of Aging Apprise Program, and the 
Brookline Village.
    In Allegheny County the Extension Service assisted 
residents of Carnegie Towers public housing in Pittsburgh to 
organize and take leadership for a fledgling community. 
Originally built for low income elderly citizens, a 
predominantly young population now occupies the project. Most 
of the households are headed by single, low-income females. 
Intergenerational conflicts existed between elderly residents 
and children, partly because the housing area did not include 
recreational facilities for youth. After Extension leader 
training workshops were completed, residents organized and 
elected a tenant council of eight adults and one youth. Since 
organizing, the council has sponsored a Community Day 
Celebration, supported by various fund raising activities. They 
have established a computer room with computer training 
classes, an outdoor play area, Extension educational programs 
related to 4-H youth development and nutrition, and a program 
highlighting guest speakers who provide useful and practical 
information.

                             South Carolina

    Clemson University Cooperative Extension Service (CES) 
specialist Katherine Carson has developed a program entitled, 
Learning, Innovation, Networking, and Celebration (LINC) 
nutrition program. LINC focuses on the elderly and preschool 
children, as well as pregnant and parenting adolescents. 
Changes in attitude, skills, knowledge, and behavior are 
documented. LINC has reached 2,407 elderly South Carolinians. 
LINC is a collaborative effort between the Clemson University 
CES, the South Carolina Department of Social Services, and the 
State Department of Health and Environmental Control Center for 
Health Promotion. South Carolina Governor David Beasley has 
recognized Carson for developing a nutrition program that 
reaches senior citizens by presenting her with the Governor's 
Health Promotion for Older South Carolinians Award. This 
program will be expanded with the assistance of a $759,000 
grant from USDA Food and Consumer Services. One phase of the 
expansion will include a Nutrition Education and Resource 
Center on the Internet for people who want information rapidly.

                    ECONOMIC RESEARCH SERVICE (ERS)

Title and purpose statement of each program or activity which affects 
        older Americans

    The ERS identifies research and social policy issues 
relevant to the elderly population from the perspective of 
rural development. Ongoing research looks at demographic and 
socioeconomic characteristics of the elderly by metro-nonmetro 
residence. Current research examines the poverty status of the 
elderly across the rural-urban continuum, and changes in the 
concentration of the older population by residential area, 
based on 1990 census data and Current Population Survey data. 
We actively participate in the Interagency Forum on Aging-
Related Statistics at the National Institutes of Health, and 
served on the Forum's work group on Population and Vital 
Statistics.

Brief description of accomplishments

    The following publications on the rural elderly have been 
prepared by our staff in 1995 and 1996:
          Beale, Calvin L., ``Nonmetro Population Rebound 
        Continues and Broadens,'' Rural Conditions and Trends, 
        Vol. 7, No. 3 (1996).
          Beale, Calvin L., and Kenneth M. Johnson, ``Nonmetro 
        Population Continues Post-1990 Rebound,'' Rural 
        Conditions and Trends, Vol. 6, No. 3 (Spring 1996).
          Fuguitt, Glenn V., Richard M. Gibson, Calvin L. 
        Beale, and Stephen J. Tordella, ``Recent Elderly 
        Population Change in Nonmetropolitan Areas,'' 
        unpublished paper (1996).
          Rogers, Carolyn C., ``Aging-Related Policy-Making; 
        Demographic Data Needs and Recommendations,'' a joint 
        report prepared as part of a working group of the 
        Interagency Forum on Aging-Related Statistics (February 
        1996).
         Rogers, Carolyn C., ``Health Status Transitions of the 
        Elderly, by Residential Location,'' Family Economics 
        Review, Vol. 8, No. 4 (Fall 1995).
          Rogers, Carolyn C., ``More Nonmetro Elderly Rate 
        Their Health as Fair to Poor'', Rural Development 
        Perspectives, Vol. 9, No. 3, June 1994 (released Fall 
        1995).

                    FOOD AND NUTRITION SERVICE (FNS)

Title and purpose statement of each program or activity which affects 
        older Americans

    The Food Stamp Program (FSP) provides monthly benefits to 
help low-income families and individuals purchase a more 
nutritious diet. In fiscal year 1996, $22 billion in food 
stamps were provided to a monthly average of 25 million 
persons.
    Households with elderly members accounted for approximately 
16 percent of the total food stamp caseload. However, since 
these households were smaller on average and had relatively 
higher net income, they received only 6 percent of all benefits 
issued although 7 percent of participants are elderly.

Brief description of accomplishments

    The FNS continues to work closely with the Social Security 
Administration (SSA) in order to meet the legislative 
objectives of joint application processing for Supplemental 
Security Income (SSI) households.
    In response to recommendations for joint processing 
improvements, FNS and SSA have stepped up efforts to ensure 
that SSI applicants are counseled on their potential 
eligibility to receive food stamps. Additionally, a joint 
Supplemental Security Income/Food Stamp processing 
demonstration--the South Carolina Combined Application Project 
(SCCAP)--was begun in the fall of 1995. Approximately 10,000 
SSI households in South Carolina receive food stamp benefits 
through this project. An independent evaluation of SCCAP is 
underway and is scheduled to be completed in 1999.

Title and purpose statement for each program or activity which affects 
        older Americans

    The Commodity Supplemental Food Program (CSFP) provides 
supplemental foods, in the form of commodities, and nutrition 
education to infants and children up to age 6, pregnant, 
postpartum or breast-feeding women, and the elderly (at least 
60 years of age) who have low incomes and reside in approved 
project areas.
    Service to the elderly began in 1982 with pilot projects. 
In 1985, legislation allowed the participation of older 
Americans outside the pilot sites if available resources exceed 
those needed to serve women, infants, and children. In fiscal 
year 1996, approximately $51 million was spent on the elderly 
component.

Brief description of accomplishments

    About 57 percent of total program spending provides 
supplemental food to approximately 219,000 elderly participants 
a month. Older Americans are served by 18 of 20 State agencies.

Title and purpose statement of each program or activity which affects 
        older Americans

    The Food Distribution Program on Indian Reservations 
(FDPIR) provides commodity packages to eligible households, 
including households with elderly persons, living on or near 
Indian reservations. Under this program, commodity assistance 
is provided in lieu of food stamps.

Brief description of accomplishments

    This program serves approximately 46,000 households with 
elderly participants per month.

Title and purpose statement of each program or activity which affects 
        older Americans

    The Child and Adult Care Food Program (CACFP) provides 
Federal funds to initiate, maintain, and expand nonprofit food 
service for children, the elderly, or impaired adults in 
nonresidential institutions which provide child or adult care. 
The program enables child and adult care institutions to 
integrate a nutritious food service with organized care 
services.
    The adult day care component permits adult day care centers 
to receive reimbursement of meals and supplements served to 
functionally impaired adults and to persons 60 years or older. 
An adult day care center is any public or private nonprofit 
organization or any proprietary Title XIX or Title XX center 
licensed or approved by Federal, State, or local authorities to 
provide nonresidential adult day care services to functionally 
impaired adults and persons 60 years or older. In fiscal year 
1996, $25 million was spent on the adult day care component.

Brief discussion of accomplishments

    The adult day care component of CACFP served approximately 
23 million meals and supplements to over 46,000 participants a 
day in fiscal year 1996.
    In 1993, the National Study of the Adult Component of CACFP 
was completed. Some of the major findings of the study include: 
overall, about 31 percent of all adult days care centers 
participate in CACFP; about 43 percent of centers eligible for 
the program participate. CACFP adult day care clients have low 
incomes; 84 percent have incomes less than 130 percent of 
poverty. Many participants consume more than one reimbursable 
meal daily; CACFP meals contribute just under 50 percent of a 
typical participant's total daily intake of most nutrients.

Title and purpose of statement of each program or activity which 
        affects older Americans

    The Emergency Food Assistance Program (TEFAP) provides 
nutrition assistance in the form of commodities to emergency 
feeding organizations for distribution to low-income households 
for household consumption or for use in soup kitchens.
    As estimated $16 million in commodities were distributed to 
households including an elderly person. (This figure is 
estimated using a 1986 survey indicating that about 38 percent 
of TEFAP households have members 60 years of age or older.)

Brief description of accomplishments

    About 38 percent of the households receiving commodities 
under this program had at least one elderly individual.

Title and purpose statement of each program or activity which affects 
        older Americans

    The Nutrition Program for the Elderly (NPE) provides cash 
and commodities to States for distribution to local 
organizations that prepare meals served to elderly persons in 
congregate settings or delivered to their homes. The program 
addresses dietary inadequacy and social isolation among older 
individuals. USDA currently supplements the Department of 
Health and Human Services' Administration on Aging with 
approximately $140 million worth of cash and commodities.

Brief description of accomplishments

    In fiscal years 1995 and 1996, over 245 million meals were 
reimbursed at a cost of almost $150 million. On an average day, 
approximately 925,000 meals were provided.

               FOOD SAFETY AND INSPECTION SERVICE (FSIS)

Title and purpose statement of each program or activity which affects 
        older Americans

    FSIS is continuing a consumer education campaign targeted 
to older Americans, one of several groups of people who face 
special risks from food-borne illness. The goal is to reduce 
the incidence of food-borne illness caused by consumer 
mishandling of food. Food-borne illness can lead to serious 
health problems and even death for someone who is chronically 
ill or has a weakened immune system. The elderly, with more 
than 35 million people in their ranks, are the largest group at 
risk and are increasing in number because of longer life 
expectancies.

Brief description of accomplishments

    FSIS continues to distribute food safety information to 
this group through direct mail of publications and liaison work 
with the Administration on Aging.

                          FOREST SERVICE (FS)

Title and purpose statement for each program or activity which affects 
        older Americans

    Senior Community Service Employment Program (SCSEP)--
Program Year 1996, July 1, 1996--June 30, 1997, the USDA Forest 
Service's Senior Community Service Employment Program (SCSEP) 
provided training and work experience in research, budget and 
finance, clerical/administrative, computer, forestry, building/
recreational maintenance, visitor interpreters, and 
communication.

Brief description of accomplishments

    The FS Senior Community Service Employment Program provided 
an opportunity for 5,055 participants, age 55 and above, to 
upgrade their work skills by receiving training and part-time 
employment opportunities while providing community service to 
the general public.

Title and purpose statement for each program or activity which affects 
        older Americans

    Volunteers in the National Forests--Volunteers continue to 
contribute to the management of the Nation's natural resources 
that are administered by the FS.

Brief description of accomplishments

    During fiscal year 1997, 112,384 participants assisted in 
the management of National Forest System lands including 13,392 
participants are 55 years and above. Volunteers participated in 
recreation, resource protection and management, cooperative/
international forestry, and research. Typical positions 
included campground hosts, administrative, recreation, 
wildlife, and fisheries assistants, fire lookouts, and 
information specialists.

                      RURAL HOUSING SERVICE (RHS)

Title and purpose statement of each program or activity which affects 
        older Americans

    Each person experiences the aging process differently. Some 
people are able to maintain lifelong health and independence, 
while others find that they face increasingly more difficult 
challenges to their abilities to take care of themselves. The 
difficulties that aging can bring are felt not only by elderly 
people but also by their children and grandchildren, making the 
question of how to address these difficulties one of 
intergenerational importance. Adding urgency to this question 
is the fact that America's elderly population is growing 
rapidly: the US Census Bureau forecasts a growth in the 
proportion of people ages 65 and older from 12.5 percent in 
1990 to 17.7 percent in 2020, a 41.6 percent increase.
    The Rural Housing Service (RHS) recognizes the importance 
of providing rural seniors with a wide range of living options. 
We invest heavily in programs that help elderly people live 
with as much independence and dignity as possible. These 
include the Section 504 loan and grant programs, which make 
vital home repairs for very low-income seniors; the Section 515 
Rural Rental Housing program, which provides affordable rental 
housing to seniors and people with disabilities (as well as 
families); the Section 521 Rental Assistance program, which 
makes rents in the Section 515 program affordable to tenants 
with very low incomes; and the Community Facilities program, 
which among other things finances a variety of elder care 
facilities. Following are descriptions of how each of these 
programs serves elderly people.
    Section 504 Loan and grant programs. The Section 504 loan 
and grant programs allow elderly people with very low to 
maintain their independence by remaining in their own homes. 
The loan program is available to any rural person with a very 
low income, but most program beneficiaries are elderly: incomes 
the average age of borrowers between 1991-1996 was 58, and the 
median age was 61, which means that half of all borrowers were 
61 or older. The grant program is available exclusively to very 
low-income rural seniors. Both programs provide funds to make 
such major repairs of renovations as removing electrical and 
fire hazards, replacing roofing, installing or improving water 
and waste-water disposal systems, and installing 
weatherization.

Brief description of accomplishments

    In 1996, the Section 504 loan program lent a total of $35.1 
million to 6,861 very low-income borrowers; in 1995, it lent 
$29.5 million to 6,116 borrowers. In 1996, the Section 504 
grant program provided $29.5 million to 6,179 very low-income 
elderly people; in 1995, it provide $27.8 million to 6,964 
people. The average income of Section 504 borrowers between 
1991-1996 was $11,652; the median income was $8,055. Average 
and median incomes for Section 504 grant recipients are not 
available but are likely very similar.

Title and purpose statement of each program or activity which affects 
        older Americans

    Section 515 Rural Rental Housing program and Section 521 
Rental Assistance program. Many relatively independent rural 
seniors find that they cannot keep up with the yard work and 
structural maintenance that home ownership requires. Others 
find that they need to live closer to vital services such as 
doctors, pharmacies, and grocery stores. For these elderly 
people, the Section 515 Rural Rental Housing program is an 
attractive option. In addition to being virtually maintenance-
free, our apartments for elderly and disabled people are 
equipped with special amenities such as strategically placed 
handrails and emergency call buttons or lights with which to 
signal for help. Many of them are wheelchair accessible. 
Managers of these complexes often arrange services such as 
transportation, grocery and pharmaceutical delivery, Meals on 
Wheels, health screenings, and entertainment, and they make 
sure that the community rooms stay in constant use. In 
addition, a small percentage of our Section 515 complexes offer 
congregate facilities in which seniors receive two cooked meals 
per day.

Brief description of accomplishments

    In 1997, we invested $45.4 million dollars (47 percent of 
the total funds we lent) to build 49 complexes and 
approximately 1,200 units for elderly people and people with 
disabilities. In addition, we lent $6.9 million to make repairs 
to 47 existing complexes. The previous figures are not 
available for 1995 or 1996. In our existing portfolio of 
approximately 18,000 complexes, 6,765 complexes (38 percent of 
the portfolio) serve elderly or disabled people. Another 375 
complexes (2 percent) serve ``mixed'' tenant populations of 
both families and elderly people. You and apply these same 
percentages to 1995 and 1996--the portfolio did not grow much 
and it's safe to assume that the percentage did not change. In 
1995 (the last year in which we conducted a complete nationwide 
tenant survey), 41 percent of our tenants were elderly people, 
and a majority of these were women. The average tenant adjusted 
income was $7,280.
    1995 letter from then 82-year-old Betty C. McAfee of 
Belfast, Maine. Before moving (to Section 515 rural rental 
housing) I lived alone in a 2-room cabin (with) no foundation, 
no plumbing and (which was) heated by a small wood-burning 
stove. I had a long walk to the rural mail box over a rough 
dirt lane. If this (Section 515) complex did not exist, I would 
still be living there. Many other low-income elderly people in 
Maine are living under these conditions, or worse.
    To make Section 515 housing available to tenants who cannot 
afford market rents, RHS provides assistance through its 
separately appropriated Section 521 Rental Assistance program, 
which brings tenants' rent down to 30 percent of their adjusted 
incomes and makes up the difference to the landlords. In 1996, 
RHS provided more than $540 million worth of Rental Assistance 
to approximately 47 percent of Section 515 households, while in 
1995 it provided $523 million. While we lack demographic 
information on beneficiaries of Rental Assistance, it is safe 
to assume that at least 25 percent of the beneficiaries are 
seniors and that in 1996 seniors received approximately $135 
million in RHS Rental Assistance while in 1995 they received 
approximately $131 million.

Title and purpose of each program or activity which affects older 
        Americans

    Community Facilities Loan and Grant Program. Through our 
Community Facilities loan and grant program, we finance a range 
of service centers for elderly people, including nursing homes, 
boarding care facilities and assisted care, adult day care, and 
a few intergenerational care facilities which serve both 
elderly people and children at the same time.

Brief description of accomplishments

    From its inception in 1974 to the end of 1996, the 
Community Facilities program has made 535 loans and guarantees 
worth $547 million facilities that directly benefit seniors. In 
1996, the Community Facilities program invested $44.4 million--
17 percent of its total funding for the year--to either build 
or make improvements to 32 senior facilities. In 1995, the 
program invested $32.4 million--14 percent of its funding--in 
27 seniors facilities. In addition, the program invested 
heavily in hospitals, clinics, and emergency services, which 
benefit people in every generation.

                     ITEM 2--DEPARTMENT OF COMMERCE

                              ----------                              


                      ORGANIZATION OF THIS REPORT

    This report provides short descriptions and listings of 
products that contain demographic and socioeconomic information 
on the elderly population, 65 years of age and older, here and 
abroad. All of the items included in this report were released 
by the Census Bureau during calendar years 1995 and 1996.
    The items mentioned are available to the public in a 
variety of formats including print, electronic databases, 
microcomputer diskettes, and CD-ROM. Many of these products can 
also be found on the Intent at the Census Bureau's web site 
(http://www.census.gov).
    1. Population, Housing, and International Reports.--Three 
of the Census Bureau's major reports series (Current Population 
Reports, Current Housing Reports, International Population 
Reports) are important sources of demographic information on a 
wide variety of population-related topics. This includes 
information on the United States' elderly population, ranging 
from their numbers in the total population, to their income, 
health insurance coverage, need for assistance with daily 
living tasks, and housing situation. Additionally, data on 
elderly around the world, including such facts as the 
decreasing age of death among Russian adults, are also found in 
this series of reports.
    Much of the data used in Current Population Reports are 
derived from the Current Population Survey (CPS) and the Survey 
of Income and Program Participation (SIPP). The Current Housing 
Report series presents housing data primarily from the American 
Housing Survey, a biennial national survey of approximately 
55,000 housing units. The International Population Report 
series includes demographic and socioeconomic data reported by 
various national statistical offices, such as the National 
Institute on Aging (NIA), agencies of the United Nations (UN), 
and the Organization for Economic Cooperation and Development.
    Additionally, the Census Bureau's population projection 
program and Special Studies Report series also contained 
information about the future estimated size of the elderly 
population and information pertaining to statistical methods, 
concepts, and specialized data.
    2. Decennial Products.--A large number of printed reports, 
computer tape files, CD-ROMs, and summary tape files are 
produced every ten years after each decennial census. Included 
in this is information (total numbers and characteristics) on 
people 65 years of age and older.
    3. Database on Aging/National Institute on Aging 
Products.--This database provides a summary of analytical 
studies and other ongoing international aging projects. Reports 
are based on compilations of data obtained from individual 
country statistical offices, various international 
organizations, and estimates and projections prepared at the 
Census Bureau. This work is funded by the NIA.
    4. Federal Interagency Forum on Aging-Related Statistics 
Summary.--The Forum, for which the Census Bureau is one of the 
lead agencies, encourages cooperation, analysis, and 
dissemination of data pertaining to the older population. A 
summary of the activities of the Forum lists a number of aging-
related statistics.
    5. Other Products

           I. POPULATION, HOUSING, AND INTERNATIONAL REPORTS

                               Population

Series P-20 (Population Characteristics):
    Regularly recurring reports in this series contain data from 
      the CPS on geographical mobility, fertility, school 
      enrollment, educational attainment, marital status and 
      living arrangements, households and families, the Black and 
      Asian and Pacific Islander populations, persons of Hispanic 
      origin, voter registration and participation, and various 
      other topics for the general population as well as the 
      elderly population 65 years of age and older.
    The Black Population in the United States; March 1994 and 1993   480
    Geographical Mobility: March 1992 to March 1993...............   481
    Household and Family Characteristics: March 1994..............   483
    Marital Status and Living Arrangements: March 1994............   484
    Geographical Mobility: March 1993 to March 1994...............   485
    The Foreign-Born Population: 1994.............................   486
    Household and Family Characteristics: March 1995..............   488
    Educational Attainment in the United States: March 1995.......   489
    Marital Status and Living Arrangements: March 1995............   491
Series P-23 (Special Studies):
    Information pertaining to methods, concepts, or specialized 
      data is furnished in these publications. The reports in this 
      series contain data on mobility rates, home ownership rates, 
      and Hispanic population for the general population and the 
      older population. The report Sixty-Five Plus in the United 
      States focuses on analyses of demographic, social, and 
      economic trends among the older population. It is a revision 
      of a 1993 report. It expands the use of 1990 census data, 
      incorporates updated national and state population 
      projections, and utilizes new survey data and analytical 
      findings from Federal agencies and numerous researchers in 
      the aging studies field.
    How We're Changing: Demographic State of the Nation; 1995.....   188
    Population Profile of the United States: 1995.................   189
    Sixty-Five Plus in the United States..........................   190
    How We're Changing: Demographic State of the Nation: 1996.....   191
Series P-25 (Population Estimates and Projections):
    This series includes monthly estimates of the total U.S. 
      population; annual midyear estimates of the U.S. population 
      by age, sex, race, and Hispanic origin; state estimates by 
      age and sex; and projections for the United States and 
      states. This series also includes estimates of housing units 
      and households for states.
    National and State Population Estimates: 1990 to 1994.........  1127
    Projections of the Number of Households and Families in the 
      United States: 1995 to 2010.................................  1129
    Population Projections of the United States by Age, Sex, Race, 
      and Hispanic Origin 1995 to 2050............................  1130
    Population Projections for States by Age, Sex, Race, and 
      Hispanic Origin: 1995 to 2025...............................  1131
Series PPL (Population Paper Listings):
    This series of reports contains estimates of population and 
      projections of the population by age, sex, race, and origin. 
      Other topics appear as well, some of which address issues 
      related to aging.
    Hispanic Tabulations from the Current Population Survey: March 
      1994........................................................    26
    The Foreign-Born Population: 1994.............................    31
    The Asian and Pacific Islander Population: March 1994.........    32
    Child Care Costs and Arrangements: Fall 1993..................    34
    U.S. Population Estimates by Age, Sex, Race, and Hispanic 
      origin: 1990 to 1995........................................    41
    Population of States by Broad Age Group and Sex: 1990 and 1995    44
    The Black Population in the United States: March 1995.........    45
    Household and Family Characteristics: March 1995..............    46
    Population Projections for States by Age, Sex, Race, and 
      Hispanic Origin: 1995 to 2025...............................    47
    Educational Attainment in the United States: March 1995.......    48
    Marital Status and Living Arrangements: March 1995............    52
Technical Working Paper Series:
    This series contains papers of a technical nature that have 
      been written by staff of the Population Division of the 
      Census Bureau. Topics covered are varied. Evaluation of 
      population projections, estimates and 1990 census results, 
      examination of immigration issues, race and ethnic 
      considerations, and fertility patterns are some of those 
      topics.
    ``Estimation of the Annual Emigration of U.S. Born Persons by 
      Using Foreign Censuses and Selected Administrative Data: 
      Circa 1980,'' Edward W. Fernandez...........................    10
    ``Fertility of American Men,'' Amara Bachu....................    14
    ``Comparisons of Selected Social and Economic Characteristics 
      Between Asians, Hawaiians, Pacific Islanders, and American 
      Indians (Including Alaskan Natives),'' Edward W. Fernandez..    15
Series SB/CENTER (Statistical Briefs):
    These are succinct reports that are issued occasionally and 
      provide timely data on specific issues of public policy. 
      Presented in narrative style with charts, the reports 
      summarize data from economic and demographic censuses and 
      surveys. In December 1996, the Statistical Brief series 
      format was revised and became known as Census Briefs.
    Sixty-Five Plus in United States..............................  95-8
    How Much We Earn--Factors That Make a Difference.............. 95-17
    Women in the United States: A Profile......................\1\ 95-19
    Health Insurance Coverage--Who Had a Lapse Between 1991 and 
      1993?....................................................... 95-21
    The Nation's Asian and Pacific Islander Population--1994...... 95-24
    The Nation's Hispanic Population--1994........................ 95-25
    What We're Worth--Asset Ownership of Households: 1993......... 95-26
    Getting a Helping Hand--Long-Term Participants in Assistance 
      Programs.................................................... 95-27
    Warmer, Older, More Diverse...................................  96-1
    Election '96--Counting the American Electorate................  96-2
Series PE (Population Electronic):
    This series comprises microcomputer diskettes or computer 
      tapes covering a variety of topics in the population field. 
      The information on the diskettes is, for the most part, 
      available in printed format.
    The Asian and Pacific Islander Population: March 1994.........    25
    Population Estimates for States, Counties, MCDs and 
      Incorporated Places: April 1, 1990 to July 1, 1994..........    28
    Estimates of the Population of States by Age, Sex, Race, and 
      Hispanic Origin: 1990 to 1992...............................    29
    Estimates of the Population of Counties by Age, Sex, and 
      Hispanic Origin: 1990 to 1992...............................    30
    The Foreign-Born Population: March 1994.......................    32
    Estimates of Population for Counties and Components of Change: 
      1990 to 1995................................................    34
    National Population Projections by Age, Sex, Race, and 
      Hispanic Origin: 1995 to 2050...............................    37
    Population Estimates of States by Single Years of Age and Sex 
      for States: 1990 to 1995....................................    38
    Population Estimates of States by Selected Age Groups and Sex: 
      1970 to 1979................................................    39
    Population Estimates of States by Single Years of Age and Sex: 
      1980 to 1989................................................     0
    Projections of the Number of Households and Families: 1995 to 
      2010........................................................    44
    Educational Attainment: March 1995............................    46
    Estimates of the Population of States by Age, Sex, Race, and 
      Hispanic Origin: 1990-1994..................................    47
    Estimates of the Population of Counties by Age, Sex, Race, and 
      Hispanic Origin: 1990-1994..................................    48
Series P-60 (Consumer Income):
    This series of reports presents data on the income, poverty, 
      and health insurance status of households, families, and 
      people in the United States.
    Income, Poverty, and Valuation of Noncash Benefits: 1994......   189
    Health Insurance Coverage: 1994...............................   190
    A Brief Look at Postwar U.S. Income Inequality................   191
    Money Income in the United States: 1995.......................   193
    Poverty in the United States: 1995............................   194
    Health Insurance Coverage: 1995...............................   195
Series P-70 (Household Economic Studies):
    These data are from the SIPP, a national survey conducted by 
      the Census Bureau. Its principal purpose is to provide 
      better estimates of the economic situation of families and 
      individuals. These reports include data on the elderly 
      population 65 years of age and older.
    Dynamics of Economic Well-Being: Health Insurance, 1991 to 
      1993........................................................    43
    The Effect of Health Insurance Coverage on Doctor and Hospital 
      Visits: 1990 to 1992........................................    44
    Dynamics of Economic Well-Being: Poverty: 1991 to 1993........    45
    Dynamics of Economic Well-Being: Program Participation, 1991 
      to 1993.....................................................    46
    Household Economic Studies, Asset Ownership of Households, 
      1993........................................................    47
    Dynamics of Economic Well-Being: Income, 1991 to 1992.........    49
    Beyond Poverty, Extended Measures of Well-Being, 1992.........\1\ 50
    Health Insurance, 1992 to 1993. Who Loses Coverage and for How 
      Long?.......................................................    54
    Poverty, 1992-1993. Who Stays Poor? Who Doesn't?..............    55
    Dynamics of Economic Well-Being: Labor Force, 1992 to 1993....    57
    Program Participation, 1992-1993. Who Gets Assistance?........    58
    Americans with Disabilities: 1994-1995........................    61

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                                Housing

Series H121 (Housing Characteristics):
    These reports present data from the American Housing Survey. 
      Some characteristics shown in these reports include 
      socioeconomic status of household, physical condition of the 
      housing unit, and affordability of housing in relation to 
      income.
    Current Housing Report: American Housing Survey, A Quality 
      Profile.....................................................  95-1
    Current Housing Reports: Our Nation's Housing in 1993.........  95-2
Series H-150 (Housing Vacancy):
    This book presents data on apartments; single-family homes; 
      vacant housing units; age, sex, and race of householders; 
      income; housing and neighborhood quality; housing costs; 
      equipment and fuels; and size of housing units. The book 
      also presents data on home-owner's repairs and mortgages, 
      rent control, rent subsidies, previous unit of recent mover, 
      and reasons for moving. A wall chart accompanies this 
      product.
    American Housing Survey of the United States in 1993..........    93
Series H-151 (Supplements to the American Housing Survey):
    This series provides additional information on occupied 
      housing units. Family type, household and financial 
      characteristics, and housing quality is included. 
      Demographic information is available, including a separate 
      discussion and data on the elderly.
    Supplement to the American Housing Survey for the United 
      States in 1993..............................................    93
    American Housing Survey: Components of Inventory Change: 1980 
      to 1991, United States and Regions..........................  91-2
Series H-170 (American Housing Survey, Selected Metro Areas):
    This book presents data for selected metropolitan statistical 
      areas for the same characteristics shown above in Series H-
      150. Eleven metro areas per year are produced on a 4-year 
      rotation for a total of 44 metro areas.
    American Housing Survey for Selected Metropolitan Statistical 
      Areas, 1994.................................................    94

                             International

Series P-95 (International Population Reports):
    The reports in this series contain demographic and 
      socioeconomic data on the older population as estimated or 
      projected by the Census Bureau or published by various 
      statistical offices, several agencies of the UN, and the 
      Organization for Economic Cooperation and Development. Older 
      Workers, Retirement and Pensions: A Comparative 
      International Chart Book provides an overview of underlying 
      demographic and socioeconomic trends as it relates to the 
      elderly. Graphical presentations of comparable statistics on 
      the status of the world's older population are also 
      included. This work is supported by the Office of the 
      Demography on Aging, NIA.
    Older Workers, Retirement and Pensions: A Comparative 
      International Chart Book....................................  95-2
Series PPT/IB (International Briefs):
    This series of summaries covers a variety of topics, some of 
      which relate to aging. Many of the reports present basic 
      demographic data on a number of countries. The series is now 
      known as International Briefs.
    Population Trends: Tanzania 1995 (PPT)........................ 92-10
    Population Trends: Philippines 1996 (PPT)..................\2\ 92-11
    Old Age Security Reform in China..............................  95-1
    Population Trends: Ghana 1996.................................  96-1
    World Population at a Glance: 1996 and Beyond.................  96-3
Series WP (World Profiles):
    This series provides comprehensive demographic information for 
      all countries and regions of the world. The information is 
      maintained in a database and is regularly updated. In 
      addition, each edition of the series focuses on a specific 
      topic of interest related to the world's population.
    World Population Profile: 1996................................    96
Series WID (Women in Development):
    This new series contains information on the world's women, 
      including elderly women. Demographic, educational, 
      employment, and political participation data are included.
    Women in Poland...............................................     5
Series SP (Staff Papers):
    A variety of economic and demographic studies are included in 
      this series of papers, some of which concern issues related 
      to the elderly population.
    Pension Reform in china: Implications for Labor Markets.......    83

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                         II. DECENNIAL PRODUCTS

                           1. Printed Reports

Series CPH-L (Population and Housing Data):
    These listings give statistics for states, counties, and 
      places, some of which contain information on the elderly 
      population.
    Social and Economic Characteristics of Selected Language 
      Groups for U.S. and States: 1990............................   194
Series CP:
    This report presents social, economic, and housing census data 
      on the Black population. It shows data on age in nine 
      categories, each category cross-classified by social, 
      economic and housing data.
    Characteristics of the Black Population.......................   3-6
Series CH:
    This report presents statistical summaries of data on 
      residences from the Residential Finance Survey conducted in 
      1991 as part of the 1990 census. The report covers owner 
      characteristics, one of which is age.
    Residential Finance...........................................   4-1

                      2. Computer Tape Files/CD-ROM

Series SSTF (Subject Summary Tape Files):
    This CD-ROM contains sample data from the 1990 Census of 
      Population and Housing on the older population. The file 
      contains statistics on persons 60 years of age and older and 
      on families with a householder 60 years of age and older.
    The Older Population of the United States.....................    19
    The compact disks contain sample data from the 1990 Census of 
      Population and Housing on the Black population of the United 
      States. There are cross-classifications by sex and detailed 
      age groups.
    Characteristics of the Black Population of the United States..    21

      III. DATABASE ON AGING/NATIONAL INSTITUTE ON AGING PRODUCTS

    The following papers are based on information contained in 
the Database on Aging and other related holdings. This work is 
carried out with the support of the NIA. The statistics shown 
in the wall chart are intended to highlight the present and 
future worldwide dimensions of aging and portray the diversity 
among nations.

``Aging Trends: Turkey,'' Journal of Cross-Cultural 
            Gerontology, Kevin Kinsella, ed. 1995. 
            ``Demographic Imperative,'' Kevin Kinsella, Cancer 
            Control, Vol. 2, No. 2, supplement, 1995.
``Aging and the Family: Present and Future Demographic 
            Issues,'' Kevin Kinsella. In Handbook on Aging and 
            the Family, Rosemary Blieszner and Victoria 
            Hilkevitch Bedford, eds. Greenwood Press, 1995.
Global Aging Into the 21st Century [Wall Chart], U.S. Bureau of 
            the Census, 1996.
``Demographic Aspects,'' Kevin Kinsella. In Epidemiology in Old 
            Age, Shah Ebrahim and Alex Kalache, eds, British 
            Medical Journal Publishing Group, 1996.

 IV. THE FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS SUMMARY

    The Census Bureau is one of the lead agencies in the 
Federal Interagency Forum on Aging-Related Statistics, a first-
of-its-kind effort. The Forum encourages cooperaton among 
Federal agencies in the development, collection, analysis, and 
dissemination of data pertaining to the older population. 
Through cooperation and coordinated approaches, the Forum 
extends the use of limited resources among agencies through 
joint problem solving, identification of data gaps, and 
improvement of the statistical information bases on the older 
population, which are used to set the priorities of the work of 
individual agencies. The work of the Forum is guided by the 
Office of Demography at the NIA, the Population Projections and 
Aging Studies Branches at the Census Bureau, and the Office of 
the Coordinator of Data on Aging, National Center for Health 
Statistics. Senior subject-matter specialists from the agencies 
are also involved in the activities of the Forum.
    The Forum goals include widening access to information on 
the older population, promoting communication between data 
producers and public policymakers, coordinating the development 
and use of statistical databases among relevant Federal 
agencies, identifying information gaps/data inconsistencies, 
and evaluating data quality. The work of the Forum facilitates 
the exchange of information about needs at the time new data 
are being developed or changes are being made in existing data 
systems. It also promotes communication between data producers 
and policymakers.
    As part of the Forum's work to improve access to data on 
the older population, the Census Bureau publishes a newsletter, 
Data Base News in Aging, which includes recent developments in 
databases of interest to researchers and others in the field of 
aging. Much of the information comes from Government-sponsored 
surveys and products. All Federal agencies are invited to 
contribute to the newsletter.
    The Census Bureau released Federal Forum Report 1991-93 
(May 1995). It reviews the activities of the Forum and its 
member agencies during 1991-1993. Various sections of the 
report summarize Forum work and accomplishments, cooperative 
efforts of members, publications by member agencies, and 
activities planned for the near future. An interagency 
telephone contact list of specialists on subjects related to 
aging is also included. During the 1991-1993 time period, the 
Forum oversaw activities of three working groups formed to 
address technical issues related to the elderly and disability, 
rural residence, and minority status. The working groups were 
composed of area-specific experts in the Federal Government who 
regularly sought advice from experts outside the Federal 
service. Four policy-related areas focused on were: health, 
retirement, population projections, and database development.

                           V. OTHER PRODUCTS

American Housing Survey

    Computer data tapes and CD-ROM are available for the 1995 
and 1996 survey efforts. The survey is designed to provide 
information on the housing situation in the United States. 
Information is available by age.

CPS and SIPP Surveys

    Data for both surveys are available in electronic media.

Statistical Abstract of the United States: 1995 and 1996

    As the national data book, this annual product contains an 
enormous collection of statistics on social and economic 
conditions in the United States. Selected international data 
are also included. The Abstract appears in both print and CD-
ROM versions.

International Database

    The International Database is a computerized data bank 
containing statistical tables of demographic and socioeconomic 
data for all countries of the world. Most of the data are 
obtained from censuses and surveys or from administrative 
records and are regularly updated. Selected information from 
the Database is highlighted in the International Briefs series 
of reports. In addition, Series WP reports, World Population 
Profiles, provide detailed data, which are taken from the 
Database.

                     ITEM 3--DEPARTMENT OF DEFENSE

    The Department of Defense has several ongoing initiatives 
in support of older Americans. They are detailed below.

                           Eldercare Support

    The Department's Family Centers reports that there is an 
increasing demand for information about eldercare. The Centers 
providing information workshops on eldercare issues describe 
them as well-attended and very useful. In addition to workshops 
and seminars on eldercare, the Centers access the national 1-
800 eldercare locator to assist family members with eldercare 
support services in other parts of the country. The Centers 
also have a number of useful pamphlets and handouts on 
eldercare that they provide to military family members seeking 
assistance for a particular eldercare issue.
    The Family Centers often work with the local Retired 
Affairs Offices across the country in sponsoring Retired 
Affairs Seminars that draw thousands of military retirees and 
their families. For these seminars, the staff brings in experts 
to discuss eldercare topics such as long-term care insurance, 
respite care, medical information, Social Security benefits, 
and eldercare legal issues. These seminars are an important 
vehicle to update the military retiree community on current 
eldercare issues.
    The Department of Defense recognizes that eldercare is a 
growing issue for military personnel and their family members 
and will continue to be responsive to the needs of the active 
duty and retired community in this regard.

                              Health Care

    The Department of Defense has nearly completed 
implementation of TRICARE, its new, regionally managed care 
program for members of the uniformed services and their 
families and survivors and retired members and their families. 
Retirees and their families are finding that this new program 
has increased their access to high-quality health care.
    TRICARE gives beneficiaries three choices for their health 
care delivery: TRICARE Standard, TRICARE Extra, and TRICARE 
Prime. All active-duty members will be enrolled in TRICARE 
Prime. Those CHAMPUS-eligible beneficiaries who elect not to 
enroll in TRICARE Prime and Medicare-eligible DoD beneficiaries 
will remain eligible for care in military medical facilities on 
a space-available basis. The three options are described below:
          TRICARE Standard--This option is the same as the 
        standard CHAMPUS program.
          TRICARE Extra--In the TRICARE Extra program, when a 
        CHAMPUS-eligible beneficiary uses a preferred network 
        provider, he or she receives an out-of-pocket discount 
        and usually does not have to file any claim forms. 
        CHAMPUS beneficiaries do not enroll in TRICARE Extra 
        but may participate in Extra on a case-by-case basis 
        just by using the network providers.
          TRICARE Prime--This voluntary enrollment option 
        offers patients the advantage of managed health care, 
        such as primary care management, assistance in making 
        specialty appointments, and having someone else to do 
        their claims filing. The Prime option offers the scope 
        of coverage available today under CHAMPUS, plus 
        additional preventive and primary care service. For 
        Prime enrollees, the new cost-sharing provisions do 
        away with the usual standard CHAMPUS cost sharing. Of 
        particular note, families of active duty personnel will 
        have no enrollment fees. CHAMPUS-eligible retirees who 
        enroll in Prime will pay an enrollment fee but will pay 
        only $11 per day for civilian inpatient care in 
        comparison to the $360 per day plus 25 percent of 
        professional fees charge faced by those retirees who 
        use TRICARE Standard. For Prime enrollees, there will 
        be copayments for care received from civilian 
        providers. These copayments are significantly less than 
        for the other two options. Enrollees in TRICARE Prime 
        obtain most of their care within the integrated 
        military and civilian network of TRICARE providers. 
        Additionally, under a new point of service option, 
        Prime enrollees may retain freedom of choice to use 
        non-network providers, but at significantly higher cost 
        sharing than in TRICARE Standard.
    Military beneficiaries over the age of 65 have 
traditionally relied on a combination of health care 
entitlements, including (1) an earned entitlement to Medicare, 
(2) space-available access to military hospitals, and (3) other 
benefits gained through non-military employment. With the post-
Cold War drawdown in the military, space in military facilities 
is less available. The Department of Defense is seeking ways to 
enhance its services to its over-65 beneficiaries; one approach 
will be tested in a three-year demonstration program authorized 
in the Balanced Budget Act of 1997. The Department will enroll 
military Medicare-eligible beneficiaries in ``TRICARE Senior 
Prime'' and receive capitated payments from the Medicare Trust 
Fund. The demonstration will be conducted at six sites and 
includes a requirement for Defense to maintain its budgeted 
level of effort for Medicare beneficiaries prior to receiving 
payments from Medicare. An additional component of the 
demonstration, Medicare Partners, will enable the Department to 
receive reimbursement from Medicare+Choice plans for inpatient 
and speciality services it renders to their military enrollees.

                     ITEM 4--DEPARTMENT OF DEFENSE

                        Postsecondary Education

    The Office of Postsecondary Education administers programs 
designed to encourage participation in higher education by 
providing support services and financial assistance to 
students.
    In fiscal year 1997, an estimated $43 billion was made 
available to students through the student financial assistance 
programs authorized by Title IV of the Higher Education Act of 
1965, as amended (HEA). There are no age restrictions for 
participation in the Title IV programs. For example, the Pell 
Grant Program, our largest grant program, made an estimated 3.6 
million awards in award year 1995-1996 (the most recent year 
for which this information is available). Approximately 6.2 
percent of the awardees were over age 40.
    The Federal TRIO programs fund postsecondary education 
outreach and student support services that encourage 
individuals from disadvantaged backgrounds to enter and 
complete college. Because age is not an eligibility criterion 
under most of these programs, data on the age of participants 
are not available.
    In addition to these programs, the Office of Postsecondary 
Education's Fund for the Improvement of Postsecondary Education 
(FIPSE) supports innovative projects, which include some 
projects designed to meet the needs of older Americans. In 
fiscal year 1997, FIPSE funded a Dissemination Project entitled 
Enhanced Intergenerational Learning at Eckerd College in St. 
Petersburg, Florida. In 1984 Eckard College initiated a program 
that drew on the experience and wisdom of high-achieving 
retired men and women who would serve as ``Living Library 
Resources'' to supplement other educational resources available 
to professors and students. Periodic evaluations by faculty and 
students attest to the educational value of this program, and 
today an Academy of Senior Professionals at Eckard College 
includes some 200 high achieving individuals who offer their 
knowledge, perspectives, and experiences to enhance the 
learning experience. FIPSE is supporting Eckerd College to 
serve as mentor to six adapter institutions throughout the 
country to determine if this program can be replicated on other 
campuses.
    Because jobs in today's workplace require an increasingly 
higher level of knowledge and skill, it is essential that all 
Americans have the opportunity for further education. The 
Administration is including two initiatives in its proposal to 
reauthorize the HEA that would encourage and assist working 
Americans improve their wages through lifelong learning.
          (1) Learning Anytime Anyplace Partnerships: This 
        program has been designed to encourage and enable 
        working Americans to increase their levels of knowledge 
        and skills by taking advantage of the increasing 
        opportunities for distance education. It calls for a 
        more innovative and comprehensive approach to lifelong 
        learning by supporting regional or national 
        partnerships among education institutions, state and 
        local governments, community agencies, software and 
        other technology developers, learning assessment 
        specialists, and private industry to expand non-
        traditional learning opportunities.
          (2) College Awareness Program: This program has been 
        designed to provide better information on preparing for 
        college and on the sources of financial aid to middle 
        and high school students, and to adults who want to 
        continue learning over their lifetimes. In addition to 
        serving middle and junior high school students, their 
        parents, teachers, and school counselors, this program 
        would also address the interests of the increasing 
        number of adults of all ages who want to go back to 
        college.

                            Adult Education

    In the past, the education of persons 60 years of age and 
older may not have been considered an educational priority in 
the United States. The 1990's may well be considered the decade 
of growth in educational gerontology. Demographics have tended 
to make this development inevitable. A recent study entitled, 
Profiles of the Adult Education Target Population--Information 
from the 1990 Census, prepared by the Center for Research in 
Education, Research Triangle Institute, indicates that more 
than 44 million adults, or nearly 27 percent of the adult 
population of the United States, have not completed a high 
school diploma or its equivalent. These individuals make up the 
adult education target population. Of the 44 million adults in 
the target population, more than 18 million or 41 percent are 
60 or more years old. Over 53 percent of the adults age 60 and 
over in the target population have completed fewer than 8 years 
of schooling. The high rate of under-education indicates a need 
for emphasizing effective basic skills and coping strategies in 
programs for older adults.
    The U.S. Department of Education is authorized under the 
Adult Education Act (AEA), Public Law 100-297, as amended by 
the National Literacy Act of 1991, (Public Law 102-73), to 
provide funds to the State and outlying areas for educational 
programs and related supporting services benefiting all 
segments of the eligible adult population. The central program 
established by the AEA is the State-administered Basic Grant 
Program. The AEA has also provided funds for programs of 
workplace and English Literacy. In addition, the 1991 
amendments established four new programs:
          State Literacy Resource Centers; National Workforce 
        Literacy Strategies; Functional Literacy for State and 
        Local Prisoners; and Life Skills Training for State and 
        Local Prisoners.
    The above-mentioned programs are administered by the Office 
of Vocational and Adult Education.
    In addition, amendments to the AEA State-administered Basic 
Grant Program include, in part:
          The authorization for competitive 2-year ``Gateway 
        Grants'' by States to public housing authorities for 
        literacy programs for housing residents.
          A requirement for States to develop a system of 
        indicators of program quality to be used to judge the 
        quality of State and local programs.
          An increase in the State set-aside under Section 353 
        for innovative demonstration projects and teacher 
        training from 10 to 15 percent, with two-thirds of that 
        amount to be used for training of professional 
        teachers, volunteers, and administrators.
          A requirement in allocating Federal funds to local 
        programs, that each State consider: past program 
        effectiveness (especially with respect to recruitment 
        retention and learning gains of program participants), 
        the degree of coordination with other community 
        literacy and social services, and the commitment to 
        serving those most in need of literacy services.
          A requirement that each State educational agency 
        receiving financial assistance under this program 
        provide assurance that local educational agencies, 
        public or private nonprofit agencies, community-based 
        organizations, correctional education agencies, 
        postsecondary education institutions, institutions 
        which serve educationally disadvantaged adults and any 
        other institution that has the ability to provide 
        literacy services to adults and families will be 
        provided direct and equitable access to all Federal 
        funds provided under this program.
          A requirement that States evaluate 20 percent of 
        grant recipients each year.
    Generally, the purpose of the AEA is to encourage the 
establishment of programs for adults lacking literacy skills 
who are 16 years of age and older or who are beyond the age of 
compulsory school attendance under State law. These programs 
will:
          (1) Enable adults to acquire the basic educational 
        skills necessary for literate functioning;
          (2) Provide sufficient basic education to enable 
        these adults to benefit from job training and 
        retraining and to obtain productive employment; and
          (3) Enable adults to continue their education to at 
        least high school completion.
    In Program Year 1992-93, 3.9 million adult learners were 
served through the AEA program nationwide. Of these learners, 
597,543 were 45 years of age or older.
    Many of the emerging workforce participants, including a 
large number of older adults, lack the basic literacy skills 
necessary to meet the increased demands of rapid change and new 
technology. Thus, employers will have to make training and 
retraining a priority in order to upgrade the labor force.
    The adult education program addresses the needs of older 
adults by emphasizing functional competency and grade level 
progression, from the lowest literacy level, to providing 
English as a second language instruction, through attaining the 
General Education Developmental Certificate. States operate 
special projects to expand programs and services for older 
persons through individualized instruction, use of print and 
audio-visual media, home-based instruction, and curricula 
relating basic educational skills to coping with daily problems 
in maintaining health, managing money, using community 
resources, understanding government, and participating in civic 
activities.
    Equally significant is the expanding delivery system, 
increased public awareness, as well as clearinghouses and 
satellite centers designed to overcome barriers to 
participation. Where needed, supportive services such as 
transportation are provided as are outreach activities adapting 
programs to the life situations and experiences of older 
persons. Individual learning preferences are recognized and 
assisted through the provision of information, guidance and 
study materials. To reach more people in the targeted age 
range, adult education programs often operate in conjunction 
with senior citizens centers, nutrition programs, nursing 
homes, and retirement and day care centers.
    Increased cooperation and collaboration among 
organizations, institutions and community groups are encouraged 
at the national, State and local levels. In addition, sharing 
of resources and services can help meet the literacy needs for 
older Americans.

                      U.S. DEPARTMENT OF EDUCATION

           Enforcement of the Age Discrimination Act of 1975

   I. Status of the Department of Education's Implementing Regulation

    The Department of Education's final regulation implementing 
the Age Discrimination Act of 1975 was published on July 27, 
1993. The effective date of implementation was August 26, 1993.
    The Department's regulation prohibiting age discrimination 
applies to all elementary and secondary schools, colleges and 
universities, public libraries, and vocational rehabilitation 
services. It covers age discrimination at these institutions 
except age discrimination in employment.
    The regulation describes the standards for determining age 
discrimination; the responsibilities of recipients; and 
procedures for enforcing the statute and regulation

               II. Age Discrimination Act Implementation

    The Department of Education's (ED) Office for Civil Rights 
(OCR) is responsible for enforcement of the Age Discrimination 
Act of 1975 (the Age Act), as it relates to discrimination on 
the basis of age in federally funded education programs or 
activities. The Age Act applies to discrimination at all age 
levels. The Age Act contains certain exceptions that permit, 
under limited circumstances, continued use of age distinctions 
or factors other than age that may have a disproportionate 
effect on the basis of age.
    The Age Act excludes from its coverage most employment 
practices, except in federally funded public service employment 
programs under the Job Training Partnership Act (formerly the 
Comprehensive Employment and Training Act of 1974). The Equal 
Employment Opportunity Commission (EEOC) has jurisdiction under 
the Age Discrimination in Employment Act of 1967 to investigate 
complaints of employment discrimination on the basis of age. 
OCR generally refers employment complaints alleging age 
discrimination to the appropriate EEOC regional office. 
However, the EEOC does not have jurisdiction over cases 
alleging age discrimination against persons under 40 years of 
age. Rather than referring such a case to the EEOC, OCR would 
close the complaint and inform the complainant that neither OCR 
nor the EEOC has jurisdiction over the complaint.
    The Department of Health and Human Services (HHS) has 
published a general government-wide regulation on age 
discrimination. Each agency that provides Federal financial 
assistance must publish a final agency-specific regulation. On 
July 27, 1993, ED published in the Federal Register its final 
regulation implementing the Age Act.
    Under ED's final regulation, OCR forwards complaints 
alleging age discrimination to the Federal Mediation and 
Conciliation Service (FMCS) for attempted resolution through 
mediation. FMCS has 60 days after a complaint is filed with OCR 
in which to mediate the age-only complaints or the age portion 
of multiple-based complaints. ED's regulation provides that 
mediation ends if: (1) 60 days elapse from the time the 
complaint is received; (2) prior to the end of the 60-day 
period, an agreement is reached; or (3) prior to the end of the 
60-day period, the mediator determines that agreement cannot be 
reached.
    If FMCS is successful in mediating an age-only complaint or 
the age portion of a multiple-based complaint within 60 days, 
OCR closes the case or the age portion of the complaint. If 
mediation is unsuccessful, the mediator returns the unresolved 
complaint to ED for further case processing.
    OCR helps its working relationship with FMCS by designating 
enforcement office contact persons who coordinate directly with 
FMCS. OCR also accepts verbal or facsimile referrals from FMCS 
after unsuccessful attempts at mediation, and may grant FMCS 
extensions of up to 10 days beyond the 60 day mediation period 
on a case-by-case basis when mediated agreements appear to be 
forthcoming.
    The other statutes which OCR enforces are Title VI of the 
Civil Rights Act of 1964, which prohibits discrimination on the 
basis of race, color, and national origin; Title IX of the 
Education Amendments of 1972, which prohibits discrimination on 
the basis of sex; and Section 504 of the Rehabilitation Act of 
1973 and Title II of the Americans with Disabilities Act of 
1990, which prohibit discrimination on the basis of disability.

                            iii. Complaints

(a) Receipts

    OCR received 203 age complaints in FY 1997. Of these 55 
were age-only complaints and 148 were multiple bases 
complaints. As shown on Table 1, 125 of the 203 receipts were 
processed in OCR and 78 were referred to other Federal agencies 
for processing. The most frequently cited issues in the FY 1997 
age-only complaint receipts were ``academic retention/
dismissal,'' ``harassment,'' and ``retaliation.'' These were 
also the most frequently cited issues contained in multiple-
based complaint receipts.

Table 1: Fiscal year 1997 age-based complaint receipts

Processed by OCR..................................................   125
Processed by FMCS.................................................    27
Processed by EEOC.................................................    42
Processed by Other Federal Agencies...............................     9
                        -----------------------------------------------------------------
                        ________________________________________________
      Total receipts..............................................   203

(b) Resolutions

    During FY 1997, OCR resolved 210 age-based complaints, 
including 62 age-only complaints and 148 multiple-based age 
complaints. The resolution of the complaints are shown in Table 
2.

Table 2: Fiscal year 1997 age-based complaint resolutions

Inappropriate for OCR Action......................................   146
OCR Facilitated Change............................................    17
No Change Required................................................    47
                        -----------------------------------------------------------------
                        ________________________________________________
      Total resolutions...........................................   210
            Inappropriate for OCR action
    Of the 210 complaint resolutions, 146 were resolved because 
they were ``Inappropriate for OCR Action.'' These would include 
a resolution achieved by (1) referral of a complaint to another 
federal agency; (2) lack of jurisdiction over recipient or 
allegation contained in a complaint; (3) complaint was not 
filed in a timely manner; (4) complaint did not contain 
sufficient information necessary to proceed; (5) complaint 
contained similar allegations repeatedly determined by OCR to 
be factually or legally insubstantial or were addressed in a 
recently closed OCR complaint or compliance review; (6) subject 
of a complaint was foreclosed by previous decisions by federal 
courts, Secretary of Education, Civil Rights Reviewing 
Authority, or OCR; (7) there was pending litigation raising the 
same allegations contained in a complaint; (8) allegations were 
being investigated by another federal or state agency or 
through a recipient's internal grievance procedures; (9) OCR 
treated complaint as a compliance review; (10) allegation(s) 
was moot and there were no class implications; (11) complaint 
could not be investigated because of death of the complainant 
or injured party or their refusal to cooperate; and (12) 
complaint was investigated by another agency and the resolution 
met OCR standards.
            OCR facilitated change
    There were 17 complaints resolved because ``OCR Facilitated 
Change.'' These would include a resolution achieved by (1) a 
recipient resolving the allegations contained in the complaint; 
(2) OCR facilitating resolution between the recipient and 
complainant through Early Complaint Resolution; (3) OCR 
negotiating a corrective agreement resolving a complainant's 
allegations; and (4) settlement achieved after OCR issued a 
letter of findings.
            No change required
    In 47 complaints, there was ``No Change Required.'' These 
would include a resolution achieved by (1) complainant 
withdrawing his or her complaint without benefit to the 
complainant; (2) OCR determining insufficient factual basis in 
support of complainant's allegations; (3) OCR determining 
insufficient evidence to support a finding of a violation; and 
(4) OCR issuing a no violation letter of findings.

       Older Americans in the 1992 National Adult Literacy Survey

    While for some the importance of literacy derives from the 
increasing needs of business for literate workers, for others 
the importance of literacy derives from the benefits of 
literacy skills in the everyday life of adults. Older adults 
need literacy skills to live independently, to manage their 
health care and personal finances, and more generally, to 
function in society. Knowing the nature and extent of the 
literacy problem in the United States today is an important 
early step in devising effective policies to ensure adequate 
literacy skills for every adult and to meet our Nation's 
literacy goal.
    The Adult Education Amendments of 1988 required the U.S. 
Department of Education to report to Congress on the definition 
of literacy and to estimate the extent of adult literacy in the 
nation. In response, the National Center for Education 
Statistics (NCES) and the Office of Vocational and Adult 
Education (OVAE) cooperated to fund a statistical survey that 
would assess the literacy of the adult population of the United 
States.
    The 1992 National Adult Literacy Survey adopted this 
definition of literacy: Using printed and written information 
to function in society, to achieve one's goals, and to develop 
one's knowledge and potential. This definition of literacy 
differed from previous definitions in that it rejected such 
arbitrary standards as signing one's name, completing some 
number of years to school, or scoring above some grade level on 
a test of reading achievement. Further, this definition went 
beyond simply decoding words, to include varied uses of many 
forms of information.
    The 1992 results are based on personal interviews with 
nearly 27,000 adults aged 16 and older--the oldest was 99 years 
old--conducted in their homes using an area-based sample of 
households located in 200 counties throughout the United 
States. The sample includes 1,100 inmates of federal and state 
prisons and 1,000 extra residents in each of thirteen states 
that paid for sample supplements (CA, FL, IL, IN, IA, LA, KY, 
NJ, NY, OH, PA, TX, and WA). The survey design provides 
nationally representative results, and for participating 
states, state-representative results. The literacy of adults 
was assessed using simulations of three kinds of literacy tasks 
adults would ordinarily encounter in daily life (prose 
literacy, document literacy, and quantitative literacy). 
Besides completing literacy tasks, participants answered 
questions about their demographic characteristics, educational 
backgrounds, reading practices, labor market experiences, and 
more.
    Results from the survey have so far been published in Adult 
Literacy in America, in Behind Prison Walls, and in Literacy of 
Older Adults in America, each available from NCES. State-
specific reports are available from the thirteen state offices 
of adult literacy. Further reports are planned in several 
areas: schooling and literacy; literacy in language minority 
communities; literacy in the labor force; and reading habits, 
voting and literacy.
    Results for older adults were briefly covered in the 
initial survey report, and more extensively presented in a 
special report on literacy among older adults. The report 
included chapters on the distribution of literacy skills among 
older adults, comparisons of older adults with adults under 60 
years old, economic issues, civic participation, and literacy 
and patterns of mass media usage. The results of the survey 
provide a factual basis for policy decisions affecting literacy 
programs designed for older adults or for adults with limited 
literacy skills.
    The results of the 1992 National Adult Literacy Survey 
indicate that low levels of prose, document, and quantitative 
literacy are a significant problem for a large portion of the 
older adult population in the United States.
          Seventy-one percent of adults age 60 and older, or 
        approximately 29 million individuals nationwide, 
        demonstrated limited prose skills, performing in the 
        two lowest levels of prose literacy defined in the 
        survey. This is a larger proportion than the 41 percent 
        of adults under age 60 performing in two lowest levels.
          Slightly more than two-thirds, or 68 percent, of 
        older adults appeared to have difficulty finding and 
        processing quantitative information in printed 
        materials. In population terms, this means that an 
        estimated 28 million persons age 60 and older across 
        the nation have limited quantitative literacy skills. 
        This is a larger proportion than the 42 percent of 
        adults under age 60 performing in the two lowest 
        levels.
          The problem appears to be even more acute in the area 
        of document literacy, which is associated with 
        activities such as filling out forms, reading and 
        following directions, and using schedules. Four of 
        every five older adults (80 percent) demonstrated 
        limited document literacy skills in the assessment, 
        performing in the two lowest proficiency levels 
        defined. This is a larger proportion than the 44 
        percent of adults under age 60 performing in the two 
        lowest levels.
          Notable differences in performance are also evident 
        within the older adult population. Those age 60 to 69 
        performed those age 70 to 79, who in turn outperformed 
        those age 80 and older.
          Many older individuals with limited literacy skills 
        do not seem to behave that they have a problem. The 
        percentage of older Americans who said they perform 
        various types of literacy activities ``very well'' was 
        about the same as that of persons under 60. In 
        actuality, however, the average literacy proficiencies 
        of older adults were much lower than those of younger 
        persons.
          Many older adults reported receiving help from family 
        or friends with literacy tasks such as filling out 
        forms, writing notes and letters, doing math, and 
        processing written information.
    The cost of including older adults in the survey and 
preparing a report on older adults came to about $870,000, or 
about 8 percent of the federal share of the total costs of the 
survey.

 National Institute on Disability and Rehabilitation Research Projects 
                          That Relate to Aging

    The National Institute on Disability and Rehabilitation 
Research (NIDRR) authorized by Title II of the Rehabilitation 
Act, has specific responsibilities for promoting and 
coordinating research that relates directly to the 
rehabilitation of disabled persons. Grants and contracts are 
made to public and private agencies and organizations, 
including institutions of higher education, Indian Tribes and 
tribal organizations, for the purpose of planning and 
conducting research, demonstrations, and related activities 
which focus directly on the development of methods, procedures 
and devices which assist in the provision of rehabilitation 
services.
    The Institute is also responsible for facilitating the 
dissemination of information concerning developments in 
rehabilitation procedures, methods, and devices to 
rehabilitation professionals and to disabled persons to assist 
them in leading more independent lives.
    The Institute accomplishes its mission through the 
following programs:
          Rehabilitation Research and Training Centers.
          Rehabilitation Engineering and Research Centers.
          Research and Demonstration Projects.
          Field-Initiated Projects.
          Dissemination and Utilization Projects.
          Career Development Projects which include: 
        Fellowships; Research Training.
          State Technology Assistance.
          Small Business Innovative Research.

              Rehabilitation research and training centers

    The primary goals of these centers are: (1) To conduct 
research targeted toward the production of new knowledge which 
will improve rehabilitation methodology and service delivery 
systems, alleviate or stabilize disabling conditions, and 
promote maximum social and economic independence; (2) To 
institute related teaching and training programs to disseminate 
and promote the utilization of research findings, thereby 
reducing the usual long intervening delay between the discovery 
of new knowledge and its wide application in practice.
    The three major activities, research, training, and 
service, are expected to be mutually supportive. Specifically, 
this synergy calls for research ideas to derive from service 
delivery problems, for research findings to be disseminated via 
training, and for new professionals to be attracted to research 
and service via training.

1. Rehabilitation Research and Training Center on Aging with a 
        Disability, Rancho Los Amigos Medical Center, Downey, CA

    This Center is a collaborative effort between the Rancho 
Los Amigos Medical Center, the University of Southern 
California School of Medicine and the Andrus Gerontology 
Center.
    In ever-increasing numbers, people who acquired a 
disability in an earlier part of life are now reaching an 
advanced age. As they age, many people are developing new 
medical, functional, social, and psychological problems. Little 
is known about the etiology, consequences, or treatment of 
these problems. This RRTC investigates several of these 
problems and conducts training to help reduce the impact of 
these changes. Studies are under way that examine: (1) the 
natural course of aging in people with postpolio, cerebral 
palsy, rheumatoid arthritis, and stroke; (2) the physiological 
demands of mobility; (3) the benefit of training aging 
individuals in the use of in-home personal assistants; (4) the 
feasibility of using residential care facilities for older 
people who have a disability; (5) ways to maintain employment 
through the use of job modification; and (6) how federal and 
state policies need to change to facilitate access to assistive 
devices as people age. The training programs focus on medical, 
allied health, and social service personnel at all levels, from 
student through practicing professional. The project provides 
information to consumers through an extensive system of 
linkages to consumer organizations and publication in consumer-
oriented periodicals.

2. Rehabilitation Research and Training Center on Aging With Mental 
        Retardation, The University of Illinois at Chicago, University 
        of Illinois UAP, 1640 West Roosevelt Road, Chicago, IL

    The Illinois University Affiliated Program in Developmental 
Disabilities (UAP), University of Illinois at Chicago (UIC) has 
established the Rehabilitation Research and Training Center on 
Aging with Mental Retardation. This center will build on the 
strength and continuity of the current RRTC on Aging and 
Developmental Disabilities and bring to it the resources of a 
major university with considerable commitment, applied research 
and clinical expertise in the fields of mental retardation and 
aging. The RRTC will build on the continuity of their 
collaboration over the last five years. The RRTC has developed 
a greater understanding of aging and developmental disabilities 
by capitalizing on large data bases, longitudinal 
investigations, and multi-state sites.
    Investigators from other universities in Minnesota, Ohio, 
Indiana, Wisconsin, Kentucky, and Hawaii contribute strengths 
to the RRTC in epidemiological and clinical research on age-
related changes, family future planning, self-determination, 
cultural diversity, and public policy analysis. In addition, 
the RRTC has assembled a network of national, state, and local 
organizations to ensure that the RRTC programs are widely 
disseminated, have practical applications, and will stimulate 
public policy change.
    The research is applied and examines individuals' lives in 
their natural settings. It is focused on outcomes in the lives 
of older persons with mental retardation. The main goal of the 
research is to translate the knowledge gained into practice 
through broad-based training; technical assistance; and 
dissemination to persons with mental retardation, their 
families,service providers, administrators and policy makers, 
advocacy groups, and the general community.

3. Rehabilitation Research and Training Center on Enhancing Quality of 
        Life of Stroke Survivors, Rehabilitation Institute Research 
        Corporation, 345 East Superior, Chicago, IL

    The project is developing methods to prevent the occurrence 
and minimize the consequences of comorbid medical conditions to 
stroke patients during rehabilitation. It is evaluating methods 
of assessing, classifying, monitoring, and predicting some of 
the clinical functioning. It is evaluating the efficacy of 
procedures used to enhance social and community functioning, 
and studying the natural history of impairment, disability, 
quality of life after stroke, and the associations between each 
of those characteristics. The Center trains rehabilitation 
professionals in new approaches, innovations, and the 
specialized principles and practices of rehabilitative care of 
individuals with stroke. The RRTC also develops and studies the 
effects of an ideal method or providing education to caregivers 
of stroke patients, disseminates information of new 
developments in the areas of stroke care and research to 
individuals with stroke and their families. Ultimately, through 
all these methods, the project enhances the quality of life of 
individuals with stroke.

4. Rehabilitation Research and Training Center on Aging with Spinal 
        Cord Injury, Craig Hospital and the University of Colorado 
        Health Science Center, Research Department, 3425 South 
        Clarkson, Englewood, CO

    This project is conducting longitudinal research to 
document the natural consequences of aging with spinal cord 
injury (SCI) and to identify risk factors associated with 
increasing medical complications, functional limitations, 
psychosocial concerns, and escalating costs. The project is 
developing, implementing, and evaluating lifetime management 
and intervention strategies that minimize, delay, or enable 
people with SCI to cope better with the problems of aging with 
SCI. The project disseminates management and intervention 
strategies and insights gained from longitudinal research and 
implementation strategies.

5. Rehabilitation Research and Training Center Aging with Spinal Cord 
        Injury and Aging, Rancho Los Amigos Medical Center, Downey, CA

    The Rehabilitation Research and Training Center (RRTC) on 
Aging with Spinal Cord Injury (SCI) is devoted to undertaking 
the unique problems people with spinal cord injury experience 
as they age. Topics of research include: the course of aging 
with SCI, cardiovascular and pulmonary aspects of aging with 
SCI, bone loss across ethnic groups, activities of daily 
living, employment, depression, and formal and informal care 
systems for people aging with SCI. The RRTC has several goals 
for education, training, dissemination, and utilization: to 
train current and future health, allied health, and 
rehabilitation professionals about aging with SCI; to train and 
develop rehabilitation research professionals in the area of 
aging with SCI; to have health and rehabilitation professionals 
adopt and use knowledge and treatment regimens developed in the 
RRTC; to disseminate information about aging with SCI to people 
with SCI and their families; and to train graduate students and 
medical students in advanced knowledge and techniques from 
studies about aging with SCI. Training and dissemination occurs 
through advanced and continuing education courses, local and 
national conferences, workshops, and the Internet.

6. Disability Statistics Rehabilitation Research and Training Center, 
        University of California, San Francisco, Institute for Health 
        and Aging, Box 0646, Laurel Heights, San Francisco, CA 94143-
        0646

    The center conducts research in the demography and 
epidemiology fields of disability and disability policy, 
including costs, employment statistics, health and long-term 
care statistics, statistical indicators, and congregate living 
statistics. Statistical information is disseminated through 
published statistical reports and abstracts, journals, 
professional presentations, and a publications mailing list. 
Training activities and resources (such as a predoctoral 
program) disseminate scientific methods, procedures, and 
results to both new and established researchers, policymakers, 
and other consumers, and assist them in interpreting 
statistical information. A National Disability Statistics and 
Policy Forum is conducted periodically to establish a national 
dialogue between people with disabilities and representative 
organizations, researchers, and policymakers.

7. Rehabilitation Research and Training Center in Secondary 
        Complications in Spinal Cord Injury, University of Alabama/
        Birmingham, Department of Physical Medicine and Rehabilitation, 
        Birmingham, AL

    The primary goal of this RRTC is to conduct high-quality 
basic and applied research that improves existing methods of 
care for people with spinal cord injury (SCI). Current RRTC 
research areas include urology, pressure ulcer healing, 
spasticity, psychosocial adjustment, obstetric/gynecologic 
complications, costs of rehospitalization, and pulmonary 
complications. The Center's training component disseminates 
RRTC research results to rehabilitation professionals and 
consumers with SCI in useable formats such as videotapes, 
audiotapes, written materials, journal articles, and short-term 
training programs.

8. Research and Training Center on Personal Assistance Services (PAS), 
        World Institute on Disability, Oakland, CA

    Activities of this project are designed to further the 
understanding that Personal Assistance Service (PAS) systems 
design can better promote the economic self-sufficiency 
independent living, and full integration of people of all ages 
and disabilities into society. This is accomplished by 
exploring the models, policies, access to, and outcomes of 
personal assistance services, through (1) gathering 
perspectives of consumers, program administrators, policy 
makers, and personal assistants using a State of the States 
survey and database development; (2) a policy study on the 
impact of devolution; (3) a cost-effectiveness study; (4) a 
study of workplace PAS; and (5) a study on the supply of 
qualified PAS

9. Rehabilitation Research and Training Center on Blindness and Low 
        Vision, Mississippi State University

    The Center is conducting a series of research, training and 
dissemination projects using a multidisciplinary strategy. The 
project works to investigate and document employment status, 
identify barriers to employment and techniques and reasonable 
accommodations to overcome these barriers, identify training 
needs in the Business Enterprise Program, and develop and 
deliver training programs. Training and dissemination 
activities include an information and referral center, national 
conferences, in-service training and technical assistance, 
advanced training for practitioners, advanced training in 
research, and publication and distribution of a variety of 
materials in accessible media.

10. Missouri Arthritis Rehabilitation Research and Training Center, 
        University of Missouri/Columbia, Multipurpose Arthritis Center

    This project conducts a coordinated and advanced 
multidisciplinary program of arthritis rehabilitation research 
in a clinical service setting. Disciplinary education and 
training, including graduate training to physicians, health 
professionals, and other potential rehabilitation personnel is 
provided to help them provide effective rehabilitation services 
to people with arthritis and musculoskeletal diseases. Research 
projects include: (1) medication and physical therapy treatment 
of primary fibromyalgia syndrome, (2) early interventions to 
prevent disability in juvenile arthritis, (3) arthritis patient 
disability and physical fitness levels before and after 
conditioning exercise intervention, (4) a computerized exercise 
performance support system for osteoarthritis rehabilitation, 
(5) depression management as a strategy for reducing disability 
in rheumatoid arthritis, and (6) a rehabilitation research 
database in musculoskeletal disease. The Center enhances 
education programs on arthritis care and rehabilitation and 
builds awareness through Missouri's Regional Arthritis Center.

11. Rehabilitation Research and Training Center on Rural Rehabilitation 
        Services, University of Montana, Missoula, MT

    This RRTC has the following objectives for improving rural 
rehabilitation services: (1) identify the employment and 
vocational rehabilitation service needs of people with 
disabilities in rural areas; (2) develop interventions to 
improve employment outcomes; (3) demonstrate rural 
entrepreneurial models; (4) identify issues in rural 
independent living and develop interventions to improve 
transportation, health care, housing, and accessibility; (5) 
coordinate with rural independent living centers to identify or 
design and test alternative models of delivery of rural 
rehabilitation services; (6) provide training in rural 
rehabilitation research and practice; (7) conduct an annual 
meeting on the state-of-the-art in rural employment and 
disability; (8) conduct an annual interactive conference on 
disability issues in rural America; and (9) disseminate 
research findings to rehabilitation service-delivery personnel.

            Rehabilitation Engineering and Research Centers

    This program provides support for the Rehabilitation 
Engineering Research Centers to conduct programs of advanced 
research of an engineering or technical nature in order to 
develop and test new engineering solutions to problems of 
disability. Each center is affiliated with a rehabilitation 
setting, which provides an environment for cooperative research 
and the transfer of rehabilitation technologies into 
rehabilitation practice. The centers' additional 
responsibilities include developing systems for the exchange of 
technical and engineering information and improving the 
distribution of technological devices and equipment to 
individuals with disabilities.

1. Rehabilitation Engineering Center: Assistance Technology and 
        Environmental Interventions for Older Persons with 
        Disabilities, New York University at Buffalo, Buffalo, NY

    Activities of the RERC focus on research, assistance device 
development, education, and information relating to assistive 
technology for older people in the home and beyond the home. 
The projects of the RERC fall into four major areas: (1) 
research: ten projects address assessments in the home and 
community, issues for minority elders, highly problematic 
device categories, clinical trials of effectiveness, and 
managed care work issues; (2) device development: six projects, 
including devices addressing automobiles, obesity, mobility, 
balance, stairs, and pubic seating; (3) education: four 
projects, addressing professional students, graduate students, 
and rehabilitation and aging service professionals; and (4) 
information: ten project areas, including a ``Helpful 
Products'' series of videos and booklets, training manuals, 
resources for hotel and motel guests, product information, 
national conferences, newsletter inserts, a World Wide Web 
site, monograph series, resource sourcebook, and a resource 
phone line.

2. Rehabilitation Engineering Research Center in Augmentative 
        Communication, Applied Science and Engineering Laboratories, 
        University of Delaware, Wilmington, DE 19899

    Research in the field of augmentative communication is 
divided into five themes: language, speech, interface, systems, 
and information. Specific projects within each of the first 
four themes are designed to enhance accessibility of 
communication for individuals with communication disabilities. 
The project serves as a dissemination service for information 
on augmentative and alternative communication. All projects are 
designed so that technology transfer can be implemented as 
quickly and effectively as possible so that people with 
disabilities can pursue their educational, vocational, and 
independent living goals.

3. Rehabilitation Engineering Research Center on Universal 
        Telecommunications Access, Gallaudet University, Washington, DC

    This RERC conducts research and engineering activities with 
the overall goal of improving the accessibility of emerging 
telecommunications systems and products. The Center moves 
forward the available telecommunications knowledge base for 
access issues confronting people with all types of 
disabilities. The program areas of the RERC are: (1) systems 
engineering analysis; (2)telecommunications access research, 
focusing on needs assessment and development of design solutions; (3) 
universal design specification and review, aimed at developers of 
products and services; (4) development of telecommunications standards 
that include accessible features; (5) telecommunications applications 
for increased independence; and (6) knowledge utilization and 
dissemination. The RERC combines expertise from Gallaudet University, 
the Trace Research and Development Center at the University of 
Wisconsin, and the World Institute on Disability (WID) with the 
expertise of the telecommunications industry through active involvement 
of two noted telecommunications consultants, Richard P. Brandt and Dale 
Hatfield.

4. Rehabilitation Engineering Research Center on Prosthetics and 
        Orthotics, Northwestern University, Rehabilitation Engineering 
        Research Program and Prosthetics Research Laboratory, Chicago, 
        IL

    Activities of the Center include material science studies 
and applications in limb prosthesis and orthoses, biomechanical 
characterizations and functional design of prostheses and 
orthoses, state-of-the-art studies that delineate the status of 
the field and help organize and plan for the advancement of 
prosthetics and orthotics, and an information and education 
resource service.

5. Rehabilitation Engineering Research Center on Accessible and 
        Universal Design and Housing, North Carolina State University 
        School of Design, Center for Universal Design, Raleigh, NC

    The RERC's mission is to: (1) conduct research in 
documenting problems in housing for people with disabilities; 
(2) identify or generate and test solutions to documented 
problems; (3) demonstrate the general utility of solutions to 
documented problems; and (4) conduct training to address skill 
acquisition, knowledge diffusion, and general awareness of 
issues related to housing for people with disabilities. The 
Center also provides information and referral services to 
address identified needs through development and dissemination 
of publications and other information materials and referral to 
other organizations and agencies who can assist with specific 
information requests. The Center's audience includes designers, 
contractors, developers, financial providers, consumer 
advocates, and users of residential environments.

6. Vermont Rehabilitation Engineering Research Center for Low Back 
        Pain, University of Vermont, Vermont Back Research Center, 
        Burlington, VT

    The Vermont RERC improves the employability of people with 
back disorders and back disability by developing and testing 
assistive technology. Engineering projects include studies of 
lifting, posture, seating, vibration, and materials handling in 
connection with back pain and disability. Applied research 
projects include the testing of rehabilitation engineering 
products, evaluation of exercise programs, and the development 
of a statewide model program to hasten return to work of people 
with back injuries. The Center's Information Services Division 
provides toll-free assistance in locating research and 
rehabilitation programs, as well as bibliographic searching and 
fact finding. The Center also maintains an Electronic 
Discussion Group: BACKS-L (Send subscription request to 
[email protected]; body of message should read: subscribe 
backs-l __your name__).

7. Rehabilitation Engineering Research Center on Adaptive Computers and 
        Information Systems, University of Wisconsin/Madison, Trace 
        Research and Development Center, Waisman Center, Madison, WI

    This REFC is focused on maximizing the number of people 
with disabilities who are able to access directly and use the 
next generation of electronic devices and information systems, 
either with or preferably without assistive technologies. This 
RERC makes all electronic products and systems more accessible 
to individuals with the full range of type, degree, and 
combination of disability, such as low vision, blindness, 
hearing impairment, deafness, deaf-blindness, physical 
disabilities, cognitive disabilities, and language 
disabilities. Electronic products include dedicated products 
(e.g., phones, faxes, ATMs, etc.), general purpose computers 
and operating systems, and access to information systems (e.g., 
Internet, television set-top boxes, kiosks, electronic 
directories, and information phones). The work of the Center 
includes basic research into more flexible interfaces; 
extensions to human interfaces of existing computers, operating 
systems, and information systems; development of design 
guidelines; development of prototype systems and simulations; 
support of industry; development of consumer awareness and 
education materials; training programs; and joint service-
delivery programs.

                    Field Initiated Research Program

    This program is designed to encourage eligible applicants 
to originate valuable ideas for research and demonstrations, 
development, or knowledge dissemination activities in areas 
which represent their own interests, yet are directly related 
to the rehabilitation of people with disabilities.

1. Aging and Adjustment after Spinal Cord Injury: A 20-Year 
        Longitudinal Study, Shepherd Center for Spinal Injuries, Inc., 
        2020 Peachtree Road, NW, Atlanta, GA

    This fourth study phase will be the most extensive follow-
up yet performed and will use an expanded version of the same 
questionnaire that was used in each of the three previous 
follow-ups (1973, 1984, 1988). Three types of research designs 
will be used for data analysis including: (1) traditional 
longitudinal analysis of 1973 to 1992 data from the original 
participant sample; (2) cross-sequential analysis of the 
repeated measures data from 1984 to 1992 for samples one and 
two; and (3) time-sequential analysis of time-lagged data 
comparing the 1984 data for sample two with that of the new 
third sample.

2. Perceived Direction and Speech Intelligibility in Sensorineural, 
        Hearing Loss and Blindness, Smith-Kettlewell Eye Research 
        Institute, 2232 Webster Street, San Francisco, CA 94115

    Experiencing great difficulty processing speech in noise is 
one of the most characteristic and devastating aspects of the 
sensory deficit of hearing loss in aging (presbycusis). 
Conventional binaural hearing aids do not satisfactorily solve 
this problem. The digital four-channel hearing aid is 
innovative because of its use of temporal as well as intensity 
parameters, unlike any other binaural hearing aid on the 
market. Since sensorineural hearing loss (SNHL) and blindness 
may interfere with localization of potentially hazardous 
situations, a second goal of this project is to explore and 
develop the parameters for improved localization as well as 
improved speech intelligibility (comprehension) utilizing a new 
rational. According to our model, a binaural balance of 
interaural intensity difference (IID) and interaural time delay 
(ITD) across frequencies is required to restore optimum speech 
intelligibility and localization ability by eliminating or 
lessening exaggerated dominance consequent of asymmetric 
hearing loss. Variations of either or both IID and ITD at 
different frequencies would impair directional localization 
and, therefore, intelligibility of one speaker in a group. This 
new hearing aid may permit people with SNHL and blindness, 
using acoustic cues, to locate and avoid a hazard. To 
accomplish this, the project will adjust the physical inputs of 
intensity and interaural delay time across frequencies to 
compensate for perceptual imbalances (i.e., deviations from IID 
and ITD) and to test for the consequent restoration of optimal 
localization and speech intelligibility inherent in normally 
balanced auditory systems.

3. Development of a Novel PC-Based Test to Aid the Rehabilitation of 
        People with Macular Vision Loss, Smith-Kettlewell Eye Research 
        Institute, San Francisco, CA

    Patients with age-related macular degeneration (AMD) lose 
the ability to read and recognize faces on television. They 
must learn to perform these tasks using their less-detailed 
peripheral vision as a substitute. Research has shown that 
people with AMD can learn this, but a majority do so only with 
goal-directed instructions and training that must be based on 
each patient's individual vision status. For the purpose of 
this assessment, a new computerized test was developed at this 
laboratory on Amiga computers that are no longer commercially 
available. The overwhelmingly positive response to this new 
procedure warrants this special effort to transfer the test to 
the most common small computer, the IMB PC and its compatibles. 
The product of this research is an inexpensive and easy-to-run 
computerized test that can be performed within minutes in the 
eyecare specialist's office, without requiring special 
expertise and on widely available equipment. The results of the 
test can be used: (1) to help the eyecare specialist customize 
instructions and training procedures in order to keep the 
required adaptation time as short as possible, and (2) to help 
AMD patients understand the nature of their impairment.

4. Remote Signage Development to Address Current and Emerging Access 
        Problems for Blind Individuals, Smith-Kettlewell Eye Research 
        Institute, San Francisco, CA

    This project is developing new, practical enhancements of 
remote signage technology to solve a range of specific current 
and emerging accessibility problems faced by people who are 
blind and who have other print-reading disabilities. For blind 
users, access to any place or facility begins with the problem 
of knowing it is there; then the problem of finding it must be 
addressed. Specific solutions are being developed for safe 
usage of light-controlled pedestrian crossings, identification 
and onboard announcements of stops for buses, identifying route 
number and destination of oncoming buses, locating and 
accessing automated teller machines and other vending 
information terminals, and access to signage by people with 
cognitive impairments. These innovative solutions are being 
developed from the infrared Talking Signs (R) system of 
remotely readable signs for people who are blind that was 
developed by Smith-Kettlewell. This system is currently gaining 
increased acceptance as an aid to orientation and navigation 
for those who cannot read the print signage that fully sighted 
people take for granted in navigating and accessing the world.

5. Toward a Risk Adjustment Methodology for People with Disabilities, 
        Medlantic Research Institute, National Rehabilitation Hospital 
        Research Center, Washington, DC

    The principle goal of this knowledge dissemination project 
is to provide its primary audiences, health care policy-makers 
and payers, with key information to advance the development of 
a risk adjustment system for working- and retirement-age people 
with disabilities. Risk adjustment reduces the incentive for 
risk selection and promotes access to needed health services. 
To achieve this goal, the project assembles a panel of leading 
experts on risk adjustment and disability to guide the 
development of a consensus report that: (1) details the state 
of science in risk adjustment, (2) evaluates the 
appropriateness of health care outcome indicators for people 
with physical and mental disabilities, and (3) provides a set 
of recommendations for modifying and implementing risk 
adjustment methodologies that enhance access to health services 
for people with disabilities enrolled in public and private 
sector health plans.

6. Cash and Counseling Models for Americans with Disabilities, The 
        National Council on the Aging, Inc. (NCOA), Research and 
        Development Department, Washington, DC 20024

    In the ``cash and counseling'' model, consumers with 
disabilities control most elements of their service needs, 
normally through cash payments that allow them to purchase 
support services. Activities of this three-year study include: 
(1) continuing in-depth field research and ongoing monitoring 
of domestic and overseas programs that currently use cash and 
counseling or a similar model; (2) conducting two surveys of 
state administrators to identify existing cash and counseling 
programs, determined their level of knowledge and interest in 
employing cash and counseling approaches, and identify 
opportunities and barriers to program implementation, as well 
as technical assistance needs; (3) collaborating on the Cash-
and Counseling Demonstration and Evaluation Project at the 
University of Maryland Center on Aging funded by the Robert 
Wood Johnson Foundation and the U.S. Department of Health and 
Human Services; (4) providing information and technical 
assistance to state administrators and policy analysts 
interested in advancing cash and counselingapproaches, 
including the four states awarded cash and counseling demonstration and 
evaluation grants; (5) developing a series of analyses concerning the 
feasibility, design, and implementation issues of cash and counseling 
approaches; and (6) disseminating new knowledge to policy makers, 
administrators, and the aging and disability communities.

7. Aging; Spinal cord injuries; Ethnic groups; Women Physician Training 
        in the Major Health Issues of Women with Disabilities: Learning 
        to Act in Partnership, Health Resource Center for Women with 
        Disabilities, Rehabilitation Institute of Chicago, Chicago, IL

    Women with disabilities report that their health needs are 
often overlooked or poorly addressed by physicians, who 
evidence unfamiliarity with, and negative attitudes toward, 
people with disabilities. These subjective reports are 
corroborated by studies that suggest women with disabilities 
may find their health service options severely compromised when 
physicians lack information about their special needs and 
experience. This project designs and tests the efficacy of a 
training module that introduces medical students to the health 
issues of women with disabilities, in three phases: (1) fourth-
year medical students respond to a questionnaire to assess 
their deficiencies in knowledge regarding the health needs and 
experiences of women with disabilities, (2) a training module 
is developed incorporating a video, a corresponding in-person 
educational presentation led by women with disabilities, and a 
handbook of supplementary readings, (3) the efficacy of the 
module in improving attitudes and knowledge is tested in a 
pretest/post-test design with a control group. Women with a 
broad range of disabilities, ages, and ethnic/racial/cultural 
backgrounds are participating in all aspects of the project, 
from research direction through training development to 
dissemination of results. Consequently, the project represents 
a model of consumer-physician partnership that is endorsed by 
women health activists with disabilities.

8. Illinois Joint Training Initiative on Disability and Abuse: Advocacy 
        and Empowerment Through Knowledge Dissemination, University of 
        Illinois/Chicago, Institute on Disability and Human 
        Development, Chicago, IL

    This project provides information and skills to advocates, 
consumers, family members, service providers, and others to 
empower them to enforce the rights of adults with disabilities 
who have been abused or neglected. It is largely a training 
project, with the following objectives regarding abuse-neglect: 
(1) develop interactive consumer-responsive materials that 
train consumers, family members, and service providers to 
recognize incidents; (2) make the social and legal system 
respond to cases; (3) provide referral to resources available 
for victims; (4) conduct state-wide training using the 
materials; (5) provide each training participant with the 
opportunity to become a local trainer on these issues; and (6) 
provide technical assistance, materials, and resources to local 
trainers hosting training events.

9. Knowledge Dissemination for Vision Screeners, University of Kansas, 
        Institute for Life Span Studies, Parsons, KS

    This project is disseminating a CD-ROM to providers of 
vision screening and evaluation services, in order to increase 
the quantity and quality of vision services available 
nationally to infants, toddlers, preschoolers, and older people 
with disabilities. These populations are sometimes considered 
difficult to test, and as a consequence, often do not receive 
traditional vision screening services. The project addresses 
the training needs of a variety of personnel by providing an 
interactive CD-ROM program, modeled after the ``knowledge on 
demand'' technology used in industry, that can be readily 
delivered in a variety of settings. The program is providing a 
model for using CD-ROM to disseminate ``knowledge on demand.''

10. Secondary Conditions, Assistance, and Health-Related Access Among 
        Independently Living Adults with Major Disabling Conditions, 
        Massachusetts Health Research Institute, Boston, MA

    Participants in this study are affiliated with six 
Massachusetts independent living centers (ILCs). The cross-
disability sample includes people with a range of significant 
physical, mental, sensory, and developmental disabilities who 
require assistance with activities of daily living. Primary 
outcomes of interest are: (1) the frequency and severity of 
secondary conditions, including skin problems, seizures, 
chronic pain, spasms, falls, fatigue, respiratory tract 
infections, and urinary tract infections; and (2) reactions to 
medication, depression, anxiety, and injuries related to 
medical equipment. Mediating variables include: adequacy of 
personal assistance, assistive technology, access to health 
promotion and health care services, environmental barriers, 
transportation, employment, education, socioeconomic status, 
smoking, use of substances, and compliance with prescribed 
health care routines. The research study includes two annual 
cross-sectional surveys, each of 300 randomly-selected ILC 
consumers, to determine prevalence, distribution, frequency, 
and severity of secondary conditions. Focus groups of ILC 
consumers and others help interpret the data.

11. The Universal Bathroom, Research Foundation of State University of 
        New York, State University of New York (SUNY)/Buffalo, Amherst, 
        NY

    While the greatest potential benefactors of a universal 
bathroom are non-institutionalized people with disabilities who 
are living independently, the new bathroom's design will be 
created to be safe, accessible and usable by all people 
regardless of their age, sex, and disabling conditions. Its 
assumed modular, interchangeable components will include three 
primary units, for bathing/showering, toileting, and grooming. 
Since the bathroom of the user's choice can be custom built 
from a large range of component units, this will be a 
marketable, culturally responsive one with accepted layouts and 
levels of privacy. Additionally, the ``lifespan perspective'' 
of the bathroom's design will allow able-bodied care-providers 
such as parents of young children and those assisting older 
individuals to make layout changes and product alterations 
based on their current needs. Thus the bathroom's assistive 
qualities will reduce temporary dependence on others and 
increase safety by preventing accidents that lead to 
disability. It will empower independent users, dependent users, 
and care-providers equally--the young, the old, married 
couples, people with children, and families with ``live-in'' 
grandparents.

12. Pressure Ulcer Prevention by Interactive Learning, MetroHealth 
        Center for Rehabilitation, Spinal Cord Injury Unit, 2500 
        MetroHealth Drive, Cleveland, OH

    This project assembles a set of materials for teaching 
pressure ulcer prevention, uses text, diagrams, animations, 
sound, and video; links existing material where possible with 
new resources where necessary; and converts the materials to 
digital format. Teaching programs are then written to provide 
access through a personal computer in a variety of interactive 
sequences. These sequences are customized, not only during 
design but also by interaction during use, for users with 
different learning abilities and requirements. The initial 
target group is people with disabilities at risk of developing 
pressure ulcers. However, the technology is well suited for 
customization for other uses such as training for nurses and 
other health professionals. The project plans to make the 
materials available to larger audiences and is producing a CD-
ROM containing a set of teaching programs for institutions to 
train people with disabilities on how to prevent pressure 
ulcers. The project expects to distribute the CD-ROM nationally 
and to make selected portions available on computer networks.

13. Further Development of a Lower Limb Prosthetic Socket CAD System 
        Based on Ultrasound Measurement Wright State University, 
        Department of Biomedical and Human Factors Engineering, Dayton, 
        OH

    This project has four objectives: (1) to improve the 
performance of an ultrasound-based computer-aided socket design 
(CASD) system developed by this research team; (2) to enhance 
the utility of the system by developing and testing new devices 
and procedures for limb measurements using the system; (3) to 
conduct a clinical trial to evaluate the usefulness of the 
ultrasound-based CASD system in improving daily prosthetic 
socket design/fitting; and (4) to investigate applications of 
ultrasound measurements in finite-element modeling for the 
study of limb-prosthesis interaction.

14. Women's Personal Assistance Services (PAS) Abuse Research Project, 
        Oregon Health Sciences University/Portland, Child Development 
        and Rehabilitation Center, Portland, OR

    The purpose of the project is to increase the 
identification, assessment, and response to abuse by formal and 
informal personal assistance service (PAS) providers of women 
with physical and physical and cognitive disabilities living 
independently in the community. The aims of the project: (1) 
develop culturally sensitive screening approaches to identify 
PAS abuse, (2) develop a culturally appropriate PAS abuse 
assessment protocol, and (3) develop culturally appropriate 
response strategies to prevent and manage PAS abuse. Culturally 
diverse participants assist in the development of these three 
aims. The study includes three phases, beginning with a focus 
group study of culturally diverse women with physical and 
cognitive disabilities. Phase II involves the use of findings 
from Phase I to develop and disseminate a survey of 260 
culturally diverse females with disabilities drawn from four 
national organizations. Phase III involves the development and 
field testing of the effectiveness of the screening, 
assessment, and support protocols, the final product being a 
comprehensive package of PAS abuse prevention materials. The 
project plans to disseminate these materials on a national 
basis.

15. A Pilot Study for the Clinical Evaluation of Pressure-Relieving 
        Seat Cushions for Elderly Stroke Patients, University of 
        Pittsburgh, Pittsburgh, PA

    This project designs and tests the feasibility of a 
randomized clinical trial to determine the efficacy of 
pressure-relieving seat cushions for immobile, elderly stroke 
patients. Older people with disabilities who are immobile and, 
thus, spend their time either in bed or seated, are at risk for 
developing pressure ulcers. Commercial seat cushions intended 
to reduce the risk of sitting-induced pressure ulcers are 
available. The elderly population, however, is not customarily 
evaluated for seating and positioning needs or provided with 
the benefits of this technology. Reimbursement is not 
available, due in part to the fact that the effectiveness of 
this intervention has not been sufficiently demonstrated for 
this high-risk population, and these services and technology 
are not available. If these cushions are a successful 
intervention for increased comfort, improved quality of life, 
and pressure ulcer incidence rate reduction, the project plans 
to disseminate the findings and provide justification for third 
party funding. If successful, the project plans to increase the 
availability of seating and positioning services and products 
to this deserving population.

16. Access Solutions, Vermont Center for Independent Living, 
        Montpelier, VT

    The Vermont Center for Independent Living, in conjunction 
with Bike Track, Inc., is developing and testing a new system 
for building modular, reusable, and highly durable access ramps 
using a newly developed, non-toxic material made from recycled 
plastic. The ramp system's performance, material, and elements 
are field tested in a variety of setting and in a wide range of 
climatic conditions. The results of this project are: (1) the 
development, testing, and evaluation of an innovative 
technology for building access ramps; and (2) dissemination of 
the findings of the project among builders, ADA compliance 
experts, and consumers.

                  Research and Demonstration Projects

    These projects address rehabilitation priorities identified 
by NIDRR and published in the Federal Register. These 
priorities address a variety of problems encountered by people 
with disabilities. Projects are funded for up to 36 months.

1. Exercise and Recreation for Individuals with a Disability: 
        Assessment and Intervention, Rehabilitation Institute of 
        Chicago, Center for Health and Fitness, Chicago, IL

    This project demonstrates that participation in exercise 
and physical activities improves function, facilitates 
community reintegration, and enhances the quality of life of 
people with disabilities. The project: (1) investigates the 
long-term effects of an exercise fitness program on the 
physiology, metabolic performance, and quality of life of 
people with spinal cord injury, stroke, and cerebral palsy; (2) 
examines the role of self-efficacy in maintaining participation 
in an exercise fitness program; (3) describes the types and 
frequency of recreation and fitness activities among people who 
have had a stroke, people with spinal cord injury, and people 
with cerebral palsy; (4) examines the relationships between 
participation in recreation and exercise programs and the 
health status, life satisfaction,and depression in the above 
populations; and (5) delineates barriers and deterrents to 
participation in recreation and exercise programs that exist for a 
variety of disability groups.

2. Research and Demonstration of a Model for Successfully Accommodating 
        Adults with Disabilities in Adult Education Programs, 
        University of Kansas Institute for Adult Studies and Kansas 
        State University Department of Special Education, Lawrence, KS

    This project provides adult educators and adults with 
disabilities with validated accommodations useful in 
instruction and assessment. These accommodations help the 
individuals meet their educational needs and successfully 
function in employment and community settings. Also, 
information about their legal rights and responsibilities is 
made available, including handbooks on legal rights and 
responsibilities for both adults with disabilities and adult 
service providers, a ``Compendium of Materials and Resources,'' 
and a ``Procedural Guide.'' These materials are compiled 
through: (1) a national survey of adult education programs, (2) 
a state survey of enrollees with disabilities in adult 
education, and (3) a case study of one local program in an 
urban center with high unemployment and multicultural 
diversity. This process is aided by information gained from two 
symposia with adult educators and subject matter experts 
(proceedings and videotapes of the first symposium are 
available). An accommodations model that matches the functional 
needs of adults with disabilities to the demands of adult 
education programs is being developed; the accommodations model 
and related products are being tested using a national sample 
of adult educators.

3. Reducing Risk Factors for Abuse Among Low-Income Minority Women with 
        Disabilities, Baylor College of Medicine, Department of 
        Physical Medicine and Rehabilitation, Houston, TX

    This project pursues strategies to reach women with 
disabilities at all stages of change in resolving abusive 
situations. To accomplish this purpose, the project has the 
following objectives: (1) identify risk factors for emotional, 
physical, and sexual abuse faced by women with disabilities; 
(2) assess the ability of rehabilitation and independent living 
counselors to identify women in abusive situations and refer 
them to appropriate community resources; (3) develop and test 
models for programs that reduce the risk of abuse for women 
with disabilities, particularly among women with disabilities 
from low-income, minority backgrounds where the incidence of 
abuse is the highest; and (4) establish an agenda for future 
research on women with disabilities using a national advisory 
panel. The project works not only with programs that help 
battered women, but also those that have contact with women 
with disabilities in various community contexts.

4. Understanding and Increasing the Adoption of Universal Design in 
        Product Design, University of Wisconsin/Madison, Trace Research 
        and Development Center, Madison, WI 53705-2280

    This project: (1) identifies the factors that cause 
industry to practice, or not to practice, universal design of 
products; and (2) identifies ways that people outside companies 
can encourage and facilitate the practice of universal design 
of products on a more widespread basis. The project brings 
together experts who have been active in universal design from 
across the technology spectrum to work with industry in 
addressing these questions. Areas of expertise include housing 
and architecture, computers and electronic products, media and 
materials, telecommunications, and educational software.

                          Utilization Projects

    This program supports activities that will ensure that 
rehabilitation knowledge generated from projects and centers 
funded by the Institute and other sources is fully utilized to 
improve the lives of individuals with disabilities.

1. Improving Access to Disability Data, InfoUse, Berkeley, CA

    InfoUse's Center on Access to Disability Data is the 
central source for disability statistics data and related 
technical reports in accessible, easy-to-understand, user-
friendly formats. The Center provides this information to 
businesses, the media, urban planners and policymakers, and the 
disability community. The first major product, the ``Chartbook 
on Disability in the United States, 1996,'' provided updated 
statistical information on a range of disability topics. 
Material for the ``Chartbook'' series and related fact sheets 
are available to the public in a variety of published and 
electronic formats, including print and electronic media. The 
Center's Web site serves as a source for electronic documents, 
includes guidelines for accessible Web publishing, and provides 
links to major national data sources including data sites 
developed by other NIDRR grantees and by major national 
disability data suppliers.

2. National Rehabilitation Information Center (NARIC), KRA Corporation, 
        Silver Spring, MD

    The National Rehabilitation Information Center (NARIC) 
maintains a research library of more than 51,000 documents and 
responds to a wide range of information requests, providing 
facts and referral, database searches, and document delivery. 
Through telephone information referral and the Internet, NARIC 
disseminates information gathered from NIDRR-funded projects, 
other federal programs, and from journals, periodicals, 
newsletters, films, and videotapes. NARIC maintains REHABDATA, 
a bibliographic database on rehabilitation and disability 
issues, both in-house and on the Internet. Users are served by 
telephone, mail, electronic communications, or in person.

3. Abledata Database Program, Macro International, Inc., Silver Spring, 
        MD

    The project maintains and expands the ABLEDATA database, 
develops information and referral services that are responsive 
to the special technology product needs of consumers and 
professionals, and provides the data to major dissemination 
points to ensure wide distribution and availability of the 
information to all who need it. The ABLEDATA database contains 
information on more than 23,000 assistive devices, both 
commercially produced and custom made. Requests for information 
are answered via telephone, mail, electronic communications, or 
in person.

4. National Center for the Dissemination of Disability Research (NCDDR) 
        Southwest Education Development Laboratory, Austin, TX

    This project provides information and technical assistance 
to NIDRR grantees in identifying and improving dissemination 
strategies designed to meet the needs of their target audience. 
The project also analyzes and reports on dissemination trends 
relevant to disability research. Task force and material 
development activities address multicultural factors that 
influence dissemination and utilization. This project conducts 
ongoing informational network through a variety of approaches, 
including an interactive World Wide Web site highlighting 
events and other information about specific NIDRR grantees, the 
production of quarterly issues of ``The Research Exchange,'' 
and in-person and online technical assistance support.

                              Fellowships

    Fellowships, named for the late Mary E. Switzer, build 
future research capacity. NIDRR makes awards on two levels: 
Distinguished Fellowships go to individuals of doctorate or 
comparable academic status who have had seven or more years of 
experience relevant to rehabilitation research. Merit 
Fellowships are given to persons in earlier stages of their 
research careers.

1. Quality Indicators for Comparative Analysis of Stroke Outcome, 
        Bartlett, IL, Principal Investigator: Robin Turpin, PhD

    The goal of this study is to develop a set of a quality 
indicators to assess the impact of medical rehabilitation 
services on the lives of stroke survivors. Development involves 
the World Health Organization's ``International Classification 
of Impairments, Disability, and Handicaps'' (ICIDH), as well as 
quality of life literature. The indicators assess the impact of 
rehabilitation services from health status of community 
integration and quality of life. Such a set of quality 
indicators would be useful and feasible for a wide variety of 
care across settings and providers.

2. Telemedicine and Neuropsychological Services: Improving Access to 
        Care to Care for Rural Residents with Brain Injury, University 
        of Missouri/Columbia, Department of Physical Medicine and 
        Rehabilitation) Columbia, MO, Principal Investigator: Laura H. 
        Schopp, PhD

    Objectives of this study include: assessing telemedicine 
versus in-person care in consumer, family member, provider, and 
rehabilitation counselor satisfaction; assessing costs, 
psychological and neuropsychological status, and level of 
community integration; and providing qualitative and (to the 
extent possible) quantitative evaluation of racial/ethnic 
differences in needs and attitudes toward telemedicine.

                        Research Training Grants

    The purpose of this program is to expand capability in the 
field of rehabilitation research by supporting projects that 
provide advanced training in rehabilitation research. These 
projects provide research training and experience at an 
advanced level to individuals with doctoral or similar advanced 
degrees who have management or basic science research, in 
fields pertinent to rehabilitation, in order to quality those 
individuals to conduct independent research on problems related 
to disability and rehabilitation.

1. Doctoral Training in Physical Therapy University of Iowa, Physical 
        Therapy Graduate Program, Iowa City, IA

    This project supports five physical therapist trainees for 
three years and five other physical therapist trainees for the 
first two years of their doctoral program of study at the 
University of Iowa. the long-term goal is to increase the 
supply of physical therapists who have both the clinical 
experience and advanced skills required to conduct effective 
rehabilitation research. Specifically, the student must: (1) be 
able to perform original scholarship and research that advances 
the understanding of physical therapy clinical practice; (2) 
have comprehensive knowledge of theoretical and research 
literature in areas of specialization; (3) be skilled in the 
application of basic and advanced concepts in the area of 
cardiopulmonary, ergonomic, musculoskeletal, or neuromuscular 
physical therapy; and (4) be able to teach at the basic 
professional, master's degree, and doctoral levels of physical 
therapy education.

2. Rehabilitation Research Training in Physical Therapy, Texas Woman's 
        University, School of Physical Therapy, Houston, TX

    The purpose of this training project is to produce 
qualified individuals who are capable of conducting valid 
scientific research in rehabilitation. Participants are 
physical therapists who have well-defined interests in pursuing 
research careers in physical therapy. Four predoctoral student 
fellows are recruited for a three-year course of study leading 
to a PhD degree with a major in physical therapy. Fellows are 
selected on the basis of their interest in programmatic 
research conducted in one of the laboratories within the School 
of Physical Therapy. Those laboratories are actively engaged in 
investigating neuromuscular and musculoskeletal aspects of 
rehabilitation. In addition, each fellow is expected to 
participate in external projects conducted in conjunction with 
the laboratory. A plan of both process and outcome evaluation 
ensures the excellence of this training program.

                   Small Business Innovative Research

    New ideas and products useful to people with disabilities 
and the rehabilitation field are encouraged with small business 
innovative research grants. This three-phase program takes an 
idea from development to market readiness.

1. Development of a Lightweight, Portable, Easily-Assembled Scooter 
        Lift-Carrier for Automobiles and Other Vehicles, ACCESS/
        ABILITIES, Mill Valley, CA

    ACCESS/ABILITIES, in collaboration with the Veterans 
Administration Rehabilitation Research and Development Center, 
is developing a portable, lightweight, easy-to-assemble lift/
carrier for 3-wheeled scooters that can be used with 
automobiles. Design selection is based on technical 
feasibility, commercialviability, physical practicality for 
users, and cost efficiency, using technical data on scooter 
specifications gathered from manufacturers. Three design approaches are 
considered.

2. Hiking Trails Web Site with Universal Access Information, Beneficial 
        Designs, Inc., Santa Cruz, CA

    Although many people with disabilities enjoy visiting 
outdoor parks and recreational areas, obtaining information 
about the accessibility of outdoor trails is currently 
difficult. The goal of the Trails Web site is to provide 
universal access information for trails throughout the United 
States that is useful to all hikers, regardless of their 
ability. The Universal Trails Assessment Process enables trail 
managers to assess specific trails objectively with regard to 
grade, cross slope, width, surface characteristics, and 
obstacles. The collected trail data is processed to create 
Trail Access Information in a format similar to the Nutritional 
Facts food label. The objectives of Phase I are to develop the 
Web site and trail access information database, to collect and 
enter trail access information, and to evaluate its 
effectiveness through online evaluations. The Web site allows 
users to search for trails that meet their specific access 
needs. The site also contains links to other Web sites with 
related information. Trail access information obtained remotely 
allows Web site users to plan appropriate outdoor travel by 
being able to determine in advance where they can hike.

3. Alternative communication; Computer applications; Communication; 
        Hearing impairments; Deaf blindness; Sign language; The 
        Adaptive Device Locator System on the World Wide Web, Academic 
        Software, Inc., Lexington, KY

    This project's goal is to save the Adaptive Device Locator 
System (ADLS), a unique and valuable national resource, by 
transforming the entire Locator System database content and 
program code into a World Wide Web site on the Internet. The 
planned state-of-the-art, multilevel format is universally 
accessible to teachers, health professionals, and consumers 
with disabilities. The site lists computer access products the 
company provides; vendor links allow ADLS visitors to jump 
directly to other commercial sites once appropriate assistive 
technology devices are located. On the Web, ADLS will be an 
export leader, focusing on international trade in this field. 
ADLS on the WEB will feature monthly infomercials, new product 
announcements, and other information of interest to consumers.

4. Broadcast Radio for Individuals Who Are Deaf: Gaining Equity 
        (BRIDGE), Associated Enterprises, Inc. (AEI), TeleSonic 
        Division, Annapolis, MD

    Talk radio reaches large audiences of people and is a 
significantly less expensive medium than television. Yet radio 
broadcasts are inaccessible to deaf and certain hard of hearing 
people. In project BRIDGE, TeleSonic's goal is to broadcast 
information via the radio simultaneously in multiple 
transmission forms to delivery both audio and visual 
information. Users of TTYs, for example, receive ``closed 
captioned'' broadcasts of radio programs. The Phase I 
hypothesis is: it is feasible to transmit multimedia signals 
over commercial radio to be received by special decoder 
devices. Phase I includes: (1) defining technical trial test 
approaches, (2) developing test transmitter/receiver devices, 
(3) producing a brief radio talk show, (4) organizing focus 
group feedback sessions, (5) conducting trials, (6) developing 
preliminary product design specifications, and (7) documenting 
results. Anticipated long-term results include development of a 
commercially marketable radio transmission and receiving 
device.

5. Miniature, Voice Output Independent Reading Device (IRA), Ascent 
        Technology Inc., Boulder, CO

    This project is developing and testing an innovative 
reading device that interprets and speaks along the printing 
found in books, labels, and other everyday items, this device 
enhances the abilities of people with visual impairments in 
schooling, employment, and independent living. The unique 
optical character recognition and voice synthesis device 
requires only one hand for operation and can read food and 
pharmacological packaging, including curved surfaces. The 
simplicity of the device allows the user to acquire functional 
reading capability after only a few minutes of training. In 
addition to serving people with visual impairments, this 
technology is applicable to the needs of people with cognitive 
impairments, such as people who have had a stroke, and to the 
needs of people who cannot read and non-native language 
readers. The prototype is being tested using 15 people with 
visual impairments aged 55 and older and four adults under the 
age of 45 to determine its applicability to the tasks of 
independent living.

                  state technology assistance programs

    This program, funded under The Technology-Related 
Assistance for Individuals with Disabilities Act of 1988, as 
amended, supports consumer-driven, statewide, technology-
related assistance for individuals of all ages with 
disabilities.
    States and territories are eligible to apply for one 3-year 
development grant, a first-extension grant for year 4 and 5, 
and a second-extension grant for years 6-10. The purpose of 
these grants is to establish a program of statewide, 
comprehensive, technology-related assistance for individuals 
with disabilities of all ages.

   Independent Living Services for Older Individuals Who Are Blind, 
                         Chapter 2 of Title VII

    Section 752 of the Rehabilitation Act of 1973, as amended, 
authorizes discretionary grants to State vocational 
rehabilitation (VR) agencies for projects that provide 
independent living services for persons who have severe visual 
impairments and who are aged 55 and older. Each designated 
State unit that is authorized to provide rehabilitation 
services to blind individuals may either directly provide 
independent living services or it may make subgrants to other 
public agencies or private non-profit organizations to provide 
these services.
    The services most commonly provided are: (1) training for 
activities of daily living, (2) the provision of adaptive aids 
and appliances, (3) low vision services, (4) orientation and 
mobility services, (5) training in communication skills, (6) 
family and peer counseling, and (7) community integration, 
which includes outreach and information and referral.
    During FY 1996, the most recent year for which we have 
analyzed data, 26,846 older individuals with significant visual 
impairment or blindness received services. Of these consumers, 
64.4 percent were at age 76 or older and 45 percent were age 81 
or older. The individuals served by this program represent 
approximately one-half of the individuals with significant 
visual impairments or blindness who receive rehabilitation and 
independent living services through public and private 
rehabilitation programs as estimated by the Mississippi State 
University and the New York Lighthouse for the Blind.

                      ITEM 5--DEPARTMENT OF ENERGY

                              ----------                              


                              Introduction

    The Department of Energy (DOE) is a major government 
enterprise. If included among the Nation's Fortune 500 firms, 
it would rank in the top 50. It funds the largest environmental 
cleanup in history as well as research and development that 
supports the Nation's defense and its energy and economic 
security. The Department employs more than 11,000 Federal 
workers and 100,000 contract employees. It owns and manages 
over 50 major installations located on 2.4 million acres in 35 
States and is the fourth largest Federal landowner in the 
United States.
    The Department of Energy is an energy policy, supply, and 
technology enterprise. It invests in developing a secure, 
clean, and sustainable energy system. It helps the Nation meet 
its environmental challenges by administering the largest 
pollution prevention and energy efficiency program in the 
world, with partners from every sector of the economy. It 
enhances the Nation's energy security by increasing the 
diversity of energy sources and fuel choices: bringing 
renewable energy sources into the market, strengthening 
domestic production of oil and gas, maintaining the U.S. 
nuclear energy option, and increasing the efficiency with which 
we use energy and generate electricity. The Department also 
maintains the Strategic Petroleum Reserve and operates Power 
Marketing Administrations that sell and distribute over $3 
billion of electric power generated at Federal hydroelectric 
plants.
    The Department of Energy is a national security enterprise. 
It is a key player in the Administration's furtherance of the 
Comprehensive Test Ban Treaty and its overall goal of reducing 
the global danger from nuclear weapons. DOE ensures the safety 
and reliability of the U.S. nuclear weapons stockpile without 
underground testing. At the same time, it manages and safely 
dismantles excess nuclear weapons, disposes of surplus fissile 
nuclear materials, and ensures the security of vital 
Departmental nuclear assets. It provides policy and technical 
assistance to curb global proliferation of weapons of mass 
destruction, emphasizing U.S. nonproliferation, arms control, 
and nuclear safety objectives in the states of the former 
Soviet Union and world-wide. Further, DOE develops and ensures 
the safety and reliability of nuclear reactor plants to power 
U.S. Navy warships.
    The Department of Energy is an environmental remediation 
enterprise. It cleans up the 50-year environmental legacy left 
at the industrial complexes where nuclear weapons were designed 
and manufactured. It manages the problems associated with the 
large quantities of various types of radioactive wastes, 
surplus nuclear materials, and spent nuclear fuels that remain 
at the sites of the Nation's nuclear weapons facilities and at 
nuclear energy research and development sites. In addition, DOE 
must address the growing inventory of spent nuclear fuel from 
commercial nuclear reactors that is awaiting disposal. These 
wastes must be dealt with responsibly to ensure the safety and 
health of the public.
    The Department of Energy is a science and technology 
enterprise. At the center of all we do are our 27 laboratories, 
our additional scientific user facilities, and our researchers 
at the Nation's universities. These form the backbone of U.S. 
scientific leadership by conducting and facilitating 
breakthrough research in energy sciences and technology, high 
energy physics, global climate change, genomics, 
superconducting materials, accelerator technologies, 
environmental sciences, and supercomputing in support of DOE's 
mission. The laboratories, described as the crown jewels of the 
Nation's science establishment, and the Department's funding of 
research at universities have resulted in 70 Nobel prize 
winners. The Department is also an investor in the Nation's 
most precious resource--its youth--by supporting science and 
mathematics education in our schools through grants, 
educational programs, and fellowships.
    The Department of Energy is a global enterprise. The 
outcome of our work is the technology that stimulates the 
private market for the expansion of clean energy to meet 
national and global energy requirements of almost 500 
quadrillion Btu's by the year 2010--a staggering 36 percent 
increase over 1995. Overseas energy market needs include coal, 
nuclear power, oil and gas exploration, energy efficiency, and 
renewable energy technologies that are available for export now 
or that will soon be available for the international 
marketplace. The Department of Energy supports the export of 
U.S. energy services and technologies by assisting the nations 
in Asia, South America, Eastern Europe, and Africa, and the 
states of the former Soviet Union in developing private markets 
for environmentally responsible, sustainable energy. These 
alliances support U.S. competitiveness in a global economy of 
growing energy infrastructure requirements and create jobs in 
the United States at all skill levels.

                       Energy Efficiency Programs

    Weatherization Assistance Program.--The program's mission 
is to make energy more affordable and improve health and safety 
in homes occupied by low-income families, particularly those 
with elderly residents, children, or persons with disabilities. 
Elderly residents make up approximately 40 percent of the low-
income households served by this program. As of September 30, 
1996 about 4.5 million homes had been weatherized with Federal, 
State, and utility funds; of these, an estimated 1.8 million 
were occupied by elderly persons.
    Low-income households spend an average 15 percent of income 
for residential energy--more than four times the proportion 
spent by higher income households. The weatherization program 
allows low-income citizens to benefit from energy efficiency 
technologies that are otherwise inaccessible to them. 
Alleviating the high energy cost burden faced by low-income 
Americans helps them increase their financial independence and 
their flexibility to spend household income on other needs.
    The program has become increasingly effective due to 
improvements in air-leakage control, insulation, water heater 
systems, windows and doors, and space heating systems. A low-
income household now saves approximately $193 per year, about 
one-third of its space heating costs. Program benefits are 
further described in Progress Report of the National 
Weatherization Assistance Program that features 90 photo 
illustrations of specific benefits. The report is available 
through the National Technical Information Service, 703/487-
4650, 5285 Port Royal Rd., Springfield, VA 22161.
    The program is implemented by states through community-
based organizations. The Department of Energy and its State and 
community partners weatherize approximately 70,000 single- and 
multi-family dwellings each year. The program awarded $214.9 
million in Fiscal Year 1995 and $111.7 million in Fiscal Year 
1996 for grants to the 50 States, the District of Columbia and 
six Native American tribal organizations. In addition to DOE 
appropriations, State and local programs receive funding from 
the Department of Health and Human Services Low Income Home 
Energy Assistance Program, from utilities, and from States.
    State Energy Program.--The program provides grants to State 
energy offices to encourage the use of energy efficiency and 
renewable energy technologies and practices in states and 
communities through technical and financial assistance. In FY 
1995 $53 million was appropriated and $25.9 million was 
appropriated in FY 1996. States have broad discretion in 
designing their projects. Typical project activities include: 
public education to promote energy efficiency; transportation 
efficiency and accelerated use of alternative transportation 
fuels for vehicles; financial incentives for energy 
conservation/renewable projects including loans, rebates and 
grants; energy audits of buildings and industrial processes; 
development and adoption of integrated energy plans; promotion 
of energy efficient residences; and deployment of newly 
developed energy efficiency and renewable energy technologies.
    There have been some projects that specifically target the 
elderly such as Louisiana's low-income/handicapped/elderly/
Native American outreach program that provided energy-related 
assistance through a joint venture with utilities. The elderly 
also benefit from programs that provide energy audits, hands-on 
energy conservation workshops, and low-interest loans for 
homeowners that can result in significant energy savings. 
Energy efficiency improvements in local and state buildings and 
services also benefit the elderly by freeing up state and local 
government tax revenues for non-energy expenses. Energy 
efficient schools can be less of a burden on property taxes.
    An emerging issue is the restructuring of the electric 
utility industry. The State Energy Program has supported 
workshops with States and local communities to ensure that 
homeowners and disadvantaged groups are not overlooked or 
denied the economic benefits of lower-cost sources of energy 
after deregulation. Utility deregulation workshops for public 
officials have emphasized techniques and negotiating 
strategies, e.g. franchising, to ensure that vulnerable 
populations such as the elderly are not excluded from energy 
pricing competition.

                Information Collection and Distribution

    The Energy Information Administration collects and 
publishes comprehensive data on energy consumption in the 
residential sector through two surveys: the Residential Energy 
Consumption Survey (RECS) and the Residential Transportation 
Energy Consumption Survey (RTECS). The RECS is now collected 
every 4 years and the RTECS was discontinued after the 1994 
survey. The Residential Energy Consumption Survey includes data 
collected from individual households throughout the country, 
along with the actual billing data from the households' fuel 
suppliers for a 12-month period. The data include information 
on energy consumption, expenditures for energy, costs by fuel 
type, and related housing unit characteristics (such as size, 
housing type, and major energy-consuming appliances). The 
Transportation Survey collected information on characteristics 
of household vehicles and annual miles traveled for a subsample 
of the RECS respondents. Both surveys contain data pertaining 
to older Americans.
    The results of these surveys are analyzed and published by 
the Energy Information Administration. The most recent 
household survey for which reports have been published is the 
1993 RECS. Results of the 1993 RECS are published in two 
reports: Housing Characteristics 1993 (published in June, 1995) 
and Household Energy Consumption and Expenditures 1993 
(published in October, 1995). The data file for the 1993 RECS 
is available on PC diskettes. The reports and data file are 
also available on the Internet at http://www.eia.doe.gov/emeu/
recs/contents.html. The RECS file contains demographic 
characteristics of the elderly such as age, employment status, 
marital status and family income, as well as estimates of 
consumption and expenditures for electricity, natural gas, fuel 
oil, kerosene, and liquefied petroleum gas used in the elderly 
households.
    In the 1993 RECS, 27.8 million, or 29 percent of all U.S. 
households, were headed by a person 60 years of age or older. 
Of these elderly households, 42 percent were one-member 
households (11.7 million people living alone) and 45 percent 
contained 2 people. In the 2-member elderly households, 78 
percent of the second persons were also at least 60 years old.
    Analysis of the 1993 RECS data shows that consumption 
patterns differed between the elderly and nonelderly for some 
uses of energy. The elderly used more energy to heat their 
homes, for example, but used less energy for air conditioning, 
water heating, and appliances. Expenditures followed the same 
pattern. Specifically,
           The average expenditures per household member in 
        elderly households was $681. This amount was higher 
        than the comparable amount for all other households, 
        due to the fact that households headed by persons 60 
        years or more of age tend to be smaller than those 
        headed by persons under 60 years of age.
          About 61 percent of total energy consumption and 
        about 38 percent of total energy expenditures in 
        elderly households were for space heating.
    The most recent triennial Residential Transportation Energy 
Consumption Survey was conducted for the calendar year 1994 and 
the results reported in Household Vehicles Energy Consumption 
1994 (published August, 1997).
    This report and the RTECS data files are also available on 
the Internet at http://www.eia.doe.gov/emeu/rtecs/
contents.html. Data in this publication, vehicle miles 
traveled, gallons of motor fuel consumed, expenditures for 
motor fuel, and number of vehicles, are categorized by 
household characteristics and type of vehicle. These data show 
that for calendar year 1994, elderly households drove fewer 
miles and used less fuel on average than did all households. 
For example, elderly households with one adult and no children 
drove an average of 8,600 miles and consumed an average of 435 
gallons of motor fuel. Elderly households with 2 or more adults 
and no children averaged 17,000 miles and 907 gallons of motor 
fuel. These averages are below the corresponding averages for 
all U.S. households, 21,100 miles and 1,067 gallons of motor 
fuel. Elderly households may travel fewer vehicle miles because 
they make relatively less use of their vehicles for commuting 
to work or earning a living.

                       Research Related to Aging

    In 1995 and 1996, the Office of Environment, Safety and 
Health (EH) sponsored research to further an understanding of 
the human health effects of radiation. As part of this research 
program, the Department of Energy sponsored epidemiologic 
studies concerned with understanding biological changes over 
time. Lifetime studies of humans constitute a significant part 
of EH's research; because the risks of various health effects 
vary with age, these studies take age into consideration. EH 
supports research to characterize late-appearing effects 
induced by chronic exposure to low levels of physical agents 
and some basic research concerning certain diseases that occur 
more frequently with increasing age.
    Because health effects resulting from chronic low-level 
exposure to energy-related toxic agents may develop over a 
lifetime, they must be distinguished from normal aging 
processes. To distinguish between induced and spontaneous 
changes, information is collected from both exposed and 
nonexposed groups on changes that occur throughout the life 
span. These data help characterize normal aging processes and 
distinguish them from the toxicity of energy-related agents. 
Summarized below are specific research projects that the 
Department sponsored in 1995-1996.
    Long Term Studies of Human Populations.--Through EH, DOE 
supports epidemiologic studies of health effects in humans who 
may have been exposed to chemicals and radiation associated 
with energy production or national defense activities. 
Information on life span in human populations is obtained as 
part of these studies. Because long-term studies of human 
populations are difficult and expensive, they are initiated on 
a highly selective basis.
    The Radiation Effects Research Foundation, sponsored 
jointly by the United States and Japan, continues to work on a 
lifetime followup of survivors of atomic bombings that were 
carried out in Hiroshima and Nagasaki in 1945. Over 100,000 
persons are under observation in this study. An important 
feature of this study is the acquisition of valuable 
quantitative data on dose-response relationships. Studies 
specifically concerned with age-related changes are also 
conducted. No evidence of radiation-induced premature aging has 
been observed.
    Multiple epidemiologic studies involving about 400,000 
contractor employees at DOE facilities are being managed by the 
Department of Health and Human Services through a Memorandum of 
Understanding between the two agencies. These studies include 
assessments of health effects at older ages due to ionizing 
radiation and other industrial toxicants. Several of the 
studies will look closely at workers who were first exposed at 
age 45 or older, assessing the impact of these late exposures 
in relation to the burden of chronic diseases that are common 
among older people. The average age of workers included in 
these studies is greater than 50 years.
    The United States Uranium/Transuranium Registry, currently 
operated by Washington State University, collects occupational 
data including work, medical, and radiation exposure histories 
and information on mortality among workers exposed internally 
to plutonium or other transuranic elements. Most of the workers 
participating in this voluntary program are retirees.
    In response to the Defense Authorization Act of 1993, EH 
has established a program involving a number of ongoing 
projects across the DOE weapons complex to identify former 
workers whose health may have been placed at risk as a result 
of occupational exposures that occurred from the 1940s through 
the 1960s. These projects provide medical screening and 
monitoring for former workers to identify those at high risk 
for occupationally related diseases and to identify workers 
with diseases that may be reduced in severity by timely 
interventions.
    In addition to its epidemiologic research and health 
monitoring programs, EH has established the Comprehensive 
Epidemiologic Data Resource, a growing archive of data sets 
from the many epidemiologic studies sponsored by DOE. This 
public archive provides the research community with data that 
continue to be used to gain additional insights into the 
relationships between occupational exposures and a variety of 
health outcomes including diseases of aging, such as cancer.

               Other DOE-Funded Research Related to Aging

    Since the inception of the Atomic Energy Commission, the 
Department and its predecessor agencies have carried out a 
broad range of research and technology development activities 
which have impacted health care and medical research. The 
Medical Applications and Biophysical Research Division within 
the Office of Biological and Environmental Research carries out 
a Congressional mandate to develop beneficial applications of 
nuclear and other energy related technologies including 
research in aging affecting older Americans. The Aging Research 
involves study of a brain chemical, dopamine (DA), and its 
function in humans as they age. A significant decline in the 
function of the brain DA system with age has long been a 
recognized fact, but the functional significance of this loss 
is not known. Medical imaging studies, using radiotracers and 
positron emission tomography, are designed to investigate the 
consequences of the age-related losses in brain DA activity in 
cerebral function and to investigate mechanisms involved with 
the loss of DA function with normal aging. The results of these 
studies have already shown that in healthy volunteers with no 
evidence of neurological dysfunction there is a decline in 
parameters of DA function, which are associated with decline in 
performance of motor and cognitive functions. The results of 
these studies also indicate that changes in life style, such as 
exercise, may be beneficial in promoting the health of dopamine 
system in the elderly.
    Cancer is a disease generally associated with aging. One of 
the essential steps in the conversion of a normal cell to a 
malignant cancer cell is a heritable loss of the cell's ability 
to control its normal growth behavior. In addition, cancer 
cells often escape from the normal cell aging process. Research 
is funded on the role of cell aging (or senescence) in the 
aging of the whole organism. This research received an award 
from the Alliance for Aging Research, the nation's leading 
citizen advocacy organization for promoting scientific research 
in human aging and working to ensure healthy longevity for all 
Americans.
    Additional research has resulted in the creation of a new 
scientific discipline known as biodemography, a melding of 
biology and demography. This research is searching for 
biological information, at all levels of biological 
organization, that predicts and explains patterns of age-
related mortality observed in populations. In the long term, 
biodemography provides a conceptual framework that helps policy 
makers assess the impact that specific biomedical interventions 
such as heart bypass surgery, renal dialysis, chemotherapy, or 
gene therapy will have on population aging and, as a result, on 
the fiscal solvency of government entitlement programs for 
aging citizens.
    The programmatic costs for aging research are estimated at 
approximately $400K annually.

             ITEM 6--DEPARTMENT OF HEALTH & HUMAN SERVICES

                              ----------                              


        THE ADMINISTRATION ON AGING AND THE OLDER AMERICANS ACT

                              Introduction

    Today, 44 million, or one in six, Americans are 60 or 
older. While most older Americans are active members of their 
families and communities, others are at risk of losing their 
independence. These include the 4 million Americans 85 or 
older, those living alone without a caregiver, members of 
minority groups, older persons with physical or mental 
impairments, low-income older persons, and those who are 
abused, neglected, or exploited.
    To meet the diverse needs of the growing number of older 
people, the Older Americans Act of 1965 (the Act), as Amended, 
calls for programs that offer services and opportunities for 
older Americans. The Act established the Administration on 
Aging (AoA), an agency of the U.S. Department of Health and 
Human Services, which is headed by the Assistant Secretary for 
Aging.
    Among its major responsibilities, the AoA administers 
programs at the federal level, which help those elderly at risk 
of premature or unnecessary institutionalization to remain in 
their own homes by providing supportive and nutrition services. 
This report summarizes the major activities of the AoA in 
Fiscal Years 1995 and 1996.

                       the national aging network

    The AoA is the federal focal point and advocacy agency for 
older persons. In this role, the AoA works to heighten the 
awareness of other federal agencies, organizations, and the 
business and public sectors about older persons--their many 
contributions to the nation, their resources, but also their 
needs and concerns. The AoA also works with these various 
groups to ensure that, whenever possible, their programs and 
resources are targeted to the elderly and coordinated with 
those of the aging network. The AoA works closely with the 
nationwide network of State Units on Aging (SUA's), Area 
Agencies on Aging (AAA's), and Indian Tribal Organizations 
(ITO's) to plan, coordinate, and develop community-level 
systems of services designed to meet the unique needs of older 
persons and their caregivers. The AoA awards funds for 
nutrition and supportive in-home and community services to the 
57 SUA's which are located in every state and territory. 
Additional funds are awarded to these state agencies for elder 
rights programs, including the nursing home ombudsman program, 
and elder abuse prevention efforts.
    Funding for programs is allocated to each SUA, based on the 
number of older persons in the state, to plan, develop, and 
coordinate systems of supportive services. Most states are 
divided into Planning and Service Areas (PSA's) so that 
programs can be developed and targeted to meet the unique needs 
of the elderly residing in that area.
    Nationwide, approximately 655 AAA's receive funds from the 
SUA to plan, develop, coordinate and arrange for services in 
each PSA. The AAA's contract with public and private groups to 
provide in-home and community-based services. Nationwide, there 
are some 27,000 service provider agencies.
    The AoA also awards funds to 222 tribes and native 
organizations to assist older American Indians, Alaskan 
Natives, and Native Hawaiians. Funds are allocated to ITO's 
based on the number of older American Indians, Alaskan Natives 
or Native Hawaiians to be served in their designated geographic 
area. The ITO's provide home and community-based service in 
keeping with the unique cultural heritage of these Native 
Americans.
    Volunteers are a vital component of the national aging 
network. The AoA uses the talents of a half-million volunteers, 
many of them older persons, to assist in service programs 
supported under the Act. These volunteers work at the community 
level to enhance the independence of the elderly. Additionally, 
the rich talents of older Americans are being tapped. Through 
intergenerational programming, they are helping families by 
working with Head Start children and their parents, as 
counselors to troubled youth, and by providing respite care for 
disabled children. Appendix I includes an organizational chart 
of the National Aging Network.
Discretionary grant programs
    The discretionary grant programs authorized by Title IV of 
the Older Americans Act constitute the major research, 
demonstration, training, and information dissemination effort 
of the AoA. These programs are aimed at expanding our 
understanding of older persons, developing innovative model 
programs, training personnel for service in the field of aging, 
and providing technical assistance and information to the aging 
network and to others who work with older persons.
    Because of severe reductions in Title IV funding for fiscal 
year 1996, there were only three demonstration project areas--
the Eldercare Locator, Family Friends, in which older 
volunteers service children with disabilities and their 
families, and Senior Legal Hotlines/Legal Assistance and 
related elder rights projects.
    The Act under Title II requires the establishment of 
resource centers. The AoA has provided funds to educational 
institutions to develop curricula and training programs for 
professionals and paraprofessionals.
    In the past, the AoA awarded funds to support national 
resource centers on long-term care, housing, nutrition, Native 
Americans, older women, and elder abuse.
    The budgets for AoA in FY 1995 and FY 1996 are included in 
Appendix II.

                          aging in the future

    During FY 1995-1996, the AoA worked to shape an environment 
where Americans will have the best opportunity to adopt 
attitudes and lifestyles that enable them to remain independent 
in their later years. Through consumer advocacy and outreach 
and education, the AoA is seeking to enable older Americans, 
and those nearing retirement, to make changes that help them to 
enjoy a fulfilling future. The key is to plan and to adopt, for 
their later years, lifestyles that include the goals of good 
health, a satisfying quality of life and financial security.
    Through these and many other programs supported by the AoA, 
the mandate of the Act--to ensure the dignity and independence 
of older Americans in their own homes and the opportunity to 
contribute to their communities and our nation--is coming 
closer to being fully realized for present and future 
generations.
    This report is organized and divided into five sections 
summarizing the major activities during FY 1995-1996. Section I 
discusses the activities focused on ``Improving Services for 
Seniors and Their Families.'' Section II discusses the 
activities related to ``Enhancing the Capacity of the 
Network.'' Section III discusses those activities geared toward 
``Planning for the Future.'' Section IV discusses those 
activities focused on ``Addressing Diversity.'' Section V 
contains those activities related to ``Expanding international 
Partnerships.''

      Section I--Improving Services for Seniors and Their Families

Preserving and strengthening the Older Americans Act

    The AoA, in consultation with key partners in the aging 
network, produced a reauthorization proposal for the Older 
Americans Act (the Act) designed to strengthen its services and 
maintain the integrity of its successful programs and titles, 
while improving local flexibility, protecting the most 
vulnerable, and preparing for a growing and diverse aging 
population. The Act was not reauthorized by the 104th Congress 
and continues to be discussed in the 105th Congress.

Protecting elders' rights

    As a result of the five Bi-Regional Elder Rights Protection 
meetings conducted in fiscal year 1995, a number of state elder 
rights coalitions were established during fiscal year 1996 to 
develop ways to resolve problems affecting large numbers of 
vulnerable older persons and to assist elders secure the rights 
and benefits to which they are entitled.
    In FY 1995, the Institute of Medicine, National Academy of 
Sciences completed its study to evaluate the State Long-Term 
Care Ombudsman Programs concluding that the ombudsman program 
serves a vital public purpose and merits continuation with its 
present mandate. Through advocacy efforts at both the 
individual resident and the system levels, paid and volunteer 
ombudsmen uniquely contribute to the well-being of LTC 
residents--complementing, but not duplicating, the 
contributions of regulatory agencies, families, community-based 
organizations, and providers. The summary report can be found 
in Appendix III.
    The Congressionally-mandated National Ombudsman Reporting 
System (NORS), established to obtain detailed ombudsman 
compliant and program information, was fully implemented. The 
information received from this report will serve as a basis for 
policy development and as a baseline against which to measure 
program outcomes in future years. The Introduction and Summary 
from the FY 1995 Long-Term Care Ombudsman Annual Report is 
included in Appendix IV.
    A special task force to develop outcome measures for the 
work of ombudsmen resulted in a report entitled ``An Approach 
to Measuring the Outcomes of the Long-Term Care Ombudsman 
Program'' which was issued to states and other interested 
parties.
    The Congressionally-mandated National Long-Term Care 
Ombudsman Resource Center continued to provide technical 
assistance and training activities for state long-term care 
ombudsmen in nursing homes and board and care facilities.

Preventing crime and violence

    A Crime/Violence Prevention Initiative which focused on the 
prevention of crimes and violence against older persons was 
initiated.
    The Congressionally-mandated National Center on Elder Abuse 
continued to serve the information, knowledge and skills 
development, and knowledge-building needs of organizations, 
individuals, and professionals working within and outside the 
nation's elder abuse/neglect prevention network.
    The AoA, in collaboration with the Department of Health and 
Human Services (HHS) Administration for Children and Families, 
is supporting a National Elder Abuse Incidence Study designed 
to examine the incidence of elder abuse, neglect, and financial 
exploitation. The study also identifies the characteristics of 
victims of domestic elder abuse, as well as those of the 
perpetrators. The second year of the three-year study was 
devoted to collecting data. The third year of the study will be 
devoted to the analysis of the data and dissemination of a 
final report upon completion.
    An interagency agreement with the Department of Justice to 
address the public safety and security needs of older Americans 
resulted in the formation of local and state TRIAD programs 
(efforts to increase cooperation between law enforcement and 
aging and social services providers to reduce criminal 
victimization).
    Final products from AoA-funded projects to link, at the 
state and local levels, domestic violence and aging networks 
were completed. They include manuals and other resources that 
are useful for developing programs for the protection of older 
women against domestic violence.

Cracking down on fraud

    The AoA worked in partnership with the Office of Inspector 
General and the Health Care Financing Administration in 
carrying out Operation Restore Trust--a Presidential initiative 
to detect and prevent fraud and abuse in the Medicare and 
Medicaid programs. This demonstration program began operating 
in five states--New York, Florida, Illinois, Texas, and 
California--and plans to expand nationally under the Health 
Insurance Accountability Act (Kassebaum-Kennedy bill).
    Through September 30, 1996, the program produced $57.5 
million in criminal and civil restitutions, fines, settlements 
and penalties.
    The AoA joined the American Association of Retired Persons, 
the National Association of Attorneys General, the Federal 
Bureau of Investigation, the U.S. Postal Inspection Service, 
the National Fraud Information Center, the Royal Canadian 
Mounted Police, MCI and Federal Express in launching 
``Operation Unload.'' This national effort, named after the 
boiler room operations (phone centers) commonly used by 
fraudulent telemarketers, warned elderly victims and potential 
victims that their names appear on telephone lists used by 
criminals and unscrupulous telemarketers for telemarketing 
schemes. Alerting potential victims that their names were on 
such lists, resulted in unloading their names from the lists. 
This effort reached nearly 2,000 people across the United 
States.

Increasing visibility of nutrition as key health component

    An independent Congressionally-mandated evaluation of the 
Elderly Nutrition Program (ENP) under Titles III and VI of the 
Act was completed. The study determined the effectiveness of 
the ENP in meeting the nutritional needs of older persons, as 
well as in addressing unmet needs. It was the first national 
evaluation of nutrition programs of the Act since 1983, and the 
first-ever to evaluate Title VI nutrition programs. Key 
findings include:
          The ENP provides an average of one million meals per 
        day to older Americans;
          People who receive ENP meals have higher daily 
        intakes of key nutrients than similar nonparticipants;
          ENP meals provide approximately 40 to 50 percent of 
        participants' intakes of most nutrients;
          Participants have more social contacts per month than 
        similar participants; and
          A dollar of Title III congregate nutrition funding is 
        supplemented with $1.70 from other sources. The 
        leveraging rate for home-delivered meals is higher: a 
        dollar of Title III home-delivered nutrition funding is 
        supplemented with $3.35 from other sources.
    The final report on the national evaluation of the Elderly 
Nutrition Program is included in Appendix V.

Implementing expedited assistance for disasters

    Because of the loss of Title IV discretionary funds in 
fiscal year 1996, AoA could not reserve funds to give to states 
for disaster assistance.
    The AoA signed a Statement of Understanding with the 
American Red Cross to make the delivery of relief efforts to 
elderly victims of disasters more efficient through cooperative 
efforts, including training, data collection, emergency meal 
distribution and transition of services.
    A training video distributed to the aging network which 
addresses the impact of disasters on the elderly was produced 
in both English and Spanish.

Improving customer service

    The first-ever strategic plan for the AoA was developed. 
The plan articulated the mission as well as goals and 
objectives for the agency and the aging network.
    A customer service plan for the AoA was included with HHS 
Secretary Shalala's plan. The plan contains nine customer 
service standards for the AoA employees in delivering services 
to older persons and their families, to State and Area Agencies 
on Aging, ITO's, as well as other agencies, organizations and 
grantees.
    The use of these standards was expanded by establishing a 
comprehensive AoA Website (http://www.aoa.dhhs.gov) on the 
Internet which provides current data and information on a 
variety of matters of concern to older consumers and their 
families.
    The ``AoA Update,'' a monthly newsletter, was created for 
distribution to the aging network, agency employees and other 
interested individuals to keep them apprised of agency 
activities/initiatives.
    A National Symposium on Performance-Based Management 
brought together representatives of the aging network to 
address data and technology requirements for the future.

           Section II--Enhancing the Capacity of the Network

Improving research, training and discretionary grants process

    The AoA undertook a variety of efforts which resulted in an 
improved discretionary grants process:
          Utilized the research, training and discretionary 
        funding program to move forward priorities of the 
        agency including home and community-based long-term 
        care, older women, nutrition/malnutrition, crime/
        violence prevention, and planning for the future.
          Improved the peer review process in awarding grants.
          Established field-initiated projects to encourage 
        creativity and innovation. Field-initiated projects 
        offer applicants an opportunity to propose and develop 
        innovative approaches which expand knowledge in any 
        policy, program, or related issue of importance to 
        older Americans without being confined by specific 
        priority areas.

Assessing cost sharing for services to older persons

    In anticipation of changes in the Act relating to cost 
sharing, the AoA commissioned the HHS Office of Inspector 
General to survey states and territories. The purpose of this 
activity was to describe current cost sharing activities within 
states and discuss implementation issues concerning cost 
sharing for services to older persons under Title III of the 
Act. The review found that although 36 states currently make 
use of cost sharing programs, states' specific experiences with 
these practices will affect their readiness to implement Title 
III cost sharing. This report is contained in Appendix VI.

Establishing a national aging data base information and resource center

    A Congressionally-mandated National Aging Information 
Center funded by AoA provided convenient access to a wide range 
of resources for those interested in aging issues and 
information. The Center served policymakers and Congress, the 
aging network, educators, researchers, practitioners and the 
public, and is the repository of documents and the final report 
of the 1995 While House Conference on Aging.

Working to expand home and community-based long-term care

    Four long-term care resource centers contributed to a long-
term care agenda aimed at the development of consumer-driven 
home and community-based systems of care for older persons who 
need services. Products included guidebooks, policy papers, 
manuals, and research briefs on such diverse topics as 
expanding consumer choices, addressing the needs of persons 
with disabilities, overcoming barriers to long-term care 
assistance in rural areas, examining managed care and frail 
elders, highlighting home and community-based cared best 
practices, evaluating housing for rural and African American 
elders, analyzing assisted living alternatives, reducing the 
cost of institutional care, improving transportation for the 
elderly, and others.
    Phase II of AoA's Health Care University (conference on 
managed care) brought together 750 representatives of the aging 
network to understand the concepts of managed care for the 
elderly and individuals with disabilities and its relationship 
to Medicare, Medicaid and the Act. The conference also provided 
an opportunity to examine ways to assure consumer protection 
and offer advocacy to those in managed care.
    The National Long-Term Care Mentoring Program continued to 
assist states to develop more extensive programs in home and 
community-based care, profile model home and community-based 
programs, and provide a corps of ``mentors'' with a wide range 
of expertise.
    The AoA continued support for the Neighborhood Senior Care 
Program which resulted in innovative neighborhood-based efforts 
which encourage health professionals and community volunteers 
to provide home and community-based services.
    A working partnership with the Department of Housing and 
Urban Development (HUD) enhanced the availability and 
accessibility of services for the elderly and persons with 
disabilities who reside in federally-assisted housing 
facilities. This collaboration with HUD also resulted in ``Best 
Practice'' awards to the top-rated housing facilities 
demonstrating successful coordination between the aging network 
and government-assisted housing facilities.

Establishing linkages between aging and disability communities

    The AoA joined as a participant in the National Coalition 
on Disability and Aging. The Coalition, comprised of twenty-
eight national aging and disability organizations, seeks to 
focus national attention on the common concerns of aging and 
disability constituencies. As a result of this linkage, 
collaboration was enhanced between the disability and aging 
communities, particularly with respect to home and community-
based services. Examples of collaborative efforts included:
          Funding projects to provide information and technical 
        assistance on consumer-directed services; building 
        model partnerships between communities; fostering 
        involvement of home and community-based consumers in 
        systems development; and coordinating with agencies 
        that serve persons with developmental disabilities;
          Provided joint funding with the HHS Office of the 
        Assistant Secretary for Planning and Evaluation for the 
        National Institute on Consumer-Directed Home and 
        Community-Based Care Systems to foster increased 
        opportunities for consumer choice and direction in 
        systems and services for adults with disabilities;
          Renewed an informal partnership with the National 
        Easter Seal Society designed to call greater attention 
        to the needs of individuals who suffer from post-polio 
        syndrome, the long-term impact of which mirrors an 
        accelerated aging process.

Documenting value of aging network in human terms

    The approval of the National Aging Program Information 
System State Program Report (SPR) by the Office of Management 
and Budget represents a successful conclusion to over four 
years of cooperative work between AoA and all levels of the 
aging network. The Congressionally-mandated SPR is a 
comprehensive and coordinated information and reporting system 
designed to provide data primarily on clients, services and 
costs of the programs provided to the elderly under the Act. 
The new state reporting requirements will replace a report 
having up to 30 categories of services with a report of no more 
than 15 categories of services, while at the same time 
providing more in-depth data on client characteristics. The 
reporting system, which includes electronic submission of 
reports to AoA, is an important step in enhancing the 
capacities of the aging network at all levels to utilize the 
data in support of policy development, program enhancement, and 
advocacy. Note that Appendix VII includes Executive Summary of 
the State Program Report for fiscal year 1995.

                  Section III--Planning for the Future

Preparing for the needs of a growing aging population

    An Initiative on Redefining Retirement resulted in a 
variety of efforts designed to lay the foundation for changing 
behaviors, attitudes and choices about planning for the future. 
This Initiative sought to educate and motivate baby boomers to 
make thoughtful choices now so that they will be more likely to 
be financially secure, productive, healthy and socially 
involved in their later years. Some examples of these efforts 
include:
          Initiated the National Planning Objectives Project 
        which brought together for the first time various 
        leaders of the public and private sector to explore and 
        initiate a process for setting national planning 
        objectives for an aging society;
          Established mechanisms for policy dialogue at the 
        national, state and local level by funding the National 
        Academy on Aging to serve as a resource for objective 
        information on broad policy issues;
          Provided funding to the Council of Governor's Policy 
        Advisors to work with states to help them better 
        understand the implications of an aging population for 
        state policymaking;
          Established partnerships with other federal agencies 
        such as the Social Security Administration and the 
        Department of Labor; and
          Cosponsored a publication produced by the 
        Metropolitan Life Insurance Company which provides tips 
        on how to enjoy one's retirement.

Improving service delivery to Hispanic elders

    The Assistant Secretary for Aging co-chaired the HHS 
Working Group on Hispanic Issues which worked to improve the 
delivery of services to Hispanic customers. The working group 
prepared a final report and recommendations for the Secretary 
on strategies for improving services to Hispanic Americans.
    Through the Eldercare Locator, a nationwide information and 
referral service funded by AoA, assistance is being made 
available in Spanish and the Locator is beginning an outreach 
campaign to inform the Hispanic community about this important 
service. A Spanish language brochure and advertisements have 
been developed.

Improving service delivery to American indians, Alaskan Natives, and 
        native Hawaiians

    To understand and respond to the home and community-based 
long-term care needs of American Indians and Alaskan Natives 
better, a survey of home and community-based long-term care in 
American Indian and Alaskan Native communities was completed. 
The Executive Summary from the report appears in Appendix VIII.
    The AoA convened the Fourth American Indian, Alaskan 
Native, and Native Hawaiian Elders Roundtable in Washington, 
D.C. The focus was on home and community-based long-term care 
in Native American communities.
    Grants totaling $16,057,000 were awarded to 221 ITO's and 
one Native Hawaiian organization for providing nutrition and 
supportive services to elders. A summary of the program 
performance data is contained in Appendix IX.
    The Third Annual National Title VI Training and Technical 
Assistance Meeting was held in Denver, Colorado. The focus was 
on ``Aging with Honor'' and included training on preventive 
health care, elder rights and abuse, and coordination of 
program resources.
    The University of Colorado at Denver and the University of 
North Dakota at Grand Forks were awarded cooperative agreements 
by AoA totaling approximately $500,000 to establish National 
Resource Centers for Older Indians, Alaskan Natives and Native 
Hawaiians. The primary focus of both centers is health, 
community-based long-term care and related issues. The Centers 
are the focal points for the development and sharing of 
technical information and expertise to ITO's, Title VI 
grantees, Native American communities, educational 
institutions, and professionals and paraprofessionals in the 
field.
    The Federal Interagency Task Force on Older Indians which 
facilitates coordination among federally-funded programs to 
improve services to older Indians focused on three areas of 
concern to older Indians during fiscal year 1996: health, 
transportation, and data. The Task Force will make 
recommendations to further interagency collaboration and 
enhance services to older Indians, and highlight problems, 
issues and/or barriers that prevent or diminish collaboration.

Working to improve the quality of life for older women

    The AoA participated in a variety of collaborative efforts 
designed to improve the quality of life for older women:
          Launching the ``Pensions Not Posies Campaign''--a 
        public education effort developed by the Pension Policy 
        Consortium to inform women about the importance of 
        pensions and future planning;
          Convening a roundtable entitled ``Grass Roots 
        Innovations for Older Women's Employment'' in 
        collaboration with the Pension Rights Center. The forum 
        highlighted innovative mechanisms at the state and 
        local level for assisting women to overcome barriers to 
        employment in areas of job training, caregiving and 
        pensions; and
          Working with HHS Secretary Donna Shalala's work group 
        to prepare for the 39th Session of the United Nations' 
        Commission on the Status of Women; the Beijing Task 
        Force which focused on implementation of 
        recommendations adopted by the 4th World Conference on 
        Women; and the National Action Plan on Breast Cancer 
        Federal Coordinating Committee.
    The National Policy and Resource Center on Women and Aging, 
established by AoA to provide a national focal point for 
coordinating efforts to educate older women at a grassroots/
local level, convened a National Conference on Women and Aging 
in conjunction with the Office of Women's Health in HHS. The 
Center published a monthly newsletter focused on critical 
issues impacting older women, as well as numerous pamphlets and 
reports on topics of interest to women including hormone 
replacement therapy, caregiving, housing, health care and 
economic security.

            Section V--Expanding International Partnerships

Established cooperative efforts with Mexico and China

    The AoA worked to establish stronger partnerships between 
Mexico, China and the United States in preparing for the 
growing numbers of older persons in their honored countries and 
to elevate aging matters as a priority issue of mutual concern.
    The Assistant Secretary for Aging was a keynote speaker at 
the International Symposium of Geriatrics and Gerontology, held 
in Guadalajara, Mexico.

Provided briefings for foreign officials

    In fiscal year 1996, the AoA held a number of briefings for 
visiting officials, including those from China, Japan, France, 
Mexico, Uruguary, Latvia, Korea, Taiwan, Turkey, Argentina and 
the Slovak Republic.

Provided international training and technical assistance

    A Memorandum of Understanding between AoA and Sister Cities 
International resulted in joining aging professionals and 
volunteers in the United States with their counterparts in 
other countries to provide technical assistance in meeting the 
needs of an aging population.
    With the cooperation of the U.S. Information Agency's 
Individual Visitor Program and the National Personnel Authority 
in Japan, the AoA also mentored two officials from the Japanese 
Ministry of Health and Welfare who studied health care reform 
and aging in the U.S.
             Section I--The National Aging Service Network





        Section II--FY 1995 and FY 1996 Budget Tables and Charts





   Section III--Summary Report of the Institute of Medicine's ``Real 
 People, Real Problems: An Evaluation of the Long-Term Care Ombudsman 
                 Programs of the Older Americans Act''





  Section IV--Long-Term Care Ombudsman Annual Report Fiscal Year 1995 
              (Executive Summary Introduction and Summary)





 Section V--``Serving Elders At Risk,'' the National Evaluation of the 
             Elderly Nutrition Program (Executive Summary)





                Section VI--Office of Inspector General





Section VII--State Program Report (Executive Summary), Fiscal Year 1995





   Section VIII--Home and Community-Based Long-Term Care in American 
        Indian and Alaska Native Communities (Executive Summary)





     Section IX--Native American Elders Report, Covering 1991-1995





                ADMINISTRATION FOR CHILDREN AND FAMILIES

              Title XX Social Service Block Grant Program

    The major source of Federal funding for social services 
programs in the States is Title XX of the Social Security Act, 
the Social Services Block Grant (SSBG) program. The Omnibus 
Budget Reconciliation Act of 1981 (Public Law 97-35) amended 
Title XX to establish the SSBG program under which formula 
grants are made directly to the 50 States, the District of 
Columbia, and the eligible jurisdictions (Puerto Rico, Guam, 
the Virgin Islands, American Samoa, and the Commonwealth of the 
Northern Mariana Islands) for use in funding a variety of 
social services best suited to the needs of individuals and 
families residing within the State. Public Law 97-35 also 
permits States to transfer up to ten (10) percent of their 
block grant funds to other block grant programs for support of 
health services, health promotions and disease prevention 
activities, and low-income home energy assistance.
    Under the SSBG, Federal funds are available without a 
matching requirement. In fiscal year 1995, a total of $2.8 
billion was allotted to States. $2.381 billion was appropriated 
for these activities in fiscal year 1996. Within the specific 
limitations in the law, each State has the flexibility to 
determine what services will be provided, who is eligible to 
receive services, and how funds are distributed among the 
various services within the State. State and/or local Title XX 
agencies (i.e., county, city, regional offices) may provide 
these services directly or purchase them from qualified 
agencies and individuals.
    A variety of social services directed at assisting aged 
persons to obtain or maintain a maximum level of self-care and 
independence may be provided under the SSBG. Such services 
include, but are not limited to adult day care, adult foster 
care, protective services, health-related services, homemaker 
services, chore services, housing and home maintenance 
services, transportation, preparation and delivery of meals, 
senior centers, and other services that assist elderly persons 
to remain in their own homes or in community living situations. 
Services may also be offered which facilitate admission for 
institutional care when other forms of care are not 
appropriate. Under the SSBG, States are not required to submit 
data that indicate the number of elderly recipients or the 
amount of expenditures provided to support specific services 
for the elderly. States are required, prior to the expenditures 
of funds under the SSBG, to prepare a report on the intended 
use of the funds including information on the type of 
activities to be supported and the categories or 
characteristics of individuals to be served. States also are 
required to report annually on activities carried out under the 
SSBG. Beginning with fiscal year 1989, the annual report must 
include specific information on the numbers of children and 
adults receiving services, the amount spent in providing each 
service, the method by which services were provided, i.e., 
public or private agencies, and the criteria used in 
determining eligibility for each service.
    Based on an analysis of post-expenditure reports submitted 
by the States for fiscal year 1995, the list below indicates 
the number of States providing certain types of services to the 
aged under the SSBG.

                                                    Number of States \1\
Services:
    Home-Based Services \2\.......................................    45
    Adult Protective Services.....................................    35
    Transportation Services.......................................    29
    Adult Day Care................................................    29
    Health Related Services.......................................    21
    Information and Referral......................................    27
    Home Delivered/Congregate Meals...............................    22
    Adult Foster Care.............................................    15
    Housing.......................................................    12

\1\ Includes 50 States, the District of Columbia, and the five eligible 
territories and insular areas.
\2\ Includes homemaker, chore, home health, companionship, and home 
maintenance services.

    In enabling the elderly to maintain independent living, 
most States provide Home-Based Services which frequently 
includes homemaker services, companion and/or chore services. 
Homemaker services may include assisting with food shopping, 
light housekeeping, and personal laundry. Companion services 
can be personal aid to, and/or supervision of aged persons who 
are unable to care for themselves without assistance. Chore 
services frequently involve performing home maintenance tasks 
and heavy housecleaning for the aged person who cannot perform 
these tasks. Based on the FY 95 data, 35 States provided Adult 
Protective Services to persons generally sixty years of age and 
over. These services may consist of the identification, 
receipt, and investigation of complaints and reports of adult 
abuse. In addition, this service may involve providing 
counseling and assistance to stabilize a living arrangement. If 
appropriate, Adult Protective Services also may include the 
provision of, or arranging for, home based care, day care, meal 
service, legal assistance, and other activities to protect the 
elderly.

               Low Income Home Energy Assistance Program

    The Low Income Home Energy Assistance Program (LIHEAP) is 
one of six block grant programs administered within the 
Department of Health and Human Services (HHS). LIHEAP is 
administered by the Office of Community Services (OCS) in the 
Administration for Children and Families.
    LIHEAP helps low income households meet the cost of home 
energy. The program is authorized by the Omnibus Budget 
Reconciliation Act of 1981, as amended most recently by the 
Augustus F. Hawkins Human Services Reauthorization Act of 1990, 
the NIH Revitalization Act of 1993 (P.L. 103-43), and the Human 
Services Amendments of 1994 (P.L. 103-252). In fiscal year 
1989, Congress appropriated $1.383 billion for the program. 
Congress appropriated $1.443 billion for LIHEAP in fiscal year 
1990, which included $50 million in supplemental 
appropriations. In fiscal year 1991, Congress appropriated 
$1.415 billion plus a contingency fund of $195 million, which 
went into effect when fuel oil prices went above a certain 
level. For FY 1992, $1.5 billion was appropriated, plus a 
contingency fund of $300 million that would have been triggered 
if the President had declared an emergency and had requested 
the funds from Congress. Congress appropriated funding of 
$1,346,029,877 for FY 1993, plus a contingency fund of 
$595,200,000 that would have been triggered if the President 
had declared an emergency and had requested the funds from 
Congress. For FY 1994, Congress appropriated $1,437,408,000, of 
which $141,950,240 could be used by grantees to reimburse 
themselves for FY 1993 expenses. In addition, Congress 
rescinded some funds and appropriated energy emergency 
contingency funds of $300,000,000, which were released when the 
President declared an emergency and requested the funds from 
Congress, thus providing a total of $1,737,392,360 for FY 1994. 
The FY 1994 appropriations act provided advance FY 1995 funds 
of $1.475 billion. The FY 1995 HHS appropriations act rescinded 
part of the advance FY 1995 appropriations included in the FY 
1994 appropriations law, leaving funding of $1,319,202,479 for 
FY 1995. In addition, Congress appropriated energy emergency 
contingency funds of $300,000,000, of which $100 million were 
released when the President declared an emergency and requested 
the funds from Congress, thus providing a total of 
$1,419,202,479 for FY 1995. The FY 1995 HHS appropriations law 
also provided for advance FY 1996 funding of $1,319,204,000. 
Congress rescinded part of the advance funding for FY 1996 in 
the FY 1995 supplemental appropriations law and in the FY 1996 
appropriations law, leaving funding of $899,997,500. In 
addition, Congress appropriated energy emergency contingency 
funds of $300,000,000, of which $180 million were released when 
the President declared an emergency and requested the funds 
from Congress, thus providing a total of $1,079,997,500 for FY 
1996. Congress did not appropriate in advance for FY 1997.
    Block grants are made to States, territories, and eligible 
applicant Indian Tribes. Grantees may provide heating 
assistance, cooling assistance, energy crisis interventions, 
and low-cost residential weatherization or other energy-related 
home repair to eligible households. Grantees can make payments 
to households with incomes not exceeding the greater of 150 
percent of the poverty level or 60 percent of the State's 
median income.\1\ Most households in which one or more persons 
are receiving Aid to Families with Dependent Children, 
Supplemental Security Income, Food Stamps or need-tested 
veterans' benefits may be regarded as categorically eligible 
for LIHEAP.
---------------------------------------------------------------------------
    \1\ Beginning with fiscal year 1986, States are prohibited from 
setting income eligibility levels lower than 110 percent of the poverty 
level.
---------------------------------------------------------------------------
    Low income elderly households are a major target group for 
energy assistance. They spend, on average, a greater portion of 
their income for heating costs than other low income 
households. Grantees are required to target outreach activities 
to elderly or handicapped households eligible for energy 
assistance. In their crisis intervention programs, grantees 
must provide physically infirm individuals the means to apply 
for assistance without leaving their homes, or the means to 
travel to sites where applications are accepted.
    In fiscal year 1995, about 34 percent of households 
receiving assistance with heating costs included at least one 
person age 60 or over, as estimated by the March 1995 Current 
Population Survey.
    OCS is a member of the National Energy and Aging 
Consortium, which focuses on helping older Americans cope with 
the impact of high energy costs and related energy concerns.
    No major program and policy changes for the elderly 
occurred in the 1990 or 1993 reauthorization legislation. The 
1994 reauthorization legislation specifically allows grantees 
to target funds to vulnerable populations, mentioning by name 
``frail older individuals'' and ``individuals with 
disabilities''. No new initiatives commenced in 1995 or 1996 
that impacted on the status of older Americans.

       The Community Services Block Grant (CSBG) and the Elderly

    I. Community Service Block Grant--The Community Service 
Block Grant Act (Subtitle B, Public Law 97-35 as amended) is 
authorized through fiscal year 1998. The Act authorizes the 
Secretary, through the Office of Community Services (OCS), an 
office within the Administration for Children and Families in 
the Department of Health and Human Services, to make grants to 
States and Indian tribes or tribal organizations. States and 
tribes have the authority and the flexibility to make decisions 
about the kinds of local projects to be supported by the State 
or tribe, using CSBG funds. The purposes of the CSBG program 
are:
          (A) to provide a range of services and activities 
        having a measurable and potentially major impact on 
        causes of poverty in the community or those areas of 
        the community where poverty is a particularly acute 
        problem.
          (B) to provide activities designed to assist low 
        income participants including the elderly poor--
                  (i) to secure and retain meaningful 
                employment;
                  (ii) to attain an adequate education;
                  (iii) to make better use of available income;
                  (iv) to obtain and maintain adequate housing 
                and a suitable living environment;
                  (v) to obtain emergency assistance through 
                loans or grants to meet immediate and urgent 
                individual and family needs, including the need 
                for health services, nutritious food, housing, 
                and employment-related assistance;
                  (vi) to remove obstacles and solve problems 
                which block the achievement of self-
                sufficiency;
                  (vii) to achieve greater participation in the 
                affairs of the community; and
                  (viii) to make more effective use of other 
                programs related to the purposes of the 
                subtitle,
          (C) to provide on an emergency basis for the 
        provision of such supplies and services, nutritious 
        foodstuffs and related services, as may be necessary to 
        counteract conditions of starvation and malnutrition 
        among the poor;
          (D) to coordinate and establish linkages between 
        governmental and other social services programs to 
        assure the effective delivery of such services to low 
        income individuals; and
          (E) to encourage the use of entities in the private 
        sector of the community in efforts to ameliorate 
        poverty in the community; (Reference Section 675(c)(1) 
        of Public Law 97-35, as amended).
    It should be noted that although there is a specific 
reference to ``elderly poor'' in (B) above, there is no 
requirement that the States or tribes place emphasis on the 
elderly or set aside funds to be specifically targeted on the 
elderly. Neither the statute nor implementing regulations 
include a requirement that grant recipients report on the kinds 
of activities paid for from CSBG funds or the types of indigent 
clients served. Hence, it is not possible for OCS to provide 
complete information on the amount of CSBG funds spent on the 
elderly, or the number elderly, or the numbers of elderly 
persons served.
    II. Major Activities or Research Projects Related to Older 
Citizens in 1995 and 1996--The Office of Community Services 
made no major changes in program or policy related to the CSBG 
program in 1995 or 1996. The Human Services Reauthorization Act 
of 1986 contained the following language: ``each such 
evaluation shall include identifying the impact that assistance 
. . . has on . . . the elderly poor.'' The reauthorization act 
of 1994 requires local community action agencies to include a 
description of how linkages will be developed to fill 
identified gaps in services through information, referral, case 
management, and followup consultations as well as a description 
of outcome measures to be used to monitor success in promoting 
self sufficiency, family stability and community 
revitalization. As a result, the CSBG Task Force on Monitoring 
and Assessment, a representative body of eligible entities, 
established a goal which states, ``Low-income people, 
especially vulnerable populations, achieve their potential by 
strengthening family and other support systems''. This goal 
assists local, state and federal agencies to focus jointly on 
vulnerable populations, particularly the frail elderly.
    III. Funding Levels--Funding levels under the CSBG program 
for States and Indian Tribes or tribal organizations amounted 
to $389.6 million in fiscal year 1995. For fiscal year 1996, 
$389.5975 million was appropriated.

              Aging and Developmental Disabilities Program

                       critical audiences project

    Grantee: Institute for the Study of Developmental 
Disabilities, Indiana University.
    Project Director: Barbara Hawkins, Ph.D., (812) 855-6506; 
Fax (812) 855-9630.
    Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY 
'95-$99,000, FY '96-$72,364.
    The project provides training in a late-life functional-
developmental model for audiences that are critical to 
effective planning and care of older persons. Activities 
include developing training modules and instructional videos 
for interdisciplinary university credit courses, and 
illustrating the model by demonstration projects in community 
retirement settings.

          center on aging and developmental disabilities/cadd

    Grantee: University of Miami/CADD, Miami, FL.
    Project Director: John Stokesberry, Ph.D., (305) 325-1043.
    Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY 
'95-$99,000, FY '96-$72,364.
    CADD is providing education and training to service 
providers, parents and families; advocacy and outreach for 
consumers, information to the public on aging and developmental 
disabilities; networking, policy direction and community-based 
research. Materials will include a manual for parents/ 
caregivers, a resource guide and a handbook on developing a 
peer companion project.

                   interdisciplinary training center

    Grantee: UAP--Institute for Human Development, University 
of Missouri-Kansas City.
    Project Director: Gerald J. Cohen, J.D., M.P.A., (816) 235-
1770; Fax (816) 235-1762.
    Project Period: 7/1/90-6/30/96, FY '91-$90,000, FY '92-
$90,000, FY '93-$90,000, FY '94-$90,000, FY '95-$99,000, FY 
'96-$72,364.
    The Center addresses personnel preparation needs with a 
focus on administration, interdisciplinary training, exemplary 
services, information/technical assistance/research; and 
evaluation. Materials include training guide for aging, 
infusion models, inservice fellowship curriculum, resource 
bibliography, guide for training volunteers, and course 
syllabus.

                    training models for rural areas

    Grantee: Montana University Affiliated Rural Institute on 
Disabilities, Missoula, MT.
    Project Director: Philip Wittekiend, M.S., (406) 243-5467; 
Fax (406) 243-2349.
    Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY 
'95-$99,000, FY '96-$72,364.
    Montana's focus is on linking exiting networks and 
expertise to meet the unique needs of a rural area with sparse 
populations and limited professional resources. The project 
will develop audio conference packages with simultaneous long 
distance training for remote areas and involve nontraditional 
networks such as churches and senior groups.

                  consortium of educational resources

    Grantee: UAP--University of Rochester Medical Center, 
Rochester, NY.
    Project Director: Jenny C. Overeynder, ACSW, (716) 275-
2986; Fax (716) 256-2009.
    Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY 
'95-$99,000, FY '96-$72,364.
    An inter-university interdisciplinary consortium of 
educational resources in gerontology and developmental 
disabilities is being established in western New York, to be 
linked to local and state networks. The project will develop 
and implement preservice and inservice education curriculum for 
direct care and nursing home staff.

aging and developmental disabilities clinical assessment, training and 
                                service

    Grantee: Waisman Center UAP, University of Wisconsin-
Madison.
    Project Director: Gary B. Seltzer, Ph.D. (608) 263-1472; 
Fax (608) 263-0529.
    Project Period: 7/1/90-6/30/96, FY '90-$90,000, FY '91-
$90,000, FY '92-$90,000, FY '93-$90,000, FY '94-$90,000, FY 
'95-$99,000, FY '96-$72,364.
    Waisman Center operates an interdisciplinary clinic, 
provides training to health care and other professionals, and 
disseminates information and technical assistance to director 
care networks. Materials include a functional assessment 
instrument and curricula for medical students, geriatric 
fellows and physician assistants.

                interdisciplinary training models (idt)

    Grantee: UAP, College of Family and Consumer and Consumer 
Sciences.
    Project Director: Zolinda Stoneman, Ph.D., (404) 542-4827; 
Fax (404) 542-4815.
    Project Period: 7/1/90-6/30/96, FY '91-$90,000, FY '92-
$90,000, FY '93-$90,000, FY '94-$90,000, FY '95-$99,000, FY 
'96-$72,364.
    This project is using IDT models for graduate and 
undergraduate training, developing community-based internship 
and practicum sites; collecting audiovisual materials for 
dissemination; and providing information to the UAP regional 
information and referral service. Products will include 
training videotapes and modules, course materials, and radio 
program recordings.

      training initiative in aging and developmental disabilities

    Grantee: Institute for the Study of Developmental 
Disabilities, University of Illinois at Chicago.
    Project Director: David Braddock, Ph.D., (312)-413-1647.
    Project Period: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
    The project addresses three priority areas emerging from 
the UAP's research activities and clinical programs: (1) 
advocacy and futures planning for older adults with 
developmental disabilities and their families; (2) to maintain 
functioning and promote community inclusion for aging persons 
with cerebral palsy; and (3) to enhance the psychosocial well-
being of aging persons with Down Syndrome and bolster older 
families' caregiving efforts.

         community membership through person-centered planning

    Grantee: Eunice Kennedy Shriver Center, Inc. Shriver Center 
UAP.
    Project Director: Karen E. Gould, Ph.D., (617) 642-0238.
    Project Period: 7/1/92-6/30/96, FY '92-$89,999, FY '93-
$89,999, FY '94-$89,999, FY '95-$99,000, FY '96-$72,364.
    The Center has two primary goals which are: (1) to 
implement a service delivery model that creates a new vision 
for individuals who are labeled ``old'' and ``developmentally 
disabled'' in Massachusetts, one in which entry into valued 
adult roles is expected and capacities and interests form the 
basis for structuring support; and (2) to provide training to 
persons with developmental disabilities, family members and 
friends, graduate students, professionals and community members 
so that they can develop the skills necessary to support 
community entry and inclusion in valued roles and relationships 
for older adults with developmental disabilities, and learn to 
use these skills in other settings.

a collaborative interdisciplinary training approach to improve services 
            to aging persons with developmental disabilities

    Grantee: Institute for Disability, University of Southern 
Mississippi.
    Project Director: Valerie M. De Coux, (601) 266-5163.
    Project Period: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
    The project develops a collaborative interdisciplinary 
training approach to meet pre-service, in-service, and consumer 
needs. Training of professionals and paraprofessionals occurs 
at both the pre-service and in-service levels and focuses on 
cross-network training in best practices which ensures an 
optimal quality of life for older persons with developmental 
disabilities.

 north dakota project for older persons with developmental disabilities

    Grantee: North Dakota Center for Disabilities, Minot State 
University.
    Project Director: Dr. Rita Curl and Dr. Demetrios 
Vassiliou, (701) 857-3580.
    Project Period: 7/1/93-6/30/96, FY '93-$90,000, FY '94-
$90,000, FY '95-$99,000, FY '96-$72,364.
    The project seeks to upgrade the training opportunities 
available to North Dakotans; (1) project staff works with pre-
service geriatric programs to develop strong DD components; (2) 
project staff expands on an existing inservice training program 
to provide information on aging DD service provision; and (3) 
the project supports the development of training opportunities 
for secondary consumer and advocates.

   interdisciplinary training initiative on aging and developmental 
                              disabilities

    Grantee: Graduate School of Public Health, University of 
Puerto Rico--Medical Sciences.
    Project Director: Dr. Margarita Miranda, (809) 758-2525, 
ext. 11453, (809) 754-4377.
    Project Period: 8/2/94-6/30/97, FY '94-$90,000, FY '95-
$90,000, FY '96-$72,364, FY '97-$90,000.
    The project provides pre-service training including 
practical experience on best practices in serving the older 
population with developmental disabilities to three (3) 
graduate and to three (3) undergraduate students from different 
disciplines per year (from the second funding year on); 
provides culturally adapted in-service training to the Catano 
Family Health Center's interdisciplinary team and to at least 
40 professionals in the aging service per year through the 
Graduate School and implementation of five regional Seminars on 
Aging and Developmental Disabilities throughout Puerto Rico.

     OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION

    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) serves as the principal advisor to the 
Secretary on policy and management decisions for all groups 
served by the Department, including the elderly. ASPE oversees 
the Department's legislative development, planning, policy 
analysis, and research and evaluation activities and provides 
information used by senior staff to develop new policies and 
modify existing programs.
    ASPE is involved in a broad range of activities related to 
aging policies and programs. It manages grants and contracts 
which focus on the elderly and coordinates other activities 
which integrate aging concerns with those of other population 
groups. For example, the elderly are included in studies of 
health care delivery, poverty, State-Federal relations and 
public and private social service programs.
    ASPE also maintains a national clearinghouse which includes 
aging research and evaluation materials. The ASPE Policy 
Information Center (PIC) provides a centralized source of 
information about evaluative research on the Department's 
programs and policies by tracking, compiling, and retrieving 
data about ongoing and completed HHS evaluations. In addition, 
the PIC data base includes reports on ASPE policy research 
studies, the Inspector General's program inspections and 
investigations done by the General Accounting Office and the 
Congressional Budget Office. Copies of final reports of the 
studies described in this report are available from PIC.
    During 1995 and 1996, ASPE undertook or participated in the 
following analytic and research activities which had a major 
focus on the elderly.

                      1. policy development--aging

Task force and Alzheimer's disease

    As a member of the DHHS Council on Alzheimer's Disease, 
ASPE helps prepare the annual report to Congress on selected 
aspects of caring for persons with Alzheimer's Disease. The 
report focuses on the Department's current and planned services 
and research initiatives on the disease.

Federal Interagency Forum on Aging-Related Statistics

    ASPE is a member of the Federal Interagency Forum on Aging-
Related Statistics. The Forum was established to encourage the 
development, collection, analysis, and dissemination of data on 
the older population. The Forum seeks to extend the use of 
limited resources among the agencies through joint problem-
solving, identification of data gaps, and improvement of the 
statistical information bases on the older population.

Departmental Data Planning and Analysis Work Group

    The Data Planning and Analysis Work Group chaired by ASPE 
analyzes Departmental data requirements and develops plans for 
fostering the full utilization of such data. The Group 
identifies needs for data within DHHS, evaluates the capacity 
of current systems to meet these needs and prepares 
recommendations for the effective performance of DHHS data 
systems.

Long-term care microsimulation model

    During 1995 and 1996, ASPE continued to use extensively the 
Long-Term Care Financing Model developed by ICF and the 
Brookings Institution. The model simulates the use and 
financing of nursing home and home care services by a 
nationally representative sample of elderly persons. It gives 
the Department the capacity to simulate the effects of various 
financing and organizational reform options on public and 
private expenditures for long-term care services.

                 2. Research and Demonstration Projects

Panel Study of Income Dynamics

University of Michigan, Institute for Social Research--Principal 
        investigators: Sandra Hofferth, Frank Stafford

    Through an interagency consortium coordinated by the 
National Science Foundation, ASPE assists in the funding of the 
Panel Study of Income Dynamics (PSID). This is an ongoing 
nationally representative longitudinal survey that began in 
1968 under the auspices of the Office of Economic Opportunity 
(OEO). The PSID has fathered information on family composition, 
employment, sources of income, housing, mobility, health and 
functioning, and other subjects. The current sample size is 
over 7,000 persons, and an increasing number of them are 
elderly. The data files have been disseminated widely and are 
used by hundreds of researchers in this and other countries to 
get an accurate picture of changes in the well-being of 
different demographic groups, including the elderly.
    Funding: ASPE and HHS precursors: FY67 through FY79--
$10,559,498; FY80--$698,952; FY81--$600,000; FY82--$200,000; 
FY83--$251,000; FY84--$550,000; FY85--$300,000; FY86--$225,000; 
FY87--$250,000; FY88--$250,000; FY89--$250,000; FY90--$300,000; 
FY93--$300,000; FY94--$800,000; FY95--$300,000; FY96--$300,000; 
FY97--$300,000.
    End date: Ongoing.

Assets and health dynamics (AHEAD) of the oldest old

University of Michigan, Survey Research Center--Principal 
        investigators: Regula Herzog, U. Michigan, Beth Soldo, 
        Georgetown Univ.

    Beginning in 1992 the Health and Retirement Survey, which 
is funded principally by the National Institute in Aging, began 
to follow a cohort of men and women aged 51 to 61 to track 
various aspects of health status, retirement patterns and use 
of health and other services.
    The AHEAD survey is a companion to the HRS. It surveys a 
nationally representative community sample of persons aged 70 
and over. It was first fielded in 1993 and is administered 
every two years longitudinally. AHEAD focuses on a variety of 
key aging-related issues, such as health and functional status, 
family structure and transfers, income and wealth; health 
insurance; and work activities. In 1994, ASPE funded an Early 
Results Workshop at the University of Michigan, at which a 
number of papers were presented using AHEAD data. The workshop 
papers subsequently became the basis for a Special Issue of the 
Journal of Gerontology: Psychological and Social Sciences (May 
1997) on AHEAD.
    Funding: FY94--$30,000 (for Early Results Workshop).
    End date: September 1994.

Analysis of State Board and Care Regulations and Their Effects on the 
        Quality of Care

Research Triangle Institute--Principal investigator: Catherine Hawes

    As the nation's long-term care system evolves, more 
emphasis is being placed on home and community-based care as an 
alternative to institutional care. Community-based living 
arrangements for dependent populations (disabled elderly, 
mentally ill, persons with mental retardation/developmental 
disabilities) play a major role in the continuum of long-term 
care and disability-related services. Prominent among these 
arrangements are board and care homes. There is a widespread 
perception in the Congress and elsewhere that too often board 
and care home residents are the victims of unsafe and 
unsanitary living conditions, abuse and neglect by operators, 
and fraud.
    This project analyzed the impact of State regulations on 
the quality of care in board and care homes in ten States and 
documented the characteristics of board and care facilities, 
their owners and operators, and collect information on the 
health status, level of dependency, program participation and 
service needs of residents. Key findings were the B&C residents 
are significantly older and more frail than was true a decade 
ago. Appropriate regulation and licensure requirements result 
in homes that are better prepared to meet the needs of the 
resident population. Thee include: (1) greater availability of 
supportive services (2) lower use of psychotropic drugs and 
medications and (3) more operator training in the care of the 
frail elderly and other persons with disabilities.
    Funding: FY 1989--$350,000; FY 1990--$300,000; FY 1991--
$400,000.
    End date: September 1995.

Evaluation of the Elderly Nutrition Program

Mathematica Policy Research--Principal investigator: Michael Ponza

    At the request of Congress (Section 206 of the 1992 Older 
Americans Act Amendments), the Department of Health and Human 
Services in conducting an evaluation of the Elderly Nutrition 
Program. The evaluation, which is co-sponsored by ASPE and the 
Administration on Aging, provided estimates of the impact of 
the program's nutritional components on the nutrition, health, 
functioning, and social well being of participants. It 
described how the program is administered, operated and funded, 
and the effectiveness of those components. The study also 
described and compared the characteristics of congregate and 
home-delivered meal participants, and assessed how well the 
program reached special populations, such as low-income and 
minority elderly. The study covered 57 State Units on Aging, 
250 Area Agencies on Aging, 100 Indian Tribal Organizations and 
200 Nutrition Projects. The key findings were that people who 
participated in the Elderly Nutrition Program have higher daily 
intake of key nutrients than similar nonparticipants, that 
participants have more social contacts per month than similar 
nonparticipants and that most participant are satisfied with 
ENP services.
    Funding: FY 1993--$1,200,000; FY 1994--$1,245,000.
    End date: September 1995.

A national study of assisted living for the frail elderly

Research Triangle Institute--Principal investigator: Catherine Hawes

    ASPE has commissioned a national study of assisted living. 
Assisted living refers to residential settings that combine 
housing, personal assistance and other supportive service 
arrangements for persons with disabilities. These settings are 
thought to offer greater autonomy and control to consumers over 
their living and service arrangements than is typically 
provided by more traditional residential settings, such as 
nursing homes or board and care homes. The study will focus on 
such issues as (a) trends the supply of assisted living 
facilities, (b) barriers to development (c) the existing 
regulatory structure, (d) the extent to which assisted living 
embodies in reality the principles of consumer autonomy and 
choice in a supportive residential setting, and (e) the effect 
of such features (or their absence) on persons who live and 
work in assisted living facilities. The study will include data 
from owner/operators, staff and residents from a national 
sample of 690 assisted living facilities.
    Funding: FY94-$200,000; FY 96-$200,000.
    End date: July 1999.

Creating a multistate database for dual eligibles

Mathematica Policy Research (MPR)--Principal investigator: Sue Dodds

    There has been growing interest in the service utilization 
and expenditure patterns of individuals enrolled in both 
Medicare and Medicaid (i.e., dual eligibles). In order to 
provide important data on these populations, two ASPE offices 
(HP and DALTCP) collaborate with HCFA to fund a project that 
will link Medicare and Medicaid data in 10-12 states. This is 
an effort to develop a uniform database that can be utilized by 
both States and the Federal Government to improve the 
efficiency and effectiveness of both acute and long-term care 
services provided to these populations. More specifically, the 
project strengthens the ability of HHS and States to develop 
effective risk-adjusted payment methods for dual eligibles, and 
further understanding of how interactions between the Medicare 
and Medicaid programs affect the access, costs and quality of 
services received by dually eligible beneficiaries.
    Funding information: FY 97--$1,024,000 (ASPS funds--
$350,000)
    End date: Fall 2000

Impact of Medicare HMO Enrollment on health care costs in California

RAND--Principal investigator: Glenn Melnick

    This work is an extension of previous APSE--funded work. 
The contractor performs three major activities including: (1) 
updating the earlier analysis of competition and selective 
contracting in California to the most recent year available; 
(2) analyzing the effects of Medicare managed care penetration 
on hospital Medicare Costs and Utilization at the county level; 
and (3) analyzing the effects on beneficiary utilization and 
costs of joining managed care plans. In addition, the 
feasibility of conducting a fourth analysis will be assessed; 
namely to replicate analysis number three for beneficiaries who 
have withdrawn from Medicare managed care plans in the recent 
past to try to see if such beneficiaries are different from 
those who remain in managed care. The contractor will put out a 
public use file with documentation of the materials gathered 
since 1980 with ASPE support beginning in 1987.
    The project builds upon previous ASPE-funded work. It 
compares pre-managed care enrollment characteristics, service 
utilization, and costs among demographically-matched 
individuals in standard Medicare and Medicare HMOs. In 
addition, the project includes comparisons with a third group 
of persons who disenrolled from Medicare HMOs. This data will 
then be used to build prediction models for subsequent years.
    Funding: FY 94--$531,000; FY 97--$160,000.
    End date: Fall 1998.

SENATE SPECIAL COMMITTEE ON AGING'S ANNUAL REPORT--CDC UPDATE FOR 1995 
                                AND 1996

(1) National Center for Chronic Disease Prevention and Health Promotion 
        (NCCDPHP)

    In the paragraph regarding Quality-of-Life, page 175, 
please change ``1993'' to ``1993-1996'' (with respect to 
BRFSS).
    There are about three paragraphs of program-specific 
language at the end of the report, regarding Diabetes and 
Breast and Cervical Cancer.

(2) National Center for Environmental Health

    The following programs should be added to update the 
information for 1995-1996:
    The National Center For Environmental Health (NCEH) has 
collaborated in a study of 180 women to determine risk factors 
for osteoporosis, including vitamin D receptor polymorphisms.
    NCEH has spearheaded the establishment of the Cholesterol 
Reference Method Laboratory Network (CRMLN) that helps assure 
the quality of total cholesterol and HDL cholesterol 
measurements in clinical laboratories in the United States. 
High quality cholesterol measurements assure correct diagnosis 
and treatment of elevated cholesterol levels.
    The Office on Disability and Health (ODH) at NCEH is 
collaborating with the NCCDPHP in two activities that relate to 
the process of aging. First, ODH is partnering with the Health 
Care and Aging Branch in the Johnston County Osteoarthritis 
Longitudinal Study to describe the epidemiology of secondary 
conditions in persons with hip and knee osteoarthritis that 
result in functional limitation and disability.
    Second, ODH provides technical assistance to disability 
related activities within the University of Washington Center 
for Health Promotion in Older Adults, A NCCDPHP Prevention 
Research Center. Aims of this prevention center related to 
disabilities include (a) implementing community-wide elderly 
chronic disease and disability reduction efforts under the 
auspices of a public health department; (b) design and evaluate 
strategies for recruiting people with disabilities to 
participate in health promotion interventions; (c) develop 
measures of attitudes, behaviors, performance, and health 
related quality of life for persons with disabilities; and (d) 
develop a method to evaluate prevention effectiveness for 
interventions on disability.

(3) National Center for Health Statistics

    The following changes and additions should be made for 
1995-1996 (The Section for NCHS begins on p. 177):
            International Collaborative Effort on Measuring the Health 
                    and Health Care of the Aging
    Page 178 top of the page--
    Strike ``Health Promotion and Disease Prevention Among the 
Aged: USA and the Netherlands,'' and add ``and'' to the end of 
the last phrase on p. 177.
    1st full paragraph on p. 178, 2nd sentence should read: A 
third and final international symposium was held in 1996 to 
present final research results and address issues of 
implementation. Proceedings will be published.
    3rd sentence fine. Add to publications:
          LTC In Five Nations, Canadian Journal on Aging, Vol. 
        15, Suppl. 1, 1996. The journal issue contains 
        individual articles about LTC in Australia, Canada, The 
        Netherlands, Norway, and the U.S. Articles on LTC in 
        the U.S. include one on institutional care by J. Van 
        Nostrand and another on home care by R. Clark.
          E. Bacon, S. Maggi, A Looker, et al, International 
        Comparisons of Hip Fracture Rates in 1988-89, 
        Osteoporosis International, Vol. 6, pp. 69-75, 1996
    Last paragraph, last sentence, strike ``NCHS Coordinator of 
Data on Aging'' replace with: Project Director, ICE on Aging, * 
* * Room 1100, * * * 20782 * * * (301) 436-7062.
            Federal Interagency Forum on Aging-Related Statistics
    Second paragraph, strike to end of section and replace 
with:
    In 1995-96, the Forum produced the following publications:
          Trends in the Health of Older Americans: United 
        States, 1994 Vital Health Statistics 3(30), 1995.
          a bibliography, Health of an Aging America: 1994 
        Bibliography, guide to Reports About Older Americans 
        from the National Center for Health Statistics.
          Policy for Aging over the Next Decade: Priority Data 
        Needs for Health and Long Term Care
          Summary of Data Sources on Alzheimer's Disease and 
        Related Dementia from the National Center for Health 
        Statistics
            Measuring Cognitive Impairment in Population-Based Surveys
    Replace with the following:
    A Work Group has been established by the Federal 
Interagency Forum on Aging-Related Statistics with the task of 
strengthening the measurement of cognitive impairment in 
national, population-based surveys. This activity builds on the 
previous work of the Forum in developing research 
recommendations for strengthening assessment of cognitive 
impairment. Specific activities for 1995-96 were to: (1) 
identify the state-of-the-art in measuring cognitive impairment 
of the elderly in national surveys, and (2) implement a 
research agenda for strengthening its measurement in national 
surveys. Results of the research activity include:
          B. Gurland, D. Wilder, et al, A flexible system of 
        detection for Alzheimer's Disease and related 
        dementias, Aging: Clinical and Experimental Research, 
        Vol. 7, No. 3, pp. 165-172, 1995.
          R. Herzog, ``Approaches to Measuring Cognitive 
        Functioning in Large Scale Surveys: Review of the 
        Literature and Analysis of Data form the Assets and 
        Health Dynamics Among the Oldest-Old Survey, Occasional 
        Paper of the Forum.
            National Mortality Followback Survey: 1986 and 1993
    Replace paragraph 4 with:

          The 1993 Survey is comprised of a nationally 
        representative sample of approximately 23,000 decedents 
        15 years of age or over who died in 1993, with over-
        sampling of some groups including black decedents, 
        females, persons under 35 years, and centenarians. The 
        design parallels that of the 1986 survey, with 
        additional emphasis on deaths due to external causes, 
        that is, accidents, homicides, and suicides, as well as 
        disability in the last year of life. Hospital records 
        are not included in the 1993 survey, but medical 
        examiner/coroner records are included. A preliminary 
        file is planned for release to the public in February 
        1998, and a final file containing the medical examiner/
        coroner information will be released later in 1998.
            National Health Interview (NHIS): Special Topics
    Insert the word ``Survey'' after Interview in the section 
title above.
    Paragraph 1--after 1st sentence revise to read: Data 
collection has been completed for the special health topics on 
disabilities. The disability topic had two phases. The first 
phase questionnaire identified persons with disabilities. The 
second phase collected detailed * * *.
    Change the beginning of the next 2 paragraphs to read:

          Disability Phase 1 included questions on: sensory, * 
        * *
          Disability Phase 2 included questions on: housing * * 
        *

    Add to the end of the last paragraph: The first year of the 
Phase I Disability file was released in 1996. The remainder of 
the Disability files will be released in 1998.
    Note: Reverse the order of the next 2 sections placing the 
SOA II writeup after the LSOA writeup.
            Longitudinal Study of Aging
    Replace the entire section with the following:

          The Longitudinal Study of Aging (LSOA) is a 
        collaborative effort of the National Center for Health 
        Statistics and the National Institute on Aging. The 
        baseline information for the LSOA came from the 
        Supplemental on Aging (SOA), a supplemental to the 1984 
        National Health Interview Survey (NHIS).
          The SOA is comprised of a nationally representative 
        sample of 16,148 civilians 55 years of age and over 
        living in the community at the time of the 1984 NIHS. 
        The Supplement obtained data on the health of older 
        Americans, information on housing, including barriers 
        and ownership; social and familial support, including 
        number and proximity of children and recent contacts in 
        the community; retirement, including reasons for 
        retirement and sources of retirement income; and 
        physical functioning measures, including activities of 
        daily living, instrumental activities of daily living, 
        and work-related activities.
          The sample for the LSOA is comprised of the 7,527 
        persons who were 70 years of age and over at the time 
        of the SOA. The survey was designed to measure changes 
        in functional status and living arrangements, including 
        institutionalization, as persons moved into and through 
        the oldest ages. The baseline SOA interviews were 
        conducted in-person. Follow up reinterviews, conducted 
        in 1986, 1988 and 1990, were conducted by telephone 
        using Computer Assisted Telephone Interviewing (CATI). 
        In addition to the interview data, permission was 
        obtained from sample persons or their proxies to match 
        interview data with other records maintained by the 
        Department of Health and Human Services.
          The fourth version of the LSOA public-use data was 
        released in October, 1991. The Version 4 files are 
        available on magnetic tape and include the following 
        information: all four waves of interview data (1984, 
        1986, 1988, 1990), National Death Index data (1984-
        1989), and Medicare records data (1984-1989. A diskette 
        containing detailed multiple cause-of-death data for 
        the LSOA sample is available. The fifth version of the 
        LSOA public-use data, released in September, 1993, is 
        available on CD-ROM. This version includes all 
        interview data available in Version 4 and updates the 
        administrative data through 1991.
          The LSOA public-use datasets are available from three 
        sources: The National Technical Information Service 
        (NTIS), the Division of Health Interview Statistics, 
        NCHS, and the National Archives of Computerized Data on 
        Aging. The multiple cause-of-death diskette is 
        available from NITS.
            Second Supplement on Aging (SOA II)
    Replace the entire section with the following:

          From 1994-1996, the National Center for Health 
        Statistics conducted the Second Supplement on Aging 
        (SOA II) as part of the National Health Interview 
        Survey. Interviews were conducted with a nationally 
        representative sample of 9,447 civilian 
        noninstitutionalized Americans 70 years of age and 
        over. The study will provide important data on the 
        elderly that can be compared with similar data from the 
        1984 SOA. In addition, the SOA II will serve as a 
        baseline for the Second Longitudinal Study of Aging 
        (LSOA II), which will follow the baseline cohort 
        through one or more reinterview waves.
          Information for the SOA II comes from several 
        sources: the 1994 NHIS core questionnaire, Phase 1 of 
        the National Health Interview Survey on Disability 
        (NHIS-D), and Phase 2 of the NHIS-D, conducted 
        approximately one year after Phase 1. The survey 
        questions and methodology are similar to the first 
        LSOA, but improvements reflect a number of 
        methodological and conceptual developments that have 
        occurred in the decade between the LSOA and LSOA II, as 
        well as suggestions made by users of the LSOA and 
        others in the research community.
          A primary objective of the SOA II is to examine 
        changes which may have occurred in the physical 
        functioning and health status of the elderly over the 
        past decade. To this end, questions concerning physical 
        functioning and health status and their correlates were 
        repeated in the SOA II. These include questions on 
        activities of daily living, instrumental activities of 
        daily living, and work-related activities, as well as 
        medical conditions and impairments, family structure 
        and relationships, and social and community support. In 
        addition to these repeated items, the SOA II 
        questionnaire was expanded to include information on 
        risk factors (including tobacco and alcohol use), 
        additional detail on both informal and formal support 
        services, and questions concerning the use of 
        prescription medications.
          These data, when used in conjunction with data from 
        the LSOA, will enables users to identify changes in 
        functional status, health care needs, living 
        arrangements, social support, and other important 
        aspects of life across two cohorts with different life 
        course perspectives. This will provide researchers and 
        policy planners with an opportunity to examine trends 
        and determinants of ``healthy aging.''
            National Health and Nutrition Examination Survey III
    Replace the entire section with the following:

    The National Health and Nutrition Examination Survey 
(NHANES) provides valuable information available through direct 
physical examinations of a representative sample of the 
population. The most recently completed cycle of this survey, 
NHANES III (1988-94), provides a unique data base for older 
persons. A number of important methodologic changes were made 
in the survey design. There was no upper age limit, (previous 
surveys had an age limit of 74) and the sample was selected to 
include approximately 1,300 persons 80 or older. Data for 1988-
94 will be released in 1997.
    The focus of the survey included many of the chronic 
diseases of aging that cause morbidity and mortality, including 
cardiovascular disease, osteoarthritis, osteoporosis, pulmonary 
disease, dental disease, and diabetes. Additional information 
on diet and nutritional status and on social, cognitive, and 
physical function was incorporated in the survey. An 
abbreviated exam in the home was included for many of those 
unable or unwilling to travel to the survey's mobile 
examination center. A sampling of reports already produced from 
the NHANES III information include:
          Looker A, Johnson C, Wahner H, Dunn W, Calvo M, 
        Harris T, Heyse S, Lindsay R (1995): Prevalence of low 
        femoral bone density in older US women from NHANES III. 
        J Bone Mineral Research 10(5): 796-802.
          Redford M, Drury TF, Kingman A, Brown LJ (1996): 
        Denture use and the technical quality of dental 
        prostheses among persons 18-74 years of age: United 
        States, 1988-1991. J Dent Res 75 (Spec Iss): 714-725.
          Sempos CT, Johnson CL, Carroll MD, Briefel RR (1995): 
        Current levels and trends in serum total cholesterol in 
        the United States adults 65 years of age and older. The 
        NHANES. In: Nutritional Assessment of Elderly 
        Populations. Raven Press, New York, pp. 121-134.

    Planning is underway for the survey to return to the field 
in 1999. NHANES is to become a continuous program, with 
changing focus on a variety of health and nutrition 
measurements to meet emerging needs. Current plans are for a 
continued emphasis on the health of older Americans, and 
persons 60 and over will be over-sampled for the survey.
            NHANES I Epidemiologic Follow up Study
    Replace the entire section with the following:

          The first National Health and Nutrition Examination 
        Survey (NHANES I) was conducted during the period 1971-
        75. The NHANES I Epidemiologic Follow up Study (NHEFS) 
        tracks and reinterviews the 14,407 participants who 
        were 25-74 years of age when first examined in NHANES 
        I. NHEFS was designed to investigate the relationships 
        between clinical, nutritional, and behavioral factors 
        assessed at baseline (NHANES I) and subsequent 
        morbidity, mortality, and hospital utilization, as well 
        as changes in risk factors, functional limitation, and 
        institutionalization.
          The NHEFS cohort includes the 14,407 persons 25-74 
        years of age who completed a medical examination at 
        NHANES I. A series of four Follow up studies have been 
        conducted to date. The first wave of data collection 
        was conducted from 1982 through 1984 for all members of 
        the NHEFS cohort. Interviews were conducted in person 
        and included blood pressure and weight measurements. 
        Continued followups of the NHEFS population were 
        conducted by telephone in 1986 (limited to persons age 
        55 and over at baseline), 1987, and 1992.
          Tracing and data collection rates in the NHEFS have 
        been very high. Ninety-six percent of the study 
        population has been successfully traced at some point 
        through the 1992 Follow up. While persons examined in 
        NHANES I were all under age 75 at baseline, by 1992 
        more than 4,000 of the NHEFS subjects had reached age 
        75, providing a valuable group for examining the aging 
        process. Public use data tapes are available from the 
        National Technical Information Service for all four 
        waves of Follow up. The 1992 NHEFS public use data is 
        also available via the Internet. NHEFS data tapes 
        contain information on vital and tracing status, 
        subject and proxy interviews, health care facility 
        stays in hospitals and nursing homes, and mortality 
        data from death certificates. All NHEFS Public Use Data 
        can be linked to the NHANES I Public Use Data.
            National Health Care Survey (NHCS)
    Replace with the following:

    The National Health Care Survey (NHCS) is an integrated 
family of surveys conducted by the National Center for Health 
Statistics to provide annual national data describing the 
Nation's use of health care services in ambulatory, hospital 
and long-term care settings. Use of health care services by the 
elderly may be investigated using NHCS data. Currently, the 
NHCS includes six national probability sample surveys and one 
inventory. These seven data collection activities include:
          the National Hospital Discharge Survey--discharges 
        from non-Federal, short-stay and general hospitals;
          the National Survey of Ambulatory Surgery--visits to 
        hospital-based and freestanding ambulatory surgery 
        centers;
          the National Ambulatory Medical Care Survey--office 
        visits to non-Federal, office-based physicians;
          the National Hospital Ambulatory Medical Care 
        Survey--visits to emergency and outpatient departments 
        of non-Federal, short-stay and general hospitals;
          the National Health Provider Inventory--a national 
        listing of nursing homes, hospices, home health 
        agencies and licensed residential care facilities;
          the National Home and Hospice Care Survey--hospices 
        and home health agencies and their patients; and
          the National Nursing Home Survey--nursing homes and 
        their residents.

    Details on specific surveys relevant to the elderly are 
presented below by specific survey.
    The following sections are recorded to match the order of 
the indented items above.
            National Hospital Discharge Survey
    Replace with the following:

          The National Hospital Discharge Survey (NHDS) is the 
        principal source of national information on inpatient 
        utilization of non-Federal, short-stay and general 
        hospitals. The NHDS was redesigned in 1988 as one of 
        the components of the National Health Care Survey. This 
        national sample survey collects data on the demographic 
        characteristics of patients, expected source of 
        payment, diagnoses, procedures, length of stay, and 
        selected hospital characteristics.
          Data reports and public use data tapes are available 
        from 1970-1995. A multi-year data set covering the 
        years 1979-92 is also available from the National 
        Technical Information Service. Diskettes containing 
        tabulations published in the Series 13, Detailed 
        Diagnoses and Procedures Report, are available for 
        1985-94.
            National Survey of Ambulatory Surgery (NSAS)
    Replace with the following:

          The National Survey of Ambulatory Surgery was 
        initiated in 1994 as an annual national survey to 
        provide data on patients and their treatment in 
        hospital-based and freestanding ambulatory surgery 
        centers. The NSAS was conducted in 1995-96. The NSAS 
        provides data on patient demographics, diagnoses and 
        procedures, anesthesia, source of payment, and facility 
        type.
          Data from the 1994 and 1995 surveys have been 
        published in NCHS Advance Data and Series reports. 
        Public use data are available in electronic form from 
        the National Technical Information Service.

    Insert new section:
            National Ambulatory Medical Care Survey
    The National Ambulatory Medical Care Survey (NAMCS) is a 
national probability sample survey of office visits made by 
ambulatory patients to non-Federal physicians, who are in 
office-based practice, and who are primarily engaged in direct 
patient care. Included are visits to physicians in solo, 
partnership, and group practice settings, and visits that occur 
in private non-hospital-based clinics and health maintenance 
organizations. Excluded are visits to specialists in radiology, 
anesthesiology, or pathology, and visits to physicians who are 
principally engaged in teaching, research or administration. 
Telephone contacts and non-office visits also are excluded.
    The NAMCS provides information on office visits in terms of 
patient, physician and visit characteristics. Data include: 
patient demographics, the patient's reason for visit, type of 
physician seen, physician's diagnoses, expected source of 
payment, ambulatory surgical procedures, medication therapy, 
disposition, and duration of the visit.
    The NAMCS was conducted from 1973-81, in 1985, and has been 
conducted annually from 1989-96. Data through 1996 have been 
released in NCHS Advance Data and Series reports.
          Public use data are available in electronic form from 
        the National Technical Information Service.
    Insert new section:
            National Hospital Ambulatory Medical Care Survey
    The National Hospital Ambulatory Medical Care Survey 
(NHAMCS) is a national probability sample survey of visits to 
the emergency and outpatient departments of non-Federal, short-
stay and general hospitals. The NHAMCS was initiated in 1992 
and has been conducted annually since that time. The survey 
includes data on the demographic characteristics of the 
patient, expected source of payment, patient's complaints, 
physician's diagnoses, procedures, medication therapy, 
disposition, and types of health professionals seen.
    Data through 1996 have been released in NCHS Advance Data 
and Series reports. Public use data are available in electronic 
form from the National Technical Information Service.
            National Health Provider Inventory (NHPI)
    Replace with the following:

          The National Health Provider Inventory, formerly 
        called the National Master Facility Inventory, was last 
        conducted in 1991. This mail survey includes the 
        following categories of health care providers; nursing 
        and related care home, licensed residential care 
        facilities, facilities for the mentally retarded, home 
        health agencies, and hospices. Data from the 1991 NHPI 
        was used to provide national statistics on the number, 
        type and geographic distribution of these health 
        providers and to serve as sampling frames for future 
        surveys in the Long-Term-Care component of the National 
        Health Care Survey. The NHPI public use data tapes are 
        available at the National Technical Information 
        Service.
            National Home and Hospice Care Survey
    Replace with the following:

          The National Home and Hospice Care Survey (NHHCS) is 
        a national probability sample survey of home health and 
        hospice care agencies, and their patients. The NHHCS 
        was conducted annually from 1992-94 and in 1996. 
        Agencies providing home health and hospice care were 
        included in the survey without regard to licensure or 
        to certification status under Medicare and/or Medicaid. 
        Information about the agency was collected through 
        personal interviews with the administrator. Information 
        was collected on a sample of current patients and 
        discharged patients through personal interviews with 
        designated agency staff.
          Data from the NHHCS may be used to examine the 
        relationships between utilization, services offered, 
        and charges for care, as well as provide national 
        baseline data about home health and hospice care 
        agencies, and their patients. Data through 1996 have 
        been released in NCHS Advance Data and Series reports. 
        An Advance Data report (based on data from the 1994 
        NHHCS) on the use of home health care by the elderly 
        has been published. Public use data are available in 
        electronic form from the National Technical Information 
        Service.
            National Nursing Home Survey
    Replace with the following:

          During 1995, the National Center for Health 
        Statistics conducted the National Nursing Home Survey 
        (NNHS) to provide information about the residents in 
        nursing homes. The NNHS was conducted in 1973-74, in 
        1997, and again in 1985. The NNHS data are from two 
        perspectives--that of the provider and that of the 
        recipient of services. Data about the facilities 
        includes: size, ownership, Medicare/Medicaid 
        certification, and services provided. Data about the 
        residents include: demographic characteristics, marital 
        status, place of residence prior to admission, health 
        status and services received. Data from the 1995 survey 
        has been published. An Advance Data report (based on 
        data from the 1995 NNHS) on the use of nursing home 
        services by the elderly has been published. Public use 
        data tapes are available through the National Technical 
        Information Service. Plans call for the NNHS to be 
        fielded in 1997 and in 1999.
            National Nursing Home Survey Follow up
    Replace with the following:

          The National Nursing Home Survey Follow up (NNHSF) is 
        a longitudinal study which follows the cohort of 
        current residents and discharged residents sampled from 
        the 1985 NNHS described above. The NNHSF builds on the 
        data collected from the 1985 NNHS by extending the 
        period of observation by approximately 5 years. Wave I 
        was conducted from August through December 1987, and 
        Wave II was conducted in the fall of 1988. Wave III 
        began in January of 1990 and continued through April. 
        The study was a collaborative project between NCHS, 
        HHS, and the National Institute on Aging (NIA). The 
        Follow up was funded primarily by NIA and was developed 
        and conducted by NCHS.
          The NNHSF interviews were conducted using a computer-
        assisted telephone interview system. Questions 
        concerning vital status, nursing home and hospital 
        utilization since the last contact, current living 
        arrangements, Medicare number, and sources of payment 
        were asked. Respondents included subjects, proxies, and 
        staff of nursing homes.
          The NNHSF provides data on the flow of persons in and 
        out of long-term care facilities and hospitals. These 
        utilization patterns can be examined in relation to 
        information on the resident, the nursing home, and the 
        community. Public-use computer tapes for Waves I, II, 
        and III of the NNHSF are available through the National 
        Technical Information Services (NTIS). In addition, the 
        National Nursing Home Survey Follow up Mortality Data 
        Tape, 1984-1990 is also available through NTIS.
            National Employer Health Insurance Survey (NEHIS)
    Replace with the following:

          The National Employer Health Insurance Survey was 
        jointly conducted by the National Center for Health 
        Statistics, the Health Care Financing Administration, 
        and the Agency for Health Care Policy and Research in 
        1994 to provide data necessary to produce national and 
        State level estimates of total employer sponsored 
        private health care insurance premiums, the employer 
        and employee premium share, the total amount of 
        benefits provided, and the administrative cost. In 
        addition to the number of workers, retirees, and former 
        workers covered, the survey provides the breadth of 
        policy benefits and the number and characteristics of 
        plans in each establishment.
          The NEHIS was conducted in all 50 States and the 
        District of Columbia. Computer assisted telephone 
        interviews were completed for approximately 39,000 
        business establishments, sampled from several size 
        categories. Data will be released to the public in the 
        form of published reports and electronic data products.
          The estimates will be used to investigate the 
        geographic variations in spending for health care and 
        the probable differential impacts that proposed health 
        policy initiatives will have by State. As the private 
        sector, State and Federal Governments develop and 
        implement reforms of the health care system, there are 
        likely to be major changes in the extent and form of 
        private health insurance coverage, benefits, and 
        premium sharing. No discussion of the impact of the 
        reform upon business and individuals can be complete 
        without analysis of these changes. Over the past 
        several years, the task of producing national private 
        health insurance premiums and benefit estimates has 
        increased in difficulty as the industry has become more 
        complex. Simultaneously, the importance of accurate 
        health care costs estimates has increased as the 
        pressure or burden of health care costs have mounted on 
        the primary health care payers such as government, 
        business and households and as initiatives to contain 
        cost growth have been discussed and implemented

    Replace title ``Improving Questions on Functional 
Limitations'' with new title ``The Questionnaire Design 
Research Laboratory'' and replace text with following:

          Testing of cognitive functioning question.--In 1996, 
        NCHS collaborated with the Survey Research Laboratory 
        of the University of Illinois to test a variety of 
        questions dealing with cognitive functioning in persons 
        age 70 or older. Methods used in this investigation 
        included a focus group and face-to-face and telephone 
        cognitive interviews. The study found that when testing 
        cognitive functioning and memory in a survey 
        environment, questions of various types should be 
        asked. These include subjective memory appraisals, 
        current behaviors, and short-term memory tests. Any 
        single question or type of question may be confounded 
        with measurement problems, social desirability issues, 
        and other physical problems.
          Results will be presented at the Conference on 
        Cognition, Aging, and Survey Measurement, February 8, 
        1997, Ann Arbor, Michigan. Study results are also 
        forthcoming in O'Rourke, D., Sudman, S., Johnson, T., & 
        Burris, J., ``Cognitive testing of cognitive 
        functioning question'', in N. Schwarz, D. Park, B. 
        Knauper, & S. Sudman (Eds.), Aging, cognition, and 
        self-reports. Washington, DC: Psychology Press.
          Improving our understanding of responses to health 
        status and quality of life questions.--This study 
        investigated issues related to question interpretation, 
        strategies used by respondents, and adequacy of 
        response scales for health status measures currently 
        used in the Behavioral Risk Factor Surveillance System. 
        Cognitive interviews were conducted with 18 subjects 70 
        years of age or older and 30 subjects under the age of 
        70; a field experiment was also conducted to validate 
        laboratory findings. Results indicated that elderly 
        respondents may have difficulty providing responses to 
        survey questions that ask for reports of number of days 
        (e.g., ``...how many days during the past 30 days was 
        your physical health not good?'') Ease or difficulty of 
        formulating a response may depend on the complexity of 
        the pattern of health status that represents the 
        person's life. Because elderly people are more likely 
        to have complex health patterns, it may be that their 
        difficulty derives not from cognitive processes 
        associated with aging, but rather with measurement 
        problems inherent in assessing quality of life for this 
        age group.
          Results will be presented at the Conference on 
        Cognition, Aging, and Survey Measurement, February 8, 
        1997, Ann Arbor, Michigan. Study results are also 
        forthcoming in Schechter, S., Beatty, P., and Willis, 
        G. ``Asking survey respondents about health status: 
        Judgement and response issues'', in N. Schwarz, D. 
        Park, B. Knauper, & S. Sudman (Eds.), Aging, cognition, 
        and self-reports. Washington, DC: Psychology Press.
          Cognitive Laboratory Testing of Cognitive Functioning 
        Questions.--The Questionnaire Design Research 
        Laboratory conducted two rounds of testing with senior 
        respondents during the summer of 1996 in collaboration 
        with the staff of LSOA II. The LSOA II staff has been 
        directed by the funding agency (NIA) to produce a 
        survey that combined questions from earlier surveys of 
        aging in order to bring consensus to the results. The 
        goal of the lab testing was to conduct validity and 
        reliability research on the modules as the 
        questionnaire was developed, by testing the adequacy 
        and suggesting improvements to the questions which had 
        been removed from their contextual framework in the 
        earlier surveys.

(4) National Center for Infectious Disease

            Paragraph 4
    Line A--delete ``80-90'' and insert ``about 60''
    Lines 8 & 9--delete the phrase ``however, the benefits to 
the population, and to society in general, would significantly 
increase with a more effective vaccine.''
            Paragraph 5
    Line 2--Change 20 to 15
    Line 5--After ``antiviral drugs.'' Add the sentence: 
``Respiratory syncytial virus vaccines are being evaluated for 
use by the elderly population.''
    Corrected paragraph should read:

          Recent studies have suggested that noninfluenza 
        viruses such as respiratory syncytial virus and the 
        parainfluenza viruses may be responsible for as much as 
        15 percent of serious lower respiratory tract 
        infections in the elderly. These infections can cause 
        outbreaks that may be controlled by infection control 
        measures and be treated with antiviral drugs. 
        Respiratory syncytial virus vaccines are being 
        evaluated for use by the elderly population. 
        Consequently, it is important to define the role of 
        these viruses and risk factors for these infections 
        amongthe elderly population. CDC is completing a 
collaborative investigation of RSV, the parainfluenza viruses, and 
adenovirus infections associated with lower respiratory tract 
infections among hospitalized adults to determine the proportion caused 
by these viruses and associated risk factors.
            Paragraph 8
    Line 3--After ``with diarrhea in the United States.'' Add 
the sentence: ``In the elderly, caliciviruses (also called 
Norwalk-like viruses or Small Round Structured Viruses) are 
likely to be the most common cause of both epidemics and 
sporadic hospitalizations for acute gastroenteritis but the 
diagnostic tests needed for confirmation are now in rapid 
development. This could lead to new strategies for detection of 
etiologic agents and prevention of disease through the 
interruption of patterns of transmission.''
    Then continue with the rest of the paragraph ``The recent 
identification * * *
    Add a new paragraph to the section:

          The role of infections in chronic diseases (e.g., 
        chlamydia pneumoniae and cardiovascular disease; H. 
        pylori and gastric cancer; hepatitis B and C and liver 
        cancer) is becoming increasingly evident. CDC is 
        developing research activities to better define 
        relations between infectious agents and chronic disease 
        sequelae; infections may play a role in many chronic 
        diseases which severely impair quality of life and 
        length of life among the elderly.

(5) National Center for Injury Prevention Control

    The following intramural projects should be included in the 
report for 1995-1996:
    Medical Conditions and Driving.--It is hypothesized that 
certain medical conditions increase the risk of motor vehicle 
crashes and may also affect the decision to stop driving. With 
data from a longitudinal data base we will be vetter able to 
understand the interrelationships between medical conditions, 
crashes, and why senior citizens stop driving. Some of the 
questions to be asked are: (1) What is the vehicle crash 
experience over the last five years of older drivers, and (2) 
which drivers are at high risk of crashes?
    Longitudinal Study of Older Drivers: Medical Conditions and 
Risk.--A longitudinal data base that will allow for additional 
older driver information to be analyzed is being used to ask 
several research questions: (1) Are driving patterns related to 
alcohol/medication use, smoking, or other socio-psychological 
and lifestyle factors, and (2) are driving patterns (e.g. 
miles/week) associated with medical conditions or health 
status?
    Older Drivers: Why Do They Stop Driving?--A module was 
added to one state's Behavioral Risk Factor Surveillance System 
to assess driving decisions made by older drivers in that 
state. Data were collected throughout 1995 and include the 
additional demographic information collected routinely in this 
survey. Descriptive information will enable a closer look at 
why older drivers stop driving.
    Older Drivers Risk to Other Road Users.--A study was 
conducted using a linked data base (hospital discharge data and 
police accident reports for one state) to determine the degree 
to which older drivers impose an excess risk of death or injury 
serious enough to require hospitalization on other road users.

(6) National Immunization Program

    On page 187, please delete the second paragraph and replace 
with: ``CDC continues to include adult immunization issues in 
its annual National Immunization Conferences. Posters and oral 
presentations are consistently used to address numerous adult 
immunization issues.''
    Please delete the fourth paragraph and replace with: ``In 
September, the Department of Health and Human (HHS) approved a 
department-wide action plan to enhance activities to protect 
adults against vaccine-preventable diseases and maximize 
accruable health care cost savings. The strategy for addressing 
adult immunization includes developing nationwide prevention 
strategies that focus on providers to reduce missed 
opportunities. Though no additional resources have been 
identified to support this effort, a CDC Working Group is 
assessing ways in which current activities on adult 
immunization can be used to monitor progress on increasing 
coverage in adult populations.''
    The fifth paragraph, second line should read ``* * * a 
network of more than 95 private, professional, volunteer 
organizations * * *''
    The fifth paragraph, last sentence should read: ``The 
objectives of the NCAI are accomplished by three working Action 
Groups--Influenza/Pnuemococcal, Measles-Mumps-Rubella-
Varicella, and Hepatitis B--that conduct * * *''
    The sixth paragraph, first sentence should read: ``* * * at 
risk of complication is 58 percent.''
    The sixth paragraph, second sentence should read: ``* * * 
have steadily improved from 23 percent in 1985 to 58 percent in 
1995.''
    Please delete the third sentence from paragraph 6 regarding 
preliminary data from the National Health Interview survey as 
more current data is reflected in the sentence change above.
    Last paragraph, please add this as a second sentence: 
``Data through 1996 are being collected and analyzed for this 
study.''

                      FOOD AND DRUG ADMINISTRATION

    As the percentage of elderly in the Nation's population 
continues to increase, the Food and Drug Administration [FDA] 
has been giving increasing attention to the elderly in the 
programs developed and implemented by the Agency. FDA has been 
focusing on several areas for the elderly that fall under its 
responsibility in the regulation of foods, drugs, biologics and 
medical devices. Efforts in education, labeling, drug testing, 
drug utilization, and adverse reactions are of primary 
interest. Working relationships exist with the National 
Institute on Aging, the Centers for Disease Control, and the 
Administration on Aging of the Department of Health and Human 
Services to further strengthen programs that will assist the 
elderly now and in the future. Some of the major initiatives 
that are underway are described below.

                     Project on Caloric Restriction

    The National Center for Toxicological Research (NCTR) in 
partnership with the National Institute on Aging has been 
working for several years on the role caloric restriction (CR) 
plays in the aging process and what effect a reduced caloric 
diet has on disease etiology. Scientists working on the Project 
on Caloric Restriction have concentrated on determining the 
mechanisms by which caloric restriction inhibits spontaneous 
disease, modulates agent toxicity and effects the normal aging 
process. Studies over the last year have focused on the premise 
that by using a single paradigm (caloric manipulation) and 
through interdisciplinary studies a comprehensive integrated 
approach can be developed to understand the effect diet has on 
the initiation and development of disease. The hypotheses that 
support this paradigm are mechanistically based and include the 
following: CR acts through its effects on body growth, on 
glucocorticoids and inflammation, on DNA damage, repair and/or 
gene expression, on toxicokinetics and/or its modification of 
oxidation and fat metabolism. All of these hypotheses have been 
explored through interdisciplinary studies being conducted at 
NCTR or at other institutions in collaboration with scientists 
at NCTR.

                              Body Growth

    Rodent studies at NCTR have found that body weight can be 
used to predict tumorigenicity. For most organs, size is 
directly proportional to the body weight of the animal and it 
has been shown that organ weight can be used to predict 
tumorigenicity. CR inhibits the induction of tumor expression 
and growth and changes the state of differentiation in 
replicating cells. It has also been that CR can specifically 
alter drug metabolism and reduce drug toxicity. This could be 
very useful in treating and diagnosing disease. In addition, 
the relevance of CR to the human population has been 
strengthened by the fact the biomarkers observed in rodents are 
associated with the risk of chronic disease in humans. Plans 
are in place to extend the CR observation in rodents to 
clinical studies in humans.

                      Oxidation and Fat Metabolism

    A common hypothesis for tumor induction suggests that DNA, 
the blue print of the cell, is damaged by oxidative chemical 
species in the cell released by the metabolism of fat. CR has 
been shown to reduce the impact of oxidative damage at the 
organ level by increasing the oxygen scavengers in the liver 
and in muscle. Similarly, it has been shown that CR reduces 
high fat induced oxidative damage in cellular DNA/

                    Glucocorticoids and Inflammation

    Glucocorticoids are used to diminish normal but undesirable 
body responses to noxious stimuli and trauma, advantages are 
gained by their use in counteracting stressful situations and 
in decreasing pain and discomfort. Another group of normal 
protective agents are stress proteins, which are produced in 
the body whenever the body undergoes a stress induced response. 
CR has been shown to elevate glucocorticoid levels shortly 
after inception, and has also been shown to alter stress 
proteins levels in the brain.

               DNA Damage, Repair and/or Gene Expression

    As mentioned above DNA is the blueprint of the cell, 
therefore any damage done to DNA has the potential of resulting 
in a disease response. CR has been shown to inhibit genes that 
are associated with tumor induction and enhances various forms 
of DNA repair. One hypothesis for tumor induction suggests that 
chemicals exert their damage to DNA by binding to the 
components of DNA forming adducts. Animals exposed to a CR 
regime and carcinogenic insult show an altered induction of 
various forms of DNA adducts.

                             Toxicokinetics

    Toxicokinetics refers to the compartmentalization of a 
toxicant within the body. Organs are complicated structures 
that are made up of different kinds of cells, transport 
structures and biological functioning units. CR has been shown 
to alter water transport, fat deposition and waste transport, 
thus complicating cellular compartmentalization, and toxic 
exposure of certain cells to damaging substances.
    Although the work over the last year has concentrated on 
the mechanisms of toxic interaction in the body and the role CR 
has on this process, studies with calorically restricted 
animals have repeatedly shown that CR extends the lifetime of 
animals. How this effects aging is still in question; however, 
the research being conducted in this area is continuing to chip 
away at the problem of how diet effects the aging process, and 
what elements or lack thereof in the human diet may help to 
extend human life.

           Rare Diseases Affecting Primarily Older Americans

    It is the intent of the Orphan Drug Act, and the Office of 
Orphan Products Development [OPD], to stimulate the development 
and approval of products to treat rare diseases. The OPD plays 
an active role in helping sponsors meet agency requirements for 
product approval. Between 1983--when the Orphan Drug Act was 
passed--through the end of 1996, 145 products to treat small 
populations of patients were approved by FDA.
    By the end of 1996, there were 645 designated orphan 
products. One hundred and two [16 percent] of these designated 
orphan products represent therapies for diseases predominately 
affecting older Americans. Sixty-seven are for treating rare 
cancers in the elderly--for instance ovarian cancer, pancreatic 
cancer, and metastatic melanoma. Twenty of the orphan products 
designated for treating elderly populations are for rare 
neurological diseases, such a amyotrophic lateral sclerosis 
[ALS], and advanced Parkinson's disease. Twenty-one orphan-
designated therapies for elderly populations have received FDA 
market approval: Most noteworthy among these is Eldepryl for 
treatment of idiopathic Parkinson's disease, postencephalitic 
Parkinsonism, and symptomatic Parkinsonism; riluzole for 
treatment of ALS; and Novantrone for treatment of refractory 
prostate cancer.
    FDA's orphan products grants had their beginning in 1983 as 
one of the incentives of the Orphan Drug Act. This incentive of 
the Act provides financial support for clinical studies 
[clinical trials] to determine the safety and efficacy of 
products to treat rare disorders, and to achieve marketing 
approval from the FDA under the Federal Food, Drug, and 
Cosmetic Act. Studies funded by the orphan products grants 
program have contributed to the marketing approval of twenty-
one of these products.
    Because the orphan products program is issue-specific/
indication-specific, it is typical for an approved product to 
be funded under the orphan products grant program for study in 
an indication unique to a distinct group of people: for 
example, women, children, or a population of elderly. Under the 
orphan drug program, disease populations are small; in many 
instances, the firms themselves are very small. The goal of 
orphan product development is to bring to market products for 
rare diseases or conditions. In so doing, it is evident that 
the goals of the Orphan Drug Act promote research and labeling 
of drugs for use by and for special populations.
    The orphan products grant program has funded 39 studies 
specifically aimed at treatment of diseases affecting adults 
and older adults. The IV Formulations of Busulfan is being 
studied for use in geriatric patients and undergoing bone 
marrow transplantation.

                      Alzheimer's Disease Research

    Alzheimer's disease currently affects approximately four 
million people age 65 and older, with the number produced to 
increase to fourteen million by the year 2050. Development of 
new drugs to diagnose, treat, and prevent this disease 
represents a goal of profound importance. Alzheimer's drug 
research efforts depend in part upon the availability of 
patients who can participate in clinical studies of these new 
drugs.
    During 1996, FDA's Office of Special Health Issues [OSH] 
conducted a search and assessment of information in the public 
domain regarding Alzheimer's drug development, and particularly 
opportunities to participate in Alzheimer's drug research. It 
was learned that little information is publicly available 
regarding Alzeimer's research and opportunities to participate 
in Alzheimer's drug development.
    To address this problem, OSHI has undertaken an initiative 
with the National Institute on Aging [NIA] to develop a 
database containing information regarding opportunities to 
participate in clinical trials of Alzheimer's drugs. This 
database, which received some initial funds from the FDA, will 
be maintained at the NIA's Alzheimer's Disease Education and 
Referral [ADEAR] Center, and will be accessible by toll-free 
telephone and the NIA home page on the world wide web. OSHI and 
NIA developed the database and announced the initiative to 
pharmaceutical manufacturers involved in domestic development 
of Alzheimer's drugs. Some manufacturers have submitted 
information for entry into the database, which will be 
operational in Spring 1998.

                FDA Approves First Treatment for Stroke

    On June 18, 1996, the FDA approved the first therapy shown 
to improve neurological recovery and decrease disability in 
adults following acute ischemic stroke, the most common type of 
stroke, caused by blood clots that block blood flow. Treatment 
must start within 3 hours of the start of the stroke and only 
after bleeding in the brain has been ruled out by a cranial 
computerized tomography [CT] scan.
    The drug, alteplase, a genetically engineered version of 
tissue plasminogen activator [t-PA], is already approved as a 
blood clot dissolver to treat heart attacks and to dissolve 
blood clots in the artery going to the lungs.
    Because of the known risks of bleeding with alteplase and 
other thrombolytic therapies, selecting stroke patients who are 
most likely to benefit from treatment is critical. It is also 
critical that patients be treated within 3 hours of the onset 
of a stroke with the correct dose.
    Each year, about 500,000 people in the United States have 
strokes, with approximately 150,000 dying as a result. Of these 
strokes, 400,000 are ischemic, or caused by a blood clot 
reducing or blocking blood flow to the brain. The rest are 
hemorrhagic strokes, caused by bleeding into and around the 
brain.

             Postmarket Drug Surveillance and Epidemiology

    The Office of Epidemiology and Biostatistics, FDA Center 
for Drug Evaluation Research [CDER], prepares an annual 
report--entitled ``Annual Adverse Drug Experience [ADE] 
Report''--which provides summary statistics describing some of 
the activities of the postmarketing drug risk assessment 
program. Each year this report contains a number of tabulations 
which show the number of reports received and evaluated by such 
factors as age group, sex, source of report, drug or type of 
outcome. In 1995, there were 130,950 evaluable reports that 
were evaluated and added to the database. In this same year, 
30, 190 or 23 percent of the reports of adverse drug 
experiences were for individuals age 60 or older. There were 
41,427 reports [31.6 percent] that did not specify age. In 
1996, the Agency added 159,504 reports to the evaluation 
database, 41,841 [26.2 percent] for persons 60 years of age or 
older who experienced an adverse drug reaction with 43,352 
[27.2 percent] for whom no age was specified.

                           Intraocular Lenses

    Over 1 million intraocular lenses are implanted each year 
in the U.S. predominately in the senior population. These 
implants have revolutionized the treatment of cataracts, which 
a few decades ago were the leading cause of blindness in the 
adult population. A number of flexible lens models have been 
aprpoved by FDA in the last few years and are now on the 
market. These lenses permit smaller incisions which heal more 
rapidly with less scarring and subsequent distortion of the 
optics of the eye.
    However, flexible lenses have led to a number of unexpected 
post-approval consequences. Discoloration, haziness, and 
glistening have all been reported. In 1996, primarily because 
of FDA laboratory testing and discovery of such problems, one 
company voluntarily recalled all distributed units of its 
recently approved flexible IOL model. FDA verified that the 
recall was effective and that monitoring was in place to access 
patients implanted before the recall. FDA tasked all involved 
firms with identifying the sources of these problems and 
revising their quality control to prevent future occurrences. 
FDA's devise laboratory developed methods and tested lenses to 
assess the effect of these problems on vision.
    Data on intraocular lenses (IOLs) have demonstrated that a 
high proportion (85-95 percent) of the patients who have 
undergone cataract surgery and IOL implantation will be able to 
achieve 20/40 or better corrected vision with a low risk of 
significant postoperative compliactions. Because of the proven 
safety and effectiveness of IOLs, they have become the 
treatment of choice for the correction of visual loss caused by 
cataracts. This has allowed elderly patients to maintain their 
sight and a normal lifestyle. FDA continues to monitor some 
investigational IOLs and to date has approved thousands of 
models that have demonstrated safety and effectiveness.
    The first IOLs were all ``monofocal,'' which were designed 
to provide good vision at one distance, usually far. Patients 
who receive monofocal IOLs usually need spectacles to obtain 
satisfactory near vision. Typically, these patients will need 
bifocal spectacles to obtain optimal distance and near vision. 
On September 5, 1997, FDA approved the first ``multifocal'' 
IOL. The multifocal IOL is designed to provide clear distance 
and near vision. The advantage of the multifocal IOL is that 
there is a greater chance that the patient may have 
satisfactory distance and near vision without spectacles, or 
will only need ``monofocal'' (not bifocal) spectacles to 
improve both distance and near vision. The disadvantages of 
multifocal IOLs are: (1) distance vision may not be quite as 
``sharp'' as with a monofocal IOL; (2) there is a higher chance 
of difficulty with glare and holos than with a monofocal IOL; 
and (3) under poor visibility conditions, vision may be worse 
than with a monofocal IOL.
    Throughout the time period of this update, FDA has worked 
closely with industry, ophthalmologists, and researchers to 
assure that the regulatory requirements for new intraocular 
lens models are scientifically valid, but not overly 
burdensome. This activity has occurred via work with both the 
ANSI and ISO standards organizations. FDA also participates in 
the Eye Care Forum, an annual meeting sponsored by the National 
Eye Institute to address issues of mutual interest to the 
clinical, research, and regulatory communities.

                        Prosthetic Heart Valves

    Approximately 80,000 people in the U.S. have artificial 
heart valves implanted every year, both mechanical and 
bioprosthetic (pig, bovine valves). The characteristics of the 
blood flow through these valves can affect the risk of thrombo-
embolism and ultimate valve failure. Turbulence, stagnation and 
caviation (bubble formation and collapse) may all cause adverse 
effects. For the past few years, and currently, the FDA has had 
programs in place, both research and regulatory, to evaluate 
the flow characteristics of these devices and their impact on 
the valves and blood components.
    These programs include the development of: (1) improved 
techniques to directly measure the flow patterns associated 
with valves using fluorescent particle visualization and 
Dopplier ultrasound; (2) mathematical models to assess flow 
patterns as a function of valve design and aortic geometry; (3) 
guidance for manufacturers to standardize and improve their 
testing; (4) techniques to acoustically detect flow induced 
caviation; (5) methods to directly assess effects on red blood 
cells. Also evaluation of specific valve designs, both 
currently implanted and protype is ongoing. Finally, analysis 
of a much used diagnostic tool, color Doppler, is being 
undertaken to improve diagnosis or diseased or faulty valves.

                               Pacemakers

    On October 28, 1994, the EP Technologies, Inc.'s Cardiac 
Ablation System, the first radio frequency powered catheter 
ablation system was approved. It is indicated for interruption 
of accessory atrioventricular (AV) conduction pathways 
associated with tachycardia, treatment of AV nodal re-entrant 
tachycardia, and for creation to complete AV block in patients 
with a rapid ventricular response to an aerial arrhythmia.
    On December 20, 1995, the Thoratec Ventricular Assist 
Device System was approved. It is indicated for use as a bridge 
to cardiac transplantation to provide temporary circulatory 
support for cardiac failure in potent transplant recipients at 
imminent risk of dying before donor heart procurement. The 
System may be used to support patients who have left 
ventricular (LVAD), right ventricular (RVAD), or biventricular 
failure (BVAD). The Thoratec VAD differs from theother two 
previously approved VADs in that it can be used for right heart and/or 
biventricular failure.
    On May 15, 1996, a new indication for use was approved for 
CPI Guidant's family of Implantable Cardioverter Defibrillators 
(ICDs). The PMA supplement was received in six days and 
contained clinical data in electronic format from the 
Multicenter Defibrillator Implant Trial (MADIT). The new 
patient population consists of patients who have a Left 
Ventricular Ejection Fraction of less than 35%, and a 
documented episode of non-sustained ventricular tachycardia 
with inducible, non-suppressible, ventricular tachycardia. 
Previously, only patients who had sustained ventricular 
tachycardia were candidates for implantation. The MADIT data 
provided evidence that an ICD used in high risk, asymptomatic 
patients produces significantly better results than drugs in 
reducing deaths.

                             Renal Dialysis

    There were a projected 244,000 patients with kidney failure 
in the United States in 1996. More than 100 individuals are 
diagnosed with end sage renal disease (ESRD) each day. ESRD 
patients will need to remain on either hemodialysis or 
peritoneal dialysis for the rest of their lives unless they are 
able to receive a successful kidney transplant. Therapy can be 
delivered at dialysis facilities or in the home, depending on 
various factors.
    Today, more than 50 percent of the ESRD population is over 
60 years of age. Through age 50, the average remaining life 
span is grater than 5 years for ESRD patients. Although the 
remaining lifetimes are shorter for the elderly ESRD 
population, the general population also faces higher mortality 
with aging. The projected expected remaining lifetime for 
dialyzed patients with ESRD is approximately one-fourth to one-
sixth that for the general population through age 50, while the 
ratio is often closer to one-third for older patients. These 
figures are based on actuarial calculations and assumed death 
rates, and are taken from the U.S. Renal Data System 1997 
Annual Data Report.
    Because of the nature of the underlying disease and 
necessary supportive therapy, ESRD patients are at risk for a 
number of potential complications during or as a result of 
their therapy. Many of the potential complications can occur 
from a failure to correctly maintain or use dialysis equipment, 
insufficient attention to safety features of the individual 
dialysis system components, or insufficient staffing or 
personnel training. FDA's Center for Devices and Radiological 
Health (CDRH), in conjunction with major hemodialysis 
organizations, such as the Health Industries Manufacturers 
Association (HIMA), the Renal Physicians Association (RPA), and 
the American Nephrology Nurses Association (ANNA), developed 
several educational videotapes which address human factors, 
water treatment, infection control, reuse, and delivering the 
prescription, as well as manuals on water treatment and quality 
assurance. Complimentary videos illustrating health and safety 
concerns and the use of proper techniques have been distributed 
to very ESRD facility in the United States. These videos have 
received a favorable acceptance from the nephrology community.
    On October 6, 1995, CDRH completed the final draft of the 
Guidance Document on Hemodialyzer Reuse labeling for safe and 
effective reprocessing for reuse manufacturers. A letter was 
issued to Manufacturers and Initial Distributors of 
Hemodialyzers on May 23, 1996 to inform them of the requirement 
to obtain 510(k) clearance for ReUse labeling for all 
hemodialyzers which were being marketed for clinics reusing 
their dialyzers. They were given until February 25, 1997, to 
comply with the request. A video on the methods for correct 
reprocessing and reuse of hemodialyzers developed by the FDA, 
RPA, and other concerned groups is available. The video 
attempts to follow the standard protocols that have been 
detailed in the Association for the Advancement of Medical 
Instrumentation (AAMI) Recommended Practice for the Reuse of 
Hemodialyzers. These practices also have been adopted by HCFA 
as a condition of coverage to ESRD providers that practice 
reuse.
    A multistate study conducted for the FDA in 1987 indicated 
that dialysis facilities appeared to have inconsistent quality 
assurance (QA) techniques for many areas of dialysis treatment. 
To address this problem, FDA funded a contract to develop 
guidelines that could be used by all dialysis facility 
personnel to establish effective QA programs. The guidelines 
printed in February 1991 were mailed to every dialysis facility 
in the United States free of charge.
    During 1995-1996, FDA prepared a Draft Guidance Document 
for the Content of Premarket Notifications for Water 
Purification Components and Systems for Hemodialysis. This 
document was circulated for comment by regulated industry and 
other government agencies and was presented at both AAMI and 
Water Quality Association Meetings. The purpose for preparing 
this document was to remind the water treatment community of 
the Federal requirement for submission of premarket 
notifications for these types of device systems (21 CFR 
876.5665). The importance of the quality of the water used for 
preparation of hemodialysate solutions used during hemodialysis 
was strongly emphasized in these presentations and the Guidance 
Document.
    In September 1996, seven patients in Alabama received 
hemodialysis when the blood alarms activated on six of the 
seven patients. Subsequently, the patients began to exhibit 
serious central nervous (CNS) symptoms. FDA field staff, CDRH 
and CDC investigated the various aspects of the incident. The 
epidemiological analysis suggests a causal relationship between 
the age of the dialyzer filters used (ten plus years), and the 
injuries reported to the patients. As a result, CDRH and CDC 
issued a joint Public Health Advisory in December 1996, with 
the simple message to ``rotate your dialysis stock using first-
in-first-out practices,'' to avoid this type of problem in the 
future. FDA laboratories began a research program to 
investigate the effects of aging on dialyzer filters, with the 
objective of establishing safe expiration dating labeling.
    FDA has continued to work cooperatively with the nephrology 
community and the ESRD patient groups to improve the quality of 
dialysis delivery. These efforts appear to be yielding 
positives results. CDRH has also been cooperating with CDC and 
HCFA in the exchange of information to try to increase the 
safety of dialysis delivery.

           Fluoroscopically-Guided Interventional Procedures

    An increasing number of therapeutic procedures are being 
employed for a variety of conditions, such as coronary artery 
disease or irregular heart rhythms, which require x-ray 
fluoroscopy to provide visualization and guidance during the 
procedures. Due to the time required to complete these 
procedures, the potential for large radiation exposures leading 
to acute skin injury exists. During the early 1990s, the FDA 
received reports of such injuries, investigated the 
circumstances and issued an FDA Public Health Advisory to alert 
physicians and health care facilities to this concern. This 
advisory was sent to hospitals and specialist physicians who 
perform such procedures. During 1995 and 1996, the FDA 
continued activities to increase the awareness of physicians to 
this problem, including publishing supporting information for 
physicians, an article in the radiology literature and numerous 
presentations at medical professional meetings. These 
activities brought the attention of physicians to this issue 
and resulted in activities in many healthcare facilities to 
assure proper attention is given to this concern. As may of 
these interventional procedures are performed on older 
patients, this activity contributed to improved care for older 
Americans.

                              Mammography

    Since 1975, CDRH [formerly the Bureau of Radiological 
Health (BRH) has conducted a great many mammography activities. 
These have been done with several goals in mind:
          To reduce unnecessary radiation exposure of patients 
        during mammography to reduce the risk that the 
        examination itself might induce breast cancer; and
          To improve the image quality of mammography so that 
        early tiny carcinoma lesions can be detected at the 
        state when breast cancer is most treatable with less 
        disfiguring and more successful treatments.

  The National Strategic Plan for the Early Detection and Control of 
                       Breast and Cervical Cancer

    FDA, the National Cancer Institute, and the Centers for 
Disease Control have coordinated a combined effort to cover 75 
professional, citizen, and government groups to develop the 
National Strategic Plan for the Early Detection and Control of 
Breast and Cervical Cancer. The goal of this plan, approved by 
the Secretary of Health and Human Services on October 16, 1992, 
is to mount a unified effort by all interested groups to combat 
these two serious cancer threats. FDA staff took the lead in 
writing the Breast Cancer Quality Assurance section, one of six 
components of the plan, and participated in the development of 
the other components.

               Mammography Quality Standards Act of 1992

    On October 27, 1992, the president signed into law the 
mammography Quality Standards ACT [MQSA) of 1992. This Act 
requires the Secretary of Health and Human Services to develop 
and enforce quality standards for all mammography of the 
breast, regardless of its purpose or source of reimbursement.
    Since October 1, 1994, any facility wishing to produce, 
develop, or interpret mammograms has had to meet these 
standards to remain in operation. The Secretary delegated the 
responsibility for implementing the requirements to FDA on June 
1, 1993, and Congress first appropriated funds for these 
activities on June 6, 1993. Implementation of MQSA is a key 
component of Secretary Shalala's National Strategic Action Plan 
Against Breast Cancer.
    FDA's accomplishments since the Agency was delegated 
authority to implement MQSA in June 1993 include--staffing of a 
new division; development of final standards; approval of four 
accreditation bodies; certification of 10,000 facilities by the 
statutory deadline of October 1, 1994, implementation of a 
rigorous training program for inspectors; development of a 
compliance and enforcement strategy [coordinated with the 
Health Care Financing Administration (HCFA); outreach to 
facility and consumer communities; and planning for program 
evaluation.
    MQSA inspections have supplanted the Health Care Financing 
Administration's Medicare Screening Mammography Inspections. 
Under MQSA, HCFA has agreed to recognize FDA-certification of a 
mammography facility as meeting quality standards for 
reimbursement purposes.

                        Blood Glucose Monitoring

    A proposed ISO standard [draft ISO TC 212/WG3] was proposed 
for evaluating the performance of self-monitoring blood glucose 
monitors by comparing monitor results to those obtained by 
clinical laboratory methods. Because the draft standard did not 
address how to select a clinical laboratory method, an attempt 
was made, based upon telephone surveys and discussions with 
CAP, the three most commonly used clinical methods for analysis 
of blood glucose. A strategy was developed to evaluate the 
accuracy of these methods by comparison to the recently 
released Standard Reference Material from the National 
Institute of Standards and Technology that has three certified 
levels of glucose in human sera. Criteria were developed for 
selection of high performance clinical laboratories in order to 
minimize effects due to analysts.

                           Patient Restraints

    Patient restraints are intended to limit the patient's 
movement to the extent necessary for treatment, examination, or 
for the protection of the patient or others.
    One of the most common uses of these devices has been to 
protect the elderly from falls and other injuries. Seventy-nine 
documented deaths have been reported to FDA's Medical Device 
Reporting System (MDR) related to patient restraint use. 
Scientific literature suggeststhat annual deaths related to the 
use of restraints may be as high as 200. These alarming numbers of 
deaths, with the use of protective restraints raised serious concerns 
regarding the safe use of these devices and prompted the FDA to alert 
the healthcare community about these problems.
    The agency worked closely with industry in arriving at 
solutions to help reduce the risk of injury and death 
associated with the use of these devices. As a result, in 
November 1991, FDA moved to make protective restraints 
prescription devices to be used under the direction of licensed 
health care practitioners. In addition, manufacturers were 
required to label patient restraints as ``prescription only'' 
to help ensure appropriate medical intervention with the use of 
these devices. In July 1992, FDA issued a Safety Alert to 
healthcare providers to heighten their awareness of the 
potential hazards associated with the use of these devices. FDA 
identified labeling as its primary focus for intervention in 
resolving this issue, and provided additional labeling 
recommendations as guidance to manufacturers to ensure safer 
designs. Education and training of personnel in the application 
of these devices has also been emphasized.
    Today, healthcare providers are electing the restraint-free 
alternative. As a result, current literature reports that 
restraint use is dropping.

                              Hearing Aids

    Several events occurred in 1995-1996 which related to FDA's 
development of a guidance document that indicated criteria for 
clinical hearing aid study protocols. Manufacturers met with 
FDA staff to review proposed clinical studies, consultants met 
with FDA to discuss interpretations of the guidance document 
and how they might best interface with the regulated industry, 
and FDA had meetings with the Hearing Industries Association 
(HIA), representing many of the major manufacturers of hearing 
aids, wherein the use of the guidance document was discussed.
    In addition, members of FDA's Hearing Aid Working Group 
completed its draft of the proposal to amend the 1977 hearing 
aid regulation. This new regulation, if adopted, would cover 21 
CFR 801.420 and 801.421, Hearing Aids, Professional and Patient 
Labeling and Conditions for Sale.

                  Orthopaedic Implant Porous Coatings

    Porous coatings are widely used in both the orthopedic and 
dental implant industries to fix prosthetic devices through the 
process of bony in-growth without the aid of cements. However, 
the coating qualities such as strength, solubility, and 
abrasion resistance vary considerably depending on 
manufacturing methods and have significant impact on durability 
of the implants. Concern over the long-term revision rates for 
plasma sprayed porous coatings prompted the FDA to require 
post-market surveillance studies for these types of coatings. 
FDA also began a program to evaluate tests to assess the 
durability of such coatings in order to help in the development 
of longer-lived implants.

                       Hazards With Hospital Beds

    On August 21, 1995, FDA issued a Safety Alert, Entrapment 
Hazards with Hospital Bed Side Rails. The Alert noted that the 
majority of deaths and injuries reported to FDA involving bed 
rails were to elderly patients, and recommended a number of 
actions to prevent deaths and serious injuries. This Alert was 
sent to nursing homes, hospitals, hospices, home healthcare 
agencies, nursing associations, and biomedical and clinical 
engineers throughout the United States.

                        Retinal Photic Injuries

    On October 16, 1995, FDA issued a Public Health Advisory, 
Retinal Photic Injuries from Operating Microscopes During 
Cataract Surgery. Cataract surgery is most frequently performed 
on elderly patients. The Advisory discussed the types of 
injuries to patients reported to FDA, and recommended actions 
to reduce the risk of retinal photic injury. The Advisory was 
sent to ophthalmologists and cataract centers throughout the 
United States.

                         Electric Heating Pads

    On December 12, 1995, FDA working with the CPSC, issued a 
Public Health Advisory, Hazards Associated with Use of Electric 
Heating Pads. At the time of the Advisory, 45% of those 
reporting injuries from using heating pads, were over the age 
of 65. The Advisory pointed out that patients who may be unable 
to feel pain to the skin because of advanced age, diabetes, 
spinal cord injury, or medication, are at high risk for injury. 
This Advisory was sent to hospitals, nursing homes, hospices, 
home healthcare agencies, and biomedical and clinical engineers 
throughout the United States.

            FDA Problem Reporting System for Medical Devices

    The Office for Surveillance and Biometrics receives reports 
involving medical devices through reporting from consumers, 
medical professionals, manufacturers, distributors, and user 
facilities. On the 191,537 reports received during the calendar 
years 1995 and 1996 from all sources, 22,749 (12 percent) 
reported the age of the patient. Of these, 10,855 (48 percent) 
were for individuals 60 years of age or older. Prior to August 
1, 1996, manufacturers of medical devices were not required to 
provide age information. In many instances when manufacturers 
were required to provide age information, the information was 
unknown and therefore not reported.

                       Markers of Bone Metabolism

    Osteoporosis is a major health concern. It is estimated 
that 1.5 million fractures are attributable to osteoporosis in 
the United States each year. One third of women older than 65 
years suffer vertebral crush fractures, and the lifetime risk 
of hip fracture is 15%. The mortality rate accompanying hip 
fracture may be as high as 20%. Twenty-five percent of the 
survivors are confined to long-term care in nursing homes. The 
estimated cost of medical care for osteoporosis each year is 
more than $10 billion.
    If a woman has postmenopause-associated osteoporosis, an 
assessment of bone turnover may be helpful. Because of an 
increasing interest in bone disease and a greater understanding 
of bone metabolism, a number of urinary markers of bone 
turnover were cleared by the FDA in 1995 and 1996. The rate of 
bone loss is related to an overall increase of bone turnover 
which can be assessed using these biochemical indicators.

                      Year 2000 Health Objectives

    A consortium of over 300 government and private agencies 
developed a set of health objectives for the Nation which is 
serving as a national framework for health agendas in the 
decade leading up to the year 2000. The overall program is 
called ``Healthy People 2000.'' FDA co-chairs the working group 
responsible for monitoring progress on the set of 21 objectives 
that focus on nutrition, dietary improvements and availability 
of nutrition services and education. In the food and drug 
safety area, objective 12.6 sets as a target to:

          Increase to at least 75 percent the percentage of 
        health care providers who routinely review all 
        prescribed and over-the-counter medicines taken by 
        their patients 65 years and older each time medication 
        is prescribed or dispensed.

    Objective 12.8 sets as a target to:

          Increase to at least 75 percent the proportion of 
        people who receive useful information verbally and in 
        writing for new prescriptions from prescribers or 
        dispensers.

    FDA's Marketing Practices and Communications Branch 
conducted a number of studies that track patients' receipt of 
medication information from doctors and pharmacists from 1982 
to 1996. The most recent survey shows that 67% of Americans 65 
and over received at least some oral information about 
prescriptions from physicians and 43% from pharmacists, while 
13% received written information about their prescription 
medications from physicians and 62% received such information 
from pharmacists. Only 2% reported asking questions at the 
doctor's office, and 3% at the pharmacy. The survey is being 
conducted again in 1998 to track progress toward meeting this 
objective. An article outlining results of the surveys from 
1982-1994 will be published in Medical Care in October 1997.
    During the coming year, FDA will work with private sector 
organizations to advance medication counseling activities.

                             Food Labeling

    Food labeling is very important to the elderly. Elderly 
people have a greater need for more information about their 
food to facilitate preparation of special diets, maintain 
adequate balance of nutrients in the face of reduced caloric 
intake, and ensure adequate levels of specific nutrients which 
are known to be less well absorbed as a result of the aging 
process [e.g., vitamin B12].
    The new food label, which is now required on most foods 
offers more complete, useful, and accurate nutrition 
information to help the elderly meet their nutritional needs. 
Significant labeling changes include: nutrition labeling for 
almost all foods; information on the amount per serving of 
saturated fat, cholesterol, dietary fiber, and other nutrients 
of major concern to today's consumers; nutrient reference 
values to help consumers see how a food fits into an overall 
daily diet; uniform definitions for terms that describe a 
food's nutrition content [e.g., light, low fat, and high-
fiber], claims about the relationship between specific 
nutrients and disease, such as sodium and hypertension; 
standardized serving sizes; and voluntary quantitative 
nutrition information for raw fruit, vegetables, and fish.
    Manufacturers were required to comply with most of the new 
labeling requirements as of May 1994--although a 3-month 
extension was granted to firms who were unable to meet the May 
deadline. Regulations pertaining to health claims became 
effective a year earlier in May 1993. A recent survey indicates 
that a vast majority of food in the stores now carries the new 
food label and that more than 87 percent of the nutritional 
information accurately measures what is in the package. A 
second survey of retail stores was completed and showed that 
there continues to be substantial compliance with FDA's 
voluntary nutrition labeling program for raw fruits, 
vegetables, and fish. This is an important indication to 
consumers that they can trust what it says on the food label.
    To help consumers get the most from the new food label, 
educational materials are being widely disseminated. Among 
materials now available is a large-print brochure, ``Using the 
New Food Label to choose Healthier Foods,'' which is easier to 
read for senior citizens who may have vision problems.
    A food label education program has been developed that 
coordinates the efforts of FDA and USDA with various public and 
private sector organizations to educate consumers about the 
availability of new information on the food label and the 
importance of using that information to maintain healthful 
dietary practices. Consumer Research was used to guide the 
development of educational materials and their messages. Print 
and video materials were developed for diverse target 
audiences, emphasizing skills and tips on how to use the food 
label quickly and easily to achieve a healthier diet. The 
agency has released two ``Questions and Answers'' documents, 
giving answers to about 400 frequently asked questions. Volume 
II, released in August 1995, primarily addresses questions 
pertinent to restaurants and other related establishments.
    FDA's food labeling education program seeks to coordinate 
the Government's efforts with those of the public and private 
sector to insure consistent, action-oriented label 
educationmessages. A key goal is to promote integrating label education 
into new and existing nutrition education programs for diverse target 
audiences (for example, through national video teleconferences on 
nutrition interventions, children's games and nutrition-oriented 
programs on CD ROM's, and community-based programs for multi-cultural 
populations). Public information and education materials are available 
from FDA's Office of Consumer Affairs and have also been posted on 
CFSAN's home page of the World Wide Web (WWW).

                          Dietary Supplements

    The Dietary Supplement Health and Education Act of 1994 was 
signed by the President in 1994. This Act required FDA to 
withdraw its Advanced Notice of Proposed rulemaking requesting 
comment on approaches to assuring the safety of dietary 
supplements. The Act also defines supplements, defines new 
dietary ingredients as dietary ingredients that were not 
marketed in the U.S. before October 15, 1994, places the burden 
of proof for safety on FDA, and sets standards for the 
distribution on third party literature [e.g. books, 
publications, and articles].
    The law also allows statements of nutritional support under 
certain conditions. Such statements may describe the role of a 
nutrient or ingredient intended to affect the structure or 
function in humans or describe general well-being from 
consumption of a nutrient or dietary supplements ingredient. 
The manufacturer must be able to substantiate that such a 
statement is truthful and not misleading, and the statement 
must contain the following disclaimer, ``This statement has not 
been evaluated by the FDA. This product is not intended to 
diagnose, treat, cure, or prevent disease.''
    The law authorizes the FDA to issue regulations for Good 
Manufacturing Practices for dietary supplements, including 
expiration date labeling. It also establishes a 7-member 
Commission on Dietary Supplement Labels to conduct a study and 
issue a report making recommendations on the regulation of 
label claims for dietary supplements by October 25, 1996. The 
law further requires the Secretary of HHS to establish an 
``Office of Dietary Supplements'' at the National Institutes of 
Health.
    FDA published proposed regulations for the nutrition 
labeling of dietary supplements in December 1995. The 
regulations, when finalized, will require that dietary 
supplement labels contain information on the nutrient content 
and composition of dietary supplements that will enable the 
elderly to make informed choices on whether a particular 
dietary supplement is appropriate for their particular needs.

                           Total Diet Studies

    The Total Diet Study, as part of FDA's ongoing food 
surveillance system, provides a means of identifying potential 
public health problems related to the diets of the elderly and 
other age groups. Through the Total Diet Study, FDA is able to 
measure the levels of pesticide residues, toxic elements, 
chemicals, and nutritional elements in selected foods of the 
U.S. food supply. In addition, the study allows FDA to estimate 
the levels of these substances in the diets of 14 age groups: 
infants 6 to 11 months old; children 2, 6, and 10 years old; 
14- to 16-year-old-boys; 14- to 16-year-old girls; 25- to 30-
year-old men; 25- to 30-year-old women; 40- to 45-year-old men; 
40- to 45-year-old women; 60- to 65-year-old men; 60- to 65-
year-old women; men 70 years and older; and women 70 years and 
older. Because the Total Diet Study is conducted yearly, it 
also allows for the determination of trends and changes in the 
levels of substances in the food supply and in daily diets.

               Postmarket Surveillance of Food Additives

    FDA's Center for Food Safety and Applied Nutrition (CFSAN) 
monitors complaints from consumers and health professionals 
regarding food and color additives and dietary practices as 
part of its Adverse Reaction Monitoring System. Currently, the 
database contains 11,939 records. Of the complainants who 
reported their age, approximately 18 percent were individuals 
over age 60.
    CFSAN also monitors complaints regarding dietary 
supplements as part of the Adverse Reaction Monitoring System 
and has an additional 5057 reports. There is no information in 
the database on the age of the complainants for these products.

                             Medical Foods

    The Orphan Drug Amendments of 1988 enacted a definition for 
a medical food. It defined the term ``medical food'' to mean 
``[a] food which is formulated to be consumed or administered 
enterally under the supervision of a physician and which is 
intended for the specific dietary management of a disease or 
condition for which distinctive nutritional requirements, based 
on recognized scientific principles, are established by medical 
evaluation.'' FDA published an advanced notice of proposed 
rulemaking (ANPR) in November 1996. The ANPR announced that FDA 
intended to initiate a re-evaluation of its regulatory approach 
to these products. Its purpose was to ensure that the products 
marketed as medical foods bear claims that are truthful and not 
misleading, that such claims are supported by sound science, 
and that label information is adequate to inform consumers and 
health care providers how to use them in a safe manner. The 
initiative is important to the elderly because they may often 
rely on these products during periods of illness or to 
supplement their diets to meet specific nutrient needs not 
being met by their regular diets.

                    Medicare Coverage Determinations

    FDA provides representatives and scientific input to the 
Health Care Financing Administration's Technology Advisory 
Committee (TAC). The TAC is a committee of government 
employees, which advises HCFA on national coverage decisions 
for Medicare recipients. FDA also provides input and expert 
review for technology assessments produced by the Agency for 
Health Care Policy and Research (AHCPR). AHCPR technology 
assessments are used by HCFA and the Civilian Health and 
Medical Program of the Uniformed Services (CHAMPUS) as a basis 
for coverage decisions.
    During the 1995-1996 reporting period, FDA and HCFA 
formulated an arrangement to afford beneficiaries Medicare 
coverage for investigational medical devices determined by FDA 
to constitute only a minor change from an already covered 
device. This arrangement allows manufacturers to validate the 
safety and efficacy of improved products without denying 
coverage during the period of study.

                          Pharmacy Initiative

    During 1995 and 1996, DHHS and FDA have sought to encourage 
greater pharmacy-based counseling. Through speeches, articles, 
and editorials in major medical and pharmacy journals, DHHS and 
FDA have encouraged the increased role of pharmacists, using 
computers to print information to informing patients about the 
uses, directions, risks and benefits of prescription 
medications. The pharmacy profession has responded positively, 
bringing many examples of their initiatives to FDA's attention. 
In particular, several organizations have informed FDA of the 
expanded use of new technology to provide patient instructional 
materials to their customers. In August of 1996 Congress took 
up this issue and developed performance goals for the private 
sector to meet. In December of 1996 the private sector had 
developed an Action Plan with criteria on how to determine the 
usefulness of information for consumers. The Plan would then be 
presented to the Secretary of HHS for concurrence. A survey by 
FDA, with data collected beginning December 1996, showed 67% of 
patients reporting that they received written information with 
their prescription drugs. FDA will conduct studies in the 
future to review the usefulness of that information and will 
continue to work closely with private sector organizations in 
an effort to increase the dissemination of useful information 
to patients about their prescription medications.

                              Health Fraud

    Health fraud.--the promotion of false or unproven products 
or therapies for profit--is big business. These fraudulent 
practices can be serious and often expensive problems for the 
elderly. In addition to economic loss, health fraud can also 
pose direct and indirect health hazards to those who are misled 
by the promise of quick and easy cures and unrealistic physical 
transformations.
    The elderly, more often than the general population, are 
the victims of fraudulent schemes. Almost half of the people 
over 65 years of age have at least one chronic condition such 
as arthritis, hypertension, or a heart condition. Because of 
these chronic health problems, senior citizens provide 
promoters with a large, vulnerable market.
    To combat health fraud, the FDA uses a combination of 
enforcement and education. In each case, the Agency's decision 
on appropriate enforcement action is based on considerations 
such as the health hazard potential of the violative product, 
the extent of the product's distribution, the nature of any 
mislabeling that has occurred, and the jurisdiction of other 
agencies.
    The FDA has developed a priority system of regulatory 
action based on two general categories of health fraud: direct 
health hazards and indirect hazards. The Agency regards a 
direct health hazard to be extremely serious, and it receives 
the Agency's highest priority. FDA takes immediate action to 
remove such a product from the market. When the fraud does not 
pose a direct health hazard, the FDA may choose from a number 
of regulatory options to correct the violation, such as a 
warning letter, a seizure, or an injunction.
    The Agency also uses education and information to alert the 
public to health fraud practices. Both education and 
enforcement are enhanced by coalition-building and cooperative 
efforts between government and private agencies at the 
national, State, and local levels. Also, evaluation efforts 
help ensure that our enforcement and education initiatives are 
correctly focused.
    The health fraud problem is too big and complex for any one 
organization to effectively combat by itself. Therefore, FDA is 
working closely with many other groups to build national and 
local coalitions against health fraud. By sharing and 
coordinating resources, the overall impact of our efforts to 
minimize health fraud will be significantly greater.
    FDA has worked with the National Association of Attorney's 
General [NAGS] and other organizations to provide consumers 
with information to help avoid health fraud. Since 1986, FDA 
has worked with the National Association of consumer Agency 
Administrators [NCAA] to establish the ongoing project called 
the NCAA Health Products and Promotions Information Exchange 
Network. Information from FDA, the Federal Trade Commission 
[FTC], the U.S. Postal Service [USPS], and State and local 
offices is provided to NCAA periodically for inclusion in the 
Information Exchange Network. This system provides information 
on health products and promotions, consumer education materials 
for use in print and broadcast programs, and the names of 
individuals in each contributing agency to contact for 
additional information.
    In 1995 and 1996, FDA's Public Affairs Specialists [PASs] 
continued to alert diverse and culturally specific elderly 
populations throughout the United States by sponsoring 
community-based education programs, information exchanges, and 
outreach efforts. Dietary supplements remained a key issue. In 
addition to health fraud workshops and other community-based 
programs, the PASs also convey this important information 
through additional networks such as radio, television shows, 
and public service announcements. With respect to enforcement, 
in 1995 and 1995, the Agency took action against distributors 
of common gas grill ignitors that were promoted for the relief 
of pain due to arthritis and other conditions.

                             Women's Health

         information about drug effects in certain populations

    Over the past decade there has been growing concern that 
the drug development process does not provide sufficient 
information about drug effects in certain populations, 
including minorities and women of all ages. On September 8, 
1995, the FDA, in an effort to collect this necessary 
information, proposed to amend its regulations regarding the 
format and content of investigational new drug applications 
(INDs) and new drug applications (NDAs). The proposed rule 
would require IND sponsors of drugs and biological products to 
include in their annual reports a characterization of study 
subjects by subgroups, such as age, gender, and race. Sponsors 
would also be required to present safety and efficacy data by 
subgroup when submitting NDAs. This rule has since gone into 
effect and will assist in the determination of the optimal use 
of drugs in special populations which have a variety of factors 
that can lead to different responses to medical products.

                     women's health research agenda

    During 1995 and 1996, FDA participated with the NIH Office 
of Women's Health in defining specific objectives of the 
research agenda for the 21st century. The effort culminated in 
plans for a workshop including experts from the federal 
government and universities to be held in 1997. Some specific 
age-related conditions were evaluated including cardiovascular 
and pulmonary diseases, oral health, bone and musculoskeletal 
disorders, kidney conditions, and cancer.

                   hispanic women's health conference

    On May 9-10, 1996, the Office of Women's Health sponsored 
the Hispanic Women's Health Conference held in Miami, Florida. 
Over 150 people attended the conference which was designed as a 
grassroots effort to bring together community based 
organizations, academia, federal, state and local agencies and 
public/private health care providers concerned with Hispanic 
women's health issues, many of which affect aging American 
women. The two day meeting featured national and local speakers 
who addressed key Hispanic health concerns in the areas of 
diabetes, heart disease, cancer, mental health, substance 
abuse, osteoporosis, and HIV/AIDS. Its purposes were to create 
an ongoing network of health professionals in Southern Florida 
to address this community's health needs, and to consider 
priority issues on which ongoing public education should occur.

              minority women health empowerment: workshops

    The office sponsored this series of Conferences in 1995, 
1996 and 1997. The purpose of the workshops was to equip 
minority women, including the aging, in urban areas of the New 
Jersey and Delaware Valley with information on how to take care 
of themselves, how to prevent illness and disease, and what the 
benefits are of early detection and treatment. This project 
targeted women who were at high risk for HIV/AIDS, 
cardiovascular disease, breast and other cancers, and diabetes. 
The programs were conducted in community centers, Head Start 
Centers, local parish halls, school auditoriums, and hospital 
conference rooms. Audiotapes in English and Spanish were given 
to participants at the end of the workshop.

                   women's health: take time to care

    In 1996, the FDA Office of Women's Health (OWH) conceived 
of a new program partnering with American women. In order to 
enhance the health of women, the FDA wanted to provide mid-life 
and older women, particularly in under served populations, with 
the information they need to promote and protect their own 
health. OWH met with 46 advocacy groups representing women, the 
elderly, and disease conditions, to discuss their health 
concerns. The theme, Women's Health: Take Time To Care, will be 
used for a variety of health prevention messages. Women, as 
represented by these organizations, told us that the first 
message should be presented Use Medicines Wisely. As major 
consumers of pharmaceuticals, women and their health are 
significantly affected by the use of medications. In 1997, 
Pilot programs using this message were conducted in Chicago, IL 
and Hartford, CT. FDA provided the printed materials and 
information and community organizations sponsored numerous 
public awareness events. This program will be rolled out 
nationally in 1998 and will be brought to 15 cities, rural 
empowerment zones, and Native-American reservations across the 
country.

                        ``before time runs out''

    Breast cancer is the number one cause of cancer related 
deaths among African American women. The FDA Office of Women's 
Health provided funds to educate African American women in the 
Houston area about the importance of screening and the impact 
of breast cancer on the African American community through the 
use of a locally-inspired play. This drama, which was written 
and produced by an African American playwright (Thomas 
Meloncon) entitled ``Before Time Runs Out'' was inspired by Mr. 
Meloncon's sister who died of breast cancer. The play was 
followed by a panel discussion and pertinent brochures were 
distributed. This series was presented in selected churches in 
under served communities in Houston in 1996 and 1997.

                       public education brochures

    Asian Pacific Islander women have low rates of utilization 
of breast and cervical cancer screening procedures due to 
language barriers and a subsequent lack of understanding of the 
importance of these tests. In 1995, the Office of Women's 
Health sponsored the translation of mammography and cervical 
cancer screening materials into several languages to address 
the needs of linguistically isolated Asian Pacific Islander 
women.

                         Outreach and Exhibits

    The Office of Consumer Affairs [OCA] sent information to 
older Americans through ``Dear Consumer'' letters, faxes, phone 
calls, and personal visits to notify, inform, and elicit 
feedback from consumers in the areas of Mammography Quality 
Standards, MedGuide, direct-to-consumer advertising for 
prescription drugs, plasma product withdrawals and recalls, 
food labeling, informed consent and issues pertaining to FDA 
advisory committees.
    OCA participated in and exhibited at the Native American 
Aging Council. Over 300 publications were distributed on 
nutrition for the elderly as well as ``The Age Page'' 
publications from the National Institutes of Health.

                        Community-Based Programs

    Public Affairs Specialists, located throughout the country 
in FDA field offices, conducted a variety of community-based 
programs in 1995-1996 to address the health concerns and 
information needs of older Americans. The topics addressed by 
field programs and outreach efforts are timely and diverse, 
including such topics as food labeling [how to get the most for 
your dollars and how to meet the requirements of special 
diets]; the safe use of medications; questions to ask your 
physician or health care provider; health fraud; clinical 
trials; blood safety; vaccines; hormone replacement therapy; 
and cancer screening.
    One of the major ongoing initiatives undertaken by FDA 
Public Affairs Specialists focused on informing older Americans 
about the Nutrition Labeling and Education Act and how to use 
the new food label for a healthy or special diet. These 
Specialists developed information kits for older people and 
distributed these kits in communities throughout the country. 
These kits included wallet cards on the new food labeling law; 
large-print face sheets; place mats; and trainer guides. Senior 
volunteers were trained in a nutrition program sponsored by 
DHHS Region V Administration on Aging in Chicago, Illinois to 
disseminate information on food labeling to senior citizen, 
especially older people in minority communities.
    Examples of other community-based programs and outreach 
initiatives carried out by FDA Public Affairs Specialists 
include:
          Health fraud activities focusing on health fraud 
        scams and products that target older people such as a 
        statewide health fraud conference held in Kentucky; a 
        health fraud symposium in New Jersey with a federal 
        panel comprised of the FDA, Federal Trade Commission, 
        and the Consumer Product Safety Commission, addressing 
        ``Knowing Your Rights is the Key to Consumer 
        Protection''; and working with state officials in 
        Hawaii to assemble a task force to teach older people 
        about health fraud products and ploys; and
          Workshops addressing proper medication storage, 
        understanding OTC/Rx labeling, food and drug 
        interactions, drug and drug interactions and medication 
        usage; and
          Participating with community organizations such as 
        the local health department, Alzheimer's Association, 
        Arthritis Foundation, local department on aging, and 
        other partners to sponsor health fairs for older 
        people; and
          Carrying out daily activities with state and local 
        agencies, local media, nonprofit organizations, 
        professional associations, and public health 
        institutions to meet the information and service needs 
        of older people within communities across the country.

                  HEALTH CARE FINANCING ADMINISTRATION

                             Long-Term Care

    The mission of the Health Care Financing Administration 
(HCFA) is to promote the timely delivery of appropriate, 
quality health care to its beneficiaries--over 75 million aged, 
disabled, and poor Americans.
    Medicaid and Medicare are the principal sources of funding 
long term care in the United States. The primary types of care 
reimbursed by these programs of HCFA are a variety of 
institutional (e.g., skilled nursing facilities (SNFs), 
intermediate care facilities for the mentally retarded (ICFs/
MR), inpatient rehabilitation) and home and community based 
care services (e.g., home health, personal care).
    HCFA's Office of Research and Demonstrations (ORD) conducts 
demonstration projects that demonstrate and evaluate optional 
coverage, eligibility, delivery system, payment and management 
alternatives to the present Medicare and Medicaid programs. ORD 
also conducts research studies on a range of issues relating to 
long term care services and their users, providers, quality and 
costs.

                        demonstration activities

    Demonstration activities in ORD include the development, 
testing, and evaluation of:
          Alternative methods of service delivery for post 
        acute and long term care, focusing on service delivery 
        systems that integrate acute and long term care;
          Innovative quality assurance systems and methods; and
          Alternative payment systems for post acute and long 
        term care systems.
    In 1996, HCFA continued work on several major initiatives 
to test innovative systems of integrated acute and long term 
care. ORD has devoted extensive effort to the testing of 
capitated payment systems for a combination of acute and long 
term care services, including conducting and evaluating the 
Program of All-inclusive Care for the Elderly (PACE) and the 
Social Health Maintenance Organization (Social HMO) 
demonstrations. The PACE demonstration has the purpose of 
replicating a unique model of managed care service delivery for 
very frail community dwelling elderly, most of whom are dually 
eligible for Medicare and Medicaid coverage and all of whom are 
assessed as being eligible for nursing home placement. Work 
continued on the evaluation of this demonstration, as well as 
the development of a quality assurance system that could be 
used by HCFA and State Medicaid agencies in monitoring 
providers, as well as by the providers for internal quality 
improvement activities. Work is also continuing to develop and 
implement a ``second generation'' model of the Social HMO, and 
the first of these sites began enrollment and service delivery 
in 1996. The first State-initiated integrated system of care 
for dually eligible beneficiaries was also implemented in 
Minnesota, the Minnesota Senior Health Options demonstration. 
The provision of integrated acute and long term care services 
to children and youth who are disabled and eligible for 
Supplemental Security Income is being test in theDistrict of 
Columbia's Health Services for Children with Special Needs. 
Implementation of this prepaid, capitated project began in late 1995, 
and 3,000 children and youth with disabilities are targeted for 
voluntary enrollment.
    In 1996, ORD continued testing capitation payment systems 
for home health care and long term nursing home care, under the 
auspices of the Community Nursing Organization (CNO) and 
EverCare demonstrations. HCFA awarded contracts to four CNO 
sites in 1992. This demonstration tests the feasibility and 
effect on patient care of a capitated, nurse-directed delivery 
system for home health and other community based services. The 
CNO sites completed a 1-year development period and began a 3-
year operational period in January 1994. HCFA is also working 
with the United HealthCare Corporation, Inc. to implement the 
EverCare demonstration. This demonstration tests the 
effectiveness of managing acute care needs of nursing home 
residents by pairing physicians and geriatric nurse 
practitioners who will function as primary medical care givers 
and case managers. Payment is on a prepaid, capitated basis. 
Five sites were operational by the close of 1996.
    In 1996 HCFA also continued operation of major 
demonstrations designed to test prospective payment of home 
health and SNF care. The Medicare home health prospective 
payment demonstration is being conducted in two phases. The 
first phase involved testing of prospectively established per-
visit payment rates for Medicare covered home health visits. A 
second phase, implemented in 1995, is testing per-episode 
payment rates for an episode of Medicare covered home health 
care. In 1995, ORD also implemented the MultiState Nursing Home 
Case Mix and Quality demonstration in four States. This 
demonstration is testing innovative quality assurance and 
prospective case-mix adjusted payment for nursing homes that 
participate in Medicare and Medicaid.
    New demonstrations designed to provide greater consumer 
direction and autonomy were under development in 1996. The 
Consumer-Directed Durable Medical Equipment demonstration, 
designed to provide greater consumer direction and control in 
the purchase and maintenance of Medicare durable medical 
equipment was designed in 1996, with site selection targeted 
for 1997. HCFA also worked collaboratively with the Assistant 
Secretary for Planning and Evaluation and the Robert Wood 
Johnson Foundation to develop a demonstration of cash payments 
and counseling services for Medicaid personal assistance 
services. Four sites were selected for demonstration 
participation in 1996, and implementation of this demonstration 
is expected in late 1997.
    HCFA continues its interest in the development and testing 
of outcome based quality assurance systems. A demonstration to 
test the effectiveness of outcome based quality assurance 
activities in Medicare home health was implemented in 46 home 
health agencies in 1996, while a demonstration of outcome based 
quality assurance for persons with developmental disabilities 
was implemented in the State of Minnesota in 1996.

                          research activities

    Long term care research activities in ORD can be classified 
according to the following objectives:
          Examining trends in disability and the relationship 
        between disability, need for and use of long term care 
        services;
          Examining the effect of the Medicare Catastrophic 
        Coverage Act on subacute and long term care services 
        and providers as well as ongoing changes in the use of 
        post acute and long term care;
          Examining alternative quality assurance, financing 
        and payment systems for long term care; and
          Supporting data development and analyses.
    Because the long term care population is diverse and its 
composition continues to change over time, it is important to 
examine changes in rates of disability as well as the 
relationship between types of disability, need for and use of 
long term care services. For example, the most rapidly growing 
segments of the Medicare population are beneficiaries under age 
65 with disabilities and those who are 85 years or older--both 
segments with significantly higher rates of disability and 
related use of services.
    A major responsibility of ORD is assessing the effects of 
various Medicare and Medicaid programs and policies on subacute 
and long term care services. Since the passage of the Medicare 
Catastrophic Coverage Act and its subsequent repeal, ORD has 
been assessing the effects of this change on other parts of the 
health care system. Included in this research is the 
examination of changes in subacute and long term care case mix, 
utilization, quality, and costs. Changes in the supply of long 
term care providers are also being studied. Major research 
projects are underway to analyze the appropriateness of post 
hospital care and the course and outcomes of that care. In 
recent years, there has been an increased emphasis on examining 
episodes of care rather than utilization of just one type of 
services. Medicare files, which link hospital with post 
hospital care, continue to be analyzed to provide information 
on trends in the post acute care utilization. In addition, 
another purpose of funding this research was to gather 
information about decision making at the point of hospital 
discharge and the types of patients who are referred to the 
various post acute modalities of care. These research studies 
involve collection and analysis of data in order to provide 
Medicare coverage, quality assurance and payment policy 
recommendations relating to subacute care (e.g., nursing homes, 
rehabilitation hospitals and home health).
    Several studies address alternative financing, payment and 
quality assurance systems. Although the majority of the elderly 
are covered by both Medicare and supplemental insurance, a 
large portion of long term care services remain uncovered. 
Medicaid covers long term nursing home and community based 
care, but only after elderly individuals have depleted personal 
resources. Research is being conducted that identifies sources 
of financing long term care, examines beneficiaries' personal 
resources to purchase long term care insurance, and examines 
the risk of catastrophic expenditures. Other research is 
continuing in the payment area, as work was initiated to 
develop case-mix payment systems for home health, as well as 
for Medicaid payments for persons with disabilities. Work to 
develop outcome-based quality assurance systems also continues.
    Efforts are also underway to improve the data bases, 
statistics and baseline information upon which future 
assessment of needs, problem identification, and policy 
decisions will be based. HCFA continues to support the 
Disability Supplement to the 1994 and 1995 National Health 
Interview Survey, the Medicare Current Beneficiary Survey, the 
National Recurring Data Set project and the Long Term Care 
Program and Market Characteristics data base.
    One subgroup of increasing importance to both the Medicare 
and Medicaid programs is individuals who receive services under 
both programs. ORD began analysis with the Medicare Current 
Beneficiary Survey, designed to improve our understanding of 
the demographic characteristics of dually eligible individuals, 
their service use and costs, as well as any potential access 
problems they might experience. These analyses are also 
intended to support the development of demonstrations targeted 
to dually eligible individuals, in which service delivery, 
quality and payment innovations will be tested.
    Information follows on specific HCFA demonstrations and 
research.

On Lok's Risk-Based Community Care Organization for Dependent Adults: 
        On Lok Senior Health Services

    Period: November 1983-Indefinite.
    Funding: Waiver only.
    Grantee: On Lok Senior Health Services, 1333 Bush Street, 
San Francisco, CA 94109 and California Department of Health 
Services, 714-744 P Street, P.O. Box 942732, San Francisco, CA 
94234-7320.
    As mandated by sections 603(c) (1) and (2) of Public Law 
98-21, the Health Care Financing Administration granted 
Medicare waivers to On Lok Senior Health Services and Medicaid 
waivers to the California Department of Health Services. 
Together, these waivers permitted On Lok to implement an at-
risk, capitated payment demonstration in which more than 300 
frail elderly persons, certified by the California Department 
of Health Services for institutionalization in a skilled 
nursing facility, are provided a comprehensive array of health 
and health-related services in the community. The current 
demonstration maintains On Lok's comprehensive community-based 
program but has modified its financial base and reimbursement 
mechanism. All services are paid for by a predetermined 
capitated rate from both the Medicare and Medicaid (Medi-Cal) 
programs. The Medicare rate is based on the average per capita 
cost for the San Francisco county Medicare population. The 
Medi-Cal rate is based on the State's computation of current 
costs for similar Medi-Cal recipients, using the formula for 
prepaid health plans. Individual participants may be required 
to make copayments, spenddown income, or divest assets based on 
their financial status and eligibility for either or both 
programs. On Lok has accepted total risk beyond the capitated 
rates of both Medicare and Medi-Cal, with the exception of the 
Medicare payment for end stage renal disease. The demonstration 
provides service funding only under the waivers. Research and 
development activities are funded through private foundations.
    Section 9220 of Public Law 99-272 has extended On Lok's 
Risk-Based Community Care Organization for Dependent Adults 
indefinitely, subject to the terms and conditions in effect as 
of July 1, 1985, with the exception of the requirements 
relating to data collection and evaluation. On Lok is 
continuing to develop collaborative projects with other 
organizations in the San Francisco Bay area. A pilot agreement 
with the Institute on Aging (IOA) has been completed and the 
twoorganizations have entered in a venture agreement in which 
IOA will be establishing an adult day health center and operating it 
under the rules of the Program of All-Inclusive Care for the Elderly 
protocol. The site will be established in the Richmond area of San 
Francisco. On Lok will provide quality assurance oversight as well as 
marketing and enrollment support. IOA will receive a portion of On 
Lok's capitation it receives via the HCFA demonstration and a portion 
will be retained by On Lok to cover administrative expenses.

Program of all-inclusive care for the elderly

    Period: June 1990-January 1997 (yearly continuation).
    Funding: Waiver only.
    Grantees: See below.
    Mandated by Public Law 99-509, as amended by section 
4118(g)(1)(2) of Public Law 100-203 and section 4744 of Public 
Law 101-508, the Health Care Financing Administration will 
conduct a demonstration that replicates, in not more than 15 
sites, the model of care developed by On Lok Senior Health 
Services in San Francisco, California. The Program of All-
Inclusive Care for the Elderly demonstration replicates a 
unique model of managed-care service delivery for 300 very 
frail community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and all of 
whom are assessed as being eligible for nursing home placement, 
according to the standards established by participating States. 
The model of care includes--as core services--the provision of 
adult day health care and multidisciplinary case management 
through which access to and allocation of all health and long-
term-care services are arranged. Physician, therapeutic, 
ancillary, and social support services are provided on site at 
the adult day health center whenever possible. Hospital, 
nursing home, home health, and other specialized services are 
provided off site. Transportation is provided for all enrolled 
members who require it. This model is financed through 
prospective capitation of both Medicare and Medicaid payments 
to the provider. Demonstration sites are to assume financial 
risk progressively over 3 years, as stipulated in the Omnibus 
Budget Reconciliation Act of 1987. The ten sites and their 
State Medicaid agencies that have been granted waiver approval 
to provide services are:
            Elder Service Plan
    Period: June 1990-January 1997 (yearly continuation).
    Grantee: East Boston Geriatric Services, Inc., 10 Gove St., 
East Boston, MA 02128.
    Period: June 1990-January 1997 (yearly continuation).
    Grantee: Massachusetts State Department of Public Welfare, 
180 Tremont St., Boston, MA 02111.
            Providence Elder Place
    Period: June 1990-January 1997 (yearly continuation).
    Grantee: Providence Medical Center, 4805 Northeast Glisan 
Street, Portland, OR 97213.
    Period: June 1990-January 1997 (yearly continuation).
    Grantee: Oregon State Department of Human Services, 313 
Public Service Building, Salem, OR 97310.
            Comprehensive Care Management
    Period: February 1992-January 1997 (yearly continuation).
    Grantee: Beth Abraham Hospital, 612 Allerton Ave., Bronx, 
NY 10467.
    Period: February 1992-January 1997 (yearly continuation).
    Grantee: New York State Department of Social Services, 40 
North Pearl Street, Albany, NY 12243-0001.
            Palmetto Senior Care
    Period: October 1990-January 1997 (yearly continuation).
    Grantee: Richland Memorial Hospital, Fifteen Richland 
Medical Park, Columbia, SC 29203.
    Period: October 1990-January 1997 (yearly continuation).
    Grantee: South Carolina State Health and Human Services 
Finance Commission, P.O. Box 8206, Columbia, SC 29202-8206.
            Community Care for the Elderly
    Period: October 1990-January 1997 (yearly continuation).
    Grantee: Community Care Organization, 5228 West Fond du Lac 
Avenue, Milwaukee, WI 53216.
    Period: October 1990-January 1997 (yearly continuation).
    Grantee: Wisconsin State Department of Health and Social 
Services, P.O. Box 7850, Madison, WI 53707-7850.
            Total Longterm Care, Inc.
    Period: August 1991-January 1997 (yearly continuation).
    Grantee: Total Longterm Care, Inc., 3202 West Colfax, 
Denver, CO 80204.
    Period: August 1991-January 1997 (yearly continuation).
    Grantee: Colorado Department of Social Services, 1575 
Sherman Street, Denver, CO 80203-1714.
            Bienvivir Senior Health Services
    Period: June 1994-January 1997 (yearly continuation).
    Grantee: Bienvivir Senior Health Services, 6000 Welch, 
Suite A-2, El Paso, TX 77905-1753.
    Period: December 1991-November 1997 (yearly continuation).
    Grantee: Texas Department of Human Services, P.O. Box 
149030 (MC-E-601), Austin, TX 78714-9030.
            Independent Living for Seniors
    Period: March 1992-March 1997 (yearly continuation).
    Grantee: Rochester General Hospital, 311 Alexander Street, 
Rochester, NY 14604.
    Period: March 1992-March 1997 (yearly continuation).
    Grantee: New York State Department of Social Services, 40 
North Pearl Street, Albany, NY 12243-0001.
            Sutter Senior Care
    Period: May 1994-April 1997 (yearly continuation).
    Grantee: Sutter Health System, 2800 L Street, Sacramento, 
CA 95816.
    Period: May 1994-April 1997 (yearly continuation).
    Grantee: California Department of Health Services, 714/744 
P Street, P.O. Box 942732 Sacramento, CA 94234-7320.
            Center for Elders' Independence
    Period: April 1995-March 1997 (yearly continuation).
    Grantee: Center for Elders' Independence, 1411 East 31st 
Street, Ward B2, Oakland, CA 94602.
    Period: April 1995-March 1997 (yearly continuation).
    Grantee: California Department of Health Services, 714/744 
P Street, P.O. Box 942732 Sacramento, CA 94234-7320.

Evaluation of the Program of All-inclusive Care for the Elderly 
        demonstration

    Period: June 1991-January 1997.
    Funding: $4,486,514.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: David Kidder, Ph.D.
    The Program of All-Inclusive Care for the Elderly (PACE) 
Demonstration replicates a unique model of managed-care service 
delivery for 300 very frail community-dwelling elderly, most of 
whom are dually eligible for Medicare and Medicaid coverage and 
all of whom are assessed as being eligible for nursing home 
placement according to the standards established by 
participating States. The model of care includes--as core 
services--the provision of adult day health care and 
multidisciplinary team case management through which access to 
and allocation of all health and long-term-care services are 
arranged. This model is financed through prospective capitation 
of both Medicare and Medicaid payments to the provider. One 
purpose of the evaluation is to examine PACE sites before and 
after assumption of full financial risk, with the purpose of 
determining whether the PACE model of care, as a replication of 
the On Lok Senior Health Services model of care, is cost-
effective to the existing Medicare and Medicaid programs. 
Another purpose is to examine the decision to enroll in PACE in 
order to understand how PACE enrollees differ from those who 
are eligible for PACE but refuse to enroll in the program; to 
determine the impact of PACE on participant health services 
utilization, expenditures, and outcomes; and to explore the 
subobjectives of PACE or the link between PACE and the outcomes 
of interest.
    This project initiated primary data collection in January 
1995 that will continue through the end of this contract. 
Reports based on site visits to demonstration sites operating 
under capitated Medicare and Medicaid payments have been 
received annually. Preliminary impact results have been 
received and suggest the following: (1) PACE reduces nursing 
home and hospital use, while increasing use of ambulatory and 
other non-institutional services; (2) PACE is associated with 
improved health status, quality of life and satisfaction, 
though not with measurable improvement in physical function; 
(3) although PACE participants survive longer than non-
participants, the difference is not statistically significant; 
and (4) PACE appears to be more effective at reducing 
institutional utilization and improving health status and 
satisfaction for participants with high levels of physical 
impairment than for the less impaired.

Program for All-inclusive Care for the Elderly data management

    Period: March 1992-August 1995.
    Funding: $613,014.
    Contractor: On Lok, Inc., 1333 Bush Street, San Francisco, 
CA 94109.
    Investigator: Marleen L. Clark, Ph.D.
    The purpose of this project is to provide continuing data 
management through out the Program for All-Inclusive Care for 
the Elderly (PACE) demonstration period to ensure that a valid, 
reliable data set is maintained for monitoring project 
operations and for use by the Health Care Financing 
Administration's independent evaluator. The PACE demonstration 
replicates a unique model of managed-care service delivery for 
very frail community-dwelling elderly persons, most of whom are 
dually eligible for Medicare and Medicaid coverage and all of 
whom are assessed as being eligible for nursing home placement 
according to the standards established by the participating 
States. DataPACE maintains a data set on PACE enrollees, 
including demographic and enrollment information, health and 
functional status, and service use. For the PACE demonstration 
project, On Lok has established a minimum dataset and has 
implemented data collection procedures at the PACE sites for 
this data set. This dataset includes the variables and program 
information originally designed to be used by evaluators. This 
contract has been concluded.

Program of All-inclusive Care for the Elderly data management

    Period: September 1995-August 1998.
    Funding: $590,630.
    Contractor: On Lok, Inc., 1333 Bush Street, San Francisco, 
CA 94109.
    Investigator: Marleen L. Clark, Ph.D.
    The purpose of this contract is to provide data management 
for the Program of All-Inclusive Care for the Elderly (PACE) 
demonstration period to ensure that a valid, reliable data set 
is maintained for monitoring project operations and for use by 
the Health Care Financing Administration's independent 
evaluator. This is a continuation of the previous contract with 
On Lok, Inc. to provide this service. DataPACE maintains a data 
set on PACE enrollees and manages data collection procedures at 
the PACE sites. In the course of this second contract, service 
utilization data are scheduled to be used by the PACE 
demonstration programs's independent evaluator. The DataPACE 
software and data management routines have been implemented at 
all sites and continue to be used to monitor data quality and 
provide feedback to the sites. The first round of data 
transmissions to the independent evaluator have taken place.

External assessment of quality assurance in the Program for All-
        inclusive Care for the Elderly

    Period: September 1993-March 1996.
    Funding: $389,218.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: David Kidder, Ph.D.
    The purpose of this study is to develop and test an 
external quality assurance program for the Program for All-
Inclusive Care for the Elderly (PACE) model of care based on 
structured implicit review. These measures may be used by the 
Health Care Financing Administration and State Medicaid 
agencies in quality assurance monitoring of the PACE program. 
The two key approaches that form the basis for the development 
of a quality assurance program are: (1) a``tracer approach'' 
that identifies certain events whose existence represents a sign of 
unsatisfactory care; and (2) ``general patient-centered measures'' of 
health outcomes that reflect the total effects of care on the 
individual patient. The quality assurance approach encompasses both 
process and outcome elements. Tracer conditions have been developed by 
the University of Minnesota, the subcontractor for this delivery order. 
The University of Minnesota has obtained copies of medical records from 
each of the PACE sites and has abstracted the necessary information 
from the medical records. Final reports describing the success of 
structured implicit review, information about patient satisfaction and 
the feasibility of conducting this type of monitoring system on a group 
of control patients have been submitted. The results suggest cautious 
optimism about using structured implicit review on a wide scale. 
Although this approach can detect differences in patterns of care, 
inter-rater reliability is not high.

Program for All-inclusive Care for the Elderly (PACE) Quality Assurance

    Period: September 1996-March 1999.
    Funding: $1,837,148.
    Contractor: Center for Health Policy Research, 1355 S. 
Colorado Blvd, Suite 306, Denver, CO 80222.
    Investigator: Peter Shaughnessy, Ph.D.
    This project will develop an outcome-based quality 
assurance and performance improvement system for the Program 
for All-Inclusive Care for the Elderly (PACE) for use by Health 
Care Financing Administration (HCFA) and States in monitoring 
sites and for continuous quality improvement (CQI). The CQI 
system will consist of two phases. In the first phase risk-
adjusted outcome reports will be produced, while during the 
second phase the PACE sites will examine why and how they are 
achieving specific outcomes and make recommendations for 
improvements in the case of poor outcomes. This project is 
currently in its design phase.

Social Health Maintenance Organization Project for long-term care

    Period: August 1984-December 1997.
    Funding: Waiver only.
    Grantees: See below.
    In accordance with section 2355 of Public Law 98-369, this 
project was developed to implement the concept of a social 
health maintenance organization (S/HMO) for acute and long-term 
care. A S/HMO integrates health and social services under the 
direct financial management of the provider of services. All 
services are provided by or through the S/HMO at a fixed, 
annual, prepaid capitation sum. Four demonstration sites were 
selected to participate; of the four, two were health 
maintenance organizations that have added long-term-care 
services to their existing service packages and two were long-
term-care providers that have added acute-care service 
packages. The demonstration sites use Medicare and Medicaid 
waivers, and all initiated service delivery by March 1985. 
HealthPartners (formerly Group Health in Minneapolis-St. Paul, 
Minnesota), one of the original sites, discontinued 
participation on January 1, 1995. On three separate occasions, 
this demonstration has been extended by legislation. Current 
legislation, Public Law 103-66, extends the demonstration 
period through December 31, 1997.
            Elderplan, Inc.
    Grantee: Elderplan, Inc., 6323 Seventh Avenue, Brooklyn, NY 
11220.
            Medicare Plus II
    Grantee: Kaiser Permanente Center for Health Research, 3800 
North Kaiser Center Drive Portland, OR 97227-1098.
            SCAN Health Plan
    Grantee: Senior Care Action Network, 3780 Kilroy Airport 
Way, Suite 600, P.O. Box 22616, Long Beach, CA 90801-5616.

Site development and technical assistance for the Second Generation 
        Social Health Maintenance Organization demonstration

    Period: September 1993-September 1998.
    Funding: $2,251,123.
    Contractor: University of Minnesota, School of Public 
Health, Institute for Health Services Research, D-351 Mayo 
Memorial Building, 420 Delaware Street, SE., Box 197 
Minneapolis, MN 55455-0392.
    Investigator: Robert L. Kane, M.D.
    In January 1995, the Health Care Financing Administration 
selected six organizations to participate in the Second 
Generation Social Health Maintenance Organization (HMO) 
Demonstration. The purpose of this project is to study the 
impact of integrating acute-and-long term-care-services within 
a capitated managed-care system. It was developed to refine the 
targeting and financing methodologies and the benefit design of 
the current social HMO model which was initiated as a 
demonstration in 1985.
    Although the same services are provided under both of these 
projects the Second Generation Social HMO Demonstration 
features a greater emphasis on geriatric care and a more 
inclusive case management system. Another distinguishing 
characteristic of the project it is risk-adjusted payment 
methodology that is based on an individual's health status and 
functioning level. The primary focus of the project's 
evaluation will be to compare beneficiaries enrolled in the 
demonstration with beneficiaries in a section 1876 HMO program.
    The University of Minnesota and its subcontractor, the 
University of California, San Francisco are providing technical 
assistance and support in the development, implementation, and 
operation of the Second Generation Social HMO Demonstration.
    The developmental phase of the Second Generation Social HMO 
Demonstration began in January 1995. Since that time the 
University of Minnesota and the University of California, San 
Francisco have been providing technical assistance to the 
organizations participating in the project. They have also 
developed a questionnaire that will be used to determine a 
beneficiary's capitated payment rate, a series of geriatric 
protocols to help physicians identify and treat certain health 
conditions, and a care coordination assessment instrument to 
assist case managers with care planning. The Health Plan of 
Nevada began enrolling beneficiaries into the demonstration in 
November 1996. Enrollment at the other five organizations is 
scheduled to begin in May 1997.

Second generation of Social Health Maintenance Organization 
        demonstration

    Period: November 1996-November 1997.
    Funding: Waiver only.
    Grantees: See below.
    In accordance with section 2355 of Public Law 98-369, the 
concept of a social health maintenance organization (S/HMO) was 
developed and implemented. The S/HMO integrates health and 
social services under the direct financial management of the 
provider of services. All acute and long-term-care services are 
provided by or through the S/HMO at a fixed, annual, prepaid 
capitation sum. The Omnibus Budget Reconciliation Act of 1990 
authorized the expansion of the Social Health Maintenance 
Organization demonstration. The purpose of this second 
generation S/HMO (S/HMO-II) demonstration is to refine the 
targeting and financing methodologies and the benefit design of 
the current S/HMO model. The S/HMO-II model will also provide 
an opportunity to test more geriatrically oriented models of 
care. Six organizations have been awarded waivers to implement 
the project.
    Grantee: CAC Ramsey Health Plan, 75 Valencia Avenue, Coral 
Gables, FL 33134.
    Grantee: Contra Costa County Health Plan, 595 Center 
Avenue, Suite 100, Martinez, CA 94553.
    Grantee: Fallon Community Health Plan, Chestnut Place, 10 
Chestnut Street, Worcester, MA 01608.
    Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las 
Vegas, NV 89114.
    Grantee: Richland Memorial Hospital, Five Richland Medical 
Park, Columbia, S.C. 29203.
    Grantee: Rocky Mountain Health Maintenance Organization, 
2775 Crossroads Boulevard, Grand Junction, CO 81505.

State of Minnesota ``Senior Health Options (SHO) Project''

    Period: April 1995-December 2000 (yearly continuation).
    Funding: Waiver only.
    Grantees: Minnesota Department of Human Services, Human 
Services Building, 444 Lafayette Road, St. Paul, MN 55155.
    In April 1995, the State of Minnesota was awarded Medicare 
and Medicaid waivers for a 5-year demonstration designed to 
test delivery systems that integrate long-term care and acute-
care services for elderly dual eligibles. The State is 
targeting the elderly dually entitled population that resides 
in the 7-county metro area and St. Louis county. Elderly 
Medicaid eligibles now required to enroll in the State's 
current section 1115 Prepaid Medical Assistance Program (PMAP) 
demonstration will be given the option to enroll in the Senior 
Health Options (SHO) Project, which in essence adds long-term 
care and Medicare benefits to basic PMAP benefits. Under this 
demonstration, the State will be treated as a health plan that 
contracts with Health Care Financing Administration to provide 
services, and provides those services through subcontracts with 
various appropriate providers. The State will continue its 
current administration of the Medicaid-managed care program 
while incorporating some Medicare requirements that apply 
directly to the health plans with which the State would 
subcontract for SHO. HCFA's direct oversight functions would 
continue to apply to the overall demonstration and managing 
entity, which would be the State.

MAINE-NET: Medicaid- and Medicare-managed care for the elderly and 
        physically disabled in Maine

    Period: September 1994-September 1997.
    Funding: $944,940.
    Grantees: Maine Department of Human Services, Bureau of 
Medical Services, State House Station No. 11, Augusta, ME 
04333.
    Investigator: Carreen Wright.
    This project is designed to demonstrate integrated models 
for the financing and delivery of managed health care and 
social services for Medicare and Medicaid elderly and 
physically disabled persons in Maine. The project seeks to 
promote the development of regional service delivery networks 
or health plans, particularly in rural areas of the State that 
would be responsible for the management, coordination, and 
integration of services, including multidisciplinary approaches 
to care planning and service delivery. The demonstration will 
provide a comprehensive package of primary, acute, and long-
term-care institutional and noninstitutional services as part 
of a prepaid-capitated health plan for the target populations. 
The demonstration seeks to expand upon nursing home quality 
indicators developed in the Health Care Financing 
Administration sponsored multistate Case-Mix Demonstration 
Project and incorporate HCFA's quality assurance guidelines for 
managed care plans. In addition, the project will develop and 
use an activity of daily living-based case-mix adjustment for 
long-term-care services in the construction of capitation 
payment rates, using the Resource Utilization Group III, 
Version classification system also developed in the multistate 
demonstration project. For services provided in boarding homes 
and in the community, two new case-mix methodologies will be 
developed for use by the demonstration.
    This project is now in its second year. During this period, 
a concept paper describing theState's health care environment 
and the challenges facing the proposed demonstration program was 
drafted. In addition, an analysis of the cost and use patterns of State 
elderly and disabled Medicare and Medicaid beneficiaries has been 
undertaken, and is expected to be complete by November 0f 1996. During 
year two, a request for information was created and issued, and the 
responses were reviewed by the State. The data from these responses, 
along with a detailed county-by-county environmental analysis informed 
the criteria used for the selection of the two sites for the proposed 
demonstration. The State currently anticipates submitting the waiver 
application in February 1997.

Managing medical care for nursing home residents

    Period: December 1992-December 1998.
    Funding: Waiver only.
    Grantee: United HealthCare Corporation, Inc., P.O. Box 
1459, Minneapolis, MN 55440-8001.
    Investigator: Jeannine Bayard.
    The objective of this demonstration is to study the 
effectiveness of managing acute care needs of nursing home 
residents by pairing physicians and geruiatric nurse 
practitioners (GNPs) who will function as primary medical 
caregivers and case managers. The major goals of the 
demonstration are to reduce medical complications and 
dislocation trauma resulting from hospitalization and to save 
the expense of hospital care when patients could be managed 
safety in the nursing home with expanded services. The 
operating principal of this demonstration is EverCare, a 
subsidiary of United Health Care Corporation, Inc. EverCare 
will receive a fixed capitated payment (based on a percentage 
of the adjusted average per capita cost) for all nursing home 
residents enrolled and will be at full financial risk for the 
cost of acute care services for enrollees. GNPs will provide 
initial assessments of enrollees; make monthly visits; 
authorize clinic, outpatient and hospital visits; and 
communicate with the patients' physicians, nursing facility 
staffs, and families. Physician incentive plans will be 
structured to offer a higher reimbursement rate for nursing 
home visits and lower reimbursement rates for services 
furnished in physicians' offices or in other settings. By 
increasing the intensity and availability of medical services, 
EverCare believes that the model will reduce total care costs; 
improve quality of care received by participants through better 
coordination of appropriate acute care services; and improve 
the quality of life for and level of satisfaction of enrollees 
and their families.
    Waivers were awarded in the summer of 1994 and currently 
sites are operational in Atlanta, Baltimore, Boston, and 
Phoenix; sites in Denver and Tampa are expected to initiate 
services in 1997.

Randomized controlled trial of expanded medical care in nursing homes 
        for acute care episodes: Monroe County Longterm Care Program, 
        Inc.

    Period: March 1992-December 1996.
    Funding: $1,054,007.
    Grantee: Monroe County Longterm Care Program, Inc., 349 
West Commercial Street, Suite 2250, Piano Works East Rochester, 
NY 14445.
    Investigator: Gerald Eggert, Ph.D.
    The objective of this demonstration is to develop, 
implement, and evaluate the effectiveness of expanded medical 
services to nursing home residents who are undergoing acute 
illnesses that would ordinarily require hospitalization. The 
intervention will include many services that are available in 
acute hospitals and are feasible and safe in nursing homes. 
These include an initial physician visit, all necessary 
followup visits, diagnostic and therapeutic services, and 
additional nursing care (including private duty), if necessary. 
The major goals are to reduce medical complications and 
dislocation trauma resulting from hospitalization and to save 
the expense of hospital care when patient could be managed 
safely in nursing homes with expanded services. The design 
phase of the demonstration has been completed. The design is 
currently being evaluated to determine the impact of the 
implementation of the Multistate Nursing Home Case-Mix and 
Quality Demonstration on the implementation of this 
demonstration.

Community Nursing Organization Demonstration

    Period: September 1992-December 1996.
    Contractors: See below.
    Section 4079 of Public Law 100-203 directs the Secretary of 
the Department of health and Human Services to conduct 
demonstration projects at four or more sites to test a 
capitated, nurse-managed system of care. The two fundamental 
elements of the Community Nursing Organization (CNO) 
demonstration are capitated payment and nurse case management. 
These two elements are designed to promote timely and 
appropriate use of community health services and to reduce the 
use of costly acute care services. The legislation mandates a 
CNO service package that includes home health care, durable 
medical equipment, and certain ambulatory care services. Four 
applicants were awarded site demonstration contracts on 
September 30, 1992. The selected sites represent a mix of urban 
and rural sites and different types of health providers, 
including a home health agency, a hospital based system, and a 
large multispeciality clinic. All CNO sites have undergone a 1-
year development period and began a 3-year operational period 
in January 1994, which continued in 1996. Abt Associates Inc. 
Was selected to evaluate the project and to provide technical 
assistance to the sites. Abt Associates Inc. Also was awarded 
the external quality assurance contract.
    Contractor: Carle Clinic Association, 307 East Oak, Suite 
3, P.O. Box 718, Mahomet, IL 61853.
    Contractor: Carondelet Health Services, Inc., Carondelet 
St. Mary's Hospital, 1601 West St. Mary's Road, Tucson, AZ 
85745.
    Contractor: Living at Home/Block Nurse Program, Ivy League 
Place, Suite 225, 475 Cleveland Avenue North, St. Paul, MN 
55104.
    Contractor: Visiting Nurse Service of New York, 107 East 
70th Street, New York, NY 10021.

Evaluation of the Community Nursing Organization Demonstration

    Period: September 1992-June 1998.
    Funding: $3,014,634.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: Robert J. Schmitz, Ph.D.
    The Community Nursing Organization (CNO) Demonstration was 
mandated by section 4079 of the Omnibus Budget Reconciliation 
Act of 1987. The legislation directs the Secretary of the 
Department of Health and Human Services to conduct a 
demonstration project at four or more sites to test a 
capitated, nurse-managed system of care. The two fundamental 
elements of the CNO are capitated payment and nurse case 
management. These two elements are designed to promote timely 
and appropriate use of community health services and to reduce 
the use of costly acute care services. The legislation mandates 
a CNO service package that includes home health care, durable 
medical equipment, and certain ambulatory care services. The 
CNO sites receive a monthly capitation payment for each 
enrollee. The capitation rate is modeled on the average 
adjusted per-capita cost-payment used for Medicare health 
maintenance organizations. The CNO per-capita payment rate will 
be set at a level that is equal to 95 percent of the adjusted 
average per-capita Medicare payment for community and 
ambulatory services in the CNO's geographic area. The 
legislation mandates the use of two types of CNO per-capita 
payment methods. Payment Method A adjusts the per capita 
payment according to an individual's age, gender, and prior 
home health use. Payment Method B adjusts the per capita 
payment according to an individual's functional status in 
addition to age, gender, and prior home health use. The 
evaluation of the CNO demonstration will test the feasibility 
and effect on patient care of a capitated, nurse case-managed 
service-delivery model. Both qualitative and quantitative 
components are included in the evaluation design. The 
qualitative component will use a case study approach to examine 
the operational and financial viability of the CNO model. The 
quantitative component will use a randomized design to measure 
the impact of the CNO intervention on mortality, 
hospitalization, physician visits, nursing home admissions, and 
Medicare expenditures, as well as on such nurse-sensitive 
outcomes as knowledge of health problems and management of 
care.
    The four CNO demonstration sites completed a 1-year 
developmental period and began a 3-year operational period in 
January 1994. A 1-year extension of the demonstration and 
evaluation has been granted. Collection of baseline data for 
CNO enrollees began in January 1994. Site visit reports 
summarizing site activities for the first and second 
operational years have been completed. An interim report was 
prepared by the evaluation contractor. A second interim report 
is expected in Spring 1997.

Community Nursing Organization Demonstration External Quality Assurance

    Period: July 1994-July 1997.
    Funding: $535,304.
    Contractor: Abt Associates Inc.
    Investigator: David Kidder, Ph.D.
    The purpose of the Community Nursing Organization (CNO) 
Demonstration External Quality Assurance project is to conduct 
an external review of the quality of health care delivered to 
Medicare beneficiaries participating in the CNO demonstration 
(a risk-reimbursed coordinated care program for home health and 
selected ambulatory services). The CNO Demonstration External 
Quality Assurance project includes a quarterly review of client 
medical records for a sample of clients receiving Medicare-
covered mandatory CNO services, and a quarterly review of CNO 
assessments and provision of CNO interventions on a sample of 
all enrollees. Under this project, the awardee will be 
responsible for monitoring the quality of care management and 
health education services provided through the CNO and 
implementing corrective actions, when necessary. The quality of 
traditional Medicare home health services will be monitored. 
The awardee also will conduct a use review of the home health 
services provided to enrollees to validate or support changes 
in capitation payment rates. The evaluation contractor will be 
provided with accurate and complete documentation of the 
findings and interventions of the quality assurance process.

Rehabilitating Medicare beneficiaries at home

    Period: April 1993-April 1994.
    Funding: $80,000.
    Grantee: Wellmark Healthcare Services, Inc., 60 William 
Street, Wellesley, MA 02181.
    Investigator: Samuel Scialabba.
    Wellmark intends to conduct a 2-year Medicare demonstration 
that will provide beneficiaries will acute rehabilitation 
services at home as an alternative to more expensive inpatient 
rehabilitation hospital services. The Health Care Financing 
Administration has awarded a cooperative agreement to Wellmark 
to further refine its project design to develop information on 
specific eligibility and screening criteria for patient 
enrollment, detailed cost data on the proposed service package, 
and informed consent policies to adequately inform patients and 
caregivers of the risks and responsibilities of rehabilitative 
home care. Medicare waivers will be required to allow Wellmark 
reimbursement as a prospective payment, system-exempt 
rehabilitation hospital. Funding for the evaluation will be 
provided by the Robert Wood Johnson Foundation as part of a 
national study entitled ``Evaluation of Innovative 
Rehabilitation Alternatives and Critical Dimensions of 
Rehabilitative Care.'' The final report has been submitted. A 
request for Medicare waivers to implement the project was 
withdrawn by the agency in May 1995.

Randomized controlled trial of primary and consumer-directed care for 
        persons with chronic illnesses

    Period: September 1994-September 1997.
    Funding: $345,243.
    Grantee: Monroe County Longterm Care Program, Inc., 349 
West Commercial Street, Suite 2250, Piano Works, East 
Rochester, NY 14445.
    Investigator: Gerald Eggert, Ph.D.
    This demonstration will assess differences in outcome for 
three treatment groups: a consumer-directed group, a case-
managed service group, and a model that combines both treatment 
patterns. Findings will be compared with a control group that 
receives no additional services or benefits. Eligibility for 
participation is determined by residence in the community (at 
home or in an assisted living setting) and by Medicare coverage 
with a diagnosis of irreversible dementia or three or more 
limitations in activities of daily living. In addition, 
participants must be at risk for hospitalization (i.e., their 
participation is based on prior use of hospitals or emergency 
rooms). This project has completed the developmental phase. A 
waiver package has been prepared and this is under review. 
Implementation is anticipated in December 1996.

Managed care system for disabled and special needs children: District 
        of Columbia

    Period: December 1995-November 1998.
    Funding: Waiver only.
    Grantee: The District of Columbia, Department of Human 
Services, Commission on Health Care Finance, 2100 Martin Luther 
King Jr. Avenue., S.W., Suite 302, Washington, D.C. 20020.
    In December 1995 the District of Columbia was awarded a 
section 1115 Medicaid waiver to test the efficacy of a managed-
care service delivery system designed for disabled and special 
needs children. Participants in the demonstration are children 
and adolescents who are under the age of 22, are eligible for 
Supplemental Security Income (SSI) payments (i.e., considered 
disabled according to SSI guidelines), and are subsequently 
eligible for Medicaid as well. The District of Columbia hopes 
to use the program to eliminate both barriers to access and 
other health care delivery problems that children who are 
disabled and their families encounter in the current Medicaid 
fee-for-service program. This managed-care program seeks to 
improve the health status and quality of life for these 
children, while reducing the overall health care costs 
associated with their care. Enrollment in the demonstration is 
voluntary; however, eligible children who do not explicitly 
choose to remain in the current fee-for-service system after 
being informed of the new program are assigned to HSCSN after a 
specified notice period. Enrollment cannot be finalized, 
however, until a health needs assessment is completed for each 
new member. Health services under this demonstration are being 
coordinated by Health Services for Children with Special Needs, 
Inc. (HSCSN), a non-profit corporation established specifically 
for the purpose of providing managed care for children 
enrolling in the demonstration.
    The project was implemented in December 1995. As of October 
1996, approximately 1,500 of the 3,000 eligible children have 
chosen to enroll in HSCSN, while approximately 500 children/
families have chose to remain in the fee-for-service system.

Evaluation of the District of Columbia's demonstration project, 
        ``Managed Care System for Disabled and Special Needs Children''

    Period: September 1996-March 2000.
    Funding: $1,203,963.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138-1168.
    Investigator: Carol Irvin, Ph.D.
    The District of Columbia submitted a waiver-only request 
for Medicaid waivers under section 1115(a)(1) for a 3-year 
demonstration project to test the efficacy of a managed care 
service delivery system designed for children and adolescents 
under the age of 22 who are eligible for Medicare and are 
considered disabled according to Supplementary Security Income 
(SSI) Program guidelines. This study represents a unique 
opportunity to examine the experiences of a managed-care system 
with voluntary enrollment of children with disabilities. The 
project, which seeks to integrate acute and long-term-care 
services for children with disabilities into a single capitated 
payment methodology, is the first approved demonstration of its 
kind. The information gathered will be used to inform both 
State and Federal policymakers who have increasingly come to 
regard managed care as a mechanism to contain growing health 
care expenditures.
    This study will provide for a special analysis of the 
enrollment and disenrollment processes, as well as of the 
project's implementation process (including enrollment and 
participation, services/benefits, provider participation and 
training, organizational and administrative issues, contracting 
and risk-sharing arrangements, provider fee schedules, 
community involvement, and quality assurance, administrative 
and data management systems). Outcome analyses will focus on 
enrollee/family outcomes (including care management, service 
utilization and costs, enrollee/family satisfaction, quality of 
care and health status indicators, access to care, and family/
informal care giving), organizational outcomes (including an 
analysis of HSCSN's financial performance, and the risk sharing 
arrangement between HSCSN and the District of Columbia), and 
the impact upon the provider community. Data for the evaluation 
will come from surveys (primary data collection), case study 
interviews, focus groups, Medicaid Management Information 
System and encounter data, and SSI data. The project was 
awarded in September 1996, and is in the early stages of 
development and implementation.

Special Care managed care initiative

    Period: February 1992-December 1996.
    Funding: $656,270.
    Grantee: Wisconsin State Department of Health and Social 
Services, 1 West Wilson Street, P.O. Box 309, Madison, WI 
53701-0309.
    Investigator: Howard Garber, Ph.D.
    The purpose of the special care initiative project is to 
gain improved understanding of the need, use, and cost of 
delivery of health services to high-risk, severely disabled 
persons. The severely disabled population is a significant user 
of medical services. Moreover, cost between 1988 and 1991 
increased at a rate double that of population increase. 
Therefore, an important objective is to contain the cost and 
use of Medicaid services by severely disabled persons, while 
maintaining or improving the level of client satisfaction.
    Special Care, Inc. (SCI) is an independent, nonprofit 
organization that represents a joint venture between the 
Milwaukee Center for Independence, a Milwaukee rehabilitation 
facility, and the Wisconsin Health Organization, an established 
health maintenance organization. SCI will create specialized 
services, including a dedicated physician panel, case-
management services, and clinical services as strategies to 
assess medical need and to better coordinate service resources 
available in the community. The State of Wisconsin will use a 
capitation methodology for reimbursement to SCI. Enrollment of 
SCI members will be voluntary.
    As a research and demonstration program, it aims to improve 
the understanding of the need, use, costs, and cost-management 
opportunities associated with the delivery of health services 
to high-risk, severely disabled persons. These individuals are 
disabled, categorically needy, noninstitutionalized, exempt 
from the spenddown provisions, eligible for Medicaid, and 
eligible for Supplemental Security Income disability benefits. 
The diagnostic distribution of cases in this population is 41 
percent mental retardation, 17.4 percent chronic mental 
illness, 13.5 percent skeletal/muscular, 11.2 percent epilepsy, 
9.3 percent cerebral palsy, 1.6 percent cardiac/circulatory, 
1.2 percent autism, and 4.9 percent other. This is a severely 
disabled and generally unemployable population whose medical 
care use and cost experience show a non-normalized pattern. The 
average hospital length of stay for members of this group is 7 
times longer than that for the general population. Their 
hospital costs are 4 times higher without clear explanation.
    To measure the performance of the SCI program, a management 
information system (MIS) file will be created to match the 
demographic characteristics of program participants with the 
cost and use data obtained from the history files maintained by 
the Wisconsin Medicaid program. Medicaid data will include 
service and procedure frequencies, service mix, billings and 
reimbursements, provider practices, and certain medical status 
indicators. MIS files will contribute additional information on 
disability condition, enrollment information, benefit 
coordination, and case management. In addition, data on client 
satisfaction, quality of care, and enrollment/disenrollment 
decisions will be collected.
    The State is operating this project under a section 1915(a) 
State Plan exception. The program officially began in June 
1994. As a point of clarification, Special Care signifies the 
initiative proposed to the Health Care Financing Administration 
(HCFA) for the managed care program, while Independent Care (I 
Care) is the formal community name of the managed care company. 
In July 1996, a no-cost extension was granted to the State to 
allow for a full 3-year operational period.
    The evaluation contract with the Human Services Research 
Institute (HSRI) was signed in May 1994, after it was reviewed 
and approved by HCFA. This evaluation contractor submitted its 
final working plan at the beginning of grant year 03. HSRI 
proposes a 3-year evaluation, which will combine survey data 
with HCFA's Medicaid Statistical Information System 
Administrative files. The evaluator developed and piloted an 
interview protocol, the Cross-Disability Integrated Health 
Outcomes Survey for use with the I Care recipients and control 
group members. Evaluation activities will include the selection 
of comparison groups, using cost cluster information from a 
State-developed profile of a sample of I Care patients. This 
sample was drawn from an aggregate of all 1994 paid claims for 
every Milwaukee and Racine county Supplemental Security Income 
beneficiary who is disabled and was then assigned to one of 
three cost categories--low, medium, or high. Interim evaluation 
findings are expected in December 1996.

Rhode Island Long-Term Care Waiver: CHOICES

    Period: May 1995-July 1996.
    Funding: $150,000.
    Grantee: Rhode Island Department of Human Services, 600 New 
London Avenue, Cranston, RI 02902.
    Investigator: Christine C. Ferguson.
    In 1994, the State of Rhode Island Department of Human 
Services (DHS) and Department of Mental Health, Retardation and 
Hospitals (MHRH) submitted a waiver-only proposal which intends 
to consolidate all current State and Federal funding streams 
for approximately 4,000 adults with developmental disabilities 
under one managed care Title XIX waiver program. The State 
proposed a 5-year demonstration with a two-phase transition 
process. The State wants to consolidate into a single program 
with a single set of rules the following separate Title XIX 
programs:
          Intermediate Care Facilities for the Mentally 
        Retarded (ICF-MR);
          Home and Community Based Waiver;
          State Plan Rehabilitation Services;
          Acute/Medical Care.
Rhode Island envisions a publicly administered managed-care 
system with a single-payer model. Each eligible person will be 
enrolled in a private health maintenance organization or 
approved health plan for acute health care. Managed care plans 
participating in Rhode Island's RIte Care program may be asked 
to participate in the CHOICES program and provide managed 
health care for people with developmental disabilities, thus 
bringing together Rhode Island's two managed care initiatives. 
Alternatively, a statewide health care plan will be established 
for adults with developmental disabilities and the employees of 
the service agencies.
    Under CHOICES, a case-management system will also be 
available to assist each eligible individual to obtain required 
long-term supports. The State intends to ascribe to all 
eligible persons a dollar amount with which they, with 
technical assistance from a broker or other source, will choose 
to manage the long-term care services directly themselves via a 
voucher, or choose an agency that can support their needs 
within the identified resources available. This dollar amount 
will be based on a methodology prepared by the assessment/
authorization work group.
    Services covered by CHOICES can be divided into several 
categories:
          Supported living services;
          Alternative living arrangements;
          Day supports;
          Acute care/medical services.
The covered target population under CHOICES consists 
principally of persons with MR or related conditions, and the 
developmentally disabled, who are already eligible for and 
receiving services under various currently operating Title XIX 
programs.
    In addition to its current population, CHOICES will serve 
up to 25 individuals with traumatic brain injury who are in 
need of long-term community living supports and who may 
beinappropriately institutionalized or living in the community with 
inadequate support; approximately 500 individuals now receiving 
supported employment services funded with State monies; about 40 people 
currently in the State-funded developmental disabilities program for 
whom there is no Federal financial participation; and approximately 125 
people turning 21 and graduating from special education, applying for 
services from the Division of Developmental Disabilities under the 
Department of Human Services for Rhode Island. The State was awarded a 
grant in June 1995 to further develop the project design. Waivers have 
not yet been awarded.

Demonstration of Integrated Care Management Systems for high-cost/high-
        risk Medicaid beneficiaries

    Period: October 1995-October 2000.
    Funding: Waiver only.
    Grantee: Department of Health and Mental Hygiene, State of 
Maryland, 201 West Preston Street, Baltimore, MD 21201.
    Investigator: Martin P. Wasserman, M.D., J.D.
    Maryland is testing a new case-management system for high-
cost/high-risk Medicaid beneficiaries and those at risk to 
become high cost. The program seeks to maintain or improve 
access to providers and the quality of the care provided. The 
demonstration also should lower health care costs by reducing 
hospital readmission rates and by maintaining patients in the 
lowest cost medically appropriate setting. The University of 
Maryland at Baltimore County, Center for Health Program 
Development and Management, under contract to the State, is 
responsible for the demonstration's operations. This project 
was approved in October 1995. In October 1996, the State 
requested to withdraw the waivers, as the project was 
incorporated in Maryland's statewide waiver, approved in 
October 1996.

Community-Supported Living Arrangements Program: Process evaluation

    Period: September 1993-March 1997.
    Funding: $411,941.
    Awardee: SysteMetrics/MedStat, 104 West Anapamu Street, 
Santa Barbara, CA 93101.
    Investigator: Marilyn Ellwood.
    The Community-Supported Living Arrangements (CSLA) Program 
is designed to test the effectiveness of developing, under 
section 1930 of the Social Security Act, a continuum of care 
concept as an alternative to the Medicaid-funded residential 
services provided to individuals with mental retardation and 
related conditions (MR/RC) as an optional State plan service. 
The CSLA program serves individuals with MR/RCs who are living 
in the community either independently, with their families, or 
in homes with three or fewer other individuals receiving CSLA 
services. This model of care includes personal assistance; 
training and habilitation services necessary to assist 
individuals in achieving increased integration, independence, 
and productivity; 24-hour emergency assistance; assistive 
technology; adaptive technology; support services necessary to 
aid these individuals in participating in community activities; 
and other services, as approved by the Secretary of the 
Department of Health and Human Services. Costs related to room 
and board and to prevocational, vocational, and supported 
employment services are excluded from coverage. In accordance 
with the legislatively set maximum, California, Colorado, 
Florida, Illinois, Maryland, Michigan, Rhode Island, and 
Wisconsin have implemented CSLA programs. The purpose of this 
contract is to provide an evaluation of the CSLA program to the 
Health Care Financing Administration's Medicaid Bureau and 
Congress for their consideration of policy options regarding 
the continuation and/or expansion of the Medicaid State Plan 
optional service. The evaluation will address five areas:
          Philosophy or goals guiding States' CSLA program;
          Description of CSLA programs with respect to 
        recipients, types of services received, and the cost of 
        such services;
          Description and discussion of quality assurance 
        mechanisms being implemented;
          Exploration of the question of compatibility of the 
        supported living concept with current goals and the 
        structure of the Medicaid program;
          Exploration of the relationship between the supported 
        living concept and the Americans with Disabilities Act.
    The contract was awarded on September 30, 1993. As of 
September 1996, the eight site visits to the participating 
States have been conducted. Six of the eight State case studies 
have been reviewed and are approved for distribution. Secondary 
data analysis will be conducted using data available from the 
participating CSLA States. A final evaluation report is 
expected in March 1997.

Texas Nursing Home Case-Mix and Quality Demonstration

    Period: February 1992-December 1998.
    Funding: $532,830.
    Grantee: State of Texas Department of Human Services, P.O. 
Box 149030 (MC-E-601), Austin, TX 78714-9030.
    Investigator: Ken. C. Stedman.
    Texas will participate in the Multistate Nursing Home Case-
Mix and Quality (NHCMQ) Demonstration. The objective of the 
demonstration is to test the feasibility and cost effectiveness 
of a case-mix payment system for nursing facility services 
under the Medicare and Medicaid programs that are based on a 
common patient classification system. The addition of Texas 
enhances the Health Care Financing Administration's ability to 
project the results of the demonstration on a national basis. 
Texas represents a western pattern of service using more 
proprietary multistate chain providers than is the pattern used 
in the East. Twenty Texas Medicare facilities were part of the 
original data collection for the development of the resource 
utilization group (RUG) III system. Texas has the second 
largest number of hospital-based facilities in the country. 
There are more than 20 metropolitan statistical areas of 
varying size. In addition, the State has a large number of 
rural areas. The State was traditionally a flat-rate 
intermediate care facility Medicaid system until 1989, when it 
implemented a RUG-type Medicaid payment system. This RUG-type 
payment system makes Texas well-suited for inclusion in the 
Medicare portion of the demonstration.
    During the first year of participation, the Texas 
Department of Human Services worked with the Texas Department 
of Health to change the resident assessment being used in the 
State. In April 1993, Texas implemented the minimum data set 
plus statewide as its resident assessment instrument. Analyses 
of 1990 Medicare Cost Report data, Medicare provider analysis 
and review Part A skilled nursing facility stay data, and the 
Texas Client Assessment an Review Evaluation (CARE) data have 
been conducted for use in developing the demonstration's 
Medicare case-mix payment system. Under the Medicaid 
demonstration, Texas began development of the Quality 
Evaluation System of Texas, a resident characteristic 
information and reporting system using the CARE instrument. 
During the first year, the staff continued the development and 
enhancement of the system, which was codified into Law by the 
Texas Legislature in Summer 1993. They now are producing 
facility-level reports with statewide comparisons for Texas 
providers on a twice-a-year basis. The Medicare portion of the 
NHCMQ demonstration was implemented July 1, 1995, in Texas.

Multistate Nursing Home Case-Mix and Quality Demonstration

    Period: June 1989-December 1998.
    Funding: $5,322,941.
    Project Nos.:
          Kansas, 11-C-99366/7
          Maine, 11-C-99363/1
          Mississippi, 11-C-99362/8
          South Dakota, 11-C-99367/8
    Grantees: State Medicaid Agencies.
    This project builds on past and current initiatives with 
nursing home case-mix payment and quality assurance. The 6-year 
demonstration will design, implement, and evaluate a combined 
Medicare and Medicaid nursing home resident classification and 
payment system in Kansas, Maine, Mississippi, and South Dakota. 
The purpose of the demonstration is to test a resident 
information system with variables for classifying residents 
into homogeneous resource use groups for equitable payment and 
for quality monitoring of outcomes adjusted for case mix. The 
new minimum data set plus (MDS+) for resident assessment will 
be used for resident-careplanning, payment classification, and 
quality-monitoring systems. The project consists of three 
phases: systems development and design, systems implementation 
and monitoring, and evaluation.
    The project has conducted a field test of the minimum data 
set on 6,660 nursing home residents. The average direct-care 
staff time across the States is 115 minutes per day per 
resident. A new patient classification system and a Multistate 
Medicare/Medicaid Payment Index containing 44 groups has been 
created. The States have collected and reviewed over 3 million 
MDA+ documents on over 500,000 different residents assessed 
between September 1990 and July 1996. In developing the payment 
systems, facility cost reports and resident characteristic data 
were analyzed to determine the case mix of residents and 
patterns of service use. The Medicare case-mix-adjusted payment 
system was implemented in August 1995. The quality-monitoring 
information system has been tested, and 30 quality indicators 
are being used for monitoring facility-level and resident-level 
quality.

New York Case-Mix Payment and Quality Demonstration

    Period: May 1990-December 1998.
    Funding: $981,718.
    Grantee: New York State Department of Health, Empire State 
Plaza, Room 1683, Corning Tower, Albany, NY 12237.
    Investigator: Robert W. Barnett.
    New York State will participate in the multistate Nursing 
Home Case-Mix and Quality (NHCMQ) Demonstration. The objective 
of the demonstration is to test the feasibility and cost 
effectivess of a case-mix payment system for nursing facility 
services under the Medicare and Medicaid programs that are 
based on a common patient classification system. The addition 
of New York State enhances the Health Care Financing 
Administration's ability to project the results of the 
demonstration on a national basis. New York represents a 
heavily regulated, northern, industrialized area with larger, 
high-cost nursing facilities that are medically sophisticated 
and highly skilled. Sixteen percent of the national Medicare 
skilled nursing facility (SNF) days are incurred in New York 
State. New York is uniquely suited for inclusion because it 
already has implemented a complementary system for its Medicaid 
nursing facility payment program.
    In early 1991, the project staff completed the minimum data 
set field test in 25 facilities on 993 residents. These data 
have been added to the database and analyzed to develop the new 
NHCMQ Medicare/Medicaid classification system. The inclusion of 
the New York State data has resulted in the addition of a very 
high rehabilitation group to the upper end of the 
classification. The State has implemented the minimum data set 
plus (MDS+) statewide as its resident assessment instrument. In 
November 1992, New York State began receiving the information 
monthly from all facilities; by July 1, 1996, it had received a 
total of 2,000,000 assessments. In developing the Medicare 
payment system, the 1990 Medicare cost reports were used, as 
well as the MDS+ data and the Medicare provider analysis and 
review file. The Medicare case-mix-adjusted payment system was 
implemented July 1, 1995, in New York. By Summer 1996, there 
were over 350 SNFs participating in the SNF demonstration, 7 of 
which are hospital based.

Implementation of the Multistate Nursing Home Case-Mix and Quality 
        Demonstration

    Period: February 1994-December 1998.
    Funding: $3,209,538.
    Contractor: Allied Technology Group, Inc., 1803 Research 
Boulevard, Suite 601, Rockville, MD 20850.
    Investigator: Robert E. Burke, Ph.D.
    This contract will support the implementation phase of the 
Multistate Nursing Home Case-Mix and Quality Demonstration. The 
demonstration combines the Medicare and Medicaid nursing home 
payments and quality monitoring system across several States: 
Kansas, Maine, Mississippi, New York, South Dakota, and Texas. 
This project builds on past and current initiatives with case-
mix payment and quality assurance in nursing homes. The purpose 
of the demonstration is to test a resident information system 
with variables for classifying residents into homogeneous 
resource utilization groups for equitable payment and for 
quality monitoring of process and outcomes adjusted for case 
mix. The project will have three phases: systems design and 
development, systems implementation and monitoring, and 
evaluation.
    The objectives of the implementation phase are as follows:
          Recruit facilities in the six demonstration States to 
        participate in the Medicare portion.
          Develop and operate the Medicare case-mix system of 
        the demonstration for the Health Care Financing 
        Administration that involves the fiscal intermediaries 
        and the Medicare skilled nursing facility (SNF) 
        provider;
          Conduct a staff-time measurement study to validate 
        the Resource Utilization Group, Version III (RUG III) 
        classification system and add a valid therapy payment 
        component;
          Validate the quality indicators (QIs) and implement 
        the quality monitoring system in the demonstration 
        States through the States' nursing home survey process;
          Implement an administrative management and 
        operational system that links distinctcomponents of the 
demonstration (e.g., classification of residents, Medicare coverage 
determination, payment systems, outcome monitoring for quality 
assessment reliability); and
          Implement a field auditing system that monitors 
        States and nursing homes participating in the Medicare 
        portion.
    In July 1993, implementation of the Medicaid prospective 
payment systems was begun, with full participation in 1994. 
Maine, Mississippi, Kansas, and South Dakota are beginning to 
routinely use the QI reports in the survey and certification 
process as of October 1995, based on the pilot test report and 
the first nine validation visits.
    In Fall 1996, there are over 2,100 Medicare SNFs in the 6 
demonstration States, in contrast to 1,120 in 1990. There were 
over 1,500 invitations sent to providers in October 1996, for 
Phase III (routine and rehabilitation) of the demonstration 
expressing interest in further information by summer 1995. 
Phase I operation of the Medicare prospective payment system 
began in July 1995. By Fall 1995, there were 300 facilities 
being paid for routine services using the 3 regional Multistate 
Medicare Payment Indices.
    The RUG III validation staff-time measurement data 
collection was completed in 7 States by July 1, 1995, including 
the minimum data set 2.0 (MDS2.0) on 2,056 residents across 
approximately 80 study units in 7 States, not counting New 
York. Data collection in New York will be completed in early 
1996 and added to the validation database. The resident level 
validation data file is currently being compiled. The multiple 
analyses will be carried out during winter 1995, with the 
rehabilitation (occupational, physical, and speech therapy) 
index added to the Medicare payment system in spring 1996.
    Phase II of the Medicare portion of the demonstration will 
begin at the start of providers' fiscal years beginning January 
1, 1996. In January 1996 and each calendar year thereafter to 
the end of the demonstration, the prospective rates will be 
inflated on January 1st. Phase III of the demonstration, when 
the rehabilitation therapies will be added to the prospective 
payment, will begin April 1996 in the fiscal year of the 
provider. Recruitment of SNF participation will end in 1997.

Evaluation of the Nursing Home Case-Mix and Quality Demonstration

    Period: September 1994-September 1999.
    Funding: $2,980,219.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: Robert J. Schmitz, Ph.D.
    Under the Nursing Home Case-Mix and Quality (NHCMQ) 
Demonstration, the Health Care Financing Administration is 
testing the feasibility of paying skilled nursing facilities 
(SNFs) for Medicare skilled nursing services on a prospective 
basis. Currently, SNFs are reimbursed on a retrospective basis 
for their reasonable costs. A case-mix classification, called 
resource utilization groups, is being used to classify 
patients, permitting HCFA to pay facilities for each covered 
day of care, according to the case mix of patients residing in 
the facility on any given day. Though some costs will continue 
to be paid on a retrospective cost basis under the 
demonstration, the prospective rate will eventually include 
inpatient routine nursing costs and therapy costs. To guard 
against the possibility that inadequate care would be provided 
to patients with heavy care needs, a system of quality 
indicators has been developed that will be used to monitor the 
quality of care.
    The demonstration project was implemented in six States 
(Kansas, Maine, Mississippi, New York, South Dakota, and Texas) 
in Summer 1995, with Medicare-certified facilities in these 
States being offered the opportunity to participate on a 
voluntary basis.
    The evaluation of this demonstration project will seek to 
estimate specific behavioral responses to the introduction of 
prospective payment and to test hypotheses about certain 
aspects of these responses. The principal goal of the 
evaluation of the NHCMQ Demonstration is the estimation of the 
effects of case-mix-adjusted prospective payment on the health 
and functioning of nursing home residents, their length of 
stay, and use of health care services; on the behavior of 
nursing facilities; and on the level and composition of 
Medicare expenditures.
    The evaluation design has been finalized and visits to a 
sample of demonstration facilities began. Current analytic 
activities center around sampling and data collection. Of 
special interest is collection of data on the provision of 
therapy services from both demonstration sites and comparison 
sites which will entail some primary data collection because 
the quantity and duration of therapies may not be reliably 
ascertained from Medicare claims data. The data collection plan 
is being developed pursuant to an assessment of the form in 
which most facilities maintain their records, and nurses are 
being recruited to abstract medical records. A key issue that 
will be analyzed is whether the probability of discharge or 
transfer changes under case-mix-adjusted prospective payment 
and what circumstances surround discharges or transfer from 
nursing facilities.

Implementation of the Home Health Agency Prospective Payment 
        Demonstration

    Period: June 1990-November 1995.
    Funding: $1,629,606.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: Henry Goldberg.
    This contract implements and monitors the demonstration 
design for the Home Health Agency Prospective Payment 
Demonstration, which was developed under an earlier contract 
with Abt Associates, Inc. Under this project, two methods of 
paying home health agencies (HHAs) on a prospective basis for 
services furnished under the Medicare program will be tested. 
The prospective payment approaches to be tested include 
payments per visit by type of discipline (Phase I), and 
payments per episode of Medicare-covered home health care 
(Phase II). HHA participation is voluntary. In each phase, HHAs 
that agree to participate are randomly assigned to either the 
prospective payment method or to a control group that continues 
to be reimbursed in accordance with the current Medicare 
retrospective cost system. HHAs participated in the 
demonstration for 3 years.
    Following an initial recruitment of HHAs, operations under 
Phase I were implemented on October 1, 1990. Forty-nine HHAs 
were recruited. All agencies under Phase I completed their 3-
year participation by October 1994. An evaluation of Phase I 
was conducted by Mathematica Policy Research, Inc., through a 
separate contract (see 500-90-0047 in this edition of Active 
Projects Report. Recruitment for Phase II agencies began in 
Fall 1994. The implementation of Phase II, the per-episode 
payment phase, will be conducted by Abt Associates under a 
separate contract.

Evaluation of the Home Health Prospective Payment Demonstration

    Period: September 1990-November 1995.
    Funding: $2,858,676 (Phase I).
    Contractor: Mathematica Policy Research, Inc., P.O. Box 
2393, Princeton, NJ 08543-2393.
    Investigator: Randall S. Brown, Ph.D.
    The purpose of this contract is to evaluate Phase I of the 
demonstration designed to test the effectiveness of using 
prospective payment methods to reimburse Medicare-certified 
home health agencies (HHA) for services provided under the 
Medicare program. In Phase I, a per visit payment method that 
sets a separate payment rate for each of six types of home 
health visits (skilled nursing, home health aide, physical 
therapy, occupational therapy, speech therapy, and medical 
social services) is being tested. Mathematica Policy Research 
is evaluating the effects of this payment method of HHAs' 
operations, service quality, and expenditures. The awardee is 
also analyzing the relationship between patient characteristics 
and the cost and utilization of home health services.
    By October 1994, all demonstration agencies exited the 
demonstration. Mathematica has completed their evaluation. The 
article ``Do Preset Per Visit Payment Rates Affect Home Health 
Agency Behavior?'' by Phillips, B.R., Brown, R.S., Bishop, 
C.E., and Klein, A.C. discusses preliminary results from Phase 
I of the demonstration and appears in the health Care Financing 
Administration, Volume 16, Number 1, pages 91-107, Fall 1994. 
Findings from the full demonstration suggest that per visit 
prospective payment had no significant effect on quality of 
care, selection and retention of patients, cost per visit, 
visit volume, use of non-Medicare services, and use and 
reimbursement of Medicare-covered services. But it appears that 
treatment agencies may have responded to the opportunities to 
earn profits under the demonstration by increasing their volume 
of visits faster than they would have in the absence of 
prospective ratesetting.

Phase II implementation of the Home Health Agency (HHA) Prospective 
        Payment Demonstration

    Period: September 1995-September 1999.
    Funding: $1,811,184.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: Henry Goldberg.
    This contract implements and monitors Phase II of the Home 
Health Agency (HHA) Prospective Payment Demonstration. Under 
phase II, a single payment per episode approach will be tested 
for Medicare-covered home health care. HHA participation is 
voluntary. It is expected that approximately 100 agencies in 
California, Florida, Illinois, Massachusetts, and Texas will 
participate in the demonstration. HHAs that agree to 
participate will be randomly assigned to either the prospective 
payment method or a control group that continues to be 
reimbursed in accordance with the current Medicare 
retrospective cost system. HHAs will participate in the 
demonstration for 3 years.
    Phase II recruitment began in Fall 1994 under a previous 
contract with Abt Associates, Inc. The HHA entered into the 
demonstration at the beginning of their fiscal years. Several 
HHAs began receiving per-episode payments in June 1994, with 
the majority entering the demonstration in January 1996. The 
episodic payment rates are prospectively set for each HHA, 
reflecting their previous practice and cost experience. Rates 
are to be adjusted annually. As a protection to both the HHAs 
and the Medicare program, there will be retrospective 
adjustments for sharing of gains or losses and for changes in 
an HHA's projected case mix.

Evaluation of Phase II of the Home Health Agency Prospective Payment 
        Demonstration

    Period: September 1994-September 1999.
    Funding: $3,528,408.
    Contractor: Mathematica Policy Research, Inc., P.O. Box 
2393, Princeton, NJ 08543-2393.
    Investigator: Barbara Phillips, Ph.D.
    This contract will evaluate Phase II of the Home Health 
Agency Prospective Payment Demonstration. This demonstration is 
testing two alternative methods of paying home health agencies 
(HHA) on a prospective basis for services furnished under the 
Medicare program. The prospective payment approaches being 
tested include payments per visit by type of HHA visit 
discipline (Phase I) and payment per episode of Medicare-
covered home health care (Phase II). Implementation of Phase 
II, which will test the per episode payment approach, is 
scheduled to begin in Spring 1995. HHAs that agree to 
participate are randomly assigned to either the prospective 
payment method or to a control group that continues to be 
reimbursed in accordance with the current Medicare 
retrospective cost system. HHAs will participate for 3 years. 
The evaluation will combine estimates of program impacts on 
cost, service use, access, and quality, with detailed 
information on how agencies actually change their behavior to 
produce a full understanding of what would happen if 
prospective payment replaced the current cost-based 
reimbursement system nationally. The findings will indicate not 
only the overall effects of the change in payment methodology, 
but also how the effects are likely to vary with the 
characteristics of agencies and patients. This information will 
be of great value for estimating the potential savings from a 
shift to prospective payment for home health care, for 
indicating where potential savings from a shift to prospective 
payment for home health care, for indicating where potential 
problems with quality of care might exist, and for identifying 
types of patients who might be at risk of restricted access to 
care as a result of their need for an unusually large amount of 
care. Because of the relatively small number of agencies 
participating, the use of qualitative information obtained in 
discussions with agencies concerning their characteristics and 
behavior will be essential for avoiding erroneous inferences. 
The first round of site visits to participating agencies has 
been completed.

Quality assurance for Phase II of the Home Health Agency Prospective 
        Payment Demonstration

    Period: September 1995-September 2000.
    Funding: $2,799,265.
    Contractor: Center for Health Policy Research, 1355 South 
Colorado Boulevard, Suite 306, Denver, CO 80222.
    Investigator: Peter W. Shaughnessy, Ph.D.
    This contract provides for developing and implementing a 
quality review mechanism for use by home health agencies (HHAs) 
participating in Phase II of the Home Health Agency Prospective 
Payment Demonstration. This demonstration is testing two 
alternative methods of paying HHAs on a prospective basis for 
services furnished under the Medicare program. The prospective 
payment approaches being tested include payments per visit by 
type of discipline (Phase I), and payments per episode of 
Medicare-covered home health care (Phase II). To ensure that 
incentives created under Phase I did not result in the 
provision of inadequate care to Medicare beneficiaries, the New 
England Research Institute, Inc. (NERI) implemented a 
qualityassurance (QA) approach that utilized patient record reviews for 
a sample of Medicare beneficiaries. However, since one of the goals of 
Heath Care Financing Administration's Medicare Home Health Initiative 
is to move toward the implementation of an outcome-based, patient-
centered (QA) system for Medicare home health, it was felt that the 
second phase of this demonstration provided an opportunity to 
incorporate a scaled-down version of the outcome-based program 
developed by the Center for Health Services Research at the University 
of Colorado.
    During the first project year, the contractor developed 
software for electronic submission of (QA) data from 
participating home health agencies, completed preliminary 
agency training, initiated the collection of (QA) data, 
developed and implemented a data receipt tracking and control 
system, and has continued to provide additional technical 
assistance and retraining for agencies as necessary.

Design and Implementation of Medicare Home Health Quality Assurance 
        Demonstration

    Period: September 1994-May 1999.
    Funding: $3,234,881.
    Contractor: Center for Health Policy Research, 1355 South 
Colorado Boulevard, Suite 706, Denver, CO 80222.
    Investigator: Peter W. Shaughnessy, Ph.D.
    Currently, Medicare's home health survey and certification 
process is primarily focused on structural measures of quality. 
Although this process provides important information about home 
health care, an approach based on patient outcome measures 
would substantially increase the Medicare program's capacity to 
assess and improve patient well-being. To address this need, 
the Medicare home health quality demonstration will test an 
approach to developing outcome-oriented quality assurance and 
promoting continuous quality improvement in home health 
agencies. The demonstration is designed to serve two purposes: 
increase Health Care Financing Administration's capacity to 
assess the quality of Medicare home health care services and 
increase home health care agencies' ability to systematically 
evaluate and improve patient outcomes. The proposed quality 
assurance approach would complement existing home health 
certification and review programs and could be used with 
current survey and certification and peer review organization 
intervening care screen approaches. The study's conceptual 
framework for home health quality assessment is based on home 
health outcomes measures developed under a HCEA-funded study by 
the University of Colorado, entitled ``Development of Outcome-
Based Quality Measures in Home Health Services'' (Contract No. 
500-88-0054). Fifty agencies have been recruited for this 
demonstration and began demonstration operations in January 
1996. In early 1997, agencies will receive their first outcome 
reports.

Project demonstration and evaluating alternative methods to assure and 
        enhance the quality of long-term care services for persons with 
        developmental disabilities through performance-based contracts 
        with service providers

    Period: September 1994-September 1997.
    Funding: $800,000.
    Grantee: Minnesota Department of Human Service, Health Care 
Administration, 44 Lafayette Road, St. Paul, MN 55155-3853.
    Investigator: Elaine J. Timmer.
    The purpose of this project is to determine whether and how 
well the implementation of new approaches to quality assurance, 
with outcome-based definitions and measures of quality, will 
replace the input and process measures of quality and, in the 
process, contribute to improving the quality of life of persons 
with developmental disabilities. The Minnesota Department of 
Human Services will seek Federal authority to waive necessary 
provisions of the intermediate care facilities for the mentally 
retarded (ICF-MR) regulations to permit alternative quality 
assurance mechanisms in selected demonstration, residential, 
and support service programs. The department will enter into 
performance-based contracts with counties and participating 
ICF-MR providers. These contracts will specify the amount and 
conditions of reimbursement, requirements for monitoring and 
evaluation, and expected client-based outcomes. These client-
based outcomes will be determined by the client and by the 
legal representative, if any, and with the assistance of the 
county case manager and provider. Some desirable outcomes 
include enhancement of consumer choice and autonomy, 
employment, and integration into the community. Criteria for 
measuring participating agency achievement will be drawn from, 
but not limited to, the outcome standards developed by the 
National Accreditation Council on Services for Persons with 
Developmental Disabilities; the ``values experiences'' of 
Frameworks for Accomplishment; and the goals established in 
Personal Futures Plans, Essential Lifestyle, and Person-
Centered planning. According to the proposed quality assurance 
framework, monitoring of individual outcomes will be done 
jointly among family members, case managers, and other members 
of the local review team on a quarterly basis.
    The award was made to Minnesota Department of Human 
Services on September 30, 1994. The first year of the 
cooperative agreement was used to further develop the 
demonstration. In December of 1995, the State was granted a 
section 1115 waiver to implement the demonstration.
    Significant progress has been made toward meeting the 
program objectives. During the first operational year the 
following goals were achieved: (1) the establishment of 
baseline data on outcome indicators to be used for the purpose 
of establishing performance target for the second operational 
year; (2) The development of Quality Enhancement Teams to 
conduct the annual performance reviews. These teams are 
comprised of consumers, advocates, volunteers, and state staff; 
(3) Training and technical assistance was provided to all 
parties involved in the project's implementation to ensure that 
they could successfully fulfill their roles in the new outcome-
based ICF/MR service delivery system; and (4) the first phase 
of the qualitative/case study review of the project's 
implementation was completed.
    Several approaches have been taken to develop alternative 
means of ensuring that quality services are provided. Providers 
were granted variances to existing State licensing rules 
governing ICFs-MR, waived services, semi-independent living 
services and day training and habilitation services; waiver to 
parts of the rule licensing supervised living facilities; and 
changes to the statute governing case management through an 
established reform process.
    The University of Minnesota is under contract with the 
State to provide project participants with technical assistance 
and training in the following areas: (1) personal futures 
planning; (2) self determination; and (3) organizational 
management and change.
    Minnesota's Department of Human Services entered into a 3-
year contract with the University of Minnesota Institute on 
Community Integration for the evaluation of the performance-
based contracting demonstration project It is central to this 
demonstration and its evaluation to be able to establish that 
the alternative quality assurance approaches improve or at 
least do not decrease the quality of life and services for the 
persons involved. This evaluation will include both process and 
outcome components. The process evaluation will describe and 
evaluate the procedures and activities undertaken to develop 
alternative outcome-based quality assurance programs. The 
process evaluation is by its nature qualitative, relying 
heavily on interviews with key people in the process of 
developing, implementing and otherwise being affected by the 
approaches being developed. Other qualitative data collection 
will include on-site direct observation and document review.
    The outcome evaluation component of the demonstration is 
primarily a quantitative data collection activity seeking to 
obtain objective quantifiable measures of the products of the 
programs and services under the alternative assurance programs. 
Quantitative measures will include frequencies of different 
types of activities, access to, utilization and satisfaction 
with the services provided, ratings of changes in the content, 
quality and person-centeredness of service plans, nature and 
frequency of social relationships and so forth. Process and 
outcome evaluation components will be examined independently in 
descriptive analyses, but also inferentially to determine if 
any process variables (independent) may be associated with 
outcomes (dependent variables). A control condition will also 
be established. A matched group sample for comparison of 
demonstration and non-demonstration group outcomes will be 
drawn from Minnesota samples currently participating in the 
Minnesota Longitudinal Study and the 1992 participants in the 
independent assessment of Minnesota's Medicaid Home and 
Community Based Services waiver program.

Synthesis of unmet need for log-term care services

    Period: June 1991-August 1995.
    Funding: $27,400.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    The purpose of this study is to conduct a literature review 
and prepare a synthesis of previous work in the area of unmet 
need for long-term-care services. This project concentrated on 
identifying unmet need using secondary analysis of survey data. 
Included is an analysis of data from the National Long-Term 
Care Surveys, the 1984 Supplement on Aging, the Longitudinal 
Study of Aging, and the Channeling demonstration projects. This 
study explores possible measures that can be constructed from 
national databases to assess unmet need for long-term-care 
services. The study evaluates the merits of alternative 
measures, establishes, definitions of unmet need, using survey 
data, and then develops a framework for comparing this analytic 
work with earlier studies. This work was completed by Barbara 
Lyons of the John Hopkins University School of Hygiene and 
Public Health under subcontract to Lewin/VHI, Inc. The final 
report has been received and is under review.

Combining formal and informal care in serving frail elderly people

    Period; June 1992-December 1995.
    Funding: $93,700.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    The purpose of this study is to determine whether formal 
care substitutes for or complements informal care. To determine 
the relationship between formal care and informal care, a data 
set generated by the management agency Connecticut Community 
Care, Inc. (CCCI) is analyzed. CCCI conducts patient 
assessments of all publicly supported long-term-care patients 
in Connecticut This dataset offers a unique opportunity to 
conduct an in-depth longitudinal analysis of the effect of 
providing formal care on the provision of informal care for a 
large population of elderly persons. Although surveys have 
repeatedly found that older persons strongly prefer community 
services to services offered in nursing homes, policymakers 
have resisted a major expansion of home-care services even 
though community services are usually less expensive than 
nursing home services. The most important reasons for this 
resistance is the fear that a publicly funded home-care program 
will encourage family caregivers of the elderly to substitute 
formal care for informal care. This project is complete and is 
included in the proceedings from the Brooking's Conference, 
Persons with Disabilities. This publication is available from 
the Brooking's Institute.

Characteristics and outcomes of persons screened into Connecticut's 
        2176 Program

    Period: June 1992-November 1994.
    Funding: $132,400.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    In recent years, a major focus of research on home and 
community based care (HCBC) has been on the number of persons 
who would be eligible for services based on dependencies in 
activities of daily living (ADLs). While previous researchers 
have estimated the size of beneficiary populations under 
different eligibility standards, little is known about the 
number of eligibles who would actually participate in HCBC 
programs. This project examines why 20 percent of persons 
meeting ADL requirements for eligibility did not participate in 
the Medicaid 2176 program in Connecticut. The subsequent use of 
long-term-care services by these nonparticipants is compared to 
the use of services by participants in the Connecticut Medicaid 
2176 program. This project has been completed. Findings from 
the study have been published as part of the conference 
proceedings from the Brooking's Institute. The publication, 
Persons with Disabilities, is available for the Brooking's 
Institute.

Issues in long-term care policy for the disabled elderly with cognitive 
        impairment

    Period January 1992-March 1995.
    Funding: $180,000.
    Contractor Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study utilizes the National Long-Term Care (NLTC) 
surveys to analyze issues related to informal caregiving to 
cognitively impaired elderly people, the mix of formal and 
informal services they use, and the risk of 
institutionalization. The main question addressed is whether 
the presence of such factors as behavioral problems or 
conditions (e.g. incontinence) that imply special service needs 
affect the mix of services used or the risk of 
institutionalization. This work will be completed by Judith 
Kasper of the Johns Hopkins University School of Hygiene and 
Public Health under subcontract to Lewin/VHI.
    The article, ``Cognitive Impairment and Problem Behaviors 
as Risk Factors for Institutionalization,'' by Judith Kasper 
and Andrew D. Shore, describes the first part of this study and 
appears in the Journal of Applied Gerontology, 13(4):371-385, 
December 1994. The NLTC survey data were used to develop a 
predictive model for nursing home institutionalization that 
includes cognitive functioning and problem behaviors in 
addition to more commonly studied indicators, such as 
disability. As expected, cognitive impairment is a risk factor 
for institutionalization, controlling for other characteristics 
such as age, living arrangement, and use of paid in-home care. 
Four problem behaviors were investigated, but only one, 
Wanders/Gets Lost, contributed to the model. Among cognitively 
impaired persons, those who wander/get lost had a twofold risk 
institutionalization. The findings suggest the need to 
differentiate among difficult or problem behaviors and to 
further investigate those that arouse concerns about safety and 
require extensive supervision as risk factors for 
institutionalization The second part of this study examining 
survey data combined with Medicare claims is final.

Use of Long-Term Care Services by Mentally Ill Persons

    Period: September 1994-December 1996.
    Funding: $391,331.
    Grantee: Center for Health Policy Research, Institute for 
Policy Research and Evaluation Pennsylvania State University, 
Office of Sponsored Programs, 110 Technology Center, University 
Park, PA 16802.
    Investigator: Dennis Shea, Ph.D.
    There has been a steady increase in the utilization of 
long-term-care services, particularly nursing homes, by 
mentally ill persons following the closure of State and county 
mental hospitals during the 1960s and 1970s. This project 
examines the determinants of long-term care service use by the 
mentally ill population. Data from the National Medical 
Expenditures Survey (NMES) Institutional Component, the 
Medicare Current Beneficiary Survey (MCBS), and the National 
Nursing Home Survey (NNHS) are being used to model long-term-
care use by this population. Information on patients, 
providers, and system characteristics, together with a more 
complete description of current use patters, will help to 
identify the potential impacts of policy changes on use of 
services and total program costs.
    Descriptive data from the Institutional Population 
Component of the 1987 National Medical Expenditure Survey 
(NMES) have been used to examine differences in nursing home 
expenditures by persons with and without reported or diagnosed 
mental illness. The results presented in ``Mental Illness and 
Nursing Home Use,'' presented at the 1995 Meetings of the 
Gerontological Society of America indicate the following:
          Mental illnesses explain variations in service use, 
        with the effects depending on how mental illness is 
        defined and whether a resident or admission cohort is 
        examined;
          Newly admitted during home residents with a mental 
        illness have higher charges due to lengths of stay that 
        are 35 percent longer than non-mentally ill admissions.
          Charges vary little between persons with or without a 
        mental illness.
These results suggest that if future reimbursement policy in 
long-term care-settings is moving toward capitation, as has 
occurred in other settings, rates should take into account the 
longer stay associated with persons with mental illness.
    Results from the initial descriptive analyses of the MCBS 
indicate that 5 years after the passage of the 1987 Nursing 
Home Reform Act, which mandated treatment of mental illnesses, 
there is a persistent level of untreated mental illness in 
nursing homes. Only 29 percent of nursing home residents with a 
mental illness were treated by mental health specialists during 
the year. Regarding the use of other long-term-care services, a 
significant relation has also been detected between diagnosis 
of a mental illness and home health use.

Synthesis of literature on effectiveness of special assistive devices 
        in managing functional impairment

    Period: August 1991-January 1996.
    Funding: $32,600.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This synthesis has two components. The first is a 
description of the special assistive devices and a summary of 
how these devices are paid for under the current system. The 
second is a summary of the effectiveness of special assistive 
devices in managing functional impairments. This synthesis also 
discusses various policy options, which relate to alternative 
financing arrangements for special assistive devices. The 
analysis of assistive device usage is obtained using the 1984 
Supplement on Aging and the 1990 National Health Interview 
Survey Supplement on Assistive Devices. This first draft has 
been received and is expected to be completed in January 1997.

Synthesis of literature on targeting to reduce hospital use

    Period: September 1991-August 1995.
    Funding: $30,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study synthesizes the literature on targeting across a 
variety of types of programs, all of which have the goal of 
reducing hospital use. These programs include geriatric 
evaluation units, nursing home staffing enhancement programs, 
and hospital-based programs for discharge planning and 
transitional case management. Although targeting is an issue 
for all of these types of programs, little attention has been 
given to evaluating targeting criteria. This project has been 
subcontracted to Mathematica Policy Research, Inc. This review 
of the literature points to familiar gaps in the current health 
care system. The review discusses the lack of overall 
coordination and monitoring of care for the elderly, an 
insufficient level for primary and acute care for nursing home 
patients, poor access to a range of subacute services, a 
shortage of physicians with geriatric training for community-
dwelling elderly persons, and insufficient efforts to reduce 
the highest cost diseases and complications that arise during 
hospitalization. The literature also suggests that several 
groups of elderly might benefit from such interventions as 
comprehensive geriatric assessment, enhanced hospital discharge 
planning, and the social health maintenance organization. These 
groups include individuals whose conditions are difficult to 
stabilize or who require regimens of medications or diet that 
must be monitored for compliance or change, individuals for 
whom medications are likely to lead to adverse events, and 
individuals facing nursing home placement without first being 
evaluated for rehabilitative potential.

Interrelationship of medical conditions in the nursing home population

    Period: January 1994-December 1995.
    Funding: $67,600.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This project, conducted in collaboration with the Health 
Care Financing Administration, uses concatenated Medicare 
provider analysis and review, skilled nursing facility (SNF), 
and minimum data set plus (MDS+) data to develop a richer 
profile of Medicare SNF patients. Data for all patients include 
their clinical conditions, their subsequent use of Medicare 
hospital and SNF services, and use of their non-Medicare-
covered nursing home services. This is a pilot study that 
focuses on three States (Maine, Mississippi, and South Dakota) 
and on patients with selected conditions (congestive heart 
failure, hip fracture/replacement, chronic obstructive 
pulmonary disease, pneumonia, and cardiovascular attack). This 
study also examines the characteristics of nursing home 
patients who are under 65 years of age. This work has been 
subcontracted to The Urban Institute. A draft paper has been 
received and reviewed. The project is expected to be completed 
in December 1996.

Medicare Catastrophic Coverage Act evaluation: Impact on industry

    Period: September 1989-September 1994.
    Funding: $993,199.
    Contractor: Urban Institute, 2100 M Street, NW., 
Washington, DC 20037.
    Investigator: Marilyn Moon, PhD.
    A series of analyses of the effects of the Medicare 
Catastrophic Coverage Act (MCCA) of 1998 on hospitals, nursing 
homes, and home health agencies. Two final reports summarize 
the work of the contract:
          Moon, M., Dubay, L. Kenney, G., Liu, K., Marsteller, 
        J., and Norton, S.: ``Medicare Catastrophic Coverage 
        Act Evaluation: Preliminary Analysis of Impact on 
        Industry: Final Report.'' September 1995; and
          Liu, K., Kenney, G., Wissoker, D., and Marsteller, 
        J.: ``The Effects of the Medicare Catastrophic Coverage 
        Act and Administrative Changes on Medicare SNF 
        Participation and Utilization: 1987-1991.'' Washington, 
        D.C., June 1995.
            Findings
    Nursing facilities.--The Health Care Financing 
Administration's claims data and nursing facility certification 
data were used in the study of changes in facility 
certification from non-Medicare SNF or intermediate care 
facility (ICF) to Medicare SNFs and changes in Medicare-
certified beds, to determine how nursing homes increased or 
decreased their capacity to provide Medicare SNF services. 
Analysis findings are consistent with the national program 
statistics, both indicating large increases in the utilization 
of Medicare SNF days between 1987 and 1989, and a decline in 
covered days between 1989 and 1991. The magnitude of the change 
between 1987 and 1989 strongly suggests that the MCCA, along 
with the clarification of coverage guidelines, had an impact on 
the SNF benefit during this period. Multivariate analyses 
demonstrated differential responses in the provisions of SNF 
services by provider characteristics, i.e., proprietary and 
larger nursing homes, rather than government-owned or smaller 
nursing homes, were the most responsive to the MCCA and 
coverage guidelines. Freestanding SNFs had greater increases in 
covered days per bed, admissions per bed and length of stay 
between 1987 and 1989 than hospital-based SNFs. Some of the 
differences in growth were probably attributable to the 
transfer of Medicaid residents of freestanding SNFs to Medicare 
payment status: hospital-based facilities generally not 
providing long-term nursing care and, hence, having fewer 
patients to convert to Medicare SNF. The increase in Medicare 
patients after the implementation of these policy changes was 
offset by a disproportionate decrease in private-pay patients, 
indicating that the policies increased the role of public 
financing for nursing home care. Nursing homes in states that 
employ a case-mix adjustment in setting their Medicaid nursing 
home payment were generally more likely than homes in other 
States to begin participating in Medicare and to have had 
greater growth in Medicare utilization. Medicare-certified 
service provision expanded greatly even with the repeal of the 
MCCA, and more nursing beds became certified for Medicare over 
the study period. The expansions in access are likely the 
consequence of (1) the coverage clarifications that may have 
served to make nursing homes more willing to serve Medicare 
patients because of greater certainty regarding Medicare 
coverage policy; (2) MCCA may have given nursing homes greater 
familiarity with Medicare; and (3) staffing data suggest that 
OBRA 1987 led to increases in staff levels, making it easier 
for more nursing homes to serve Medicare patients. Although 
Medicaid still dominates the financing in the nursing home 
industry, the policy and industry changes have pushed Medicare 
more to the forefront of financing nursing home care.
    Home health.--Analyses of the changing home health market 
in response to MCCA and other regulatory changes suggest a 
complicated set of relationships and causal factors. The 
descriptive analysis suggested an inverse relationship between 
SNF use and home health use. Similarly, the simultaneous 
regression results did not show a substantial number of 
Medicare enrollees shifting away from the Medicare home health 
benefit in favor of the Medicare SNF benefit as a result of 
MCCA. Although analyses found no offset between nursing home 
and home health utilization, they did show that larger 
increases in home health occurred in areas with higher Medicare 
discharges in diagnosis-related groups with high use of 
postacute care. Larger increases in home health use also 
occurred in areas with higher proportions of dually eligible 
enrollees. Findings that much of the growth in home health care 
was associated with less skilled agencies suggest that the 
service needs of new Medicare beneficiaries are more likely to 
involve personal care rather than specialized care such as 
physical therapy or medical services. Users of rehabilitation 
services seem to be similar to those using home health services 
across many dimensions; SNF users, in contrast, are older and 
more likely to be female and/or unmarried. The ratio of home 
health agencies per enrollee and nursing home bed moratoria had 
significant effects on use of health services. Home health 
agencies substantially expanded the scope of services offered 
between 1983 and 1989, with urban areas offering more 
comprehensive services than rural settings.
    Hospitals.--Analyses concluded that MCCA decreased 
beneficiary out-of-pocket expenditures. Even though overall bad 
debt in hospitals increased, the bad debt for hospitals with 
the largest maternity load decreased, reflecting the impact of 
MCCA's Medicaid eligibility expansion for poor/pregnant women 
and their infants.

Medicare Catastrophic Coverage Act evaluation: Beneficiary and program 
        impact

    Period: September 1989-September 1995.
    Funding: $2,846,906.
    COntractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: David Kidder, Ph.D.
    MCCA of 1988 expanded and simplified Medicare hospital 
coverage effective January 1989, only to be repealed, effective 
January 1990. The legislation reduced Medicare beneficiary 
liability to one hospital deductible per year, eliminated the 
concept of ``spell of illness,'' and eliminated the coinsurance 
calculations necessary under the original Medicare program. The 
legislation made the Part A Extended Care Benefit more generous 
by increasing the day limit on skilled nursing facility care 
from 100 to 150 days per year, and eliminated the prior 3-day 
hospital stay. The coinsurance requirements were revised, and 
the rate was lowered to 20 percent of the daily cost of nursing 
home care instead of being linked to the average cost of a day 
of hospital care. Also, the coinsurance was to apply only to 
the first 8 days of the stay, instead of applying to the 21st 
through 100th day. These changes meant that more beneficiaries 
would qualify forcoverage and that longer stays would be 
covered. The skilled nursing facility changes went into effect in 
January 1989 and were rescinded, effective January 1990. Changes to the 
Medicare hospice benefit, implemented in January 1990 and rescinded in 
January 1990, eliminated the 210-day lifetime limit on hospice 
benefits, but retained a cost limit. None of the other Medicare 
benefits (Part A or Part B or Drug) of MCCA were implemented, having 
been scheduled for implementation after the date that the provisions 
were repealed. The Medicaid provisions of the legislation were left 
intact, including the payment of Part B premiums, deductibles and 
copayments for qualified (poor) Medicare beneficiaries, and mandatory 
Medicaid coverage for pregnant women and their infants with income of 
up to 100 percent of the Federal poverty level. (The coverage was 
phased in--75 percent by July 1989 and 100 percent by July 1990).
    The evaluation contract comprised a series of research 
projects related to the analysis of Medicare benefit changes 
and Medicaid beneficiary expansions introduced by the Medicare 
Catastrophic Coverage Act (MCCA) of 1988. The analyses focused 
on the Medicare benefit changes in skilled nursing care and 
hospice care. The analyses also addressed the MCCA-introduced 
payment of Part A and Part B premiums, and the deductibles and 
copayments for low-income qualified Medicare beneficiaries by 
State Medicaid programs. Data on use in a private nursing home 
chain were studied, and nursing home episodes for Medicare 
beneficiaries are identified through a linkage of Part A and 
Part B bills. Post-hospital use was studied through two tracer 
conditions-stroke and hip fracture. The Medicaid analyses 
primarily focused on the effects of the expansions for pregnant 
women and their infants. Analyses of birth and death records 
were conducted on national vital statistics data; Missouri 
birth and infant death data were linked with Medicaid 
eligibility and utilization data and analyzed for changes in 
Medicaid enrollment of pregnant women and the birth outcomes of 
their infants. Analysis of a year of infant health care 
utilization includes data from birth certificates and mothers' 
Medicaid eligibility. A trend analysis of Massachusetts 
hospital discharge data focuses on shifts in Medicaid use, 
lengths of stay, severity of birth outcomes, and neonatal 
intensive care unit use before and after the MCCA legislation.
    Two final reports summarize the findings:
    (1) Laliberte, L., Mor, V., Berg, K., Banaszak-Holl, J., 
Calore, K., Intrator, O., and Hiris, J., ``Medicare 
Catastrophic Coverage Act Evaluation: The Impact of the 
Medicare Catastrophic Coverage Act on the Long-Term Care 
System.'' June 1995. and
    (2) Coulam, R.F., Cole, N., Irvin, C., Kidder, D., and 
Schmitz, R.J.: ``Evaluation of the Medicare Catastrophic Care 
Act: Final Report, ``December 19, 1995, which summarizes the 
MCCA impacts on maternal and child health programs and 
beneficiaries.
    All reports are being prepared for submission to the 
National Technical Information Service.

Long-Term Care Studies (Section 207)

    Period: September 1989-March 1996.
    Funding: $3,790,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031-1207.
    Investigator: David Kennell.
    The purpose of this project is to conduct research related 
to the Health Care Financing Administration's (HCFA's) Medicare 
and Medicaid programs in the area of long-term-care (LTC) 
policy development. The contractor has focused on four major 
areas:
          The financial characteristics of Medicare 
        beneficiaries who receive or need LTC services;
          How the Medicare beneficiaries' characteristics 
        affect their use of institutional and noninstitutional 
        LTC services;
          How relatives of Medicare beneficiaries are affected 
        financially and in other ways when beneficiaries 
        require or receive LTC services; and
          How the provision of LTC services may reduce 
        expenditures for acute care health services.
    Analyses used existing LTC and other survey databases 
(e.g., the National Long-Term Care Surveys, the Longitudinal 
Study of Aging, the National Nursing Home Survey, the Medicare 
Current Beneficiary Survey, the Survey of Income and Program 
Participation, the National Medical Care Expenditure Survey). 
Medicare administrative records and other extant information 
also will be used. A number of focused analytic studies, policy 
reports, syntheses, and special studies are required under the 
contract.
    With the repeal of the Medicare Catastrophic Coverage Act 
of 1988, this project was no longer congressionally mandated. 
The following updates the status of each of the studies, 
indicating which reports are final and those that are in draft 
or pending final review. The final reports are as follows:
          ``Analysis of Choice Processes in Capitated Plan 
        Enrollment: Statistical Models for Evaluation of 
        Voluntary Enrollment to Long-Term Care Demonstration 
        Projects,''
          ``Analysis of Transitions in the Characteristics of 
        the Long-Term Care Population''
          ``Case Studies of Medicaid Estate Planning''
          ``Consumer Protection and Private Long-Term Care 
        Insurance''
          ``Elderly Wealth and Savings: Implications for Long-
        Term Care''
          ``Health Care Service Use and Expenditures of the 
        Noninstitutionalized Population''
          ``Consumer Protection and Private Long Term Care 
        Insurance; Key Issues for Private Long-Term Care 
        Insurance''
          ``Issues in Long Term Care for the Disabled Elderly 
        with Cognitive Impairment''
          ``Nursing Home Payment by Source: Preliminary 
        Statistics from the Medicare Current Beneficiary 
        Survey''
          ``Potential of Coordinated Care Targeted to Medicare 
        Beneficiaries with Medicaid Coverage''
          ``Regional Variation in Home Health Episode Length 
        and Number of Visits Per Episode''
          ``Simulations of Skilled Nursing Facility Payment 
        Options''
          ``State Responses to Medicaid Estate Planning''
          ``Synthesis of Financing and Delivery of Long-Term 
        Care for the Disabled Nonelderly''
          ``Synthesis of Literate on Targeting to Reduce 
        Hospital Use''
          ``Synthesis of the Nursing Home Bed Supply''
          ``Synthesis of Unmet Need for Long-Term-Care 
        Services''
    A conference to present selected findings was held in 
November 1994 and the conference proceedings have been 
published as Persons with Disabilities: Issues in Health Care 
Financing and Service Delivery. This is available from the 
Brookings Instute and HCFA's Office of Research and 
Deomonstrations. Papers included in this book are:
          ``Long-Term Care: The View from the Health Care 
        Financing Administration''
          ``Private Long Term Care Insurance: Barriers to 
        Purchase and Retention''
          ``Medicaid Estate Planning: Case Studies of Four 
        States''
          ``Implications of Health Care Financing, Delivery and 
        Benefit Design for Persons with Disabilities''
          ``Program Payment and Utilization Trends for Medicare 
        Beneficiaries with Disabilities''
          ``Cognitive Impairment in Older People and Use of 
        Physician Services and Impatient Care''
          ``Catastrophic Costs of Long Term Care for Elderly 
        Americans''
          ``Characteristics and Outcomes of Persons Screened in 
        Connecticut's 2176 Program''
          ``Combining Formal and Informal Care in Serving Frail 
        Elderly Persons''
          ``Regional Variation in the Use of Medicare Home 
        Health Services''
          ``Long Term Care for the Younger Population: A Policy 
        Synthesis''
    Studies currently in progress are:
          ``Catastrophic Health Care Expenditures and Medicaid 
        Coverage Among Community Residents''
          ``Synthesis of Nursing Home Reimbursement Options''
          ``The Effect of Geographic Variation on Medicare 
        Capitation for the Social HOM, PACE, CNO''
          ``Synthesis of Literature on Effectiveness of Special 
        Assistive Devices in Managing Functional Impairments''
          ``Catastrophic Costs and Medicaid Spenddown''
          ``Costs of Medicare SNF Therapy Services''
          ``Longitudinal Health Care Use and Expenditures of 
        Disabled''
          ``Interrelationship of Medical Conditions in the 
        Nursing Home Population''
          ``An Analysis of Post-Acute Care and Therapy Services 
        Using the HCFA Episode Database, Post-Acute Portion''
    Final reports on these projects are expected to be 
completed in Winter 1996.

Analysis of post-acute care and therapy services using the Health Care 
        Financing Administration Episode Database

    Period: August 1994-April 1995.
    Funding: $138.300.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This two-part study uses the Health Care Financing 
Administration Episode Database to do the following:
          Update earlier research on post-hospital care and 
        rehabilitation following hospital admissions with more 
        recent data;
          Examine trends in use over time by comparing the 1992 
        findings to several RAND analyses and a Lewin/VHI 
        analysis on therapy services conducted for the American 
        Association for Retired Persons;
          Analyze the use of rehabilitation/therapy services 
        across settings; and
          Contribute to the discussion of policy and payment 
        implications of increased use of post-acute services.
Tabulations on rehabilitation are under way. The post-acute 
analysis is expected in January 1997.

Synthesis of the nursing home bed supply

    Period: May 1991-September 1994.
    Funding: $49,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    Analyses have shown that there is excess demand for using 
home care. Part of this excess demand is attributed to State-
imposed constraints on the supply of nursing home beds. States 
have imposed these supply constraints in an attempt to control 
their Medicaid budgets and to redirect resources from 
institutional to noninstitutional care. This synthesis 
addresses:
          How much variation is there in the supply of nursing 
        home beds?
          Why do variations in the supply of beds exist across 
        States?
          To what extent does a State's capital reimbursement 
        system encourage/discourage sufficient investment of 
        capital to meet its demand for new beds?
          What is the relationship between certificate of need 
        and capital replacement?
          What is ``excess demand'' and how is it measured?
    This report found that much of the attention paid to the 
adequacy of a State's supply of nursing home beds focuses on 
the effect that supply has on access to care and often ignores 
important demand-side issues. One of these issues, the 
subsidization of health care expenses for Medicaid 
beneficiaries, results in excess demand for nursing home 
services by Medicaid beneficiaries, who are encouraged to 
demand more services than they otherwise would. This study 
found that, in general, access problems do not exist for 
private patients. However, access problems do exist for some 
Medicaid beneficiaries, especially for heavy-care persons with 
head injuries, with behavioral problems, or who need 
ventilators. Since each State has a unique long-term-care 
system, measures of the adequacy of the supply of nursing home 
beds in one State may not accurately measure the adequacy of 
supply in another State. Furthermore, given the differences in 
programs, laws, and market conditions across States, policies 
that help control long-term-care expenses in one State may not 
necessarily be appropriate for other States.

Program payments and utilization trends for Medicare beneficiaries and 
        disabilities

    Period: December 1992-November 1994.
    Funding: $175,300.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study is an extension of the analyses of the acute 
care costs of chronically disabled persons completed using the 
1984-89 National Long-Term Care Survey (NLTCS). This analysis 
employs recently released 1989 NLTCS data to examine possible 
cost shifts for groups of personswith very different levels of 
health and functioning. Analyses were made of seven different 
categories of Medicare service (short-stay hospital, home health 
agency, skilled nursing facility, physician, outpatient, durable 
medical equipment, and renal therapy) for 1982 to 1990 using Medicare 
records linked to data on community and institutional residents from 
NLTCS 1982, 1984, and 1989. The purpose of the combined survey and 
administrative record analyses was to ascertain how the chronic health 
and functional characteristics of community and institutional residents 
using Medicare-reimbursed services changed over the period and how 
those changes related to the use of each of seven categories of 
Medicare services. Over this period, a number of regulatory and 
legislative changes had been made in the Medicare system that altered 
the use of different services by persons with specific health and 
functional profiles. The final report is included in the proceedings 
from the Brookings Conference entitled,: ``Persons With Disabilities''. 
This is available from The Brookings Institute.

Health Care Service Use and Expenditures of the Noninstitutionalized 
        Population

    Period: June 1993-February 1995.
    Funding: $148,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    Using data from the 1987 National Medical Expenditures 
Survey Household Component, this study addresses the following:
          Differences in the utilization of health care 
        services by disabled and nondisabled populations;
          Whether community-based long-term-care services and 
        expenditures substitute for acute-care expenditures for 
        the population using community-based long-term-care 
        services and the implications for costs;
          Medicaid asset spenddown in the community; and
          Trends in out-of-pocket expenditures and total health 
        care expenditures for the elderly population with 
        comparisons to the 1977 National Medical Care 
        Expenditure Survey.
Analysis files have been constructed. A draft report has been 
completed. The final report is expected in January 1997.

Longitudinal health care use and expenditures of disabled persons

    Period: January 1994-June 1995.
    Funding: $143,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This project, conducted in collaboration with the Health 
Care Financing Administration, uses data from the Medicare 
Current Beneficiary Survey to examine health care use by 
persons with disabilities and the cost of providing these 
services. In this study, Medicare beneficiaries are categorized 
by different definitions of disability and by duration of 
disability. An analysis of the types of health care services 
and patterns of use for each subgroup is performed to determine 
the extent to which differences in such constructs are 
associated with differences in health care use and costs. This 
study is designed, in part, to provide information parallel 
with that from Lewin-VHI's analysis of National Medical Care 
Expenditure Survey data and Duke University's analysis of 
National Long-Term Care Survey data. This work has been 
subcontracted to The Urban Institute. A draft report has been 
received and reviewed. The final report is expected to be 
completed in December 1996.

Changes in population characteristics and Medicaid utilization/
        expenditures among children and adolescent Supplemental 
        Security income recipients

    Period: September 1994-September 1997.
    Funding: $642,035.
    Grantee: Massachusetts General Hospital Children's Service, 
Fruit Street, WACC715 Boston, MA 02114.
    Investigator: James Perrin, M.D.
    The Supplemental Security Income (SSI) program for children 
and adolescents has expanded in the past 5 years as a result of 
new Social Security Administration (SSA) guidelines for 
determining disability caused by mental impairments, new 
guidelines for determining childhood disability in general, and 
major outreach efforts by SSA to identify children with 
disabilities. The project has four main objectives:
          Determine the current clinical characteristics of 
        child and adolescent SSI recipients and the changes in 
        these characteristics during the period of program 
        expansion that began in the late 1980s;
          Determine patterns of Medicaid utilization and 
        expenditures among important clinical subgroups and 
        examine changes in these patterns during the period of 
        program expansion;
          Examine the utilization trajectories and clinical 
        characteristics of certain SSI recipient groups over 
        time, including recipients with high-cost physical 
        conditions such as cystic fibrosis, congenital heart 
        disease, and spina bifida, and high-prevalence, low-
        cost conditions such as attention deficit disorder, 
        hyperactivity, and learning disabilities; and
          Determine the degree to which new recipients reflect 
        shifting among Medicaid eligibility categories and the 
        coverage and use of other insurance after getting SSI.
    Data files construction is almost complete, and analyses on 
three of the six States are underway and three papers have been 
prepared:
          ``Secular Trends in Conditions Among Children 
        Receiving SSI Benefits,'' which found that the number 
        of SSI children in institutions increased minimally (3 
        percent), despite an 83 percent increase in SSI 
        enrollment. The number of children with leukemia 
        enrolled in SSI increased 33 percent, while those with 
        other physical conditions increased over 70 percent; 
        the number of children with mental retardation 
        increased 615. In contrast, the number of SSI children 
        with asthma increased dramatically (185 percent), but 
        at a rate similar to the 162 percent increase in asthma 
        among the non-SSI Medicaid population. A four-fold 
        increase in Attention Deficit Hyperactivity Disorder 
        among SSI enrollees is comparable to the four-fold 
        increase in the condition among the non-SSI Medicaid 
        enrolled children.
          ``The SSI Children's Disability Program: New Entrants 
        of AFDC Upgrades?,'' found that about half of the 
        children newly receiving SSI benefits had previously 
        received AFDC benefits and thus experienced a major 
        increase in monthly cash benefits. The other half of 
        new SSI recipients were new to public insurance.
          ``The Supplemental Security Income Children's 
        Disability Program: Impact of Program Growth on 
        Population with High Expenditures.'' This preliminary 
        analysis on only Georgia data found that the number of 
        children with costs over $25,000 decreased very 
        slightly from 4.3 percent of the SSI population in 1989 
        to 4.1 percent in 1992.

Changing roles of nursing homes

    Period: September, 1994-January, 1998.
    Funding: $831,182.
    Grantee: Institute of Gerontology, University of Michigan, 
300 North Ingalls Building, Room 900, Ann Arbor, MI 48109-2007.
    Investigator: Brant Fries, Ph.D.
    Although nursing homes have traditionally provided 
custodial care to the physically and cognitively impaired 
elderly, nursing homes are increasingly treating a more diverse 
and more clinically complex patient mix. Since the 
implementation of Medicare's prospective payment system for 
hospitals, growing numbers of nursing homes have begun caring 
for patients requiring ``subacute'' or post-acute care 
following a hospital stay. Between 1986 and 1993, the number of 
Medicare certified hospices in the U.S. grew from 355 to 1,445. 
From 1992 to 1995, the number of special care hospice units in 
nursing homes grew 100 percent, to 206.
    This study examines two special nursing home populations: 
hospice patients and the chronically mentally ill (other than 
dementia). Several hypotheses regarding quality, use, and cost 
issues will be examined for both groups, such as that residents 
with chronic mental illness are more likely than are other 
similarly functionally impaired residents, to experience 
increasing functional impairment, to have increased behavior 
problems and to be chemically restrained. It is hypothesized 
that mentally ill patients will have greater overall use of 
Medicare services than will non-mentally impaired nursing home 
residents with similar levels of functional impairment. The 
study utilizes 1993 data on the entire nursing home populations 
of eight states (Kansas, Maine, Mississippi, Nebraska, New 
York, Ohio, Pennsylvania, South Dakota, and Washington), about 
250,000 residents, linked with the HCFA Survey and 
Certification Reports, the Medicare Part A and Part B claims 
files and the Area Resource File data. The Minimum Data Set for 
Nursing Home Resident Assessment and Care Screening is used to 
collect health status data on all residents in Medicaid-
certified, Medicare-certified and dually certified nursing 
facilities. The hospice substudy will describe how nursing home 
hospice services are concentrated in particular regions, 
markets and facilities; compare rates of hospital use and costs 
of terminal care residents in nursing homes that do and do not 
use the Medicare hospice benefit; and describe the quality of 
life, including pain experience and analgesics prescribed among 
terminal cancer patients in nursing homes who are served by 
hospice care and those not so served.
    A draft report, ``Hospice in Nursing Homes,'' presents 
initial analyses of longitudinal files of 1991-95 nursing home 
survey data merged with patient assessment data. Multivariate 
analyses indicate that hospice special care units are located 
in relatively small and medium size facilities with low 
occupancy, high technological capacity and a higher skill level 
of staffing mix. Also, nursing home characteristics such as 
being a proprietary facility, not part of a chain and being 
located in a competitive environment are significantly related 
to having a hospice special care unit. The authors note that 
the growth in special care hospice units in nursing homes 
reflects changes in reimbursement mechanisms, increases in the 
proportion of all deaths occurring in nursing homes, and by 
nursing home efforts to specialize. A paper, ``Special 
Populations in Nursing Homes: Residents with Chronic Mental 
Illness or Developmental Disabilities,'' is being presented at 
the November 1996 meeting of the Gerontological Society of 
America.

Predictors of access and effects of Medicare post-hospital care for 
        beneficiaries 65 years of age or over

    Period: September 1994-September 1996.
    Funding: $502,614.
    Grantee: Georgetown University, Division of Community 
Health Studies and Family Medicine, 3750 Reservoir Road, NW., 
Washington, DC 20007-2197.
    Investigator: David L. Rabin, Ph.D.
    As a consequence of regulatory and legislative changes in 
the late 1980s, Medicare post-hospital care (PHC) has become 
the most rapidly growing Medicare expenditure. PHC consists of 
home health care, inpatient skilled nursing facility care, and 
rehabilitation hospital care. The growth in use, changes in 
eligibility requirements, and the increase in Medicare costs 
have raised questions about equal access and the effects of PHC 
use. The literature on PHC suggests two important trends. A few 
Medicare prospective payment inpatient hospital diagnosis-
related-groups (DRG) account for most PHC, but within these 
DRGs large variations exist in use. Personal health, economic, 
sociodemographic, and household factors, as well as area and 
health system characteristics, and predictive of the use of PHC 
despite equal access under the Medicare program. This study 
uses the Medicare Current Beneficiary Survey to investigate 
three major research objectives:
          Describe the personal, area, and health system 
        characteristics of users and those of similar persons 
        with unmet needs for PHC in order to access differences 
        by gender, race, and income class and the potential for 
        substitution of care modes;
          Study the longitudinal effects of PHC on Medicare 
        program costs and rehospitalization; and
          Study the personal health effects associated with 
        PHC.
    Because of the delay experienced in releasing the Medicare 
Beneficiary Cost and Use File and the dependence of this 
project on the Medicare Current Beneficiary Survey Data, this 
project is initiating the data analysis phase. The final report 
is expected to be completed in June 1997.

Acute and long-term care: use, costs, and consequences

    Period: September 1994-August 1997.
    Funding: $595,787.
    Grantee: The Urban Institute, 2100 M Street, NW., 
Washington, DC 20037.
    Investigator: Korbin Liu, Ph.D.
    This study will provide current information that will aid 
policymakers in developing options to better integrate acute, 
subacute, and long-term-care services. Data from the Medicare 
Current Beneficiary Survey will be used to address three 
issues: transitions among acute, subacute, and long-term care; 
catastrophic costs resulting from the use of those services; 
and interactions between Medicare and Medicaid home health 
care. The transitions analysis is designed to measure 
differences in the patterns of acute, subacute, and long-term-
care use by the characteristics of Medicare beneficiaries, and 
to determine potential areas of access or quality of care 
problems. The cost analysis is designed to access the 
cumulative risks over 3 years of incurring catastrophic health 
care costs or experiencing Medicaid spenddown. The effect of 
the Qualified Medicare Beneficiaries program will be evaluated. 
The home health care analysis is designed to estimate the 
interactions and possible overlaps between two rapidly 
expanding public programs that finance similar services. The 
relationship between home health care use and costs and the 
personal characteristics of Medicare beneficiaries and the 
characteristics of geographic areas, including Medicaid 
policies, will be examined.
    The first part of this project is complete. A final report, 
``Interactions between the Medicare and Medicaid Home Care 
Programs: Insights from States,'' has been produced and is 
available from Genevieve Kenny at the Urban Institute (202-857-
8568). For the second phase, this project was dependent on the 
Medicare Current Beneficiary Survey's Cost and Use File. The 
file has been released, and the agency is in the data cleaning 
and analysis phase.

Regional variation in home health episode length and number of visits 
        per episode

    Period: July 1993-November 1994.
    Funding: $168,600.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study focused on two questions: (1) Why does the use 
of home health care vary across the regions? (2) Is there a 
corresponding variation across the regions in patient outcomes 
suggesting that lower levels of care lead to poorer outcomes 
for patients, or that higher levels lead to improved outcomes? 
This study used the Medicare claims files, the provider of 
services file, the area resource file, and the Regional Home 
Health Intermediary database to determine the contribution of 
three sets of factors to regional variation. These sets of 
factors are patient characteristics, supply of home health 
agencies and staff, and availability of alternatives to home 
health care. The final report has been received and is under 
review.

Sources of Medicare home health expenditure growth: Implications for 
        control options

    Period: February 1992-December 1995.
    Funding: $210,706.
    Grantee: Brandeis University, Heller Graduate School, 
Institute for Health Policy, 415 South Street, P.O. Box 9110, 
Waltham, MA 02254-9110.
    Investigator: Christine Bishop, Ph.D.
    The overall objective of the project is to develop and 
consider options for restraining home health expenditure 
growth. The project has two phases. First is to use secondary 
data to examine the composition of Medicare home health 
expenditure growth between 1985 and 1989 and 1989 to 1991 to 
attribute total growth to growth in persons served, visits per 
person, mix of visits, and visit charges; and to attribute 
growth to types of agencies by auspice and scale. Second is to 
examine data from the Regional Home Health Intermediary 
database to measure variation in types of patients served at 
intake, and the characteristics of high-use patients, by 
auspice and region, and to consider differences in mix and 
intensity of services provided.
    The first phase has been completed, resulting in an 
overview, ``Recent Growth in Medicare Home Health: Sources and 
Implications.'' An edited version of this analysis, ``Recent 
Growth of Medicare Home Health,'' by Christine Bishop, Ph.D., 
and Kathleen Carley Skwara, was published in Health Affairs, 
12(3):95-110, Fall 1993. The second phase, which has been 
delayed, will analyze the length of Medicare home health 
episodes using survival analysis techniques. A report for this 
phase is expected in 1997.

Maximizing the cost effectiveness of home health care: The influence of 
        service volume and integration with other care settings on 
        patient outcomes

    Period: September 1994-December 1998.
    Funding: $1,231,466.
    Grantee: Center for Health Policy Research, 1355 South 
Colorado Boulevard, Suite 706 Denver, CO 80222.
    Investigator: Peter W. Shaughnessy, Ph.D.
    Home health care (HHC) is the most rapidly growing 
component of the Medicare budget in recent years. The rapid 
growth in home health use has occurred despite limited evidence 
about the necessary volume of HHC to achieve optimal patient 
outcomes and whether in substitutes for more costly 
institutional care. Little is known about integrating HHC with 
care in other settings to reduce overall health care costs. The 
central hypotheses of this study are that volume-outcome 
relationships are present in HHC for common patient conditions, 
that upper and lower volume thresholds exist that define the 
range of services most beneficial to patients, that and a 
strengthened physician role and better integration of HHC with 
other services during an episode of care can optimize patient 
outcomes while controlling costs. To test those hypotheses, a 
total of 3,600 patient records will be selected from agencies 
in 20 States. Trained data collectors at each agency will 
record patient outcomes and costs within the HHC episode. Long-
term, self-reported outcomes will be assessed from telephone 
interview data at HHC admission and from 6-month followups. 
These primary data concerning patient status and outcomes will 
be combined with Medicare claims data over the episode of care 
to access the relationship between service volume in HHC and in 
both patient outcomes and costs. Analysis of data relating to 
physician involvement and the sequence of use of other 
providers will address issues of integration with other 
services. Eighty-nine agencies have been recruited for this 
project and are beginning to collect the necessary data.

Home care quality studies

    Period: October 1989-September 1995.
    Funding: $2,848,782.
    Contractor: The University of Minnesota, School of Public 
Health, D-351 Mayo Memorial Building, 420 DeLaware Street, SE., 
Box 197, Minneapolis, MN 55455-0392.
    Investigator: Robert L. Kane, M.D.
    This study examines quality of long-term care-services in 
community-based and custodial settings, and the effectiveness 
of (and need for) State and Federal protections for Medicare 
beneficiaries that ensure adequate access to nonresidential 
long-term-care-services and protection of consumer rights. The 
research design focuses on in-home care, examining traditional 
home health services that are reimbursed by Medicare and 
Medicaid, as well as personal care and supportive services that 
more recently have been covered by Federal and State sources of 
funding. Primary project tasks include the following:
          Development of a taxonomy clarifying the various 
        objectives ascribed to home and community-based care 
        from the various perspectives of consumers, payers, and 
        care providers;
          Development and feasibility testing of a survey 
        design measuring the extent of, need for, and adequacy 
        of home care services for the elderly;
          A study of variations in labor supply and related 
        effect(s) on home care quality, as well as factors that 
        contribute to these variations; and
          Recommendations to improve the quality of home and 
        community-based services by identifying best practices 
        and promising quality assurance approaches.
    The first project task--development of a taxonomy of 
objectives--has been completed, and a report on this component 
has been received. Findings from this task are presented in the 
article, ``Perspectives on Quality of Home Care'' by Kane, 
R.A., Kane, R.L., Illston, L.H., and Eustis, N.N. in the Health 
Care Financing Review, 16(1):69-89, Fall 1994. Final reports 
have also been submitted on the remaining three project tasks 
(i.e., developing a survey to measure the adequacy of home care 
for the elderly, a study of variations in labor supply and 
related effects on home care quality, and an identification of 
best home care practices and promising quality assurance 
approaches). The final report for the project is currently 
under review.

Validation of nursing home quality indicators

    Period: July 1992-September 1996.
    Funding: $990,094.
    Grantee: The MEDSTAT Group, 104 West Anapamu Street, Santa 
Barbara, CA 93101.
    Investigator: Susan A. Flanagan, M.P.H.
    This project is a continuation of a cooperative agreement 
to investigate the usefulness of claims data from Medicaid and 
Medicare administration record systems as sources of nursing 
home quality-of-care measures. The previous study involved 
retrospective analysis of 1987 Medicaid and Medicare claims 
data and facility deficiency data from Michigan and Tennessee. 
The objective of the current project is to validate these 
resident-level claims-based quality of care indicators (QCI) by 
recomputation of the claims-based indicators for California and 
Georgia using data for 1990. To complete the validation 
process, a sample of residents in a sample of nursing homes 
will be drawn for these two States, and the medical records for 
these patients will be reviewed by a team of physicians and 
nurses. The results of the record review will then be compared 
with the findings of the QCI algorithms to test the 
relationship of the QCIs to cited deficiencies and adverse 
outcomes.
    This project has completed collection of medical record 
data from California and Georgia, and the data has been 
reviewed by nurse and physician evaluators. Initial analysis 
had been completed and a draft report of early study findings 
has been submitted. The final report is expected in early 1997.

Development of outcome-based quality assurance measures for small, 
        integrated services settings

    Period: July 1994-January 1996.
    Funding: $22,750.
    Contractor: The Accreditation Council, 8100 Professional 
Place, Suite 204, Landover, MD 20785.
    Investigator: James Gardner, Ph.D.
    The purpose of this contract is to determine the cost of 
applying outcome measures in small, integrated service 
settings. This study will provide a database to maintain 
information on quality reviews of organizations that serve 
people with disabilities, an analysis of individual and 
organizational variables that relate to desirable outcomes, and 
a final report that analyzes quality reviews conducted in 
accordance with the outcome-based performance measures 
developed by the Accreditation Council on Services for People 
with Disabilities. The results will be used to assess the 
quality of services in facilities serving people with chronic 
mental illness, physical challenges, and mental retardation in 
diverse settings such as supported independent living or 
intermediate care facilities for the mentally retarded. Of 
particular importance is the assessment of the extent to which 
the outcome-based performance measures can coexist with the 
traditional quality assurance variables, such as abuse, 
neglect, safety, health, and physical and psychological 
welfare.
    During the period September through December 1994, seven 
organizations participated in the Accreditation Council's 
review process. During these reviews, staff from the 
Accreditation Council interviewed 54 people served by the seven 
organizations. A total of 28 organization variables (e.g., 
types of services provided, license type, disabilities of 
people served, prior accreditation status) were analyzed with 
regard to outcome scores. Analysis of outcome data was also 
performed on the characteristics of the individual people who 
were interviewed. These characteristics include age, sex, 
disability, living arrangement, communication method, services 
obtained, and source of person's funding. A final report is 
under review.

Elderly wealth and savings: Implications for long-term care

    Period: June 1991-August 1995.
    Funding: $126,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study synthesizes what is known about the wealth of 
the elderly and includes recent empirical research conducted 
using the 1984 and 1989 Panel Study of Income Dynamics and the 
1983, 1986, and 1989 Survey of Consumer Finances. The 
information in this study is pertinent to the issue of long-
term care (LTC) for the elderly because much of the debate 
concerning expansion of the Federal role in LTC financing 
centers on the economic status of the elderly. A key issue in 
the debate is whether or not the elderly have the financial 
resources to pay for their own LTC cost directly or through the 
purchase of private LTC insurance.
    The main finding of the synthesis report is that the 
elderly, as a group, are doing well economically. Incomes of 
the elderly are lower than incomes of the nonelderly, but this 
gap narrows when taxes and other benefits (i.e., Medicare) are 
considered. Furthermore, the elderly have among the highest 
wealth holdings of any age group. However, the elderly face 
substantial economic risks, such as incurring unfunded 
catastrophic medical expenses, and leaving poverty is harder 
for the elderly than for the nonelderly. This study also funds 
that existing theories on both whether and why the elderly save 
sharply disagree with one another. Testing these theories is 
challenging because data sources are usually poor or out of 
date, and many of the theories do not yield refutable 
hypotheses.

Catastrophic costs and Medicaid spenddown

    Period: January 1993-May 1995.
    Funding: $180,300.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study uses data from the Medicare Current Beneficiary 
Survey (MCBS) to analyze the occurrence of catastrophic costs 
among the elderly resulting from Medicaid spenddown. The 
purpose of this study is to support the formulation of policy 
for health care reform for the elderly. Consequently, this 
study categorizes the causes of out-of-pocket costs for 
different types of acute and long-term-care services that may 
create financial hardships and identifies which subgroups of 
the elderly are likely to incur catastrophic costs. This work 
will be completed by the Urban Institute under subcontract to 
Lewin/VHI, Inc. Preliminary analyses have been completed. The 
final report is expected in January 1997.

Catastrophic costs of long-term care for elderly Americans

    Period: December 1991-November 1995.
    Funding: $50,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study employs the Brookings/Intermediate Care Facility 
Long-Term Care Financing Model to examine both current and 
future financial burdens associated with long-term-care costs. 
This chapter focuses on the financial burden that out of pocket 
expenditures will have in the next 25 years, assuming that 
there are no changes in public or private financing. The 
results of these long term care spending projections included 
both nursing home and home health care. Catastrophic nursing 
home spending patterns of selected elderly groups, by age, 
gender, income financial status, length of stay and discharge 
status are also described. Findings from this study have been 
published in conference proceedings from the Brooking's 
Institute. These proceedings, Persons with Disabilities, is 
available from the Brooking's Institute.

Consumer protection and private long-term care insurance; Key issues 
        for private long term care insurance

    Period: December 1992-December 1994.
    Funding: $130,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    This study consists of a two-part analysis. The first is a 
policy-oriented synthesis of research conducted to date on 
long-term-care (LTC) insurance. The purpose of this synthesis 
is to serve as a baseline of understanding for policymakers and 
to identify relevant issues at which future research should be 
directed. The second part focuses on regulatory issues. This 
part contains case studies of Arizona, California, Florida, 
Indiana, North Dakota, New York, Oregon, South Carolina, Texas, 
and Wisconsin, which have passed legislation to regular private 
LTC insurance, and summarizes how insurance companies have 
responded to this regulation. This project was carried out 
jointly by Lewin/VHI and the Brookings Institution.
    The policy-oriented synthesis has been completed. This 
synthesis discusses the growth of the LTC insurance market from 
fewer than 50,000 policies in 1984 to nearly 3 million sold in 
1992. Although this growth is significant, the market 
penetration is less than expected; approximately 5 percent of 
the elderly have LTC insurance, while 70 percent purchase 
Medigap policies. The study reviews potential reasons for 
limited market penetration, including consumer confusion, 
barriers to coverage, marketing and sales abuses, concern over 
product value, and regulation.

Synthesis of financing and delivery of long-term care for the disabled 
        nonelderly

    Period: June 1991-December 1995.
    Funding: $30,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031-1207.
    Investigator: David Kennell.
    This study synthesizes the current literature and 
information from various data sources on the financing and 
delivery of long-term care for the disabled nonelderly. This 
study also summarizes the current knowledge of demographic and 
economic characteristics of the disabled nonelderly, types of 
services and patterns of service used by the disabled 
nonelderly, how these services for the disabled nonelderly are 
paid, and other unique issues related to the disabled 
nonelderly. This work was completed by Joshua Wiener of The 
Brookings Institution under subcontract to Lewin/VHI, Inc. 
Findings from this project are present in the conference 
proceedings from the Brookings Institute, Persons with 
Disabilities. The proceedings is available from the Brookings 
Institute.

State response to Medicaid estate planning

    Period: May 1992-May 1993.
    Funding: $41,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    The purpose of this report is to provide readers with an 
overview of recent State initiatives regarding Medicaid estate 
planning. Data for the report were collected primarily through 
telephone interviews with key personnel at Medicaid eligibility 
offices in 26 States. In those States where initiatives were 
under way, copies of recent legislation, regulations, task 
force reports, internal memoranda, and other documents were 
obtained and reviewed. This project was completed by 
SysteMetrics/MedStat under subcontract to Lewin/VHI, Inc.
    The study found that many States are attempting to place 
limitations on asset transfers in an effort to restrict 
Medicaid estate-planning practices. Furthermore, States have 
expressed a strong desire for Federal clarification on Medicaid 
transfer-of-asset provisions and want additional Federal 
legislation that further restricts the transfer of assets.

Case studies of Medicaid estate planning

    Period: April 1993-December 1994.
    Funding: $200,000.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    These case studies provide in-depth descriptive analyses of 
State policy responses to Medicaid estate planning, including 
the effectiveness of estate recovery programs. In addition, a 
methodology for conducting quantitative empirical studies that 
measure the extent of Medicaid estate planning activity and the 
relative cost-effectiveness of alternative State policy 
responses is presented. The data used were obtained from 
Medicaid eligibility offices in Connecticut, Florida, 
California, and New York. This project was completed by 
SysteMetrics/MedStat, under subcontract to Lewin/VHI, Inc. The 
report has been received and is under review.

Synthesis of reimbursement options

    Period: September 1991-January 1996.
    Funding: $77,600.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031-1207.
    Investigator: David Kennell.
    The purpose of this synthesis is to assist the Health Care 
Financing Administration and other relevant policymakers in 
answering specific questions concerning nursing home 
reimbursement. The first part of the synthesis is organized 
into four sections: summary, overview of the Medicaid 
reimbursement system and State policy goals, design of the 
details of a reimbursement system, and analysis of options for 
capital reimbursement. The second part is organized into two 
sections:
          Synthesis of research studies relevant to modifying 
        the current method by which skilled nursing facilities 
        (SNF) receive payments under Part A of the Medicare 
        program;
          Synthesis of research studies relevant to replacing 
        the current system with a system underwhich Medicare 
SNF payment would be made on the basis of prospectively determined 
rates.
    A draft report has been received. The final report is 
expected to be completed in January 1997.

Nursing home payments by source: Preliminary statistics from the 
        Medicare current beneficiary survey

    Period: May 1992-December 1994.
    Funding: $55,500.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    Although national estimates of nursing home expenditures 
have been derived from various databases, direct estimates of 
the distribution of nursing home patients by the amount of 
payment and by the source of payment have not been derived. 
This study is the first attempt to utilize a major source of 
new information on nursing home payment, the Medicare Current 
Beneficiary Survey, to estimate these distributions. This study 
provides an indication of the differences in Medicaid and 
private nursing home payments for 1992. Variations in payments 
by nursing home characteristics are also presented and the 
findings were compared with the National Health Accounts. This 
work has been subcontracted to Korbin Liu of the Urban 
Institute. This report has been submitted and is currently 
under review.

Costs of Medicare skilled nursing facility therapy services

    Period: July 1993-December 1994.
    Funding: $160,800.
    Contractor: Lewin/VHI, Inc., 9302 Lee Highway, Suite 500, 
Fairfax, VA 22031.
    Investigator: David Kennell.
    Approximately two-thirds of all Medicare skilled nursing 
facility (SNF) stays involve physical, occupational, or speech 
therapy. The importance of therapy services to the Medicare SNF 
benefit suggests that changes over time in charges for this 
service, as well as the patterns of charges between Part A and 
Part B, need to be tracked. This study employs Medicare 
provider analysis and reviews SNF data to examine the 
characteristics of patients who receive high and very high-
intensity therapy services. It also analyzes episodes of 
illness of Medicare patients who experience an SNF stay to 
elucidate the relationship between SNF use and providers of 
Medicare services. A draft report was submitted to the Office 
of Research and Demonstrations. The final report is expected to 
be completed by December 1996.

Case-mix adjustment for a national home health prospective payment 
        system

    Period: August 1996-January 1999.
    Funding: $1,588,573.
    Contractor: Abt Associates Inc., 55 Wheeler Street, 
Cambridge, MA 02138.
    Investigator: Henry Goldberg.
    The primary focus of this study is to understand the 
variation that currently exists in terms of home health 
resource patterns and to use this information for the 
development of a case-mix adjustment system for a national home 
health prospective payment system. In this study, the Outcome 
and Assessment Information Set (OASIS) which has been developed 
for outcome-based quality assurance and improvement for 
Medicare home health agencies will be examined to see whether 
items included in this instrument will be useful for case-mix 
adjustment. Detailed information, including information on 
resource utilization and items needed for case-mix adjustment, 
will be collected from 60 to 90 agencies. This project is 
currently in its design phase.

Risk adjustment for Medicaid recipients with disabilities

    Period: August 1996-July 1998.
    Funding: $50,000.
    Grantee: University of California, San Diego, 9500 Gilman 
Drive, La Jolla, CA 92093.
    Investigator: Richard Kronick, Ph.D.
    The objective of this project is to develop a 
diagnostically based, risk-adjusted payment system that may be 
used by State Medicaid programs when contracting on a capitated 
basis with health plans for Medicaid recipients with 
disabilities. The project will use data from three States 
(California, Georgia, and Tennessee). In addition to developing 
a risk adjustor payment system, the authors will identify 
solutions to implementation problems that States are likely to 
encounter. Tape-to-tape data from California, Georgia, and 
Tennessee have been ordered. Once these data are received, the 
analysis phase of the project will begin.

National recurring data set project: Ongoing national state-by-state 
        data collection and policy/impact analysis on residential 
        services for persons with development disabilities

    Period: October 1996-September 1997.
    Funding: $35,000.
    Award: Interagency Agreement.
    Grantee: University of Minnesota, Institute of Community 
Integration, 150 Pillsbury Drive, SE., Minneapolis, MN 55455.
    Investigator: Charlie Lakin, Ph.D.
    This interagency agreement will support secondary data 
analyses and the production of a report that describes and 
updates the status of persons with mental retardation and 
related conditions (MR/RC) in institutional care facilities for 
the mentally retarded (ICF-MRs), Medicaid waiver programs, and 
nursing homes funded under the Medicaid program to assist in 
the evaluation of Medicaid services for persons with MR/RCs and 
to point out areas in need of reform. The report will include 
the following:
          Background description of key Medicaid programs of 
        interest;
          State-by-state and national statistics on ICF-MRs, 
        Medicaid home and community-based services, and nursing 
        home use;
          Description of the characteristics of ICF-MRs and 
        their residents, with comparative statistics for 
        noncertified facilities.
    The University of Minnesota continues to collect data to 
produce its annual report on the status of the Medicaid 
programs that serve the developmentally disabled.

Long-term care survey

    Period: September 1990-February 1993.
    Funding: Interagency Agreement.
    Awardee: National Institute on Aging, 9000 Rockville Pike, 
Bethesda, MD 20892.
    Investigator: Richard Sussman.
    The Office of the Assistant Secretary for Planning and 
Evaluation and the Health Care Financing Administration agree 
to transfer funds to the National Institute on Aging (NIA) to 
support an existing NIA grant to Duke University, Center for 
Demographic Studies. This grant is entitled Functional and 
Health Changes of the Elderly, 1982-89. The National Long-Term 
Care Survey (NLTCS) is a detailed household survey of persons 
65 years of age or over who have some chronic functional 
impairment (90 days or more). The survey has been administered 
3 times. The first, conducted in 1982, was devised as a cross-
sectional survey. The second, conducted in 1984, added a 
longitudinal component to the sample design. The third, 
administered in 1989, used the cohorts from the previous 
surveys in addition to persons becoming 65 years of age to form 
a nationally representative sample of impaired elderly persons. 
To facilitate the use of the database, these tasks related to 
the 1982, 1984, and 1989 surveys were performed under this 
agreement:
          File linkage over the entire period 1982-89;
          Derivation of new longitudinal sample weights;
          Linkage of Medicare administrative records;
          Improvement of coding by checking consistency of 
        survey items;
          Improvement in survey documentation;
          Seminars and education
    The public use version can be obtained from Michigan 
Archives by calling (313) 763-5011. The files are currently 
being matched with the HCFA administrative data to verify 
status (i.e., Medicare status and mortality). NIA is planning 
to repeat this study in 1999.

Long-Term care program and market characteristics

    Period: February 1992-December 1995.
    Funding: $808,047.
    Grantee: University of California at San Francisco, Office 
of Research Affairs, 3333 California Street, Suite 11, San 
Francisco, CA 94143-0962.
    Investigator: Charlene Harrington, Ph.D.
    This project will collect data on and study the effects of 
nursing home and home health care characteristics and markets 
on Medicare and Medicaid services in the 50 States. Primary and 
secondary data for the 1990-94 period will be collected to 
update earlier data on previous studies for the 1978-89 period. 
Through surveys, data will be collected on licensed nursing 
home bed supply and occupancy rates, State certificate of need 
programs, State pre-admission screening programs, and Medicaid 
nursing home and home health reimbursement. Data also are being 
collected on Medicaid waiver programs, Boren amendment 
litigation, provider characteristics, resident characteristics, 
and deficiencies of nursing homes. Analysis will provide 
detailed information on each State's current methodology for 
determining nursing home capital costs, the impact of proposed 
case-mix reimbursement on operating income, reimbursement 
methodology for freestanding subacute units, and Medicaid 
methodology used to reimburse for care provided in board and 
care homes, geriatric day care centers, and intermediate care 
facilities for the mentally retarded. A publicly accessible 
database will be developed that will provide a complete set of 
demonstration data for the period 1978-94.
    This project has been completed. The second State data book 
presenting data on the long-term-care program and market 
characteristics across the 50 States and the District of 
Columbia has been published by the Health Care Financing 
Administration as State Data Book on Long-Term Care Program and 
Market Characteristics, 1993 Health Care Financing Extramural 
Report, HCFA Pub. No. 03366. U.S. Government Printing Office 
Washington, D.C. February 1995. The public use data base and 
documentation have been received and are being reviewed.

National Health Interview Survey Disability Supplement: 1994-95

    Period: June 1993-June 1994.
    Award: Interagency Agreement.
    Awardee: Centers for Disease Control, National Center for 
Health Statistics, 6325 Belcrest Road, Room 850, Hyattsville, 
MD 20782.
    Investigator: Owen Thornberry.
    The Health Care Financing Administration (HCFA) transferred 
funds to the National Center for Health Statistics to support 
the implementation of the 1994/1995 disability survey as a 
supplement to the National Health Interview Survey. Although 
HCFA provides extensive support for the disabled through the 
Medicare and Medicaid programs, very little is known about this 
population. The National Health Interview Survey Disability 
Supplement (NHISDS) will be thefirst survey on the disabled in 
15 years. The NHISDS will be conducted during calendar years 1994 and 
1995, with approximately 250,000 people of the 96,000 sampled 
households. The survey will consist of two phases:
          Phase I will screen the relevant populations and will 
        collect basic descriptive information;
          Phase II will obtain information on all house-hold 
        members who experience limitations caused by a health 
        condition.
    Data from Phase I will be used to make estimates of the 
prevalence of disability and to determine eligibility for Phase 
II questionnaires. In Phase II, separate questionnaires will be 
given to adult and child respondents. This survey will be the 
first source of information to determine the size, 
characteristics, service use, and out-of-pocket costs for 
individuals will mental retardation and related conditions. The 
survey of children will provide information on the number, 
characteristics, severity, and effects on families of children 
with disabilities. This survey will collect information on 
income and assets, along with basic disability information, to 
better understand the characteristics of actual and potential 
Supplemental Security Income recipients. The information 
gathered from the NHISDS will be crucial for addressing a broad 
number of HCFA policy concerns affecting persons with 
disabilities.
    Questionnaires for the disability supplement have been 
revised. Phase I interviews began in January 1994 and Phase II 
adult and children interviews began during Summer 1994. The 
first wave of data from Phase I is available.

                  future directions for long term care

    During 1996, HCFA devoted substantial resources to the 
further development and implementation of demonstrations to 
develop, implement and evaluate new coordinated systems of care 
for beneficiaries with disabilities, develop more consumer 
centered and controlled services, develop outcome oriented 
quality measures to improve the quality of care and to test the 
cost effectiveness of prospective payment systems for nursing 
homes and home health agencies.
    We will continue our efforts to develop, operate and 
evaluate coordinated care systems for the frail elderly, as 
well as younger persons with disabilities in need of long term 
care, including the Program of All-inclusive Care for the 
Elderly demonstration, the Social Health Maintenance 
Organization demonstration, the Community Nursing Organization 
demonstration, the EverCare demonstration, the Minnesota Senior 
Health Options demonstration, and the Health Services for 
Children with Special Needs demonstration. We will also 
continue to work with States who are developing innovative 
service delivery and payment interventions for dually eligible 
demonstrations. We plan to release a grants announcement to 
select States interested in reforming service delivery for 
dually eligible individuals along areas of interest of 
importance to HCFA.
    HCFA will continue to test alternative payment methods for 
long term care services through the continuation of the Home 
Health Agency Prospective Payment demonstration and the 
MultiState Nursing Home Case Mix and Quality demonstration.
    We will also continue our development of models of care 
that provider beneficiaries with more direction and control of 
long term services. We plan to release a grants announcement to 
select providers to participate in the Consumer Directed 
Durable Medical Equipment demonstration. We will be working 
closely with the Assistant Secretary for Planning and 
Evaluation to further develop and implement the 4-State Cash 
and Counseling demonstration.
    HCFA will continue the development and testing of outcome 
oriented measures of quality for nursing home and home health 
services, as well as long term care services of persons with 
developmental disabilities. We will also continue our efforts 
to develop a quality assurance system for the PACE program.
    An important new area of research and demonstration 
activity will build from our post acute care research to 
develop and test more integrated, flexible systems of post 
acute care that construct services and payment around 
beneficiaries' health care needs and preferences. Work focused 
on assessment tools, payment methodologies, care management 
systems and outcomes measures will be initiated.
    Another important area that will continue to be explored is 
alternative financing mechanisms for long term care. Although 
the majority of the elderly are covered by both Medicare and 
supplemental insurance, a large portion of long term care 
services remain uncovered. Medicaid covers long term nursing 
care, but only after elderly individuals have depleted their 
resources. Research is continuing that will identify the 
sources of financing for long term care at various points 
throughout institutionalization. This research will further 
examine characteristics of individuals who come to rely upon 
Medicaid for payment for their care. By identifying the risks 
associated with nursing home use, we hope to be able to propose 
improved methods of paying for this care.
    We will continue to support data collection and data 
analyses from projects that gather detailed data from national 
and State data bases. Research is continuing on estimating 
future acute and long term care need and utilization based on 
available surveys. We will continue our efforts to improve our 
understanding of the characteristics, health care needs and 
service use of individuals eligible for both Medicare and 
Medicaid, drawing upon the Medicare Current Beneficiary Survey 
as well as developing new State data bases that link Medicare 
and Medicaid data. We will continue initiatives to make data 
bases available for research and analyses, including State 
Medicaid data, the Medicare Current Beneficiary Survey, and the 
National Recurring Data Set. We plan to expand the data 
gathered under the Long Term Care Program and Market 
Characteristics data base to capture additional State data 
related to States' community-based care system infrastructure.





                      OFFICE OF INSPECTOR GENERAL

                              Introduction

    The Inspector General Act establishes the statutory 
authority and responsibilities for the OIG. The OIG's mission 
is to: (1) protect the integrity of departmental programs and 
the health and welfare of program beneficiaries; (2) promote 
the economy, efficiency, and effectiveness of departmental 
programs and operations; and (3) prevent and detect fraud, 
waste and abuse in departmental programs and operations.
    This mission is accomplished by conducting independent and 
objective audits, evaluations, and investigations, designed to 
reach all organizational levels of the Department and provide 
timely, useful, and reliable information and advice to 
Departmental officials, the Administration, the Congress and 
the public. OIG's goal is to detect and prevent fraud and 
abuse, and to ensure that beneficiaries receive high-quality, 
necessary services at appropriate payment levels.
    Within the Department, the OIG is an independent 
organization, reporting to the Secretary and communicating 
directly with the Congress on significant issues. The OIG is 
comprised of the following components:
    The Office of Audits Services (OAS) performs audit 
activities which include: conducting and overseeing audits of 
HHS programs, operations, grantees and contractors; identifying 
systemic weaknesses that give rise to opportunities for fraud 
and abuse; and making recommendations to prevent their 
recurrence. OIG auditors also perform financial statement 
audits near the Chief Financial Officer (CFO) Act of 1990 and 
the Government Management Reform Act (GMRA) OF 1994.
    The Office of Investigations (OI) develops cases concerning 
fraud, waste, abuse, and mismanagement which occur within the 
Department's programs. Working with Federal and State law 
enforcement agencies, OIG investigators seek criminal, civil 
actions and exclusions against those who commit fraud or who 
thwart the effective administration of HHS programs. OIG 
investigations focus on: the providers of services and supplies 
under Medicare and Medicaid; program applicants and grantees; 
beneficiaries and other recipients of Federal funds; and HHS 
employees.
    The Office of Evaluation and Inspections (OEI) conducts 
short-term program evaluations (called inspections) that focus 
on issues of concern to the Department, the Congress, and the 
public, such as Medicare services, device and drug approvals/
removals, child support enforcement programs, and Medicare 
client satisfaction. The results of this work generate rapid 
and reliable information on how well HHS programs are operating 
and offer recommendations to improve their efficiency and 
effectiveness.
    The Office of Enforcement and Compliance (OEC) is 
responsible for the imposition of those mandatory and 
permissive program exclusions and civil money penalty (CMP) and 
assessment actions not handled by the Office of Counsel to the 
Inspector General (OCIG), Civil Recoveries Branch. The office 
serves as a liaison with HCFA, State Licensing Boards and other 
outside organizations and entities with regard to exclusion, 
compliance and enforcement activities. It develops models for 
corporate integrity, compliance and enforcement programs; 
monitors ongoing compliance, exclusion, enforcement activities 
and HCFA suspension agreements; and promotes industry awareness 
of corporate integrity and enforcement agreements developed by 
the OIG.
    The Office of Counsel to the Inspector General is 
responsible for providing all legal service and advice to the 
Inspector General, Principal Deputy Inspector General and all 
the subordinate components of the Office of Inspector General, 
in connection with OIG operations and administration. OIG fraud 
and abuse enforcement activities, and OIG activities designed 
to promote efficiency and economy in the Department's programs 
and operations. The OCIG is also responsible for litigating 
civil money penalty (CMP) and program exclusion cases within 
the jurisdiction of the OIG, for the coordination and 
disposition of False Claims Act qui tam and criminal, civil and 
administrative matters involving the Department of Justice 
(DoJ), and for the resolution of voluntary disclosure and 
program compliance activities.
    The Office of Management and Policy (OMP) provides support 
services to OIG, including congressional relations, legislative 
and regulatory review and public affairs, strategic planning 
and budgeting, financial and information management, resources 
management, and preparation of the OIG's semiannual and other 
reports.

                            Accomplishments

    Within HHS OIG we are continuing to streamline our 
operations while maintaining our vigorous pursuit of fraud, 
waste and abuse. As examples of our streamlining efforts, we 
completed early outs and buyout programs targeted at reducing 
management positions (SES through GS-13) and closed 17 out of 
65 field offices. On March 31, 1995, the Social Security 
Administration became an independent agency with its own OIG 
formed of staff from the HHS OIG. With the departure, OIG has 
had to reexamine its use of resources in order to concentrate 
its work more fully in areas of health and welfare. Our total 
savings for fiscal years 1995 and 1996 total $14.9 Billion. Our 
accomplishments included the second largest health care fraud 
settlement ever, against a health care corporation for 
kickbacks and fraud in its home infusion, oncology, hemophilia 
and human growth hormone businesses. The company agreed to 
plead guilty and pay approximately $161 million in criminal 
fines, civil restitution and damages. The settlement included a 
corporate compliance plan.

                               Health Care

    In May 1995, The President announced a 2-year partnership 
of Federal and State agencies working together to prevent and 
detect health care fraud in specific industries. This Operation 
Restore Trust initially targets five States which together 
account for 40 percent of the Nation's Medicare and Medicaid 
beneficiaries. Operation Restore Trust, led by HHS OIG working 
jointly with the Health Care Financing Administration (HCFA) 
and the Administration on Aging (AoA),represents one of the 
largest and most complex efforts against health care fraud ever 
undertaken. The project is designed to share resources and collaborate 
with numerous entities to prevent and detect fraud and abuse in three 
rapidly growing sectors of the health care industry: home health 
agencies, nursing facilities and durable medical equipment suppliers. 
Operation Restore Trust also prompted a new OIG fraud hotline, 1 800-
HHS-TIPS, and a voluntary disclosure program that encourages health 
care entities to come forward with fraud they discover for themselves.
    During this period we marked the 1-year anniversary of 
Operation Restore Trust. In the first year, 32 criminal 
convictions, 10 civil judgments and 18 indictments were 
obtained. Twenty-eight criminal convictions, 9 civil 
settlements and 18 indictments involved nursing facilities and 
related medical services cases, and 4 convictions and 1 
settlements concerned home health agencies. In addition, OIG 
has identified more than $37 million in fines, recoveries, 
settlements and civil monetary penalties during this same 
period. Thirty-six exclusions of ORT providers from the 
Medicare and Medicaid programs for convictions of health care 
fraud have been processed.
    The new hotline received more than 23,600 calls and letter, 
of which well over 6,600 were related to Department programs. 
Of the 780 calls or letter related to ORT during this time 
period, about 560 were related to nursing homes and related 
medical services, and 2220 to home health agencies.
    Medicare Patient Transfers: This report is the result of 
OIG's review of transfer recovery projects undertaken jointly 
by OIG, HCFA and Medicare Fiscal Intermediaries. The projects 
identified overpayments that occurred because transfer of 
patients between PPS hospitals were erroneously reported and 
paid as discharges. In total, these projects resulted in 
Medicare Part A trust fund recoveries totaling $219 million and 
annual savings totaling $8 million. In addition, it is 
estimated that $22 million will be recovered by FIs from 
transfer transactions that warrant further resolution. The HCFA 
concurred with our recommendations that it place a high 
priority on recovering the remaining overpayments, including 
those over 4 years old, and that it inform OIG of the final 
resolution of the remaining unresolved cases.
    Hospital Reporting to the National Practitioner Data Bank: 
The OIG conducted this inspection in response to a PHS request 
to determine how hospitals are responding to their legal 
obligation to report adverse actions to the National 
Practitioner Data Bank. The report noted that about 75 percent 
of all hospitals in the United States have never reported an 
adverse action taken against practitioners to the data bank, 
and that there has been considerable State-by-State variation 
in reporting rates.
    OIG recommended that PHS support further inquiry to foster 
a better understanding of the factors influencing hospital 
reporting to the data bank and sponsor a conference to focus 
attention on issues influencing such reporting. Further, OIG 
proposed that PHS work with the Health Care Financing 
Administration (HCFA) to ensure that the Joint Commission on 
Accreditation of Healthcare Organizations assesses more fully 
hospitals' compliance with the law. The PHS and HCFA agreed to 
prepare a joint letter that will be sent to the Joint 
Commission urging it to devote greater attention to hospital 
compliance with the data bank law.

                     NATIONAL INSTITUTES OF HEALTH

    The National Institutes of Health (NIH) is the principal 
biomedical research arm of the Federal Government. This report 
highlights a number of research advances conducted or supported 
during 1995 and 1996 by NIH. Part of the NIH, the National 
Institute on Aging (NIA), is the primary sponsor of aging 
research in the United States.
    Section 1 of this report outlines NIA's key advances for 
1995. Section 2 outlines NIA's key advances for 1996. Other NIH 
components also conduct or support aging research. They are the 
National Cancer Institute; the National Center for Research 
Resources; the National Eye Institute; the National Heart, 
Lung, and Blood Institute; the National Institute of Nursing 
Research; the National Institute of Arthritis and 
Musculoskeletal and Skin Diseases; the National Institute of 
Dental Research; the National Institute of Diabetes and 
Digestive and Kidney Diseases; the National Institute of Mental 
Health; the National Institute on Alcohol Abuse and Alcoholism; 
the National Institute of Environmental Health Sciences; and 
the National Institute on Deafness and Other Communication 
Disorders. Section 3 provides selected findings from these 
other NIH institutes.

                               Section 1

                           1995 introduction

    NIH was created in 1974 to conduct and support research on 
aging processes with a focus on diseases and other special 
problems of older people. The remarkable life span that has 
been realized during this century now presents Americans with 
three important and related challenges: how to maintain quality 
of life with advanced age, how to provide cost-effective health 
care, and how best to divide adult life into working years and 
retirement years.
    The ``graying of America,'' that is, those demographic 
changes that will occur as the post-World War II baby-boom 
generation ages, is markedly raising the median age of 
America's population. The aging of our society will impact 
health care costs, regardless of the means by which these costs 
are covered. The over-85 age group is the fastest growing 
segment of the American population and is often referred to as 
the ``oldest old.''
    Even with the hope of major advances in the treatment and 
prevention of debilitating disease, the demand for long-term 
care is expected to expand dramatically in our society. 
Research will be pursued on many different aspects of long-term 
care in general and particularly on new and evolving forms of 
care. NIA supports research on preventing the need for long-
term care or institutionalization, enhancing the quality and 
efficiency of such care, easing the burden of care, and 
forecasting the requirements for care.
    Alzheimer's disease continues to be a top research priority 
for NIA. This disease currently affects as many as four million 
older Americans and their families, causes enormous personal 
suffering, and costs the nation at least $90 billion each year. 
Without the development of new treatments, cures, or preventive 
approaches to this dreaded disease, the number of individuals 
and families devastated by Alzheimer's disease will likely 
increase up to five-fold within the next 50 years.
    In addition to Alzheimer's disease, priority initiatives 
include research on the biology of the aging process and on 
physical disabilities such as osteoporosis and cardiovascular 
disease. These initiatives are wide-ranging and can be based on 
cutting-edge laboratory technologies or upon simple by highly 
effective strategies such as exercise or behavioral 
interventions. The goal of NIA-supported research is to 
understand the basic mechanisms of normal aging and age-
associated disease and disability and to translate this basic 
knowledge into treatment and prevention strategies.

Basic research

    NIA funded basic research is a prerequisite for the 
rational development of treatment and prevention strategies. 
Because of the advances from basic aging-related science made 
possible by NIA support, real hope exists for true increases in 
independence and active life expectancy, helping to stem the 
rising cost of health care expenditures. To prevent or cure 
diseases associated with age such as cancer, cardiovascular 
disease, osteoporosis, and Alzheimer's disease, we need to 
continue extensive basic research into their underlying causes 
as well as to better understand the aging process itself.
    For example, research will continue on antioxidants to 
discover their role and protective action against the damaging 
effects of naturally occurring ``free radicals'' on subcellular 
components. There is increasing evidence that certain 
nutrients, including vitamin C, vitamin E, and betacarotene, 
serve as agents of free radical capture and otherwise augment 
the body's natural protective mechanisms. Any preventive 
effects of antioxidants would have extraordinary potential for 
forestalling a wide range of degenerative diseases. With the 
escalating costs of medical treatment and care for an aging 
population, simple preventive therapies involving dietary 
supplementation may have tremendous benefits.
    Molecular genetic studies are developing evidence that 
longevity and cellular senescence (loss of a cell's ability to 
divide and reproduce itself) are, in part, under genetic 
control. Characterization of the specific genes which promote 
longevity and postpone aging and cellular senescence are 
central to discovering the mechanisms which govern longevity 
and aging in humans. Knowledge of these fundamental mechanisms 
will guide and hasten the development of effective prevention 
and intervention strategies to extend human longevity and 
health span.
    Major breakthroughs have recently occurred in Alzheimer's 
disease (AD) research that promise to yield definitive results 
in the near future. Most recently, NIA-supported researchers at 
Duke University found that a variation of the apolipoprotein E 
(ApoE) gene, ApoE4, is associated with an unexpectedly high 
number of AD cases and is probably a major risk factor to 
developing AD. It is not yet clear how APoE4 affects cellular 
function. Depending on the results of this research, new 
diagnostic tests may identify those persons at risk for AD and 
lead to protective therapies and better outcomes.
    Since 60 percent of U.S. deaths are due to vascular 
disease, NIA has a prime interest in supporting research on 
age-associated vascular disease. During atherosclerosis, some 
of the vascular smooth muscle cells (VSMC) begin to multiply 
and produce proteins which they secrete into their environment. 
Intramural researchers have discovered that VSMC, when placed 
in an environment that simulates arterial injury, not only 
proliferate, but invade membranes and proteins that normally 
surround the VSMC and the inner lining of blood vessels. Thus, 
therapeutic measures to prevent this invasion may reduce the 
extent of the atherosclerotic process, with a significant 
reduction in vascular disease and in health care costs.

Applied/Clinical research

    NIA supports pre-clinical and clinical treatment research 
on AD, made possible by past investments in basic laboratory 
studies. Tacrine, recently approved by the FDA for use in 
Alzheimer's patients, was tested several years ago in a major 
clinical trial and found to have an effect in delaying the 
progress of disease in some patients. However, it provides only 
temporary relief, and NIA continues its work towards developing 
and testing new treatments that will allow patients to continue 
to function independently. NIA is currently testing the drug 
Deprenyl in combination with the antioxidant vitamin E in a 
clinical trial. Preliminary results are due by early 1995.
    NIA is supporting a number of major clinical initiatives 
which address the problems of physical frailty and loss of 
independence that are associated with older persons. Physical 
frailty is a major cause of long-term care needs and imposes 
annual costs of at least $54 billion. Results from ongoing NIA-
supported studies have provided convincing evidence of the 
benefits of exercise for maintaining independent function in 
older persons. FICSIT (Frailty and Injuries: Cooperative 
Studies of Intervention Techniques) is a set of clinical 
trials; some interventions have shown more than a 30 percent 
reduction in fall rates, which could markedly lower the rate of 
disabling injuries such as hip fractures.
    Osteoporosis affects over 25 million Americans, mainly 
women, and is a serious public health problem since associated 
fractures are a major cause of disability in older people: 
costs associated with hip fractures exceed an estimated $7 
billion annually. NIA-supported research into new therapies and 
interventions would impact a very large percentage of the older 
population and save billions of dollars in health care costs.
    Recently, attention has focused on treating degenerative 
conditions such as osteoporosis, osteoarthritis, and muscle 
atrophy through replacement therapy with ``trophic'' factors. 
These factors promote growth and maintenance of tissues such as 
bone, muscle, and cartilage.
    NIA has a keen interest in research particularly relevant 
to older women. There are many questions surrounding the health 
implications of menopause and hormonal changes in women and 
will continue support for a major initiative, the Women's 
Health and Aging Study, to determine what diseases and other 
events cause and influence disability in women age 65 years and 
older. NIA is also committed to research which focuses upon 
minority subpopulations and the similarities and differences 
which exist between them and non-minority populations, such as 
their relative use of long term care services.
    These and other initiatives described in the following 
pages are representative of NIA's broad research portfolio. As 
we approach the next century, it will be through the continued 
support of this research that we can develop the means to 
prevent or cure the major causes of costly disease and 
disability to maintain good health and independence for older 
Americans.

                          extramural research

Alzheimer's disease

    Recent genetic discoveries have shed new light on the 
causes and biological mechanisms which result in the 
development of Alzheimer's disease (AD). Among the potential 
causes of AD, genetic factors have been implicated to a much 
greater extent than was previously suspected. It is now known 
that mutations in the amyloid precursor protein (APP) gene and 
in a gene localized to a small region of chromosome 14 account 
for most inheritance of early onset AD. Late onset AD has been 
more difficult to trace, but linkage to chromosome 19 was 
reported in some late onset families. Recently, ApoE4, whose 
gene is located on chromosome 19, has been shown to be 
associated with greater increased risk of AD. This may account 
for the chromosome 19 linkage reported earlier. More 
significantly, the ApoE4/AD association has been found not just 
in late onset families but also in the general population. The 
increased risk associated with ApoE4 could account for many AD 
cases previously designated ``sporadic.''
    Larger epidemiological studies are necessary to confirm the 
association of ApoE4 with AD. Should ApoE4 be found to be a 
major factor in determining AD susceptibility, modification of 
ApoE4 activity would become an attractive target for 
development of therapeutics. Ultimately, the elucidation of the 
complete molecular pathway which results in the development of 
AD will allow the design of optimal pharmacological treatment 
and prevention strategies.

Risk factors associated with AD

    One of the long range goals of AD research is to determine 
the full range of risk factors for AD which will lead to a more 
complete understanding of its etiology. A major theme of 
epidemiological research in Alzheimer's disease is to address 
specific biomedical problems in minority and other distinct 
population groups in an effort to extend knowledge about age-
specific incidence, prevalence rates, and risk factors for the 
onset of AD. Three studies have recently been initiated in 
African-American populations. The major purpose is to identify 
and clarify the risk factors for Alzheimer's disease and multi-
infarct dementia (MID) in three groups of patients--those with 
Alzheimer's disease, those with MID, and those with multiple 
strokes but without evident cognitive dysfunction. The 
investigation will provide important new information about risk 
and protective factors for cognitive and functional decline in 
older African-Americans. NIA also supports the Honolulu 
Dementia Study. The objectives of this study are to determine 
rates and risk factors for Alzheimer's disease and vascular 
dementia in aging Japanese-American men.

Sleep

    As many as half of the older population suffer from chronic 
sleep disturbance, a condition that frequently leads to 
problematic use of sedative medication, reduced quality of 
life, and increased morbidity and mortality. NIA supported 
studies on sleep disorders, such as the multi-center 
``Established Populations for the Epidemiologic Study of the 
Elderly'' (EPESE), provide support for the effective detection, 
treatment, and prevention of sleep disorders. Data generated 
from EPESE have shown that sleep disorders are often associated 
with poorer self-perceived health, increased depressive 
symptoms, physical disability, respiratory symptoms, and over-
the-counter medication use. Treatment and prevention of sleep 
disorders can result in savings in health expenditures as well 
as enhancing the quality of life of older persons.

Control of cell proliferation in aging and cancer

    Regulation of cell proliferation is required to maintain 
the human body's equilibrium. NIA research has provided a 
greater understanding not only of normal cell proliferation but 
also the causes and effects resulting from cell senescence--the 
loss of proliferation capacity--or the opposite, uncontrolled 
proliferation seen in cancer. Understanding these biological 
mechanisms will further our knowledge of normal aging and 
cancer at the cellular level and promises to provide key 
contributions to unravelling the fundamental mechanisms 
underlying the aging process and other age-related diseases in 
the near future.
    Research progress is currently being made in several areas. 
Two NIA-funded laboratories have independently obtained 
evidence that p53, a tumor suppressor proteins, induces 
expression of another protein which binds to kinases, a class 
of enzyme, and inhibits their function. The activity of these 
kinases is essential for replication. Further research will 
reveal the mechanisms of these reactions with the ultimate goal 
of designing drugs which can restore this tumor suppressive 
property.
    A second protein of interest to both aging and cancer 
research is a protein known as bcl-2, which inhibits a natural 
process known as programmed cell death. If this programmed 
death is inhibited the result will be overpopulation of cells, 
as in cancer. This is also thought to be one explanation for 
benign prostatic hypertrophy. The mechanism for controlling 
bcl-2 expression needs to be elucidated, opening up the 
possibility of interventions to regulate bcl-2 when needed.
    A third area of interest to both aging and cancer research 
is the role of telomere shortening in controlling cell 
proliferation. Telomeres are repeated DNA sequences found at 
the ends of chromosomes that shorten each time a cell divides. 
A very recent working hypothesis is that telomeres shorten 
because of the ``end-replication problem,'' and that continued 
proliferation requires some, as yet undefined, minimal telomere 
length. The implications of this research are that both 
senescence and cancer could be regulated by developing 
interventions which either prevent telomere shortening or 
inhibit telomerase activity.

 Role of oxidative damage in aging

    ``Free oxygen radical'' damage has long been believed to be 
a risk factor for the degenerative processes which accompany 
aging. These compounds can damage DNA, proteins, and lipids. 
The resulting damage can lead to cancers or dysfunctional 
proteins and damaged membranes which lessen a cell's ability to 
carry out its proper function. There is increasing evidence 
that certain micro-nutrients, including vitamins C and E, serve 
as agents of free radical capture or ``antioxidants,'' and 
augment the body's protective mechanisms. The preventive 
effects of antioxidants have potential for forestalling a range 
of degenerative diseases. There appears to be a role for 
dietary antioxidants in the prevention of some cancers, senile 
dementias, and cardiovascular diseases. Simple preventive 
schemes involving dietary supplementation could lead to 
significant savings in the costs associated with medical 
treatment.

Biology of aging muscle

    A decrease in mass and functional capability of skeletal 
muscle contributes substantially to the impairment of 
locomotive performance that accompanies human aging and is a 
significant risk factor for physical frailty. NIA continues to 
support basic research into the molecular basis of skeletal 
muscle growth, age-related muscle degeneration, and selective 
fiber atrophy. The development of effective intervention 
strategies to retard or prevent age-related muscle degeneration 
is dependent on basic research to delineate the underlying 
mechanisms. Such interventions would be expected to 
significantly extend human health span, reduce frailty, and 
increase independence and quality of life for older adults.

Protein structure and function

    NIA is also focusing efforts on determining the structures 
of proteins which have undergone non-hereditary changes to 
their amino acids. For many years it has been clear that 
``modified proteins'' accumulate during aging and may interfere 
with normal cellular processes. These unstable proteins lead to 
such age-related problems as cataracts, interrupted blood flow 
to the heart and brain, failure of the immune system, impaired 
ability to heal wounds, and loss of cognitive function. NIA is 
attempting to discover the mechanisms by which modification of 
proteins occur, why they accumulate in aging, and the 
physiological consequence of these changes. Understanding these 
mechanisms may ultimately lead to effective treatment and 
prevention strategies.

Treatment of Alzheimer's disease (AD)

    The primary manifestation of AD dementia is intellectual/
cognitive deterioration and the sole FDA approved drug for the 
treatment of AD currently on the market, Tacrine, provides only 
temporary relief for treatment of AD. In FY 1991, the Drug 
Discovery Groups in AD program was initiated to facilitate the 
pre-clinic development of new compounds for treating 
Alzheimer's disease by expanding the range of approaches to 
drug treatment beyond the current focus. The research 
activities of three of the Groups deal with attempts to 
circumvent the blood brain barrier's ability to keep out 
peripherally administered peptides and proteins. This is 
important because one potential treatment for AD would be to 
raise the concentration in the brain of neurotrophic factors 
which promote the health and well being of neurons. Since 
neuron death and dysfunction is a major problem in AD, these 
factors may be effective in delaying or reversing cognitive and 
behavioral symptoms of AD.

Behavioral aspects of AD

    NIA also supports research aimed at ameliorating those 
alterations in behavior, mood, and function associated with AD 
that cause the greatest stress for family members, and 
difficulties for both professionals and family members in 
providing optimal care. It is important to provide tools for 
families and nursing homes which will replace physical and 
pharmacological restraints. The goal is to reduce the severity 
and frequency of disruptive behavior, to allow patients to live 
in the least restrictive environmental and manner, to maximize 
dignity and independence, and to retain or reestablish self-
care practices.
    NIA supports several research projects examining the 
extent, causes, and consequences of caring for people with AD 
and related dementias. These include ten coordinated research 
projects to examine the nature and outcomes of special care 
units for persons with dementia. Other activities include 
initiatives in family caregiving and health services, burdens 
of care research in special populations, specifically minority 
family caregivers; supportive environments and everyday 
functioning; and demographic and economic aspects of 
Alzheimer's disease.
    In 1991, the NIA, in conjunction with the National 
Institute for Nursing Research and the Alzheimer's Association, 
began fourteen pilot feasibility studies for new and innovative 
methods for managing the behavioral symptoms associated with 
AD. The symptoms of special concern included wandering, 
disturbed sleep, pacing, agitation, feeding and dressing 
difficulties, incontinence and toileting difficulties, 
screaming and other vocalizations, aggression and violence, and 
inappropriate sexual behavior. Studies were specifically sought 
for strategies to enhance AD patients' self-care abilities and 
activities of daily living. These feasibility studies will lay 
the scientific and clinical groundwork that may lead to large-
scale clinical studies/trials on the assessment and 
nonpharmacologic management of secondary symptoms and 
disabilities.

Language, attention and cognition

    Cognitive dysfunction in aging is defined by the changes in 
neural and psychological processes that control or regulate 
attention, memory, thought, communication, spatial competence, 
decision making, and other cognitive processes. Ongoing studies 
are being conducted to explore the range of normal and abnormal 
cognitive processing. A particularly exciting development is 
the use of neuroimaging techniques that permit researchers to 
image the brain while cognitive processing occurs. These 
techniques hold great promise for isolating brain structures 
which control various aspects of cognitive function and for 
determining what parts of the brain are controlling age-related 
changes in cognitive function.

Frailty and physical functional independence

    Physical frailty is a major cause of long-term care needs 
and afflicts over 3.25 million older Americans. Epidemiologic 
studies have shown a relationship between impairment and 
strength, endurance, gait, and the occurrence of loss of 
independence. FICSIT (Frailty and Injuries: Cooperative Studies 
of Intervention Techniques) is an NIA supported set of clinical 
trials which have demonstrated that fall rates in moderately 
frail older persons can be reduced significantly by 
intervention targeted to individuals' specific fall risk 
factors. Other findings show that balance, strength, and 
endurance training can markedly improve physical performance 
abilities in a wide variety of older populations ranging from 
relatively healthy community-dwelling persons to very frail 
nursing home residents. Other research has demonstrated that 
the administration of growth hormone has been associated with 
arresting or reversing degenerative tissue changes which 
decrease strength and mobility.

Claude D. Pepper Older Americans Independence Centers

    The NIA added one new Claude D. Pepper Older Americans 
Independent Center (OAIC) in fiscal year 1993 and plans to add 
at least one additional center in fiscal year1994. The OAICs 
were authorized by Congress to promote research on interventions that 
can help older people live independently, and avoid 
institutionalization or prolonged hospitalization. Besides testing 
specific ways to prevent disability, the OAICs train additional 
researchers capable of doing such studies and disseminate information 
on successful interventions to clinicians and the general public.

Cardiovascular disease

    Cardiovascular diseases and stroke account for more deaths 
in the population 75-84 years old than the next nine leading 
causes of death together. Cardiovascular diseases associated 
with aging include hypertension, stroke, ischemic heart 
disease, heart failure, peripheral vascular disease, cardiac 
arrhythmias, and impairments in blood pressure regulation which 
cause intermittent hypotension. The incidence and prevalence of 
these conditions rise with age.
    NIA supported investigators at the Claude Pepper Center at 
Harvard have shown that a reduction in overall heart rate 
variability is associated with aging, congestive heart failure, 
coronary artery disease, sudden death syndromes, and after-meal 
low blood pressure. Although the average heart rate did not 
differ between the age groups or sexes, heart rate variability 
was greater in women than men at all ages. The increase in 
heart rate variability in women compared to men may be related 
to lower cardiovascular disease risk and greater longevity in 
women. Future studies are needed to gain a better understanding 
of this and other mechanisms by which age and gender 
contributes to cardiovascular diseases. NIA plans a significant 
research initiative in this area for fiscal year 1994.

Osteoporosis and bone quality

    The progressive loss of bone, which is universal after 
middle age, very commonly leads to osteoporosis, a condition 
characterized by increased skeletal fragility. NIA supports a 
range of research into the causes and treatment of 
osteoporosis. Research aimed at identifying markers and risk 
factors that predict changes in bone mass, bone competence, and 
fracture susceptibility is of vital importance in identifying 
individuals at risk and evaluating the effectiveness of 
treatment strategies.
    For example, while diabetes has been hypothesized to be a 
risk factor for bone loss and osteoporosis, recent research has 
shown that some diabetic women actually had increased bone mass 
compared to non-diabetic women. This distinction did not appear 
among men. This gender-related difference suggests that certain 
hormonal agents would play a potentially important role as risk 
factors and/or in a therapeutic strategy to preserve bone mass. 
Additional research has uncovered a link between cigarette 
smoking and reduced bone mass on the hip. These findings are 
particularly important, not only in light of the public health 
implications, but because they also apply to men, in whom the 
need for research on risk factors for osteoporosis has received 
little attention.
    The decrease in estrogen levels which follows the onset of 
menopause frequently results in rapid bone loss which often 
precedes osteoporosis. Recent research has discovered the 
osteoclasts (cells that break down and remove bone) are target 
cells for estrogen, and that estrogen directly inhibits the 
breakdown of bones by osteoclastic cells. This finding will 
encourage the development of new approaches which will be 
effective in halting bone breakdown and hence preventing 
osteoporosis.

Menopause and post-menopausal problems

    Menopause is a universal event in female aging and is also 
associated with an acceleration in the rate of bone loss. 
However, it is unclear whether osteoporosis in old age is 
greater in women who had a relatively early menopause compared 
to those whose menopause was later. Recently, a study has shown 
that the total number of reproductive years may be a 
significantly more sensitive index for identifying women at 
increased risk of osteoporosis. In order to gain an increased 
understanding of the inner-relationship between menopause and 
osteoporosis and other problems associated with menopause, NIA 
began a major initiative in this area in fiscal year 1994. 
Because the menopausal experience in minority women has been 
particularly neglected, special emphasis in minority 
populations is an integral part of this initiative.
    NIA also continues to support the NIH Women's Health 
Initiative, which includes 70,000 post-menopausal women ages 
50-79. This study is intended to assess the long term benefits 
and risk of hormone therapy as it relates to cardiovascular 
disease, osteoporosis, and breast and uterine cancer. Related 
to this effort, NIA began the Women's Health and Aging Study 
which is exploring the causes and course of physical disability 
in women aged 65 and older. The study will also provide 
important information on how the disease-disability 
relationship is modified by cognitive functioning; on 
psychological factors; and on social, economic, and medical 
resources of older women.

Failure to thrive and malnutrition

    The ``failure to thrive'' syndrome consists of weight loss, 
decreased appetite, poor nutrition, and inactivity. It is often 
accompanied by dehydration, depressive symptoms, impaired 
immune function, and low serum cholesterol. NIA actively 
encourages research to develop interventions designed at 
preventing, arresting, or reversing the failure to thrive 
syndrome. NIA is also interested in research on a variety of 
dietary disorders in older persons, especially malnutrition and 
the role of nutrition in overall health status in old age. 
There is a great deal of conflicting information on dietary 
recommendations for older people, leading to inappropriate use 
of dietary supplements and potentially harmful eating habits. 
Research in this area can lead to the development of 
scientifically sound guidelines for older people, particularly 
those relating to medications or to diseases that may require 
dietary changes to maintain functioning.

Improving long term care for the elderly

    Recent discussions of health care reform emphasize research 
in regard to long-term care needs. Identifying factors that 
subsequently lead to placement in nursing homes (NH) is of 
particular importance for recognizing those at risk and then 
developing interventions that can minimize, if not eliminate, 
associated risks. NIA research provides valuable information 
for predicting NH placement and mortality. These analyses 
confirmed the predictability of several key sociomedical risk 
factors--living alone, having fewer non-kin social supports, 
low sense of personal control, and other functional 
limitations.
    The NIA Special Care Initiative Study predicts, examines, 
and evaluates the use of long term care services and practices, 
and identifies strategies for modifying and improving services 
for those in need. The idea behind a Special Care Unit (SCU) is 
that people with dementia might benefit from specially designed 
programs or environments that are different from those provided 
in a traditional nursing home setting. While special care units 
have proliferated across the country in recent years, very 
little is known about their effectiveness in caring for 
Alzheimer's patients, in relieving burdens of care for the 
patient's family, or how these programs compare to traditional 
nursing home care in terms of cost and effectiveness. The NIA 
Special Care Unit Initiative projects are designed to evaluate 
the impact of these new care units on people with Alzheimer's 
disease, their families, and nursing home staff. These studies 
will provide the public, nursing home facilities personnel, and 
policy makers with the first comprehensive look at how special 
care units work.
    Self-care refers to a broad range of activities undertaken 
by an individual to maintain or promote health, as well as to 
detect, prevent and treat common health problems and 
conditions. Research being conducted in this area seeks to 
assess the extent and nature of self-care practiced by older 
adults, the strategies used to maintain independence, the 
relationship between self-care and other forms of care, and the 
subsequent use and costs of health care.

Economic and health status of the elderly

    The well-being of America's elderly clearly depends on 
their economic and health security. The reciprocal and 
multidimensional relationship between income and health in 
adult life is poorly understood; almost nothing is known about 
the effects of these transitions at advanced ages.
    Two major new NIA-supported studies aim to clarify how 
people experience and evaluate their health and economic status 
from immediate pre-retirement years to very old age. The Health 
and Retirement Study (HRS) follows transitions in reliance on 
earned income, private pensions, Social Security, Medicare 
benefits, etc. in an initial sample of over 12,000 persons aged 
51-61 years. An emerging portrait of this population depicts 
sharp contrasts between desires for gradual retirement and 
actual departure from the work force. The role of health and 
disability in the timing of retirement, and of retirement in 
the health and economic well-being of this cohort, are also 
being examined. An auxiliary study, Asset and Health Dynamics 
of the Oldest-Old (AHEAD), follows 7,300 persons aged 70 years 
and over--almost a third of them over age 80--to examine how 
late-life changes in physical and cognitive health affect, and 
are affected by, patterns of saving and income flows.
    NIA also plans to support up to six Demographic Centers on 
Population Aging which apply state-of-the art demographic, 
economic, and mathematical methods to analyses of these and 
other new databases, providing timely reports on national 
public policy issues. The centers will include outreach 
activities that benefit researchers at many institutions across 
the nation.

Aging and family life

    Family based research identifies how health, illness, and 
disability in later life are affected by intergenerational 
exchanges, informal caregiving for frail elders, and cultural/
ethnic diversity in family relationships. These relationships 
are pivotal to the health and health care of older people. This 
research contributes to an understanding of adequacy of 
informal care for frail elders and of the factors that 
determine the use of health care services by older people and 
their caregivers. In advancing basic social science research, 
family aging studies seeks an understanding of interpersonal 
relationships in physical and emotional health and illness 
across the life span.

Special populations

    The NIA continues to be committed to minority populations, 
women, and rural older populations. Most recently, the 
Institute began a research effort to establish Exploratory 
Centers for Research on Health Promotion in Older Minority 
Populations. These centers will conduct pilot research and plan 
for a program of medical, behavioral, and social research; 
medical and psychosocial interventions; and programs of health 
education and community outreach aimed at improving the health 
status of older ethnic minority populations.
    NIA is vigorously expanding its minority research focus and 
minority participation in all of its research initiatives. For 
example, investigators are testing intervention strategies to 
prevent frailty in older black and Hispanic-American 
populations and focusing on health conditions such as 
hypertension, diabetes, and prostate cancer, which are 
disproportionately prevalent in older Americans. NIA also 
supports four rural health centers established to explore the 
special health needs of older rural Americans, including access 
to and results of health care services.
    The long-term goals of the NIA intramural research program 
(IRP) are: (1) to conduct basic research relevant to 
understanding aging processes and age-associated disabilities. 
The IRP conducts the landmark Baltimore Longitudinal Study of 
Aging and is a major setting for post-doctoral training of 
promising investigators.

                          INTRAMURAL RESEARCH

Intervening in aging processes

    The causes of aging are complex and involved both internal 
and environmental factors that damage molecules, cells, and 
tissues as well as the ability of the host to resist and repair 
such damage. IRP scientists, using the latest techniques of 
molecular and cellular biology, continue to search for the 
causes of aging and ways to retard and reverse age-associated 
deficits before they progress to disease, disability, and 
institutionalization. Current projects include: (1) 
investigations of DNA repair in genes including those with 
implications in malignancy and longevity; (2) research on the 
mechanisms by which the death of cells is increased with age 
and diseases such as Alzheimer's disease and osteoarthritis; 
(3) studies on the loss of host defense to aging; and (4) the 
potential use of gender therapy to prevent or reverse age 
deficits or diseases.
    Regarding the immune system, it is well known that many 
older individuals show an impaired immune response that puts 
them at greater risk of infections. NIA and National Cancer 
Institute scientists have defined a novel cell surface protein 
that is essential for immune activation. Better definition of 
the molecular components in the immune response offers new 
possibilities for enhancing appropriate and suppressing 
inappropriate immunologic reactions.

Baltimore Longitudinal Study of Aging (BLSA)

    The BLSA, begun in 1958, seeks to understand how and why we 
age. The study panel is a group of over 1,100 highly dedicated 
women and men, from 20 to 97 years of age, who have volunteered 
to come to Baltimore every two years for intensive study to 
establish their physiologic and psychologic status. Over 160 
new participants have been recruited as part of a multi-year 
strategy to enroll 350 more women and minorities, meeting 
specific health criteria, for major initiatives with hypotheses 
about gender and racial differences. Biologic samples are 
collected from participants at sequential visits and banked 
which, with the extensive health and behavioral data assembled 
over time, allows ``instantaneous longitudinal studies'' to be 
conducted. These studies would otherwise take a decade or more 
to complete and cost millions of dollars. Initial research 
projects using a newly established DNA bank include studies of 
age-associated changes in DNA repair and preferential DNA 
repair in breast cancer. A vascular initiative is examining 
age, race, and gender differences in blood pressure, arterial 
stiffness, thickening of the heart muscle and the relationship 
of these parameters to heart and vascular disease. The BLSA 
Perimenopausal Study is characterizing the biological and 
psychosocial antecedents of the menopausal transition in 200 
women.

Alzheimer's Disease (AD)

    The IRP has a focused research program on the etiology, 
diagnosis, and treatment of AD. The distinctive aspect involves 
applying and refining sophisticated technologies--positron 
emission tomography, magnetic resonance imaging, and 
spectroscopy--to study patients throughout the disease course 
to yield new insights. For example, NIA scientists have devised 
new ways to evaluate drug efficacy using only a few patients by 
studying the longitudinal ``trajectory'' of function and 
pathology in individual patients. These are being applied in 
studies to evaluate sites and mechanisms of action in AD. NIA 
scientists have hypothesized that early functional and 
metabolic deficits in AD reflect reversible failure of nerve 
impulse transmission. Research will continue to study the use 
of drugs on the course of AD to delay development of morbidity 
and hospitalization. NIA scientists have also shown that 
biopterin, a natural compound that regulates many fundamental 
brain mechanisms, is reduced in the cerebrospinal fluid of 
certain AD patients. A clinical trial has been initiated to 
study the possible role of biopterin in the pathophysiology of 
AD and of its potential as a therapeutic agent.

Vascular disease

    A major ongoing intramural program studies age-associated 
vascular disease such as atherosclerosis, hypertension, and 
stroke. NIA studies show that older men and women with higher 
fitness levels generally have arteries which are less stiff 
than those of less fit individuals. These results suggest that 
the age-associated increase of arterial stiffness may be slowed 
by aerobic exercise; longitudinal follow-up is underway. 
Researchers have found that, with age, vascular smooth muscle 
cells become highly motile and invasive and produce degradative 
enzymes that destroy normal blood vessel architecture and 
weaken the blood vessels. Various compounds have been found to 
stabilize the dedifferentiation of the smooth muscle cells and 
further research will continue on these prototype drugs. Other 
opportunities that are being pursued include: (1) the use of 
gene therapy as a potential new approach to the treatment of 
coronary artery disease; (2) studies of the relationship 
between hypertension associated with stress and high sodium 
intake, particularly in minorities; and (3) insights into the 
basic cellular and molecular mechanisms contributing to 
renarrowing of an artery following balloon dilation.

Frailty, osteoporosis, hormone replacement therapy and women's health

    Issues of women's health and well-being command special 
attention within the IRP and include the following emphases: 
First, a decline in growth hormone (GH) levels parallels the 
loss of muscle as well as the development of frailty. Recent 
intramural studies show that a natural stimulator of growth 
hormone production, growth hormone releasing hormone, restores 
the normal pattern and level of GH in older individuals. 
Significant increases in muscle strength were apparent after 
six weeks of treatment suggesting that such factors could be 
utilized to reverse certain age-associated diseases and 
disabilities. If successful, this therapeutic approach could 
speed recovery and reduce bed days and hospital costs. Also, a 
collaborative trial is underway comparing the effects of 
replacement of GH and a gender appropriate sex steroid in 160 
women and men. This will enable the effects of hormone therapy 
on a wide variety of relevant health variables to be compared 
in women versus men. A National Institute for Nursing Research 
and NIA collaborative intramural program will continue to 
examine post-operative complications from hip fracture and 
devise behavioral nursing interventions to enhance outcomes.

Diabetes and other age associated metabolic defects

    NIA conducts a multifaceted research effort to develop new 
therapies that are safe and specific for the control of blood 
glucose in older diabetic patients to prevent the disease's 
late complications. Significant progress has been made in 
defining and modifying the regulatory signals controlling 
pancreatic insulin secretion. INA scientists have found that 
the action of insulin can be enhanced and prolonged by 
preventing the removal of phosphate from the activated form of 
the insulin receptor. These results are being aggressively 
pursued given their promise for opening new avenues in the 
treatment of diabetes associated with aging.

Longitudinal studies of prostate disease and PSA

    Collaborative studies will continue to investigate 
potential uses of rates of change in prostate-specific antigen 
(PSA) levels to improve clinical detection of prostate cancer 
and benign prostatic hyperplasia (BPH). Recent findings suggest 
that: (1) rates of change of PSA are significantly more 
accurate than the traditional single measure for the early 
detection of prostate cancer; (2) certain PSA criteria now in 
use may lead to many unnecessary prostate biopsies and should 
be dropped from clinical practice; and (3) PSA tests may be 
useful in guiding optimal treatment decisions for BPH.

                               Section 2

                           1996 introduction

    Congress created the NIA in 1974 as part of the NIH. At 
that time, aging research was just in the early stages of 
developing ways to explore the fundamentals of the aging 
process. Now, over 20 years later, the science base has grown 
in depth, breadth, and detail. And with this growth have come 
new insights into the processes and the experience of aging.
    Driving an increasing interest in aging research is a 
projected dramatic increase in the older population. People 
over 65, who were four percent of the U.S. population in 1900, 
will constitute approximately 13 percent in the year 2000 and 
20 percent by the year 2025. The over-85 age group is the 
fastest growing segment of the American population and is often 
referred to as the ``oldest old''. This boom in the population 
of older Americans will have a profound impact on the Nation's 
health, social, and economic institutions.
    Research in aging over the last two decades has contributed 
to the realization that aging should not be equated with 
inevitable decline and disease. Consider Alzheimer's disease 
(AD): This form of dementia has now been linked to alterations 
in specific proteins and has been shown to affect specific 
regions of the brain. As a result, it is no longer possible to 
think of AD as ``senile dementia,'' an old and discredited term 
which implied that losing one's memory was simply part of 
growing older. Part of this new perspective has its roots in 
the use of new technologies to explore the fundamental biology 
of aging. Where researchers once theorized about the causes of 
growing old, they now have the means--in recombinant DNA 
techniques and nuclear magnetic resonance, for instance--to 
track down the actual mechanisms of aging in cells and tissues. 
Once the mechanisms of aging are understood, the interactions 
between aging and disease will yield to preventive measures and 
treatments for the disorders that often accompany aging.
    Fueling the growth of this science are increasingly 
important links between aging research and other areas of 
biomedical and behavioral investigation. For example, the study 
of aging cells now overlaps substantially with research on the 
cellular mechanisms of cancer and cardiovascular disease. 
Similarly, the study of the aging brain now has numerous 
intersections with basic neurobiology and research on brain 
disease. Increasingly, research on aging has become an integral 
part of mainstream health research.
    Even with the hope of major advances in the treatment and 
prevention of debilitating diseases, the demand for long-term 
care is expected to expand in our society. Research will be 
conducted on many aspects of long-term care, particularly on 
new and evolving forms of care. NIA supports research on 
preventing the need for long-term care or institutionalization, 
enhancing the quality and efficiency of such care, easing the 
burden of long-term care, and forecasting the requirements for 
long-term care.
    Alzheimer's disease is a top research priority for NIA. It 
currently affects as many as four million older Americans and 
their families, causes enormous personal suffering, and costs 
the nation billions of dollars each year. Without the 
development of new treatments, cures, or preventive approaches 
to this dreaded disease, the number of individuals and families 
devastated by Alzheimer's disease will likely increase up to 
five-fold within the next 50 years. In addition to Alzheimer's 
disease, priority initiatives include research on the biology 
of the aging process and on physical disabilities such as 
osteoporosis and cardiovascular disease. These initiatives are 
wide-ranging and can be based on cutting-edge laboratory 
technologies or upon simple but highly effective strategies 
such as exercise or behavioral interventions. The goal of NIA-
supported research is to understand the basic mechanisms of 
normal aging and age-associated disease and disability and to 
translate this basic knowledge into treatment and prevention 
strategies.

                             basic research

Caloric restriction and biomarkers of aging

    As aging becomes more and more a topic of public concern, 
interest in interventions to delay or eliminate the 
consequences of aging has grown enormously. Although the 
molecular processes that must be responsible for species-
specific rates of aging are poorly understood, the gross 
physical and physiological manifestations of aging are well 
characterized in many species. The differences in these aging 
changes within and between species suggest that aging is a 
multi-process phenomenon. As a result, chronological age is not 
a good predictor of physiological or functional age. Better 
measures of physiological or functional age are known as 
``biomarkers of aging.'' The NIA is currently in the seventh 
year of a ten year initiative to develop a set of biomarkers of 
aging which could be used as measures of aging-related 
biological changes in experimental systems and in human beings.
    It has been known since early this century that caloric 
restriction extends the lifespan of rodents; useful biomarkers 
of aging might predict the life extension that results from 
caloric restriction. Studies conducted so far show that caloric 
restriction retards the development of virtually all age-
related lesions and tumors, reduces oxidative damage to neurons 
and slows the decline in the immune system associated with 
aging. An understanding of how caloric restriction produces 
this effect would provide important insights into preventive 
measures and therapies to retard and/or alleviate the effects 
of aging. The NIA and the Food and Drug Administration (FDA) 
have sponsored more than 30 groups to conduct research on 
biomarkers and caloric restriction. Currently, they are in the 
final stages of testing in rodent models prior to considering 
their translation to human studies.

The roles of oxidative damage and programmed cell death in aging

    Oxidative damage to critical cell components is chronic and 
ubiquitous in living cells. Although extensive repair systems 
exist in these cells, repair is never 100 percent complete. The 
purpose of this initiative is to determine: (1) what factors 
regulate the amount of damage incurred by cells, (2) what 
factors regulate the repair of this damage, (3) whether 
unrepaired damage contributes to aging, (4) the role of ``cell 
suicide'' in eliminating damaged cells, and (5) whether 
interventions can be developed to retard aging. Recent research 
results by NIA grantees include the following:
          long-lived nematode (round worm) mutants express 
        increased levels of antioxidant defense enzymes, and 
        higher levels of antioxidant enzymes in fruit flies 
        extend maximum life span.
          when ``-amyloid'' protein, which accumulates 
        in the brains of patients with Alzheimer's disease, is 
        placed in solution it generates reactive oxygen capable 
        of killing neurons through oxidative damage.
          mice carrying one or more extra copies of the 
        antioxidant defense enzyme ``superoxide dismutase'' are 
        more resistant to oxidative stress compounds which 
        induces diabetes in animal models.
    When oxidative stress overwhelms the cellular defense and 
repair systems, an alternative protective strategy for the 
organism is for the damaged cell to actually commit suicide. 
Whereas this may be the best way to eliminate a heavily damaged 
and potentially cancerous liver cell, the elimination of a 
neuron has more serious consequences because of the inability 
to replace lost neurons. Thus, an understanding of how cell 
death is regulated may be crucial not only in preventing 
cancer, but also in preventing neurodegenerative disease. 
Recent research results of NIA grantees include the 
identification of several genes required for induction of the 
programmed cell death pathway.

Cellular senescence

    It is possible that specific genes determine how many times 
a cell divides or proliferates and that the end of cell 
division, known as senescence, helps determine certain aspects 
of aging. Most cells are limited in the amount of times they 
can divide; a built-in barrier to unlimited growth. This limit 
is higher in longer-lived species, such as humans, than in 
shorter-lived species. Hence, human cells can proliferate more 
times than mouse cells. This and other observations have led to 
speculation that life spans and aging may be linked to the 
limit on cell division.
    Cellular senescence intrigues researchers for another 
reason: While on one hand it limits life span, it may also 
prevent cancer. When the limit on cell division is removed, as 
it is for presently unknown reasons in cancer cells, the cells 
continue growing indefinitely. If cell senescence is indeed one 
of the fundamental mechanisms of aging, as some biologists 
speculate, then aging itself may be the flip side of the cancer 
coin, the byproduct of a mechanism that prevents cells from 
growing into tumors. Whatever the ``purpose'' or end result of 
cell senescence, the genes that regulate it are the focus of 
intense study. NIA-supported scientists in several laboratories 
have already isolated genes that seem to promote cell 
proliferation--called oncogenes--and other genes that seem to 
stop proliferation, often referred to as tumor suppressor 
genes. Understanding why and how these genes are ``turned on'' 
or expressed may uncover new pathways for understanding both 
aging and cancer.
    It has been found, for example, that each time human or 
animal cells divide, there is a loss of DNA from the ends of 
each chromosome. The ends of chromosomes are called 
``telomeres''. When telomeres have shortened beyond a critical 
point, cells can no longer divide and are senescent. This 
mechanism would limit the amount of cell division that any cell 
can undergo, potentially limiting life span but also providing 
protection against the uncontrolled cell division that occurs 
in cancer. Recent analysis, however, has shown that an enzyme 
called telomerase can reverse telomere shortening in some 
normal cells such as sperm cells, as well as in cancer cells 
where telomerase allows cancer cells to continue uncontrolled 
division. Further molecular and genetic studies of telomeres 
and telomerase are therefore of potential importance for the 
understanding of both aging and cancer, and will be supported 
by NIA.

Gene therapy

    Whereas aging results from both genetic and environmental 
factors, appropriately designed genetic interventions may be 
able to slow aging due to both kinds of factors. For example, 
increased expression of genes for antioxidant enzymes might be 
effective in reducing damage due to oxidative stress in 
specific tissues. If specific age-related degenerative changes 
can be delayed by genetic intervention, high quality of life 
can be maintained, and health care costs can be delayed until 
later in life. This will be of particular benefit if the period 
of time ultimately spent in ill health can be shortened, and if 
the severity of the loss of function can be attenuated, thus 
reducing overall health costs.
    For example, it is well known that would healing declines 
with age. An NIA grantee is carrying out basic studies to 
determine what factors are limiting wound healing in aged 
animals. He has developed a protocol to test whether treatment 
of tissue with transforming growth factor by injection along 
the line of the incision prior to surgery improves wound 
healing. Preliminary results with another cytokine show a 
temporary increase in wound strength. Such studies offer great 
potential if they could be applied to the elderly undergoing 
elective surgery. This research is also attempting to develop a 
safe and effective method for introduction of the gene coding 
for cytokine DNA into the tissue around wounds.

Mechanisms of neuronal cell dysfunction

    Understanding why brain cells become dysfunctional and die 
in older persons is of primary concern to NIA; elucidating the 
underlying causes could lead to new therapeutic strategies to 
delay, correct, or prevent the loss of these vital cells and 
the resulting neurological deficits. Research into mechanisms 
of nerve cell death and the compensatory response of central 
nervous system cells has been recently stimulated by NIA. 
Critical to an understanding of some of the neurodegenerative 
diseases may be the link that impaired energy metabolism could 
have with nerve cell death. NIA will also encourage research on 
protein transport and signal transduction at the nerve cell 
membrane. Study of the components essential for membrane 
function will provide information on how the specialization of 
nerve cell surface is constructed, but even more importantly, 
will show how it may change leading to a variety of 
neurodegenerative diseases as well as the conditions such as 
cognitive decline normally associated with aging.

Sensory and sensory-motor dysfunction

    Visual and hearing impairments are present in respectively 
about 10 and 32 percent of American adults aged 65 years and 
older. The somatosensory areas of touch, temperature, pain, and 
motion are also important to successful aging but have received 
even less attention than studies of visual and hearing 
dysfunction. All too often older individuals have more than one 
sensory impairment. Because individual researchers tend to 
focus work on the study of one sense or another, questions 
about neural mechanisms that may be common to sensory 
processing and/or sensory dysfunction have not been explored 
adequately. The NIA stimulates multimodal sensory research, 
addressing questions such as the contribution of sensory 
processes to the control of balance, posture, and locomotion, 
areas of importance because impairments can severely compromise 
the mobility for older adults. Falls in older adults, which 
account for almost all of the 250,000 hip fractures occurring 
annually and commonly result in long-term disability, may be 
due in large part to impairments in these sensory systems.

                          alzheimer's disease

    Alzheimer's disease will reach critical proportions in the 
U.S. and other countries as the population ages. We are now 
faced with a major public health crisis if something is not 
done to halt the progress of this dreaded disease. Since the 
prevalence of Alzheimer's disease increases dramatically with 
age after about 65 years, delay of the onset of Alzheimer's 
disease by five years would substantially reduce the number of 
cases, and a delay of ten years would largely eliminate the 
disease in the normal human lifespan. Several exciting recent 
genetic discoveries have shed new light on the etiology and 
pathogenesis of Alzheimer's disease. Recently, apolipoprotein 
E4 (ApoE4), a blood protein whose gene is located on chromosome 
19, has been shown to be associated with greatly increased risk 
of Alzheimer's disease. This extremely important observation 
has been confirmed in a number of laboratories and is the first 
report of a major biological risk factor of the disease. In 
addition, there are many laboratories currently involved with 
trying to identify the gene on chromosome 14 associated with 
early-onset familial Alzheimer's disease. Other important 
studies in the etiology area include extensive analysis of the 
cellular, genetic, and molecular parameters of nerve cell 
function in health and in disease. Such basic research will 
provide a necessary understanding of the molecular 
underpinnings of Alzheimer's disease. Alzheimer's disease 
research has been of paramount importance at NIA since the 
Institute came into existence. To conquer the disease and to 
bring urgently needed support to patients, families, and 
researchers, NIA has built a nationwide framework for research 
and assistance. The structure includes:
    Alzheimer's Disease Centers (ADCs).--Located at major 
medical institutions around the country, the 28 ADCs are 
collecting and studying longitudinal data on the disease; 
working to translate research advances into clinical services; 
and educating and training professionals. Satellite centers in 
rural and remote communities are recruiting minority 
participants into the Centers' programs.
    Drug Discovery Groups.--Located at six research centers, 
these groups are designing, developing, and testing new drugs 
aimed at delaying, halting, or reversing the progress of 
Alzheimer's disease. These groups focus on drugs at the pre-
clinical stage, before testing in people.
    Cooperative Study Units.--These 32 research sites are 
conducting cooperative clinical studies (i.e., in people) of 
drugs developed by the Drug Discovery Groups and other 
projects. The first study to assess the effectiveness of 
Deprenyl plus Vitamin E in slowing the course of the disease 
began in October, 1992. Another study, for drug and behavioral 
treatment of agitation began in June, 1994, and a study of the 
anti-inflammatory drug prednisone for treatment of Alzheimer's 
disease began in November, 1994. A conference was held in 1994 
to evaluate the state-of-the-art in behavioral management in 
Alzheimer's disease, and to discuss the possibility of 
initiating larger-scale studies.
    Alzheimer's Disease Education and Referral Center 
(ADEAR).--This clearinghouse with its toll-free number (800-
438-4380) is a central source of information on all aspects of 
the disease. During calendar year 1994, 82,022 calls were 
received.
    Consortium to Establish a Registry for Alzheimer's 
Disease.--This network is working to establish uniform 
standards for diagnosis to facilitate early and accurate 
detection of the disease and support research.
    National Cell Repository.--This growing repository of blood 
samples from Alzheimer's disease patients facilitates the study 
of genetic defects associated with the disease.
    A major theme in Alzheimer's disease is to extend knowledge 
about the age incidence, prevalence rates, and risk factors. 
The search for risk factors in minority and other distinct 
population groups could lead to better understanding of the 
pathophysiology of Alzheimer's disease and novel treatments. 
Thee ideas have been the underlying themes for three sets of 
studies that have been completed over the past year. One group 
of researchers conducted an incidence study of dementia in 
relation to education and occupation and found that the risk 
was greatest for individuals with both low education and low 
lifetime occupational attainment. A study by another group, 
done in pairs of older twins, has indicated an apparent inverse 
relationship of Alzheimer's disease with sustained exposure to 
steroidal and, possibly, non-steroidal anti-inflammatory drugs, 
suggesting that these agents may prevent or delay the symptoms 
of Alzheimer's disease. A third study found that the risk of 
developing Alzheimer's disease decreased significantly with 
increasing dose and duration of estrogen replacement therapy, 
suggesting that estrogen deficiency may be one of the factors 
that elevates a woman's risk of developing the disease. 
Estrogen replacement therapy may be useful for both symptomatic 
treatment and preventing or delaying the onset of dementia in 
susceptible postmenopausal women. After further preliminary 
research, clinical trials of anti-inflammatory drugs and 
estrogen may be initiated.
    The clinical diagnosis of Alzheimer's disease has improved 
as the result of work of many investigators. In specialized 
research facilities, clinical diagnosis by research 
neurologists and psychiatrists now approaches 90 percent 
concordance with the subsequent neuropathological diagnosis. 
However, there remain important questions and gaps in 
knowledge. A major area in the development of new noninvasive 
diagnostic procedures has been that of imaging using Positron 
Emission Tomography (PET), Single Photon Emission Computed 
Tomography (SPECT), Magnetic Resonance Imaging (MRI), and 
Magnetic Resonance Spectroscopy Imaging (RSI), These kinds of 
techniques hold the promise of early diagnosis of Alzheimer's 
disease and the ability to monitor, non-invasively, the course 
of the illness.

               CLINICAL, APPLIED, AND BEHAVIORAL RESEARCH

Influenza vaccine

    Influenza, commonly known as the flu, can be a very serious 
and often life-threatening illness in older persons. An NIA-
supported study demonstrated the efficacy of an improved 
influenza vaccine in approximately 400 nursing home residents. 
Half of the participants received the commercially available 
influenza vaccine (HA) and the other half received an influenza 
vaccine against the same flue strains, but which was linked to 
another vaccine component, diphtheria toxoid. Clinical 
surveillance of all participants for respiratory illness was 
performed twice weekly for 5 months. During an outbreak of 
influenza, fewer diphtheria-toxoid-linked vaccine recipients 
than HA vaccine recipients had laboratory-confirmed infection. 
Of these recipients, fewer of the diphtheria-toxoid-linked 
vaccine-treated participants had bronchial and lung infections. 
The investigators concluded that the toxoid-linked vaccine 
produced greater protection from influenza infection for 
institutionalized elderly recipients. NIA will continue to 
support studies of basic cellular and molecular immunology in 
order to better understand the changes in immune function that 
occur with aging as well as clinical research because of the 
potential of improving vaccines for a variety of infections in 
older persons.

Physical frailty

    NIA is supporting a number of major clinical initiatives 
that address the problems of physical frailty and loss of 
independence associated with older persons. Physical frailty is 
a major cause of need for long-term care and imposes annual 
costs of billions of dollars. Results from ongoing studies 
provided convincing evidence of the benefits of exercise for 
maintaining independent function in older persons. Some 
interventions from a clinical trial of frailty and injuries 
have shown more than a 30 percent reduction in fall rates, 
which could markedly lower the rate of disabling injuries such 
as some hip fractures. Tow studies have demonstrated efficacy 
of interventions to prevent falls and improve strength in frail 
order persons. Both have received widespread attention from 
health care providers and the public and have begun to 
influence health care practices for older persons.
    One study employed a ``targeted intervention'' strategy for 
frail community-dwelling subjects with a variety of risk 
factors for falls. The subjects received individualized 
treatment for their particular risk factors including 
medication adjustments, strength and balance training, 
instruction on safe practices to avoid lightheadedness and 
environmental hazards, and raining in specific activities such 
as getting in and out of the bathtub. Over a one-year follow-up 
period, the treated subjects had 44 percent fewer falls per 
year than the control group who received social visits only.
    In another controlled study of frail nursing home 
residents, it was found that a ten-week resistance exercise 
program approximately doubled leg strength, increased walking 
speed by 11 percent, improved stair-climbing power by 28 
percent, and led to increased spontaneous physical activity. 
This study also found that supplementing the diet with protein 
and calories had no effect alone and no significant additional 
effect when combined exercise.

Menopause and aging

    There is little consensus on the significance of menopause 
in healthy aging or on its role in the chronic diseases/
disorders of old age such as cardiovascular disease, 
osteoporosis and urinary incontinence. Not surprisingly, 
considerable controversy exists over the scope of the 
physiological changes surrounding menopause or that appear 
later in life that are attributable to reduce ovarian function 
per se. Menopause is a universal phenomenon; however, the 
manifestations of menopause are not. Cross-cultural research 
demonstrates considerable variability between populations in 
symptom presentation and associated psychosocial and 
physiological effects of those symptoms.
    In order to gain an increased understanding of the inter-
relationship between menopause and disorders such as 
osteoporosis, cardiovascular disease, and the other chronic 
diseases and disorders of old age, NIA began a major research 
initiative in this area in 1994. Future success in preventing 
and managing diseases and disorders which impact on post-
menopausal women will require a substantially improved 
knowledge base to differentiate the contribution of ``hormone 
deficiency'' from that of aging. Advances can do much to 
clarify ambiguities in the presentation of age-related disease, 
improve diagnosis and treatment, and ultimately reduce health 
care costs. Similar considerations also apply to age-related 
changes in other endocrine factors, such as growth hormone and 
testosterone.
    NIA also continues to support the NIH Women's Health 
Initiative, which includes 70,000 post-menopausal women ages 
50-79. This study is intended to assess the long term benefits 
and risk of hormone therapy as it relates to cardiovascular 
disease, osteoporosis, and breast and uterine cancer. Related 
to this effort is NIA's Women's Health and Aging Study which is 
exploring the cases and course of physical disability in women 
aged 65 and older. The study will provide important information 
on how the disease-disability relationship is modified by 
cognitive functioning; on psychological factors; and on social, 
economic, and medical resources of older women.

Osteoporosis

    Osteoporosis and its consequences, particularly vertebral 
and hip fractures, are a significant cause of frailty, 
morbidity, and even mortality in old age. NIA-supported 
osteoporosis research includes clinical studies of age-related 
bone loss and fracture epidemiology, intervention trials to 
prevent or reverse bone loss, studies of skeletal biology and 
the effects of sex steroids and growth factors on bone cell 
function. Five clinical studies recently funded will conduct 
prospective longitudinal studies to determine the contributions 
of age and ovarian hormone status to changes in bone mass as 
women approach and cross menopause. Some studies will explore 
underlying mechanisms whereby menopause-related changes 
accelerate bone remodelling and adversely impact on bone 
mineral metabolism.
    Future progress in the prevention and treatment of 
osteoporosis clearly requires an expanded knowledge of the 
pathophysiology of this disorder. In particular, NIA will seek 
research studies to determine the most appropriate methods for 
studying the biology of the aging human skeleton. Such an 
approach will permit us to understand the nature of the age- 
and menopause-related changes that lead to bone loss. In 
addition, it will facilitate the identification of risk factors 
for, and specific markers of, the occurrence or reversal of 
bone loss, which will be valuable in identifying the potential 
of response to treatment, and/or monitoring the course of 
treatment.

Biology of age-related muscle weakness (Sarcopenia)

    Although a number of studies have noted correlations of 
age-related changes in muscle properties will disability and 
metabolic impairments, considerable gaps in our knowledge are 
still present. With respect to outcomes, muscle weakness in the 
extremities contributes to loss of functional independence and 
falls. However, we still know little about (1) which age-
related changes in specific muscle properties (e.g., mass, 
isometric strength, isokinetic strength, rate of torque 
development, fiber type distribution, fatiguability) 
significantly affect function and performance of specific tasks 
(walking, maintaining balance, etc.), and (2) what level of 
changes in muscle properties is required to significantly 
affect function.
    Age-related changes in muscle properties may also 
contribute to non-insulin dependent diabetes mellitus, 
osteoporosis, risk for fracture, impaired fracture healing 
rates, and risk for hypo- and hyperthermia. Clarifying these 
relationships, including their quantitative aspects, would 
reveal much about the pathologic significance of these changes 
in muscle and their overall health impact.

Self-care and aging

    NIA is currently supporting research on the nature, extent, 
and outcomes of self-care behaviors in diverse populations of 
older people in order to develop social and behavioral 
interventions for encouraging health and effective functioning 
in later life. While health surveys have indicated that most 
older people engage in some form of self-care behavior, there 
has been a lack of specification in these prior surveys. NIA is 
now documenting the wide variability in older people's self-
care practices, specifying factors associated with engaging in 
particular self-care behaviors (e.g., self-management for 
chronic health conditions and self-care practices to compensate 
for functional limitations affecting routine activities of 
everyday living). Such specifications are important for 
documenting the links between particular self-care practices 
and illness or disability.
    Inappropriate self-care can lead to delays in seeking 
needed care or conversely, overutilization of the medical care 
system for trivial symptoms. Recent NIA studies on medical 
self-care dispel myths that suggest older people are incapable 
of recognizing the significant of illness symptoms and that 
they are more prone than younger persons to use inappropriate 
strategies that could exacerbate conditions. While most older 
people have a good knowledge of symptoms and risks, NIA studies 
show there is a need for greater health education regarding the 
causes and consequences of common non-specific symptoms (such 
as fatigue, sleep difficulties, headache, an stomach pain), 
which are often erroneously attributed to age or stressful 
situations. Future research initiatives are being planned to 
develop a better understanding of complex processes involved in 
care-seeking and to suggest ways to better interpret symptoms 
and self-treatment.

Minority aging and long-term care

    Dramatic increases are expected in the number of non-
minority older people, 92 percent by the year 2030; but the 
projected growth in the older minority population--over 250 
percent by 2030--points to a need for research on aging in 
minority populations. Recent comparisons show that with 
comparable levels of frailty, African-Americans are less likely 
to enter nursing homes or enter at older ages than non-
minorities. Other findings are that family care is more common 
than the use of formal care for all minorities, and that recent 
immigrants are least likely to be institutionalized. Future 
studies, however are challenged by the need to disentangle the 
influence of cultural preferences for home or institutional 
care from the effect of socioeconomic differences for the 
largely disadvantaged older minority population. Understanding 
these and other ethnic variations in long term care has 
significant implications for structuring of formal services and 
assisting the possibly cost-effective alternative of continued 
family care.

Cognitive factors in everyday functioning of older people

    NIA supports research on social, behavioral, and biological 
factors affecting cognitive functioning as people age. More 
recently, effects are being directed at the implications of 
declines in cognitive functioning for older people's ability to 
perform daily tasks, such as driving, decision-making, and 
understanding and following medical instructions. Of particular 
importance for such tasks are changes in ``attentional 
resources''--the ability to identify and process relevant 
information simultaneously from multiple sources. While older 
people perform less well in general on tasks requiring divided 
attention, expertise in or familiarity with the task 
considerable lessens older people's disadvantage. Research has 
confirmed that older people have greater difficulty than 
younger people in understanding written medical instructions. 
However, how the information is presented can have a 
significant impact upon comprehension. For example, older 
people can more easily understand instructions presented as a 
list as opposed to paragraphs. Taken together, these and other 
research projects highlight the practical implications of basic 
cognitive research for the daily lives of older people. For 
example, those older people who suffer deficits in visual 
attention are at greater risk for automobile accidents. NIA 
research has shown that through proper training and practice, 
these deficits can be overcome or lessened.

Demography of population aging

    Population aging will become one of the most important 
social phenomena of the next half century, especially when the 
babyboom generation becomes eligible for Social Security and 
Medicare. How this nation and its institutions accommodate 
themselves to the dramatic demographic age-shift will have a 
significant effect on the quality of life in the twenty-fist 
century. NIA-supported research in the field of demography of 
aging can be characterized by an orientation towards 
intergenerational relations, especially within the family; and 
a focus on the characteristics and behaviors of older people 
themselves, especially in he critical areas of economics and 
health. To further these goals, NIA recently funded nine 
Demography Centers to promote the use of data from national 
surveys of health, retirement, and long-term care by the larger 
research and policy-making communities. The field of 
``biodemography'' is emerging, which integrates biological and 
genetic research with demographic methods, and which should 
enable a better understanding of how to forecast life and 
health expectancies.
    Research progress in the demography of aging is currently 
being made in several areas. According to NIA-funded studies, 
it is evident that the rate of increase in human mortality 
slows after age 95; possibly even declining after age of 110, 
and thatcentenarians are the fastest growing age group. The 
findings emerging from this body of research are increasingly being 
used to inform actuarial estimates for the Social Security and Medicare 
Trust Funds. One interesting study of a small group of nuns suggests 
that persons who earn college degrees and constantly challenge their 
minds, are likely to live longer and suffer less from dementia. One 
hypotheses explaining this finding is that education builds a greater 
``brain reserve capacity'' which can better compensate for the affects 
of neurological disorders.
    The Health and Retirement Study (HRS), which follows 
persons aged 51-61, has completed the second interview wave. 
The HRS will be used to study topics such as the influence of 
health and private pensions on retirement, the impact of 
changing Social Security's age of eligibility provisions, and 
the impact of the Americans with Disabilities Act. The Asset 
and Health Dynamics of the Oldest-Old study, which follows 
persons age 70 years and over to examine the interplay of 
family and economic resources and late life health transitions, 
has completed the first wave of data collection; analysis is 
underway.

                          intramural research

    The Intramural Research Program (IRP) supports research 
conducted by government scientists in Baltimore, Maryland and 
at the NIH Clinical Center, as well as the operation of NIA's 
Epidemiology, Demography, and Biometry Program and also 
supports the post-doctoral training of promising investigators 
in the intramural laboratories.

Intervening in aging processes

    The causes of aging are complex and involve both 
environmental and internal factors that damage molecules, 
cells, and tissues and the ability of the host to resist and 
repair such damage. NIA scientists, using the latest techniques 
of molecular and cellular biology, are making significant 
progress in elucidating mechanisms that underlie aging 
processes and in devising ways to retard and reverse age 
associated deficits. Findings and related opportunities include 
the following. (1) A commonly occurring mineral has been shown 
to inhibit programmed cell death (apoptosis) of endothelial 
cells following removal of growth factors and to improve the 
angiogenic response in aged animals. This may be a useful 
strategy to restore the growth of blood vessels in degenerative 
diseases of aging. (2) Chondrocytes (cells responsible for 
production of cartilage) can be induced to divide in culture by 
treatment with growth factors and then stimulated to reform 
cartilage when injected back into mice. This lays the 
foundation for cell-based repair of cartilage defects that are 
common in age associated disease of cartilage. (3) NIA 
scientists developed techniques to measure DNA damage and its 
repair in the telomeres (end regions of chromosomes that decay 
with aging) and recently demonstrated that repair declines with 
age. (4) The isolation of factors from old animals that inhibit 
blood vessel formation and tumor growth is ongoing. Analysis of 
spontaneous rat breast tumor cells may yield insights into the 
loss of suppressor gene function in the progression of breast 
cancer.

Baltimore Longitudinal Study of Aging (BLSA)

    The BLSA, begun in 1958, seeks to understand how and why we 
age. At this stage of its evolution, health outcomes are 
accumulating and participants, now numbering over 1,170, have 
been followed for significant segments of their lives. A BLSA 
DNA bank is being established; enabling protocols on apoE risk 
and protective factors in cognitive aging and on preferential 
DNA repair in breast cancer to proceed. BLSA studies also 
explore the role of risk factors for health and longevity, such 
as obesity, glucose and insulin metabolism, and plasma 
cholesterol. Each of these has been shown to continue to play a 
role into very old age, but the definition of ``normality'' for 
each must be age-specific. Prevention efforts depend upon 
accurate definition of risk, and such data are becoming 
uniquely available through the BLSA. A ten year BLSA study of 
the causes and natural history of prostate cancer, benign 
prostatic hyperplasia (BPH) and normal prostatic growth in 
Caucasian and African-American men continues. The BLSA 
perimenopausal study is an intensive evaluation of 100 
Caucasian and 100 African-American women who will be seen four 
times each year until menses have ceased for two years or 
hormone replacement is begun. Age-matched men, premenopausal 
women and older postmenopausal women already enrolled in the 
BLSA provide contrast groups to assess the separate effects of 
sex and estrogen status on normal aging.

Alzheimer's disease (AD)

    The IRP has a focused research program on the etiology, 
diagnosis and treatment of AD. Scientists have shown that 
overexpression of mutant forms of the amyloid precursor protein 
(APP), which have been implicated in AD, correlates with a 
reduced rate of capillary tube formation when cells are grown 
in culture and leads to enhanced cell death in differentiated 
neuronal cells. These results suggest new approaches for AD 
treatment involving reducing the expression of APP and 
intervening in the cell death pathway induced by APP. Also, 
recent studies suggest that apolipoprotein E (ApoE) is a risk 
factor for AD and that the ApoE4 gene is more frequent in AD 
patients. IRP scientists are relating ApoE4 genotypes of BLSA 
participants to repeated cognitive assessments made over the 
past 30 years. As this research continues, ApoE genotypes will 
be related to normal and pathological rates of cognitive 
changes, especially risks for developing AD.

Vascular disease

    The ongoing intramural research on age associated vascular 
disease will continue to capitalize on recent advances. These 
include the finding that the injury-transformed vascular smooth 
muscle cell, which is largely responsible for the vascular 
blockage in restenosis--renarrowing of an artery following 
angioplasty or balloon dilation--is critically dependent on 
intact microtubule function. Intramural scientists have found 
that taxol, a potent microtubule stabilizing agent, prevents 
this vascular narrowing by 70-80 percent in an animal model 
without significant toxicity. Others are investigating the 
potential utility of gene therapy to induce the formation of 
new blood vessels and enhance collateral blood flow to 
compromised or damaged heart tissues and to prevent restenosis 
after coronary artery angioplasty. ``Advanced glycation 
endproducts'' (AGE) are proteins that accumulate in the blood 
stream and blood vessels of diabetic patients and older 
individuals; these products interact with specific receptors 
present on circulating blood and blood vessel cells. Intramural 
scientists, in concert with extramural colleagues, have made a 
number of recent discoveries that have fueled a growing 
excitement about the potential role of this system as a novel 
therapeutic target for preventing and alleviating vascular 
disease. These include observations suggesting that the 
signalling pathway activated by this receptor plays an 
important role in the progression of all vascular disease and 
that activation of these receptors leads to increased 
intracellular oxidant stress.

Frailty, osteoporosis, hormone replacement and women's health

    Issues of women's health and well-being command special 
attention within the intramural program. Studies are ongoing 
with models of postmenopausal osteoporosis to determine the 
efficacy of an analog of the common antibiotic tetracycline in 
preventing accelerated bone loss. A collaborative clinical 
trial comparing the effects of growth hormone, sex steroid 
replacement, and growth hormone combined with sex steroid in 
men and women over 65 continues; it is expected to provide 
important new data on the risk benefit ratio of such treatments 
in older people. Women aged 65-75, treated for two years with 
constant oral estrogen/low dose daily protestin, showed 
improved bone mineral density, decreased biochemical evidence 
of bone resorption, a decrease in percent body fat, increases 
in lean body mass, and improved cholesterol profiles compared 
with BLSA controls. A new study of the interactions of 
treatment with growth hormone releasing hormone with and 
without estrogen replacement therapy on bone biochemistry and 
microanatomy in osteoporotic women 55-75 years of age has 
begun. A National Institute for Nursing Research and NIA study 
of elderly patients hospitalized with hip fracture suggests 
that an aggressive nursing intervention during the acute period 
of hospitalization could improve function and increase 
independence at discharge.

Diabetes and other age associated metabolic defects

    Metabolic abnormalities, including type II diabetes, are 
extremely common in the older population. A major intramural 
initiative is underway to develop new therapies that are safe 
and specific for the control of blood glucose in older diabetic 
patients to prevent the disease's late complications. Molecular 
approaches are being used to address the factors responsible 
for type II diabetes--an impaired ability of the beta cells of 
the pancreas to respond to blood glucose and a decreased 
insulin responsivity at target tissues--and to elucidate 
underlying mechanisms. Intramural studies have shown that 
specific gut hormones can restore beta cell responsiveness in 
conjunction with glucose and also increase insulin effects on 
insulin sensitive tissues. To investigate potential therapeutic 
strategies, studies of the effects of acute and chronic 
treatments of the pancreatic beta cells with these hormones and 
their effects on skeletal muscle, a major site of insulin 
resistance, are being pursued. Emphasis is directed to defining 
further a region of the insulin receptor that is essential for 
its activation status to prolong insulin's action. These 
advances are being aggressively pursued given their promise for 
opening new therapeutic avenues.

                               Section 3

    research advances on aging supported and conducted by other nih 
                               institutes

National Center for Research Resources

    Old age is often a slow decline into frailty and 
dependence. Researchers studying the aging process find that 
muscles--or lack of them--play an important role in determining 
quality of life. Physical impairment is a major cause of 
institutionalization in nursing homes, costing this country 
billions of dollars each year. An insidious condition called 
sarcopenia--loss of muscle tissue--seems to be a strong 
contributor to physical deterioration. Only recently has it 
become apparent that muscle loss begins as early as age 35 and 
is much greater than previously thought. Sarcopenia, largely 
masked by increases in fat, leads to loss of strength, balance, 
mobility, and ultimately independence.
    Dr. William J. Evans of the Knoll Physiological Research 
Center at Pennsylvania State University, supported by the 
National Institute on Aging and the National Center for 
Research Resources, has shown that strength training with 
exercise machines and free weights in men and women 60 to 98 
years old--some in nursing homes--in many cases doubled or 
tripled the muscle mass. Although walking, biking, and swimming 
are healthy exercises, ``the way one prevents or reverses 
sarcopenia is through resistance exercise, or strength 
training,'' Dr. Evans emphasizes.

National Institute of Neurological Disorders and Stroke

    The National Institute of Neurological Disorders and Stroke 
(NINDS) is the lead institute for research on a number of 
nervous system disorders--such as Parkinson's disease and 
stroke--that occur with greater frequency in older people. The 
institute also conducts and supports research on a number of 
other diseases that occur more commonly in older people, such 
as Alzheimer's disease.
            Parkinson's disease
    In 1995, Congress encouraged the NIH to sponsor a research 
planning workshop on Parkinson's disease. This debilitating 
disease affects more than 500,000 Americans and causes 
progressive symptoms including tremor, muscle rigidity, and 
immobility that ultimately lead to total disability and death. 
Because the disease most commonly affects people in later life, 
the number of people with Parkinson's disease and the 
associated costs will grow as the average age of the American 
population increases.
    In response to this Congressional directive, the 
Parkinson's Research Planning Workshop, co-sponsored by NINDS, 
NIA, NIEHS, and NIMH, took place August 28-30, 1995. The 
workshop's purpose was to bring together key Parkinson's 
disease researchers and experts from other fields to foster new 
ideas and research directions that might lead to rapid advances 
in the understanding and treatment of the disease.
    The workshop discussions centered upon several major 
themes. Chief among these was the recognition that both genetic 
and environmental factors are important in understanding 
Parkinson's disease. Many participants also emphasized a need 
to identify biological traits, or biomarkers, that would allow 
researchers to identify people at risk fordeveloping 
Parkinson's disease, allow earlier diagnosis of the disease, and mark 
its progression. Participants encouraged collaboration between basic 
and clinical scientists. In recognition of the common themes emerging 
from research on different diseases, they also called for collaboration 
with scientists outside the Parkinson's field.
    The discussions highlighted several key areas for 
productive investigation, but Parkinson's is a complex disease 
and there is no definitive cure on the immediate horizon. 
Improved understanding of the underlying biology of the disease 
will lead to better ways of relieving the symptoms of 
Parkinson's patients and ultimately halting the underlying 
degeneration of brain cells.
    Efforts to locate a gene responsible for some cases of 
Parkinson's disease intensified after the August 1995 workshop. 
In the fall of 1996, scientists from the NINDS and the NCHGR 
(now the NHGRI), in collaboration with researchers from the 
UMDNJ-Robert Wood Johnson Medical School in New Brunswick, New 
Jersey, and the Istituto de Scienze Neurologiche in Naples, 
Italy, pinpointed the location of such a gene. Previously, most 
scientists believed the disease was due almost exclusively to 
environmental factors such as drugs on toxic chemicals, 
although in most cases, no environmental cause has been 
identified. But many people appear to have an inherited 
susceptibility to the disease. The significance of the NIDS/
NHGRI finding is that scientists now believe that a single gene 
alteration can cause Parkinson's disease. The next step will be 
to find and identify the specific gene involved, which is 
located somewhere within a region of DNA on the long arm of 
chromosome 4. Learning the gene's exact location and isolating 
it may eventually lead to genetic testing that will enable 
early diagnosis and treatment for all forms of Parkinson's 
disease--not only inherited cases, but also those with no 
familial link. It may also help researchers discover how the 
disease occurs and how to develop methods of preventing or 
curing it.
            Stroke
    In 1995, about 500,000 Americans suffered a stroke. Of 
these strokes, about 80 percent were ischemic, caused by a 
blood clot that reduces blood flow to the brain. The remaining 
20 percent were hemorrhagic strokes, caused by bleeding into 
the brain. Stroke ranks as the third leading cause of death in 
the country after heart disease and cancer, killing about 
150,000 Americans each year. The overall cost of stroke to the 
nation is estimated to be $30 billion each year.
    In December 1995, NINDS-funded investigators published the 
results of a 5-year clinical trial demonstrating that treatment 
with the clot-dissolving drug t-PA is an effective emergency 
treatment for acute ischemic stroke despite some risk from 
bleeding. The trial found that carefully selected stroke 
patients who received t-PA treatment within 3 hours of their 
initial stroke symptoms were at least 30 percent more likely 
than untreated patients to recover from their stroke with 
little or no disability after 3 months. The nationwide study 
included more than 600 stroke patients.
    The drug t-PA works by dissolving the blood clots that 
block brain arteries. Although it had been proven effective in 
the treatment of heart attack, t-PA's potential as a treatment 
for stroke had been unclear because of an increased risk of 
brain hemorrhage. Bleeding into the brain within 36 hours of 
treatment worsened strokes in 6.4 percent of those patients in 
the NINDS trial who received t-PA compared to 0.6 percent of 
those who received placebo. Overall, however, there were 
greater numbers of stroke survivors who were able to live 
normal lives in the t-PA treated group, leading the 
investigators to conclude that the use of t-PA for stroke is 
beneficial. Furthermore, the NINDS trial showed lower levels of 
brain hemorrhage than previously published stroke trials 
involving clot-dissolving drugs.
    The investigators agree that substantial efforts by the 
health care community will be necessary before t-PA can be used 
on a widespread basis. These efforts include intensive public 
education about the signs of stroke and the importance of 
immediate treatment, the organization and training of medical 
personnel to evaluate and treat stroke patients, as well as 
planning for the rapid transport of patients to treatment 
centers through emergency medical services.

National Institute on Nursing Research

    Americans expect to live longer than earlier generations, 
but these additional years should be lived well--with health 
and independence intact for as long as possible. Nursing 
researchers are exploring interventions with this goal in mind 
in order to preserve cognition and the ability to function, and 
to maintain or improve quality of life.
    The National Institute of Nursing Research (NINR) supports 
studies that address these and other health issues of the older 
population, including prevention of illness and disability; 
health promotion strategies; management of the symptoms of 
chronic diseases, including pain; interventions for family 
caregivers to help them maintain their own health as well as 
that of their ill relatives; and end-of-life care to promote a 
comfortable death with dignity.
    Among the findings of FY 1995-96 are two that hold promise 
to improve older people's recovery from the effects of 
immobility and illness.
    Immobility is frequently associated with more serious 
chronic illnesses, and a preventable secondary effect, pressure 
ulcers, still occurs too often. These ulcers are caused by 
constant pressure on the body's bony areas, which results in 
damage and death of skin, muscle and bone tissues. The care of 
these wounds is quite costly, estimated to the $737 million 
nationally. Nursing home populations have benefited from an 
assessment scale developed by nurse researchers that identifies 
patients most likely to develop pressure ulcers within a few 
days of their entering a nursing home, thus alerting the staff 
to the need for immediate preventive action. The assessment 
scale has been adapted for use in routine clinical practice and 
has been incorporated into the ``Guidelines on Pressure 
Ulcers'' published by the Agency for Health Care Policy and 
Research.
    Stroke patients usually have low endurance for exercise, 
although physical activity is thought to be important in the 
recovery process. When patients with moderate hemiparesis used 
an exercise bicycle regularly for 30 minutes 3 times a week for 
10 weeks, they improved not only their aerobic capacity, but 
also their sensorimotor function, as measured by such factors 
as sensation, balance and awareness of body position. The 
exercise training also significantly improved systolic blood 
pressure. The nursing research findings indicate that patients 
who have a propensity for increased blood pressure during 
activity could benefit from an aerobic exercise program to 
lower their systolic pressure, thereby reducing their risk of a 
future stroke.

National Institute of Environmental Health Sciences

    The incidence, prevalence, and severity of many chronic 
conditions increase with age. As the elderly segment of the 
U.S. population increases, it will be important to understand 
which conditions are an inevitable consequence of aging and 
which are due to cumulative effects of low-dose environmental 
exposures that could be prevented. Scientists already know that 
cancer initiation and progression is influenced by 
environmental exposures. It is only beginning to be appreciated 
that other disease states--cardiovascular disease, respiratory 
problems, kidney function impairment--can also be influenced by 
involuntary, environmental exposures.
    These research needs are being pursued by the National 
Institute of Environmental Health Sciences (NIEHS). It is the 
mission of the NIEHS to define (1) how environmental exposures 
affect our health, (2) how individuals differ in their 
susceptibility to these exposures, and (3) how these 
susceptibilities change with age. Some of the important work at 
the NIEHS on the environmental components of aging-related 
disorders is described below.
    Cancer. An environmental component for many cancers is 
clearly established. Since its inception, the NIEHS has 
supported work exploring the connection between environmental 
exposures and cancer risks. This work continues in ongoing 
investigations into the risks of lung cancer from household 
radon exposures and the risks of breast cancer from a variety 
of exposures including pesticides, polychlorinated biphenyls, 
and other estrogenic compounds. Some of the most exciting work 
is being done in linking environmental risk factors to 
underlying individual vulnerabilities, such as defective 
genetic repair mechanisms or inadequate detoxification 
mechanisms. This work includes:
    Breast Cancer: Isolation to two breast cancer 
susceptibility genes, BRCA1 and BRCA2, by NIEHS scientists 
working with non-Institute research teams.
    Prostate Cancer: Studies of a vitamin D receptor gene 
variant that showed an association with increased prostate 
cancer risk.
    Urinary Bladder Cancer: An epidemiologic study that showed 
a 70% increased risk for bladder cancer development in 
individuals lacking the gene that codes for the carcinogen 
detoxification enzyme, glutathione transferase M1.
    Senescence (``Aging'') Gene: NIEHS scientists are 
interested in understanding the processes governing cellular 
aging, or senescence. An NIEHS laboratory identified the first 
senescence gene, a finding with important implication in 
understanding the molecular basis of cancer.
    Impaired Kidney Function and Lead Exposure: NIEHS-supported 
scientists discovered a link between lead exposure and impaired 
kidney function. This study showed that even low blood lead 
levels, a measure of lead exposure, correlated with significant 
reductions in kidney function as measured by serum creatine 
concentration. Environmental sources of lead include old 
paints, lead solder, some ceramic glazes, and dusts and soils 
that were contaminated by automobile exhausts from leaded 
gasoline. These studies give further support to the need to 
continue these environmental programs and also provide 
clinicians with an important diagnostic tool for determining 
causes for reduced renal functions in patients.
    Hypertension and Lead Exposure: High blood pressure, or 
hypertension, is a leading risk factor for heart disease. A new 
NIEHS-supported study identified a potentially important 
environmental component of this disease--long-term lead 
exposure. This finding is particularly important because lead 
is an environmental agent whose exposure can be controlled.
    Neurodegenerative Disorders: Neurodegenerative disorders 
such as Alzheimer's and Parkinson's might well prove to be the 
consequence of long-term, low-level exposures to environmental 
compounds. Understanding the environmental components of these 
diseases is complicated by the fact that individuals probably 
differ in their susceptibility to these effects and that there 
is probably a long latency period between exposure and disease 
expression. The NIEHS is investigating the environmental causes 
of these diseases, with particular emphasis on neurotoxic 
compounds such as metals and solvents.
    Osteoporosis: Osteoporosis is a crippling bone disorder 
that worsens with age and, in women, accelerates after 
menopause. NIEHS-supported scientists are investigating 
environmental agents that could play a role in increasing 
(e.g., cadmium) or reducing (e.g., natural plant estrogens) 
disease risks. Additionally, work has led to a reevaluation of 
current air quality standards to assess their ability to 
protect the public's health. Asthma, a frequently fatal 
condition that can persist from childhood, is being intensely 
studied by NIEHS-funded scientists who are examining the role 
of indoor exposures, including cockroach and dust mite 
allergens, and the efficacy of allergen control strategies in 
reducing asthma attacks.
    Environmental Justice: Those least likely to enjoy a long 
and healthy life are those who inhabit the bottom rungs of the 
socio-economic ladder. A critical research need is to determine 
if their health problems are due solely to low income or due in 
part to the environmental consequences of low income. These 
consequences would include hazardous jobs, lead-contaminated 
homes, living in neighborhoods near hazardous waste sites, and 
water sources contaminated by pollutants leaching from 
landfills. The NIEHS has provided vigorous leadership in the 
area of environmental justice and continues to reach out to 
disadvantaged communities to understand what unique 
environmental risks that might face that could affect their 
health.

National Institute of Mental Health

    In elderly people, major depression may be chronic or recur 
frequently, and, while their depressive episodes can be treated 
successfully, elderly people are more prone to relapse during 
continuation therapy than are younger patients. NIMH is 
conducting a study of elderly outpatients susceptible to 
recurrent depression who are on maintenancetreatment after 
having been successfully treated for a depressive episode, with the 
objective of learning how to identify which patients will benefit from 
a particular form of maintenance psychotherapy after discontinuation of 
antidepressant medications. Researchers assessed the subjective sleep 
quality that patients had achieved early in their continuation 
treatment phase and found that a high percentage of patients who report 
good subjective sleep quality at this point remained well over the next 
year, provided they also received maintenance psychotherapy once a 
month.
    The efficiency of vascular function in the brain is 
increasingly commanding the attention of researchers interested 
in diverse facets of health and illness in older people. Now, 
and NIMH-funded investigator has reported that a particular 
gene product the E-4 type of apolipoprotein, which is a known 
risk factor for coronary artery disease, cerebral 
atherosclerosis, and Alzheimer's disease also is more commonly 
associated with the occurrence of depression in advanced old 
age as opposed to depression with an earlier onset among older 
patients. This finding sparks particular interest in light of 
the fact that depressed, elderly cardiac patients have much 
higher rates of mortality than do comparably aged patients who 
are not depressed. Further information about apolipoprotein 
variants as correlates of, and possibly risk factors for mental 
disorders in late life may prove to have implications for 
tailoring pharmacologic treatments with an eye toward 
maximizing treatment effects and minimizing side effects, or 
even preventing symptom development. The potential import of 
the finding is buttressed by a separate NIMH-funded study in 
which researchers have described a specific clinical profile of 
elderly patients with what appears to be a subtype of 
depression associated with cerebrovascular disease. This 
subtype of depression describes patients whose lack of 
depressive thought patterns marks a departure from an otherwise 
``classic'' presentation of depressive symptoms. If the 
syndrome of vascular depression is validated, it may have 
direct treatment implications. Animal studies suggest that some 
antidepressant promote neurological recovery after 
cerebrovascular incidents, but others inhibit recovery.
    Research has shown that the apolipoprotein E4 (ApoE4) 
allele is a genetic risk factor for both familial and sporadic 
Alzheimer's disease, and it is estimated that up to 65 percent 
of patients carry this allele, compared to only 24-31 percent 
of healthy controls. In studies with a group of Alzheimer's 
disease patients, NIMH-supported researchers found that there 
is no correlation between the ApoE4 ``dosage'' (number of these 
alleles in a patient's DNA) and the rate of cognitive decline. 
In a related study, these researchers also found that this 
ApoE4 risk factor is associated with increased behavioral 
disturbances in Alzheimer's disease.

National Institute on Deafness and other communication disorders

            PSP, Parkinson's, and Alzheimer's
    Errors in differentiating the diagnosis of individuals with 
various neurodegenerative diseases can have serious medical 
consequences. For example, progressive supranuclear palsy 
(PSP), a rare disease, is often misdiagnosed as the more 
prevalent Parkinson's disease because the two diseases share 
many motor symptoms and signs. Because PSP does not respond to 
medications for Parkinson's disease, the misdiagnosis can delay 
appropriate intervention. Research has revealed that testing of 
the sense of smell may be useful in the differential diagnosis 
of individuals in the early stages of PSP. PSP patients perform 
well on smell identification tests, whereas Parkinson's disease 
patients perform poorly. Further, the applications of 
contemporary imaging and molecular biologic techniques to 
biopsies of olfactory sensory tissue may prove useful in the 
early diagnosis of brain diseases, such as Alzheimer's disease, 
in which the olfactory neurons are the only affected neural 
tissue that can be readily obtained from living patients.
            Hearing aid developments
    National Institute of Deafness and Communication Disorder 
(NIDCD) scientists funded through the Small Business Innovation 
Research program have made progress in alleviating ringing 
``feedback,'' a common complaint of many hearing aid users. By 
physically delivering sound deeper into the ear canal via 
improved hearing aid shell designs, hearing aid users 
experience less feedback and reduced occlusion effects, a 
common complaint of hearing aid users described as 
``hollowness'' or a feeling of ``talking inside a barrel.''
            Voice Disorders Associated with Parkinson's Disease
    Of the 1.5 million individuals with the progressive 
neurogenic disorder Parkinson's disease, at least 89% have a 
breakdown in their ability to speak. The long-term goals of one 
study are to evaluate the efficacy of a model of behavioral 
voice treatment for these patients and to examine the 
physiologic and neural mechanisms underlying voice and speech 
changes that occur during treatment or with progression of the 
disease. Preliminary analysis indicates beneficial increases in 
movement of the vocal folds and improved stability of the voice 
accompanying treatment. To further assess the underlying 
changes associated with successful treatment, a number of 
patients with Parkinson's disease are being evaluated for 
variables in speech physiology such as vocal loudness, voice 
quality, and speech intelligibility. All of these measures 
improve significantly after treatment that focused on the 
voice. In most cases, these posttreatment improvements were 
maintained for one to two years without additional treatment. 
After voice treatment, patients reported that they spoke more 
often and had more confidence because people could now 
understand them. These findings document that Parkinson's 
disease patients can make changes in their speech production in 
response to voice treatment; they also suggest that stimulating 
improved phonation may be a key to improving their overall 
speech production.
            Collaborative efforts to improve hearing aids
    The NIDCD continues an innovative collaboration with the 
Department of Veterans Affairs (VA) in an effort to support the 
development of better hearing aids. Five initiatives have been 
developed and are in various stages of implementation. These 
initiatives include a call to the research community for the 
submission of grant proposals to determine how hearing aids 
affect speech understanding, in quiet and in noise, published 
in January 1994. There was also a call for research to 
determine ways to measure the benefit received from hearing 
aids by persons who are hearing impaired, also published in 
1994. A contract for a program of device development for 
hearing aids will begin in the near future. This will support 
the design and evaluation of creative new technologies and 
strategies for hearing aids. The protocol for a first clinical 
trial has been developed and is expected to begin in Fiscal 
Year 1995 through an interagency agreement with the VA. The 
clinical trials will identify specific subgroups of individuals 
who benefit most from the existing and newly developed hearing 
aid technologies. A hearing aid research and development 
conference, scheduled for September 1995, will be a national 
forum for the presentation of research relevant to hearing 
aids. This collaborative effort between the NIDCD and the VA is 
facilitating progress towards the improved use of existing 
devices, as well as stimulating research to develop new 
technologies and devices.
            Century auditory processing in elderly people
    Early diagnosis of certain dementias is now being 
facilitated by a battery of central auditory tests with elderly 
patients. One disease known to cause deterioration of neuronal 
circuits is a form of Alzheimer's disease called ``Mild Senile 
Dementia of the Alzheimer's type.'' These patients also suffer 
from hearing loss. Using an extensive audiologic testing 
battery, it was demonstrated that all measures of pure-tone 
hearing and recognition of simple words were similar between 
subjects with neurodegenerative disease and otherwise normal 
elderly subjects. However, when presented with complex sentence 
tests specifically designed to assess the processing 
capabilities of the higher level auditory structures, patients 
with mild neurodegenerative disease could not perform the test. 
Mild neurodegenerative diseases appear to affect central 
auditory processing and thus the ability to process more 
complex acoustic signals.
            Cochlear implant technology
    The NIDCD, together with the Office of Medical Applications 
of Research, convened a NIH Consensus Development Conference on 
Cochlear Implants in Adults and children on May 15-17, 1995. 
Co-sponsored by NIA, NICHD, NINDS, and the Department of 
Veterans Affairs, the conference summarized current knowledge 
about the range of benefits and limitations of cochlear 
implantation. One of the major conclusions of the panel 
addressed the auditory criteria for adult implant candidacy. 
Previously, only adults with profound hearing impairment were 
candidates for implantation, and individuals receiving marginal 
benefit from hearing aids were not considered implant 
candidates. However, recent data show that most marginally 
successful hearing aid users will have improved speech 
perception performance with a cochlear implant. The panel 
therefore concluded that it is reasonable to extend cochlear 
implants to postlingualy hearing-impaired adults currently 
obtaining marginal benefits from other amplification systems, 
increasing the number of Americans to some one million who may 
benefit from a cochlear implant.
            Hearing loss and its effect on older women
    Projections based on figures from the National Center for 
Health Statistics estimate that by the year 2030, at least 21 
million Americans beyond 65 years of age will be classified as 
hearing impaired. Age-related hearing loss (presbycusis) is a 
seemingly complex disorder developed in senior years, typically 
characterized by a decrease in speech understanding, though not 
necessarily a parallel decrease in sensitivity to simple tones. 
The functional consequences of hearing loss in senior citizens, 
as evidenced by its impact upon psycholosocial well-being, can 
be substantial. This is particularly true for elderly women 
since during their later years an increased susceptibility to a 
variety of conditions of aging seems only to further the 
functional impact of the hearing loss. To gain a better 
understanding of gender-specific presbycusis, NIDCD-supported 
investigators are exploring the pathophysiologic factors 
potentially related to hearing capabilities in older women, to 
include the relation between incidence of hearing loss and 
cardiovascular risk factors.

National Institute on Alcohol Abuse and Alcoholism

    Problems of alcohol abuse and alcoholism among the elderly 
remain a priority at the National Institute on Alcohol Abuse 
and Alcoholism (NIAAA). In fact, one of NIAAA's 14 Alcohol 
Research Centers focuses exclusively on understanding the brain 
changes that result from both chronic and acute alcohol uses, 
characterizing the clinical manifestations of these phenomena, 
and developing and evaluating methods for screening and 
intervention among elderly alcohol-abusing and alcoholic 
patients.
    Major objectives at the Alcohol Research Center on Aging 
include characterizing how alcohol interacts with aging to 
produce central nervous system abnormalities; developing 
strategies for early diagnosis and treatment of alcoholism in 
older individuals; and understanding how aging interacts with 
alcohol consumption in interfering with complex motor 
activities, such as driving.
    Investigators use state-of-the-art noninvasive brain 
imaging technologies (i.e., positron emission tomography and 
magnetic resonance imaging) to better characterize the 
mechanisms underlying alcohol-induced central nervous system 
changes in the elderly. Investigators also conduct detailed 
electroencephalographic studies of sleep physiology in alcohol-
dependent and nonalcohol-dependent elderly subjects and use 
computer simulation of driving performance to assess changes in 
performance under conditions of intoxication. Ongoing NIAAA 
research projects investigate:
          Combined effects of alcohol abuse and the aging 
        process on alterations of brain metabolism, brain 
        receptor binding, and neuropsychological functioning;
          The interactions of chronic alcohol use, sleep apnea, 
        sleep disruption, and aging;
          The effects of alcohol on complex driving skills in 
        the elderly, including the effects of sleep deprivation 
        on driving performance;
          The effectiveness and acceptability of brief 
        intervention strategies on drinking problems in older 
        adults;
          The role of alternations in serotonin on the clinical 
        features and pharmacotherapy of alcoholism among the 
        elderly,
    As the proportion of the U.S. population reaching old age 
continues to grow, the relevance and importance of alcohol use 
and abuse in this age segment increases.





          ITEM 7--DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

                              ----------                              


       U.S. HOUSING FOR THE ELDERLY--CALENDAR YEAR 1995 AND 1996

    The Department of Housing and Urban Development is 
committed to providing America's elderly with decent affordable 
housing appropriate to their needs. The Department's goal is to 
provide a variety of approaches so that older Americans may be 
able to maintain their independence, remain as part of the 
community, have access to supportive services, and live their 
lives with dignity and grace.

                               I. HOUSING

a. section 202--capital advances for supportive housing for the elderly 
    and section 811 supportive housing for persons with disabilities

    The National Affordable Housing Act of 1990 authorized a 
restructured Section 202 program while separating out and 
creating the new Section 811 program for Housing for Persons 
with Disabilities. Funding for both programs is provided by a 
combination of interest-free capital advances and project 
rental assistance. Project rental assistance replaces Section 8 
rent subsidies. The annual project rental assistance contract 
amount is based on the cost of operating the project. The 30 
percent maximum tenant contribution remains unchanged.
    Since the passage of the National Affordable Housing Act of 
1990, there have been 43,357 units approved under the Section 
202 program and 13,041 units approved under the Section 811 
program. Of those amounts 8,669 Section 202 units and 1,971 
Section 811 were approved in Fiscal Year 1996.

     b. section 231--mortgage insurance for housing for the elderly

    Section 231 of the National Housing Act authorized HUD to 
insure lenders against losses on mortgages used for 
construction or rehabilitation of market rate rental 
accommodations for persons age 62 years or older, married or 
single. Nonprofit as well as profit-motivated sponsors are 
eligible under this program. The program is largely inactive 
since most sponsors and lenders prefer to use the Section 
221(d)(3) and 221(d)(4) programs instead.

     c. section 221(d) (3) and (4)--mortgage insurance program for 
                          multifamily housing

    Sections 221(d)(3) and (4) authorized the Department to 
provide insurance to finance the construction or rehabilitation 
of market rate rental or cooperative projects. The programs are 
available to non-profit and profit-motivated mortgagors as 
alternatives to the Section 231 program. While most projects 
under the programs have been developed for families, projects 
insured under Section 221 may be designed for occupancy wholly 
or partially for the elderly, and the mobility impaired of any 
age.

d. section 232--mortgage insurance for nursing homes, intermediate care 
  facilities, and board and care homes, and assisted living facilities

    The Section 232 program assists and promotes the 
construction and rehabilitation (or purchase or refinance of 
existing projects) of nursing homes, intermediate care 
facilities, board and care homes, and assisted living 
facilities by providing mortgage insurance to finance these 
facilities. The vast majority of the residents of such 
facilities are the frail elderly. In FY 1996, HUD insured 156 
projects containing 20,608 units and worth $1 billion.

                     e. section 8--new construction

    The Section 8 program sponsored the new construction of 
housing for families and for the elderly by attaching subsidy 
to the units being developed. That way the landlord was 
guaranteed a stream of income that would facilitate finding 
financing and that would guarantee the ability to make payments 
and operate the developments. The new construction program was 
active from 1974 until the mid-1980s. There are 1.4 million 
private, project-based Section 8 units, about 47 percent of 
which serve elderly households. About 193,000 of these 658,000 
units were built under the Section 202 program before the 
restructuring of that program in 1990. That means that about 
465,000 units developed with Section 8 project-based assistance 
serve elderly households. The Section 8 new construction 
program is no longer in operation.

                        f. service coordinators

    The National Affordable Housing Act authorized funding for 
service coordinators under the Section 202 program in 1990. 
Eligibility was expanded to cover Sections 8, 221(d)(3), and 
236 projects in 1992. A service coordinator is a social service 
staff person who is part of the project's management team. That 
individual is responsible for ensuring that the residents of 
the project are linked with the supportive services they need 
from agencies in the community to assure that they can remain 
independently in their homes and avoid premature and 
unnecessary institutionalization as long as possible.
    In FY 1995, HUD awarded $19.5 million to 179 projects, 
almost all of which were Section 202 projects; another $5 
million was awarded to 34 Section 202 projects in 1996.

               g. the congregate housing services program

    The Congregate Housing Services Program (CHSP), initially 
authorized in 1978 and revised in 1990, provides direct grants 
to States, Indian tribes, units of general local government and 
local non-profit housing sponsors to provide case management, 
meals, personal assistance, housekeeping, and other appropriate 
supportive services to frail elderly and non-elderly disabled 
residents of HUD public and assisted housing, and for the 
residents of Section 515/8 projects under the Department of 
Agriculture's Rural Housing and Community Department Service.
    In 1995 HUD made one grant for $252,595 to serve an 
estimated 20 additional non-elderly disabled residents of 
eligible housing. The program covers 111 grantees, which serve 
about 5,000 people.

    h. flexible subsidy and loan management set aside (lmsa) funding

    The Flexible Subsidy Program provides funding to correct 
the financial and physical health of HUD subsidized properties, 
including those which house the elderly. Flexible Subsidy 
provides funds for projects insured under Section 221(d)(3), 
Section 236, and funding under the 202 program (once they have 
reached 15 years old).
    The Loan Management Set Aside (LMSA) Program provides 
Project-based Section 8 funding to HUD-insured and HUD-held 
projects and projects funded under the 202 Program, which need 
additional financial assistance to preserve the long term 
fiscal health of the project.

                       i. manufactured home parks

    The Housing and Urban-Rural Recovery Act (HURRA) of 1983 
amended Section 207 of the National Housing Act to permit 
mortgage insurance for manufactured home parks exclusively for 
the elderly. The program has been operational since the March 
1984 publication of a final rule implementing the legislation, 
although HUD insures very few manufactured home parks.

             j. title i property improvement loan insurance

    Title I of the National Housing Act authorizes HUD to 
insure lenders against loss on property improvement loans made 
from their own funds to creditworthy borrowers. The loan 
proceeds are to be used to make alterations and repairs that 
substantially protect or improved the basic livability or 
utility of the property. There are no age or income 
requirements to qualify for a Title I loan.

              k. title i manufactured home loan insurance

    Title I of the National Housing Act authorizes HUD to 
insure lenders against loss on manufactured home loans made 
from their own funds to creditworthy borrowers. The loan 
proceeds may be used to purchase or refinance a manufactured 
home, a developed lot on which to place a manufactured home, or 
a manufactured home and lot in combination. The home must be 
used as the principal residence of the borrower. There are no 
age or income requirements to qualify for a Title I loan.

          l. home equity conversion mortgage insurance program

    The Department has implemented a program to insure Home 
Equity Conversion Mortgages (HECM), commonly known as ``reverse 
mortgages.'' The program is designed to enable persons aged 62 
years or older to convert the equity in their homes to monthly 
streams of income and/or lines of credit.
    As of September 30, 1996, the cumulative number of active 
insured loans reached 20,321. Two hundred and thirty-two 
lenders in 49 states participate in the program. The volume of 
loans increased significantly during the 1990's, from 151 in 
1990 to 4,083 in 1995 as more lenders and the general 
population become more aware of the HECM program. For that 
reason, the Department is planning program changes that will 
offer consumer protection against excessive fees.

                     II. PUBLIC AND INDIAN HOUSING

          a. section 8 rental certificates and rental vouchers

    Section 8 of the U.S. Housing Act of 1937 authorizes 
housing assistance payments to aid low-income families in 
renting decent, safe, and sanitary housing that is available in 
the existing housing market.
    About 16 percent of Section 8 certificate and voucher 
recipients are elderly. This represents 224,000 units.

                b. elderly/disabled service coordinators

    Section 673 of the Housing and Community Development Act of 
1992 authorized the Department to fund services coordinators in 
public housing developments to assure the elderly and non-
elderly disabled residents have access to the services they 
need to live independently. The Department awarded $60 million 
in FY 1994 and 1995 funds for public housing authorities to 
hire services coordinators for their elderly and non-elderly 
disabled residents to provide case management and link these 
needy residents to other supportive services.

                     c. tenant opportunity program

    Section 20 of the U.S. Housing Act of 1937 authorized the 
Tenant Opportunity Program. This program provides training and 
technical assistance to resident entities to organize their 
communities and to establish various resident managed 
initiatives. The program began in 1988 and to date has funded 
about 900 resident groups. Public andIndian housing 
developments with elderly residents are eligible to participate and we 
would estimate a small portion, perhaps 5 percent are in fact primarily 
elderly grantees.

                 d. public housing development program

    The Public Housing Development Program was authorized by 
Sections 5 and 23 of the United States Housing Act of 1937 to 
provide adequate shelter in a decent environment for families 
that cannot afford such housing in the private market.
    In 1995, 208 additional units of public housing for the 
elderly were reserved, 469 were under construction, and 514 
became available for occupancy. In 1996 another 43 were 
reserved, 272 were under construction, and 233 became available 
for occupancy. The following statistics are provided for the 
elderly low income population of public and Indian housing:

Public housing residents......................................   360,000
Indian housing................................................    11,400
                    --------------------------------------------------------------
                    ____________________________________________________

    Total Public and Indian Housing...........................   371,400

                             e. set-asides

    The Department is currently conducting a demonstration 
program called HOPE for Elderly Independence which was created 
in 1992. The purpose of the demonstration is to test the 
effectiveness of providing rental voucher and supportive 
services to frail elderly people who are living in the general 
community and require this combined assistance to continue 
living independently and to avoid premature or unnecessary 
institutionalization.
    Hope for Elderly Independence grants worth $7.7 million 
made in FY 94. Hope for Elderly Independence vouchers worth 
$32.1 million (11,186 units) were assigned in FY 94 and another 
$990,805 (150 units) were assigned in FY 1995.

                III. COMMUNITY PLANNING AND DEVELOPMENT

  a. community development block grant (cdbg) entitlement communities 
                                program

    The CDBG Entitlement Communities Program is HUD's major 
source of funding to large cities and urban counties for a wide 
range of community development activities. These activities 
primarily help low- and moderate-income persons and households, 
however, they can also be used to help eliminate slums and 
blight or meet other urgent community development needs.
    The Department normally does not ask grantees to report 
program beneficiaries by age. Despite this, grantees did report 
on their 1994 Grantee Performance Report (the most recent 
performance report for which the Department has reliable 
information) that they spent about 1.1 percent of their program 
funds (over $34 million) that year for public services that 
were specifically targeted to senior citizens and about 0.7 
percent of their funds (over $22 million) for public facilities 
for senior citizens. In addition, HUD staff are aware that 
senior citizens frequently benefit from local housing 
rehabilitation programs that are funded by CDBG. What is not 
known is how many of those benefiting from rehabilitation 
projects are elderly. It has been the experience of the 
Department that the percentage of CDBG funds spent on these 
activities by grantees has not varied much from year to year.
    No further information is available at this time.

 b. cdbg state-administered and hud-administered small cities programs

    The CDBG State-administered program and the HUD-
administered Small Cities program for the States of New York 
and Hawaii are HUD's principal vehicles for assisting 
communities with under 50,000 population that are not central 
cities of metropolitan areas. States and small cities/counties 
use the CDBG funds to undertake a broad range of activities and 
structure their programs to give priority to eligible 
activities that they wish to emphasize. As is also true with 
the Entitlement Communities program, these activities must 
primarily help low- and moderate-income persons and households, 
however they can also be used to help eliminate slums and 
blight or meet other urgent community development needs.
    The Department has no specific information on the extent of 
benefit from these programs for the elderly, however HUD staff 
are aware that elderly persons and households who live in these 
small cities and counties are benefiting from CDBG-funded 
activities.
    No further information is available at this time.

                     c. home investment partnership

    The HOME Program provides funds by formula to States and 
local governments for acquisition, rehabilitation, and 
construction of affordable housing for rent or homeownership. 
As of September 1996, the program, which was first funded in 
1992, had assisted 21,500 elderly households. Over 80 percent 
of these households had incomes at or below 50 percent of the 
area median income. Most assistance was provided to existing 
homeowners (15,200) to rehabilitate their homes. HOME provided 
rental units for 3,200 elderly households, tenant based rental 
assistance to 2,300 elderly households, and assistance to 
purchase homes to 750 elderly households. The publication, Home 
Repair/Modification Programs for Elderly Homeowners, is 
designed to assist jurisdictions in designing programs using 
HOME funds specifically to meet the needs of the elderly.

                  d. emergency shelter grants program

    The Emergency Shelter Grants Program provides funds to 
States, metropolitan cities, urban counties, Indian tribes, and 
territories to improve the quality of emergency shelters, make 
available additional shelters, meet the cost of operating 
shelters, provide essential social services to homeless 
individuals, and help prevent homelessness.
    No further information is available at this time.

              e. supportive housing demonstration program

    The Supportive Housing Demonstration Program (SHDP) has two 
components, Transitional Housing and Permanent Housing for the 
Handicapped Homeless. The Transitional Housing Program is 
designed to provide short-term housing and support services 
that facilitate the transition of homeless persons to 
independent living. The Permanent Housing for the Handicapped 
Homeless Program assists States in developing community-based, 
long-term housing and supportive services for handicapped 
persons who are homeless.
    No other information is available at this time.

             IV. FAIR HOUSING AND EQUAL OPPORTUNITY (FHEO)

                        a. the fair housing act

    The Fair Housing Act prohibits discrimination in housing 
based on race, color, religion, sex, national origin, handicap, 
or familial status. The Act exempts from its provisions against 
discrimination based on familial status ``housing for older 
persons.'' which is defined as housing intended and operated 
for occupancy by elderly persons. The statutory exemption of 
``housing for older persons'' comprises three categories of 
housing: (1) housing provided under any State or Federal 
Program that the Secretary of HUD determines is specifically 
designated and operated to assist elderly persons; (2) housing 
intended for and solely occupied by residents 62 years of age 
and older; and (3) housing intended for and solely occupied by, 
at least one person 55 years of age or older per unit, provided 
various other criteria are met.

             b. the housing for elderly persons act of 1995

    The Housing for Older Persons Act (HOPA) of 1995 named the 
``55 and older'' senior housing exemption to the Fair Housing 
Act's prohibition against discrimination based on familial 
status. HOPA eliminates the requirement that ``housing for 
older persons'' have significant services and facilities for 
its elderly residents and establishes a good faith reliance 
defense from monetary damages based on a legitimate belief that 
the housing was entitled to an exemption. In order to qualify 
for the ``55 and over housing'' exemption a housing community 
or facility must: (1) have at least 80 percent of its occupied 
units occupied by at least one person 55 years of age or older; 
(2) adhere to policies and procedures which demonstrate an 
intent by the owner or manager to provide housing for persons 
55 and older; and (3) verify the age of its residents through 
reliable surveys and affidavits.

                       c. age discrimination act

    During Fiscal Year 1995, the Department received five 
complaints alleging age discrimination in federally-assisted 
programs. It appears that three of these complaints were filed 
by persons over 62 years of age. (Age discrimination complaints 
may be filed by persons of any age.) In Fiscal Year 1996, there 
were 10 such complaints, 6 of which were filed by elderly 
persons.

                         d. designated housing

    The 1992 Housing and Community Development Act authorized 
HUD to approve Public Housing Authority plans to designate 
mixed population housing units (serving elderly and persons 
with disabilities) for elderly families only, if the plans met 
certain statutory requirements. The Housing Opportunities 
Program Extension Act of 1996 simplified and streamlined those 
requirements, but continued to require HUD to review and 
approve or disapprove designate housing plans.
    As of December 1996, 38 housing authorities had received 
approval to designate four units for elderly families only.

              V. OFFICE OF POLICY DEVELOPMENT AND RESEARCH

                       a. american housing survey

    The American Housing Survey for the United States, Current 
Housing Reports H. 150 for the year 1995 contains special 
tabulations on the housing situations of elderly households in 
the United States. (Data for 1997 will be available in Fall 
1998.) Chapter 7 of the regular report provides detailed 
demographic and economic characteristics of elderly households, 
detailed physical and quality characteristics of their housing 
units and neighborhoods and the previous housing of recent 
movers, and their opinions about their house and neighborhood. 
The data are displayed for the four census regions, and for 
central cities, suburbs, and non metropolitan areas, and by 
urban and rural classification. The non-elderly chapters (total 
occupied, owner, renter, Black, Hispanic, central cities, 
suburbs, and outside MSAs) as well as the publications for the 
44 largest metropolitanareas individually surveyed over a 4-
year cycle, Current Housing Reports H. 170, also contain data on the 
elderly.
    An elderly household is defined as one where the 
householder, who may live alone or head a larger household, is 
aged 65 years or more. Special information in these 
publications is provided on households in physically inadequate 
housing or with excessive cost burden, and on households in 
poverty.

   b. evaluation of the hope for elderly independence demonstration 
                                program

    The program was conceived as an alternative to the 
Congregate Housing Services Program (CHSP). The major 
difference between the two programs is that HOPE IV is a 
tenant-based program implemented by the PHAs. Beyond specifying 
minimum age, level of frailty and income requirements, HUD has 
allowed considerable flexibility in local implementation of the 
HOPE IV coordinator, obtain matching funds for its share of the 
cost of services, and serve as a contractor for service 
delivery.
    The second interim report was published in August 1996.
    This report describes the baseline characteristics of the 
program participants and those of a comparison group composed 
of frail elderly recipients of Section 8 rental assistance who 
are not receiving HOPE IV supportive services. It also presents 
the HOPE IV participants' initial view of the program and it's 
services.
    The PHAs have had to work very hard to get the HOPE IV 
program fully operational.--Most HOPE IV grantees have had to 
modify their normal Section 8 operating procedures and initiate 
an array of new linkages with other agencies in the community 
to recruit participants, help them relocate, and meet the 
special challenges of serving the very frail elderly. Two years 
into the program, the PHAs continue to have difficulties 
finding candidates not in assisted housing who are sufficiently 
frail. After two-years, only one-third of the projected slots 
have been filled. The grantees have had to help the 
participants find new housing (almost 25 percent of the 
eligible candidates) to be eligible for the program and 
physically move. This was unexpected, but many homes did not 
meet Section 8 housing quality standards and the landlords were 
unwilling to upgrade them; in other cases the sponsoring PHA 
chose a program design option that permitted targeting services 
to a specific neighborhood so applicants had to move to 
participate. Some of the eligible participants could not make 
the transition into new housing and they were lost to the 
program. The comparison group survey shows that there are frail 
elderly receiving Section 8 assistance who need the program's 
services, but these elderly people are not eligible for HOPE IV 
services because HUD opted to selected participants from the 
waiting list, not from current recipients.
    Even though the HOPE IV participants are considered very 
frail, over 20 percent of the participants do not meet the 
required level of frailty by HOPE IV program standards.--There 
are explanations for this disparity. First, the grantees had 
considerable difficulty interpreting the eligibility criteria 
regarding ADL deficiency as defined by the program. The 
professional assessment instruments available for measuring 
frailty are not perfectly suited for assessing frailty required 
by HOPE IV. Second, prior research in measuring ADL difficulty 
shows self-reports (which these are) tend to be inaccurate 
because the person has either compensated for the failure by 
changing how they approach an activity they have trouble 
performing or because they are unaware that they are 
functionally declining.
    Even though not all HOPE IV participants meet the minimum 
ADL criteria for eligibility, the HOPE IV program appears to 
appropriately targeted to those at risk of being 
institutionalized.--The HOPE IV participants are much frailer 
than non-institutionalized elderly persons in the general 
population. However, they are less frail than persons in 
community based programs for nursing home eligible persons or 
than persons in nursing homes.
    Even though most HOPE IV participants are considered very 
frail, with many adverse health conditions, they actively 
participate in activities outside the home and enjoy social 
contact.--Over half of the participants report they are 
satisfied with their lives, like their neighborhoods and living 
arrangements, have good appetites, have control over their 
activities, and have few worries. Almost all say that the HOPE 
IV program is integral to keeping them independent.

    c. evaluation of the congregate housing services program (chsp)

    The New Congregate Housing services program was authorized 
under the National Affordable Housing Act of 1990 and amended 
by the Housing and Community Development Act of 1992.
    The (CHSP) combines project-based rental assistance with 
community-based supportive services to help low-income frail 
elderly and non-elderly persons with disabilities maintain 
independence and avoid institutionalization. In addition to 
rental assistance, HUD pays 40 percent of the supportive 
services cost, the grantees pay 50 percent of the cost, and the 
participants pay 10 percent, if they are able. To be eligible 
for the program, residents must need assistance with at least 
three activities of daily living (ADL) as defined by HUD or, if 
they are non-elderly, they must have temporary or permanent 
disabilities.
    The second interim report of the CHSP evaluation project 
was published October 1996.
    The third interim report describes the characteristics of 
the program participants, their functional status, the services 
received, the cost of the program and the impact of the 
program.
    The CHSP appears to be targeted to those at risk of being 
institutionalized and who are likely to be appropriately served 
by community-based options.--CHSP participants are older and 
much frailer (in terms of ADL criteria) than elderly persons in 
the general population, but they are somewhat similar to 
residents of more restrictive environments such as board and 
care homes, and in some cases, nursing homes.
    Although overall the program participants include a 
substantial proportion of very old people (75 years or older) 
most of whom have six or more ADL impairments, about 22 percent 
of the program participants report having fewer than three 
ADLs.--This is for the same reasons as in the HOPE for Elderly 
Independence program: difficulty interpreting the eligibility 
criteria regarding ADL deficiency; problems with the 
professional assessment instruments available for measuring 
frailty; and inaccuracy of self reports.
    About half of the original baseline participants have left 
the program.--Because the CHSP participants are so frail and 
old, a high number are not able to continue to live 
independently, even with CHSP services. An overwhelming 
majority (71 percent) of those who left the program moved to a 
more restrictive environment or died. Of those remaining in the 
program, 45 percent of the participants report more ADL 
limitations than at baseline, 31 percent fewer, and 24 percent 
report the same number.

Comparison of HOPE IV and CHSP

    Both programs appear to be targeted to those at risk of 
being institutionalized and who are likely to be appropriately 
served by community-based options.--The two populations are 
very similar in most reports, except that the HOPE IV 
participants are frailer at a younger age. In general, elderly 
participants in both programs are much frailer (in terms of ADL 
criteria) than elderly persons in the same age range in the 
general population, even though about 20 percent of the 
participants currently in each of the programs do not meet the 
strict level of frailty required by the program standards.
    In many cases, coordinated service delivery is new to the 
persons in these programs, particularly the HOPE IV elderly. 
This coordination has resulted in individual participants 
receiving greater total amounts of assistance than before 
participation. However, the level of assistance necessary to 
maintain independence with these populations corresponds to the 
level of frailty and impairment of the participants.--Most 
participants receiving services say they are satisfied with the 
program, especially HOPE IV participants, 86 percent of which 
say they are very satisfied. However, around one-fourth of the 
elderly in these programs say that they need more services to 
remain independent.

               d. service coordinator program evaluation

    The Office of Policy Development and Research completed an 
evaluation of the Service Coordinator Program (SCP) in early 
1996. The major goal of study was to assess the effectiveness 
of the SCP, which pays the cost of a service coordinator who 
arranges to bring the needed supportive services to the elderly 
and persons with disabilities so that they may continue to live 
independently; the program does not pay for the cost of the 
services. The evaluation objectives were to describe early 
implementation experiences of SCPs; ongoing program operations; 
and resident satisfaction with the program.
    There are several policy relevant findings:
    The study provides evidence that the program worked 
effectively. Across the 18 study sites, residents were very 
satisfied with the program and the service coordinator. Even 
residents who believed that they did not currently need any 
help from the service coordinator indicated that they liked 
knowing that assistance was available should they need it.
    Property managers and service coordinators believed that 
the SCP had prevented early institutionalization of some 
residents. Their estimates of the number of residents able to 
continue living independently as a result of the SCP ranged 
from 3 to 30 per project, or about 12 percent of residents on 
average across projects.
    The flexibility of the program allowed service coordinators 
to address the myriad of supportive service needs of their 
residents, which ranged from coordinating transportation to 
medical-related services.

                   ITEM 8--DEPARTMENT OF THE INTERIOR

                              ----------                              


               Departmental Office for Equal Opportunity

    In 1995 and 1996, the Departmental Office for Equal 
Opportunity (OEO) civil rights mission was to ensure compliance 
with the various Federal laws and regulations that prohibit 
discrimination on the bases of race, color, national origin, 
age, and disability in programs and activities that received 
Federal financial assistance. The Office also served as the 
focal point for all equal opportunity functions in the 
Department of the Interior. During the period, the Departmental 
OEO provided technical assistance on age discrimination matters 
to bureaus and offices of the Department and to entities of 
State and local governments. The Office developed policies and 
programs relating to age discrimination compliance and 
enforcement matters. Work force data based on age and other 
factors were collected and analyzed for the purpose of 
identifying illegal equal employment trends. Age discrimination 
complaints were adjudicated. In instances where age 
discrimination complaints were filed against the Department, 
the Departmental OEO routinely issued final agency decisions in 
response to such cases. In 1996, the Department's civil rights 
and Federal equal employment programs were the focus of 
``reinvention'' laboratories which were associated with the 
Administration's National Performance Review Initiative. These 
laboratories served to improve customer service with respect to 
identifying instances of age discrimination; investigating and 
resolving civil rights complaints including ones that allege 
age discrimination; and, reengineering complaint processing 
practices that proved costly and inefficient. On March 4, 1996, 
the Interior Management Council formed a ``Diversity Task 
Force'' to review the affirmative employment issues regarding 
under-representation in the Department of the Interior. The 
Task Force looked at, among other concerns, age discrimination 
issues affecting the Department in such areas as recruitment, 
retention and employee development, and performance management 
standards. Age factors were considered by the Task Force in 
studying these issues. During the period, an electronic home 
page was developed on the ``Internet.'' The home page described 
the Department's nondiscrimination policies and the procedures 
for filing complaints including those based upon age. Also, 
civil rights training was conducted for all bureaus and offices 
of the Department on the requirements of the Age Discrimination 
Act of 1975. In addition, the Departmental OEO oversaw the 
conduct of complaint investigations and compliance reviews and 
the resolution of accessibility problems in areas where 
federally assisted and federally conducted program areas. These 
activities also included people with disabilities who were 
predominantly senior citizens.

          Office of Surface Mining Reclamation and Enforcement

    The Office of Surface Mining Reclamation and Enforcement 
(OSM) is committed to ensuring that persons are provided equal 
opportunity in all employment matters. During calendar years 
1995 and 1996, a policy statement from the Director of OSM was 
in effect which stated that discrimination based on age (40 
years of age and older) will not be tolerated. In addition, 
during calendar year 1995, a diversity policy statement was 
issued committing OSM to creating and maintaining a diverse 
work force that would be inclusive of elderly persons. Older 
workers are represented in most of OSM's occupational series. 
During Calendar year 1995, OSM's work force shrank from 874 to 
640 employees due to a ``Reduction-In-Force'' and retirements. 
The bureau recognized that these types of situations could 
cause some older workers to experience work changes or stress. 
In order to help all its workers deal with these situations, 
OSM sponsored a number of seminars on ``change.'' These 
seminars were designed to assist individuals in the transition 
from work to retirement or from one occupation to another. 
Older workers were also given the opportunity to attend various 
retirement seminars. Also, awards for 25, 30, and 35 years of 
service were given to many OSM employees in calendar years 1995 
and 1996.

                     U.S. Fish and Wildlife Service

    The U.S. Fish and Wildlife Service (Service) recognizes its 
responsibility for providing opportunities to all citizens 
throughout its system and strives to ensure that aging citizens 
are fully utilized and supported through special programs, 
volunteerism, employment opportunities and the modification of 
facilities to improve accessibility.
    In 1995, the Service employed a total of 7,242 persons. Of 
that number, 4,764 employees were 40 years of age and older. 
This represented 66 percent of the total work force. Of the 
4,764 employees, 269 were 60 years and older and worked various 
schedules in a wide variety of occupations with the majority 
employed in the biological sciences positions. The following 
occupational categories are reflective of that group:
          2,179 (46%) were in Professional positions with 86 
        (4%) of them over the age of 60;
          926 (19%) were in Administrative positions with 40 
        (4%) of them over the age of 60;
          627 (13%) were in Technical positions with 48 (8%) of 
        them over the age of 60;
          466 (10%) were in Clerical positions with 37 (8%) of 
        them over the age of 60;
          14 (.3% were in Other positions with (7%) of them 
        over the age of 60; and
          552 (12%) were in Wage Grade positions with 57 (10%) 
        of them over the age of 60.
    Through its Office of Human Resources, the Service provided 
training and technical assistance to managers, supervisors and 
equal employment opportunity counselors on the regulations and 
guidelines governing age discrimination to sensitize them to 
the rights of employees who were 40 and older. In 1995, there 
were a total of 60 employment related discrimination complaints 
filed Service wide. Of these, 16 (26.7%) were filed alleging 
discrimination on the basis of age (40 and above). The Service 
investigated a total of 45 federally assisted program related 
complaints, of which 5 (11.1%) were filed alleging 
discrimination on the basis of age (40 and above). The Service 
increased its efforts in making programs, activities and 
facilities more accessible to persons with disabilities and to 
meet the needs of older employees and citizens. There were more 
than 23,000 volunteers Service-wide including 1,937 (8.4%) 
individuals over the age of 61. The Service sponsored 
recreational and environmental education programs in which 
senior citizens volunteered at National Wildlife Refuges, Fish 
Hatcheries, and Ecological Services Field Stations. The seniors 
conducted tours of Service facilities and answered questions 
about camping, fishing, hiking, and wildlife viewing. The 
Service entered into cooperative agreements; such as, Sullys 
Hill Visitor Center and the Devils Lake Retired Senior 
Volunteer Program (RSVP) and the ``Serendipity'' Club at the 
Salvation Army Senior Citizen Center, in Anchorage, Alaska.
    In 1996, the Service employed a total of 6,997 persons. Of 
that number, 4,331 employees were 40 years of age and older. 
This represents 62 percent of the total work force. Of the 
4,331 employees, 148 were 60 years and older and worked various 
schedules in a wide variety of occupations with the majority 
employed in the biological sciences positions.
    The following occupational categories are reflective of 
that group:
          1,972 (46%) were in Professional positions with 43 
        (2%) of them over the age of 60;
          873 (20%) were in Administrative positions with 25 
        (3%) of them over the age of 60;
          585 (14%) were in Technical positions with 27 (5%) of 
        them over the age of 60;
          387 (9%) were in Clerical positions with 19 (5%) of 
        them over the age of 60;
          13 (.3%) were in Other positions with 0 of them over 
        the age of 60; and
          501 (12%) were in Wage Grade positions with 34 (7%) 
        of them over the age of 60.
    There were more than 25,000 volunteers Service-wide 
including 3,542 (14.2% individuals over the age of 61. The 
Service sponsored recreational and environmental education 
programs inwhich senior citizens volunteered at National 
Wildlife Refuges, Fish Hatcheries, and Ecological Service Field 
Stations. The seniors conducted tours of Service facilities and 
answered questions about camping, fishing, hiking, and wildlife 
viewing. The Service received a significant portion of written and 
telephonic inquiries from retired individuals who were interested in 
natural resource oriented issues, especially concerning endangered 
species and non-game birds and animals. The Service's publication unit 
made available educational materials and provided practical methods and 
techniques to enhance fish and wildlife habitats to the public. The 
Service continued its involvement in cooperative agreements with 
various Senior Centers and Organizations.
    The Service's Office of Human Resources provided training 
and technical assistance to Service managers, supervisors and 
equal employment opportunity counselors on the regulations and 
guidelines governing age discrimination. This training enhanced 
their skills by enabling them to informally resolve complaints 
and sensitizing them to the rights of employees who were 40 and 
older. In 1996, there were a total of 45 employment related 
discrimination complaints filed Service wide. Of these, 16 
(35.6%) were filed alleging discrimination on the basis of age 
(40 and above). Additionally, the Service investigated a total 
of 34 Federally Assisted Program related complaints, of which 3 
(8.8%) were filed alleging discrimination on the basis of age 
(40 and above).

                         National Park Service

    The National Park Service (NPS) continues to ensure that a 
broad range of services and activities are provided to the 
visiting public including senior citizens. The NPS hosts the 
``Senior Community Service Employment Program (SCSEP).'' This 
activity is carried out in cooperation with the U.S. Forest 
Service and Voyageurs National Park. Program participants must 
possess a valid State driver's license; be at least 55 years of 
age; pass a physical examination and live in or near Voyageurs 
National Park. Under SCSEP, Voyageurs National Park employed 
four senior citizens, i.e., three maintenance workers and one 
receptionist. The program seeks to provide supplemental income 
to seniors in general and to rural communities in particular. 
It provides invaluable work experience to older Americans. This 
employment program has worked very well at Voyageurs. The NPS 
also offers the ``Volunteers-in-Parks Program'' which operates 
at Voyageurs and other national parks. The program serves a 
variety of older couples who work at various park sites during 
the summer.
    The George Washington National Monument serves as a 
worksite for older Americans who are employed by the Area 
Agency on Aging. The Agency on Aging pays the salary and the 
park provides work projects, supervision and training for 
program participants. Participants usually work part-time (20 
hours per week).
    The Golden Age Passport, for persons 62 and older, is a 
lifetime entrance pass to most national parks monuments, 
historic sites, recreation areas, and national wildlife refuges 
that charge an entrance fee. The passport admits the pass 
holder and any accompanying passengers in private automobiles. 
The Golden Age Passport also provides a 50% discount on fees 
charged for park services, facilities and services such as 
parking, boat launching, swimming, camping, and cave tours.
    The NPS continues to ensure nondiscrimination on the basis 
of age in its workforce. For example, in 1996, out of 288 
issues raised in complaints of alleged discrimination, in 40 
instances, allegations of age discrimination were raised. The 
NPS processed a total of 26 complaints of alleged age 
discrimination out of a total of 99 complaints received during 
the period.
    The NPS Accessibility Office is an office that is staffed 
by experienced park and recreation professionals who have 
provided park and recreation services to special populations 
including the elderly and people with disabilities. A primary 
goal of the office is to develop and implement a comprehensive 
and system wide approach for ensuring that the national park 
system is readily accessible to all people including the 
elderly and people with disabilities. Since its creation, the 
office has been providing training and technical assistance to 
all NPS regional offices in an effort to improve and make more 
accessible park and recreation services to senior citizens and 
other special populations.

                         U.S. Geological Survey

    The U.S. Geological Survey (USGS) provides opportunities to 
all individuals throughout its system and ensures that older 
individuals were utilized through special programs, 
volunteerism, and employment opportunities.
    In 1996, USGS employed a total of 8,949 individuals. There 
were, 5,700 (64%) USGS employees aged 40 and over. Of USGS 
employees aged 40 and over, there were 334 (6%) employees who 
were 60 years of age and older, and there was one employee over 
the age of 80.
    The majority of USGS' mission related occupations, which 
include occupations such as hydrologists, geologists, and 
cartographers, are in the professional category. Of the 5,700 
USGS employees age 40 and over, there were 2,777 (49%) in 
professional positions, 191 (3%) of whom were age 60 and over, 
and one employee over the age of 80. Other demographic 
information regarding USGS employees age 40 and over was as 
follows:
          855 (15%) were in the ``administrative'' positions 
        with 28 (3%) of them aged 60 and over;
          1,645 (29%) were in ``technical'' positions with 77 
        (5%) of them aged 60 and over;
          301 (5%) were in ``clerical'' positions with 33 (11%) 
        of them aged 60 and over;
          12 (0.2%) were in other positions with none of them 
        aged 60 and over; and
          110 (2%) were in the ``wage grade'' positions with 5 
        (5%) aged 60 and over.
    In 1995, USGS employed a total of 9,220 people. There were 
5,824 (63%) Survey employees aged 40 and over. Of USGS 
employees aged 40 and over, there were 400 (7%) employees who 
were 60 years of age and older, and four employees aged 80 and 
over.
    In USGS' professional occupational series, 2,883 (49%) of 
the employees were aged 40 and over, 237 (8%) were aged 60 and 
over, and four employees aged 80 and over. Other demographic 
information regarding USGS employees age 40 and over was as 
follows:
          807 (14%) were in the ``administrative'' positions 
        with 31 (4%) of them aged 60 and over;
          1,686 (29%) were in ``technical'' positions with 34 
        (11%) of them aged 60 and over;
          316 (5%) were in ``clerical'' positions with 34 (11%) 
        of them aged 60 and over;
          8 (0.1%) were in other positions with none of them 
        aged 60 and over; and
          124 (2%) were in the ``wage grade'' positions with 8 
        (6%) aged 60 and over.
    In addition to the full time employees, USGS also had many 
volunteers. These individuals provided outstanding services to 
USGS and the public nation-wide in a variety of capacities. The 
various types of volunteer opportunities, and the number of 
individuals involved, were:

------------------------------------------------------------------------
                      Categories                          1995     1996 
------------------------------------------------------------------------
USGS Retirees.........................................       50       50
Other Retirees........................................      200      300
Docents...............................................       25       15
Scientists Emeritus...................................      252      260
                                                       -----------------
      Totals..........................................      527      625
------------------------------------------------------------------------

    The USGS Scientist Emeriti are welcomed back to the USGS 
after retirement to continue important scientific research. The 
USGS benefits immeasurably from the accumulated knowledge, 
experience, and dedication of over 250 Scientist Emeritus. For 
example, Scientist Emeritus astrogeologist, Gene Shoemaker and 
his wife, contributed to the understanding of our solar system 
by significantly sharing in the discovery of Comet Shoemaker-
Levy.
    The following are examples of some of the other activities 
in which USGS' volunteers were involved:
    A retired Federal government employee logged over 4,000 
hours of volunteer service working in the Reston, Virginia, 
Earth Science Information Center filing maps and brochures and 
assisting customers. He epitomized the highest standards of 
customer service recognized at the USGS.
    USGS retirees served as docents in the National Visitors 
Center, leading tours and providing information about the USGS 
to groups from pre-school age to senior citizens.
    Scores of senior citizens volunteered nationwide for the 
Water Resources Division, collecting analyzing water quality 
data in their communities.
    Two retirees from outside the Federal sector donated their 
time in Reston, Virginia, to provide critical assistance to the 
development and management of the USGS Earth Science Corps, a 
project that utilizes hundreds of citizens across the country 
to update USGS maps. It was estimated that within the Earth 
Science Corps contingent, 200 volunteers made valuable 
contributions to the USGS and the Nation by providing accurate, 
up-to-date geographic information about their communities.
    Two retirees served as volunteers on a special project in 
Alaska to investigate the movement and impact of the Bering 
Glacier. Working under rugged conditions, the volunteers helped 
make it possible for USGS scientists to complete numerous 
studies and advance our understanding of this significant 
glacier.
    Senior citizens and retirees with backgrounds in 
mathematics and computer science volunteered to instruct 
employees on software applications, enter data and evaluate 
software and hardware upgrades.
    In the Water Resources Division, Volunteers aged 60 and 
over contributed their services to the USGS in the following 
ways:
          1. Assisted in processing computer data for the 
        Annual Data Report;
          2. Worked on surface-water and quality-water record;
          3. Assisted with field trips for the National Science 
        Foundation and USGS Water Workshops;
          4. Completed Volume VI, Water Resources Division 
        History, 1957-1966;
          5. Reviewed sediment laboratories for the Office of 
        Surface Water, examining method consistencies of Water 
        Resources Division sediment laboratories, and providing 
        insight to the Sediment Action Laboratory Subcommittee;
          6. Completed two models: Blaine Aquifer, Oklahoma, 
        and the High Plains Aquifer, Twin Platte, Nebraska;
          7. Provided support and guidance to the Central 
        Region Hydrologist's office;
          8. Provided technical support and consultation for 
        flood hydrology and hydraulics program;
          9. Reviewed Titan reports for McConnell Air Force 
        Base, aquifer maps, reports, and other services as 
        necessary;
          10. Assisted in making discharge measurements and 
        checking gages;
          11. Assisted in the ``Extreme Storm Study'';
          12. Prepared for and attended the International 
        Records Annual meeting in Maple Creek, Saskatchewan, 
        Canada;
          13. Helped in selecting and monitoring wells for USGS 
        observation well network;
          14. Worked on the South Dakota History, Volume 7;
          15. Assisted with Water Resources data collection and 
        processing in the Data Unit;
          16. Processed East Fork River bedload report and 
        Wyoming dye tracing report;
          17. Completed reports on river sediments, Powder 
        River, Orinoco River, and Amazon River;
          18. Revised the report entitled, Transport, Behavior, 
        and Fate of Volatile Organic Compounds in Streams and 
        Rivers;
          19. Conducted laboratory work for the Nation Research 
        Project in Boulder, Colorado; and,
          20. Consulted on sediment transport, data collection, 
        and interpretation of data.

                       Bureau of Land Management

    The Bureau of Land Management (BLM) administers a multi-
faceted, multiple-use natural resource management program 
intended to serve all members of the public regardless of age, 
gender, national origin, race, color, religion or mental or 
physical disability. It fosters an environment of equality of 
opportunity through initiatives aimed at programmatic and work 
force diversification. The BLM's approach incorporates broad 
policies and practices which encourage participation and 
inclusion among all employees, applicants for employment, users 
of the public lands, and other members of the public who 
support the BLM's mission.
    The BLM does not routinely gather and publish information 
on age groups within its nationwide work force. However, as of 
September 30, 1997, the BLM employed 8,949 permanent employees, 
of whom 705 individuals, or nearly 8 per cent of the work 
force, were eligible for voluntary retirement. This level of 
total employment is down from previous years, reflecting the 
effects of voluntary retirements and Government-wide early-out 
and other retirement incentive programs offered during 1995 and 
1996 when the BLM, along with other Federal agencies, lost a 
considerable number of older employees.
    During 1996, approximately 17,000 persons through the 
contiguous United States and Alaska contributed their skills 
and services to the BLM's natural resource management and 
protection activities as volunteers and hosted workers. Again, 
while no statistics on age were maintained, an appreciable 
number of individuals over the age of 65 traditionally have 
participated in the BLM's volunteer programs and have received 
public recognition for their contributions and dedication.
    The BLM values the skills, perspectives and energy that 
older Americans can bring to its programs, both as employees 
and as volunteer workers. And recognizing its debt to the 
efforts of previous generations, the BLM carefully monitors its 
operations to ensure that older employees and volunteers can 
contribute meaningfully in accordance with their talents and 
interests. Finally, the BLM strives to ensure that all members 
of the public have full access to BLM installations, 
facilities, and programs--without discrimination or restricted 
access based upon age--in order to use, enjoy, and appreciate 
America's public lands.

                        Bureau of Indian Affairs

    During the reporting period of 1995 and 1996, the Bureau of 
Indian Affairs (BIA) administered initiatives and programs to 
benefit older (aging) American Indians and Alaskan Natives. 
More specifically, the BIA's Division of Social Services 
provided and financed adults with custodial and protective care 
services. These services were provided in homes, group homes, 
and nursing care facilities for elderly persons who lacked the 
financial, physical and mental capacity to care for themselves. 
Other aging citizens have received protective and counseling 
services without custodial care payments. They coordinated 
intensive skill nursing care service needs for aging residents 
through referrals to other Federal, State or local agencies. 
This office is currently establishing standards that will 
upgrade custodial care facilities making them eligible to 
receive Medicare and Medicaid payments and provide better 
subsequent custodial care to eligible aging Native Americans. 
The BIA's Social Services Division administers a Housing 
Improvement Program that makes existing housing repairs and 
renovations and some new home constructions on Indian 
reservations or communities. This program is a grant program 
designed to improve housing standards for citizens who are not 
qualified for such assistance under conventional housing 
assistance programs. Program participants are selected from 
weighted variables that favor low income individuals, people 
with disabilities, elderly applicants. Furthermore, Tribal 
governments are ``638 Contracts'' as a means for meeting the 
special housing needs of elderly Native Americans.
    BIA's Office of Indian Education Programs has developed and 
administers a Family and Child Education (FACE) Program. FACE 
is a family literacy program. The program serves all family 
members including the elderly who have guardian responsibility 
for minor children. The program provides for early childhood 
and adult education, instructions on parenting skills. These 
services are provided in homes, community centers, and schools. 
These services empower elderly Native Americans to become more 
proficient in caring for children that remain in their custody.
    BIA's Office for Equal Employment Opportunity Programs 
continues to vigorously enforce the Age Discrimination in 
Employment Act which prohibits discrimination on the basis of 
age in its work force. These anti-discrimination enforcement 
efforts ensure that older employees may continue their careers 
uninhibited.

                      Minerals Management Service

    The Minerals Management Service (MMS) continues to work to 
support programs for older Americans. MMS's work force 
statistics are as follows:
          Seventy-eight percent of MMS' work force is comprised 
        of employees aged 40 and over (1,362 or 1737);
          Older employees are well represented in a variety of 
        occupations within MMS including accountants, auditor, 
        computer specialist, engineers, and physical 
        scientists; and,
          The MMS has implemented and continues to implement 
        effective personnel management policies to ensure that 
        equal opportunity is provided to all employees and 
        applicants, including the aged.
    The MMS continues to perform its mission-related functions 
with diligence and with appreciation of the importance of its 
actions. A major mission responsibility affecting large numbers 
of citizens is the approval of mineral royalty payments of 
various landholders, including numerous older Americans who 
often depend heavily on these payments to meet their basic 
human needs and rely on the ability of the MMS to effectively 
discharge their financial responsibilities.
    The MMS offshore mission has the ultimate objective of 
increasing domestic mineral (oil and gas) production through 
offshore Resources, thereby decreasing its dependence on 
foreign imports. Such activities have a significant effect on 
the economic well-being of all Americans, especially older 
Americans. In summary, the MMS has a strong commitment to all 
of its employees including older workers. Older workers are a 
source of valuable knowledge and experience and a significant 
factor in the success of the MMS mission.

                         Bureau of Reclamation

    The Bureau of Reclamation (Reclamation) conducts many 
activities throughout the year that affect and benefit aged 
individuals. Its Personnel Offices maintain contact with and 
provide services to many retirees who need advice or have 
questions concerning their retirement and health benefits. In 
addition, retirees and their spouses attend annual health 
insurance fairs where representatives from insurance carriers 
are available to discuss the provisions of, or changes to, 
their respective medical plans. Several of Reclamation's 
regional offices continue to mail out a monthly newsletter to 
all retirees. The newsletters contain information on 
Reclamation, current employees, past employees, and is highly 
regarded by retirees as a way to keep in touch. Additionally, 
pre-retirement briefings and seminars are held for all 
interested employees who are within five years of retirement 
eligibility.
    Work and Family Programs.--The Bureau of Reclamation 
established a Work and Family Team (WAFT) in September 1995 to 
implement the President's directive on Family-Friendly Federal 
Work Arrangements. The Team is comprised of representatives 
from all the Regions in Reclamation. Initiatives taken on 
behalf of older Americans and their families are principally 
addressed in this arena. The Bureau of Reclamation maintains 
family friendly workplace information in the Human Resources 
Offices, located in 7 geographically dispersed regions. A Human 
Resources Center is established within each office to provide 
information and assistance on various Human Resources. It is a 
``One Stop Shopping Center'' including job information, 
References and Resources Library, Equal Employment Opportunity, 
Work and Family Resources Issues (to include elder care) and, 
etc. The Office of Personnel Management's Handbook on Child and 
Elder Care is available as well as information from the 
American Association of Retired Persons. The WAFT has developed 
a Web page to provide information on Resources, topics of 
interest and updates on information relating to family issues 
as well as a LAN address, ``TALKTOWAFT,'' to enable employees 
to send questions about work and family policies or to ask for 
information. In addition, the WAFT has developed a handbook on 
a variety of family-related topics. One of the sections in the 
handbook addresses elder care and Resources.
    Family and Medical Leave Initiatives.--Reclamation is in 
the process of testing an alternative work schedule program, 
which would allow employees greater flexibility in constructing 
their work hours to accommodate family needs. This is in 
addition to its telecommuting initiative already in place and 
vigorous support of the Family and Medical Leave Acts.
    Employment Opportunities.--Reemployed annuitants are hired 
to perform special projects or provide assistance in 
specialized technical areas of work since they are able to 
offer invaluable experience and expertise to these assignments. 
Our Boise, Idaho, Office has signed a Memorandum of Agreement 
with the State of Idaho, Department of Health and Welfare, to 
provide work opportunities for individual interested in getting 
back into the work environment. The Region provides work 
opportunities while the State provides the salary. The period 
of time is usually 10-15 weeks. Traditionally, the individuals 
have been senior citizens.

                     ITEM 9--DEPARTMENT OF JUSTICE

                              ----------                              


                 INITIATIVES RELATED TO OLDER AMERICANS

                              Introduction

    As the largest law firm in the Nation, the Department of 
Justice (DOJ) serves as counsel for its citizens. It represents 
them in enforcing the law in the public interest. Through its 
thousands of lawyers, investigators, and agents, the Department 
plays the key role in protecting against criminals and 
subversion, ensuring healthy competition of business in our 
free enterprise system, safeguarding the consumer, and 
enforcing drug, immigration, and naturalization laws. The 
Department also plays a significant role in protecting citizens 
through its efforts for effective law enforcement, crime 
prevention, crime detection, and prosecution and rehabilitation 
of offenders.
    In addition, the Department conducts all suits in the 
Supreme Court in which the United States is concerned. It 
represents the Government in legal matters generally, rendering 
legal advice and opinions, upon request, to the President and 
to the heads of the executive departments. The Attorney General 
supervises and directs these activities, as well as those of 
the U.S. Attorneys and U.S. Marshals in the various judicial 
districts around the country.
    Within the Department, two components--the Civil Rights 
Division and the Office of Justice Programs--conduct 
initiatives related to older Americans.

                         Civil Rights Division

    The Civil Rights Division was established in 1957 to secure 
effective Federal enforcement of civil rights. The Division is 
the primary institution within the Federal Government 
responsible for enforcing Federal statutes prohibiting 
discrimination on the basis of race, sex, disability, religion, 
and national origin.
Americans with Disabilities Act (ADA) Enforcement
    The Division's Disability Rights Section enforces the ADA's 
provisions prohibiting discrimination against people with 
disabilities in state and local government services and places 
of public accommodation. The Section has established a 
comprehensive technical assistance program to educate those 
with rights and responsibilities under the law. This program 
includes the establishment of an ADA Information File, 
containing over 70 documents, in 15,000 public libraries across 
the country, a toll-free ADA Information Line, which receives 
over 100,000 calls per year, and an ADA home page on the World 
Wide Web, which receives over 50,000 hits per week. The 
Internet address is www.usdoj.gov/crt/adahom1.htm.
    Through the ADA technical assistance grant program, the 
American Association of Retired Persons (AARP) has developed 
materials to help older persons understand their rights and to 
help businesses and agencies serving older persons understand 
their obligations under the law. The AARP provides training to 
service providers, advocates, and older persons throughout the 
country.
    Since 1992, the Division has reached voluntary agreements 
with businesses and local governments in more than 600 cases 
involving state and local government services and the private 
sector. The resolution of these complaints has resulted in the 
removal of architectural and communication barriers in a wide 
variety of settings, including retail stores, restaurants, 
hotels, stadiums, and town halls. A 1996 agreement with the 
Cineplex Odeon Corporation, one of the Nation's largest 
operators of motion picture theaters, established a model for 
the industry on compliance with the ADA's requirements for 
assistive listening devices used by persons who are hard-of-
hearing.
Civil Rights of Institutionalized Persons Act (CRIPA) Enforcement
    The Division's Special Litigation Section has 
responsibility under CRIPA to investigate conditions in 
publicly operated nursing homes and to file suits where there 
is a pattern or practice of violations of the constitutional or 
Federal statutory rights of nursing home residents, including 
the right to adequate care and treatment. In 1996, the Section 
initiated investigations of several publicly operated nursing 
homes.
    Further information about the activities of the Civil 
Rights Division is available online at www.usdoj.gov/crt or by 
calling the Department of Justice's Office of Public Affairs at 
202/514-2007.

                       Office of Justice Programs

    Since 1984, the Office of Justice Programs (OJP) has 
provided Federal leadership in developing the nation's capacity 
to prevent and control crime and delinquency, improve the 
criminal and juvenile justice systems, increase knowledge about 
crime and related issues, and assist crime victims. OJP is 
comprised of five program bureaus, three Crime Act program 
offices, the Executive Office for Weed and Seed, the American 
Indian and Alaskan Native Desk (AI/AN), and the Violence 
Against Women Office (VAWO).
    The Bureau of Justice Assistance (BJA) provides funding, 
training, and technical assistance to state and local 
governments to combat violent and drug-related crime and help 
improve the criminal justice system. It also administers the 
Edward Byrne Memorial State and Local Law Enforcement 
Assistance Program, the Local Law Enforcement Block Grants, the 
State Criminal Alien Assistance Program, the Public Safety 
Officers' Benefits Program, Regional Information Sharing 
Systems, and the Church Arson Prevention Grant Program.
    The Bureau of Justice Statistics (BJS) is the principal 
criminal justice statistical agency in the nation. BJS collects 
and analyzes statistical data on crime, criminal offenders, 
crime victims, and the operation of justice systems at all 
levels of government. It also provides financial and technical 
support to state statistical agencies and administers special 
programs that aid state and local governments in improving 
their criminal history records and information systems, 
including grant programs that implement the Brady Handgun 
Violence Prevention Act and the National Child Protection Act.
    The National Institute of Justice (NIJ) is the principal 
research and evaluation agency in the Department of Justice. 
NIJ supports research and development programs, conducts 
demonstrations of innovative approaches to improve criminal 
justice, develops new criminal justice technologies, and 
evaluates the effectiveness of justice programs. NIJ also 
provides primary support for the National Criminal Justice 
Reference Service, a clearinghouse of criminal justice-related 
publications, articles, videotapes, and online information.
    The Office of Juvenile Justice and Delinquency Prevention 
(OJJDP) provides Federal leadership in preventing and 
controlling juvenile crime and improving the juvenile justice 
system at state and local levels. OJJDP also provides grants 
and contracts to states to help them improve their juvenile 
justice systems and sponsors innovative research, 
demonstration, evaluation, statistics, replication, technical 
assistance, and training programs to help improve the nation's 
understanding of and response to juvenile violence and 
delinquency. In addition, OJJDP administers the Missing and 
Exploited Children's program and four programs funded under the 
Victims of Child Abuse Act.
    The Office for Victims of Crime (OVC) provides Federal 
leadership in assisting victims of crime and their families. 
OVC administers two grant programs created by the Victims of 
Crime Act of 1984 (VOCA). The Victims Assistance Program gives 
grants to states to support programs that provide direct 
assistance to crime victims. State victim assistance 
subgrantees reported expenditures of over $2 million for elder 
abuse victims in Fiscal Year 1996 (from October 1, 1995 through 
September 30, 1996). The Victims Compensation Program provides 
funding to state programs that compensate crime victims for 
medical and other unreimbursed expenses resulting from a 
violent crime. OVC also sponsors training for Federal, state, 
and local criminal justice officials and other professionals to 
help improve their response to crime victims and their 
families.
    The three Crime Act Offices--the Violence Against Women 
Grants Office (VAWGO), the Corrections Program Office (CPO), 
and the Drug Courts Program Office (DCPO)--administer major 
programs authorized by the 1994 Crime Act.
    VAWGO administers one formula and four discretionary grant 
programs. The grant programs are designed to help prevent, 
detect, and stop violence against women, including domestic 
violence, sexual assault and stalking.
    CPO provides financial and technical assistance to state 
and local governments to implement the corrections-related 
programs created by the Crime Act. CPO administers two formula 
and two discretionary grant programs.
    DCPO administers the discretionary drug court grant program 
authorized by Title V of the Crime Act. The purpose of the 
grant program is to provide support for the development, 
implementation, and improvement of drug courts through grants 
to local or state governments, courts, and tribal governments, 
as well as through technical assistance and training. A survey 
of 93 drug courts by OJP's Drug Court Clearinghouse found that 
1 percent of drug court participants were over age 60.
    OJP's American Indian and Alaskan Native Desk (AI/AN) 
improves outreach to tribal communities. AI/AN works to enhance 
OJP's response to tribes by coordinating funding, training, and 
technical assistance and providing information about available 
OJP resources. An overview of OJP's response to preventing and 
controlling crime in Indian Country is provided in the February 
1997 report, Office of Justice Programs Partnership Initiatives 
in Indian Country. The report is available at no cost from the 
National Criminal Justice Reference Service at 1-800/851-3420 
or online through OJP's home page at www.ojp.usdoj.gov.
    The Executive Office for Weed and Seed (EOWS) is dedicated 
to building stronger, safer communities through the Weed and 
Seed strategy, a community-based, multi-disciplinary approach 
to combating crime. EOWS works closely with United States 
Attorneys and OJP's bureaus to implement Operation Weed and 
Seed in communities throughout the country.
    Also within OJP is the Violence Against Women Office 
(VAWO), which coordinates the Department of Justice's 
legislative and other initiatives relating to violence against 
women, including intradepartmental activity. To stop violence 
against older women, the VAWO Director works with organizations 
such as the Older Women's League (OWL), the American 
Association of Retired Persons (AARP), and the National Task 
Force on Violence Against Women.
    The following describes OJP's major activities on behalf of 
older Americans:
    Working Group on Victimization of Older Persons.--OJP leads 
a Department-wide Working Group on Victimization of Older 
Persons. Participants include OJP, BJA, NIJ, OVC, VAWGO, the 
Department's Criminal Division, and the Executive Office for 
U.S. Attorneys. The Working Group explores ways to elevate the 
Department's focus on victimization of senior citizens through 
new or ongoing efforts. It also coordinates related activities 
among its member agencies and provides planning and other 
assistance to DOJ agencies in conducting initiatives related to 
older persons.
    Research.--In Fiscal Year 1996, NIJ awarded a 2-year 
research grant to Victim Services in New York City to conduct 
(in cooperation with the New York City Police Department) an 
evaluation of a program teaming community policing and social 
services to respond to elder abuse. The study is examining the 
effects of the project's public education efforts and home 
visitations to elderly residents. Preliminary findings were 
reported at the November 1996 annual meeting of the American 
Society of Criminology. The study found that home visits 
increased crime reporting, reduced the incidence of financial 
abuse, and increased the victim's confidence to call the police 
again; public education increased victims' satisfaction with 
police; and victims who received the home visits and/or public 
education information believed these interventions to be 
helpful. The final report is expected by April 1998. For 
copies, contact NIJ's National Criminal Justice Reference 
Service at 1-800/851-3420 or online at www.ncjrs.org.
    Safe Return Program.--At the direction of Congress, OJJDP 
administers this program to facilitate the identification and 
safe return of memory-impaired persons who are at risk of 
wandering from their homes. Directed by the Alzheimer's Disease 
and Related Disorders Association, the Safe Return Program 
operates a national photographic registry of memory-impaired 
persons, maintains a toll-free telephone service, provides a 
Fax Alert System, conducts ``train-the-trainers'' programs for 
law enforcement and emergency personnel, develops information 
and educational materials, conducts public awareness campaigns, 
and works to network with other ``wandering persons'' programs. 
For more information, contact the Safe Return Program at 1-800/
572-1122.
    Telemarketing Fraud.--In Fiscal Year 1996, with a $2 
million appropriation for ``programs to assist law enforcement 
in preventing and stopping marketing scams against senior 
citizens,'' BJA awarded a grant to the National Association of 
Attorneys General (NAAG) to develop a training curriculum for 
prosecutors and investigators to help address these crimes. 
NAAG is collaborating in this project with the National 
District Attorneys Association and the National White-Collar 
Crime Center. A small, regional pilot training course was held 
in San Diego in February 1998. A larger training program is 
planned in Boston, Massachusetts, in the spring of 1998. BJA 
and OVC also are funding the development of education and 
public awareness campaigns to address telemarketing fraud aimed 
at senior citizens.
    Triad.--Through a grant to the National Sheriffs' 
Association, BJA and OVC support Triad. Triad programs involve 
a three-way effort among a sheriff, the county police chief(s), 
and members of the American Association of Retired Persons 
(AARP) or other older/retired leadership in the area. These 
groups agree to work together to reduce criminal victimization 
of older citizens and enhance the delivery of law enforcement 
services to this population. Triad provides the opportunity for 
an exchange of information between law enforcement and senior 
citizens. It focuses on reducing unwarranted fear of crime and 
improving the quality of life for seniors.
    A Triad program is tailored to meet the needs of each 
community and is guided by a senior advisory council called 
SALT (Seniors and Lawmen Together). More than 415 counties 
participate in Triad nationwide, and efforts are under way to 
encourage Native American tribal governments to initiate Triad 
projects. For more information about Triad, or for help in 
starting a program, contact the National Sheriffs' Association 
at 1-800/424-7827.
    Training and Technical Assistance.--Through its Trainers' 
Bureau, OVC provides training to Federal, state, and local law 
enforcement officials on issues relating to elder abuse and 
financial exploitation of the elderly. For example, in November 
1996, OVC staff conducted a training program on elder abuse 
issues for tribal governments in Warm Springs, Oregon. The 
training conference was attended by 180 people, including 
representatives of 12 Native American tribes, as well as 6 
tribal chiefs. Further information about OVC's Trainers' Bureau 
is available from Donna Ray at 202/616-3572 or e-mail at 
[email protected].
    Victimization Statistics.--Through its National Crime 
Victimization Survey (NCVS), the OJP's Bureau of Justice 
Statistics annually collects data on crime victimization on 
individuals age 12 and older in a statistically representative 
sample of U.S. households. A BJS Special Report, Age Patterns 
of Victims of Serious Violent Crime, released in September 
1997, uses data from 1992 through 1994 to examine serious 
violent crime across different age groups. Serious violent 
crimes include rape and sexual assault, robbery, and aggravated 
assault, as measured by NCVS, and homicide from data reported 
by law enforcement agencies to the FBI.
    The report found that vulnerability to violent crime 
victimization varies across the age spectrum. The victimization 
rate increases through the teenage years, crests at around age 
20, and steadily decreases through the remaining years. This 
pattern, with some exceptions, exists across all race, sex, and 
ethnic groups. According to the report, persons age 50 or older 
made up 30 percent of the population, 12 percent of murder 
victims, and 7 percent of serious violent crime victims. Copies 
of this report are available at no cost from the BJS 
Clearinghouse at 1-800/732-3277 or online at www.ojp.usdoj.gov/
bjs/.
    Indian Country Initiatives.--OJP's American Indian/Alaska 
Native Desk is working to expand existing OJP efforts 
concerning elder abuse to address problems in Indian Country. 
It also is collaborating with the Indian Health Service at the 
U.S. Department of Health and Human Services to explore 
partnership efforts regarding elder abuse in tribal 
communities.
    Future Initiatives.--On March 30, 1998, BJA sponsored a 
focus group on elder victims of crime to discuss issues and 
plan strategies related to prevention, enforcement, and the 
response of the criminal justice system and other institutions, 
as well as to make recommendations to the Justice Department. 
Participants included staff from the OJP components, the 
Executive Office for U.S. Attorneys, the Department of 
Justice's (DOJ) Criminal Division and other representatives of 
the DOJ Working Group on Elder Victimization, representatives 
from agencies in states with the highest senior citizen 
populations, and national senior citizen organizations.
    For More Information about OJP programs or activities on 
behalf of older Americans, contact OJP's Office of 
Congressional and Public Affairs at 202/307-0703 or access the 
OJP home page at www.ojp.usdoj.gov. Funding information is 
available from the Department of Justice Response Center at 1-
800/421-6770. OJP and other criminal and juvenile justice-
related publications are available from the National Criminal 
Justice Reference Service by calling toll-free, 1-800/851-3420, 
or online at www.ncjrs.org.

                      ITEM 10--DEPARTMENT OF LABOR

    The welfare of our Nation's older citizens is a matter of 
substantial concern to the Department of Labor. The Department 
of Labor is pleased to provide this summary of the programs it 
administers which can provide helpful assistance to older 
citizens. These include--job training and related services, 
dislocated worker services, and other employment services, 
under programs administered by the Department of Labor's 
Employment and Training Administration; a public information 
and assistance program on matters relating to certain pension 
and welfare plans under programs administered by the Pension 
and Welfare Benefits Administration; the Bureau of Labor 
Statistics' statistical programs providing employment and 
unemployment data for older persons; protection for certain 
employees to take unpaid, job-protected leave to provide care 
for sick, elderly parents under a program administered by the 
Employment Standards Administration; and a Clearinghouse 
administered by the Women's Bureau which provides information 
and resources to workers and employers interested in developing 
or implementing family-friendly policies such as elder care and 
child care. These programs and services are addressed more 
fully in the following discussion.

                 EMPLOYMENT AND TRAINING ADMINISTRATION

                              introduction

    The Department of Labor's (DOL's) Employment and Training 
Administration (ETA) provided a variety of training, employment 
and related services for the Nation's older individuals during 
Program Years 1994 (July 1, 1994-June 30, 1995) and 1995 (July 
1, 1995-June 30 1996) through the following programs and 
activities: the Senior Community Service Employment Program 
(SCSEP); programs authorized under the Job Training Partnership 
Act (JTPA); and the Federal-State Employment Service system.

              senior community service employment program

    SCSEP, authorized by Title V of the Older Americans Act, 
employs low-income persons age 55 or older in a wide variety of 
part-time community service activities such as health care, 
nutrition, home repair and weatherization, child care, and in 
beautification, conservation, and restoration efforts. Program 
participants work an average of 20 hours per week in schools, 
hospitals, parks, community centers, and in other government 
and private, non-profit facilities. Participants also receive 
personal and job-related counseling, annual physical 
examinations, job training, and in many cases, referral to 
private sector jobs.
    About 82 percent of the participants are age 60 or older, 
and about 58 percent are age 65 or older. Almost three-fourths 
are female; about 40 percent have not completed high school. 
All participants are economically disadvantaged.
    Table 1 below shows SCSEP enrollment and participant 
characteristics for the program year July 1, 1994, to June 30, 
1995, in Column 1 and July 1, 1995, to June 30, 1996, in Column 
2.

 TABLE 1.--SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP): CURRENT 
 ENROLLMENT AND PARTICIPANT CHARACTERISTICS--PROGRAM YEARS JULY 1, 1994,
   TO JUNE 30, 1995, (PY94) AND JULY 1, 1995, TO JUNE 30, 1996 (PY95).  
------------------------------------------------------------------------
                                                   (PY94)       (PY95   
------------------------------------------------------------------------
Enrollment:                                                             
    Authorized positions established..........       67,645       64,600
    Unsubsidized employment rate (Percent)....         27.7         25.7
Characteristics (Percent):                                              
    Sex:                                                                
        Male..................................         27.9         27.6
        Female................................         72.1         72.4
    Educational status:                                                 
        8th grade and less....................         20.4         19.6
        9th grade through 11th grade..........         19.4         19.0
        High School graduate or equivalent....         38.1         38.8
        1-3 years of college..................         15.2         15.6
        4 years of college or more............          6.9          7.0
    Veterans..................................         13.0         13.4
    Ethnic Groups: \1\                                                  
        White.................................         59.4         59.4
        Black.................................         24.3         24.6
        Hispanic..............................         10.1         10.0
        American Indian/Alaskan Native........          1.7          1.8
        Asian/Pacific Island..................          4.3          4.1
    Economically disadvantaged................       100.00        100.0
    Poverty level or less.....................         80.7         85.4
    Age groups:*                                                        
        55-59.................................         18.9         17.2
        60-64.................................         24.5         23.7
        65-69.................................         24.4         24.8
        70-74.................................         19.2         19.8
        75 and over...........................         13.0         14.5
------------------------------------------------------------------------
\1\ Figures may not add to 100% due to rounding.                        
Source: U.S. Department of Labor, Employment and Training               
  Administration.                                                       

                 job training partnership act programs

    The Job Training Partnership Act (JTPA) provides job 
training and related assistance to economically disadvantaged 
individuals, dislocated workers, and others who face 
significant employment barriers. The ultimate goal of JTPA is 
to move program participants into permanent, self-sustaining 
employment. Under JTPA, Governors have the approval authority 
over locally developed plans and are responsible for monitoring 
local program compliance with the Act. JTPA functions through a 
public/private partnership which plans, designs and delivers 
training and other services. Private Industry Councils (PICs), 
in partnership with local governments in each Service Delivery 
Area (SDA), are responsible for providing guidance for and 
oversight of job training activities in the area.
    Amendments to JTPA became effective July 1, 1993. These 
amendments target program services to those with serious skill 
deficiencies; and individualize and intensify the quality of 
services provided. Five percent of the funds appropriated for 
the adult program (Title II-A) must be used by States in 
partnership with SDAs for older workers. The amendments also 
require Governors to ensure that services under the adult 
program are provided to older workers on an equitable basis.

                           basic jtpa grants

    Title II-A of JTPA authorizes a wide range of training 
activities to prepare economically disadvantaged youth and 
adults for employment. Training and training-related services 
available to eligible older individuals through the basic Title 
II-A grant program include vocational counseling, jobs skills 
training (either in a classroom or on-the-job), literacy and 
basic skill training, job search assistance, and job 
development and placement. Table 2 below shows the number of 
persons 55 years of age and over who terminated from the Title 
II-A program during the period July 1, 1994, through June 30, 
1995, and during the period July 1, 1995, through June 30, 
1996. (The data do not include the 5 percent set-aside for 
older individuals, which is discussed separately.)

              TABLE 2--JTPA DATA JULY 1, 1994-JUNE 30, 1996             
                              [Title II-A]                              
------------------------------------------------------------------------
                                         Number Served                  
               Item               --------------------------   Percent  
                                       PY94         PY95                
------------------------------------------------------------------------
Total Adult Terminees............      237,470      224,458          100
55 years and over................        3,831        3,485            2
------------------------------------------------------------------------
Source: U.S. Department of Labor, Employment and Training Administration
  (April 1998 Data).                                                    

                         section 204 set-aside

    The 1992 JTPA amendments require 5 percent of the Title II-
A allotment of each State to be made available for the training 
and placement of older individuals in private sector jobs. Only 
economically disadvantaged individuals who are 55 years of age 
or older are eligible for services under this State set-aside.
    Governors have wide discretion regarding use of the JTPA 5 
percent set-aside. Two basic patterns have evolved. One is 
adding set-aside resources to Title II-A to ensure that a 
specific portion of older persons participates in the basic 
Title II-A program. The other is using the resources to 
establish specific projects targeted to older individuals which 
operate independently of the basic job training program for 
disadvantaged adults. Likewise, States are required to provide 
``equitable services to older individuals throughout the State, 
taking into consideration the incidence of such workers in the 
population.'' Some States distribute all or part of the 5 
percent set-aside by formula to local SDAs; other States retain 
the resources for State administration or model programs.
    Governors are expected to coordinate services as much as 
possible with those provided under Title V of the Older 
Americans Act--Senior Community Service Employment Program. 
There are two separate provisions for older individual programs 
as they relate to Title V of the Older Americans Act. First, 
under the Title II-A program, up to ten percent of the 
participants may be individuals who are not economically 
disadvantaged, but who have a serious barrier to employment. 
Second, when a JTPA grantee and Title V sponsor establish joint 
projects, individuals eligible under Title V of the Older 
Americans Act ``shall be deemed to satisfy the requirements'' 
of JTPA. These joint (JTPA-SCSEP) projects may include co-
enrollment of Title V participants in Title II-A activities. 
Joint programs must have a written agreement, which may be 
financial or nonfinancial in nature, and may include a broad 
range of activities. For Program Year 1994 (July 1, 1994, 
through June 30, 1995), 16,101 participants were enrolled in 
the State set-aside program for economically disadvantaged 
individuals 55 years of age and older. For Program Year 1995 
(July 1, 1995, through June 30, 1996), 16,594 participants were 
enrolled in the State set-aside program for economically 
disadvantaged individuals 55 years of age and older.

                    programs for dislocated workers

    Title III of JTPA authorizes a State and locally-
administered dislocated worker program that provides retraining 
and readjustment assistance to workers who have been, or have 
received notice that they are about to be, laid-off due to a 
permanent closing of a plant or facility; laid off workers who 
are unlikely to be able to return to their previous industry or 
occupation; and the long-term unemployed with little prospect 
for local employment or reemployment. Those older dislocated 
workers eligible for the program may receive such services as 
job search assistance, retraining, pre-layoff assistance and 
relocation assistance. During the period July 1, 1994,through 
June 30, 1995, approximately 28,257 individuals 55 years of age and 
over exited the program (9 percent of the program terminations). During 
the period July 1, 1995, through June 30, 1996, approximately 26,640 
individuals 55 years of age and over left the program (10 percent of 
the program terminations).

              The Federal-State Employment Service System

    The State-operated public employment service (ES) offices 
offer employment assistance to all job seekers, including 
middle-aged and older persons. A full range of basic labor 
exchange services are provided, including counseling, testing, 
job development, job search assistance and job placement. In 
addition, labor market information and referral to relevant 
training and employment programs are also available.
    Federal reporting requirements for State employment service 
agencies (SESAs) were revised effective July 1, 1992, to 
capture additional information on applicant characteristics, 
including data on the age of all ES applicants and those placed 
in employment. During the period July 1, 1994 through June 30, 
1995 over 1,219,000 ES applicants were age 55 and over. 
Approximately 98,100 of the ES applicants age 55 and over were 
placed in jobs during this period. During the period July 1, 
1995 through June 30, 1996 over 1,191,000 ES applicants were 
age 55 and over. Approximately 87,600 of the ES applicants age 
55 and over were placed in jobs during this period.

              Pension and Welfare Benefits Administration

                              Introduction

    The Pension and Welfare Benefits Administration (PWBA) is 
responsible for enforcing the Employee Retirement Income 
Security Act (ERISA). PWBA's primary responsibilities are for 
the reporting, disclosure and fiduciary provisions of the law.
    Employee benefit plans maintained by employers and/or 
unions generally must meet certain standards, set forth in 
ERISA, designed to ensure that employees actually receive 
promised benefits. Employee benefit plans exempt from ERISA 
include church and Government plans.
    The requirements of ERISA differ depending on whether the 
benefit plan is a pension or a welfare plan. Pension plans 
provide retirement benefits, and welfare plans provide a 
variety of benefits, such as employment-based health insurance 
and disability and death benefits. Both types of plans must 
comply with provisions governing reporting and disclosure to 
the Government and to participants (Title I, Part 1) and 
fiduciary responsibility (Title I, Part 4). Pension plans must 
comply with additional ERISA standards (contained in both Title 
I, Parts 2 and 3, and Title II), which govern membership in a 
plan (participation); nonforfeitability of a participant's 
right to a benefit (vesting); and financing of benefits offered 
under the plan (funding). Welfare plans providing medical care 
must comply with ERISA continuation of coverage requirements 
and medical child support orders (Title I, Part 6).
    The Departments of Labor and Treasury have responsibility 
for administering the provisions of Title I and Title II, 
respectively, of ERISA. The Pension Benefit Guaranty 
Corporation (PBGC) is responsible for administering Title IV, 
which established an insurance program for certain benefits 
provided by specified ERISA pension plans. On a regular basis, 
PWBA meets and coordinates closely with the Internal Revenue 
Service (IRS) and PBGC on matters concerning pension issues.
    In FY 1996, PWBA worked to advance the Health Insurance 
Portability and Accountability Act (P.L. 104-91), enacted 
August 21, 1996, which amended ERISA to provide increased 
access to health care benefits, to provide increased 
portability of health care benefits, and to provide increased 
security of health care benefits. The Newborns' and Mothers' 
Health Protection Act and the Mental Health Parity Act, enacted 
on September 26, 1996 (P.L. 104-204), added to ERISA mental 
health parity provisions and provisions regarding minimum 
mandatory hospital stays for newborns and mothers. 
Implementation of these laws requires PWBA's continuing 
attention.
    PWBA also worked to advance the Administration's Retirement 
Savings and Security Act. Many of its provisions were 
incorporated in the Small Business Jobs Protection Act (P.L. 
104-188) (SBJPA) enacted on August 20, 1996. The SBJPA created 
a new simplified retirement plan for small businesses, and 
simplified plan distribution and nondiscrimination rules.
    Because of the risk of abuse or loss (e.g., from employer's 
bankruptcy), many employees have raised questions about the 
time period during which employers must transmit participant 
contributions to employee benefit plans. To address their 
concerns, PWBA issued a rule under Title I of ERISA which 
substantially shortens the time period during which covered 
private sector employers may hold employees' contributions to 
pension plans, including 401(k) plans, before depositing the 
funds in the plans. Under the new rule, for example, an 
employer that sponsors a 401(k) plan must deposit its 
employees' contributions in the plan as soon as the 
contributions can reasonably be segregated from the employers' 
general assets, but not later than 15 business days following 
the month in which the employer withholds the money from 
employees' paychecks, or receives employees' checks for the 
amount of the contributions.
    With the growth of participant-directed individual account 
pension plans, more employees are directing the investment of 
their pension plan assets and, thereby, assuming more 
responsibility for ensuring the adequacy of their retirement 
income. In order to help employers address the need of 
participants for more investment information, PWBA issued an 
interpretive bulletin providing guidance to plan sponsors, 
fiduciaries, participants and beneficiaries concerning the 
circumstances under which the provision of investment related 
educational information, programs and materials to plan 
participants and beneficiaries will not give rise to liability 
under ERISA.
    In fiscal year 1996, PWBA continued its program of research 
directed toward improving the understanding of the employment-
based pension and health benefit systems. PWBA published 
comprehensive data and statistics on the private retirement 
income system and pension plan investments in its semiannual 
``Private Pension Plan Bulletin.'' Another key component of the 
research program was the project with the National Academy of 
Sciences to improve retirement income modeling. Under PWBA's 
small grants program, twelve new contracts were awarded and 
products were received from thirteen previously awarded 
projects. Studies completed included ``Does 401(k) Introduction 
Affect Defined Benefit Plans?'' and ``Health Insurance Coverage 
of Children of Working Parents.''

                               Inquiries

    PWBA publishes literature and audio-visual materials which, 
in some depth, explain provisions of ERISA, procedures for plan 
to ensure compliance with the Act and the rights and 
protections afforded participants and beneficiaries under the 
law. In addition, PWBA maintains a public information and 
assistance program, which responds to many inquiries from older 
workers and retirees seeking assistance in collecting benefits 
and obtaining information about ERISA. Among the publications 
disseminated, the following are designed exclusively to assist 
the public in understanding the law and how their pension and 
health plans operate: Top Ten Ways to Beat the Clock and 
Prepare for Retirement; Women and Pensions--What Women Need to 
Know and Do; What You Should Know About Your Pension Rights; 
Protect Your Pension--A Quick Reference Guide; How to File a 
Claim for Your Benefits; How to Obtain ERISA Plan Documents 
from the Department of Labor; Handling Inquiries on Pension and 
Welfare Benefits; Guide to Summary Plan Description 
Requirements; Reporting and Disclosure Guide for Employee 
Benefit Plans; Trouble Shooter's Guide to Filing the ERISA 
Annual Report; Exemption Procedures under Federal Pension Law; 
Health Benefits under COBRA; Multiple Employer Welfare 
Arrangements under ERISA (MEWAs); Customer Service Standards--
Our Commitment to Quality; How Did We Measure Up.

                       Bureau of Labor Statistics

    The Department of Labor's Bureau of Labor Statistics (BLS) 
regularly issues a wide variety of statistics on employment and 
unemployment, prices and consumer expenditures, compensation 
including wages and benefits, productivity, economic growth, 
and occupational safety and health. Data on the labor force 
status of the population, by age, are prepared and issued on a 
monthly basis. Data on consumer expenditures, classified by age 
groupings, are published annually. In 1994 BLS published the 
first results of the redesigned survey of occupational injuries 
and illnesses; these data are now available by age, race, and 
gender, providing important new information on this aspect of 
the labor market experiences of older Americans. In addition to 
regularly recurring statistical series, BLS undertakes special 
studies as resources permit. In May 1994 BLS published a report 
on an experimental series that reweighted the official Consumer 
Price Index using expenditure data for older Americans. This 
report updated a portion of a study originally performed by BLS 
in response to the Older Americans Act Amendments of 1987. BLS 
continues to compute the reweighted index each month.

                    The Women's Bureau Clearinghouse

    Established by the Women's Bureau of the U.S. Department of 
Labor in 1989, the Clearinghouse is a computerized database and 
resource center responsive to dependent care and women's 
workplace issues. Services help employers and employees make 
informed decisions about which programs and services help in 
balancing work and family. The Clearinghouse offers information 
in five broad option areas for child care and elder care 
services: direct services, information services, financial 
assistance, flexible leave policies, and public-private 
partnerships. The workforce quality component of the 
Clearinghouse offers information and guidance on the rights of 
women workers such as age, wage discrimination, the Family and 
Medical Leave Act (FMLA), pregnancy discrimination, and sexual 
harassment and the agencies that enforce them. Within each of 
these areas customers can be provided with model programs from 
other companies, implementation guides, national and State 
information sources and bibliographic references.
    The Clearinghouse continues to receive requests for 
information on work-site elder care program options. 
Information provided included flexible work schedules, adult 
day care, case management, decision making, information and 
referral, respite care, and transportation services.
    The Clearinghouse can be accessed through 1-800-827-5335.

                  Employment Standards Administration

    The Family and Medical Leave Act of 1993 became effective 
on August 5, 1993, for many employers. This statute provides 
potential benefit to the elderly in that it empowers eligible 
employees of covered employers to take up to 12 weeks of 
unpaid, job-protected leave in any 12-month period to provide 
care for a parent who has a serious health condition. In the 
past, the employee had to make a decision in many instances of 
whether or not to give up their job to provide care to a sick, 
elderly parent.

                      ITEM 11--DEPARTMENT OF STATE

    The Department is pleased to report that we continue to 
expand services for aging Americans. Not only are employees 
working longer (the mandatory retirement age for Foreign 
Service is 65, and there is no mandatory retirement age for 
Civil Service), but employee responsibilities for caring for 
aging family members have grown significantly. In recognition 
of this, in 1995 the Office of Medical Services, Education and 
Wellness Programs, conducted a panel discussion on a variety of 
topics focused on older persons. That office hosted a health 
fair and offered several medical tests aimed at identifying 
diseases found primarily in older persons, such as prostate, 
cholesterol, and blood pressure screenings. The Office of 
Medical Services also hosted a panel of experts from the 
Washington metropolitan area to describe long-term care 
programs in local jurisdictions. Seminars were offered on 
Alzheimer's disease, living wills, osteoporosis and menopause. 
The Office of Employee Consultation Services, staffed by 
licensed clinical social workers, arranged support groups and 
special presentations on topics such as caring for elderly 
parents and dementia.
    The Office of Work and Family Programs in the Bureau of 
Personnel was established in 1995 as a focal point for work and 
family programs. This office assists employees with questions 
on locating elder care services and recently hosted a monthly 
series of noontime sessions on family related topics, including 
elder care. The Work and Family Program Coordinator represented 
the Department on the Office of Personnel Management's 
Interagency Working Group on Adult Dependent Care.
    In support of the Foreign Service's employees based 
overseas, the family Liaison Office continued to provide 
Foreign Service families with oral and written information on 
caring for elderly parents, medical insurance, and procedures 
for taking an elderly relative to overseas posts. In addition, 
they make referrals, upon request for information on payment 
options for long-term care and legal issues.
    In 1996, the Department's Work and Family Programs office 
expanded its outreach efforts. They held seminars for 
grandparents who are primary caretakers for their grandchildren 
and repeated their most popular seminar topics, i.e. caring for 
aging parents and the diseases most common in the elderly. In 
addition, the Office of Employee Consultation Services hired an 
additional clinical social worker who had a specialty in 
geriatrics.
    Thank you for your continuing interest in this issue. The 
Department continues to identify ways to adapt or expand our 
current elder care services to help employees balance their 
work and family responsibilities.

                 ITEM 12--DEPARTMENT OF TRANSPORTATION

                              ----------                              


   SUMMARY OF ACTIVITIES TO IMPROVE TRANSPORTATION SERVICES FOR THE 
                              ELDERLY \1\

                              Introduction

    The following is a summary of significant actions taken by 
the U.S. Department of Transportation during calendar years 
1995 and 1996 to improve transportation for elderly persons.\2\
---------------------------------------------------------------------------
    \1\ ``Prepared for the U.S. Senate Special Committee on Aging--
February 1998.
    \2\ Many of the activities highlighted in this report are directed 
toward the needs of persons with disabilities. However, one-third of 
the elderly are persons with disabilities and thus will be major 
beneficiaries of these activities.
---------------------------------------------------------------------------

                           Direct Assistance

                 federal railroad administration (fra)

    The National Railroad Passenger Corporation (Amtrak) 
continued throughout calendar years 1995 and 1996 to provide 
discounted fares, accessible accommodations, and special 
services, including assistance in arranging travel for disabled 
and elderly passengers. These passengers continue to represent 
a substantial part of Amtrak's ridership--in recent years, 28 
percent of long-distance passengers were 62 or older.
    Discounted Fares.--Amtrak has a systemwide policy of 
offering to elderly persons and persons with disabilities a 15 
percent discount on one-way ticket purchases. This 15 percent 
discount cannot be combined with any other discounts.
    Accessible Accommodations.--Amtrak provides accommodations 
that are accessible to elderly persons and passengers with 
disabilities, including those using wheelchairs, on all of its 
trains. Long-distance trains include accessible sleeping rooms. 
Short-distance trains, including Northeast Corridor trains, 
have accessible seating and bathrooms. Many existing cars are 
being modified to provide more accessible accommodations and 
all new cars will provide enhanced accessibility for passengers 
with mobility and other types of disabilities.
    Mechanical lifts operated by train or station staff provide 
passengers with access to single-level trains from stations 
with low platforms and short plate ramps provide access to bi-
level equipment. An increasing number of Amtrak stations are 
fully accessible, particularly key intermodal stations that 
provide access to commuter trains and other forms of 
transportation.
    Special On-Board Services.--Amtrak continues to provide 
special on-board services to elderly persons and passengers 
with disabilities, including aid in boarding and deboarding, 
special food service, special equipment handling, and 
provisions for wheelchairs. Amtrak has also improved training 
of its employees to enable them to respond better to passengers 
with special needs. It is recommended that passengers advise 
Amtrak of any special needs they may have in advance of their 
date of departure.
    Assistance in Making Travel Arrangements.--Persons may 
request special services by contacting the reservations office 
at 1-800-USA-Rail. This office is equipped with text telephone 
(TTY) service for customers who are deaf or hard of hearing. To 
ensure that passengers receive the assistance they need, Amtrak 
maintains a Special Services Desk which supports its 
reservations agents seven days a week. This desk has completed 
successful responses to nearly 100,000 requests for special 
services. Passengers may also inform their travel agent or the 
station ticket agent of their assistance requirements when 
making travel reservations.

                  federal transit administration (fta)

    Under 49 USC 5310, the FTA provides assistance to private 
non-profit organizations and certain public bodies for the 
provision of transportation services for the elderly and 
persons with disabilities. In FY 1995, $57.7 million was used 
to assist 1,371 local providers purchase 1,783 vehicles, and in 
FY 1996, $52 million was used to assist 1,260 local providers 
purchase 1,562 vehicles for the provision of transportation 
services for the elderly and individuals with disabilities. 
Most of the agencies funded under this program are either 
disability service organizations or elderly service 
organizations, and service provided under the program is nearly 
equally divided between the two. Those agencies serving the 
elderly are, however, more dependent on funding from the 
elderly and persons with disabilities program as 53 percent of 
their vehicles are purchased with Section 5310 funds compared 
to 42 percent of vehicles purchased by agencies serving the 
disabled. Vehicles purchased with these funds may also be used 
for meal delivery to the homebound as long as such use does not 
interfere with the primary purpose of the vehicles.
    Under 49 USC 5311, the FTA obligated $169.4 million in FY 
1995 and $137.6 million in FY 1996. These funds were used for 
capital, operating, and administrative expenditures by state 
and local agencies, nonprofit organizations, and operators of 
transportation systems to provide public transportation 
services in rural and small urban areas (under 50,000 
population). The nonurbanized area program funds are also used for 
intercity bus service to link these areas to larger urban areas and 
other modes of transportation. An estimated 36 percent of the ridership 
in nonurbanized systems is elderly which represents nearly three times 
their proportion of the rural population.
    Under 49 USC 5307, the FTA obligated $3.2 billion in FY 
1995 and $2.4 billion in FY 1996. These funds were used for 
capital and operating expenditures by transit agencies to 
provide public transportation services in urbanized areas. 
while these services must be open to the general public, a 
significant number of passengers served are elderly.
    Under the Transportation Cooperative Research Program, FTA 
provided funding in 1996 to assist the Southern Maine Area 
Agency on Aging to develop and implement an operational 
demonstration of the Independent Transportation Network (ITN) 
in Portland, Maine. The ITN is a nonprofit, membership based 
transportation service for seniors that uses cars along with 
both paid and volunteer drivers to pick up seniors in and 
around Portland and take them where they need to go. The goal 
of the ITN is to become a financially self-sufficient 
transportation program specifically designed to provide 
transportation services for the elderly who own their own 
vehicles but, because of diminished capacity, no longer want to 
drive themselves or can no longer safely drive their own 
automobiles. The ITN uses demand responsive automobiles to 
match the convenience of private cars. It offers payment 
options ranging from cash or transportation credits earned from 
trading in unused vehicles to payment into an individual ITN 
account from the elderly users or their children.
    The National Easter Seal Society's Project ACTION 
(Accessible Community Transportation in Our Nation) is a $2 
million a year research and demonstration grant program. 
National and local organizations representing public transit 
operators, the transit industry, and persons with disabilities 
are involved with the development and demonstration of workable 
approaches to promote access to public transportation services 
for persons with disabilities. A significant proportion of the 
population of persons with disabilities are elderly and, as a 
result, will benefit from this project. Project ACTION also 
assists in the implementation of the Americans with 
Disabilities Act by identifying and addressing training needs 
related to accessibility in transportation. Project ACTION has 
also targeted other model projects to be refined and replicated 
throughout the country.

                                Research

                 federal aviation administration (faa)

    The Office of Aviation Medicine's Civil Aeromedical 
Institute has contributed to the following research related to 
the needs and concerns of the aging population in aviation 
transportation.
    Cognitive Function Test.--An automated cognitive function 
test (CogScreen) was developed to permit the more sensitive and 
specific evaluation of pilots after brain injury and disease. 
Administration of CogScreen to groups of pilots led to the 
establishment of a data base that could be used to assess 
fitness to perform flying duties in relation to the age of the 
subject being evaluated. A report describing age-related 
changes in CogScreen performance is under review.

                 federal highway administration (fhwa)

    Beginning in 1989, a High Priority Area for research was 
established to address the needs of older drivers with respect 
to the roadway environment. Research under this program started 
as problem identification, and quickly moved to focus on the 
specific areas which cause the greatest problems for older 
drivers and pedestrians. The studies described below were 
ongoing during the calendar years 1995 and 1996. It should be 
noted that all human factors research, including Intelligent 
Transportation Systems initiatives, conducted by FHWA includes 
an older driver component to ensure the system's utility for 
all potential users.
    Pavement Markings and Delineation for Older Drivers used 
simulation and field techniques to investigate the use of 
improved pavement marking and delineation systems to enhance 
their value for older drivers. Findings showed that delineation 
treatments that included both an edge line and an off-road 
element (post-mounted delineators, chevron signs) have the best 
recognition distance for both younger and older drivers. Better 
recognition distances mean that the driver has more time to 
preview the road ahead and to plan steering maneuvers.
    Human Factors Study of Traffic Control in Construction and 
Maintenance Zones is using laboratory and field studies to 
evaluate the entire traffic control system, including Traffic 
Control Devices (TCD) placement and layout, and operational 
aspects, in construction zones. Specific problems which older 
drivers encounter will be addressed, and countermeasures will 
be developed and tested.
    Intersection Geometric Design for Older Drivers and 
Pedestrians investigated specific problems that older drivers 
and pedestrians have in negotiating intersections. For example, 
channelized right turns can add to the distance which 
pedestrians have to cross, and because older pedestrians have 
slower walking speeds, they may be put at greater risk. One 
critical finding of this research was with respect to left turn 
operations. The research suggests that if the right-of-way is 
available, left turn lanes should be offset to the left, such 
that drivers trying to turn may have unrestricted sight 
distance in viewing oncoming traffic.
    Investigation of Older Driver Freeway Needs and 
Capabilities was a preliminary research study investigating the 
problems older drivers have with freeways. Prior to this study, 
it had often been assumed that older drivers avoided freeways; 
however, it was found that they generally do not avoid them. 
Problems identified for future older driver research included 
navigation and way-finding, freeway merging and transition 
areas, visual acuity and contrast sensitivity, and lane-
changing behavior.
    Delineation of Hazards for Older Drivers evaluated object 
markers for comprehension, conspicuity, and recognizability 
under day and night conditions, both in laboratory and field 
testing. It was found that all drivers tend to notice the 
object being marked (e.g., tree, bridge abutment) rather than 
the marker. None of the existing or experimental object markers 
from this study was consistently noticed by subjects. Future 
research will address this problem.
    Computer-Aided Optimization and Evaluation of Candidate 
Manual on Uniform Traffic Control Devices (MUTCD) Signs was a 
laboratory study of recognition distance and comprehension of 
13 novel or redesigned symbol signs, including lane reduction 
transition, tractor crossing, and number of railroad tracks. 
The results were used by the Office of Highway Safety in 
selecting the best new or redesigned signs to be included in 
the revised MUTCD.
    Improved Traffic Control Device Design and Placement to Aid 
the Older Driver is a field study which investigated issues 
related to the design and placement of signs to aid older 
drivers in terms of detection, comprehension, recognition 
distances and response times. This study is being conducted 
under the auspices of the National Cooperative Highway Research 
Program (NCHRP).
    Uniform Traffic Signal Displays for Protected/Permissive 
Left Turn Control investigated problems with left turn control, 
particularly with the variety of signs currently in use. 
Problems looked at included the ``yellow trap'' and driver 
confusion. This study was the first phase of an NCHRP study. 
The second phase will include experimental treatments to 
address specific problems.
    Effect of Advanced Traveler Information Systems (ATIS) 
Display Views and Age on Intersection Recognition investigated, 
in a laboratory setting, the performance of younger and older 
drivers in terms of speed and accuracy in using different types 
of in-vehicle displays. Older drivers were slower than younger 
drivers; however, the real differences in times were small. 
Researchers found that older drivers using Head Up Displays 
(HUDs), small windshield projected displays that present 
information closer to the driver's line of sight than 
instrument panel displays, performed better than those using 
displays mounted next to the steering wheel, indicating the 
potential benefit of HUDs for navigational assistance.

            national highway traffic administration (nhtsa)

    Vehicle Design for Crash Avoidance.--NHTSA's crash 
avoidance research program addresses the relationship between 
vehicle design and driver performance and behavior. New vehicle 
technologies could help reduce older driver crashes and enhance 
their mobility. For example, in-vehicle navigation systems may 
allow drivers to concentrate on watching for dangerous traffic 
conflicts instead of being distracted while searching for road 
signs. Collision avoidance systems may alert drivers to 
potential crash situations. Additional research in this area 
could provide useful information regarding the acceptability of 
technology-based innovations designed to help older, 
functionally less able people continue to drive. The focus is 
to determine how the design and function of vehicle systems 
need to be adapted to the unique capabilities and needs of 
older drivers.
    Research was initiated to develop human factors guidelines 
for consideration in developing a warning display for back up 
collision warning systems. These systems sense the presence and 
distance of objects behind vehicles and warn drivers through 
various types of visual displays and auditory signals. Older 
drivers often express difficulties when backing due in part to 
restricted head movements, as well as poor vehicle visibility 
to the rear. This ongoing research will help to assure that 
warning information will be presented to drivers in an 
understandable and timely format.
    Occupant Protection.--One of the most significant reasons 
for elderly drivers over-involvement in fatal crashes is the 
inability of their bodies to absorb crash forces. What would be 
a survivable crash for a younger person is often a fatal crash 
for an older person. Current occupant-protection standards do 
not specifically address the frailty of older occupants. More 
information is needed to establish the feasibility of improving 
the protection of older people when they are in a crash.
    At people age, their vulnerability to injuries and fatality 
increases dramatically. NHTSA is continuing two major 
activities begun in 1993 that will better understand and 
increase the survivability of older vehicle occupants who are 
involved in a crash. Work is continuing under a grant awarded 
to the William Lehman Injury Research Center at the Ryder 
Trauma Center, Jackson Memorial Hospital in Miami, Florida. 
This will develop an Automobile Trauma Care and Research 
Facility, and establish an information system that will advance 
both the delivery of trauma care and the detailed data for 
research on automobile injuries, treatments, outcomes, and 
costs. The availability of an older population of automobile 
injury victims in the Miami area is providing information on 
the prevention of restrained occupant injuries that will be of 
increasing national importance as the population ages and the 
use of occupant restraints (air bags and automatic and manual 
belts) grows.
    NHTSA is also continuing research with the Transportation 
Systems Center using computer simulation and experimental work 
to improve belt/air bag systems for vehicle occupants. 
Particular attention is being paid to possible approaches to 
improving alternate restraint designs or requirements for 
elderly vehicle occupants. It is expected that this work will 
be of particular value to older vehicle occupants and to women 
who, due to their more fragile bone structure, can benefit most 
from improved belt/air bag designs.
    In addition, NHTSA's new side impact standard provides a 
higher level of protection to older occupants in vehicles 
meeting the standard. The new standard is based on a dynamic 
crash test which incorporated age effects for the first time 
and, thus, will provide better protection to older vehicle 
occupants. Manufacturers are required to apply the standard to 
100 percent of care manufactured after September 1, 1996.
    Pedestrian Safety Issues.--Older pedestrians, 65 and over, 
account for a smaller proportion (7.7 percent) of all 
pedestrian crashes than would be expected by their numbers in 
the population (12.8 percent). However, they account for almost 
one-quarter (22.4 percent) of all pedestrian fatalities. In 
response to this problem, NHTSA and FHWA are continuing work 
aimed at preventing crashes involving older pedestrians. A 
joint research initiative is ongoing in Phoenix and Chicago, 
and involves a demonstration program of behavioral safety 
information [public information and education materials] 
combined with traffic engineering applications [installing 
overhead and signal information signs, etc.] in selected zones 
of the cities that have been shown to have a high incidence of 
older pedestrian crashes. An impact evaluation is planned in 
Phoenix.
    Safe Driving Assessment.--The majority of older drivers do 
not constitute a major safety problem. Research has indicated 
that most older drivers adjust their driving practices to 
compensate for declining capabilities. They reduce or stop 
driving after dark or in bad weather and avoid rush hours, and 
unfamiliar routes. Men appear to be somewhat more reluctant 
than women to stop driving and consequently are at a higher 
risk of crashing than women of comparable age. Conditions such 
as memory loss, glaucoma, and antidepressant use appear to be 
related to increased crash risk.
    Some older persons are not aware of their changing 
conditions; most notably, those with cognitive disorders, such 
as Alzheimer's disease, and certain visual problems. These 
drivers may not self regulate and, as a result, pose an 
increased risk of crash involvement. Such individuals may 
require outside intervention to remove them from traffic. 
Unfortunately, research suggests that most family members, 
social service agencies, and health care professionals are 
either not sufficiently aware or choose not to provide 
assistance in making driving related decisions to those who 
need it. For a variety of reasons, many appear hesitant to get 
involved with this issue.
    Those elderly drivers who remain a problem are not easily 
detected with standard licensing procedures. Further, there is 
some doubt as to whether most licensing staff have the skills 
necessary to detect these problem drivers, even with training 
and state-of-the-art testing techniques. Diagnostic tests 
currently in use have not been shown to be effective in 
identifying those older drivers who are at increased crash 
risk, but some recently developed tests of ``speed of 
attention'' and ``visual perception'' may have such potential.
    Several long-term efforts are not approaching conclusion. 
These developmental projects include: (1) procedures to help 
elderly drivers make better decisions about adapting their 
driving to accommodate their changing abilities are being 
developed in ajoint project with the Federal Highway 
Administration and the Commonwealth of Pennsylvania; (2) procedures for 
family members, friends, social service agencies, physicians, and other 
health care providers to recognize when an older person needs to adjust 
his or her driving to adapt to functional limitations; (3) model 
screening and assessment procedures to aid driver licensing agencies 
deal with those who do not appropriately restrict their driving; and 
(4) model programs for medical and social service agencies to help 
older people to make appropriate decisions about driving while 
maintaining their mobility. Current efforts also include a survey to 
determine societal perceptions and willingness to assist older drivers 
to better regulate their driving.
    Mobility Issues.--One factor that must be considered with 
regard to interventions is the fact that elderly people who 
give up driving often lose mobility. For many, the automobile 
is their primary mode of transportation and acceptable 
alternatives are simply not available. Decreased mobility is 
frequently followed by decreased quality of life as elderly 
people are cut off from the social events, family visits, 
medical attention, and opportunities for worship that are 
critical in maintaining their sense of well being. These issues 
are being studied in a joint project with the Department of 
Health and Human Services and in a separate project with the 
Federal Transit Administration.

          RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA)

    RSPA played a key role in initiating an effort to develop a 
Transportation Science and Technology Strategy for the Federal 
Government. Staff activities in late 1996 identified 
Accessibility for Aging and Transportation-Disadvantaged 
Populations as one of twelve topics warranting partnership 
initiatives between Federal agencies and the transportation 
community. (The Strategy was subsequently released in November 
1997, and development of implementation plans is continuing.)

                       Information Dissemination

            OFFICE OF THE SECRETARY OF TRANSPORTATION (OST)

    Improving Transportation for a Maturing Society discusses 
the impact of postponing retirement, longer productive lives 
and the growing segment of older operators will have on the 
Nation's impact the transportation system. It is also available 
through the Internet.

                 FEDERAL RAILROAD ADMINISTRATION (FRA)

    Information about Amtrak accessibility is available to 
senior citizens and passengers with disabilities in a brochure 
entitled ``Access Amtrak'' which can be obtained by calling 1-
800-USA-RAIL. Amtrak also works directly with a number of 
organizations each year on moving groups of passengers needing 
assistance and traveling together.

                 FEDERAL HIGHWAY ADMINISTRATION (FHWA)

    Synthesis of Research Findings on Older Drivers gathered 
all available research and synthesized it into a report of the 
major replicable findings regarding older drivers. This 
research was then incorporated into an Older Driver Highway 
Design Handbook which became available in January 1998. The 
handbook will serve as an important resource for traffic 
engineers in assuring that highways meet the needs and 
capabilities of older drivers and pedestrians.

         NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)

    A Pedestrian and Bicyclist Safety and Accommodations 
course, funded by NHTSA and FHWA, was completed. This course 
was designed to address the pedestrian and bicyclist traffic 
safety needs of highway safety specialists, police, traffic 
engineers, and other professionals. A resource guide was 
prepared which provides information about traffic safety 
problems and ways to avoid them for all pedestrians, including 
older pedestrians. Also, as a countermeasure to the hazards 
that older Hispanic pedestrians face, materials are being 
prepared for Hispanic senior citizens. These materials include 
a report, slide show, a presenters guide, brochure, and a video 
``novela.''

          RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA)

    RSPA's Technology Sharing Program has continued the 
distribution of technical materials responding to needs and 
priorities identified by state and local officials. Key 
products published and distributed during 1995 and 1996 
relating to the provision of transportation for special users 
include the following:
    Access for Persons with Disabilities to Passenger Vessels 
and Shore Facilities: The Impact of the Americans with 
Disabilities Act of 1990 (July 1996, DOT-T-96-20) describes 
approaches to making marine passenger vessels and dockside 
facilities accessible to the disabled, including the elderly. 
It was developed for the Office of the Assistant Secretary for 
Transportation Policy and distributed in cooperation with them.
    The Effects of Age on the Driving Habits of the Elderly: 
Evidence from the 1990 National Personal Transportation Study 
(October 1994, DOT-T-95-12) focuses on safety-related changes 
in the behavior of elderly (post-65) drivers. Six aspects are 
considered: the amount of daily driving exposure, driving by 
time of day, driving speed, driving by type of roadway, vehicle 
size, and number of passengers carried.
    Operational Strategies for Rural Transportation (March 
1996, DOT-T-97-01) explores the potential of advanced 
electronics for improving transit services to rural patrons, 
particularly the elderly. It emphasizes trip request and 
billing processes for the bus service provided.
    Operator Performance Measurement: Developing Commonality 
Across Transportation Modes--Proceedings of a September 1994 
Workshop (November 1996, DOT-VNTSC-RSPA-95-2) describes 
techniques to determine and assure the performance of vehicle 
operators, including elderly persons, and to thereby assure 
system safety.
    Planning Intermodal and Operations Facilities for Rural and 
Small Urban Transit Systems: Workshop Manual (October 1995, 
DOT-T-96-08) describes how to develop transportation intermodal 
terminals to suit the scale and conditions of rural and small 
urban areas.

                  ITEM 13--DEPARTMENT OF THE TREASURY

                              ----------                              


        TREASURY ACTIVITIES IN 1995-96 AFFECTING OLDER AMERICANS

    The Treasury Department recognizes the importance and the 
special concerns of older Americans.

                      social security trust funds

    The Secretary of the Treasury is Managing Trustee of the 
Social Security trust funds. The short- and long-run financial 
status of these trust funds is presented in annual reports 
issued by the Trustees. The April 1997 report, covering 
calendar year 1996, estimated that combined Old Age and 
Survivors Insurance and Disability Insurance (OASDI) benefits 
can be paid on time for about the next 31 years. The OASDI 
cost-of-living increase was 2.6 percent in 1995 and 2.9 percent 
in 1996. The taxable base for OASDI was increased to $61,200 
for 1995 and to $62,700 for 1996. The amount a 65- to 69-year-
old beneficiary could earn before OASDI benefits were reduced 
was $11,280 in 1995; in 1996 it was $12,500.

                          medicare trust funds

    The Secretary of the Treasury is also Managing Trustee of 
the Federal Hospital Insurance (HI) and Supplementary Medical 
Insurance (SMI) trust funds. In their April 1997 report, 
covering calendar year 1996, the Trustees estimated that the HI 
trust fund would be exhausted in 2001.

                          personal income tax

    Each year, pursuant to statute, the width of the income tax 
brackets and personal exemption and standard deduction amounts 
are increased to reflect the effects of inflation during the 
preceding year.
    The personal exemption allowed for each taxpayer and 
dependent increased from $2,450 in 1994 to $2,500 in 1995, and 
to $2,550 in 1996.
    Taxpayers aged 65 or over (and taxpayers who are blind) are 
entitled to larger standard deductions than other taxpayers. 
Each single taxpayer who is at least 65 years old was entitled 
to an extra $950 standard deduction in 1994 and 1995, and 
$1,000 in 1996. Each married taxpayer aged 65 or over was 
entitled to an extra standard deduction of $750 in 1994 and 
1995, and $800 in 1996. Thus, a married couple, both of whom 
were over age 65, was entitled to extra standard deduction 
amounts of $1,500 in 1994 and 1995, and $1,600 in 1996. 
Including the extra standard deduction amounts and the basic 
standard deduction amounts, taxpayers over age 65 were entitled 
to the following standard deductions for tax years 1994 through 
1996:

------------------------------------------------------------------------
             Filing status                  1994       1995       1996  
------------------------------------------------------------------------
Single.................................     $4,750     $4,850     $5,000
Unmarried head of household............      6,550      6,700      6,900
Married filing jointly:                                                 
    One spouse age 65 or older.........      7,100      7,300      7,500
    Both spouses age 65 or older.......      7,850      8,050      8,300
------------------------------------------------------------------------

    The tax credit for the elderly (and permanently disabled) 
was retained throughout the period.
    The 15 percent excise tax on excess accumulations in, and 
distributions from, the aggregate amount of qualified 
retirement plans, tax-sheltered annuities, and IRAs was 
eliminated, effective in 1997. The separate limits on 
contributions and benefits applicable to each type of 
retirement saving vehicle remain.
    Two provisions of the Health Insurance Portability and 
Accountability Act of 1996 (HIPA) are particularly relevant to 
the aged. Both provisions became effective for tax year 1997. 
Qualified long-term care insurance premiums and the 
unreimbursed expenses for the care of a chronically ill 
individual may be deductible, but only as part of the itemized 
deduction for medical expenses. Employer-paid long-term care 
premiums are excludable from the employee's income subject to 
taxation. Long-term care premiums paid by self-employed workers 
are partially deductible in the calculation of adjusted gross 
income to the same extent as other health insurance premiums. 
HIPA also provides that accelerated death benefits received 
under a life insurance contract or from a viatical settlement 
provider are generally excluded from income subject to tax.

                        Internal Revenue Service

    The Internal Revenue Service (IRS) recognizes the 
importance and special concerns of older Americans, a group 
that will comprise an increasing proportion of the population 
in the years ahead. Major programs and initiatives of the 
Office of the Assistant Commission (Taxpayer Services) and the 
Office of Strategic Planning and Communications that are of 
interest to older Americans and to others are described below.
    The following publications, revised on an annual basis, are 
directed to older Americans:
          Publication 524, Credit for the Elderly or the 
        Disabled, explains that individuals 65 and older may be 
        able to take the Credit for the Elderly or Disabled, 
        reducing taxes owed. In addition, individuals under 65 
        who retire with a permanent and total disability and 
        receive taxable disability income from a public or 
        private employer because of that disability may be 
        eligible for the credit.
          Publication 554, Older Americans' Tax Guide, explains 
        the income conditions under which single taxpayers aged 
        65 or older, and married taxpayers filing jointly if at 
        least one of the spouses is 65 or older, are generally 
        not required to file a Federal income tax return. The 
        publication also advises older taxpayers about possible 
        eligibility for the earned income credit. The taxpayer 
        may be eligible for a credit based on the number of 
        qualifying children in the home or a smaller credit if 
        the taxpayer has no qualifying children.
          Publication 721, Tax Guide to U.S. Civil Service 
        Retirement Benefits, and Publication 575, Pension and 
        Annuity Income, provide information on the tax 
        treatment of retirement income.
          Publication 907, Tax Highlights for Persons with 
        Disabilities is a guide to issues of particular 
        interest to persons with handicaps or disabilities and 
        to taxpayers with disabled dependents.
          Publication 915, Social Security Benefits and 
        Equivalent Railroad Retirement Benefits, assists 
        taxpayers in determining the taxability, if any, of 
        benefits received from Social Security and Tier I 
        Railroad Retirement.
    All publications are available free of charge. They can be 
obtained by using the order forms found in the tax forms 
packages or by calling 1-800-TAX-FORM (1-800-829-3676.) Many 
libraries, banks, and post offices stock the most frequently 
requested forms, schedules, instructions and publications for 
taxpayers to pick up. Also, many libraries stock a reference 
set of IRS publications and a set of reproducible tax forms.
    Most forms and some publications are on CD-ROM, available 
in some larger libraries, and are on sale to the general public 
through the Government Printing Office's Superintendent of 
Documents. Information about ordering can be obtained by 
calling (202) 512-1800. Over 100 forms and instructions and 
about 150 tax topics are available by fax by calling 703-363-
9694.
    Taxpayers may obtain most forms, instructions, publications 
and other products via the IRS's Internet Web Site at 
www.irs.ustreas.gov. They can also reach IRS using:
          Telnet at iris.irs.ustreas.gov
          File Transfer Protocol at ftp.irs.ustreas.gov
          Direct Dial (by modem) at 703-321-2020, IRIS, the on-
        line information service
    The 1990 tax year was the first year older Americans could 
use the expanded Form 1040A to report income from pensions and 
annuities, as well as other items applicable to older 
Americans, such as estimated tax payments and the credit for 
the elderly or the disabled. More than half of the potential 
filing population eligible to use this simpler, shorter form 
made the switch from the much longer Form 1040.
    Responding to requests from the public for such a product, 
the Tax Forms and Publications Division developed large-print 
versions of the Form 1040 and Form 1040A packages earmarked for 
older Americans. These packages (designated as Publications 
1614 and 1615, respectively) are newspaper-size and contain 
both the instructions and the forms (for use only as 
worksheets, with the amounts to be transferred to regular-size 
forms for filing).

                   IRS volunteer & outreach programs

    The Volunteer Income Tax Assistance (VITA) Program offers 
FREE tax help to people who cannot afford paid professional 
assistance. Volunteers help prepare basic tax returns for 
taxpayers with special needs, including persons with 
disabilities, non-English speaking persons, those with low 
income, and elderly taxpayers. Assistance is provided at 
community and neighborhood centers, libraries, schools, 
shopping malls and other convenient locations across the 
nation. Volunteers generally include college students, law 
students, members of professional, business and accounting 
organizations, and members of retirement, religious, military 
and community groups.
    In 1995, over 46,000 volunteers assisted over 1.7 million 
taxpayers at nearly 8,100 sites across the nation through the 
VITA Program. In 1996, over 47,000 volunteers assisted over 1.8 
million taxpayers at 8,300 sites across the nation through the 
VITA Program.

Banks, Post Offices, and Library (BPOL) Programs

    During 1995 and 1996, the Banks, Post Offices and Library 
Program (BPOL) provided approximately 46,500 libraries, banks, 
post offices, and other sites with free tax preparation 
materials such as tax forms and publications that can assist 
older Americans in preparing Forms 1040, 1040A, 1040EZ, and 
related schedules. IRS provided volunteers in some libraries to 
answer tax questions and direct taxpayers to the correct tax 
forms.

Small Business Tax Education Program (STEP)

    The Small Business Tax Education Program (STEP) provides 
information about business taxes and the responsibilities of 
operating a small business. During 1995 and 1996, small 
business owners and other self-employed persons had an 
opportunity to learn what they needed to know about business 
taxes through a partnership between IRS and approximately 2,000 
community colleges, universities, and business associations. 
Assistance was offered at convenient community locations and 
times. Many elderly persons, such as those beginning second 
careers, availed themselves of this program.

Community Outreach Tax Education Program

    The Community Outreach Tax Education Program provides 
individuals with group income tax return preparation assistance 
and tax education seminars. IRS employees and trained 
volunteers conduct these seminars which address a variety of 
topics. They are tailored for groups and individuals with 
common tax interest, such as groups of older Americans. These 
seminars are conducted at convenient community locations.
    In 1995, over 1,400 volunteers assisted over 660,000 
taxpayers in over 7,200 sessions across the nation through this 
program. In 1996, almost 500 volunteers assisted over 421,000 
taxpayers in over 5,000 sessions. In addition, the IRS 
coordinated outreach activities with the Center for Budget and 
Policy Priorities that led to grassroots EITC and AEITC 
information campaigns by state and local social advocacy groups 
throughout the nation.

Tax Counseling for the Elderly (TCE) Program

    The Tax Counseling Program was first authorized by Congress 
in 1978 as part of the Revenue Act of 1978. The Revenue Act 
authorizes an appropriation of special funds, in the form of 
grants, to provide free income tax assistance to individuals 60 
years of age or older. TCE sponsors recruit volunteers that are 
trained by the Service to provide income tax assistance to 
older individuals. TCE volunteer sites can be found in 
retirement homes, neighborhood sites, and shopping malls. 
Volunteers also travel to the private residences of the 
homebound. In 1996, 33,000 volunteers assisted 1.6 million 
taxpayers at nearly 11,000 sites.

                      Financial Management Service

    The Financial Management Service (FMS) makes 700 million 
Social Security, Supplemental Security Income, and Veterans 
benefit payments annually. Working under the mandate of the 
Debt Collection Improvement Act (DCIA) signed by President 
Clinton on April 26, 1996, Federal departments and agencies are 
on the fast track to convert all Federal payments to electronic 
funds transfer (EFT) by January 1999. EFT significantly 
improves the certainty of the payments reaching the intended 
recipients on a timely basis, and improves the ability of 
recipients to use those payments safely and conveniently. 
Payment inquiries and claims will be significantly reduced 
under EFT.
    Payment by EFT has substantial benefits in terms of 
reliability, safety, and security that are especially important 
for the elderly. Recipients are twenty times more likely to 
have a problem with a paper check than with an EFT transaction; 
each year Treasury replaces over 800,000 checks that are lost, 
stolen, delayed, or damaged during delivery. Waiting days for a 
replacement check is an inconvenience and a burden on 
recipients, especially elderly persons living on low incomes. 
EFT payments are much more convenient and secure--misrouted EFT 
payments are never lost, and are typically rerouted to the 
correct bank account within 24 hours.
    FMS is overseeing implementation of DCIA government-wide 
and is working with agencies to identify and resolve the major 
issues confronting stakeholders so that Treasury's formulation 
of regulations and policy on EFT conversion will reflect 
Federal agencies' and key stakeholders' participation in 
addressing and resolving issues. During 1996 Treasury began a 
major initiative to assure the successful implementation of the 
EFT mandate. Treasury will ensure that individuals required to 
receive payments electronically will, for that purpose, have 
access to an account at a financial institution at reasonable 
cost, and with the same consumer protections as other account 
holders at that financial institution. In addition, the 
Secretary of the Treasury is authorized to grant waivers based 
on recipient hardship, for classes of checks, or where 
otherwise necessary. The transition to EFT will be made with 
the interests of recipients being of paramount importance, and 
waiver guidelines will be liberal.
    The law required EFT to be used for Federal payments to new 
recipients who become eligible to receive such payments after 
July 26, 1996. On that date, an Interim Rule was published in 
the Federal Register, providing initial guidance on 
implementation. A follow-up rulemaking will be published in 
1997 to offer guidance for EFT conversion for all Federal 
payments after January 1, 1999.
    During 1996, FMS contracted with Booz Allen & Hamilton and 
Shugoll Research for a four-phase research effort that will 
help determine the future marketing efforts aimed at individual 
recipients of Federal benefit checks. A comprehensive public 
education and marketing campaign involving presentations 
nationwide and distribution of a variety of informational 
materials is being planned to communicate the requirements of 
the EFT legislation and the impact it will have on recipients, 
financial institutions, and Federal agencies.
    FMS continues to support the implementation of Electronic 
Benefit Transfer (EBT). Geared toward those individuals without 
a bank account or who choose not to use Direct Deposit, EBT is 
an electronic benefit delivery mechanism that enables 
recipients to use plastic cards to access their benefits at 
automated teller machines or point-of-sale terminals. FMS 
developed guidelines for banks to use in designing low-cost 
``Direct Deposit Too'' all-electronic accounts to provide basic 
banking services to the unbanked.
    FMS continues to support the implementation of a nationwide 
program to make EBT a viable electronic payment mechanism. 
Forty states have some type of EBT program which provides 
benefit access to recipients: six of these are full-fledged, 
state-wide programs, and the others are either in the pilot 
phases or in the process of being awarded to providers. In 
1996, FMS was instrumental in establishing the Southern 
Alliance of States (SAS), and five contracts have been awarded 
under the SAS Federal EBT contract. Nationwide EBT will be 
operational by 1999, and all 50 states expect to be operating 
statewide EBT systems by 2002.

                               U.S. Mint

    The U.S. Mint continues to consider the needs and concerns 
of older persons.
    The Exhibits and Public Services staff of the Philadelphia 
Mint and staff of the Denver Mint Visitors Center are available 
to help older persons and people with special needs who wish to 
take the Mint self-guided tour. A wheelchair is also available 
for those wishing to take the tour. In addition, benches are 
strategically placed along the tour route to provide resting 
areas for visitors.
    In 1996-97, seven videodisc monitors were installed in the 
tour gallery of the Philadelphia Mint. The videos highlight the 
history of the Mint and coin production. The new system allows 
older visitors and visitors with sight impairments to view coin 
production up close. While visitors may still view the factory 
from forty feet above the plant floor, the monitors allow for a 
better understanding of coin production.

                    Bureau of Engraving and Printing

Series 1996 currency

    The new Series 1996 $100 notes, the first in the series, 
were introduced in March 1996. During the next several years, 
lower denominations will be issued in order of decreasing 
value. An international public information campaign is being 
coordinated between BEP, the Federal Reserve System, and the 
Secret Service, to make the public aware of the new notes; the 
Department has conducted a special outreach to older 
individuals. The new currency is the same size, color, and has 
the same feel as the old notes, and depicts the same historical 
figures and national symbols. The new security features, 
benefitting those with reduced vision are: the portrait is 
shifted slightly off-center, to provide room for a watermark, 
making it harder for counterfeiters to print; serial numbers on 
the new currency differ slightly from old currency; and the ink 
used for the numeral in the lower right-hand corner changes 
color from green to black when viewed from different angles.

Other assistance

    BEP's on-site medical staff continued to provide life-style 
counseling for employees who are senior citizens. The emphasis 
is on wellness and prevention of disease, and includes advice 
on nutrition and weight control, testing of blood pressure and 
cholesterol levels, and examination of possible vision and 
hearing deficiencies.
    An assessment of BEP facilities, including the tour areas, 
has been completed and found to be in accordance with the 
Americans with Disabilities Act (ADA).
    The BEP continued its contract with the National Academy of 
Sciences to conduct a study, with the cooperation of the 
American Counsel for the Blind, to determine ways to assist the 
blind and partially sighted with handling currency.

                      Office of Thrift Supervision

    The Office of Thrift Supervision (OTS) carried out a number 
of activities affecting older Americans.
    OTS continues its Community Affairs program, established in 
1993 and designed to provide outreach and support to the thrift 
industry's efforts to meet housing and other community credit 
and financial services needs. One of the primary objectives of 
the program is to serve as a liaison between the thrift 
industry and consumer and community groups on housing and 
community development issues. Most of the groups with which we 
interact represent low- and moderate-income individuals, 
including older persons.
    During 1995 and 1996, the Community Affairs staff in the 
headquarters office and in each of our regional offices, along 
with senior management, initiated or participated in meetings 
with hundreds of thrift and community organizations across the 
country, including groups with particular emphasis on the 
elderly. During those meetings, information was shared on 
affordable housing, financial services and economic development 
needs; on thrifts' authorities and abilities to meet those 
needs; and on opportunities for collaborative partnerships.
    OTS also periodically issues its Community Liaison 
newsletter to all thrifts and several hundred community and 
consumer organizations. One goal of this publicationis to 
promote understanding and awareness of successful achievements in 
affordable housing and community development. By spotlighting these 
initiatives, many of which have benefited elderly Americans, it is our 
hope that other financial institutions, community and consumer groups, 
and government entities will be encouraged to replicate these 
approaches in their communities.
    For many years, OTS has had an active program designed to 
address complaints that consumers may have against the thrifts 
that OTS regulates. OTS operates a free nationwide consumer 
hotline that offers the options of obtaining information about 
filing a complaint or speaking immediately with an analyst. A 
senior analyst is assigned each day to help people evaluate 
whether their concerns are addressed by our regulations. Senior 
citizens are more likely to use this service, and appear to 
appreciate the direct contact.
    During 1996, OTS expanded its services to seniors and 
others who have disabilities, by establishing a TDD line for 
complaints, and publicizing it in OTS' consumer literature. We 
also continued to provide appropriate accommodation to 
customers with disabilities, such as blindness or arthritis, 
that make it difficult to file a written complaint. In most 
cases, this involves writing out the complaint for the consumer 
and sending it to them for signature or some other form of 
verification.
    OTS has also issued a Customer Service Plan for consumer 
complaints and urged the institutions it regulates to give high 
priority to consumer relations. Of approximately 5,000 
complaints filed with OTS in 1996, 17 complaints alleged credit 
discrimination based on age. OTS investigated each of the 
complaints in accordance with its expanded procedures for 
discrimination complaints. The procedures provide that the 
complainant is interviewed, the entire loan file is obtained 
from the thrift, and OTS staff determines if a special on-site 
investigation is needed. None of the 1996 complaints led to a 
finding of discrimination.

                       Bureau of the Public Debt

    The Bureau of the Public Debt continues to make 
improvements in its programs to better serve all investors. The 
following steps to streamline and simplify access to Treasury 
securities are of particular benefit to the elderly investor.

Savings securities

    Public Debt's Savings Bond Webb Site provides much useful 
information about bonds and is a very popular site with bond 
owners, many of whom are elderly. In addition to savings bond 
facts, many forms can be downloaded from, or ordered through 
the site.
    The Bureau continues to update and improve the Savings Bond 
Wizard, an easy-to-use bond pricing software application 
available via diskette and on Public Debt's Web Site. With 
Wizard, bond owners can keep an inventory of their bonds, and 
compute current redemption values and earned interest on their 
personal computers. Because the Bureau receives frequent 
positive feedback about Wizard, it remains one of the highest 
priorities.
    By accessing a new, automated system via telephone, 
customers can easily request the forms needed for savings bond 
transactions and receive the forms much sooner than when 
requesting them by mail.
    More inquiries from savings bond owners are now answered by 
telephone or Internet electronic mail. These types of contacts 
allow for better communication and clearer understanding of the 
information needed and provided, which is especially helpful to 
older customers.
    The number of Series H/HH bondowners receiving semi-annual 
interest payments by electronic deposit continues to increase 
steadily. Over 70 percent participate in the Automated Clearing 
House (ACH) method, many of whom are older people who exchange 
matured Series E/EE bonds for Series H/HH. A major benefit of 
electronic deposits is the assurance that payments will be 
received on time, without having to make a special trip to 
deposit interest checks.
    Savings Bond forms are printed in as large a print as 
possible.
    Public Debt plans to make savings bonds available for 
purchase in 1998 by automatic, electronic debits to purchasers' 
financial accounts, on the dates and in the denominations and 
registrations specified by the purchasers. This process will 
provide a convenient way for persons who are retired (or do not 
have access to payroll savings plans through their employers) 
to invest in savings bonds.
    Public Debt is finalizing plans for an inflation-indexed 
savings bond, which will offer investors protection from the 
effects of inflation. These bonds will offer investment 
security that older Americans desire.

Marketable securities

    Treasury marketable securities provide a safe investment 
and interest income, features that are popular with older 
Americans. The latest survey of investors using the Treasury 
Direct service indicated that 62 percent were aged 65 or older. 
Therefore, recent improvements to Treasury Direct will benefit 
older Americans.
    To help all of its customers, including the elderly, Public 
Debt implemented a new Statement of Account that was larger, 
easier to read, and provided more information. Also, a special 
brochure explaining the Statement of Account was provided to 
investors.
    Public Debt continues to encourage owners of registered and 
bearer securities to convert these certificates to book entry 
form in Treasury Direct. Holding Treasury securities in book 
entry form provides a much safer and more convenient method 
than holding certificates.

                      United States Secret Service

White House tours

    The U.S. Secret Service processes approximately 1.5 to 2 
million people through the White House Tours annually. In a 
reinvention effort to provide better customer service to the 
public, the Secret Service Uniformed Division makes available 
for the elderly and physically disabled escorted wheelchair 
tours of all the White House areas open to the public. Past 
procedures only provided for tours of the State Floor. 
Additionally, upon request, ``special sign language tours'' are 
made available for the hearing impaired and ``special touch 
tours'' are provided for the visually impaired.

SCEP

    The Secret Service has been working to develop a senior 
citizen employment program (SCEP). SCEP is a work training 
program designed to provide older, economically disadvantaged 
seniors with an opportunity to upgrade outdated skills and 
develop new skills which may enhance future employment 
opportunities. At the same time, seniors hired under this 
program will provide administrative clerical support to Secret 
Service offices. The Personnel Division will work closely with 
designated organizations such as the American Association of 
Retired Persons and other community associations to identify 
eligible seniors. Implementation of the SCEP is projected for 
Fiscal Year 1998.

Advance fee fraud

    Advance fee fraud schemes emanating from Nigeria are 
targeting American citizens and have resulted in reported 
financial losses exceeding a hundred million dollars. It is 
believed the true losses are much higher as many victims fail 
to report their losses due to fear or embarrassment. The 
Service's experience has shown that the elderly population is 
especially susceptible to advance fee frauds, as they are to 
other types of confidence schemes. The Secret Service has 
received scores of reports from members of the older community 
who report that they have lost their life savings and more in 
pursuit of an advance fee scheme.
    From the onset of its involvement in the investigation of 
this crime, the Secret Service has realized that a large scale 
public awareness program must accompany aggressive 
investigation and prosecution. In conjunction with the 
Departments of State and Commerce, the Secret Service has 
reached out to organizations that are associated with the 
principal targets of this scam, namely small businesses and the 
elderly. Organizations such as the Better Business Bureau, the 
American Bankers Association, and the AARP have assisted the 
Secret Service in publishing articles designed to educate the 
public to these schemes and hopefully prevent them from failing 
prey to these frauds.

Government benefits

    The Secret Service continues to protect the nation's 
elderly recipients from fraud perpetrated against their 
government benefits. The Secret Service is committed to 
investigating all fraud related to government benefits. During 
Fiscal Year 1995-1996, the Secret Service received and 
investigated 16,942 cases relating to U.S. Treasury check 
violations (which includes Social Security benefits, Railroad 
Retirement, Office of Personnel Management, et al) of which 
16,167 were closed.
    As a result of the Electronic Funds Transfer (EFT) 
Provision of the Debt Collection Improvement Act of 1996, the 
Secret Service has received 2,778 cases for investigation 
involving the illegal diversion of funds through the Direct 
Deposit/Electronic Funds Transfer process. In FY 1996, the 
Secret Service closed 1,136 EFT cases.

                              U.S. Customs

    U.S. Customs Service's major activities affecting older 
Americans include the following:
    The Customs Service offers special treatment for the aging, 
the handicapped, the ill, and those who are unable to wait in 
line when arriving from abroad. Such travelers can speak with a 
Customs supervisor upon arrival in the Customs processing area 
of the airport or other Customs port of entry. The supervisor 
is able to facilitate the traveler's Customs clearance.
    Customs strives to treat all travelers entering and leaving 
the United States with professionalism and courtesy. In 
addition, Customs works to ensure that Federal inspection 
facilities, such as restrooms, etc., facilitate the movement of 
the elderly or handicapped who must rely on a wheelchair or 
walker.
    In addition, the Customs Service has a number of programs 
to support Customs employees. For example, the Employee 
Assistance Program encourages elderlyemployees to seek 
additional assistance if needed. The Customs Health Enhancement Program 
offers activities and classes to Customs employees, including the 
elderly, in areas such as the fitness center, CPR/first aid, stress 
management, conflict resolution, defense tactics, allergy and asthma, 
nutrition, and health screening. The Customs Service also offers 
retirement seminars several times each year to all employees who are 
eligible to retire within the succeeding 5 years. These seminars cover 
retirement benefits, legal matters and financial planning.

                     Alcohol, Tobacco and Firearms

    The Bureau of Alcohol, Tobacco and Firearms (ATF) has 
several programs that benefit all employees, but specifically 
can be viewed as addressing an aging workforce:
    ATF supports its Health Improvement Program and encourages 
employees of all ages, especially those over age 50 and who are 
medically cleared, to participate.
    The Employees Services Branch conducts annual pre-
retirement seminars for employees who are eligible to retire 
within the succeeding 5 years. These seminars address civil 
service retirement benefits, social security, tax implications 
and financial planning.
    The Employee Assistance Program provides all employees and 
their family members with free confidential assistance for 
personal problems that may impact work life. This program 
provides counseling/support services regarding numerous issues 
such as: finances, family, health, legal, substance abuse, and 
emotional well being.

                 Office of Comptroller of the Currency

    During 1995 and 1996, the Office of Comptroller of the 
Currency (OCC) continued to enforce fair lending laws relating 
to age discrimination and continued its active liaison and 
outreach program with national and regional consumer 
organizations, including the American Association of Retired 
Persons.
    Comptroller Eugene Ludwig met monthly with representatives 
from national consumer organizations at informal meetings held 
at the OCC'S Washington, D.C., headquarters and met semi-
monthly with representatives of regional consumer and community 
organizations from each of the OCC's six districts. The purpose 
of these outreach meetings was to share information about OCC 
policy and national bank examination practices with consumer 
organizations and to learn first-hand of concerns these 
organizations may have with the activities of national banks 
and the OCC's supervision of the national banking system.
    During 1995, the OCC established its Community Reinvestment 
and Development Specialist program. As a result, the OCC now 
employs two full-time specialists in community development and 
consumer banking in each of the OCC's six districts. they are 
responsible for regular outreach and information dissemination 
to community and consumer organizations, including local and 
regional organizations representing the interests of elderly 
consumers. These specialists focus on banking industry and 
consumer organizations awareness of innovative practices of 
national banks in meeting the credit and financial service 
needs of disadvantaged consumers, including those of elderly 
consumers.
    The OCC also is responsible for resolving consumer 
complaints against national banks, including those complaints 
made by older Americans. During 1995 the OCC received 15,745 
written complaints and 21,970 telephone complaints. During 
1996, the OCC received 13,695 written complaints and 14,077 
telephone inquiries. In 1995, to improve the process for 
handling consumer complaints, the OCC established the Consumer 
Assistance Unit, a centralized complaint processing center in 
Washington, D.C., and launched a toll-free national consumer 
complaint telephone number (800-613-6743).

                  ITEM 14--COMMISSION ON CIVIL RIGHTS

    During calendar years 1995 and 1996 the Commission 
continued to process complaints received from individuals 
alleging denials of their civil rights. Specifically, in 1995, 
17 complaints alleging discrimination on the basis of age were 
received by the Commission and referred to the appropriate 
agency for resolution. In 1996, the Commission referred 40 
complaints alleging age discrimination.

              ITEM 15--CONSUMER PRODUCT SAFETY COMMISSION

                              ----------                              


       Report on Activities To Improve Safety for Older Consumers

    Each year, according to estimates by the U.S. Consumer 
Product Safety Commission (CPSC), nearly one million people 
over age 65 are treated in hospital emergency rooms for 
injuries associated with products they live with and use every 
day. The death rate for older people is almost six times that 
of the younger population for unintentional injuries involving 
consumer products. Consumer products used in and around the 
home are associated with over 35 deaths per 100,000 persons 65 
and older, and over 6 deaths per 100,000 persons under 65.
Fires and burns in the home
    Burns from fires in the home are an important source of 
injury to older Americans. CPSC recommends the installation and 
maintenance of smoke detectors on every floor of the home. 
Older consumers should look for nightwear that will resist 
flames, such as a heavy weight fabric or tightly woven fabrics 
such as polyester, modacrylics, or fabrics made from wool.
    Cooking fires also cause injury and death to older 
consumers. As part of its work on range fires, CPSC is 
evaluating the feasibility of technologies that detect a pre-
fire condition and shut the burner off before a fire occurs.
    Older consumers are at greater risk of dying from fires 
involving both upholstered furniture and mattresses and bedding 
than the general population. CPSC is currently considering ways 
to address upholstered furniture and mattress and bedding 
flammability.
    Burns from hot tap water are another cause of injury to 
many older Americans. CPSC recommends that consumers turn down 
the temperature of their water heater to 120 degrees Fahrenheit 
to help prevent scalds.
    In 1995 and 1996, CPSC distributed approximately 130,000 
copies of the ``Home Safety Checklist for Older Consumers'' 
(English and Spanish). The ``Home Safety Checklist'' is a room-
by-room check of the home, identifying hazards and recommending 
ways to avoid injury. Consumers may order a free copy by 
sending a postcard to ``Home Safety Checklist,'' CPSC, 
Washington, D.C. 20207.
    CPSC also contributed to the publication ``What Smart 
Shoppers Know About Nightwear Safety.'' This brochure was 
developed by a group of experts in apparel flammability and 
distributed by the American Association of Retired Persons 
(AARP). The brochure encourages older consumers to look for 
sleepwear that is flame resistant. Consumers may request a copy 
by sending a postcard to AARP, 601 E Street, N.W., Washington, 
D.C. 20049.

Electrical wiring in older homes

    In 1994-95, CPSC conducted a study of electrical wiring 
fires in older homes. This is a subject of particular 
importance to senior citizens, since they frequently live in 
older homes, which are especially vulnerable to electrical 
wiring fires. Based on this study, CPSC produced a video 
entitled ``Wired for Safety,'' emphasizing hazards with old 
electrical wiring and safety measures to prevent fire and 
electric shock. About 3,000 copies of the video were 
distributed to electrical safety inspectors, code officials, 
and others nationwide.
    CPSC launched this campaign to help prevent the estimated 
40,000 home electrical wiring fires each year. These fires 
claim 400 lives each year and cost society $2.2 billion 
annually. Working with fire departments, electrical safety 
experts, and building code officials, CPSC encourages 
electrical reinspections and upgrades to home electrical 
wiring. Consumers may obtain a free guide to eliminating home 
wiring hazards by sending a postcard to ``Home Wiring 
Hazards,'' CPSC, Washington, D.C. 20207.

Adult-friendly poison prevention packaging

    Older consumers are involved in the childhood poisoning 
issue because many young children are poisoned when they 
swallow grandparents' medicine. Child-resistant (CR) packaging 
has saved children's lives. CPSC has data estimating that the 
widespread use of child-resistant closures on aspirin and oral 
prescription medicines saved the lives of at least 800 children 
under age five since 1972. However, CR packaging can only work 
if people choose it and use it properly. Many older consumers 
find it difficult to open CR packaging and may not replace the 
caps or use the packaging at all.
    To make it easier for all adults, especially older ones, to 
use child-resistant packaging, CPSC in 1995 adopted a change in 
its rules for testing packaging under the Poison Prevention 
Packaging Act. The new regulation requires that packaging be 
tested by panels of adults 50 to 70 years of age rather than 18 
to 45 years old, as was previously the case. This change--
effective for packaging marketed after January 1998--assures 
that child resistant packaging will become more ``adult-
friendly.'' The change is encouraging the industry to develop 
innovative closures that rely on older people's ``cognitive 
skills'' instead of their physical strength. CPSC expects the 
new packaging to help prevent more child poisonings. In 
addition, CPSC reminds all adults to keep medicines locked up 
and out of reach of children.
    In 1994, Chairman Ann Brown awarded commendations to two 
companies for safety innovations in child-resistant packaging 
that were especially useful for older consumers. Procter and 
Gamble received an award for marketing a major product in 
adult-friendly child-resistant packaging and Sunbeam Plastics 
was recognized for developing an entire line of adult-friendly 
child-resistant packaging.

               ITEM 16--CORPORATION FOR NATIONAL SERVICE





                ITEM 17--ENVIRONMENTAL PROTECTION AGENCY

                              ----------                              


Environmental Protection Agency--Senior Environmental Employment (SEE) 
                                Program

    The SEE Program was established by the Environmental 
Programs Assistance Act, P.L. 98-313. This law authorizes EPA 
to enter into grants or cooperative agreements with 
organizations authorized by the Secretary of Labor under Title 
V of the Older Americans Act. The EPA funded cooperative 
agreements with six national aging organizations during 
calendar years 1995 and 1996 that included the American 
Association of Retired Persons, National Council on the Aging, 
National Caucus and Center on Black Aged, Inc., National 
Association for Hispanic Elderly, National Senior Citizens 
Education and Research Center, and the National Asian Pacific 
Center on Aging.
    The SEE Program draws upon the vast pool of talent, 
experience and skills possessed by retired and older workers 
age 55 or older. The Program has two major benefits, to support 
the Environmental Protection Agency (EPA) staff in 
administering projects necessary for the support of 
environmental programs and to give older workers an opportunity 
to remain active using their matured skills in meaningful 
tasks.
    SEE enrollees performed a wide range of technical 
assistance for EPA from answering telephones to performing 
clerical support to providing assistance in radiation and air 
pollution monitoring. No matter what is the critical 
environmental concern of the day, from understanding and 
explaining in a credible manner the analyzed data of nearby 
toxic substance exposures to local citizens or providing the 
temporary technical talent of local monitors to spot check 
underground storage tanks, the SEE program provides support 
where it is most needed. The work being done by the many SEE 
participants demonstrates the effectiveness of older Americans 
in helping to prevent, abate and control environmental 
pollution.
    SEE Program participants work in one year temporary 
positions at EPA Headquarters offices, ten EPA Regional 
offices, EPA Laboratories, and in other federal, state, and 
local environmental offices. The utilization of the SEE Program 
offers EPA a golden opportunity for achieving the environmental 
challenges of today.

            ITEM 18--EQUAL EMPLOYMENT OPPORTUNITY COMMISSION





               ITEM 19--FEDERAL COMMUNICATIONS COMMISSION

                              ----------                              


     SUMMARY OF 1995-1996 ACTIVITIES OF THE FEDERAL COMMUNICATIONS 
                  COMMISSION AFFECTING OLDER AMERICANS

    This report summarizes the major 1995-1996 activities of 
the Federal Communications Commission (hereafter ``FCC'' or 
``the Commission'') affecting older Americans.
    A number of these actions were taken to implement statutory 
requirements or Commission policies on behalf of the general 
public, the 49 million Americans with some kind of hearing, 
vision, speech or other disability, and all consumers of 
telecommunications, rather than ``on behalf of older 
Americans.'' However, since many older Americans may be in 
declining health, e.g., losing hearing or vision, or may be 
especially vulnerable to anti-consumer scams and schemes, e.g., 
``slamming'', or unauthorized transfer to a new long distance 
carrier, older Americans clearly were affected by and benefited 
from the various disability-related and consumer protection 
activities described below.

Disabilities Issues Task Force

    One of the Commission's chief concerns in 1995 was to 
ensure that the benefits of the information revolution were 
available to everyone, including the disability community. This 
community contains a sizeable percentage of older Americans 
with a hearing, vision, speech or other disability. Thus, many 
of the activities the FCC undertook in 1995 and 1996 to assist 
the disability community also affected and benefited older 
Americans.
    The FCC's Disabilities Issues Task Force (DITF) was formed 
in March 1995 with representatives of each of the FCC's Bureau 
and Offices. The Task Force serves as the FCC's main point of 
contact and coordination on all disability access initiatives, 
and works to ensure that the FCC takes steps to promote access 
to the Information Superhighway by individuals with 
disabilities, including many older Americans.
    In 1995, the Commission implemented a policy ensuring that 
all Commission open meetings are closed-captioned for people 
with hearing disabilities. Members of the DITF and other FCC 
officials also met in 1995 with cable industry representatives 
and representatives of the disability community to negotiate a 
plan to ensure that the Emergency Alert System for emergency 
local, state and national emergencies is accessible to persons 
with disabilities.
    In 1996, the DITF completed pending projects noted above 
and began educational outreach within the Commission's various 
Bureau and Offices, the activities of many of which affecting 
older Americans are summarized below.

Common Carrier Bureau

    Some of the most important policy actions of the FCC 
affecting older Americans were initiated in 1995-1996 by the 
Commission's Common Carrier Bureau (``CCB''). This Bureau 
regulates wire and radio communications common carriers in the 
telephone and telegraph industries. An excellent example of a 
relevant CCB issue is hearing aid compatibility and volume 
control ``HAC/VC''). This is of great relevance to older 
Americans because many people who lose their hearing later in 
life depend on HAC telephones with VC to be able to use the 
telephone.
    Hearing Aid Compatibility.--The Hearing Aid Compatibility 
Act of 1998 required the Commission to establish rules that 
ensure reasonable access to telephone service by persons with 
hearing disabilities, and to seek to eliminate the disparity 
between hearing aid users and non-users in obtaining access to 
the telephone network.
    To resolve various compliance issues, and recommend new 
rules to replace original rules suspended in April 1993, the 
Commission in the spring of 1995 established a 19-member 
Hearing Aid Compatibility Negotiated Rulemaking Committee. Its 
members represented all interested parties, including the 
Commission, telephone equipment manufacturers, employers, 
hospitals, nursing homes, hotels and motels, and persons with 
disabilities, including some older Americans.
    On July 3, 1996, the Commission adopted final rules, many 
of which were recommended to it by the Negotiated Rulemaking 
Committee in its report to the FCC of August 1995. In general, 
the FCC's revised and final rules required eventually all 
wireline telephones in workplaces, in confined settings (e.g., 
hospitals and nursing homes) and in hotels and motels to be 
hearing aid compatible according to certain timelines. In 
addition, telephones that are newly acquired or are replacement 
telephones eventually will have to have volume control 
features. Workplaces with fewer than 15 employees were 
exempted, except for telephones provided directly for employees 
with hearing disabilities. Finally, the date of November 1, 
1998 adopted by the FCC in July 1996 for implementation of the 
volume control features in all telephones manufactured or 
imported for use in the United States was later extended on 
reconsideration to January 1, 2000.
    Anti-``Slamming.''--``Slamming'' is the prohibited practice 
of the unauthorized conversion of a person's long distance 
telephone company. Older Americans, especially those with 
speech and/or hearing disabilities, are especially vulnerable 
to such anti-consumer activity. In 1995, the Commission amended 
its rules to ensure that carriers do not use misleading or 
confusing forms that consumers sign to change their long 
distance service. The Commission required that certain 
information be clearly stated on the form and prohibited the 
inclusion of misleading promotional material. The Commission 
took this action because some carriers were using forms, such 
as contest entry forms, that masked the effect of the 
subscriber's signature.
    On June 13, 1995, the Commission adopted a Report and Order 
amending the rules concerning the Letters of Agency used to 
change the long-distance carrier of a telephone consumer. The 
new rule requires that the Letters of Agency be separated from 
inducements such as prizes or contests, and that they clearly 
state that by signing the Letter of Agency, the consumer is 
requesting a change in his or her long distance service.
    In conjunction with the amendment of the rules concerning 
the unauthorized conversion of long distance service, the 
Common Carrier Bureau's Enforcement Division initiated a series 
of investigations in 1995 into carrier ``slamming'' practices. 
Notably, one carrier was fined for converting a widow's 
telephone service by forging the signature of her husband who 
had been dead for three years!
    Charges for Toll-free Numbers.--In 1996, the Commission 
amended its rules to place further restrictions on the use of 
toll-free numbers to provide information services. The 
Commission took this action because certain companies were 
encouraging consumers, including many older Americans, to call 
an 800 number they though would be a free call and then later 
charging a fee on the telephone where the call originated. The 
rules now require the consumer's written authorization, or the 
use of a calling or credit card, for such charges to be valid.
    Renting of Telephone Sets.--In 1996, the Commission and the 
Federal Trade Commission issued information advising consumers 
that they may be unknowingly renting their phone sets at a cost 
that far exceeds the purchase of a set. Continuing to rent 
rather than buy telephone handsets is a very common practice 
among older Americans. The Commission found that in many cases, 
the unintended, long-term rental resulted from consumers not 
buying their handsets from AT&T when, in the early 1980s, the 
Commission required AT&T to offer the sets for sale rather than 
charge each month for rental of the handset equipment.
    Brochures on Unauthorized Changes and Excessive Charges.--
In June 1996, the Commission issued bi-color, consumer-friendly 
brochures containing information to help consumers, including 
older Americans, avoid ``slamming'' or unauthorized changes in 
their long distance service as well as excessive charges for 
calls from public telephones.
    Telecommunications Relay Services (``TRS'').--Older 
Americans in 1995-1996, especially those with hearing 
disabilities, also continued to benefit from the Commission's 
rules implementing Title IV of the Americans with Disabilities 
Act (``ADA''). Title IV of the ADA governs the operation and 
funding of both interstate and intrastate telecommunications 
relay services. The TRS technology allows people with hearing 
and speech disabilities to use the telephone. TRS facilities 
are equipped with specialized equipment and staffed by trained 
communications assistants who relay conversations between 
people who are using text telephones, sometimes also called a 
TTY, and people using wireline telephones.
    Universal Service.--The Telecommunications Act of 1996 
established certain principles for the Commission to follow in 
revising and expanding the scope and definition of ``universal 
service'' in telecommunications services for all Americans, 
including older Americans. Among the explicit provisions 
established by this landmark legislation, Section 254 (b)(6) 
mandates access to advanced telecommunications services for 
``health care providers'', including hospitals and health 
clinics which, of course, serve many older Americans.

Cable Services Bureau

    Older Americans with hearing and sight disabilities can now 
be helped by a number of technologies related to television, 
especially closed captioning and video description. These two 
technologies are designed to increase ``video accessibility.''
    Video Accessibility.--In December 1995, the Commission 
adopted a Notice of Inquiry to assess the current availability, 
cost and uses of closed captioning and video description, and 
to examine what further Commission action may be appropriate to 
promote these services. It also asked for comments on the 
appropriate means of promoting their wider use in programming 
delivered by television broadcasters, cable operators, and 
other video programming providers. Closed captioning provides 
important benefits primarily for individuals with hearing 
disabilities by displaying the audio portion of a television 
signal as printed words on the television screen. Video 
description benefits individuals with visual disabilities by 
providing audio descriptions of a program's key visual elements 
that are inserted during the natural pauses in the program's 
dialogue.
    Closed Captioning.--In the 1996 Act, Congress directed the 
Commission to ensure that closed captioning is available to 
persons with hearing disabilities and to assess the appropriate 
method for phasing video description into the marketplace to 
benefit persons with visual disabilities. As a first step, 
Congress required the Commission to submit a report addressing 
these issues. Since the 1996 Act adopted the provisions 
concerning the availability of video programming with closed 
captioning and video description which formed the basis of the 
Commission's inquiry, the Commission decided to use the 
comments filed in that proceeding and publicly available 
information for its report to Congress. The Commission 
submitted its Report to Congress on July 29, 1996.
    In its Report, the Commission found that between 50 and 60 
million U.S. homes can receive closed captioning; through the 
efforts of Congress, government agencies and a variety of 
private parties, captioned video programming has grown over the 
past 25 years and is now a common feature of many video 
programming types; and the quality of closed captioning varies 
greatly and generally reflects the method of adding the 
captions, the quality of the captions and the entity providing 
the captions. Estimates of the cost of captioning range from 
$800 to $2500 per hour of prerecorded programming and from $150 
to $1200 per hour of live programming. The Report also found 
that the Department of Education provided about $7.9 million 
for closed captioning last year, which represents roughly 40% 
of the total amount spent on captioning.
    Video Description.--With respect to video description, the 
Commission reported to Congress that there is a lack of 
experience with developing and assessing the best means for 
promoting its use since it is a newer service. The Public 
Broadcasting Service and a few cable networks include video 
description with some of their programming. Costs for video 
description are approximately one and a half the costs 
associated with closed captioning of similar programming. Video 
description also receives substantially less government 
funding, which has been a significant factor in promoting the 
development of closed captioning. For example, the Commission 
observed that the Department of Education allocated only $1.5 
million for video description in 1995. Additional legal and 
technical issues exist. For example, video description requires 
the development of a second script, which raises creativity and 
copyright issues, must use the second audio programming channel 
and thus must compete for use with other audio services, 
particularly bilingual audio service.

Mass Media Bureau

    Digital Television.--In 1996, the Mass Media Bureau, which 
regulates the radio and television industries, drafted and the 
Commission adopted a Report and Order dealing with technical 
standards for digital television (``DTV''). This proceeding 
addressed technical standards for DTV which will be the next 
generation of television. DTV will affect all citizens, 
including older Americans, by providing more choices in video 
programming with dramatically better visual and aural 
resolution. Future proceedings may deal with the potential 
effects of DTV on society in general, including people with 
disabilities and older Americans.

Wireless Telecommunications Bureau

    In 1995-1996, the Wireless Telecommunications Bureau which 
regulates all wireless telecommunications services such as 
cellular, paging and personal communications services undertook 
a number of activities that affected older Americans. These 
included the following:
    Section 255 (Access to Telecommunications) Notice of 
Inquiry.--Section 255 of the Communications Act, added by the 
Telecommunications Act of 1996, provides that 
telecommunications equipment manufacturers and service 
providers must make their equipment and services accessible to 
those with disabilities, to the extent that it is readily 
achievable to do so. The Commission initiated the 
implementation of Section 255 by adopting a Notice of Inquiry 
in September 1996.
    Wireless Hearing Aid Compatibility.--In January, 1996, the 
Commission launched a Hearing Aid Compatibility Summit to 
encourage consumers, hearing aid manufacturers, and wireless 
telephone equipment manufacturers to address the interference 
and compatibility problems for hearing aid wearers that are 
caused by digital phones.
    Possible Interference Between Wireless Phones and 
Pacemakers.--The Commission met in 1996 with researchers, 
consumers, industry, and the Food and Drug Administration on 
concerns regarding possible interference between wireless 
phones and pacemakers and industry efforts to resolve any 
possible interference.
    Spectrum for assistive listening devices.--In July 1996, 
the Commission established a Low Power Radio Service in the 
216-217 Mhz band for, among other things, auditory assistive 
listening devices (``ALDs'') and radio-based health care aids 
(i.e., remote monitoring of patients' vital signs in hospitals 
and health care facilities.). ALDs are designed to help hard of 
hearing people to better understand speech, music, and the 
sounds during a movie, play, concert, lecture, etc. ALDs are 
sound-reinforcement equipment which, figuratively, gets the 
speaker's mouth close to the listener's ear in order to 
minimize the negative impact and sound distortions of distance, 
room reverberation, and ambient noise.
    Family Radio.--In May 1996, the Commission established a 
very short distance, unlicensed, two-way voice personal radio 
service called the Family Radio Service to give families, 
friends and associates the capability to communicate with one 
another during group outings where group members may become 
separated, either planned or inadvertently.
    Public Safety.--During 1995-1996, the Commission took a 
number of steps to improve the Nation's public safety wireless 
communications system. These improvements will benefit all 
citizens, including older Americans who may need the services 
and telecommunications capabilities of police, fire and medical 
emergency personnel as much as, or even more than, any other 
segment of the population. For example, the Commission together 
with NTIA established the Public Safety Wireless Advisory 
Committee (PSWAC) to provide advice and recommendations on 
various requirements of public safety agencies through the year 
2010. The Commission also initiated a rulemaking proceeding (WT 
Docket No. 96-86) to address the present deficiencies in public 
safety wireless communications.
    Combatting Telecommunications Fraud.--The Commission in 
1995-1996 published with the Federal Trade Commission consumer 
alerts for Specialized Mobile Radio (``SMR'') and paging 
licensees and gave presentations to the public on ``How to 
Avoid Being Bilked by Telecommunications License Investment 
Scams.''
    Finally, in 1995-1996, three of the Commission's support 
offices also undertook activities affecting and benefiting 
older Americans. These are summarized as follows;

Office of Engineering and Technology

    In 1995-1996, the Office of Engineering and Technology 
(``OET'') began and continued an investigation of potential 
interference from handheld Personal Communications Services 
devices to hearing aids. (OET is the FCC's chief technical 
adviser on engineering and scientific matters, and is 
responsible for helping the FCC manage the non-Government use 
of the electromagnetic spectrum.)

Office of Managing Director

    In 1995-1996, the Office of Managing Director, Human 
Resources Management, continued its past practice of expanding 
the FCC's job recruitment activities to reach more older 
Americans by, for example, sending vacancy announcements to 
various older American groups such as ``Forty Plus of Greater 
Washington.''

Office of Public Affairs

    In 1995-1996, the Commission expanded its outreach to 
senior citizens, the population most at risk of being 
victimized by schemes and scams via telephone. The Commission 
held off-site sessions for diverse groups of seniors and senior 
organizations around the Washington Metropolitan area, and 
produced special fact sheets, brochures and other informational 
products, both in print versions and electronically for the 
Commission's Internet Web Site.
    In 1995, the FCC participated in a special ``Fireside 
Forum,'' an off-site program for senior citizens at ``Leisure 
World'' in Silver Spring, Maryland. The program provided the 
audience the opportunity to learn about telephone issues and 
telephone frauds and scams. FCC subject matter experts offered 
explanations and guidance about telephone issues as well as 
about competitive bidding or auctioning of spectrum and other 
spectrum licensing processes.
    In 1996, FCC-sponsored events included fora for seniors on 
telephone-related topics. The Commission held four off-site 
workshops. For example, the session in Washington included 
representatives of the District of Columbia Commission on 
Aging, the Greater Washington Urban League's Annual Senior 
Citizens Crime Prevention and Education program, the American 
Association of Retired Persons, and the FCC.
    Another session also on telephone-related topics was 
presented to a culturally diverse group of older Americans with 
simultaneous translation in Vietnamese, Chinese, and Spanish. 
Finally, one of the sessions was covered by a local access 
community cable TV station and cablecasted to its audience.

Conclusion

    This report has summarized the many activities undertaken 
by the Bureaus and Offices of the Federal Communications 
Commission in 1995-1996 affecting and benefiting older 
Americans. Any one who wants more information on any of these 
activities can contact the Commission via its Office of Public 
Affairs at 202-418-0500, its National Call Center at 1-888-
CALL-FCC (225-5322), or its Web Site on the Internet at 
www.fee.gov.

                   ITEM 20--FEDERAL TRADE COMMISSION

                              ----------                              


                            1995-1996 REPORT

 Staff Summary of Federal Trade Commission Activities Affecting Older 
                               Americans

    This report discusses the Federal Trade Commission's 
activities of particular significance for older consumers in 
calendar years 1995 and 1996. The first section of the report 
describes Commission initiatives to eliminate telemarketing 
frauds that target older consumers, who represent the majority 
of victims in many telemarketing scams. The second section 
reports Commission activities relating to the health concerns 
of senior citizens. Older consumers, in general, experience 
more health problems and therefore may be more vulnerable to 
injury from misleading health claims made about products or 
services or from anticompetitive mergers or other forms of 
anticompetitive conduct in health care markets. The third 
section discusses Commission law enforcement activities of 
particular importance to older consumers in other areas. The 
final section of the report addresses the Commission's consumer 
education initiatives that may be of particular benefit to 
older consumers.

                    Telemarketing Fraud Initiatives

    On March 6, the Senate Special Committee on Aging conducted 
a hearing on one of the greatest societal problems affecting 
older Americans--telemarketing fraud.\1\ Fraudulent 
telemarketers often target older citizens, knowing that many of 
them may have significant assets from a lifetime of saving, 
including self-directed retirement accounts. These 
telemarketers also know that the victim, shamed at suffering 
such losses, often will not tell friends and family about the 
scam and will be desperate to make back the losses. The 
telemarketers then have other con artists ``reload'' the victim 
with more offers until the victim has no more to give, 
monetarily or psychologically. One witness at the Senate 
hearing, Mary Downs, testified that she lost over $74,000 to 
fraudulent telemarketers from April 1992 to March 1993.\2\ Some 
fraudulent telemarketers, in perhaps the most pernicious 
scheme, also operate ``recovery rooms'' that purport to help 
fraud victims get back their money for a substantial fee.
---------------------------------------------------------------------------
    \1\ Hearing before the Senate Special Committee on Aging, March 6, 
1996: ``Telemarketing Fraud and Senior Consumers,'' March 6, 1996.
    \2\ Statement of Mary Ann Downs, March 6, 1996.
---------------------------------------------------------------------------
    It has been estimated that telemarketing fraud may cost all 
American consumers as much as $40 billion a year in losses. 
Older Americans account for 60% of the fraud victims who call 
the National Consumers League's National Fraud Information 
Center.
    To combat these and other frauds, the Federal Trade 
Commission in 1995 and 1996 employed a new array of effective 
weapons. First, the Commission promulgated a new Telemarketing 
Sales Rule (``TSR''), as directed by Congress in the 
Telemarketing Consumer Fraud and Abuse Prevention Act of 1994, 
15 U.S.C. Sec. 6101. This Rule, which went into effect on 
December 31, 1995, defines a number of telemarketing frauds 
with greater specificity and allows both the FTC and state 
Attorneys General to bring actions in federal court. Second, 
the Commission used both the Rule and its FTC Act authority to 
conduct coordinated law enforcement ``sweeps,'' working with 
state Attorneys General, state securities officials, the FBI, 
the U.S. Postal Service, and other agencies. In 1996 alone, the 
Commission formed alliances that produced over 200 actions 
against fraudulent telemarketers. The Commission itself, from 
October 1995 through December 1996, brought nearly 100 federal 
court actions stoppingfraudulent operations that cost consumers 
$250 million a year and over $700 million over the lives of these 
schemes.

                        telemarketing sales rule

    The Telemarketing Sales Rule, 16 CFR Part 310, imposes 
general requirements for all telemarketers and addresses 
specific fraudulent practices. Under the TSR, telemarketers 
must promptly disclose certain information in telephone calls 
to consumers, including their identities, the fact that they 
are making a sales call, and the nature of the goods or 
services they are offering. The Rule also prohibits 
telemarketers from misrepresenting the services or products 
they sell and from debiting a consumer's checking account 
without the consumer's express authorization. The TSR also 
outlaws a number of telemarketing practices such as credit card 
laundering. In addition to addressing the conduct of 
telemarketers, the TSR also bars third parties from providing 
substantial assistance to telemarketers--specifically, 
assistance such as providing consumer lists, marketing 
materials, or appraisals of investment offerings--when the 
person ``knows or consciously avoids knowing'' that the 
telemarketer is engaged in unlawful conduct. Violations of the 
TSR may result in civil penalties of as much as $11,000 per 
violation, and consumers who have lost over $50,000 are able to 
sue under the TSR to recoup their losses.
    In 1995 and 1996, the telemarketing frauds that most 
affected older Americans included bogus prize promotions, 
investment frauds, charitable solicitations, recovery rooms, 
and credit schemes sold over the telephone. This Report 
discusses each below.

                            prize promotions

    Prize promotion is an egregious type of telemarketing fraud 
in which a high percentage of victims are older Americans. In 
1996, more than 40% of the complaints logged into the 
Telemarketing Complaint System \3\ pertained to prize 
promotion. In a typical scheme, telemarketers make unsolicited 
calls or mail notification cards to consumers stating that they 
have won a valuable prize, such as a vacation, car, cash or 
jewelry. Consumers are told that they should purchase some 
product such as vitamins, cosmetics or magazine subscriptions 
and they will then receive the prize.\4\ The TSR requires that, 
in any prize promotion, telemarketers must disclose that no 
purchase or payment is required to win a prize, and must 
provide information about the odds of winning the prize and how 
to participate in the promotion at no cost. 16 CFR 
Sec. 310.3(a)(1)(iv).
---------------------------------------------------------------------------
    \3\ The Telemarketing Complaint System (``TCS'') is a nationwide 
database of consumer complaints on telemarketing fraud. The Commission 
maintains this database, which is accessible by 100 participating law 
enforcement organizations who can query the system to locate the 
victims of telemarketing fraud, target law violators, identify other 
investigative agencies that have opened investigations, and coordinate 
law enforcement efforts. In 1995 alone, over 16,000 complaints were 
entered on the TCS, reflecting dollar losses of more than $21 million.
    \4\ The Commission has traced expenditures by victims of bogus 
prize promotion schemes and found that some consumers have actually 
lost tens of thousands of dollars to prize promotion telemarketers.
---------------------------------------------------------------------------
    Operation Senior Sentinel: The FTC played a significant 
role in Operation Senior Sentinel, announced in December 1995. 
This enforcement effort, led by the U.S. Department of Justice, 
was the largest criminal crackdown ever on telemarketing fraud. 
It focused on telemarketing scams targeting older Americans 
such as prize promotions and recovery rooms. Nearly 80% of the 
victims in the underlying prize promotion and recovery room 
cases targeted in Operation Senior Sentinel were older persons. 
The operation was launched with the simultaneous arrest of 
nearly 400 telemarketers. By the end of 1996, more than 800 
individuals had been prosecuted or arrested on charges of 
federal crimes.
    The Commission participated by assisting criminal law 
enforcement authorities to identify victims and witnesses as 
well as by filing five civil complaints--four against allegedly 
fraudulent prize promotions and the fifth against an alleged 
recovery room. The courts in these actions issued strong 
preliminary relief, closing down those ``boilerrooms''--
telephone sales rooms--and freezing defendants' assets.
    Chattanooga Project: During 1995 and 1996, the Commission 
also provided other substantial direct support to the criminal 
prosecution of fraudulent prize promoters. In 1995, the FTC 
detailed eight attorneys to the Chattanooga, Tennessee 
Telemarketing Fraud Task Force. Chattanooga had became a 
leading center of fraudulent telemarketing activity, 
particularly prize promotions. The overwhelming majority of the 
victims of the Chattanooga operations were senior citizens. The 
FTC attorneys were cross-designated as Special Assistant U.S. 
Attorneys and brought criminal actions against telemarketers 
operating in the area. By the end of 1996, the Chattanooga Task 
Force largely had completed its work, having obtained fifty 
convictions and combined prison sentences against fraudulent 
telemarketers totaling over 1,695 months. The defendants were 
ordered to pay more than $13 million in restitution. In 
recognition of the FTC's contributions, the U.S. Department of 
Justice honored the FTC attorneys with its John Marshall Award 
for interagency cooperation in support of litigation in 1996.
    Operation Jackpot: In June and July 1996, the Commission 
joined with the U.S. Postal Inspection Service and 16 state 
Attorneys General to bring 56 law enforcement actions against 
79 fraudulent prize promoters in 17 states. The Commission 
itself brought eight cases alleging violations of both the FTC 
Act and the TSR.\5\ The complaints named companies that 
allegedly lured consumers to buy ``Say No to Drugs'' 
paraphernalia or magazine subscriptions to obtain a prize. 
Another target, Publishers Award Bureau, allegedly promised 
land in Baja California as awards accompanying magazine sales. 
In another case, American Exchange Group, Inc., the Commission 
alleged that the company had promised consumers that they would 
receive large, valuable awards on the condition that they 
purchase magazine subscriptions. As with other prize promotion 
offerings, the prizes were allegedly either non-existent or 
were worth significantly less than the amount paid. The 
Commission also filed suit against Ideal Concepts and its 
principals, charging that the defendants, who operated a 
nationwide telemarketing operation selling novelty items, e.g., 
hats, frisbees, etc., imprinted with anti-drug statements, had 
fraudulently promised that consumers would receive valuable 
prizes.
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    \5\ Other 1996 Commission-led sweeps to enforce the Telemarketing 
Sales Rule or to target other types of fraud included ``Operation 
Payback'' (fraudulent credit repair operations), ``Operation Loan 
Shark'' (advance fee loan schemes), ``Operation CopyCat'' (fraudulent 
telemarketing of office supplies), ``Project Career Sweep'' (misleading 
offers of employment services), ``Project $cholar$cam'' (bogus 
scholarship search services), Internet/Credit Repair (deceptive 
Internet advertising of credit repair), ``Project BuyLines'' 
(fraudulent marketing of 900-number business opportunities), and 
``Operation Missed Fortune'' (deceptive offers of get-rich-quick and 
self-employment schemes).
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                           investment frauds

    Fraudulent telemarketers know that many senior citizens 
have substantial savings and that many may need substantial 
investment returns to help finance retirement. The stock market 
boom of the mid-1990's also led many investors to seek and 
expect high returns. Fraudulent telemarketers were only too 
happy to respond to these desires, peddling bogus investment 
opportunities ranging from gold, rare coins, art prints, 
gemstones, and wine investments totelecommunications licenses 
issued by the Federal Communications Commission. The telemarketers 
invariably assured consumers that they would realize a substantial 
return on their investment, usually in a short period of time and with 
minimal risk. The amounts of individual losses often were quite high, 
sometimes $5,000 to $20,000 or more per person. In one case, a woman 
who had saved over $100,000 over forty years of babysitting lost all of 
it to a scam touting investments in supposed application services for 
FCC paging system licenses. Older citizens taken by these scams often 
are not in a position to recoup their losses.
    DIRECTV and IVDS Frauds: In 1995, the Commission brought a 
coordinated action against three alleged purveyors of 
investment frauds touting new FCC license technologies. Two 
cases involved supposed profits to be made in connection with 
new wireless communication FCC licenses for Interactive Video 
and Data Service (IVDS). In one case, Digital Interactive 
Associates, the telemarketers sold over $19 million in 
partnership interests in such businesses allegedly by such 
means as understanding their risks and failing to disclose the 
amount of funds being drained off to telemarketers and 
insiders. In a second case, Chase McNulty Group, Inc. allegedly 
misrepresented the nature and value of these IVDS licenses and 
made other misrepresentations. Finally, the Commission alleged 
that Satellite Broadcasting Corp. misrepresented that it had 
the rights to market a type of satellite television programming 
called DIRECTV to certain markets and that investors could earn 
a substantial return from investing in the venture. The courts 
in all three cases issued injunctive relief that included asset 
freezes and the appointment of receivers. In the case against 
Chase McNulty, the court approved a consent decree awarding a 
judgment of $1 million \6\ and requiring individual defendants 
to pay $160,000 and to post a bond of $350,000 before engaging 
in future telemarketing. Defendants in the Satellite 
Broadcasting Corp. case agreed to pay more than $700,000 in 
consumer redress. The Digital Interactive case is still in 
litigation.
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    \6\ The consumer redress amounts included in McNulty and the 
following cases have been ordered by the court (whether through 
litigation or settlement) and may be higher than the amounts collected 
and returned to consumers. Collection is often difficult because, in 
many cases, the defendants do not have identifiable assets subject to 
execution. In December 1995, the Commission entered into a Memorandum 
of Understanding with the U.S. Treasury, under which Treasury provides 
assistance in collecting judgments owed to the Commission. The 
Commission was the first agency to refer its uncollected judgments to 
Treasury's Financial Management Services Division, which uses its 
collection expertise to aggressively collect on these judgments.
    Where practicable, the Commission seeks to redress injured victims. 
Where redress is not practicable, any monies paid by defendants 
typically are disgorged to the U.S. Treasury.
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    Operation Roadblock: In January 1996, the Commission, 
together with the North American Securities Administrators 
Association, coordinated a federal and state initiative aimed 
at high-tech scam promoters peddling Federal Communications 
Commission paging licenses and 900-number companies as 
investments. The Commission and 21 states filed 85 law 
enforcement actions against telemarketing companies. These 
companies had taken in more than $250 million from consumers 
touting bogus investments on the ``Information Superhighway.'' 
As a result of Operation Roadblock, FTC-FCC cooperation, and 
intensive consumer education efforts, telemarketing scams 
relating to FCC licenses took a sharp drop in 1997.
    Miscellaneous Investment Frauds: Counterfeit art works were 
the subject of a 1995 Commission lawsuit against Renaissance 
Fine Arts, Ltd. and its owner. In that case, the individual 
defendant fled the United States but subsequently returned and 
was arrested by U.S. Postal authorities on charges related to 
the Commission's complaint allegation. The court-ordered 
default judgment required the defendants to pay $2.3 million in 
consumer redress and banned the company's president from 
further telemarketing of artwork. Permanent injunctions also 
were entered in settlement of pending lawsuits against 
Georgetown Galleries (alleged misrepresentations in the 
telemarketing of antiquarian art prints) and Cambridge 
Exchange, Ltd. (alleged misrepresentations in the telemarketing 
of animation cells and other art works coupled with an 
allegedly deceptive prize promotion).
    Finally, the Commission obtained a settlement in an earlier 
case against Unimet Credit Corp., involving allegations that 
defendants had assisted other companies that deceptively 
telemarketed leveraged investments in precious metals and 
foreign currency. The defendants were required to pay $1.9 
million in consumer redress.

                        Charitable Solicitations

    Legitimate charities often offer prizes in connection with 
their fundraising efforts. However, the Commission in 1995 and 
1996 also saw substantial numbers of telemarketing operations 
where salespeople, in the name of a charity, promised consumers 
extravagant prizes in return for an allegedly tax-deductible 
donation to a specific charity (``telefunding''). Not 
surprisingly, the prizes were almost worthless and the amounts 
of money that ever reached charitable organizations were 
infinitesimal.
    In 1995, the Commission charged NCH, Inc. and its 
principals for their roles in a fraudulent telefunding scheme. 
The Commission alleged that the company had misrepresented that 
consumers would win valuable prizes in exchange for making a 
donation to a charity called``Operation Life.'' The court 
ordered the defendants to pay over $2.6 million in redress to consumers 
and permanently banned them from engaging in prize promotion 
activities.
    During the 1995-96 period, the Commission also settled a 
number of lawsuits previously brought against other 
telefunders. In one matter, the complaint had alleged that 
corporate defendants, Publishing Clearing House (not the 
familiar Publishers Clearinghouse), M.A.A., Inc. and certain 
individual defendants had made unsolicited calls to consumers, 
telling them that they had been selected to receive a valuable 
prize--ranging in value from $3,500 to $50,000 in cash. The 
consumers were then told that all they had to do to receive the 
prize was to make a tax-deductible donation of a significant 
specified amount to a designated charity. The Commission 
alleged that the consumers did not receive the promised prize 
(or if they did, it was of nominal value) and that the 
``donation'' was not tax-deductible. In settling this case, the 
Commission required the defendants to post a $1 million 
performance bond before engaging in any prize promotion or 
charitable solicitation activity.
    The Commission obtained comparable relief through 
settlement of another case with a Las Vegas telemarketer and 
telefunder, Marketing Twenty-One dba Genesis Enterprises. As 
with PCH, the company promised prizes in exchange for a 
purportedly tax-deductible contribution. The Commission alleged 
that these claims were false. The settlement requires the 
individual defendant, Markos Mendoza, to post a $1 million 
performance bond before engaging in a similar telemarketing 
venture.
    In 1995 and 1996, the Commission also obtained consent 
decrees with 24 defendants involved with an organization of 
telefunders for The Gleaners. In these cases, the Commission 
charged that defendants falsely represented the value and 
nature of prizes that consumers would receive in return for 
their donations to teenage alcohol and drug-abuse 
rehabilitation programs and food banks purportedly run by The 
Gleaners. The complaint also alleged that defendants 
misrepresented the charitable activities undertaken by the two 
charitable organizations. The settlements provide that the 
individual defendants must post a $1 million bond before 
engaging in any telephone prize promotion business and must 
disclose the existence of the bond to customers.

                             Recovery Rooms

    ``Recovery rooms'' prey on persons who have already been 
victimized by telemarketers. Telemarketers obtain the names and 
addresses of these victims by purchasing, or trading for, lists 
of victims from other fraudulent operations. The recovery room 
salesperson then falsely promises the victims that, for a fee, 
the telemarketer can help them obtain the promised prize or 
money lost in a previous telemarketing scam. Often, 
telemarketers represent themselves as governmental entities or 
as agents hired to locate victims and distribute money back to 
them. After the consumers sends in the requested fee, the 
company invariably fails to deliver the refund or prize, 
thereby exacerbating the victim's losses. A review of victim 
demographics in several of the Commission's recovery room cases 
has confirmed that older consumers are prominent in the victim 
universe. In one case, 81% of the consumers were at least 65 
years of age and 23% were at least 80 years old. In another 
case, 82% were at least 65 and 32% were at least 80 years old.
    During 1995 and 1996, the Commission brought or settled 
lawsuits against numerous individuals and companies involved in 
nearly a dozen recovery room operations. Some of these cases 
were brought as part of Senior Sentinel or other sweeps. 
Examples include the Commission's cases against USM and 
Meridian Capital Management. In USM, the defendants did 
business as Senior Citizens Against Telemarketing, or ``SCAT.'' 
SCAT allegedly masqueraded as a consumer protection 
organization that worked closely with government agencies. 
According to the Commission's complaint, SCAT represented to 
consumers that it would recover substantial sums of money that 
consumers had lost in previous telemarketing scams and would 
even file lawsuits on consumers' behalf, if necessary. The 
charge to consumers ranged from $200 to $1,000.
    Another of the Commission's 1995 lawsuits targeted Meridian 
Capital Management, which allegedly made unsolicited telephone 
calls to consumers who had been victims of various investment 
frauds, often involving Federal Communications Commission 
wireless telecommunications licenses. For a fee of 10% of the 
consumer's previous investment, Meridian claimed it could 
recover all or a substantial portion of the money invested. In 
addition, according to the complaint, Meridian also represented 
that it was on the verge of filing a class action lawsuit and 
the consumer had to pay immediately in order to participate as 
a member of the class. Finally, the complaint also challenged 
Meridian's representation that it could collect on performance 
bonds supposedly posted by fraudulent telemarketers.\7\ In 
1996-1997, the Commission obtained default judgments for $1.6 
million against Meridian and several individual defendants, and 
stipulated or court-ordered permanent injunctions were entered 
against all defendants. With Commission staff acting as Special 
Assistant U.S. Attorneys, the U.S. Department of Justice in 
1998 obtained indictments charging 17 defendants involved in 
the Meridian scam with the crimes of conspiracy, mail fraud, 
and wire fraud. In addition, seven of the defendants were 
charged with money laundering.
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    \7\ The Commission also settled its recovery room case against 
Regeneration & Renewing dba AWARE, described in the 1994 report, with 
monetary judgments of more than $4.1 million.
---------------------------------------------------------------------------
    The Commission's efforts against recovery rooms were 
enhanced by the implementation of the Telemarketing Sales Rule, 
which specifically prohibits telemarketers from requesting or 
receiving payment for recovery room services until after the 
refund or prize is delivered to the consumer. 16 C.F.R. 
Sec. 310.4(a)(3). Our law enforcement efforts and the deterrent 
effect of this TSR provision have borne fruit. The volume of 
consumer complaints concerning recovery rooms logged into the 
FTC Telemarketing Complaint System in 1996 plummeted to 153--
less than one-fifth the record high volume of 869 complaints 
recorded in 1995.

                              Credit Fraud

    Three types of credit-related telemarketing scams that have 
plagued older Americans involved unauthorized check cashing, 
advance fee loan schemes, and bogus credit repair services. The 
Telemarketing Sales Rule addresses prevalent practices in these 
areas.
    In attacking unauthorized check cashing or demand draft 
fraud, the Commission filed complaints against a cluster of 
telemarketers, including, for example, Windward Marketing, 
Ltd., charging violations of the demand draft provision of the 
TSR. These telemarketers allegedly tricked consumers into 
revealing their checking account numbers and then used that 
information to debit consumers' checking accounts without the 
consumers' authorization. This ruse was in conjunction with a 
magazine subscription offering. The case was settled with 
monetary judgments of more than $14 million.
    In mid-1996, the Commission and 15 state Attorneys General 
joined in a sweep called Project Loan Shark, bringing 13 
lawsuits against 45 firms and individuals that ran advance 
feeloan schemes, in which telemarketers represent that, for a fee, they 
will guarantee consumer credit in the form of a loan or credit card. 
The TSR makes it illegal for telemarketers who guarantee consumers a 
loan or credit to charge an advance fee. Among the targets of Project 
Loan Shark was Global E, which marketed credit cards for an advance fee 
and was charged with violations of the TSR. The Commission also filed a 
complaint alleging that Patricia Popp charged advance fees in 
connection with the offer of debt-consolidation services and loans.
    Bogus credit repair firms promise that, for a fee, they 
will remove negative, though accurate, information contained in 
consumers' credit reports. Since credit reporting bureaus 
legally may include verifiable, negative information in 
consumers' reports for a period of seven years, and 
bankruptcies for ten years, credit repair companies cannot 
deliver the service they promise. The TSR prohibits credit 
repair companies from obtaining payment until six months after 
they have, in fact, fulfilled their promise to clean up credit 
histories. The Commission charged Universal Credit Corp., with 
violations of both the FTC Act and the TSR--the company claimed 
a 90% success rate in removing negative, accurate information 
from customers' reports and promised a money-back guarantee. 
The company was also charged with making unauthorized demand 
drafts on customers' checking accounts. As part of the 
enforcement strategy in this industry, the Commission launched 
Operation Payback, a joint federal-state law enforcement sweep 
in 1996 in which the Commission filed four complaints against 
deceptive credit repair companies.\8\
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    \8\ As part of the 1996 Fair Credit Reporting Act Amendments, the 
Congress enacted the Credit Repair Organization Act, 15 U.S.C. 
Sec. 1679 et seq., which specifically addresses credit repair scams. 
Effective April 1, 1997, the law will be enforced by the Federal Trade 
Commission and state Attorneys General.
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                    cross-border telemarketing fraud

    In 1995, the Commission stepped up its response to the 
globalization of telemarketing fraud. The Commission had 
detected an increase in Canadian-based telemarketing companies 
targeting United States citizens, often older consumers. 
Canadian officials confirmed that the reverse was also true. 
The Commission is tackling this problem through workshops, task 
forces, and cooperative law enforcement efforts. In August 
1995, representatives of U.S. and Canadian law enforcement 
agencies agreed to coordinate enforcement of their competition 
and deceptive marketing practices laws. In 1996, the Commission 
co-sponsored two conferences on cross-border fraud and 
established a task force on Cross-Border Deceptive Marketing 
Practices with Canada's Competition Bureau to facilitate 
coordinated law enforcement between the two countries.
    Also in 1996, the Commission brought its first enforcement 
actions against Canadian-based telemarketers. The first case 
was against Ideal Credit Referral Services, which operated from 
a boilerroom in British Columbia and peddled advance fee loan 
services. The next cross-border firm to be sued was another 
Canadian firm, Incentive International, which allegedly 
fraudulently ran a prize promotion.
    The Commission also has pursed defendant's assets across 
international borders. In an Operation Roadblock case against 
Online Communications, one of the defendants allegedly 
transferred assets to the Bahamas. With FTC staff's assistance, 
the Department of Justice's Office of Foreign Litigation 
obtained an injunction freezing the assets in the Bahamas; the 
defendant subsequently agreed to repatriate $300,000 to the 
U.S. This was the first time the U.S. government obtained an 
asset freeze from a foreign court and obtained the funds for 
redress to American telemarketing victims.

                             internet fraud

    Finally, the Commission has anticipated the next great 
competitor to telemarketing fraud--fraud on the Internet. Older 
Americans are frequent users of the Internet, and the 
Commission in 1995 and 1996 held hearings on how not only the 
Internet, but many new technologies, were likely to be of 
concern in the coming decades.\9\ The Commission also 
extensively trained its staff and brought the first significant 
actions against Internet fraud artists. In 1996, the Commission 
joined with criminal authorities to bring actions against 
Fortune Alliance involving a multi-million dollar, online 
international pyramid scheme. Other cases included allegations 
that defendants used the Internet as a medium for fraudulent 
messages.
---------------------------------------------------------------------------
    \9\ Anticipating the 21st Century: Consumer Protection Policy in 
the New High-Tech Global Marketplace, a Report of the Federal Trade 
Commission Staff, May 1996.
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    In December 1996, the Commission also initiated the first 
of many subsequent ``surf days,'' in which Commission staff 
join with other law enforcement agencies and private groups to 
detect and warm potentially fraudulent sellers on the Internet. 
In this project, the Commission coordinated an effort by four 
federal agencies and 70 state and local law enforcement 
officials from 24 states to target pyramid schemes. The FTC 
staff and other law enforcers contacted over 500 Internet web 
sites, advising them of applicable law and conducting follow-up 
communications. Since then, the Commission has conducted surf 
days in numerous areas of concern, including health fraud, 
business opportunities, scholarship scams, and others.

                       Health-Related Activities

    While health care is a subject of concern for all of our 
citizens, it is of disproportionate concern to the aging. A 
significant portion of the Commission's consumer protection 
work helps to ensure that consumers are not harmed by deceptive 
claims about the health benefits of products or services. 
Similarly, a substantial portion of the Commission's antitrust 
law enforcement activity is aimed at ensuring that competition 
among providers of health care goods and services is not 
unlawfully impaired. This activity contributes both to cost 
containment and to the maintenance of quality in health care.

             consumer protection in health-related matters

Hearing aids and eyeglasses

    In 1994, the Commission filed an order-enforcement action 
against Dahlberg, Inc., one of the largest hearing aid 
manufacturers in the United States. The Commission's complaint 
charged that Dahlberg, maker of the ``Miracle-Ear'' brand of 
hearing aids, violated a 1976 FTC order by making false and 
unsubstantiated claims about its Miracle-Ear ``Clarifier,'' 
purportedly a ``noise-suppression'' hearing aid. These claims 
included assertions that the Clarifier focuses its 
amplification on sounds the user wants to hear, such as speech, 
and reduces all unwanted background noise. In 1995, the court 
entered a consent decree requiring Dahlberg to pay a penalty of 
$2.75 million--at that time the highest penalty obtained for 
alleged violations of an FTC consumer protection order.
    In another case, the Commission charged in federal court 
that the Telebrands Corporation exaggerated the benefits of its 
WhisperXL hearing aid, and also violated the Commission's Mail 
or Telephone Order Merchandise Rule, 16 CFR Part 435, by 
failing to ship products in a timely fashion. The 1996 consent 
decree prohibits violations of the Rule, requires the company 
to pay a $95,000 civil penalty, and prohibits 
misrepresentations about hearing devices. That year, the 
Commission also obtained an administrative consent order that 
banned false claims, including that the WhisperXL hearing aid 
produces clear amplification of whispered or normal speech and 
allows the user to hear a whisper from as far as 100 feet away. 
The consent order further requires that any claim that is made 
about the performance or effectiveness of any hearing aid be 
truthful and supported by competent and reliable evidence.
    In the vision care area, the Commission obtained a court-
ordered consent decree that required Doctors Eyecare Center, 
Inc. and its president to pay a $10,000 civil penalty to settle 
charges that they violated the Commission's Ophthalmic Practice 
Rules, 16 CFR Part 456, by failing to provide many patients 
with a copy of their eyeglass prescription after completing an 
eye examination and by unlawfully including on their 
prescription forms a waiver of liability as to accuracy. The 
purpose of this Rule is to remove unwarranted restraints on the 
ability of consumers to shop for competitive eyeglass prices.

Health claims for food and dietary supplements

    Consumers rely on the truthfulness of health claims for 
food and dietary supplements when making purchasing decisions. 
Senior citizens, because of special dietary requirements or 
other health concerns, may be particularly vulnerable to 
misleading claims for such products. The Commission continues 
to be active in this area and has engaged in several important 
law enforcement efforts since 1994.
    In 1995, the Commission accepted a consent agreement that 
prohibits Good News Products, Inc. from claiming that its eggs 
were lower in saturated fat and total fat than ordinary eggs, 
and that these eggs contained Omega 3 fatty acids that could 
positively affect heart attack risk factors. The order against 
Good News Products prohibits the company from misrepresenting 
the absolute or comparative amount of total fat, saturated fat, 
or any other nutrient or ingredient in eggs or food containing 
egg yolks. It also requires the company to have competent and 
reliable scientific evidence before making claims about the 
absolute or comparative effects of such food on heart disease, 
heart disease risk factors, and serum cholesterol, and claims 
about the health benefits for such foods.
    In 1996, the Commission obtained a civil penalty of 
$100,000 from Eggland's Best, Inc. to settle allegations that 
the company violated a 1994 order by making unsubstantiated 
cholesterol-related claims for its eggs. Specifically, the 
Commission alleged that Eggland's violated the order by: (1) 
representing, without substantiation, that eating its eggs will 
not increase serum cholesterol at all, or that doing so will 
not increase cholesterol as much as ordinary eggs; and (2) 
misrepresenting that clinical studies have proven that adding 
12 Eggland's Best eggs a week to a low-fat diet does not 
increase serum cholesterol.
    Also in 1996, the Commission obtained a settlement with 
Mrs. Field's Cookies, Inc. The company claimed that a certain 
line of cookies was ``low fat,'' when, in fact, the cookies did 
not meet the FDA requirements for low fat claims. The Mrs. 
Field's order prohibits the company from misrepresenting the 
existence or amount of fat, saturated fat, cholesterol, or 
calories in any bakery food product.
    Finally, the Commission in 1996 issued a cease and desist 
order against The Dannon Company to settle allegations that it 
made deceptive fat and calorie content claims for its frozen 
yogurt. The order prohibits Dannon from making false claims 
regarding the existence or amountof fat, saturated fat, 
cholesterol, or calories in any frozen food product. It also requires 
the respondent to pay the Commission $150,000.
    In the dietary supplement area, the Commission in 1996 
completed administrative litigation against Metagenics, Inc., 
challenging claims for its over-the-counter calcium supplement. 
The Administrative Law Judge ruled that Metagenics could not, 
without adequate substantiation, represent that the product, 
Bone Builder, restores lost bone, restores bone strength, 
reduces or eliminates bone pain, and is superior to other forms 
of calcium. The ALJ found for Metagenics with respect to 
certain other complaint allegations, and both sides appealed 
the ALJ's ruling.\10\
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    \10\ The Commission in 1997 issued a final consent order in the 
Metagenics case, among other things, requiring the respondents to have 
scientific substantiation for any claim that Bone Builder or any food, 
drug, or dietary supplement containing calcium will treat or prevent 
any disease, disorder, or condition, or that any food, drug, or dietary 
supplement is more effective than any other product in doing so.
---------------------------------------------------------------------------
    In 1995, the Commission issued a cease and desist order 
against Nature's Bounty, Inc. and two of its subsidiaries to 
settle allegations that they made deceptive weight-loss, body-
building, disease-treatment and/or other health-related claims 
for 26 nutrient supplements they marketed. The order prohibits 
the respondents from making various allegedly false claims, as 
well as requiring them to have substantiation for future health 
claims. The order also requires the respondents to pay $250,000 
to the Commission--to be used for consumer redress, if 
practical, or to be paid to the U.S. Treasury.
    Also in 1995, the Commission gave final approval to a 
consent agreement with Body Wise International, Inc., settling 
charges that the company made deceptive weight-loss and 
cholesterol-reduction claims for its nutritional supplements. 
The order prohibits the company from making health benefits 
claims regarding its products--including weight loss or 
cholesterol reduction claims--unless the claims, including 
those made through testimonials, are true and supported by 
adequate scientific evidence.
    Finally, the Commission in 1995 obtained a civil penalty of 
$45,000 from HealthComm, Inc. and Jeffrey S. Bland to settle 
allegations that they violated a 1992 order by making deceptive 
weight loss and related health claims. The Commission alleged 
that the defendants violated the order by: (1) representing 
that their supplements UltraMaintain and UltraMeal alter the 
mitochondria in the body's cells so that cells convert more 
food into energy; and (2) making unsubstantiated weight-loss, 
disease symptom-reduction, toxin-elimination, and blood 
cholesterol and blood pressure-reduction claims.

Over-the-counter drugs and medical devices

    Senior citizens rely heavily on the truthfulness of 
advertising claims for over-the-counter (``OTC'') drugs and 
medical devices. While the Commission has primary 
responsibility for ensuring that advertising for these products 
is truthful and nondeceptive, the FDA exercises primary 
jurisdiction with respect to the labeling of such products and 
their safety.
    In 1996, the Commission announced a settlement with Natural 
Innovations, Inc., advertiser of ``The Stimulator,'' a 
purported pain-relief device said to effectively relieve all 
types of pain and provide immediate, long-term pain relief 
better than other medications and treatments. In a separate 
settlement with World Media T.V., Inc., the Commission alleged 
that World Media directly participated in the creation and 
dissemination of the ``Say No To Pain'' infomercial on behalf 
of Natural Innovations. The Commission charged that the claims 
were unsubstantiated. The orders require the companies to 
provide scientific proof to back up any pain-relief or other 
health or medical benefit claims they make in the future.
    In 1995, the Commission issued consent orders against two 
marketers of ``facilitated communications'' devices--devices 
similar to a typewriter, computer or alphabet chart that 
purportedly enable those with developmental or communication 
disabilities to communicate through the device. One company, 
for example, claimed that its device would help consumers who 
had problems such as speech disorders, cerebral palsy, multiple 
sclerosis, or Alzheimer's disease. The Commission alleged that 
the companies' advertisements contained false or 
unsubstantiated representations concerning the efficacy of 
their devices. The consent orders ban certain claims and 
prohibit the companies from making representations about the 
ability of any communications aid to assist those with other 
disabilities to communicate through facilitated communications, 
unless the representation is true and substantiated by 
competent and reliable scientific evidence.

Other health-related devices and services

    As with OTC drugs and devices, older consumers are 
particularly vulnerable to fraudulent practices and misleading 
health benefit claims for other devices and services. The 
Commission in 1995-1996 took numerous law enforcement actions 
in this area.
    One initiative was against telemarketing firms engaged in 
fraudulent medical billing practices. The Commission brought 
federal court actions against three medical equipment companies 
that allegedly marketed relatively inexpensive wheelchairs, 
scooters, and other devices to disabled persons but then 
submitted insurance claims for more expensive equipment that 
was never delivered. In some cases, the Commission charged, 
insurance claims were filed for items that had never been 
ordered by consumers. Under the court-approved settlements, 
Freedom Medical, Inc., Independence Medical, Inc., Motion 
Medical, Inc., and individual defendants were required to pay a 
total of $754,850 for consumer redress, and some individual 
defendants were barred from any aspect of marketing medical 
products or services for ten years. In addition, some 
defendants were required to post a performance bond before 
engaging in the sale or rental of durable medical equipment, 
and all defendants were prohibited from making various 
misrepresentations in the future.
    In addition, Cancer Treatment Centers of America, Inc. and 
two affiliated hospitals agreed to settle Commission charges 
that they made false and unsubstantiated claims promoting their 
cancer treatments. The companies also allegedly failed to 
substantiate a claim that their five-year survivorship rate 
ranked among the highest recorded for cancer patients. The 
consent order requires the companies to have competent and 
reliable scientific evidence to substantiate future claims 
regarding the success or efficacy of their cancer treatments 
and to ensure that testimonials they use do not misrepresent 
the typical experience of their patients.
    In another settlement, Genetus Alexandria, Inc. and its 
owners, who sold impotence treatments, agreed to settle charges 
that they falsely represented that a physician would examine, 
diagnose, and treat every patient, that the treatment was 
unqualifiedly safe, and that the treatment would arrest each 
patient's impotence. The respondents also allegedly billed 
insurance companies for medical tests that were not performed. 
The consent order prohibits the respondents from 
misrepresenting the nature or extent of a physician's 
participation in any treatment, the safety or efficacy of any 
procedure, and the extent to which a treatment is covered by a 
patient's medical insurance.
    The Commission also brought a number of actions that could 
affect older consumers with respiratory ailments. In a matter 
involving air pollution claims, Ford Motor Company and its 
advertising agency, Young & Rubicam, Inc., agreed to settle 
Commission charges that they made false claims about the extent 
to which Ford's MicronAir Filtration System could remove air 
pollution from automobile passenger cabins. The Commission 
alleged that the system had no effect on gaseous pollutants, 
such as hydrocarbons, carbon monoxide and nitrogen oxide. The 
1996 consent orders prohibit certain claims and require the 
firms to have competent and reliable scientific evidence for 
any efficacy claims for car cabin air filters.
    In 1995, the Commission in two separate cases also obtained 
consent agreements with marketers of ozone generator air 
cleaners. One case involved Living Air Corporation and its 
sister company, Alpine Industries, Inc. The other involved 
Quantum Electronics Corporation. In both matters, the 
Commission alleged that the companies lacked substantiation for 
claims that the devices eliminate or clear specified chemicals, 
gasses, mode, mildew, bacteria, or dust from the environment, 
that the devices do not create harmful by-products, and that 
the devices prevent or provide relief from allergies, asthma, 
or other specified conditions. The consent orders require that 
the manufacturers of the devices have competent and reliable 
scientific evidence before making such claims and contain other 
relief to prevent misleading claims about other air cleaning 
products.
    Finally, the Commission settled allegations that David 
Green, M.D. deceptively advertised as pain-free permanent his 
varicose vein and spider vein treatments. The consent order 
requires Dr. Green to have competent and reliable scientific 
evidence to substantiate any future claims on this subject.

Diet and weight loss products and services

    Older consumers continue to invest heavily in the weight-
loss industry. The Commission in 1995-1996 has continued to be 
active in this area, and has taken numerous actions involving 
diet and weight-loss products, programs, and services. These 
cases include the settlements mentioned above with Mrs. Field's 
Cookies, The Dannon Company, Nature's Bounty, Body Wise 
International, and HealthComm, all of which included claims 
relating to weight-loss products. The Commission also obtained 
a consent order against NordicTrack, Inc., a major manufacturer 
of indoor exercise equipment. The Commission had charged that 
the firm had made false and unsubstantiated claims about the 
weight-loss benefits of its cross-country ski exercise machine, 
including claims that overstated users' weight-loss success. 
The consent order requires the company to have competent and 
reliable evidence to support weight-loss, weight maintenance, 
or related claims for any weight-loss equipment that it sells.
    The Commission also entered a final consent order against 
Choice Diet Products and its owner, marketers of the 
FormulaTrim 3000, MegaLoss 1000, and MiracleTrim diet pills, 
settling charges of false advertising. The order requires the 
company's owner to post a $300,000 performance bond to be used 
for consumer redress should he engage in deceptive practices 
when marketing weight-loss products in the future and contains 
further relief to prevent misleading claims regarding such 
products.
    In addition to weight-loss products, many older consumers 
purchase services from diet clinics. The Commission, having 
obtained twelve consent orders against such firms in 1992-1994, 
continued this program with further actions in 1995-1996 
involving low-calorie and very-low-calorie weight-loss 
programs. Formu-3 International, Inc., the franchisor of Form-
You-3 or Formu-3 weight-loss centers, and two related companies 
agreed to settle allegations that they made unsubstantiated 
weight-loss and weight-loss maintenance claims, engaged in 
deceptive pricing, and made misleading representations about 
the program's safety, participants' rate of weight loss, and 
other deceptive claims. The consent order prohibits the company 
from misrepresenting the performance, efficacy, or safety of 
any weight-loss program they offer or the competence or 
training of their personnel. The order also requires them to 
have scientific data to back up future claims about weight-loss 
success, rates, or time frames, and weight maintenance.
    In a case involving Diet Workshop, Inc., a franchisor of 
weight-loss plans and products, the Commission's consent order 
similarly prohibits the firms from misrepresenting the 
performance of any weight-loss program and requires them to 
have reliable scientific evidence to substantiate claims about 
achieving or maintaining weight loss, or the rate at which the 
loss can be expected to occur. The order also requires 
disclosure statements in certain advertising and bars the 
misleading use of consumer testimonials. The Commission's 
administrative complaints against Weight Watchers 
International, Inc. and Jenny Craig, Inc., issued in 1993, 
remained in litigation,\11\ and the Commission obtained a 
consent order against J. Walter Thompson USA, Inc. in 
connection with advertising it had created for the Jenny Craig 
Weight Loss Program. That case concerned a study purportedly 
showing that nine out of ten Jenny Craig clients would 
recommend the program to a friend.
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    \11\ The Commission in 1998 issued final consent orders in 
settlement of the charges against Jenny Craig and Weight Watchers.
---------------------------------------------------------------------------
    Finally, the Commission obtained consent orders against 
three marketers of single-session, group-hypnosis seminars that 
purportedly helped consumers lose weight. The Commission had 
charged that the companies and their owners had made false and/
or unsubstantiated claims about the success of participants in 
losing weight. The consent orders prohibit the respondents from 
making performance or efficacy claims for any weight-loss 
program they sell in the future without having competent and 
reliable scientific evidence that substantiates the claims.

              antitrust guidance to health care providers

    The rapid evolution of health care markets in response to 
changes in the way health care services are paid for and 
delivered has created concerns that the impact of antitrust 
enforcement in this sector might impede efficient, 
procompetitive combinations and collaborations. As was 
described in the Commission's 1994 report, the Commission and 
the Department of Justice's Antitrust Division jointly issued, 
in September 1993, their Antitrust Enforcement Policy 
Statements in the Health Care Area in response to these 
concerns. These statements defined ``antitrust safety zones'' 
for health care activity in various areas; these ``safety 
zones'' identified conduct that will not be challenged by the 
agencies, absent extraordinary circumstances. Additionally, for 
conduct falling outside these ``safety zones,'' the statements 
explained how the agencies will analyze the conduct to 
determine its legality. Finally, the statements highlighted the 
availability of Commission advisory opinions and DOJ business 
review procedures, and, for the first time, adopted time limits 
for agency answers to most health industry requests. 
Subsequently, in September 1994, the Commission and the 
Antitrust Division issued updated and expanded policy 
statements, Analytical Principles Relating to Health Care and 
Antitrust.
    The agencies recognized that additional guidance might 
become necessary as the health care market continued to evolve 
in response to consumer demand and competition in 
themarketplace. New arrangements and variations on existing 
arrangements involving joint activity by health care providers continue 
to emerge to meet the desire of consumers, purchasers and payers for 
more efficient delivery of high quality health care services. This 
evolution has led, in particular, to the development of many physician 
and multiprovider networks.
    On August 28, 1996, the agencies announced revisions to the 
agencies' enforcement policy statements regarding health care 
provider networks. These changes expanded upon the guidance 
contained in the agencies' 1993 and 1994 policy statements, in 
order to ensure that uncertainty about the antitrust laws does 
not deter the formation of new types of networks that could 
benefit competition and consumers. Revisions were made 
affecting two kinds of networks: (1) physician network joint 
ventures; and (2) multiprovider networks.
    The revised statement on physician network joint ventures 
provides an expanded discussion of the antitrust principles 
that apply to such ventures. The revised statement explains 
that where physician integration through the network is likely 
to produce significant efficiencies, any agreements on price 
reasonably necessary to accomplish the venture's procompetitive 
benefits will be analyzed under the rule of reason. The 
revisions focus on networks that fall outside of the safety 
zones, particularly those networks that do not involve the 
sharing of substantial financial risk by the physician 
participants. The statements stress that a physician network 
that falls outside of the safety zones is not necessarily 
anticompetitive.
    Because multiprovider networks involve a large variety of 
structures and relationships among many different types of 
health care providers, the agencies have not set out a safety 
zone in this area. The 1996 revisions state that multiprovider 
networks will be evaluated under the rule of reason, and will 
not be viewed as per se illegal if the providers' integration 
through the network is likely to produce significant 
efficiencies that benefit consumers, and if any price 
agreements by the networks are reasonably necessary to realize 
those efficiencies.
    In 1995 and 1996, the Commission staff provided substantial 
guidance in the form of advisory opinions analyzing proposed 
ventures on a case-by-case basis.

          antitrust law enforcement in the health care sector

Hospital mergers

    Pressures for cost-containment have led to an increasing 
number of hospital mergers. As in other industries, the 
Commission challenges only those hospital mergers that it has 
reason to believe are likely to have anticompetitive results, 
and it seeks a remedy that is carefully tailored to eliminate 
only the anticompetitive part of the transaction while allowing 
the remainder to proceed.
    In 1995 and 1996, the Commission obtained consent 
agreements in five cases involving hospital mergers. Three 
cases involved mergers of large hospital chains and 
demonstrated the Commission's sharply focused approach to 
anticompetitive situations. In the first of these cases, the 
Commission issued a final consent order involving Columbia/HCA 
Healthcare Corporation's acquisition of Healthtrust Inc., which 
combined the two largest chains of acute-care hospitals in the 
country. Although there were a significant number of overlaps 
throughout the country--where both chains had hospitals in the 
same area--Commission staff, after thorough investigation, 
found that the merger would substantially lessen competition 
for general acute-care hospital services in only six geographic 
markets: the Salt Lake City-Ogden Metropolitan Statistical 
Area, Utah; the Denton, Texas area; the Ville Platte-Mamou-
Opelousas, Louisiana area; the Pensacola, Florida area; the 
Okaloosa, Florida area; and the Orlando, Florida area. As part 
of a settlement agreement, the companies agreed to divest seven 
hospitals in those areas. The Commission did not challenge 
other aspects of the merger.
    The Commission also issued final consent orders in two 
other hospital merger cases involving large national chains. 
One involved the merger of Charter Medical Corporation and 
National Medical Enterprises, the two largest chains of 
psychiatric hospitals in the country. Charter agreed to modify 
its purchase agreement so as not to acquire the NME facilities 
in four geographic markets--Atlanta, Memphis, Orlando and 
Richmond--in which the Commission alleged that the acquisition 
would substantially lessen competition in the psychiatric care 
market. Charter's acquisition was allowed to proceed in the 
other markets. Another case involved the merger of HEALTHSOUTH 
Rehabilitation Corporation, the nation's leading operator of 
rehabilitation hospitals and other rehabilitation facilities, 
with ReLife Inc., which operated a number of rehabilitation 
facilities. The Commission obtained a consent agreement in 
which HEALTHSOUTH agreed to divest a hospital in Nashville, 
Tennessee, and to terminate management contracts to operate 
rehabilitation units at hospitals in Birmingham and Charleston.
    In a fourth hospital merger case, the Commission approved a 
consent agreement concerning Columbia/HCA's acquisition of John 
Randolph Medical Center in Hopewell, Virginia. John Randolph 
provided psychiatric services in that market and Columbia 
already owned Poplar Springs Hospital, a psychiatric hospital 
in Petersburg, Virginia. Under the consent agreement, Columbia/
HCA was allowed to purchase John Randolph only if it divested 
Poplar Springs.
    Finally, the Commission authorized the staff to seek a 
preliminary injunction to block the merger of Port Huron 
Hospital and Mercy Hospital-Port Huron, Inc., the only two 
general acute care hospitals in Port Huron, Michigan. Prior to 
trial, the Port Huron hospitals called off the transaction and 
a consent agreement was signed requiring prior approval before 
the parties attempt to merge again.

Conduct involving health care providers

    During 1995 and 1996, the Commission issued four final 
consent orders in cases alleging joint conduct by physicians 
that prevented competition among health care providers.
    The Commission issued a consent order against the medical 
staff of Good Samaritan Regional Medical Center in Phoenix, 
Arizona. The agreement settled charges that the staff members 
conspired, or threatened, to boycott the hospital in order to 
induce it to end its ownership interest in the Samaritan 
Physicians Center, a multi-specialty physicians' clinic that 
would have competed with the medical staff. Under the 
agreement, members of the medical staff are prohibited from 
agreeing, or attempting to agree, to prevent or restrict the 
services offered by Good Samaritan, the Samaritan Physicians 
Center, or any other health care provider.
    The Commission also issued a consent order against 
Physicians Group, Inc. and seven physician board members of the 
organization, settling charges that they conspired to fix the 
prices, terms, and conditions of cost-containment under which 
they would deal with third-party payers. The complaint alleged 
that the group conspired to prevent or delay the entry of 
third-party payers into Pittsylvania County and Danville, 
Virginia. The order required the dissolution of Physicians 
Group, Inc. and prohibits the physician respondents from 
engaging in similar anticompetitive conduct with respect to 
third-party payers.
    In addition, the Commission issued a consent order against 
the Medical Association of Puerto Rico, its Physiatry Section, 
and two of its physiatrist members. The Commission charged that 
the Association illegally conspired to boycott a government 
insurance program in order to obtain exclusive referral powers 
from insurers, and to increase reimbursement rates. The 
respondents agreed not to boycott or refuse to deal with any 
third-party payer, or refuse to provide services to patients 
covered by any third-party payer. The agreement places 
restrictions on meetings of physiatrists to discuss refusals to 
deal with any third-party payer, or the provision of services 
covered by any third-party payer; and prohibits the respondents 
from soliciting information from physiatrists about their 
decisions to participate in agreements with insurers and 
provide service to patients, passing such information along to 
other doctors, and giving physiatrists advice about making 
those decisions.
    Finally, the Commission issued a consent order against a 
physician association (MAPI) and a physician-hospital 
organization (BPHA) in Billings, Montana. The complaint alleged 
that MAPI blocked the entry of an HMO into Billings, obstructed 
a PPO that was seeking to enter, recommended physician fee 
increases, and later acted through BPHA to maintain fee levels. 
The associations agreed not to boycott or refuse to deal with 
third-party payers, to determine the terms upon which 
physicians deal with such payers, or to fix the fees charged 
for any physician services. MAPI also is prohibited from 
advising physicians to raise, maintain, or adjust the fees 
charged for their medical services, or from creating or 
encouraging adherence to any fee schedule. The order does not 
prevent these associations from entering into legitimate joint 
ventures that are non-exclusive and involve the sharing of 
substantial financial risk.

                       restraints on advertising

    The Commission issued a complaint charging that the 
California Dental Association had unreasonably restricted its 
dentist members' truthful and nondeceptive advertising of the 
price, quality, and availability of their services, and had 
imposed what were effectively prohibitions against advertising 
senior-citizen discounts. In March 1996, the Commission issued 
an opinion and order affirming an ALJ's decision finding that 
the California Dental Association's rules violated Section 5 of 
the FTC Act. The Commission's order requires CDA, among other 
things, to cease and desist from restricting truthful, 
nondeceptive advertising (including truthful, nondeceptive 
superiority claims, quality claims, and offers of discounts); 
to remove from its Code of Ethics any provisions that include 
such restrictions; and to contact dentists who have been 
expelled or denied membership in the last 10 years based on 
their advertising practices and invite them to re-apply. The 
order also requires CDA to set up a compliance program to 
ensure that its constituent societies interpret and apply CDA's 
rules in a manner that is consistent with the order. The 
Commission's order was affirmed by the 9th Circuit in 1997.\12\
---------------------------------------------------------------------------
    \12\ California Dental Association v. FTC, 128 F. 3d 720 (9th Cir. 
1997).
---------------------------------------------------------------------------

Competition activities in the pharmaceutical field

    Competition and competitive prices in the pharmaceutical 
industry are particularly important to older Americans. There 
are at least three reasons why this is so. First, merely by 
virtue of their age, older persons are more likely to have 
medical problems than the average American and thus are more 
likely to purchase pharmaceutical products. It has been 
reported that roughly 13 percent of our population is over the 
age of 65 but that this group consumes more than a third of all 
prescription drugs dispensed, and that this percentage is 
increasing. Second, older persons are less likely to have 
insurance that helps pay for their drugs and thus must bear the 
entire cost of their medicines. Almost all elderly consumers 
rely on Medicare, which does not have a prescription drug 
benefit. Reimbursement is available only to Medicare recipients 
who can afford Medi-gap coverage, are poor enough to qualify 
for Medicaid, or are in a managed care plan that offers a 
prescription drug benefit. Third, because many of the nation's 
senior citizens have limited financial resources, as a group 
they are disproportionately affected by pharmaceutical prices.

Mergers in manufacture and distribution of pharmaceuticals

    The Commission was quite active during 1995 and 1996 in the 
role of protecting competition in this area, focusing on 
oversight of merger activity in both the manufacturing and 
distribution of pharmaceuticals.
    In the manufacturing sector, in 1995 the Commission issued 
a consent order requiring American Home Products to divest its 
tetanus and diphtheria vaccines and to license its rotavirus 
vaccine research as a condition for acquiring American Cyanamid 
Company. Also made final in 1995 was a consent order 
prohibiting IVAX Corporation from acquiring any rights to 
market a generic version of verapamil--a drug used to treat 
patients with chronic cardiac conditions--from Zenith 
Laboratories. IVAX and Zenith were the only two suppliers of 
generic verapamil. This settlement ensured that two generic 
suppliers of this drug remained in the market.
    In 1995, the Commission also accepted a consent agreement 
with Glaxo plc, settling charges that its acquisition of 
Wellcome plc lessened competition in the research and 
development of drugs to treat migraine headaches. The consent 
order required Glaxo to divest one of the competing research 
and development projects to a Commission-approved buyer.
    The Commission also obtained relief in four pharmaceutical 
markets when it challenged the proposed acquisition of Marion 
Merrell Dow by Hoechst AG. The consent agreement with Hoechst 
required the company to divest assets and take other actions to 
restore competition in the following markets: (1) once-a-day 
diltiazem, a medication used to treat hypertension and angina; 
(2) mesalamine, a medication used to treat gastrointestinal 
diseases; (3) rifampin, a drug for tuberculosis; and (4) drugs 
used to treat intermittent claudication, a circulatory disease. 
These four product markets have annual sales of over $1.25 
billion. The consent order against Hoechst was issued in 1996.
    Another consent order that was issued in 1996 involved the 
merger of Upjohn Company and Pharmacia Aktiebolag. In that 
case, the companies agreed to divest one of their research and 
development projects to develop a drug to treat colorectal 
cancer, in order to maintain competition in the development of 
such drugs.
    Finally, two consent agreements were accepted for public 
comment in December of 1996. In one, Baxter International, Inc. 
agreed to divest blood plasma products in order to proceed with 
its acquisition of Immuno International AG. In the other 
consent agreement, the Commission required Ciba Geigy, Ltd. and 
Sandoz, Ltd. to license their patents and intellectual property 
in the broad area of gene therapy research to an independent 
competitor as a condition for allowing their merger to proceed.
    The Commission also challenged two acquisitions in the 
retail sale of prescription drugs in order to protect 
competition for the millions of Americans that obtain 
prescription drugs through pharmacy benefit plans. In December 
of 1996, J.C. Penney/Thrift agreed to divest over 100 
drugstores in North and South Carolina before it purchased the 
Eckerd drugstore chain and certain drugstores from Rite Aid. In 
the other case, the Commission voted on April 17, 1996, to seek 
a preliminary injunction in federal district court to block 
Rite Aid's proposed acquisition of Revco. As a result of this 
vote, Rite Aid abandoned its planned acquisition.

Pharmacy services

    Older consumers also are vulnerable to non-merger-related 
anticompetitive conduct in the pharmacy industry. The 
Commission has therefore acted to eliminate agreements among 
pharmacies that raise the price of medications.
    In June 1996, the Commission issued a consent order barring 
RxCare of Tennessee, Inc., a pharmacy network, and the 
Tennessee Pharmacists Association, its owner, from using ``Most 
Favored Nation'' clauses in RxCare's contracts with pharmacies. 
The Commission alleged that RxCare enforced these clauses 
against pharmacies that accepted reimbursement rates from other 
third-party payers that were lower than the RxCare rate, and 
thus discouraged pharmacies from participating in rival, lower-
priced networks. The clause forced third-party payers to pay 
higher rates in Tennessee than in other states.
    Finally, Commission staff in 1996 opened an investigation 
of a pharmacy network and its members, who are large 
institutional pharmacies in one state that serve nursing homes 
and similar institutions. The investigation concerned joint 
negotiation of prescription drug reimbursement rates for the 
state's Medicaid program.

                         health care regulation

    The staff of the Commission continued in 1995-1996 to 
monitor restraints imposed by existing or proposed regulations 
and actions that could raise costs to consumers by reducing 
competition in the health care industry, without providing 
countervailing benefits to consumers. As part of the 
Commission's competition advocacy programs, Commission staff 
\13\ in 1995-1996 submitted comments to the Kansas legislature 
on a bill to amend Kansas's laws governing optometry. The bill 
proposed clarifying the restrictions on commercial forms of 
practice and would have facilitated optometrists locating in 
space leased from optical goods stores. The staff concluded 
that relaxing constraints on commercial practices is consistent 
with the direction the Commission took in its Eyeglasses II 
rulemaking, and clarifying conditions under which optometrists 
may lease space from optical goods stores could benefit 
consumers through greater competition and efficiencies in 
operation.
---------------------------------------------------------------------------
    \13\ Staff advocacy comments and testimony are authorized by the 
Commission but are not substantively approved by the Commission and do 
not necessarily reflect the views of the Commission or any individual 
Commissioner.
---------------------------------------------------------------------------
    Regarding consumer protection issues, the staff filed two 
sets of comments with the Food and Drug Administration in 
response to a notice of proposed rulemaking. The first 
concerned its regulation of direct-to-consumer advertising for 
prescription drugs. The staff suggested that the FDA consider 
adopting an approach similar to the FTC's Deception Policy 
Statement and Statement on Advertising Substantiation to assist 
in evaluating the accuracy of prescription drug advertisements. 
The staff recommended that limiting current disclosure 
requirements and adjusting disclosure requirements according to 
advertising venues could increase the net benefits of direct-
to-consumer advertisements. The staff also recommended that the 
FDA consider alternative means for ensuring consumer access to 
important information to replace the highly technical and 
lengthy ``brief summary'' currently appearing in consumer-
directed prescription drug advertising. The second comment 
concerned how structural changes in the health care industry 
affect its responsibilities to regulate drug marketing and 
promotion. The staff suggested that the FDA consider a more 
flexible substantiation standard--one that requires competent 
and reliable evidence whose level could depend on the claim 
being made, rather than on an a priori requirement. The staff 
also suggested that the FDA may wish to consider a disclosure 
approach for any deception concerning ``switch'' programs, 
because clear and conspicuous disclosures of material 
connections between pharmacy benefit plans and drug producers 
could cure deception while preserving the potential economic 
benefits of the programs.

                   Commission Action in Other Fields

                            funeral services

Consumer protection

    The Commission is responsible for enforcing the FTC's 
Funeral Industry Practices Rule, 16 CFR Part 453, a Rule of 
considerable importance to older Americans and their families. 
The Rule is designed to ensure that consumers receive accurate 
information about prices, options, and legal requirements for 
funeral services, so that they can make informed purchasing 
decisions. Funeral services, which often cost $10,000 or more, 
come at emotionally difficult times and may be among the most 
expensive of consumer purchases. In many cases, these also are 
first-time purchases, making it particularly important for 
consumers to receive immediate and accurate information.
    From 1984 through 1994, the Commission brought 43 
enforcement actions against funeral homes for failing to comply 
with the Rule. Despite the Commission's enforcement efforts, 
compliance with the Rule remained as low as 36 percent. Thus, 
it became apparent that a new strategy was needed. In 1995 and 
1996, Commission staff, with the assistance of the Tennessee, 
Mississippi, and Delaware Attorneys General, conducted four 
sweeps in which investigators posing as consumers ``test 
shopped'' funeral homes in those states for Rule compliance. 
The FTC also conducted a pilot sweep in Florida. Those sweeps 
of 89 funeral homes resulted in 20 FTC enforcement actions,\14\ 
nearly half as many as were brought in the previous decade 
since the Rule went into effect.
---------------------------------------------------------------------------
    \14\ The State of Tennessee also brought four additional actions in 
connection with the sweep conducted in that state. Also in 1995, in 
settling a case filed against Restland Funeral Homes, Inc. of Dallas 
and four subsidiaries, the Commission obtained a civil penalty of 
$121,600, the highest ever paid in a Funeral Rule case. In other non-
sweep 1995 cases, the Commission filed actions against two Northern 
California funeral homes: Chapel of the Chimes agreed to pay a $70,000 
civil penalty to settle charges that it violated the Funeral Rule; and 
Lewis & Ribbs Mortuary, Inc. agreed to pay $20,000 as a civil penalty.
---------------------------------------------------------------------------
    The funeral industry took note of the Commission's new 
enforcement efforts, and in September 1995, the National 
Funeral Directors Association (``NFDA'') submitted a proposal 
to the Commission for an industry self-certification and 
training program to increase Rule compliance. The Commission 
agreed to this proposal in January 1996.
    The first component of this new NFDA initiative is the 
Funeral Rule Offenders Program (``FROP''), which offers a non-
litigation alternative for correcting apparent ``core'' 
violations of the Rule--i.e., failing to provide itemized price 
lists of available goods and services to consumers seeking to 
arrange a funeral. Under FROP, if a funeral home is identified 
by investigators as having failed to provide the required price 
lists, the home may, at the Commission's discretion, be offered 
the choice of a conventional investigation and potential law 
enforcement action resulting in a federal court order and civil 
penalties as high as $11,000 per violation, or participation in 
FROP. Violators choosing to enroll in FROP make voluntary 
payments to the U.S. Treasury or state Attorney General, but 
those payments generally are less than the amount the 
Commission would seek as a civil penalty. NFDA attorneys then 
review the home's practices, revise them so they are in 
compliance with the Funeral Rule, and then conduct on-site 
training and testing.
    The Commission, in cooperation with state Attorneys 
General, has continued to conduct Funeral Rule sweeps since the 
adoption of FROP. Those sweeps, conducted in Massachusetts, 
Oklahoma, Ohio, Colorado, and Illinois, indicate that 
compliance among funeral homes has improved significantly since 
1994. Nearly 90 percent of funeral homes subjected to test 
shopping in 1996 complied with the key general price list 
requirements.\15\
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    \15\ In one survey conducted before the Commission adopted FROP, 
only 36 percent of the homes tested were in compliance.
---------------------------------------------------------------------------

Competition activities

    The Commission is active on the antitrust side of its 
jurisdiction in ensuring that competition is maintained in 
funeral services and cemetery services. Where mergers take 
place between two chains providing such services, we examine 
them for overlaps in particular local markets, in order to 
ensure that every local market retains enough providers to give 
consumers acompetitive range of alternatives. As part of this 
program, the Commission during 1995 obtained a consent order against 
Service Corporation International (``SCI''), the largest owner and 
operator of funeral homes and cemeteries in North America, for its 
acquisition of Uniservice Corporation. That acquisition was likely to 
result in a substantial lessening of competition for funeral services 
and perpetual care cemetery services in and around Medford, Oregon. The 
consent agreement required the divestiture by SCI of two funeral homes, 
a cemetery, and a crematory there. The Commission also obtained a 
number of other, similar consent agreements involving funeral-chain 
acquisitions during 1995-96. These orders protected local markets in 
Amarillo, Brownsville, Harlingen, and San Benito, Texas; Brevard and 
Lee Counties, Florida; and Castlewood, Virginia.

                  mail or telephone order merchandise

    The Commission's Mail or Telephone Order Merchandise Rule, 
16 CFR Part 435, requires sellers to make timely shipment of 
orders; give options to consumers to cancel an order and 
receive a prompt refund, or to consent to any delay in 
delivery; have a reasonable basis for any promised shipping 
dates (the Rule presumes a 30-day shipping date when no date is 
promised in an advertisement); and make prompt refunds. In 
issuing the original Mail Order Rule in 1975, the Commission 
noted that consumers with mobility problems, including older 
consumers, frequently order by mail. On March 1, 1994, the 
Commission amended the Rule to include telephone sales, one 
consideration being evidence submitted by the AARP indicating 
that a significant percentage of persons age 65 and older order 
products and services by telephone.
    The Commission staff works closely with industry members 
and trade associations to obtain compliance with the Rule, and 
it initiates law enforcement actions where appropriate. During 
1995 and 1996, courts entered three consent decrees resolving 
alleged Rule violations, resulting in judgments for civil 
penalties totaling $245,000.

                             used car sales

    The Used Car Rule, 16 CFR Part 455, requires that used care 
dealers display ``Buyers Guides'' on the windows of their cars 
to tell consumers whether the vehicle comes with a warranty or 
is sold ``as is.'' These warranty disclosure requirements can 
be of particular benefit to older consumers, who may be on 
fixed incomes and therefore more likely to purchase less 
expensive used cars. They also may be less able to meet sudden, 
unexpected repair expenses. In 1995, a U.S. District Court 
judge upheld Commission charges against an Illinois used car 
dealer for Rule violations. The defendant paid a civil penalty 
of $4,500 and is prohibited from any future violations of the 
Rule. The Commission solicited public comment on the Rule in 
1994 as part of its systematic review of all current Commission 
regulations and guides, and, in December 1995, announced that 
it would retain the Rule with minor changes.

                           door-to-door sales

    The Cooling-Off Rule, 16 CFR Part 429, requires that 
consumers be given a three-day right to cancel certain sales 
occurring away from the seller's place of business (often known 
as ``door-to-door sales''). In addition, the Commission, in 
some administrative cease and desist orders against companies 
engaged in door-to-door sales, has required companies to allow 
consumers the right to cancel purchases not covered under the 
Rule. The Rule and these orders can particularly benefit older 
Americans who are retired and at home, and who may be exposed 
more frequently to high pressure sales tactics by door-to-door 
or other sellers.
    As part of its systematic review of all current Commission 
regulations and guides, the Commission requested public 
comments in 1994 on, among other things, the economic impact 
of, and the continuing need for, the Cooling-Off Rule; possible 
conflict between the Rule and state, local or other federal 
laws; and the effect on the Rule of any technological, 
economic, or other industry changes. Comments from both buyers' 
and sellers' representatives were submitted. All of the 
comments stated that the Rule provides important protections 
for consumers and favored retaining the Rule. The AARP 
commented that the Rule is especially needed to protect older 
consumers who are most vulunerable to unscrupulous door-to-door 
sellers. In 1995, the Commission decided to retain the Rule 
with minor changes.

                              energy costs

    The cost of heating and cooling one's home can be 
especially burdensome to older consumers. Retired individuals, 
who tend to spend more time at home than working individuals, 
may have less opportunity to lower their home heating or 
cooling requirements during the day. In addition, senior 
citizens, being more susceptible to hypothermia, are often 
counseled to maintain a higher temperature in their homes than 
younger persons might comfortably tolerate. Those on fixed 
incomes also may face greater relative economic burdens in 
meeting energy costs.
    Properly insulated homes can maintain more constant 
temperatures and can save consumers substantial amounts on 
heating and cooling costs. The Commission's Rule Concerning the 
Labeling and Advertising of Home Insulation (``R-value Rule''), 
16 CFR Part 460, assists consumers by requiring that sellers of 
insulation accurately disclose the ``R-value,'' or insulating 
effectiveness, of such products. The Rule also requires 
installers and new home sellers to give consumers a written 
disclosure of the type and R-value of the insulation installed; 
requires retailers to make specific information available at 
the point-of-sale to consumers who purchase insulation for do-
to-yourself installation; and requires advertisers to include 
important disclosures in advertisements that contain claims. 
The Commission solicited public comments in 1995 on the current 
need for, benefits of, and burdens imposed by, the Rule. Based 
on the comments submitted, the Commission in 1996 found that 
the Rule had significant benefits for both consumers and 
insulation sellers, imposed minimal, if any, costs or other 
burdens on consumers or sellers, and that there was a 
continuing need for the Rule.
    The Commission also has investigated the accuracy of claims 
of the insulating effectiveness, known as ``U-value'' of 
windows and doors used in homes. Insulating effectiveness of 
such products is often determined by independent laboratories 
following government-approved test methods. State and local 
governments then use the U-value test results to determine if 
windows and doors comply with state and local building codes.
    In 1996, the Commission filed a consent decree in the U.S. 
District Court for the Western District of Washington settling 
charges that Insulate Industries modified test samples to 
improve the U-Value of its windows and used the deceptive 
results to sell windows that did not perform as the test 
results indicated that they would. The decree prohibited the 
alleged conduct and required the manufacturer to provide new 
windows for distribution to customers by the states of 
Washington and Oregon, which maintain certification programs 
for that industry.

                        appliance labeling rule

    Utility costs are some of the least discretionary items in 
the household budget, and are of particular concern to those on 
fixed incomes. The Commission's Appliance Labeling Rule, 16CFR 
Part 305, helps consumers control costs in several ways. First, the 
Rule enables consumers to reduce energy costs by requiring 
manufacturers to disclose the energy usage of major household 
appliances and the water usage of showerheads, faucets, toilets, and 
urinals. For appliances, the Rule requires disclosure of specific 
energy consumption, efficiency, or cost consumption for covered 
products in catalogs. It also requires information at the point of sale 
in the form of an ``Energy Guide'' label or fact sheet, or in an 
industry directory. Because energy efficient appliances cost less to 
run over the life of the product, the Rule enables those older 
consumers who may be on limited incomes to keep down monthly expenses 
for running major home appliances, such as refrigerators and heating 
and cooling equipment.
    Second, the Rule requires certain disclosures relating to 
three categories of light bulbs or tubes: general service 
incandescent bulbs (including spot lights and flood lights); 
general service fluorescence tubes; and medium screw-base 
compact fluorescent tubes. For the bulbs most commonly used in 
the home, incandescent light bulbs and screw-base compact 
fluorescent tubes, the Rule requires that package labels 
disclose: light output, in lumens; energy used, in watts; 
voltage, average life, in hours; the number of bulbs or tubes 
in the package; and a statement explaining how to select the 
most energy efficient bulb.
    Compliance with the Rules is generally high. The appliance 
industry is largely self-policing through certification 
programs maintained by the several large trade associations 
that represent most manufacturers.

                            fuel rating rule

    The Commission's Fuel Rating Rule, 16 CFR Part 306, 
established national, standardized procedures for determining, 
certifying, and posting (on pumps) octane rating for gasoline 
and other ratings for certain liquid alternative fuels like 
ethanol and methanol. Accurate certification and posting of 
fuel ratings deter distributors and retailers from deceptively 
selling lower-rated fuel as being higher-rated. The Rule may be 
particularly beneficial to many older Americans who increase 
vacation travel during retirement, and, with more time and 
reduced income, do so by automobile or recreation vehicles.
    To help ensure accurate ratings, the Commission in 1995 
completed a nationwide survey of gasoline distributors to 
determine whether they are accurately certifying gasoline 
octane ratings and keeping required records. The survey, which 
began in 1991, focused on gasoline distributors in states that 
have no octane-testing program, and in states that had 
expressed concern about possible octane mislabeling problems. 
While indicating generally high overall compliance with the 
Commission's Fuel Rating Rule, the investigation did lead to 
three law enforcement actions, and the FTC obtained a total of 
$82,500 in civil penalties in those cases.

                            credit practices

Credit fraud

    The Credit Practices Program enforces several federal 
credit statutes that affect more than 113 million consumers 
holding credit cards and many millions more who apply for 
credit and loans. Credit fraud continues to affect consumers of 
all ages and income levels. The impact of such abuses can be 
particularly devastating to seniors who rely on credit to 
augment their income and therefore may be more receptive to 
credit offers that are ``to good to be true.''
    Each year, the Commission receives thousands of consumer 
complaints regarding harassing and abusive behavior by debt 
collectors. Often, these letters come from senior citizens. The 
Commission brought a number of lawsuits in 1995 and 1996 
against debt collectors for violations of the Fair Debt 
Collection Practices Act (``FDCPA''), 15 U.S.C. Sec. 1692 et 
seq.
    In March 1995, Payco American Corporation (``Payco''), one 
of the nation's largest debt collection agencies, agreed to pay 
a $500,000 civil penalty to settle allegations that it violated 
the FDCPA. The Commission's lawsuit, filed in August 1993 
through the Department of Justice, charged, among other things, 
that Payco illegally revealed consumer debts to third parties; 
used obscene or profane language; telephoned debtors at times 
and places known to be inconvenient to the consumers being 
contacted; and made several misrepresentations to consumers. In 
addition to the $500,000 civil penalty, the settlement 
prohibits Payco from violating the FDCPA in the future, and 
requires the company to give notice to all employees who are 
responsible for debt collection that they may be held liable 
individually if they are found to be violating the FDCPA.
    The Commission brought several other FDCPA actions in 1995. 
The Commission settled allegations that Great Lakes Collection 
Bureau, Inc. violated the FDCPA by, among other things, 
communicating or threatening to communicate with the third 
parties and to disclose the debt, harassing and abusing the 
consumer, and falsely representing or implying that an attorney 
had been involved in the collection effort and that non-payment 
would result in attachment, garnishment, or legal action. The 
company paid $150,000 in civil penalties, and agreed to 
injunctive relief. The Commission also sued Trans Continental 
Affiliates (``TCA'') and TCA principal charging a number of 
egregious violations of the FDCPA, including using obscene 
language, calling repeatedly or calling at all hours, and 
misrepresenting that failing to pay debts would result in 
arrest or imprisonment. Settlements with two of the individual 
defendants were filed with the compliant.
    During 1996, the Commission, through the Department of 
Justice, concluded its litigation against National Financial 
Services (``NFS''), its owner, and an attorney who helped 
devise and mail the collector's dunning notices for serious, 
persistent violations of the FDCPA involving false threat of 
legal action. In July 1995, the district court ordered NFS and 
its owner to pay a $50,000 civil penalty, and its attorney to 
pay a $500,000 civil penalty. That order was upheld on appeal 
by the Fourth Circuit in 1996. Finally, the Commission in 1996 
resolved a variety of similar allegations in settlements with 
United Creditor's Alliance Corp. ($146,000 civil penalty), 
Allied Bond and Collection Agency ($140,000 civil penalty), and 
G & L Financial Services, Inc. ($10,000 civil penalty). The 
federal court consent decrees in these cases also include 
injunctive relief to prohibit future violations.

Equal Credit Opportunity Act

    Among other things, the Equal Credit Opportunity Act 
(``ECOA''), 15 U.S.C. Sec. 1691 et seq., prohibits 
discrimination based on age in determining whether or not to 
extend credit. To help detect discrimination based on age or 
other prohibited factors (such as sex or race), the ECOA 
requires written notice to consumers of the reasons for a 
denial of consumer credit. In 1996, the Commission filed a 
settlement with J.C. Penny to resolve allegations that the 
company had violated consumers' rights under the ECOA to 
receive such written notice. The settlement provided for an 
innovative consumer notification program costing the company an 
estimated $1 million, in addition to $225,000 in civil 
penalties.

                     consumer protection regulation

    In 1995 and 1996, the Commission continued to monitor 
regulatory proposals and actions by federal, state and other 
entities that could have actual or potential economic impact 
onconsumers. Commission staff testified before the Michigan State House 
of Representatives on proposed legislation that would have amended the 
Michigan statutes regulating the licensing and operation of funeral 
establishments and cemeteries in Michigan. The staff supported the 
legislation, concluding that joint ownership or operation of a funeral 
establishment and a cemetery could make possible new business formats 
and improvements in efficiency and could encourage entry of new 
competitors, which could, in turn, lead to lower prices and improved 
service to consumers.
    Also during the period, Commission staff filed comments 
with the Federal Communications Commission supporting the FCC's 
efforts to keep unscrupulous pay-per-call service providers 
from evading federal regulations governing the 900-number 
industry. In particular, the staff supported the FCC's efforts 
to prevent pay-per-call transactions from being disguised as 
long-distance calls, by requiring that whenever a provider of 
information or entertainment programs receives any remuneration 
for calls to such a program, the call must fall within the 900-
number dialing code. The staff said that consumers would likely 
benefit from this proposal, because it would allow them to 
recognize telephone numbers for calls that entail charges above 
regular long distance charges, would subject the calls to cost-
disclosure and billing-dispute requirements, and would enable 
consumers to prevent charges for unauthorized calls by blocking 
900 numbers.

        Consumer Education Activities Affecting Older Consumers

    The Commission, through its Office of Consumer and Business 
Education (``OCBE''), is involved in preparing and distributing 
a variety of consumer publications and broadcast materials. 
Many of the subjects are of significant interest to older 
consumers. In addition, Commission staff in 1995-1996 engaged 
in substantial, additional consumer education efforts at the 
local and regional levels, including regional ``town hall'' 
meetings with consumers and Consumer Education Fairs.

                1995-1996 Consumer education activities

    During calendar years 1995-1996, the OCBE produced or 
revised more than 100 publications covering a broad range of 
consumer protection topics. Eighteen of these publications are 
of special interest to older Americans. Most FTC consumer 
publications are not age-specific. However, publications on 
certain topics, such as telemarketing scams, health care, 
funeral services, or credit issues highlight many of the needs 
and concerns of older citizens.

                          telemarketing scams

    Some telemarketers have admitted that older consumers are 
attractive targets for unscrupulous promotions. The FTC 
produced or revised five publications during this period that 
focus on a variety of telemarketing scams and offer solid tips 
on how to recognize and avoid these scams. One especially 
offensive scheme that preys on former victims of telemarketing 
fraud is covered in the publication Telemarketing Recovery 
Scams. The Commission issued this brochure in 1996. The four 
related brochures issued during the period include Straight 
Talk About Telemarketing, Prize Offers, International Telephone 
Number Scams, and Are You A Target of Telephone Scams? The last 
brochure mentioned also was published in a large-print edition 
for older consumers.
    At the local level, the elderly in many cultures and 
communities seek advice on business transactions from their 
religious leaders, particularly where they may not have adult 
children, lawyers, or accountants to consult. In 1995, 
Commission staff co-sponsored the Commission's first Consumer 
Workshop for religious leaders. In partnership with the Harlem 
Consumer Education Council, the U.S. Office for Consumer 
Affairs, and the Harlem Branch Office of the New York State 
Attorney General, workshops were conducted at a Harlem church 
for ministers, priests, and rabbis on a wide range of consumer 
issues, including the continued victimization of older 
Americans via telemarketing fraud and door-to-door sales. The 
workshop was aired on two local Cable TV channels over a period 
of three-months.
    In Denver, Colorado, Commission staff teamed with the 
Colorado Attorney General, the Denver District Attorney, the 
Better Business Bureau, and the American Association of Retired 
Persons to sponsor a conference to educate seniors about all 
types of fraud, including telemarketing fraud, under the group 
name Seniors Against Fraud and Exploitation (``SAFE''). Also, 
Commission staff trained student and senior volunteers to give 
presentations on telemarketing fraud to senior centers in the 
Seattle area. Seven volunteers made presentations at 14 senior 
centers during the summer of 1996. In Columbia, South Carolina, 
the staff participated in a video-teleconference that included 
presentations by the White House Special Assistant for Consumer 
Affairs and the AARP, as well as representatives from several 
other consumer protection agencies. The teleconference was 
aired on South Carolina Education Television, channel C, 
reaching about 150,000 to 200,000 consumers. The telecast 
included statements from consumers who had been victimized and 
actual footage of scam artists making various 
misrepresentations to consumers. The topics discussed included 
telemarketing travel fraud, sweepstakes and prize promotions, 
recovery scams, investment scams, charitable solicitations and 
tips on how to avoid being scammed.
    Finally, Commission staff participated in two ``reverse 
boilerrooms'' coordinated by the AARP and the Illinois Attorney 
Generals's Office. The reverse boilerroom is a means of 
providing consumer education to persons whose names appear on 
lead, or ``mooch,'' lists and therefore are particularly likely 
to be contacted by fraudulent telemarketers. The volunteers in 
a reverse boilerroom call consumers on the lists, talk with 
them about the risks of telemarketing fraud, and inform them 
that their names and telephone numbers are circulating among 
real boilerroom scam artists.

                                 health

    Two Commission publications produced in 1996 address health 
issues that affect older consumers. The first, Fraudulent 
Health Claims: Don't Be Fooled, produced in cooperation with 
the U.S. Food and Drug Administration, focuses on the 
worthless, and sometimes life-threatening, bogus health care 
products and treatments upon which American consumers spend 
billions of dollars each year. The brochure also addressed 
cross-border health care fraud by providing information on 
government contacts in Mexico and its states. The second 
brochure, Who Cares?--Sources of Information About Health Care 
Products and Services, is a joint effort with the National 
Association of Attorneys General and provides a listing of 
federal, state and private organizations that provide 
assistance and information to consumers about such things as 
prescription drugs, hearing aids, nursing facilities, 
alternative medicine, cataract surgery, purported arthritis 
cures, direct-mail schemes, and abusive care-givers.

                                funerals

    Choosing and buying funeral services and caskets and 
understanding consumer rights protected by the FTC's Funeral 
Rule were topics of two publications revised during this 
period--Caskets and Burial Vaults Funerals: A Consumer Guide. 
In a third brochure, Viatical Settlements: A Guide for People 
with Terminal Illnesses, the Commission describes this method 
of allowing living persons to receive the benefits of their 
life insurance policies, which benefits could be used to pre-
pay funeral expenses.

                      credit and financial matters

    Credit and money issues that have a direct impact on older 
consumers were among the topics of several publications 
distributed by the FTC in 1995-96. Credit and Older Americans, 
Equal Credit Opportunity, and Mortgage Discrimination emphasize 
and explain consumer rights under the law. The pros-and-cons of 
taking advantage of home equity is discussed in Reverse 
Mortgages, a brochure designed for older consumers and their 
families. Likewise, High-Rate, High-Fee Loans (Section 32 
Mortgages) explains consumer rights under the Home Ownership 
Equity Protection Act of 1994, 15 U.S.C. Sec. 1639. According 
to reports from federal and state law enforcement agencies and 
the AARP, older consumers are frequently the targeted victims 
of unscrupulous high-rate lenders.

                       access to FTC publications

    In early 1995, the FTC began to offer its publication 
online through the Internet. By December 1996, FTC 
Consumerline, a component of the FTC world wide web site, was 
offering the full-text of all consumer publications produced by 
the agency.

                               conclusion

    This report reviews Commission programs in 1995 and 1996 
that may be of particular concern to older consumers and their 
families. Through the combination of law enforcement and 
consumer education described above, the Commission strives to 
ensure a vigorous, fair, and competitive marketplace for all 
consumers.

                   ITEM 21--GENERAL ACCOUNTING OFFICE

AGING ISSUES: RELATED GAO REPORTS AND ACTIVITIES IN CALENDAR YEARS 1995 
                                AND 1996

    The elderly represent one of the fastest growing segments 
of the country's population, and the Congress faces many 
complex issues as a result of this growth. In the United 
States, the number of people aged 65 and older has grown from 
about 9 million in 1940 to about 34 million in 1995. Moreover, 
the number is expected to reach 80 million by 2050, according 
to Bureau of the Census projections. In 1940, people aged 65 
and older made up 7 percent of the total population, and this 
proportion is expected to grow to 20 percent by as early as 
2030. Although the aging of the baby-boom generation will 
contribute greatly to these trends, increased life expectancies 
and falling fertility rates are also important factors. 
Together, these demographic changes pose serious challenges for 
our Social Security system, Medicare, Medicaid, the federal 
budget, and our economy as a whole.
    This report responds to your request for a compilation of 
our products from calendar years 1995 and 1996 that pertain to 
programs and issues affecting older Americans and their 
families.
    In summary, our work on these programs and issues reflects 
the broad range and importance of federal programs for older 
Americans. Some federal programs, such as Social Security and 
Medicare, are directed primarily at older Americans. Other 
federal programs, such as Medicaid or federal housing programs, 
target older Americans as one of several groups served. Our 
work during calendar years 1995 and 1996 covered issues 
concerning education and employment, health care, housing and 
community development, income security, and veterans. In the 
enclosures, we describe three types of GAO products that relate 
to older Americans:
      166 reports and correspondence (see encl. I) and
      69 congressional testimonies (see encl. II).
    The summaries in these enclosures were prepared shortly 
after the products were issued and have not been updated to 
reflect subsequent developments.
    Table 1 gives a breakdown of those products by category. 
The table shows that health, income security, and veterans' 
issues were the areas most frequently addressed among our 
products that focused on older Americans.

TABLE 1: GAO PRODUCTS RELATING TO THE ELDERLY IN CALENDAR YEARS 1995 AND
                                  1996                                  
------------------------------------------------------------------------
                                       Reports and                      
          Elderly issues              correspondence      Testimonies   
------------------------------------------------------------------------
Education and employment..........                  4                  2
Health............................                 75                 35
Housing and community development.                  8                  3
Income security...................                 45                 20
Veterans and defense..............                 34                  9
                                   -------------------------------------
      Total.......................                166                 69
------------------------------------------------------------------------

                             [Enslosure I]

   Calendar Years 1995 and 1996 Reports and Correspondence on Issues 
                       Affecting Older Americans

    During calendar years 1995 and 1996, GAO issued 166 reports 
on issues affecting older Americans. Of these, 4 were on 
education and employment, 75 on health, 8 on housing and 
community development, 45 on income security, and 34 on the 
Department of Defense (DOD) and veterans.

                    education and employment issues

Adult Education: Measuring Program Results Has Been Challenging (GAO/
        HEHS-95-153, Sept. 8, 1995)
    According to a recent national survey, nearly 90 million 
adults in the United States have difficulty writing a letter 
explaining an error on a credit card bill, using a bus 
schedule, or calculating the difference between the regular and 
sale price of an item. To address these deficient literary 
skills, the Congress passed the Adult Education Act, which 
funds state programs to help adults acquire the basic skills 
needed for literate functioning, benefit from job training, and 
continue their education at least through the high school 
level. The most common types of instruction funded under the 
act's largest program--the State Grant Program--are basic 
education (for adults functioning below the eighth grade 
level), secondary education, and English as a second language. 
Because many clients of federal employment training programs 
need instruction provided by the State Grant Program, 
coordination among these programs is essential. Although the 
State Grant Program funds programs that address the educational 
needs of millions of adults, it has had difficulty ensuring 
accountability for results because of a lack of clearly defined 
program objectives, questionable validity of adult student 
assessments, and poor student data.
Adult Education Review (GAO/HEHS-95-65R, Feb. 16, 1995)
    GAO provided information on the Adult Education Act (AEA) 
that focused on the (1) funding history of AEA; (2) changes 
that have taken place in the amount of services that the State-
Administered Basic Grant Program provides; and (3) goals, 
targeted populations, and service recipients of the State-
Administered Basic Grant Program. GAO noted that (1) AEA 
funding under this program increased from $100 million in 
fiscal year 1984, to $255 million in fiscal year 1995, (2) 
enrollment in the State-Administered Basic Grant Program rose 
from approximately 377,000 participants in 1966 to almost 4 
million participants in 1994, and (3) the purpose of the 
program is to provide educational opportunities for adults who 
lack the necessary literacy skills to become a citizen and to 
be productive in their employment.
Department of Labor: Senior Community Service Employment: Program 
        Delivery Could Be Improved Through Legislative and 
        Administrative Actions (GAO/HEHS-96-4, Nov. 2, 1995)
    The Department of Labor's Senior Community Service 
Employment Program finances part-time minimum-wage community 
service jobs for about 100,000 poor elderly Americans. GAO 
found that Labor distributes program funds through 
noncompetitive grants to 10 national organizations, called 
national sponsors, and to state agencies. These national 
sponsors and state agencies, in turn, use the grant funds to 
finance local employment projects run by community service host 
agencies, such as libraries, nutrition centers, and parks, that 
directly employ older Americans. GAO found that the relative 
distribution of funds to the national sponsors and state 
agencies along with Labor's method of implementing the hold-
harmless provisions have resulted in the distribution of funds 
among and within states that bears little relationship to 
actual need. GAO also found that, under Labor's regulations, 
expenditures that GAO believes to be administrative in nature 
may be charged to another cost category, allowing grantees to 
exceed the statutory 15-percent limit on administrative costs. 
GAO summarized this report in testimony before the Congress; 
see Senior Community Service Employment: Program Delivery Could 
Be Improved Through Legislative and Administrative Actions, 
(GAO/T-HEHS-96-57, Nov. 2, 1995), statement by Cornelia M. 
Blanchette, Associate Director for Education and Employment 
Issues, before the Subcommittee on Early Childhood, Youth and 
Families, House Committee on Economic and Educational 
Opportunities.
People With Disabilities: Federal Programs Could Work Together More 
        Efficiently to Promote Employment (GAO/HEHS-96-126, Sept. 3, 
        1996)
    How efficient are federal efforts to help people with 
disabilities? In 1994, the government provided a range of 
services to people with disabilities through 130 different 
programs, 19 federal agencies, and a host of public and private 
agencies at the state and local levels. Although research 
groups and independent panels have stressed the need to 
simplify and streamline programs serving the disabled, creating 
a new service delivery system may prove difficult. GAO urged 
caution in 1992 when the Congress was considering proposals 
that would have made fundamental changes in human service 
delivery systems at the federal, state, and local levels. GAO 
also urges caution with regard to programs serving people with 
disabilities. Although the potential benefits of creating a new 
system to deliver services more comprehensively to people with 
disabilities may be great, so are the barriers and the risks of 
failure. Obstacles preventing officials from reorganizing 
service agencies, creating new funding and service agreements, 
and divesting authority from their own agencies are hard to 
overcome. Mandates alone are unlikely to secure the major time 
and resource commitments needed from officials--whether they 
are charged with directing reforms or have responsibility for 
administering services. In the current fiscal environment, a 
renewed focus by federal agencies on improving coordination 
would be a useful step toward improving services and enhancing 
the customer orientation of their programs.

                             health issues

AARP Medigap Premium Increases, 1996 (GAO/HEHS-96-119R, Apr. 19, 1996).
    Pursuant to a congressional request, GAO examined why 
Medigap premiums offered through the American Association of 
Retired Persons (AARP) were increasing. GAO noted that (1) in 
January 1996 premiums for more than 3 million AARP Medigap 
policyholders increased an average of 26 percent; (2) the 1996 
increases varied by state and ranged from 0 to 40 percent for 
both standardized and prestandardized policies; (3) in 1994 and 
1995, premiums increased in 8 and 10 states, respectively; (4) 
because benefit payments were less than expected, AARP 
standardized policyholders received an average credit of $75 
and prestandardized policyholders received an average credit of 
$79 in 1994 and 1995; (5) in 1992, policyholders in 45 states 
received refunds averaging $47 because of lower-than-expected 
benefit payments; (6) AARP believes that the 1996 Medigap rate 
increases are justified because the number of services received 
and costs incurred by policyholders substantially increased; 
(7) although the average Medigap loss ratio decreased to 81 
percent between 1991 and 1993, in 1994, the average loss ratio 
increased to 93 percent; (8) in 1994, the average loss ratio 
for prestandardized policies was 98 percent and 82 percent for 
standardized policies; and (9) the average loss ratio for 1995 
policies was 100 percent and could increase to 112 percent 
without a rate increase.
Analysis of ``Florida's Fair Share'' (GAO/HEHS-96-168R, June 10, 1996)
    Pursuant to a congressional request, GAO commented on the 
appropriateness of the Medicaid funding formula contained in 
H.R. 3507. GAO noted that (1) over time, the proposed formula 
would cause Medicaid funding distribution to more closely 
reflect states' poor and elderly populations; (2) there are 
more generous matching rates for low-income states that spend 
more on Medicaid services for eligible recipients; (3) because 
Florida spends less on benefits for eligible recipients than 
the other states reviewed, it receives less matching federal 
funds; (4) the new funding formula would establish targets for 
federal funding in proportion to the poor population in each 
state; (5) each state's federal allocation would increase 
depending on the differences between the current level of 
federal funding and the target amount; and (6) by giving states 
like Florida higher growth rates, the new formula would enable 
states to receive federal funding in proportion to their poor 
population.

Arizona Medicaid: Competition Among Managed Care Plans Lowers Program 
        Costs (GAO/HEHS-96-2, Oct. 4, 1995)

    Many states are converting their traditional fee-for-
service Medicaid programs to managed care delivery systems. 
Arizona's Medicaid program offers valuable insights--especially 
in fostering competition and monitoring plan performance. Since 
1982, Arizona has operated a statewide Medicaid program that 
mandates enrollment in managed care and pays health plans a 
capitated fee for each beneficiary served. Although the program 
had problems in its early years, such as the dismissal of the 
program administrator and the state's takeover of the 
administration, it has successfully contained health care costs 
while maintaining beneficiaries' access to mainstream medical 
care. Arizona's recent cost-containment record is noteworthy. 
According to one estimate, Arizona's Medicaid program saved the 
federal government $37 million and the state $15 million in 
acute care costs during fiscal year 1991 alone. Arizona 
succeeded in containing costs by developing a competitive 
Medicaid health care market. Health plans that submit 
capitation rates higher than their competitors' bids risk not 
winning Medicaid contracts. Other states considering managed 
care programs can benefit from Arizona's experience. GAO 
concludes that the key conditions for holding down Medicaid 
costs without compromising beneficiaries' access to appropriate 
medical care include freedom from some federal managed care 
regulations, development and use of market forces, controls to 
protect beneficiaries from inadequate care, and investment in 
data collection and analysis capabilities.

Blue Cross FEHBP Pharmacy Benefits (GAO/HEHS-96-182R, July 19, 1996).

    Pursuant to a congressional request, GAO provided 
information on the Blue Cross and Blue Shield Association's two 
pharmacy benefit managers and the services they provide to the 
Federal Employees Health Benefits Program (FEHBP). GAO noted 
that (1) to control drug costs, the Association is requiring 
Medicare part B participants to pay the standard copayment for 
drugs bought at participating retail pharmacies, but it is 
waiving copayments on drugs bought through its mail-order 
program for those participants; (2) the Association expects 
this change to achieve significant savings and prevent a 
premium increase in standard option coverage; (3) the 
Association's mail-order subcontractor has had significant 
difficulty meeting its customer-service performance measures 
because the increase in mail orders has been much larger and 
quicker than expected; (4) the subcontractor has increased its 
processing capacity to meet the unexpected demand; (5) retail 
pharmacies have experienced a 36-percent decrease in drug sales 
to part B participants and a 7-percent decrease in drug sales 
to all enrollees; and (6) the Association believes its pharmacy 
benefits managers provide valuable services to FEHBP, meet most 
of their contractual performance measures, and produce 
significant savings.

Cholesterol Treatment: A Review of the Clinical Trials Evidence (GAO/
        PEMD-96-7, May 14, 1996).

    Clinical trials showed men who took cholesterol-lowering 
treatments had fewer non-fatal heart attacks compared to those 
not treated. Reductions in coronary deaths in the same trials 
were restricted to high risk men, that is, those with a history 
of heart disease and high cholesterol. Surprisingly, the men 
that took the cholesterol lowering treatments suffered higher 
death rates from all non-coronary causes that canceled out the 
modest reduction in coronary deaths. The mixed benefit picture 
here may result from the generally modest cholesterol 
reductions achieved by the group of trials in our review. One 
of two recent trials that lowered cholesterol more found a 
significant reduction in total fatalities.
    Trials are limited by the selected populations recruited 
and by limited duration. Since trials focused on middle-aged 
white men with higher than average cholesterol readings and a 
history of heart disease, useful trial data are lacking on 
benefits or risks for women, minorities, the elderly or people 
with the most common cholesterol readings. Trials proposed or 
underway may provide information on these groups. Trials 
usually follow people for 5 years or less, while drug treatment 
would be longer.

Community Health Centers: Challenges in Transitioning to Prepaid 
        Managed Care (GAO/HEHS-95-138, May 4, 1995).

    As states move to prepaid managed care to control costs and 
improve access for their Medicaid clients, the number of 
participating community health centers continues to grow. 
Medicaid prepaid managed care is not incompatible with health 
centers' mission of delivering health care to medically 
underserved populations. However, health centers face 
substantial risks and challenges as they move into these 
arrangements. Such challenges require new knowledge, skills, 
and information systems. Centers lacking expertise and systems 
face an uncertain future, and those in a vulnerable financial 
position are at even greater risk. Today's debate over possible 
changes in federal and state health programs heightens the 
concern over the financial vulnerability of centers 
participating in prepaid managed care. If this funding source 
continues to grow as a percentage of total health center 
revenues, centers must face building larger cash reserves while 
not compromising services to vulnerable populations. GAO 
summarized this report in testimony before the Congress; see 
Community Health Centers: Challenges in Transitioning to 
Prepaid Managed Care, (GAO/T-HEHS-95-143, May 4, 1995), 
statement by Mark V. Nadel, Associate Director for Health 
Financing and Policy Issues, before the Senate Committee on 
Labor and Human Resources.

Consumer Health Information: Emerging Issues (GAO/AIMD-96-86, July 26, 
        1996)

    Technology has increased the amount of health information 
available to the public, allowing consumers to become better 
educated and more involved in their own health care. Government 
and private health care organizations rely on a variety of 
technologies to disseminate health information on preventive 
care, illness and injury management, treatment options, post-
treatment care, and other topics. This report discusses 
consumer health informatics--the use of computers and 
telecommunications to help consumers obtain information, 
analyze their health care needs, and make decisions about their 
own health. GAO provides information on (1) the demand for 
health information and the expanding capabilities of 
technology; (2) users' and developers' views on potential 
systems advantages and issues surrounding systems development 
and use; (3) government involvement--federal, state, and 
local--in developing these technologies; and (4) the status of 
related efforts by the Department of Health and Human Services 
(HHS). As part of this review, GAO surveyed consumer health 
informatics experts and presents their views on issues that 
need to be addressed when developing consumer health 
information systems. GAO summarized this report in testimony 
before the Congress; see Consumer Health Informatics: Emerging 
Issues (GAO/T-AIMD-96-134, July 26, 1996), statement by 
Patricia T. Taylor, Director of Information Resources 
Management Issues, before the Subcommittee on Human Services 
and Intergovernmental Relations, House Committee on Government 
Reform and Oversight.

District of Columbia: Information on Health Care Costs (GAO/AIMD-96-42, 
        Apr. 22, 1996).

    Recent studies on the District of Columbia's health care 
system have concluded that the city's health care problems are 
aggravated by such social factors as high rates of poverty, 
crime, substance abuse, and unemployment. These factors account 
for the sizable numbers of persons who do not seek preventive 
health care and cannot pay for medical treatment, the 
inappropriate use of D.C. General Hospital for primary care, 
and the many trauma care patients at area hospitals. To help 
the Congress evaluate various restructuring proposals being 
considered for the District, this report discusses the 
District's health care budget and the composition of the 
District's health care system, including the number of Medicaid 
recipients and uninsured and the distribution of hospitals and 
clinics.

Durable Medical Equipment: Regional Carriers' Coverage Criteria Are 
        Consistent With Medicare Law (GAO/HEHS-95-185, Sept. 19, 1995).

    In November 1993, the Health Care Financing Administration 
(HCFA) began consolidating the work of processing and paying 
claims for durable medical equipment, prostheses, orthoses, and 
supplies at four regional carriers. Claims for such items had 
previously been processed and paid by local Medicare carriers. 
As part of the transition to regional processing, the four 
regional carriers developed coverage criteria for the items. 
GAO found that the final criteria adopted by the regional 
carriers are consistent with Medicare's national coverage 
policies and the law. GAO does not believe that the criteria 
have impeded disabled beneficiaries' access to needed durable 
medical equipment and other items. Also, in 1994 the regional 
carriers approved a similar percentage of service for durable 
medical equipment and other items for the disabled and aged 
Medicare beneficiaries, so there was no significant difference 
in access to durable medical equipment and other items between 
the two groups of beneficiaries.

Employer-Based Health Plans: Issues, Trends, and Challenges Posed by 
        ERISA (GAO/HEHS-95-167, July 25, 1995).

    As the movement for comprehensive federal health care 
reform has lost steam, the focus of reform has shifted to the 
states and the private market. States remain concerned about 
the growing number of people lacking health coverage and about 
financing health plans for poor people. Employers have become 
increasingly aggressive in managing their health plans and have 
adopted various managed care plans and innovative funding 
arrangements. However, the Employee Retirement Income Security 
Act of 1974 (ERISA) effectively blocks states from directly 
regulating most employer-based health plans, although it allows 
states to regulate health insurers. GAO found that nearly 40 
percent of enrollees in employer-based health plans--44 million 
people--are in self-funded plans. The divided federal and state 
framework for regulating health plans produces a complex set of 
trade-offs for regulating health plans. Self-funded plans, 
which are exempt from state regulation under ERISA, provide 
employers greater flexibility to design a health benefits 
package that may have been less feasible to provide under state 
regulation. At the same time, however, states are unable to 
extend regulations, such as solvency standards, preexisting 
condition clause limits, and guaranteed issue and renewal 
requirements, even indirectly, to enrollees in these self-
funded plans. GAO summarized this report in testimony before 
the Congress; see Employer-Based Health Plans: Issues, Trends, 
and Challenges Posed by ERISA (GAO/T-HEHS-95-223, July 25, 
1995), statement by Mark V. Nadel, Associate Director for 
National and Public Health Issues, before the Senate Committee 
on Labor and Human Resources.

Food Assistance Programs (GAO/RCED-95-115R, Feb. 28, 1995)

    GAO reviewed the Department of Agriculture's (USDA) 
domestic food and nutrition assistance programs, focusing on 
those programs that target benefits to women, children, 
infants, the elderly, and the needy. GAO noted that (1) USDA 
food assistance programs constitute about 60 percent of the 
USDA budget, and the Food Stamp Program accounts for more than 
one-half of those benefits; (2) 6 of the 14 USDA food programs 
target the groups reviewed; (3) participants' characteristics 
and the nature and level of benefits vary widely across the 
programs; (4) most of the programs have income eligibility 
criteria and some programs have additional criteria that 
individuals must meet to receive benefits; (5) benefit overlap 
is built into most of the programs, but it is not known how 
many persons participate in more than one program; (6) state 
and local governments and nonprofit organizations play a large 
role in distributing program benefits; (7) some USDA programs 
are similar to other agencies' assistance programs; (8) 
ineffective targeting of low-income people, burdensome 
administration, subsidizing providers rather than families, 
rising costs, duplication of services, inequitable funding 
allocations, and unfunded mandates affect the distribution of 
food benefits; and (9) alternatives to reduce costs and 
streamline program operations include improving low-income 
targeting, consolidating multiple programs, reducing some 
programs' funding levels, and eliminating some ineffective 
programs.

Fraud and Abuse: Providers Target Medicare Patients in Nursing 
        Facilities (GAO/HEHS-96-18, Jan. 24, 1996)

    Nursing home patients are an attractive target for 
fraudulent and abusive health care providers that bill Medicare 
for undelivered or unnecessary services. A wide variety of 
providers, ranging from durable medical equipment suppliers to 
laboratories to optometrists and doctors, have been involved in 
fraudulent and abusive Medicare billing schemes. Several 
features make nursing home patients attractive targets. First, 
because a nursing facility houses many Medicare beneficiaries 
under one roof, unscrupulous billers of services can operate 
their schemes in volume. Second, nursing homes sometimes make 
patient records available to outsiders, contrary to federal 
regulations. Third, providers are permitted to bill Medicare 
directly, without certification from the nursing home or the 
attending physician that the items are necessary or have been 
provided as claimed. In addition, Medicare's automated systems 
do not collect data to flag improbably high charges or levels 
of services. Finally, even when Medicare spots abusive billings 
and seeks recovery of unwarranted payments, it often collects 
little money from wrongdoers, who either go out of business or 
deplete their resources so that they cannot repay the funds.

HCFA: Medicare Program--Changes to the Hospital Inpatient Prospective 
        Payment Systems and Fiscal Year 1997 Rates (GAO/OGC-96-41, 
        Sept. 13, 1996)

    Pursuant to a legislative requirement, GAO reviewed the 
Health Care Financing Administration's (HCFA) new rule on 
changes to the Medicare program's hospital inpatient 
prospective payment systems and fiscal year 1997 rates. GAO 
found that (1) the rule would adjust the classifications and 
weighting factors for diagnosis related groups, update the wage 
index associated with hospital operating costs, and make 
certain clarifications regarding the calculation of hospital 
payments excluded from the prospective payment systems; and (2) 
HCFA complied with applicable requirements in promulgating the 
rule.

HCFA's Approach to Evaluating Medicare Technology (GAO/AIMD-95-234R, 
        Sept. 29, 1995)

    GAO reviewed HCFA's approach to analyzing the benefits of 
commercial technology in the Medicare program. GAO noted that 
HCFA (1) is limiting its analysis of the benefits of commercial 
technology to determining whether Medicare contractors complied 
with existing payment controls and is using a flawed sampling 
methodology to select claims for review; (2) is attempting to 
verify the savings achievable through commercial systems 
without understanding how the systems operate; (3) believes 
that it cannot examine commercial systems without actually 
procuring a system; and (4) is failing to identify real 
monetary benefits of commercial detection systems in its 
analysis.

Health Care Fraud: Information-Sharing Proposals to Improve Enforcement 
        Efforts (GAO/GGD-96-101, May 1, 1996)

    Estimates of health care fraud range from 3 to 10 percent 
of all health care expenditures--as much as $100 billion based 
on estimated 1995 expenditures. In late 1993, the Attorney 
General designated health care fraud as an enforcement priority 
second only to violent crime initiatives. This report discusses 
(1) the extent of federal and state immunity laws protecting 
persons who report information on health care fraud and (2) the 
advantages and disadvantages of establishing a centralized 
health care fraud database to strengthen information-sharing 
and support enforcement efforts.

Health Care Shortage Areas: Designations Not a Useful Tool for 
        Directing Resources to the Underserved (GAO/HEHS-95-200, Sept. 
        8, 1995)

    Many Americans live in places where barriers exist to 
obtaining basic health care. These areas range from isolated 
rural locations to inner-city neighborhoods. In fiscal year 
1994, the federal government spent about $1 billion on programs 
to overcome access problems in such locations. To be effective, 
these programs need a sound method of identifying the type of 
access problems that exist and focusing services on the people 
who need them. The Department of Health and Human Services 
(HHS) uses two main systems to identify such locales. One 
designates Health Professional Shortage Areas, the other 
Medically Underserved Areas. More than half of all U.S. 
counties fall into these two categories. GAO reviewed the two 
systems to determine (1) how well they identify areas with 
primary care shortages, (2) how well they help target federal 
funding to benefit those who are underserved, and (3) whether 
they are likely to be improved under proposals to combine them.

Health Insurance: Coverage of Autologous Bone Marrow Transplantation 
        for Breast Cancer (GAO/HEHS-96-83, Apr. 24, 1996)

    Although many insurers now cover the cost of autologous 
bone marrow transplantation, a new and expensive treatment for 
breast cancer, issues surrounding the procedure have put 
several goals of the U.S. health care system in conflict: 
access to the best, most advanced care; cost containment; and 
research adequate to assess the value of new treatments. 
Proponents of insurance coverage argue that autologous bone 
marrow transplantation provides breast cancer patients with a 
promising, potentially life-saving treatment. Critics say that 
the proliferation of such unproven treatments is costly and 
harmful, potentially hindering clinical research to determine 
whether the treatment is effective. This report discusses (1) 
the factors that have influenced insurers' decisions on whether 
to cover the treatment, (2) the status of research on 
autologous bone marrow transplantation for breast cancer and 
the consensus on what is known about its effectiveness, and (3) 
the consequences of increased use and insurance coverage of the 
treatment while it is still being evaluated in clinical trials.

Health Insurance Portability: Reform Could Ensure Continued Coverage 
        for up to 25 Million Americans (GAO/HEHS-95-257, Sept. 19, 
        1995)

    Although federal and state laws have improved the 
portability of health insurance, an individual's health care 
coverage could still be reduced when changing jobs. Between 
1990 and 1994, 40 states enacted small group insurance 
regulations that include portability standards, but ERISA 
prevents states from applying these standards to the health 
plans of employers who self-fund. As a result, some in the 
Congress have proposed broader national portability standards. 
GAO estimates that as many as 21 million Americans each year 
would benefit from federal legislation to ensure that workers 
who change jobs would not be subject to new health insurance 
plans that impose waiting periods or preexisting condition 
exclusions. In addition, as many as 4 million Americans who at 
some point have been unwilling to leave their jobs because they 
feared losing their health care coverage would benefit from 
national portability standards. Such a change, however, could 
possibly boost premiums, according to insurers.

Health Insurance Regulation: Varying State Requirements Affect Cost of 
        Insurance (GAO/HEHS-96-161, Aug. 19, 1996)

    As concern about the affordability of health coverage has 
grown, the costs attributed to state regulation of health 
insurance have come under increasing scrutiny. State health 
insurance regulation is intended to protect consumers through 
oversight of health plans' financial solvency, monitoring of 
insurers' market conduct to prevent abuses, and mandated 
coverage for particular services. Although these measures do 
benefit consumers, they result in costs to insurers that are 
ultimately passed on to consumers in their premiums. These 
costs may influence an employer to self-fund its health plan--a 
move that avoids state insurance regulation. This report 
examines the costs associated with (1) premium taxes and other 
assessments, (2) mandated health benefits, (3) financial 
solvency standards, and (4) state health insurance reforms 
affecting small employers. GAO discusses the impact of these 
requirements on the costs of insured health plans compared with 
the cost of self-funded health plans.

HMO Enrollment Data (GAO/HEHS-95-159R, May 25, 1995)

    GAO provided information on health maintenance organization 
(HMO) enrollment, focusing on the number of Medicare 
beneficiaries enrolled in risk-based HMOs. GAO noted that (1) 
between December 1993 and 1994, the percentage of Medicare 
beneficiaries enrolled in risk-based HMOs increased from 5.1 to 
6.3 percent for a total of about 2.3 million beneficiaries; (2) 
although older beneficiaries had lower enrollment rates than 
the general Medicare population, they also increasingly joined 
risk-based HMOs; (3) between 1993 and 1994, the percentage of 
Medicare beneficiaries aged 75 and older enrolled in risk-based 
HMOs increased from 4.8 to 6.1 percent; and (4) the percentage 
of beneficiaries aged 85 and older enrolled in risk-based HMOs 
increased from 3.9 to 4.7 percent between 1993 and 1994.

Hospital-Based Home Health Agencies (GAO/HEHS-95-209R, July 19, 1995)

    GAO reviewed whether increased hospital ownership of home 
health agencies (HHA) has contributed to the growth in Medicare 
home health costs. GAO found that hospital-based HHAs (1) 
generally care for beneficiaries with less chronic conditions 
and provide fewer visits to patients than all other types of 
HHAs, except those run by the government, and (2) apparently 
are not driving up Medicare costs any more than other types of 
HHAs.

Indian Health Service: Improvements Needed in Credentialing Temporary 
        Physicians (GAO/HEHS-95-46, Apr. 21, 1995)

    Indian Health Service (IHS) facilities, which provide 
medical care to more than 1 million American Indians and 
Alaskan Natives, supplement their staffs with temporary 
physicians. But weak policies have led IHS to unknowingly hire 
doctors who have been disciplined for such offenses as gross 
and repeated malpractice and unprofessional conduct. IHS does 
not explicitly require verifying all active and inactive state 
medical licenses that a temporary physician may have. Further, 
most IHS facilities that have contracts with companies that 
supply temporary physicians do not require the companies to 
inform IHS of the status of all medical licenses a physician 
may hold. In addition, IHS facilities do not have a formal 
system for sharing information on temporary physicians who have 
worked within the IHS medical system. This report also 
discusses what happens when requested medical services are 
delayed.

Long-Term Care: Current Issues and Future Directions (GAO/HEHS-95-109, 
        Apr. 13, 1995)

    Today, an increasing number of Americans need long-term 
care. Unprecedented growth in the elderly population is 
projected for the twenty-first century, and the population aged 
85 and older--those most in need of long-term care--is expected 
to outpace the rate of growth for the entire elderly 
population. In addition to the dramatic rise in the elderly 
population, a large portion of the long-term care population 
consists of younger people with disabilities. The importance of 
long-term care was underscored by the 1994 congressional debate 
over health care reform and, more recently, by the ``Contract 
with America,'' which proposed assistance such as tax 
deductions for long-term care insurance and tax credits for 
family caregiving. This report (1) defines what is meant by 
long-term care and discusses the conditions that give rise to 
long-term care need, how such need is measured, and which 
groups--young and old--require long-term care; (2) examines the 
long-term care costs that are borne by federal and state 
governments as well as by families; (3) addresses strategies 
that states and foreign countries are pursuing to contain 
public long-term care costs; and (4) discusses predictions by 
experts on the future demand for long-term care.

Long-Term Care: Some States Apply Criminal Background Checks to Home 
        Care Workers (GAO/PEMD-96-5, Sept. 27, 1996)

    Pursuant to a congressional request, GAO examined federal 
and state requirements for criminal background checks of home 
health care workers. GAO found that (1) there are few formal 
safeguards to protect elderly persons from unscrupulous home 
care workers; (2) the federal government indirectly regulates 
home care workers by requiring home care organizations or the 
individual provider to meet certain requirements for 
participation in Medicaid or Medicare; (3) states may be 
directed to disqualify home care providers convicted of 
fraudulent health care delivery; obstruction of justice; or the 
illegal manufacture, distribution, prescription, or dispensing 
of controlled substances; (4) state and local governments, as 
well as professional boards, impose certain restrictions on 
home care organizations and individual providers; (5) some 
states require all home care organizations to meet state 
imposed licensure or Medicare certification requirements; (6) 
some states incorporate home care workers into their state 
nursing home aide registry; (7) few states require criminal 
background checks of home care workers; and (8) most states do 
not use the Federal Bureau of Investigation's national criminal 
database system to check home care workers' backgrounds due to 
cost concerns.

Mammography Services: Initial Impact of New Federal Law Has Been 
        Positive (GAO/HEHS-96-17, Oct. 27, 1995)

    The Mammography Quality Standards Act of 1992 imposed 
uniform standards for mammography in all states, requiring 
certification and annual inspection of mammography facilities. 
GAO found that the act has had a positive impact, resulting in 
higher quality equipment, personnel, and practices. Mammography 
quality standards are now in place in all states, and these 
standards do not appear to have hampered access to services. To 
avoid large-scale closure of facilities, however, the Food and 
Drug Administration (FDA) settled on an approach that allowed 
some delay in meeting the certification requirements. For this 
and other reasons, such as the availability of outcome data, 
more time will be needed before the act's full impact can be 
determined. GAO is required to assess the effects of the act 
again in 2 years and to issue a report in 1997.

Medicaid Funding Formula Changes (GAO/HEHS-96-164R, June 10, 1996)

    Pursuant to a congressional request, GAO provided 
information on the proposed changes to Medicaid funding 
formulas under H.R. 3507. GAO noted that (1) states with large 
numbers of poor and disabled persons receive less federal 
assistance than states with larger numbers of poor and weaker 
tax bases; (2) states that offer extensive services and provide 
high provider reimbursement rates receive more federal funding; 
(3) the revised Medicaid formula would link the amount of 
federal aid a state receives to the number of poor people in 
need of Medicaid services; (4) over 90 percent of the federal 
formula grant programs target funding on the basis of need; (5) 
H.R. 3507 would realign federal Medicaid funding over a number 
of years, so that funding is related more to state need than to 
state spending patterns; (6) H.R. 3507 would place greater 
weight on the number of elderly and disabled people that 
require expensive services; and (7) the proposed formula change 
would enable states with low funding to acquire more federal 
funds.

Medicaid Long-Term Care: State Use of Assessment Instruments in Care 
        Planning (GAO/PEMD-96-4, Apr. 2, 1996)

    GAO examined how publicly funded programs assess the need 
for home and community-based long-term care for the elderly 
with disabilities. This care is provided to persons living at 
home who, because of a chronic condition or illness, cannot 
care for themselves. Services range from skilled nursing to 
assistance with day-to-day activities, such as bathing and 
housekeeping. Under the Medicaid program, 49 states have 
obtained waivers to provide home and community-based services 
to low-income elderly persons who would otherwise need 
institutional care paid for by Medicaid. These states are 
responsible for developing a care plan tailored to a client's 
specific needs. A well-designed assessment instrument helps 
identify all appropriate needs--increasing the likelihood that 
important aspects of the client's situation will not be 
overlooked in care planning. Standardized administration of the 
assessment instrument increases the likelihood that the needs 
of all clients will be determined in the same way. This report 
provides information on the (1) comprehensiveness of assessment 
instruments, (2) uniformity of their administration, and (3) 
training for staff who do the assessments.

Medicaid Managed Care: More Competition and Oversight Would Improve 
        California's Expansion Plan (GAO/HEHS-95-87, Apr. 28, 1995)

    The Medicaid program was established to make health care 
more accessible to the poor. In many communities, however, 
beneficiaries' access to quality care is far from guaranteed. 
Too few doctors and other health care providers choose to 
participate in Medicaid because of low payment rates and 
administrative burdens. To address the access problem, as well 
as rising costs and enrollment in its $15 billion Medi-Cal 
program (which serves about 5.4 million beneficiaries), 
California intends to increase its reliance on managed care 
delivery systems. This report (1) describes California's 
current Medicaid managed care program, (2) reviews the state's 
oversight of managed care contractors with a focus on financial 
incentive arrangements and the provision of preventive care for 
children, (3) describes the state's plans for expansion, and 
(4) identifies key issues the state will face as it implements 
the expanded program.

Medicaid: Restructuring Approaches Leave Many Questions (GAO/HEHS-95-
        103, Apr. 4, 1995)

    Over the years, various proposals have been made to 
restructure the Medicaid program. One approach calls for 
providing federal block grants to the states and giving them 
increased responsibility for running the program. Under another 
proposal, Medicaid would be entirely funded and administered by 
the federal government. Yet another would split Medicaid into 
two programs, one encompassing acute and primary care and the 
other long-term care. This report compares the different 
restructuring approaches and discusses their implications for 
federal-state financing and administration of the program. GAO 
also provides information on the need to establish a federal 
``rainy day'' fund if restrictions, such as block grants, are 
placed on federal revenues paid to states. GAO also provides 
the most recent data on the amount of federal Medicaid funds 
provided to each state.

Medicaid Managed Care: Serving the Disabled Challenges State Programs 
        (GAO/HEHS-96-136, July 31, 1996)

    With its emphasis on primary care, restricted access to 
specialists, and control of services, managed care is seen as a 
way to control spiraling Medicaid costs, which totaled $159 
billion in fiscal year 1995. So far, states have extended 
prepaid care largely to low-income families--about 30 million 
persons--but to few of the additional 6 million Medicaid 
beneficiaries who are mentally or physically disabled. Managed 
care's emphasis on primary care and control of services is 
seemingly at odds with the care requirements of disabled 
beneficiaries, many of whom need extensive services and access 
to highly specialized providers. However, because more than 
one-third of all Medicaid payments go for the care of the 
disabled, policymakers have been exploring the possibility of 
enrolling disabled persons in managed care plans. These efforts 
affect three key groups: disabled beneficiaries, who include a 
small number of very vulnerable persons who may be less able to 
effectively advocate on their own behalf for access to needed 
services; prepaid care plans, which are concerned about the 
degree of financial risk in treating persons with extensive 
medical needs; and the state and federal governments, which run 
Medicaid. This report examines the (1) extent to which states 
are implementing Medicaid prepaid managed care programs for 
disabled beneficiaries and (2) steps that have been taken to 
safeguard the interests of all three groups. GAO's review of 
safeguards focuses on two areas: efforts to ensure quality of 
care and strategies for setting rates and sharing financial 
risk.

Medicaid: Oversight of Institutions for the Mentally Retarded Should Be 
        Strengthened (GAO/HEHS-96-131, Sept. 6, 1996)

    Medicaid provides more than $5 billion each year to support 
state institutions that house and care for the mentally 
retarded. Despite federal standards, serious quality-of-care 
problems exist at some institutions. Insufficient staffing, 
lack of treatments to enhance patients' independence and 
functional ability, and deficient medical and psychiatric care 
are some of the shortcomings that have been cited most 
frequently. In a few cases, these practices have led to 
injuries, illness, physical degeneration, and even death for 
some residents. States, which play a key role in ensuring that 
these institutions meet federal standards, do not always 
identify serious deficiencies and sometimes do not take 
adequate enforcement measures to prevent therecurrence of poor 
care. Although the Health Care Financing Administration has tried to 
improve the process for spotting serious deficiencies in these 
institutions and has sought to make more efficient use of limited 
federal and state resources, oversight weaknesses persist. Moreover, 
state surveys may lack independence because states are responsible for 
surveying their own institutions. This potential conflict of interest 
raises concern, given the decline in direct federal oversight of both 
care in these facilities and the performance of state surveying 
agencies.

Medicaid: Spending Pressures Drive States Toward Program Reinvention 
        (GAO/HEHS-95-122, Apr. 4, 1995)

    The $131 billion Medicaid program is at a crossroads. 
Between 1985 and 1993, Medicaid costs tripled and the number of 
beneficiaries rose by more than 50 percent. Medicaid costs are 
projected to rise to $260 billion, according to the 
Congressional Budget Office. Despite federal and state 
budgetary constraints, several states are exerting pressure to 
expand the program and enroll hundreds of thousands of new 
beneficiaries. The cost of expanded coverage, they believe, 
will be offset by the reallocation of Medicaid funds and the 
wholesale movement of beneficiaries into some type of managed 
care arrangement. This report examines (1) federal and state 
Medicaid spending, (2) some states' efforts to contain Medicaid 
costs and expand coverage through waiver of federal 
requirements, and (3) the potential impact of these waivers on 
federal spending and on Medicaid's program structure overall. 
The Comptroller General summarized this report in testimony 
before the Congress; see Medicaid: Spending Pressures Drive 
States Toward Program Reinvention (GAO/T-HEHS-95-129, Apr. 4, 
1995), by Charles A. Bowsher, Comptroller General of the United 
States, before the House Committee on the Budget.

Medicaid: Tennessee's Program Broadens Coverage But Faces Uncertain 
        Future (GAO/HEHS-95-186, Sept. 1, 1995)

    In early 1993, Tennessee predicted that increases in state 
Medicaid expenditures and the loss of tax revenues used to 
finance Medicaid would produce a financial crisis. To avert a 
financial crisis, control its Medicaid expenditures, and extend 
health insurance coverage to most state residents, Tennessee 
converted its Medicaid program into a managed care health 
program--TennCare--to serve both Medicaid recipients and 
uninsured persons. GAO found that although TennCare met its 
objectives of providing health coverage to many uninsured 
persons while controlling costs, concerns remain with respect 
to access to quality care and managed care performance. 
Specifically, questions have been raised about TennCare's rapid 
approval and implementation, lack of provider buy-in to the 
program, and delays in monitoring TennCare's access and quality 
of care. In addition, the soundness of the methodology for 
determining and the resulting adequacy of the program's 
capitation rates have been questioned. This report discusses 
(1) TennCare's basic design and objectives, (2) the degree to 
which the program is meeting these objectives, and (3) the 
experiences of TennCare's insurers and medical providers and 
their implications for TennCare's future.

Medicare: Allegations Against ABC Home Health Care (GAO/OSI-95-17, July 
        19, 1995)

    In response to a congressional request, GAO investigated 
allegations against ABC Home Health Care, a home health agency 
(HHA), and its participation in Medicare's home health care 
program. In the Medicare program, providers may receive 
reimbursement for only those expenses that are reasonable in 
amount and related to patient care for eligible patients. 
Current and former employees told GAO that local ABC office 
managers directed them to alter records to make it appear that 
patients continued to need home health visits. Additionally, 
managers directed employees to continue visiting patients who, 
in the employees' opinions, did not qualify for home health 
care because they no longer met Medicare rules defining 
homebound status. ABC also reportedly charged Medicare for the 
cost of acquiring other HHAs by paying owners a small sum up 
front and the balance in the form of salary under employment 
agreements, a practice that is inconsistent with Medicare 
regulations for reimbursement. Finally, according to former 
employees, some managers directed employees to market ABC and 
its services with the intent of charging Medicare for costs 
that were not reimbursable. GAO has shared information 
concerning possible illegal activities with appropriate law 
enforcement authorities. GAO summarized this report in 
testimony before the Congress; see Medicare: Allegations 
Against ABC Home Health Care (GAO/T-OSI-95-18, July 19, 1995), 
by Richard C. Stiener, Director, Office of Special 
Investigations, before the Subcommittee on Health and 
Environment and the Subcommittee on Oversight and 
Investigations, House Commerce Committee.

Medicaid Section 1115 Waivers: Flexible Approach to Approving 
        Demonstrations Could Increase Federal Costs (GAO/HEHS-96-44, 
        Nov. 8, 1995)

    Several states have been given waivers allowing them to use 
savings from managed care Medicaid programs to cover additional 
beneficiaries. GAO found that contrary to assertions that such 
waivers would be ``budget neutral,'' most of them could 
increase federal Medicaid expenditures. Specifically, approved 
spending limits for demonstration waivers in Oregon, Hawaii, 
and Florida could boost federal Medicaid outlays. Only 
Tennessee's 1115 waiver agreement should cost no more than the 
continuation of its smaller, prewaiver program and, in fact, 
should yield savings. Federal Medicaid spending could rise 
significantly if the administration continues to show a similar 
flexibility in reviewing state 1115 financing strategies. Five 
waivers have been approved since Florida's in late 1994, and 
the large backlog of pending waivers includes three states with 
large Medicaid programs--New York, Illinois, and Texas. 
Additional federal dollars are available along with other 
funding sources identified in state waiver applications. GAO 
believes that the potential for additional federal funding 
serves as a hedge against the many uncertainties states face in 
implementing these ambitious demonstrations--including changing 
economic conditions, the accuracy of cost-containment 
assumptions, the availability of anticipated funding cited in 
waiver applications, and the lack of reliable cost data on the 
uninsured.

Medicaid: States' Efforts to Educate and Enroll Beneficiaries in 
        Managed Care (GAO/HEHS-96-184, Sept. 17, 1996)

    With managed care now being increasingly offered as an 
option for Medicaid recipients, reports of marketing abuses by 
managed care organizations have grown, prompting several states 
to restrict direct marketing efforts by managed care 
organizations. GAO found that some managed care organizations 
and their agents have engaged in unscrupulous practices to 
maximize beneficiary enrollment--and thereby boost plan 
revenues and commissions. These practices include bribing 
public officials to obtain confidential information on 
beneficiaries, paying beneficiaries cash and providing other 
incentives to sign up, deliberately misinforming beneficiaries 
about access to care, and enrolling ineligible beneficiaries--
as many as 4,800 in one state. To avoid these problems, many 
states have banned or restricted direct-marketing activities by 
managed care organizations and have retained responsibility for 
enrolling or disenrolling Medicaid beneficiaries. This report 
provides detailed information on four states--Minnesota, 
Missouri, Ohio, and Washington--with innovative education and 
enrollment programs.

Medicaid: Waiver Program for Developmentally Disabled Is Promising But 
        Poses Some Risks (GAO/HEHS-96-120, July 22, 1996)

    More than 300,000 adults with developmental disabilities--
typically mental retardation--receive long-term care paid for 
by Medicaid or, to a lesser extent, state and local programs. 
Such long-term care often involves supervision and assistance 
with everyday activities, such as dressing or managing money. 
Persons with developmental disabilities receive more than $13 
billion annually in public funding for long-term care, second 
only to the elderly. Recently, states have begun to 
significantly expand the use of the Medicaid waiver program, 
which seeks to provide alternatives to institutional care for 
persons with developmental disabilities. The waiver program has 
two advantages. First, it helps states to control costs by 
allowing them to limit the number of recipients being served. 
Without the waiver, states must serve all eligible persons in 
the regular Medicaid program. Second, it permits states to meet 
the needs of many persons with developmental disabilities by 
offering them a broader range of services in less restrictive 
settings, such as group or family homes, rather than in an 
institutional setting. This report examines (1) expanded state 
use of the waiver program, (2) the growth in long-term care 
costs for individuals with developmental disabilities, (3) how 
costs are controlled, and (4) strengths and limitations in 
states' approaches to ensuring quality in community settings.

Medical ADP Systems: Defense Achieves Worldwide Deployment of Composite 
        Health Care System (GAO/AIMD-96-39, Apr. 5, 1996)

    As the backbone of the military's medical operations, the 
Composite Health Care System--an automated medical system 
developed by the Department of Defense (DOD) at a cost of $2.8 
billion--will provide doctors and nurses with almost instant 
access to patient information, from medical history to current 
treatment and vital statistics. DOD should be able to 
significantly improve operations at its medical facilities 
while reducing costs. Improved appointment scheduling will 
increase patients' access to health care, while better access 
to patient information will save medical personnel time. If DOD 
is to realize the system's full potential, however, physicians 
and other health care providers must be able to access the 
system at all times. Although DOD's backup and recovery plan 
provides for recovery from disruptions in computer service 
because of power outages, it does not effectively address major 
disruptions requiring the repair or the replacement of 
equipment damaged by a natural disaster. Health care providers 
have become dependent on the patient data in the system, so any 
major disruption could result in injury or even death. DOD 
could greatly reduce this risk by developing a more effective 
backup and recovery plan for its equipment.

Medicare: Antifraud Technology Offers Significant Opportunity to Reduce 
        Health Care Fraud (GAO/AIMD-95-77, Aug. 11, 1995)

    Medicare continues to suffer large losses each year due to 
fraud. Existing risks are sharply increased by the continual 
growth in Medicare claims--both in number and in percentage 
processed electronically. Existing Medicare payment safeguards 
can be bypassed and apparently do not deter fraudulent 
activities. HCFA should be able to benefit by taking full 
advantage of emerging antifraud technology to better identify 
and prevent Medicare fraud. The number and types of Medicare 
fraud schemes perpetrated in south Florida may make that area 
the best place to test antifraud systems before nationwide use.

Medicare Claims: Commercial Technology Could Save Billions Lost to 
        Billing Abuse (GAO/AIMD-95-135, May 5, 1995)

    With an investment of only $20 million in off-the-shelf 
commercial software, Medicare could save nearly $4 billion over 
5 years by detecting fraudulent claims by physicians--primarily 
manipulation of billing codes. On the basis of a test in which 
4 commercial firms reprocessed samples of more than 20,000 paid 
Medicare claims,GAO estimates that the software could have 
saved $603 million in 1993 and $640 million in 1994. GAO estimates that 
because beneficiaries are responsible for about 22 percent of the 
payment amounts--mainly in the form of deductibles and copayments--
Medicare could have saved them $134 million in 1993 and $142 million in 
1994. The test results indicate that only a small portion of providers 
are responsible for most of the abuses: fewer than 10 percent of 
providers in the sample had miscoded claims. GAO summarized this report 
in testimony before the Congress; see Medicare Claims Billing Abuse: 
Commercial Software Could Save Hundreds of Millions Annually (GAO/T-
AIMD-95-133, May 5, 1995), by Frank W. Reilly, Director of Information 
Resources Management in the Health, Education, and Human Services Area, 
before the Subcommittee on Labor, Health and Human Services, Education, 
and Related Agencies, Senate Committee on Appropriations.

Medicare Claims (High Risk Series) (GAO/HR-95-8, Feb. 1995)

    In 1990, GAO began a special effort to identify federal 
programs at high risk of waste, fraud, abuse, and 
mismanagement. GAO issued a series of reports in December 1992 
on the fundamental causes of the problems in the high-risk 
areas. This report on Medicare claims is part of the second 
series that updates the status of this high-risk area. Readers 
have the following three options in ordering the high-risk 
series: (1) request any of the individual reports in the 
series, including the Overview (HR-95-1), the Guide (HR-95-2), 
or any of the 10 issue area reports; (2) request the Overview 
and the Guide as a package (HR-95-21SET); or (3) request the 
entire series as a package (HR-95-20SET).

Medicare Drug and Nutrient Prices (GAO/HEHS-97-22R, Oct. 11, 1996)

    Medicare part B covers (1) drugs that are incident to 
physician services and are not self-administered and (2) tube-
fed liquid nutrients for patients who cannot ingest food orally 
or whose digestive systems are impaired. Reports by the 
Department of Health and Human Services Office of Inspector 
General have indicated that the prices paid by Medicare for 
some medications and nutrients are higher than necessary and 
recommended reduced reimbursement for these items. Also, a home 
infusion and nutritional service provider GAO contacted had 
collected data indicating that Medicare payment levels for some 
drugs were much higher than the provider's cost to acquire 
them.

Medicare: Early Resolution of Overcharges for Therapy in Nursing Homes 
        Is Unlikely (GAO/HEHS-96-145, Aug. 16, 1996)

    Nursing homes and therapy companies continue to bill 
Medicare at very high rates for occupational and speech 
therapy. Moreover, the bills do not specify the amount of time 
spent with patients or the treatments provided. The weaknesses 
that GAO reported more than a year ago--the lack of salary 
guidelines setting limits on Medicare reimbursements for 
occupational and speech therapist's services and unclear 
billing for these services--persist. Although HCFA recognized 
as early as 1990 that inappropriate charges for occupational 
speech therapy were a problem, it is still trying to establish 
salary equivalency guidelines for these services. HCFA proposed 
guidelines based on a Bureau of Labor Statistics survey of 
average salaries for hospital therapists, but the industry was 
not satisfied and did its own survey. HCFA is now analyzing 
those survey results. The prospect for a quick resolution to 
the billing problem with therapy services is unlikely. 
Historically, it has taken HCFA years to reduce high payment 
rates for supplies or services. Given the typical time involved 
in meeting federal notification and publication requirements 
for changing Medicare prices, salary equivalency guidelines may 
not be implemented until the summer of 1997 at the earliest. 
GAO urges the Congress to consider granting HCFA legislative 
relief from these requirements.

Medicare: Enrollment Growth and Payment Practices for Kidney Dialysis 
        Services (GAO/HEHS-96-33, Nov. 22, 1995)

    Medicare is the predominant health care payer for people 
with end-stage renal disease--the permanent and irreversible 
loss of kidney function. Medicare's cost for this program has 
increased, mainly because of the substantial increase in new 
program enrollees. The annual rate of increase averaged 11.6 
percent between 1978 and 1991. In addition to the rise in 
enrollment, the mortality rate for new patients decreased. For 
example, deaths among beneficiaries during the first year in 
the program fell from 28 percent to 24 percent between 1982 and 
1991. Because the program began in 1973, technological advances 
and greater availability of kidney dialysis machines have meant 
that persons who were not considered good candidates for kidney 
dialysis in 1973--those 65 years old or older and those whose 
kidney failure was caused by diabetes and hypertension--are now 
routinely placed on dialysis. GAO's review of medical services 
and supplies provided to all Medicare end-stage renal disease 
patients in 1991 shows that no separately billable service or 
supply was provided often enough to make it a good candidate to 
be considered part of the standard dialysis treatment and thus 
included in a future composite rate.

Medicare: Excessive Payments for Medical Supplies Continue Despite 
        Improvements (GAO/HEHS-95-171, Aug. 8, 1995)

    In fiscal year 1994 alone, Medicare was billed more than 
$6.8 billion for medical supplies. Congressional hearings and 
government studies have shown that Medicare has been extremely 
vulnerable to fraud and abuse in its payments for medical 
supplies, especially surgical dressings. In one case discussed 
in congressional testimony in 1994, Medicare paid more than 
$15,000 in claims for a month's supply of surgical dressings 
for a single patient, apparently without reviewing the 
reasonableness of the claims before payments. Until recently, 
medical suppliers had considerable freedom in choosing the 
Medicare contractors that would process and pay their claims. 
Some exploited this freedom by ``shopping'' for contractors 
with the weakest controls and highest payment rates. This 
report discusses the (1) circumstances allowing payment for 
unusually high surgical dressing claims and (2) adequacy of 
Medicare's internal controls to prevent paying such claims.

Medicare: Federal Efforts to Enhance Patient Quality of Care (GAO/HEHS-
        96-20, Apr. 10, 1996)

    In the past decade, Medicare costs have risen on average 
more than 10 percent per year. Expanding managed care options 
for Medicare patients has been proposed as a way to contain 
costs. Concerns have been raised, however, that such changes 
may undermine the quality of care provided to Medicare 
beneficiaries. Currently, Medicare reimburses only for care 
provided in health maintenance organizations (HMO) and by the 
fee-for-service sector. This report (1) discusses the present 
and future strategies of HCFA, which administers the Medicare 
program, to ensure that Medicare providers furnish quality 
health care in both fee-for-service and HMO arrangements and 
(2) provides the views of experts on attributes a quality 
assurance program should have if more managed care options are 
made available to Medicare beneficiaries.

Medicare: HCFA Should Release Data to Aid Consumers, Prompt Better HMO 
        Performance (GAO/HEHS-97-23, Oct. 22, 1996)

    Until recent years, nearly all Medicare beneficiaries 
received care through a fee-for-service arrangement, with 
benefits and cost-sharing provisions standardized nationwide. 
Today, however, nearly 4 million beneficiaries have opted for 
health maintenance organizations (HMO), Medicare's leading 
managed care alternative. Although HMOs must cover the benefits 
available under traditional fee-for-service Medicare, they 
differ from one another in the provision of additional 
benefits, required premiums, provider networks, and ability to 
satisfy members. As a result, beneficiaries need reliable 
information to pick the plan that is right for them. Some 
beneficiaries do not understand even the basic difference 
between traditional Medicare and HMOs and may confuse HMOs with 
supplemental ``Medigap'' insurance. Moreover, some HMO sales 
agents have misled or used other questionable marketing 
practices to enroll poorly informed beneficiaries. This report 
reviews (1) the performance of HCFA, which administers 
Medicare, in providing beneficiaries with enough information on 
Medicare HMOs and (2) the usefulness of readily available HCFA 
data to caution beneficiaries about poorly performing HMOs.

Medicare Hospital Payments (GAO/HEHS-95-158R, May 25, 1995)

    GAO provided information on the growth in Medicare hospital 
payments, focusing on the annual payment growth rates for 
various types of hospitals. GAO noted that (1) while general 
inflation grew about 3.5 percent annually from 1984 through 
1992, hospital payments per discharge grew at an annual rate of 
5.4 percent; (2) major teaching hospitals averaged a 5.7 
percent annual payment growth rate and nonteaching hospitals 
averaged a 5.3 percent annual payment growth rate; (3) 
hospitals receiving disproportionate share payments had a 
higher per discharge payment growth rate than hospitals not 
receiving such payments; (4) larger hospitals in both urban and 
rural settings had higher payment growth rates; (5) government-
owned hospitals had higher payment growth rates than voluntary 
or proprietary hospitals; (6) increased payments did not 
necessarily translate to increased profits, since expenses were 
not accounted for; and (7) case complexity grew more rapidly 
among large urban and rural hospitals, which partially explains 
their higher payment growth rate.

Medicare: Increased HMO Oversight Could Improve Quality and Access to 
        Care (GAO/HEHS-95-155, Aug. 3, 1995)

    This report discusses problems that HCFA has had monitoring 
HMOs it contracts with to provide services to Medicare 
beneficiaries and ensuring that they comply with Medicare's 
performance standards. GAO found weaknesses in HCFA's quality 
assurance monitoring, enforcement measures, and appeal 
processes. Although HCFA routinely reviews HMO operations for 
quality, these reviews are generally perfunctory and do not 
consider the financial risks that HMOs transfer to providers. 
Moreover, HCFA collects virtually no data on services received 
through HMOs to enable it to identify providers who may be 
underserving beneficiaries. In addition, HCFA's HMO oversight 
has two other major limitations: enforcement actions are weak 
and the beneficiary appeal process is slow. HCFA's current 
regulatory approach to ensuring good HMO performance appears to 
lag behind the private sector. GAO summarized this report in 
testimony before the Congress; see Medicare: Increased Federal 
Oversight of HMOs Could Improve Quality of and Access to Care 
(GAO/T-HEHS-95-229, Aug. 3, 1995), by Sarah F. Jaggar, Director 
of Health Financing and Public Health Issues, before the Senate 
Special Committee on Aging.

Medicare HMOs: Rapid Enrollment Growth Concentrated in Selected States 
        (GAO/HEHS-96-63, Jan. 18, 1996)

    Private-sector insurers cite extensive use of HMOs and 
other managed care approaches as a key factor in slowing the 
growth of their insurance premiums. As a result, part of the 
current interest in controlling Medicare costs has centered on 
ways to increase HMO use among Medicare beneficiaries. This 
report provides informationon trends in the number of (1) 
Medicare beneficiaries enrolling in HMOs and (2) HMOs enrolling 
beneficiaries. GAO analyzed these data for factors that might be 
influencing decisions by HMOs to enroll Medicare beneficiaries and 
decisions by beneficiaries to enroll in HMOs. GAO found that about 2.8 
million Medicare beneficiaries--about 7 percent of the total--were 
enrolled in risk-contract HMOs as of August 1995. This was double the 
percentage enrolled in 1987. The growth has been particularly rapid 
during the past 4 years and has centered on certain states. California 
and Florida, for example, have more than half of all enrollees.

Medicare: Home Health Utilization Expands While Program Controls 
        Deteriorate (GAO/HEHS-96-16, Mar. 27, 1996)

    Use of the Medicare home health benefit has increased 
dramatically, with spending rising from $2.7 billion in 1989 to 
$12.7 billion in 1994. Costs are projected to reach $21 billion 
by the year 2000. In earlier reports (GAO/HRD-81-155 and GAO/
HRD-87-9), GAO cited lax controls over the use of the home 
health benefit and recommended measures to improve Medicare's 
ability to detect claims that were not medically necessary or 
did not meet the coverage criteria. Medicare's escalating home 
health outlays continue to raise concerns about the extent of 
benefit abuse. This report examines the factors underlying the 
growth in the use of the home health benefit. GAO discusses (1) 
changes in the composition of the home health industry, (2) 
changes in the composition of Medicare home health users, (3) 
differences in utilization patterns across geographic areas, 
(4) incentives to overuse services, and (5) the effectiveness 
of payment controls in preventing payments for services not 
covered by Medicare.

Medicare Insured Groups (GAO/HEHS-6-93R, May 1, 1996)

    Pursuant to a legislative requirement, GAO examined 
Medicare insured groups, focusing on (1) the status of the 
demonstration program and individual projects and (2) efforts 
to establish a reliable payment system. GAO found that (1) with 
the passage of the Omnibus Reconciliation Act of 1987, five 
groups had entered into agreements with HCFA to operate 
Medicare insured groups; (2) HCFA expenditures for the 
agreements totalled $1.1 million over the last 8 years; (3) all 
the agreements have been terminated due to concerns over the 
projects' financial viability; (4) HCFA terminated one of the 
projects after experiencing prolonged delays and problems with 
contract negotiations; (5) another company encountered delays 
in obtaining employer commitments and data needed for rate-
setting analysis; (6) the most recent group to terminate had 
developed an operating plan and proposed a payment rate-setting 
method before experiencing lengthy delays and problems with 
payment update methodology; (7) the proposed payment 
methodology would have established a base rate using 1986 to 
1990 claims data and updated the rate on the basis of revised 
per capita costs; and (8) in using more recent claims data, 
groups would have faced financial risk, as well as additional 
time and expense.

Medicare Managed Care: Growing Enrollment Adds Urgency to Fixing HMO 
        Payment Problem (GAO/HEHS-96-21, Nov. 8, 1995)

    Enrollment of Medicare beneficiaries in HMOs has soared in 
recent years, concentrated in some states and locales. This 
rapid growth in enrollment highlights the urgency of correcting 
Medicare's excessive payment rates to HMOs--particularly in 
certain areas. Likewise, enrollment stagnation elsewhere 
underscores the need to examine the causes of payment rate 
disparities among states and counties. Medicare's HMO payment 
method is plagued by three flaws. First, the rigidity of the 
formula-based fixed payment rate does not allow Medicare to 
capitalize on the competition among HMOs that, in the private 
market, leads to lower rates. Second, rate adjustments for 
differences in beneficiaries' health status are so imprecise 
that Medicare overpays HMOs that enroll beneficiaries who are 
in good health. Third, the reliance on a county's fee-for-
service health care costs to establish a payment rate produces 
rates that vary considerably within market areas. GAO concludes 
that a sensible approach would be to pursue three promising 
strategies concurrently--foster price competition among HMOs, 
improve risk adjusters' accuracy, and allow for adjustments in 
the current formula to reflect market competition and HMO's 
local health care costs. HCFA plans demonstration projects 
using competitive bidding and improved risk adjustment but 
results of a full-scale evaluation of these projects are years 
away. In the interim, HCFA should promptly gather and use 
valuable design and implementation data as they become 
available. HCFA's legislative authority to carry out these 
projects does not address managed care options explicitly, 
which raises questions about HCFA's authority to mandate HMO 
participation in the projects.

Medicare Managed Care Growth (GAO/HEHS-96-47R, Oct. 18, 1995)

    Pursuant to a congressional request, GAO reviewed the 
growth of Medicare beneficiaries in managed health care plans. 
GAO noted that (1) although more than 50 percent of employees 
covered by employer-provided insurance are enrolled in managed 
health care plans, fewer Medicare beneficiaries are enrolled in 
such plans; (2) the only managed care option Medicare offers is 
HMOs and they are not uniformly available; (3) the percentage 
of Medicare beneficiaries enrolled in an HMO has increased from 
about 3 percent in 1987 to about 7 percent in 1995; (4) 
although Medicare beneficiaries are increasingly choosing HMOs, 
about 87 percent of these beneficiaries live in 10 states, 
while about 55 percent live in just 2 states; and (5) only 3 
states have Medicare HMO enrollment of 20 percent or more, 
while 7 states have non-Medicare HMO enrollments of 30 percent 
or more.

Medicare: Millions Can Be Saved by Screening Claims for Overused 
        Services (GAO/HEHS-96-49, Jan. 30, 1996)

    Medicare contractors routinely pay hundreds of millions of 
dollars in Medicare claims without first determining if the 
services provided are necessary. GAO reviewed payments to 
doctors for six groups of high-volume medical procedures--
ranging from eye examinations to chest X rays--that accounted 
for nearly $3 billion in Medicare payments in 1994. GAO also 
surveyed 17 contractors to determine if they had used medical-
necessity criteria in their claims processing to screen for 
these six groups of procedures. For each of the six groups, 
more than half of the 17 contractors failed to use automated 
screens to flag claims for unnecessary, inappropriate, or 
overused treatments. These prepayment screens could have saved 
millions of taxpayer dollars now wasted on questionable 
services. Problems with controlling payments for widely 
overused procedures continue because HCFA lacks a national 
strategy to control these payments. HCFA now relies on 
contractors to focus on procedures where local use exceeds the 
national average. Although this approach helps reduce local 
overuse of some procedures, it is not designed to control 
overuse of a procedure nationwide. GAO summarized this report 
in testimony before the Congress; see Medicare: Millions Can Be 
Saved by Screening Claims for Overused Services (GAO/T-HEHS-96-
86, Feb. 8, 1996), by Sarah F. Jaggar, Director of Health 
Financing and Public Health Issues, before the Subcommittee on 
Human Resources and Intergovernmental Relations, House 
Committee on Government Reform and Oversight.

Medicare Providers' Legal Expenses (GAO/HEHS-95-214R, July 18, 1995)

    GAO provided information on Medicare reimbursement of 
providers' legal expenses, focusing on (1) the conditions that 
Medicare imposes on provider legal expense reimbursements and 
whether these conditions differ from those applied in other 
government contexts, (2) the amount Medicare spends on 
providers' legal expenses, and (3) whether Medicare providers 
have abused current provisions covering legal expense 
reimbursement. GAO noted that (1) HCFA has not specified the 
conditions under which legal fees are reimbursable; (2) 
Medicare decides whether providers' legal fees are reimbursable 
on a case-by-case basis; (3) the provisions for reimbursing 
Medicare providers' legal fees are more generous than those in 
other government contexts in that providers can be reimbursed 
by Medicare regardless of outcome and providers' legal expenses 
are not capped; (4) in 1994, 46 HHAs had a combined total of 
$6.5 million in legal expenses; and (5) HHAs are more likely to 
submit claims for Medicare reimbursement and to appeal denied 
cost adjustments, despite limited chances of success.

Medicare Secondary Payer Program (GAO/HEHS-95-101R, Mar. 6, 1995)

    GAO provided information on and suggested language for 
proposed legislation regarding the recovery of health care 
costs from private insurers where Medicare is the secondary 
payer. GAO noted that (1) the proposed legislation would give a 
clearer statutory basis for existing Medicare regulations on 
cost recovery from private insurers, which were recently 
invalidated by a court ruling; (2) HHS is also preparing a 
legislative proposal to address this and other Medicare issues; 
(3) the government may have to refund millions of dollars in 
past recoveries and forego future recoveries because of the 
court ruling; and (4) the court ruling barred recoveries from 
third-party administrators and claims filed past the insurers' 
filing deadlines and before 1989.

Medicare Spending: Modern Management Strategies Needed to Curb Billions 
        in Unnecessary Payments (GAO/HEHS-95-210, Sept. 19, 1995)

    Medicare's vulnerability to billions in unnecessary 
payments stems from a combination of factors. First, Medicare 
pays higher than market rates for some services and supplies. 
For example, Medicare pays more than the lowest suggested 
retail price for more than 40 types of surgical dressings. 
Second, Medicare's anti-fraud-and-abuse controls do not prevent 
the unquestioned payment of claims for improbably high charges 
or manipulated billing codes. Third, Medicare's checks on the 
legitimacy of providers are too superficial to detect the 
potential for scams. Various health care management strategies 
help private payers avoid these problems, but Medicare 
generally does not use these strategies. The program's pricing 
methods and controls over utilization, consistent with health 
care financing and delivery 30 years ago, have not kept pace 
with major financing and delivery changes. GAO believes that a 
viable strategy for remedying the program's weaknesses would 
involve adapting the health care management approach of private 
payers to Medicare's public payer role. This strategy would 
include (1) more competitively developed payment rates, (2) 
enhanced fraud and abuse detection efforts through modernized 
information systems, and (3) more rigorous criteria for 
granting authorization to bill the program.

Medicare: Tighter Rules Needed to Curtail Overcharges for Therapy in 
        Nursing Homes (GAO/HEHS-95-23, Mar. 30, 1995)

    Nursing homes and rehabilitation centers are taking 
advantage of ambiguous payment rules and the lack of guidelines 
to bill Medicare at inflated rates for therapy services. State 
averages for physical, occupational, and speech therapists' 
salaries range from about $12 to $25 per hour, but Medicare has 
been charged upwards of $600 per hour. The extent of 
overcharging and its precise impact on Medicare outlays are 
unclear; however, billing schemes uncovered in recent years 
suggest that the problem is nationwide and growing in 
magnitude. Extraordinary markups on therapy can resultfrom 
providers exploiting regulatory ambiguity and weaknesses in Medicare's 
payment rules. Payment rules and procedures developed when the therapy 
industry was much smaller and less sophisticated have proved no match 
for increasingly complex business practices designed to generate 
increased Medicare revenue and skirt program controls. Although the 
overbilling problem has been known since 1990, no action has been taken 
to close loopholes that allow payment for these overcharges.

Medigap Insurance: Alternatives for Medicare Beneficiaries to Avoid 
        Medical Underwriting (GAO/HEHS-96-180, Sept. 10, 1996)

    Although the Medicare program covers a substantial share of 
its beneficiaries' health expenses, it does require deductibles 
and coinsurance that can amount to thousands of dollars a year. 
Most beneficiaries obtain private insurance to supplement 
Medicare when they become eligible for the program at age 65. 
On occasion, beneficiaries decide to change Medigap policies 
and may then become subject to medical underwriting; that is, 
the insurer can take into account a person's health status or 
medical history in deciding whether to sell a policy. GAO found 
that few beneficiaries decide later to change their policies 
and those that do have at least one alternative for changing 
without being subject to medical underwriting. These 
alternatives, however, are not guaranteed by federal law, and 
it is possible that circumstances could change in the future. 
Federal Medigap law could be amended to furnish such a 
guarantee to beneficiaries who have been continuously covered 
by Medigap. Such a change should not have any major effect 
because it would not alter beneficiary incentives for Medigap 
coverage.

Medigap Insurance: Insurers' Compliance With Federal Minimum Loss Ratio 
        Standards, 1988-93 (GAO/HEHS-95-151, Aug. 23, 1995)

    The Medigap market grew steadily from 1988 to 1993, from 
$7.3 billion to $12.1 billion. Medigap insurers' aggregate loss 
ratios were relatively stable during the first 4 years of that 
period. During the next 2 years, however, these ratios fell 
about 10 percent, to an aggregate 75 percent for individual 
policies and 85 percent for group policies. In 1991, 19 percent 
of Medigap policies failed to meet loss ratio standards; this 
rose to 38 percent by 1993. The premium dollars spent on such 
policies increased from $320 million in 1991 to $1.2 billion in 
1993. If insurers had been required to give refunds or credits 
on substandard policies, as they will in the future, 
policyholders would have been due about $124 million during 
1992 and 1993.

MediGrant: Florida (GAO/HEHS-96-11R, Oct. 2, 1995)

    Pursuant to a congressional request, GAO provided 
information on how the proposed MediGrant Program will affect 
Florida's federal Medicaid funding between fiscal years 1996 
and 2002. GAO noted that (1) Florida state officials estimated 
that Florida would receive $7.6 billion less under the proposed 
MediGrant program than it does under current law; (2) between 
1996 and 2002 Florida is expected to match $30.6 billion under 
the current Medicaid spending law and $15.8 billion under the 
MediGrant proposal; (3) the MediGrant program would phase in a 
new formula by guaranteeing minimum growth rates for some 
states and placing limits on the maximum growth a state could 
receive each year; and (4) the MediGrant program would increase 
Florida's share of federal Medicaid funding from 3.67 percent 
in fiscal year 1994 to 4.13 percent in fiscal year 2002.

Michigan Financing Arrangements (GAO/HEHS-95-146R, May 5, 1995)

    GAO provided information on Michigan's 1995 Medicaid 
funding arrangements. GAO noted that (1) Michigan has been 
among the most successful states in obtaining additional 
federal Medicaid funds; (2) since fiscal year 1991, Michigan 
has reduced its Medicaid costs by $1.8 billion due to a variety 
of financing partnerships with medical providers; (3) most 
federal matching funds paid to providers have been returned to 
the state, thus reducing state appropriations; (4) although 
federal legislation has curtailed certain financing practices, 
Michigan has found new ways to obtain federal matching funds, 
such as using provider donations to maximize federal funds and 
reduce state costs; (5) Michigan's use of intergovernmental 
transfers could reduce Medicaid costs by an additional $428 
million in fiscal year 1995; (6) Michigan expects to obtain 
over $414 million in federal matching funds in fiscal year 
1996; (7) Michigan should realize a net benefit of $196.5 
million in fiscal year 1995 by adjusting nursing home and 
mental health Medicaid services payments; and (8) Michigan 
determined that it could make additional hospital outpatient 
payments of $40 million without exceeding established cost 
limits for such services.

Montana's Medical Assistance Facilities (GAO/HEHS-96-12R, Oct. 2, 1995)

    Pursuant to a congressional request, GAO provided 
information on Montana's medical assistance facilities (MAF), 
focusing on the (1) cases treated and services performed at 
MAFs; (2) costs to Medicare for inpatient services provided at 
MAFs compared to the costs at acute-care hospitals; and (3) 
number of hospitals that might qualify as MAFs if the program 
was expanded nationwide. GAO noted that (1) MAFs mainly serve 
patients with uncomplicated conditions or stabilize patients 
with more severe conditions before transferring them to full-
service hospitals; (2) MAFs serve as primary care providers for 
Medicare beneficiaries living in rural areas; (3) Medicare 
costs are generally less at MAFs than if the same patients had 
been treated at non-MAFs; (4) patients who are transferred from 
MAFs to acute-care hospitals increase Medicare costs, because 
the two facilities receive payments for the same patient; and 
(5) if the MAF or a similar program for rural hospitals in 
seven other states were expanded nationwide academic 
researchers estimated that although over 500 hospitals meet the 
qualifying criteria for MAFs, no more than 150 hospitals would 
convert to such limited service centers.

Nonphysician Specialists (GAO/HEHS-96-135R, May 29, 1996)

    Pursuant to a congressional request, GAO provided 
information on the policies and procedures governing the 
participation of certain nonphysician health specialists in 
several federal health care programs. GAO noted that (1) 
although nonphysician specialists are authorized to participate 
and provide services in federal health care programs, 
participation requirements and allowable services vary among 
and within the programs; (2) participation requirements vary as 
to training, supervision, and specialty autonomy; and (3) some 
agencies that administer federal health programs are more 
involved in setting requirements and establishing service 
parameters for nonphysician specialists than other agencies.

Patient Self-Determination Act: Providers Offer Information on Advance 
        Directives But Effectiveness Uncertain (GAO/HEHS-95-135, Aug. 
        28, 1995)

    The Congress passed the Patient Self-Determination Act in 
1990 to reinforce individuals' constitutional right to decide 
their final health care. The act requires health care providers 
to increase public awareness about the use of ``advance 
directives''--a living will or health care power of attorney. 
An advance directive spells out how life-support decisions 
should be carried out should the patient become terminally ill 
and unable to communicate his or her wishes. This report 
provides information on the act's implementation and on the 
effectiveness of advance directives in ensuring patient self-
determination. GAO looked at the extent to which (1) 
institutional health care providers and the federal government 
are complying with the act's provision, (2) the public uses 
advance directives to express their end-of-life treatment 
wishes, and (3) an advance directive affects a patient's 
desired care.

Practice Guidelines: Managed Care Plans Customize Guidelines to Meet 
        Local Interests (GAO/HEHS-96-95, May 30, 1996)

    The inappropriate use of medical services can be costly and 
raises quality-of-care concerns. For example, a 1988 study 
found that 14 percent of bypass surgeries were performed 
inappropriately. To narrow the gap between current and optimal 
practice, some federal agencies and other groups develop 
clinical practice guidelines on the best practices for 
effective and appropriate care. Managed care plans, which 
employ various techniques intended to reduce inappropriate 
care, are likely sites of guideline use. This report discusses 
(1) the purposes clinical practice guidelines serve and (2) how 
health plans make use of already published guidelines developed 
by federal agencies and other groups.

Prescription Drugs and the Elderly: Many Still Receive Potentially 
        Harmful Drugs Despite Recent Improvements (GAO/HEHS-95-152, 
        July 24, 1995)

    The inappropriate use of prescription drugs is particularly 
hazardous for the elderly. Not only do they use more 
prescription drugs than any other age group, the elderly are 
more likely to take several drugs at once, increasing the 
likelihood of harmful drug reactions. Furthermore, the elderly 
do not eliminate drugs from their systems as efficiently as 
younger patients because of decreased liver and kidney 
function. GAO found that 17.5 percent of nearly 30 million 
noninstitutionalized Medicare recipients aged 65 or older used 
at least one drug identified as generally unsuitable for 
elderly patients since safer alternative drugs exist. 
Inappropriate prescription drug use can result from doctors 
using outdated prescribing practices, pharmacists not doing 
drug utilization reviews, and patients not telling their 
doctors and pharmacists about all the drugs they are taking. 
Recent initiatives are seeking to address this problem. Federal 
and state efforts have encouraged the development and 
dissemination of detailed information on the effect of 
prescription drugs on the elderly, and the medical community is 
urging doctors to increase their knowledge of geriatrics and 
elderly clinical pharmacology. At the same time, drug 
utilization review systems now allow prescriptions to be 
screened before they are filled to identify potential problems, 
such as adverse drug interactions or inappropriate dosage 
levels. Changes in the health care delivery system may also 
help reduce inappropriate use of prescription drugs. For 
example, managed care plans, through the use of controls such 
as a ``gatekeeper,'' could potentially improve the coordination 
of drug therapies for newly enrolled elderly patients.

Prescription Drugs and Medicaid: Automated Review Systems Can Help 
        Promote Safety, Save Money (GAO/AIMD-96-72, June 11, 1996)

    Inappropriate use of prescription drugs can lead to drug-
induced illness, hospitalization, and even death. Inappropriate 
drug use can also prove expensive for the Medicaid program. As 
a result, the Congress mandated that states establish 
utilization review programs--called prospective reviews--to 
review Medicaid prescriptions before drugs are dispensed. 
Automated prospective drug utilization review systems are 
proving a low-cost way for states to help both doctors and 
pharmacies safeguard Medicaid recipients from potentially 
harmful medical reactions. Although the main emphasis of these 
systems--appropriately--has been safety, both safety benefits 
and dollar savings accrue from their use. Because results vary 
on the basis of how such systems are administered, it is 
important that states share their experiences. Absent any 
analysis of data from the Iowa demonstration project or 
anyconcerted effort by HCFA to collect and share other states' 
experiences, states have had only limited access to both safety and 
cost data--information that is critical to informed decisionmaking and 
to maximizing the effectiveness and efficiency of automated prospective 
drug utilization review systems.

Preventing Abusive Medicare Billing (GAO/HEHS-95-260R, Sept. 5, 1995)

    GAO discussed its recommendations for preventing abusive 
billing practices for therapy services furnished to nursing 
home residents who are covered by Medicare and whether the 
recommendations can be implemented legislatively. GAO noted 
that (1) Medicare law could be amended to require HHS to 
establish the requirements recommended as well as a higher 
limit on the amount that Medicare will recognize as reasonable 
for therapy services; (2) expense claim limits could be set at 
the amount established under Medicare's part B fee schedules 
for therapy services; (3) establishing an upper limit would 
partially define billable units of service, since the procedure 
codes for occupational and speech therapy do not define the 
amount of time the codes cover; and (5) proposals have been 
made to require nursing homes to bill for the services provided 
to their residents, whether payment is sought from part A or 
part B fee schedules.

Private Health Insurance: Millions Relying on Individual Market Face 
        Cost and Coverage Trade-Offs (GAO/HEHS-97-8, Nov. 25, 1996)

    Most Americans obtain health insurance coverage through 
their jobs or through government programs like Medicare and 
Medicaid. About 10.5 million Americans, however, purchased 
private health insurance for themselves or their families in 
1994. The family farmer, the recent college graduate, the early 
retiree, and the employee of a company that does not offer 
health insurance coverage are all examples of persons who are 
often not covered in a voluntary, employment-based insurance 
market. Integrating the individual market into health insurance 
reform proposals has been a thorny issue at both the federal 
and state level, in part because of the paucity of information 
on the nature of this market and the characteristics of its 
participants. This report discusses the (1) size of the 
individual market, recent trends in it, and the demographic 
characteristics of its participants; (2) market structure, 
including how persons access the market, the prices and other 
characteristics of health plans offered, and the number of 
individual carriers offering plans; and (3) insurance reforms 
and other measures states have taken to improve individuals' 
access to health insurance.

Psychiatric Hospital Oversight (GAO/HEHS-96-132R, May 24, 1996)

    Pursuant to a congressional request, GAO reviewed federal 
and state oversight of state-operated and private psychiatric 
hospitals. GAO noted that (1) as of August 1995, 702 
psychiatric hospitals were certified to participate in Medicare 
and Medicaid; (2) to become certified for participation in 
Medicare and Medicaid, psychiatric hospitals must satisfy 
general hospital requirements for health and safety, and 
special psychiatric hospital requirements for active treatment; 
(3) hospital medical records must reflect the degree of active 
treatment and hospitals must have qualified staff to evaluate 
and treat patients; (4) HCFA requires states to conduct surveys 
of psychiatric hospitals to determine whether they satisfy 
certification requirements; (5) surveys of psychiatric 
hospitals include examinations of hospital and patient records, 
direct observations of patients, and interviews with staffs and 
patients; (6) as of August 1995, most certified psychiatric 
hospitals satisfied HCFA requirements for medical records and 
staffing; and (7) the failure to evaluate a patient's strengths 
when developing a treatment plan, specify each patient's 
treatment goals, and indicate the methods of treatment were the 
most common deficiencies cited in surveys of psychiatric 
hospitals that failed to satisfy HCFA certification 
requirements.

Public Health: A Health Status Indicator for Targeting Federal Aid to 
        States (GAO/HEHS-97-13, Nov. 13, 1996)

    Premature mortality is the best single proxy for reflecting 
differences in the health status of states' populations as 
measured by both the Healthy People 2000 indicators and the 
ReliaStar index. GAO's analysis showed that using premature 
mortality to distribute federal funding for core public health 
functions would systematically target federal assistance to 
states on the basis of their populations' rates of mortality, 
disease incidence, and risk for mortality and morbidity. 
Several other variables, including the proportion of states' 
populations that are poor or minorities, were also found to be 
correlated with health status differences as measured by the 
Healthy People 2000 indicators and the ReliaStar index. 
However, including these variables along with premature 
mortality did not significantly enhance GAO's ability to 
differentiate the health status of state populations. Moreover, 
improving the targeting of funds beyond that obtained by using 
premature mortality alone would require using several 
additional variables, which would add to the complexity of the 
allocation formula.

Skilled Nursing Facilities: Approval Process for Certain Services May 
        Result in Higher Medicare Costs (GAO/HEHS-97-18, Dec. 20, 1996)

    Skilled nursing facilities provide posthospital care for 
people who need more care than is available in the home. 
Medicare payments to these facilities have grown rapidly, from 
$456 million in 1983 to nearly $11 billion in 1996. The number 
of facilities that have sought and been granted payments higher 
than those normally allowed by Medicare has also grown, from a 
total of 80 during fiscal years 1979-92 to 552 in fiscal year 
1995. The skilled nursing facility industry contends that the 
higher payments are justified because these facilities care for 
more complex and costly patients than they did in the past. 
However, GAO did not find that skilled nursing facilities that 
collected the higher fees had a larger proportion of patients 
requiring complex care than did other facilities. Moreover, in 
the area of therapy, which could be indicative of complex care 
needs, GAO found no major differences in the amount and types 
of therapy provided. Although the number of skilled nursing 
facilities granted exceptions to routine cost limits under 
Medicare soared from 62 in fiscal year 1992 to 552 in 1995, the 
Health Care Financing Administration's review process for 
exception requests does not ensure that facilities actually 
provide atypical services to their Medicare patients. In 
addition, the patient-specific data obtained from requesting 
skilled nursing facilities generally are not used to assess 
whether the Medicare beneficiaries need or receive atypical 
services.

State Medicaid Financing Practices (GAO/HEHS-96-76R, Jan. 23, 1996)

    Pursuant to a congressional request, GAO provided 
information on state Medicaid financing arrangements in 
Michigan, Tennessee, and Texas. GAO noted that (1) until HCFA 
ruled in 1985 that states could use Medicaid provider donations 
to reduce their share of Medicaid expenditures, states could 
only use provider donations for the cost of training 
administrative personnel; (2) Michigan raised $684 million for 
its Medicaid program through hospital donations and federal 
matching funds in fiscal years 1991 through 1993, allowing it 
to fund $566 million in additional Medicaid payments; (3) in 
1993, Tennessee required certain medical providers to pay a 
$2,600 tax on their nursing home beds and a 6.75-percent tax on 
services, but it discontinued the hospital services tax in 1994 
when it implemented the TennCare program; (4) Tennessee earned 
$458 million from nursing home and hospital taxes in fiscal 
year 1993 and received $954 million in federal matching funds, 
which accounted for over half of its 1993 Medicaid spending; 
(5) the Congress enacted legislation in 1993 that restricted 
state financing arrangements by limiting disproportionate share 
hospital (DSH) program payments, causing states to modify their 
DSH programs and overall DSH payments to decline; and (6) 
despite the 1993 legislation, states were able to use 
intergovernmental transfers and other creative funding 
arrangements to reduce their share of Medicaid costs.

                HOUSING AND COMMUNITY DEVELOPMENT ISSUES

Community Development: Status of Urban Empowerment Zones (GAO/RCED-97-
        21, Dec. 20, 1996)

    The Empowerment Zone and Enterprise Community Program 
targets federal grants to distressed urban and rural 
communities for social services and community redevelopment and 
provides tax and regulatory relief to attract or retain 
businesses in distressed communities. This report focuses on 
six urban empowerment zones that receive most of the program's 
funds--Atlanta, Baltimore, Chicago, Detroit, New York, and 
Philadelphia/Camden. GAO discusses the (1) status of the 
program's implementation in the urban empowerment zones, 
including the extent to which public housing officials and 
residents have been involved; (2) factors that participants 
believe have either helped or hindered efforts to carry out the 
program; and (3) plans for evaluating the program.

Housing Counseling Demonstration Program (GAO/RCED-96-238R, Sept. 16, 
        1996)

    The National Affordable Housing Act of 1990 required GAO to 
report on the effectiveness of a U.S. Department of Housing and 
Urban Development prepurchase and foreclosure-prevention 
counseling demonstration program. This counseling was intended 
to (1) reduce defaults and foreclosures on single-family 
mortgages insured by the Federal Housing Administration (FHA), 
(2) encourage responsible and prudent use of such mortgages, 
(3) help homeowners with FHA mortgages keep their homes, and 
(4) encourage the availability and expansion of home ownership 
through the FHA mortgage insurance program. The act required 
that the demonstration program, which was funded from September 
30, 1992, to September 30, 1994, include a comparison of three 
locations where the counseling was provided (target areas) and 
three similar locations where counseling was not provided 
(control areas).
    Several implementation problems precluded GAO from 
assessing the impact of the program. Specifically, target and 
control areas were not comparable, the counseling intervention 
was not always implemented properly, and the program was 
geographically more limited than originally planned. 
Consequently, valid data does not exist upon which to base a 
study for determining whether a permanent program of mandatory 
counseling would be effective in reducing defaults and 
foreclosures.

HUD-Assisted Renters (GAO/RCED-95-167R, May 18, 1995)

    GAO provided information on the Department of Housing and 
Urban Development's (HUD) rental assistance programs, focusing 
on the potential for assisted households to move toward or 
achieve economic self-sufficiency. GAO noted that based on 
samples of 1989 data (1) HUD-assisted renters' median age was 
50 years, with 29 percent 34 years or younger, 36 percent 
between the ages of 35 and 64, and 35 percent 65 years or 
older; (2) the elderly and the disabled, who constituted about 
49 percent of HUD-assisted households, had limited potential 
for achieving self-sufficiency; (3) 45 percent of assisted 
households had children, with 12 percent having three or more 
children; (4) about 55 percent of the households were headed by 
single parents; (5) single parents needed child care and other 
services to participate in training or employment programs; (6) 
about 36 percent of the heads of assisted households had 
graduated from high school, another 18 percent had 1 or more 
years of college, and 21percent had fewer than 8 years of 
schooling; (7) at least 45 percent of HUD-assisted renters needed 
additional education or training to become self-sufficient; (8) the 
renters' median income was $7,320; (9) about 7 percent of the renters 
had incomes of $20,000 or more; (10) only 40 percent of the households 
reported income from wages or salaries; and (11) a 3-member family 
renting a 2-bedroom apartment would need an annual income ranging from 
$18,396 to $36,264 to become economically independent of the housing 
program.

HUD Management: Greater Oversight Needed of FHA's Nursing Home 
        Insurance Program (GAO/RCED-95-214, Aug. 25, 1995)

    HUD has insured private lenders against financial losses 
arising from defaults on mortgages for nursing homes and 
retirement service centers. Although HUD officials believe that 
the program has enabled the agency to assist populations or 
areas that are not well served by the private sector, GAO found 
that the nursing home program has not been targeted to specific 
populations or communities and that HUD does not collect or 
analyze information on whom the program is servicing. The 
Federal Housing Administration (FHA) has not completely 
assessed the financial performance of the nursing home and 
retirement service center programs. Available data indicate 
that the nursing home program has incurred losses of $187 
million, adjusted for inflation, during its 35-year history. 
Additionally, FHA's fiscal year 1994 loan loss reserves 
anticipate future losses equivalent to about 19 percent of the 
$3.7 billion balance of nursing home loans in the portfolio as 
of September 1994. HUD data show that about 46 percent of the 
retirement service center's total portfolio of about $1.4 
billion had defaulted and resulted in FHA insurance claims as 
of September 1994. GAO doubts whether HUD will be able to 
effectively manage the nursing home and retirement service 
center programs in the near future.

Information Technology: Streamlining FHA's Single Family Housing 
        Operations (GAO/AIMD-97-4, Oct. 17, 1996)

    The Secretary of Housing and Urban Development has proposed 
a major overhaul of the agency's programs and operations during 
the next several years. One proposal is to cut staff at FHA by 
more than 50 percent by the year 2000. Information technology 
figures prominently in FHA's plans to streamline its single 
family operations, boost efficiency, and meet mandated staff 
reductions. Thus far, the planned actions are consistent with, 
but are not as extensive as, efficiency improvements taken by 
leading mortgage industry organizations. FHA's streamlining 
efforts, however, are in the early stages and, as other efforts 
continue, FHA will be deciding on specific operational changes, 
information technology applications, and management controls 
that will determine the efficiency and effectiveness of its 
operations and the achievement of staff reductions. In doing 
so, it can use the recently enacted Information Technology 
Management Reform Act of 1996 to establish an effective 
framework for making these information technology decisions.

Multifamily Housing: Effects of HUD's Portfolio Reengineering Proposal 
        (GAO/RCED-97-7, Nov. 1, 1996)

    About 8,600 privately owned multifamily properties with 
federally insured mortgages totaling nearly $18 billion receive 
federal rental subsidies for all or some of their apartments 
under the Department of Housing and Urban Development's (HUD) 
Section 8 program. For subsidized apartments, HUD pays the 
difference between the rent and 30 percent of the household's 
income. The rents at many properties exceed market levels, 
resulting in high subsidies. To reduce costs and address other 
problems, HUD has proposed adjusting the rents to market levels 
and writing down mortgages as needed to allow the properties to 
operate at market rents. In essence, HUD's proposal recognizes 
a reality that has persisted for some time--namely, that many 
of the properties in the insured Section 8 portfolio are worth 
far less than their mortgages suggest. This report examines the 
(1) problems affecting the properties in HUD's insured Section 
8 portfolio and HUD's plans for addressing them, (2) results 
and reasonableness of a study done by Ernst & Young assessing 
the effects of HUD's proposal on the properties in the 
portfolio, and (3) key issues facing the Congress as it 
assesses HUD's proposal.

Public Housing: Partnership Can Result in Cost Savings and Other 
        Benefits (GAO/RCED-97-11, Oct. 17, 1996)

    The Congress is considering giving the nation's 3,300 
public housing authorities greater flexibility in managing 
their properties and in operating public and assisted housing 
for more than 4 million households. This greater discretion is 
expected to strengthen the long-term viability of public and 
assisted housing and allow the public housing authorities to 
better meet the needs of local communities. Public housing 
authorities have begun establishing partnerships with public 
and private sector groups to help stretch limited financial 
resources. Some partnerships have generated quantifiable cost 
savings, while others have produced nonmonetary benefits, such 
as improved social services, that would not have been possible 
without the partnership. This report describes four types of 
arrangements that public housing authorities have established 
and provides the views of public housing authority officials on 
the advantages of these arrangements.

Rural Housing Programs: Opportunities Exist for Cost Savings and 
        Management Improvement (GAO/RCED-96-11, Nov. 16, 1995)

    The Agriculture Department's Rural Housing and Community 
Development Service provides about $2.85 billion each year for 
rural housing loans. As of June 1995, the Service had an 
outstanding single-family and multifamily housing loan 
portfolio of about $30 billion, which represented a significant 
federal investment in affordable housing for the rural poor. 
The largest portion of the loan portfolio is for single-family 
direct and guaranteed mortgage loans that are made to families 
or individuals who are without adequate housing and who are 
unable to obtain loans from private lenders at reasonable 
costs. Rural multifamily rental housing loans, made to finance 
apartment-style housing or to buy and rehabilitate existing 
rental units, make up the rest of the portfolio. This report 
provides information on the Service's single- and multifamily 
housing loan programs and discusses suggestions made by GAO and 
others that could yield cost savings or improve management in 
these programs.

                         INCOME SECURITY ISSUES

Buyout Recipients' Compliance with Reemployment Provisions (GAO/GGD-97-
        7R, Oct. 3, 1996)

    In Reemployment of Buyout Recipients (GAO/GGD-96-102R), GAO 
identified 68 persons who took a buyout to leave government, 
were reemployed as civil servants, and also were required to 
take certain steps to satisfy reemployment requirements. On the 
basis of information from Office of Personnel Management (OPM) 
data and interviews with personnel officials at the affected 
agencies, GAO concluded in this report that 11 of the 68 
individuals were in apparent violation of the reemployment 
requirements, while 45 were not. GAO could not determine 
whether the remaining 12 were in violation because of 
inconsistencies between OPM and agency data. GAO will refer 
information about the 11 individuals in apparent violation of 
reemployment requirements and has already referred the 12 whose 
compliance was uncertain to the appropriate Office of Inspector 
General (OIG). GAO will report on the status of the OIG's 
investigations of the 23 cases and whether agencies had 
adequate internal controls to ensure compliance with buyout 
repayment requirements. [This was subsequently reported in GAO/
GGD-98-12, Jan. 26, 1998.]

Combined Fund Update (GAO/HEHS-95-166R, May 25, 1995)

    GAO reviewed the United Mine Workers of America (UMWA) 
Combined Benefit Fund, focusing on the fund's (1) 
beneficiaries, expenses, and revenues; and (2) Medicare 
reimbursement arrangements. GAO noted that (1) as of October 1, 
1994, the fund had 96,700 beneficiaries, about three-quarters 
of whom were coal industry operators; (2) 29 firms terminated 
their contributions to the fund between October 1994 and March 
1995, which necessitated the reassignment of 3,114 
beneficiaries; (3) the fund had billed all operators about $162 
million for fiscal year 1995 premiums; (4) the fund's Medicare 
per capita reimbursement rate was renegotiated and reduced for 
the year beginning July 1994, which makes it unlikely that 
future annual surpluses will occur; and (5) overall annual 
operating deficits are expected to begin in 1995, which would 
eliminate the current surplus by 2003.

Combined Fund Analysis (GAO/HEHS-95-230R, Aug. 4, 1995)

    GAO reviewed two studies of the UMWA Combined Benefit Fund. 
GAO noted that (1) the consultants' models projected widely 
differing financial results for the UMWA Combined Benefit Fund; 
(2) the models' expense estimates for 1995 differed by about 
$16 million; (3) one of the models underestimated the UMWA 
fund's 1995 net expenses by approximately $3 million; (4) one 
consultant based its medical cost inflation assumptions on the 
fund's past and current efforts to contain cost growth in 
prescription drugs; (6) the other consultant relied on the 
Medicare trust fund's projections of medical inflation and 
adjusted these estimates to reflect the fund's past 
experiences; and (7) the later assumptions may be more 
reasonable and may be more accurate in predicting the fund's 
status beyond 1995.

Congressional Retirement Costs (GAO/GGD-96-24R, Oct. 12, 1995)

    Pursuant to a congressional request, GAO provided 
information on the proposal to change the congressional 
retirement system, focusing on (1) the cost of congressional 
retirement benefits; (2) the potential savings from the 
proposal; (3) how private sector retirement systems compare 
with the congressional retirement system; and (4) the extent to 
which private sector employers are replacing defined benefit 
pension plans with defined contribution plans. GAO noted that 
(1) the estimated cost of providing future retirement benefits 
to 1994 congressional members would total $14,327,224; (2) over 
a 5-year period, the cost of providing retirement benefits 
would total $71.5 million; (3) if the proposal were enacted, it 
would significantly reduce the cost of member retirement 
programs; (4) the cost of providing retirement benefits to 1994 
congressional staff members would total $116.5 million; (5) 
although federal employees receive greater benefit amounts 
under the Civil Service Retirement System (CSRS) than 
nonfederal employees before age 62, they receive smaller 
amounts after age 62 when social security benefits are 
available to nonfederal employees; and (6) the private sector 
does not appear to be moving toward replacing defined benefit 
plans with defined contribution plans.

CSRS Funding (GAO/GGD-95-200R, Apr. 3, 1995)

    GAO reviewed information on the funding status of the Civil 
Service Retirement System. GAO noted that (1) the system's 
unfunded liability is not a problem that needs to be fixed to 
avoid a steep increase in outlays from the Treasury or 
increases in the deficit and (2) there should be sufficient 
assets in the retirement fund to cover benefit payments to all 
current and future retirees.

D.C. Disability Retirement Rate (GAO/GGD-95-133, Mar. 31, 1995)

    The federal government makes annual payments to the 
District of Columbia retirement fund for police officers and 
firefighters. To encourage the District government to control 
disability retirement costs, these payments must be reduced 
when the disability retirement rates exceed a certain limit. 
GAO concludes that no reduction is required in the fiscal year 
1996 payment to the fund.

District's Workforce: Annual Report Required by District of Columbia 
        Retirement Act (GAO/GGD-96-95, Mar. 29, 1996)

    The federal government makes annual payments to the 
District of Columbia retirement fund for police officers and 
firefighters. To encourage the District government to control 
disability retirement costs, these payments must be reduced 
when disability retirement rates exceed a certain limit. GAO 
concludes that no reduction is required in the fiscal year 1997 
payment to the fund.

Federal Employees' Compensation Act: Issues Associated With Changing 
        Benefits for Older Beneficiaries (GAO/GGD-96-138BR, Aug. 14, 
        1996)

    The Federal Employees' Compensation Act (FECA) now allows 
beneficiaries who are at or beyond retirement age to receive 
worker's compensation benefits. Possible changes to the 
legislation would reduce these benefits. This briefing report 
provides (1) a profile of beneficiaries on the long-term FECA 
rolls, (2) views of proponents and opponents of changing FECA 
benefits for older beneficiaries, and (3) questions and issues 
that the Congress might consider if crafting benefit changes.

Federal Grants: Design Improvements Could Help Federal Resources Go 
        Further (GAO/AIMD-97-7, Dec. 18, 1996)

    Grants-in-aid are payments from the federal government to 
state and local governments to help them finance various 
activities, such as public assistance, highway construction, 
and education. In addition, lesser-known grant programs help 
finance public libraries, efforts to restore sport fish, 
programs to promote boating safety, and other activities. In 
fiscal year 1995, the federal government earmarked $225 billion 
for more than 600 grant programs--about 15 percent of all 
federal spending. This report focuses on the extent to which 
the grant system meets two goals frequently cited by public 
finance experts: (1) encouraging the states to use federal 
dollars to supplement rather than replace their own spending on 
nationally important activities and (2) targeting grant funding 
to states with relatively greater programmatic needs and fewer 
fiscal resources.

Federal Pensions: Thrift Savings Plan Has Key Role in Retirement 
        Benefits (GAO/HEHS-96-1, Oct. 19, 1995)

    As of September 1994, about 940,000 federal workers covered 
by the Federal Employees Retirement System (FERS) were 
voluntarily contributing an average of 5.7 percent of their 
salaries to the Thrift Savings Plan (TSP). Most of the 
remaining 300,000 FERS-covered workers who were not 
contributing were in the lower pay ranges. Lower-paid workers 
who were contributing were doing so at lower rates than higher-
paid workers--an average of 4.4 percent of their salaries. 
However, lower-paid workers may achieve satisfactory retirement 
income levels even with low contribution rates because Social 
Security benefits are proportionately greater for them than for 
higher-paid workers. Higher-paid workers need to defer at least 
5 percent of their salaries throughout their careers--if not 
more--to achieve retirement income of 60 to 80 percent of their 
preretirement salaries. Educating FERS workers can play a key 
role in their making wise preretirement investment choices. 
Although TSP materials discuss the plan's financial aspects, 
they do not explicitly discuss how TSP can help workers covered 
by FERS achieve their retirement income goals. The TSP Board is 
seeking legislation that would enable employees to invest in a 
domestic small capitalization fund and an international stock 
fund. GAO found that these two additions would make TSP's 
investment options more closely resemble those in similar 
private sector plans.

Federal Retirement: Benefits for Members of Congress, Congressional 
        Staff, and Other Employees (GAO/GGD-95-78, May 15, 1995)

    The retirement benefits provided by the Civil Service 
Retirement System for Members of Congress are generally more 
generous than those provided for other federal employees. The 
major differences are found in the eligibility requirements for 
retirement and the formulas used to calculate benefits. The 
Member benefit formula applies to congressional staff, but they 
are covered by the general employee retirement eligibility 
requirements. Law enforcement officers and firefighters may 
retire earlier than general employees and are covered by a more 
generous benefit formula than are general employees. Under the 
Civil Service Retirement System, the provisions for air traffic 
controllers fall between those for law enforcement officers and 
firefighters and those for general employees. Many of the 
advantages afforded to Members of Congress and congressional 
staff under the Civil Service Retirement System were continued 
under the Federal Employees Retirement System, which covers 
workers hired in 1984 and thereafter. But under the Federal 
Employee Retirement System, provisions for law enforcement 
officers, firefighters, and air traffic controllers are very 
similar to provisions for Members. GAO summarized this report 
in testimony before the Congress; see Congressional Retirement 
Issues (GAO/T-GGD-95-165, May 15, 1995), by Johnny C. Finch, 
Assistant Comptroller General for General Government Programs, 
before the Subcommittee on Post Office and Civil Service, 
Senate Committee on Governmental Affairs.

Food Stamp Program: Achieving Cost Neutrality in Minnesota's Family 
        Investment Program (GAO/RCED-96-54, Feb. 12, 1996)

    In 1994, Minnesota began a 5-year federally authorized 
welfare reform project known as the Minnesota Family Investment 
Program. Aimed at simplifying the welfare system, the project 
consolidates the food assistance and the cash benefits provided 
by three programs--Aid to Families With Dependent Children, the 
Food Stamp Program, and Minnesota's Family General Assistance 
Program--into a single monthly payment. The Food Stamp Act of 
1977 requires that the federal government spend no more for 
this project's food assistance component in any fiscal year 
than it would have spent for the Food Stamp Program. That is, 
the project must be cost neutral. To ensure cost neutrality, 
the act requires the Agriculture Department and the state of 
Minnesota to agree upon methodologies for estimating what the 
costs of the Food Stamp Program for both benefits and 
administration would have been had there been no project. This 
report (1) describes the methodologies that Minnesota agreed to 
use for estimating Food Stamp Program costs that would have 
been incurred if the project had not been implemented; (2) 
determines if Minnesota implemented these methodologies; (3) 
assesses the reasonableness of these methodologies, as 
implemented, for estimating the cost of the Food Stamp Program 
for fiscal year 1994; and (4) compares the payments that would 
have been paid to Minnesota using the agreed-upon methodologies 
with the actual payments in fiscal year 1994.

Means-Tested Programs (GAO/HEHS-95-94R, Feb. 24, 1995)

    GAO provided information on welfare reform proposals to 
simplify means-tested public assistance programs. GAO noted 
that (1) welfare services should be easily accessible to all 
who seek assistance; (2) there is no integrated strategy to 
unify these programs to address the interrelated needs of 
individuals and families; (3) despite efforts to better 
coordinate federal programs, conflicting requirements make it 
difficult for program staff to coordinate activities and share 
resources; and (4) program integration could be facilitated by 
reducing or eliminating federal program barriers and 
reengineering the welfare delivery process.

Military Retirement: Possible Changes Merit Further Evaluation (GAO/
        NSIAD-97-17, Nov. 15, 1996)

    Payments to military retirees and their survivors totaled 
$29 billion in fiscal year 1996. Various factors, including the 
end of the Cold War, defense downsizing, changes in civilian 
retirement systems, and increasing federal budgetary 
constraints, have raised questions about whether the military 
retirement system today best meets the needs of the Pentagon 
and members of the armed forces. A number of analysts, 
including several who participated in a roundtable discussion 
convened by GAO, believe that fundamental changes to the 
military retirement system could increase its effectiveness or 
reduce costs by yielding a force of different composition and 
size than exists today. The suggestions of the GAO panel, which 
included Defense Department experts and compensation analysts, 
ranged from earlier vesting of retirement benefits to more 
sweeping reforms, such as placing military personnel under a 
system similar to the Federal Employees Retirement System.

Older American Act Funding Formula (GAO/HEHS-96-137R, Apr. 24, 1996)

    Pursuant to a congressional request, GAO provided 
information on how proposed changes to the funding formula for 
title III of the Older Americans Act would affect equity in 
state funding and per-person-in-need income. GAO found that (1) 
the proposed formula changes would improve funding equity and 
target more aid to the elderly in the oldest age groups and 
low-income states; (2) the formula changes would not affect 
small states that are guaranteed at least 0.5 percent of the 
funds made available for state distribution; (3) the changes 
would reduce cross-state disparities, increase funding for 
states whose funding is below the national average, and 
decrease funding for those states whose funding is above the 
average; and (4) funding disparities could be further reduced 
if minority status and poverty were included in the formula 
changes.

PASS Program: SSA Work Incentive for Disabled Beneficiaries Poorly 
        Managed (GAO/HEHS-96-51, Feb. 28, 1996)

    The Social Security Administration (SSA) is poorly managing 
a small but growing program to encourage disability 
beneficiaries to seek employment. The plan for achieving self-
support (PASS) program, established in 1972, is currently 
small--only about 10,300 persons participated in December 
1994--but the number of participants has swelled more than 5-
fold during the past 5 years as awareness of the program has 
increased and millions more disabled beneficiaries have become 
eligible to participate.The PASS program is vulnerable to abuse 
because of vague guidelines, and its impact on employment is unknown 
because SSA does not collect basic data on participants and their 
employment. In addition, SSA top management has not adequately 
considered the potential problems posed by professional PASS preparers, 
whose fees--as much as $800--are often included as PASS expenses. SSA 
is trying to address some of these internal control weaknesses, but it 
cannot guarantee today that taxpayer dollars are being well spent.

PBGC (GAO/AIMD-95-225R, Aug. 24, 1995)

    GAO reviewed the Pension Benefit Guaranty Corporation's 
(PBGC) accounting procedures and internal controls that 
warranted management's attention as of September 30, 1994. GAO 
noted that PBGC (1) used evidence about significant 
transactions that occurred after year-end in assessing its 
year-end contingent liabilities; (2) misclassified several 
pension plans based on their prior year classifications; (3) 
placed greater emphasis on bond ratings and debt-equity ratios 
in classifying pension plans; (4) had financial statements that 
did not disclose factors that represented high contingent 
liability risks; (5) did not adequately disclose the monetary 
effects that actuarial assumptions had on the amounts 
disclosed; (6) did not provide all available information about 
its efforts to recover amounts from sponsors of terminated 
plans in its financial statements; (7) incorrectly recorded its 
estimated losses; (8) did not provide adequate documentation in 
its Single Employer Program's Statement of Cash Flows; (9) 
inconsistently reviewed its financial assistance to 
multiemployer plans; (10) had yet to evaluate the effectiveness 
of its ratio screens in identifying troubled plans; (11) 
incorrectly listed 16 multiemployer plans as inactive in its 
Premium Processing System; (12) incorrectly allocated some of 
its losses to the Multiemployer Program; and (13) had not fully 
implemented its new computerized premium accounting system, 
disaster recovery plan, and software changes.

Pension COLAs (GAO/HEHS-95-219R, Aug. 11, 1995)

    GAO provided information on the frequency and 
characteristics of cost-of-living adjustments (COLA) that 
retirees receive from public and private pension plans. GAO 
noted that (1) Social Security and federal pension plans 
incorporate automatic, annual COLAs; (2) over half the states 
reporting to the Bureau of Labor Statistics provide automatic 
COLAs annually, generally capped between 3 and 5 percent; (3) 
the remaining states mainly provide ad hoc COLAs, although the 
number of states granting ad hoc COLAs has gradually decreased 
since 1987, due to lower inflation; (4) ad hoc COLAs in private 
pension plans occur less frequently than automatic COLAs in the 
public sector, and the plans often specify a maximum increase; 
(5) a number of factors, such as union negotiations, affect 
employers' decisions to provide COLA increases; (6) COLA 
provisions vary widely among industries, ranging from 3 percent 
of pension plans in the retail sector to over 60 percent in the 
transportation industry; and (7) ad hoc adjustments to private 
sector pension benefits have declined in recent years from over 
50 percent to under 10 percent of plans.

Private Pensions: Most Employers That Offer Pensions Use Defined 
        Contribution Plans (GAO/GGD-97-1, Oct. 3, 1996)

    In response to congressional interest in possibly changing 
the structure of federal employee retirement plans, this report 
provides information on the approaches that private sector 
employers are using to provide their employees with retirement 
benefits and the extent to which these approaches may be 
changing. GAO describes (1) the numbers and types of pension 
plans sponsored nationwide by private employers during 1984 to 
1993, (2) the proportions of total contributions made to these 
plans by employers and employees, (3) the average 
administrative expense for the plans, and (4) the explanations 
provided in retirement literature on why employers might decide 
to sponsor a particular type of pension plan.

Proposed Pension Reversions (GAO/HEHS-96-54R, Oct. 24, 1995)

    Pursuant to a congressional request, GAO provided 
information on pension plan underfunding, focusing on a 
proposed legislative provision that would allow companies to 
transfer excess assets out of their defined benefit pension 
plans for any purpose. GAO noted that (1) current and 
termination liabilities are measures of liabilities that a plan 
has accrued as of its valuation date, and each relies on 
different assumptions and yields very different estimates; (2) 
plans that are significantly funded over their current 
liability can lose plan funding rapidly due to bankruptcy, 
early retirements, or a decline in interest rates; (3) 
participants can lose benefits when a plan is terminated 
because the Pension Benefit Guaranty Corporation (PBGC) 
generally does not insure all benefit amounts; (4) companies 
may not transfer or obtain excess assets from a defined benefit 
plan under current law, but some transfers may be permissible 
if the plans merge and participants' benefits are not reduced; 
(5) it is unclear whether the transfer of excess plan assets 
would release capital for investment; and (6) although the 
proposed provision would allow withdrawal of overfunded assets, 
plan sponsors may be required to make larger cash contributions 
in the future.

Public Pensions: Section 457 Plans Pose Greater Risk Than Other 
        Supplemental Plans (GAO/HEHS-96-38, Apr. 30, 1996)

    Millions of state and local government employees are trying 
to increase their future retirement benefits by deferring some 
of their wages to supplemental pension plans, known as salary 
reduction arrangements or plans. The amount deferred or 
contributed to these plans, however, may be at risk. Recent 
media stories have recounted instances of imprudent investment, 
improper use of plan funds by sponsors, and possible seizure of 
plan funds by sponsoring governments' creditors. This report 
examines the risks of financial loss inherent in such plans and 
discusses whether the provisions of such plans treat 
participants comparably. See also Public Pensions: Summary of 
Federal Pension Plan Data (GAO/AIMD-96-6, Feb. 16, 1996) and 
Public Pensions: State and Local Government Contributions to 
Underfunded Plans (GAO/HEHS-96-56, Mar. 14, 1996).

Public Pensions: State and Local Government Contributions to 
        Underfunded Plans (GAO/HEHS-96-56, Mar. 14, 1996)

    State and local governments with underfunded pension plans 
risk tough budget choices in the future if they do not make 
progress toward full funding. Their taxpayers will face a 
liability for benefits earned by current and former government 
workers, forcing these governments to choose between reducing 
future pension benefits or raising taxes. Funding of state and 
local pension plans has improved significantly since the 1970s. 
After adjusting for inflation, the amount of the unfunded 
liability has been cut in half. Still, in 1992, 75 percent of 
state and local government pension plans in the Public Pension 
Coordinating Council survey were underfunded; 38 percent were 
less than 80 percent funded. Sponsors of slightly more than 
half of the plans in the survey made contributions on schedule 
to pay off any unfunded liability. One-third of the pension 
plans, however, were underfunded in 1992 and were not receiving 
the actuarially required sponsor contributions. Of all plans 
with complete data, one-fifth were underfunded and were not 
receiving full contributions in both 1990 and 1992. See also 
Public Pensions: Summary of Federal Pension Plan Data (GAO/
AIMD-96-6, Feb. 16, 1996) and Public Pensions: Section 457 
Plans Pose Greater Risk Than Other Supplemental Plans (GAO/
HEHS-96-38, Apr. 30, 1996).

Public Pensions: Summary of Federal Pension Plan Data (GAO/AIMD-96-6, 
        Feb. 16, 1996)

    This report--one in a series of three reports on the status 
of public pension plan funding--provides summary data on 
federal government pension plans. The other two reports in the 
series address state and local government pension plans. GAO 
focuses on federally sponsored defined benefit and defined 
contribution plans. See also Public Pensions: State and Local 
Government Contributions to Underfunded Plans (GAO/HEHS-96-56, 
Mar. 14, 1996) and Public Pensions: Section 457 Plans Pose 
Greater Risk Than Other Supplemental Plans (GAO/HEHS-96-38, 
Apr. 30, 1996).

Reemployment of Buyout Recipients (GAO/GGD-96-102R, June 14, 1996)

    As part of its downsizing efforts, the federal government 
has offered employees of various federal agencies incentive 
payments, or buyouts, to leave federal employment through 
voluntary separations. Pursuant to a congressional request, GAO 
reviewed agencies' use of buyout authority and whether agencies 
subsequently reemployed buyout recipients as civil servants or 
government contractors. Using the Office of Personnel 
Management's (OPM) data, GAO determined that governmentwide 
agencies paid 87,743 buyouts from January 1993 through June 30, 
1995. However, GAO could not determine the total number of 
employees who were eligible to receive buyouts. Of the 87,743 
buyout recipients, agencies rehired 394 as civil servants. 
However, it is not clear how many were reemployed as federal 
contractors. The limited available data suggest the practice 
was not used extensively. Reemployment of buyout recipients as 
civil servants or contractors is not prohibited, but, under 
certain circumstances, buyout recipients are required to take 
steps to satisfy reemployment provisions. Of the 394 buyout 
recipients reemployed as civil servants, GAO identified 68 
cases in which these reemployment provisions applied. Finally, 
through a survey of National Aeronautics and Space 
Administration and Department of Transportation units, 
respondents reported that they had management controls designed 
to prevent reemployment abuses.

Service Corps of Retired Executives (GAO/RCED-95-127R, Mar. 10, 1995)

    GAO provided information on the Small Business 
Administration's Service Corps of Retired Executives Program 
(SCORE), focusing on how SCORE (1) determines budget 
allocations for regional locations; (2) officials view the 
fairness of the allocations; and (3) meets the needs of rural 
communities. GAO noted that (1) SCORE regional budget 
allocations are based primarily on historical trends in actual 
expenditures; (2) SCORE officials stated that their areas 
receive a fair share of SCORE funds, given the small size of 
the total budget; and (3) to meet the needs of rural 
communities, SCORE uses approaches such as waiving the 
guidelines for the number of volunteers needed to start a 
chapter and using persons or funds from larger chapters to 
subsidize rural chapters.

Social Security Administration: Effective Leadership Needed to Meet 
        Daunting Challenges (GAO/HEHS-96-196, Sept. 12, 1996)

    With a staff of 64,000, SSA runs the nation's largest 
federal program--Social Security--as well as the largest cash 
welfare program--the Supplemental Security Income (SSI) 
program. SSA's expenditures totaled $363 billion in fiscal year 
1995, nearly one-fourth of the $1.5 trillion federal budget. 
SSA programs touch the lives of nearly every American, 
providing benefits to the retired, the disabled, and their 
dependents and survivors. This report, which is based on July 
1995 testimony before the Congress (GAO/T-OCG-96-7), discusses 
SSA's progress in meeting the challenges of managing for 
results and accountability; funding future retirement benefits; 
rethinking SSI fraud, waste, and abuse; handling increasing 
workloads with fewer resources; and establishing effective 
leadership.

Social Security Administration: Leadership Challenges Accompany 
        Transition to an Independent Agency (GAO/HEHS-95-59, Feb. 15, 
        1995)

    In 1994, the Congress passed legislation making the Social 
Security Administration (SSA) an independent agency. As part of 
the transition, GAO was required to evaluate the interagency 
agreement for transferring personnel and resources from HHS to 
SSA. GAO concluded that the two agencies have developed an 
acceptable methodology for identifying the functions; 
personnel; and other resources, such as furniture and computer 
equipment, to be transferred to an independent SSA. They have 
also made good progress toward completing the initiatives 
necessary for SSA to be a fully functional independent agency 
by March 31, 1995. However, SSA will continue to face serious 
policy and management challenges, including the long-range 
shortfall in funds to pay future Social Security benefits. 
Also, questions have been raised by GAO and others about the 
future growth of the Disability Insurance (DI) program and 
recent increases in Supplemental Security Income (SSI) 
benefits.

Social Security: Telephone Access Enhanced at Field Offices Under 
        Demonstration Project (GAO/HEHS-96-70, Feb. 23, 1996)

    The Social Security Administration (SSA) runs a nationwide 
toll-free telephone number and is testing enhanced local office 
telephone service at selected offices. In February 1995, SSA 
began installing new telephone equipment, called automated 
attendant and voice mail, at 30 of its 800 nationwide field 
offices that list their telephone numbers in local telephone 
directories. The equipment was installed in different 
configurations. Telephone access--calls reaching an SSA 
employee with the caller spending less than 2 minutes on hold--
improved 23 percent under one of the configurations being 
tested by SSA. In addition, busy signals dropped by more than 
55 percent. Staffing, however, did not increase, and many 
callers reaching SSA did spend some time on hold before 
reaching an SSA representative. SSA field office staff viewed 
the installation of voice mail equipment at their desks as 
having a very positive effect on office efficiency and public 
service. SSA has not yet completed its two internal evaluations 
of the demonstration project. GAO concludes that the technology 
tested in the demonstration projects has the potential to 
further SSA's public service goals. Public reaction and the 
effect on operations, however, will need to be considered as 
SSA weighs the costs and the benefits of this technology.

Social Security: Union Activity at the Social Security Administration 
        (GAO/HEHS-97-3, Oct. 2, 1996)

    The Social Security Administration (SSA), like other 
federal agencies and some private sector firms, pays for 
approved time spent by its employees on union activities. SSA 
has a special fiduciary responsibility to effectively manage 
and maintain the integrity of the social security trust funds 
from which most of these expenses are paid. In a time of 
shrinking budgets, it is crucial that SSA, as well as other 
agencies, evaluate how resources are being spent and have 
reliable monitoring systems to support this evaluation. To 
ensure accurate tracking of time spent on union activities and 
the staff conducting these activities, SSA has developed and is 
testing a new time-reporting system for its field offices and 
teleservice centers. GAO believes that the new system should be 
implemented agencywide. With an improved agencywide system, SSA 
management should have better information on where its money is 
being spent.

SSA Benefit Statements: Well Received by the Public But Difficult to 
        Comprehend (GAO/HEHS-97-19, Dec. 5, 1996)

    SSA in 1995 began sending statements--called Personal 
Earnings and Benefit Estimate Statements--automatically to 
workers who had reached age 60. By fiscal year 2000, these 
statements will reach an estimated 123 million people 
annually--almost every U.S. worker aged 25 and older. These 
six-page statements provide workers with information on their 
yearly earnings on record at SSA, information on their 
eligibility for social security retirement and other benefits, 
and estimates of these benefits. Experts agree that SSA's 
approach is generally reasonable, and feedback suggests that 
the public generally finds the statements to be helpful in 
retirement planning. However, GAO believes that the statements 
could benefit from extensive revisions. Specifically, the 
statements need a better layout and design and simpler 
explanations. SSA will need to start now to complete these 
changes by its 1999 redesign target date because the agency 
will require time to collect data and test alternatives.

SSA Disability: Program Redesign Necessary to Encourage Return to Work 
        (GAO/HEHS-96-62, Apr. 24, 1996)

    During the past decade, the number of persons receiving 
benefits from Social Security's DI and SSI programs increased 
70 percent because of program changes and economic and 
demographic factors. These programs, which provide assistance 
to persons with disabilities until they return to work, if that 
is possible, provided $53 billion in cash benefits to 7.2 
million people in 1994. Advances in technology, such as 
standing wheelchairs and synthetic voice systems, and the 
medical management of some physical and mental disabilities 
have allowed some persons to work. Moreover, there has been a 
greater trend toward inclusion of and participation by people 
with disabilities in the mainstream of society. Yet both 
programs have done little to identify recipients who might 
benefit from rehabilitation and employment assistance and 
ultimately return to work.

SSA Overpayment Recovery (GAO/HEHS-96-104R, Apr. 30, 1996)

    Pursuant to a congressional request, GAO reviewed how SSA 
recovers overpayments of benefits. GAO found that (1) the 
amount of SSI, RSI, and DI payments that SSA withholds to 
recoup overpayments is not upwardly adjusted with cost-of-
living increases in the many cases in which the withholding is 
based on a fixed dollar amount negotiated with the beneficiary, 
as opposed to a fixed percentage of the recipient's monthly 
income or monthly benefit amount; (2) basing the withholding on 
a percentage instead of a dollar amount would accelerate the 
recovery of overpayments without imposing an undue burden on 
recipients or causing excessive administrative costs; (3) 
accelerating recoveries while recipients are still receiving 
benefits improves the chance of collecting overpayments; (4) 
SSA administrative costs would likely increase only in the 
first year of implementation; and (5) the cost of notifying 
recipients of the new withholding procedures would be 
negligible, because SSA already notifies recipients when 
overpayments occur.

Social Security: Issues Involving Benefit Equity for Working Women 
        (GAO/HEHS-96-55, Apr. 10, 1996)

    When the social security program was established in the 
1930s, less than 15 percent of married women held paying jobs 
outside the home; today, about 60 percent of married women are 
paid workers. Despite the movement of women into the labor 
market, the social security benefit structure has remained 
essentially unchanged over the years. The fairness of the 
benefit structure has come under increasing scrutiny, 
especially as it affects women who have earned benefits in 
their own right. For example, a two-earner couple will receive 
lower combined benefits in retirement than an otherwise 
identical one-earner couple. And, a married woman who works and 
pays social security taxes might not, because of the dual 
entitlement limitation, receive higher benefits than if she had 
never worked and received only a spousal benefit. Several 
proposals seek to remedy these inequities. These include two 
broad proposals--``earnings sharing'' and a ``double-decker'' 
plan--and several narrower proposals, such as reducing spousal 
benefits. None of the measures has been adopted, however, 
partly because they would either boost program costs or reduce 
benefits for some beneficiaries. Their enactment could also 
impose a large administrative burden on SSA.

Social Security Disability: Backlog Reduction Efforts Under Way; 
        Significant Challenges Remain (GAO/HEHS-96-87, July 11, 1996)

    SSA runs the nation's largest programs providing cash 
benefits to people with severe long-term disabilities. The 
number of persons receiving either Disability Insurance (DI) or 
SSI benefits has soared during the past decade. At the same 
time, SSA has struggled to deal with unprecedented growth in 
appeals of its disability decisions and the resulting backlog 
of cases awaiting hearing decisions. Processing delays stemming 
from a backlog of more than half a million appealed cases have 
created hardships for disability claimants, who often wait more 
than a year for final disability decisions. This report 
discusses (1) factors contributing to the growth in appealed 
cases, (2) SSA initiatives to reduce the backlog, and (3) long-
term steps that need to be taken to make the disability appeals 
process more timely and efficient.

Social Security Trust Funds (GAO/AIMD-96-30R, Dec. 12, 1995)

    Pursuant to a congressional request, GAO reviewed the 
Secretary of the Treasury's actions during the 1995 debt 
ceiling crisis, focusing on whether the Department of the 
Treasury followed normal investment and redemption policies 
regarding the Social Security trust funds. GAO noted that 
Treasury records show that the Secretary followed normal 
investment and redemption policies for all transactions 
affecting the trust funds between November 1, 1995, and 
December 8, 1995.

SSI Disability Issues (GAO/HEHS-95-154R, May 11, 1995)

    GAO provided information on several SSI issues related to 
(1) SSI outreach activities; (2) the status of continuing 
disability reviews involving interpreter fraud; (3) the 
function of referral and monitoring agencies (RMA) in 
overseeing the drug addict and alcoholic populations; and (4) 
the number of drug and alcohol addicts in treatment. GAO noted 
that (1) very few SSI outreach activities are targeted to drug 
addicts and alcoholics; (2) SSA has not requested funding for 
SSI outreach for fiscal years 1993 through 1996; (3) in two 
states, SSA continuing disability reviews are yielding a high 
rate of initial benefit terminations, of which about 60 percent 
have been appealed; (4) SSA is developing an interpreter 
database to understand the extent of the fraud problem; (5) 
RMAs assess beneficiaries' treatment needs, make treatment 
referrals, monitor beneficiaries' compliance with treatment, 
and report their compliance status to SSA; (6) RMAs do not 
conduct SSI outreach activities; (7) only 1 in 6 addicted 
beneficiaries are in required treatment, mainly due to the lack 
of RMA funding to monitor beneficiaries' treatment; and (8) in 
fiscal year 1996, the administration is requesting $195 million 
for RMA monitoring activities, which is a significant increase 
over 1990 through 1993 levels.

Supplemental Security Income: Administrative and Program Savings 
        Possible by Directly Accessing State Data (GAO/HEHS-96-163, 
        Aug. 29, 1996)

    The Supplemental Security Income program, which provides 
cash benefits to the aged, the blind, and the disabled, could 
be run more efficiently. More importantly, millions of dollars 
in overpayments could be prevented or detected quickly if 
information were available on-line during eligibility 
assessments. GAO estimates that direct on-line access to state 
computerized income information could have prevented or quickly 
detected more than $131 million in overpayments caused by 
unreported or underreported income nationwide in one 12-month 
period. However, in SSA field offices where direct access to 
computerized state information has been implemented, SSA claims 
representatives did not use it to detect overpayments. The 
claims representatives did use it to process claims more 
efficiently, and SSA's preliminary results have shown that its 
use has reduced administrative expenses. Establishing on-line 
access between SSA field offices and state agency databases 
would require only minimal computer programming in most states; 
some states would need additional hardware, such as computer 
lines.

Supplemental Security Income: Growth and Changes in Recipient 
        Population Call for Reexamining Program (GAO/HEHS-95-137, July 
        7, 1995)

    The SSI program is the largest cash assistance program for 
the poor and one of the fastest growing entitlement programs; 
program costs have risen 20 percent annually during the last 4 
years. SSI provides means-tested income support payments to 
aged, blind, or disabled persons. Last year, more than 6 
million people received about $25 billion in federal and state 
benefits. In response to SSI's rapid growth, the Congress 
passed legislation limiting drug addicts' benefits, and this 
year it is considering further restrictions for these 
recipients as well as for children and noncitizens. This report 
provides an overview of the SSI program and its recent history. 
Specifically, it examines factors contributing to caseload 
growth and changes in the characteristics of SSI recipients.

Supplemental Security Income: SSA Efforts Fall Short in Correcting 
        Erroneous Payments to Prisoners (GAO/HEHS-96-152, Aug. 30, 
        1996)

    Despite SSA procedures to detect supplemental security 
income recipients in county and local jails, GAO found that $5 
million had been erroneously paid to prisoners in the jail 
systems it reviewed. SSA had been unaware of many of these 
payments and, therefore, had made no attempt to recover them. 
Various factors contributed to these payments. First, SSA field 
offices have not been obtaining information regularly on 
prisoners in county and local jails. Second, the supplemental 
security income recipient--or the person or organization 
designated to receive payments on the recipient's behalf--has 
not been reporting the incarceration, as required. Third, SSA 
sometimes falls short in periodically reviewing--either by mail 
or interview--a recipient's continued financial eligibility for 
supplemental security income. Under a new SSA initiative, field 
offices will be required to obtain prisoner information from 
county and local jails, and SSA plans to monitor field office 
compliance with this requirement. It is too early to tell, 
however, whether this initiative will be successful.

Supplemental Security Income: Some Recipients Transfer Valuable 
        Resources to Qualify for Benefits (GAO/HEHS-96-79, Apr. 30, 
        1996)

    Existing law does not prohibit people from transferring 
resources to qualify for benefits under the SSI program--the 
largest cash assistance program for the poor and one of the 
fastest growing entitlement programs. Between 1990 and 1994, 
3,505 SSI recipients transferred resources, including cash, 
houses, land, and other items, valued at $74 million. Reported 
resource transfer values ranged as high as $800,000; most 
transfers fell between $10,000 and $25,000. The total amount of 
resources transferred, however, is likely to be larger than 
GAO's estimate because SSA is not required to verify the 
accuracy of resource transfer information, which is self-
reported by individuals. Moreover, because the information is 
self-reported, SSA is unlikely to detect unreported transfers. 
Without a transfer-of-resource restriction, GAO estimated the 
3,505 SSI recipients who reported transferring resources to 
qualify for benefits would receive nearly $8 million in SSI 
benefits during the 24 months after they transferred resources. 
Many of these recipients also could have received Medicaid 
acute-care benefits at an annual value of between $2,800 and 
$5,300 per recipient. GAO estimated that from 1990 through 
1995, SSA could have saved $14.6 million with a transfer-of-
resource restriction similar to that used for Medicaid which 
delays individuals' date of eligibility for benefits. Such a 
restriction could also boost the public's confidence in the 
program's integrity.

Thrift Savings Plan (GAO/HEHS-96-66R, Nov. 14, 1995)

    Pursuant to a congressional request, GAO reviewed (1) why 
the Congress replaced CSRS with FERS; and (2) the Federal 
Retirement Thrift Investment Board's response to the GAO 
recommendation concerning the inclusion of participant 
information on contributions to TSP retirement accounts. GAO 
noted that (1) the Congress replaced CSRS with FERS to provide 
federal employees with a retirement benefit that included a 
Social Security payment, a basic FERS annuity, and payments 
from amounts accumulated in a TSP account; and (2) the board 
did not implement the recommendation because it believed that 
it would be violating its fiduciary duty to TSP participants 
and misusing its funds.

Welfare Benefits: Potential to Recover Hundreds of Millions More in 
        Overpayments (GAO/HEHS-95-111, June 20, 1995)

    Under welfare reform legislation being considered by the 
Congress, resources for helping poor families may become 
increasingly limited--making it critical that only those who 
are eligible for benefits receive them. In 1992, benefit 
overpayments in three welfare programs--Aid to Families With 
Dependent Children (AFDC), Food Stamps, and Medicaid--totaled 
$4.7 billion, or about 4 percent of the total benefits paid. 
Moreover, nationwide recovery of these benefits was relatively 
low. This report discusses (1) what states are doing to recover 
benefit overpayments, what the more effective practices are, 
and what states could do better and (2) what the federal 
government could do to help states recover more overpayments.

Welfare Programs: Opportunities to Consolidate and Increase Program 
        Efficiencies (GAO/HEHS-95-139, May 31, 1995)

    The federal government provides billions of dollars in 
public assistance each year through an inefficient welfare 
system that is increasingly cumbersome for program 
administrators to manage and difficult for eligible clients to 
access. Program consolidation may be one strategy to reduce the 
inefficiency of the current system of overlapping and 
fragmented programs. This report (1) describes low-income 
families' participation in multiple welfare programs, (2) 
examines program inefficiencies, such as program overlap and 
fragmentation, and (3) identifies issues to consider in 
deciding whether and to what extent to consolidate welfare 
issues. Regardless of how the welfare system is restructured, 
ensuring that federal funds are used efficiently and that 
programs focus on outcomes remains important. Without a focus 
on outcomes, concerns about the effectiveness of welfare 
programs will not be adequately addressed.

Welfare Reform: Implications of Proposals on Legal Immigrants Benefits 
        (GAO/HEHS-95-58, Feb. 2, 1995)

    GAO found that the percentage of immigrants receiving 
public assistance--specifically SSI or AFDC--is higher than the 
percentage of citizens receiving these benefits. Six percent of 
all immigrants receive benefits compared with 3.4 percent of 
all citizens. Most immigrant recipients live in four states: 
California, New York, Florida, and Texas; more than one-half of 
all immigrant recipients live in California. Between 1983 and 
1993, the number of immigrants receiving SSI more than 
quadrupled, increasing from 151,000 to 683,000. During this 
period, immigrants grew from about 4 percent of all SSI 
recipients to more than 11 percent. As a percentage of all 
adult AFDC recipients, immigrants grew from about 5 percent to 
8 percent. In all, immigrants received an estimated $3.3 
billion in SSI benefits and $1.2 billion in AFDC benefits in 
1993. Most immigrant recipients are lawful permanent residents 
or refugees, but other characteristics of immigrants receiving 
SSI and AFDC vary. For example, the number of immigrants 
receiving SSI aged benefits--available to those 65 years and 
older--has increased dramatically. According to the 
Congressional Budget Office, a welfare reform proposal now 
before the Congress (H.R. 4) would save $9.2 billion from the 
SSI program and $1 billion from the AFDC program over 4 years. 
GAO estimates that 522,000 SSI recipients and 492,000 AFDC 
recipients would become ineligible for benefits under H.R. 4.

401(k) Pension Plans: Many Take Advantage of Opportunity to Ensure 
        Adequate Retirement Income (GAO/HEHS-96-176, Aug. 2, 1996)

    Many workers fill the gap between social security and an 
adequate retirement income with pension benefits, and one in 
four workers with pension coverage participates in a 401(k) 
program. GAO found, among other survey results, that workers 
with higher incomes and college educations tended to contribute 
more to 401(k) plans than others and women tend to invest more 
conservatively than do men. Also, higher-income workers and 
better-educated workers with 401(k) pension plans tend to 
contribute a larger percentage of their salaries to their 
pension accounts and to invest their pension funds in higher-
yielding assets than do other 401(k) plan participants. 
Consequently, although many workers will have enough retirement 
income, some workers, especially those with less education and 
lower incomes, risk inadequate retirement incomes.

                        veterans' and dod issues

Defense Health Care: Effects of Mandated Cost Sharing on Uniformed 
        Services Treatment Facilities Likely to Be Minor (GAO/HEHS-96-
        141, May 13, 1996)

    The establishment of uniform benefits and cost sharing for 
DOD beneficiaries is a key component of the TRICARE program--
DOD's new nationwide managed health care program--and is 
something that GAO and others have long advocated. Such 
uniformity would, in GAO's view, eliminate inequities and 
confusion that now exist among beneficiaries of military health 
plans. Although adopting TRICARE cost shares may cause some 
minor adverse selection for the Uniformed Services Treatment 
Facilities (USTF), there should be no lasting negative 
financial impact on the USTFs. Moreover, the new cost shares, 
which are similar to HMOs, are appropriate for the risks to be 
borne by the USTFs and will likely make the USTF population 
more similar to DOD's general beneficiary population. DOD's 
current USTF capitation methodology takes into account and 
allows for adjusted reimbursement levels for such higher costs 
that result from changes in the enrollee cost shares and 
population characteristics.

Defense Health Care: Issues and Challenges Confronting Military 
        Medicine (GAO/HEHS-95-104, Mar. 22, 1995)

    DOD's military health care system provides medical services 
and support both in peacetime and in war to members of the 
armed forces and their families, as well as to retirees and 
survivors. Post-Cold War planning scenarios, efforts to reduce 
the overall size of the military, federal budget cuts, and base 
closures and realignments have focused attention on the size of 
DOD's health care system, its makeup, how it operates, whom it 
serves, and whether its missions can be carried out in a more 
cost-effective way. This report describes the Military Health 
Services System, past problems faced by DOD as it ran the 
system and efforts to solve those problems, and the management 
challenges now confronting DOD. GAO summarized this report in 
testimony before the Congress; see Defense Health Care: DOD's 
Managed Care Program Continues to Face Challenges (GAO/T-HEHS-
95-117, Mar. 28, 1995), by David P. Baine, Director of Federal 
Health Care Delivery Issues, before the Subcommittee on 
Military Personnel, House Committee on National Security.

Defense Health Care: Medicare Costs and Other Issues May Affect 
        Uniformed Services Treatment Facilities' Future (GAO/HEHS-96-
        124, May 17, 1996)

    Since fiscal year 1994, the Congress has appropriated 
nearly $1 billion for USTF to deliver health care to what now 
totals 124,000 beneficiaries. In recent years, the Congress has 
grown concerned about the rising cost to treat USTF members, in 
part because some members retain dual eligibility and 
unrestricted access to other government health care services, 
such as Medicare and DOD hospitals. The Congress directed DOD 
in 1991 to reform the USTF program by introducing a managed 
care program. As DOD begins to implement its new nationwide 
managed care program--TRICARE--questions about the program's 
future persist. This report discusses (1) whether unnecessary 
costs result from USTF members' use of other federally funded 
health care sources and (2) other issues that need to be 
considered as the Congress deliberates reauthorization of the 
USTF program.

Defense Health Care: New Managed Care Plan Progressing, But Cost and 
        Performance Issues Remain (GAO/HEHS-96-128, June 14, 1996)

    The DOD health care system, which costs $15 billion 
annually, is undergoing sweeping reform. Through TRICARE, DOD 
is trying to improve access to care among its 8.3 million 
beneficiaries while containing costs. How well DOD implements 
and operates TRICARE may define and shape military medicine for 
years to come. Because of TRICARE's complexity, scale, and 
impact on beneficiaries, GAO reviewed the program, focusing on 
(1) whether DOD's experiences with early implementation yielded 
the expected results, (2) how early outcomes may affect costs, 
and (3) whether DOD has defined and is capturing data needed to 
manage and assess TRICARE's performance. GAO concludes that 
despite initial confusion among beneficiaries arising from 
marketing and education problems, as well as problems with the 
compatibility of computer systems, early implementation of 
TRICARE is progressing consistent with congressional and DOD 
goals. However, the success of DOD's efforts to implement 
resource-sharing agreements and utilization management is 
critical to containing health care costs. DOD also needs to 
gather enrollment and performance data so that it and the 
Congress can assess TRICARE's success in the future.

Defense Health Care: Problems with Medical Care Overseas Are Being 
        Addressed (GAO/HEHS-95-156, July 12, 1995)

    The American military presence in Europe has declined 
dramatically since 1989. The active duty population has been 
cut by 57 percent--from 332,000 to 138,000. At the same time, 
the military health services systems has also been 
substantially reduced. Many beneficiaries have expressed 
concern about their reduced access to health care from military 
medical facilities overseas and are dissatisfied with the care 
they receive from host nation providers. This report discusses 
(1) the availability of health care in military facilities, (2) 
any obstacles to providing that care, (3) the experiences of 
beneficiaries who have used host nation providers as an 
alternative to military health care, and (4) whether DOD is 
addressing service delivery problems and beneficiary concerns. 
To develop this information, GAO visited 15 military 
communities in Germany and northern Italy, where many of the 
beneficiary complaints about medical and dental care 
originated.

Neoplasms in Persian Gulf Veterans (GAO/PEMD-96-15R, June 21, 1996)

    Pursuant to a congressional request, GAO reviewed 
Department of Veterans Affairs' (VA) data on the frequency of 
abnormal tissue growths among Persian Gulf War veterans and 
other military personnel. GAO noted that (1) VA data show that 
Persian Gulf War veterans have a neoplasm-diagnosis rate that 
is more than three times higher than that of nonwar veterans; 
(2) the higher neoplasm rate for war veterans may be due to 
causes other than service in the Persian Gulf, such as war 
veterans seeking VA hospital treatment more often than nonwar 
veterans; (3) the rate of surgical procedures for the two 
groups is not significantly different, which could mean that 
war veterans' neoplasms are not as serious as those diagnosed 
among nonwar veterans; and (4) analyzing alternative 
explanations for war veterans' neoplasm rates would require 
extensive statistical analysis and professional judgment.

Proposed VA Hospital at Travis Air Base (GAO/HEHS-95-268R, Sept. 19, 
        1995)

    GAO provided information on the proposed construction of a 
Department of Veterans Affairs (VA) hospital at Travis Air 
Force Base in Fairfield, California, focusing on (1) reasons 
that the project cost estimate was higher than VA originally 
proposed to the Congress and (2) where veterans living in the 
Travis facility target area currently receive medical care. GAO 
noted that (1) the project cost estimate increased because VA 
believed it needed to construct and renovate more space than 
originally anticipated; (2) many veterans in the Travis target 
area currently receive hospital care at VA medical centers in 
the northern California and Nevada areas; and (3) although 
veterans' use of VA medical centers decreased in fiscal years 
1992 and 1993, the reason for the decrease was unclear.

Readjustment Counseling Service: Vet Centers Address Multiple Client 
        Problems, But Improvement Is Needed (GAO/HEHS-96-113, July 17, 
        1996)

    VA operates 205 community-based facilities known as Vet 
Centers to help veterans make a successful transition from 
military to civilian life. Vet Center counselors reported 
visiting with about 138,000 veterans during fiscal year 1995, 
84,000 of whom were new to Vet Centers. Most veterans do not 
establish long-term relationships with Vet Center counselors; 
however, those who do represent a core group who use services 
over extended periods for serious psychological problems, such 
as post-traumatic stress disorder. Other veterans usually visit 
Vet Center counselors only once or twice for social concerns, 
such as employment or benefit needs.

Substance Abuse Treatment: VA Programs Serve Psychologically and 
        Economically Disadvantaged Veterans (GAO/HEHS-97-6, Nov. 5, 
        1996)

    About 25 percent of all Department of Veterans Affairs (VA) 
patients discharged from inpatient settings in fiscal year 1995 
were diagnosed with alcohol or drug abuse problems. VA 
estimates that it spent $2 billion--or about 12 percent of its 
total health care budget in fiscal year 1995--to treat veterans 
with substance abuse disorders. The VA health care system is 
now evaluating what services to offer and where to provide 
them. VA's new organizational structure, called the Veterans 
Integrated Service Network, replaces VA's central office and 
regional structure with 22 networks of hospitals and clinics. 
VA expects this consolidation and realignment to boost 
efficiency by trimming management layers, eliminating 
duplicative medical services, and making better use of 
available public and private resources. This report provides 
information on the (1) characteristics of veterans who receive 
substance abuse treatment, (2) services that VA offers to 
veterans with substance abuse problems, (3) methods that VA 
uses to monitor the effectiveness of its substance abuse 
treatment programs, (4) community services available to 
veterans who suffer from substance abuse disorders, and (5) 
implications of changing VA's current methods for delivering 
substance abuse treatment.

VA Clinic Funding (GAO/HEHS-95-273R, Sept. 19, 1995)

    GAO provided information on how two VA medical centers 
financed their new free-standing primary care clinics to 
improve veterans' access to health care services. GAO noted 
that (1) the two centers have financed their 4 new clinics from 
savings derived from local management initiatives to improve 
operating efficiency; (2) the centers plan to open 10 more 
clinics over the next several years that will also be financed 
from other cost-saving initiatives; (3) the centers have 
contracted with predominantly rural clinics to provide primary 
care to veterans; (4) the yearly contract costs for the current 
and future clinics are expected to be less than $2 million; (5) 
cost savings have been derived from inpatient ward 
consolidations, patient utilization reviews, health education 
classes, service contract modifications, and staff reductions; 
and (6) the new clinics are expected to reduce veterans' use of 
fee-for-service private care and reimbursements for travel 
expenses to VA medical facilities.

VA Health Care: Better Data Needed to Effectively Use Limited Nursing 
        Home Resources (GAO/HEHS-97-27, Dec. 20, 1996)

    VA reported spending $1.6 billion in fiscal year 1995 on 
nursing home care for nearly 80,000 veterans--about 14 percent 
of the estimated demand by veterans for such care. VA provides 
nursing home care in its own facilities, contracts with 
community nursing homes, and pays state veterans' homes part of 
the cost to care for veterans. All veterans are eligible for 
nursing home care essentially on a first-come, first-served 
basis within VA's budget constraints. As the number of veterans 
aged 65 and older increases to 9.3 million by the year 2000, 
the demand for nursing home care will likely rise. The funds 
for VA nursing home care, however, are expected to be limited. 
This report provides information on the (1) distribution of 
veterans in VA, community, and state nursing homes; (2) costs 
to VA for these nursing homes; (3) factors affecting VA's use 
of community and state veterans' nursing homes; and (4) 
relative quality of the care provided by VA, community, and 
state veterans' homes.

VA Health Care: Effects of Facility Realignment on Construction Needs 
        Are Unknown (GAO/HEHS-96-19, Nov. 17, 1995)

    As part of the fiscal year 1996 budget, the President 
requested $524 million for major VA construction projects. 
These projects include the construction of two new VA medical 
facilities and major renovations at seven existing facilities. 
This report discusses how the projects are expected to benefit 
veterans and the relationships between the proposed projects 
and VA's recent efforts to realign all of its facilities into a 
new service network. GAO also discusses the potential effects 
of funding delays on VA's construction award dates and costs.

VA Health Care: Exploring Options to Improve Veterans' Access to VA 
        Facilities (GAO/HEHS-96-52, Feb. 6, 1996)

    Since its creation in 1930, VA's health care system has 
become one of the nation's largest networks of direct delivery 
health care providers, with 173 hospitals and 376 outpatient 
clinics nationwide. But because public and private health 
insurance programs have also grown, most veterans now have 
alternatives to VA health care. Many veterans indicate that 
they use private providers because they live too far from VA 
hospitals or outpatient clinics. VA has recently encouraged its 
facilities to improve veterans' access to VA health care. This 
report discusses (1) characteristics of recent users of VA 
medical facilities; (2) the geographic accessibility of VA and 
private medical facilities that provide standard benefits; and 
(3) options that VA facilities might want to consider to 
improve the accessibility of VA health care, such as locating 
new medical facilities closer to where veterans live and 
contracting with private providers.

VA Health Care: How Distance From VA Facilities Affects Veterans' Use 
        of VA Services (GAO/HEHS-96-31, Dec. 20, 1995)

    Living within 5 miles of a VA Hospital or outpatient clinic 
significantly increases the likelihood that veterans will use 
VA health care services. Although most veterans live within 25 
miles of a VA hospital or outpatient clinic, use of VA 
facilities declines significantly among veterans living more 
than 5 miles from a VA facility. Only about 11 percent of 
veterans live within 5 miles of a VA hospital providing acute 
medical and surgical care and 17 percent within 5 miles of a VA 
outpatient clinic. Use of VA health care services does not 
decline with distance as rapidly among veterans receiving VA 
compensation or pension payments. Even those veterans with a 
service-connected disability who live more than 100 miles from 
a VA outpatient clinic are more likely to avail themselves of 
VA outpatient services than are higher-income veterans with 
nonservice-connected disabilities who live within 5 miles of a 
VA outpatient clinic. Other factors that may contribute to 
differences in the use of VA services include broader 
eligibility and entitlement to outpatient care for service-
connected and low-income veterans, veterans' ages, and 
differences in available resources.

VA Health Care: Issues Affecting Eligibility Reform Efforts (GAO/HEHS-
        96-160, Sept. 11, 1996)

    Pursuant to a congressional request, GAO reviewed various 
proposals that would simplify and expand eligibility for 
veterans' health care benefits. GAO found that (1) eligibility 
requirements for veterans' health care benefits have become 
increasingly complex and a source of frustration to veterans, 
VA physicians, and administrators; (2) VA does not have a 
defined or uniform benefits package and cannot ensure the 
availability of covered services; (3) VA physicians sometimes 
must decide to either deny needy veterans noncovered services 
or ignore the law and provide the noncovered services free of 
charge; (4) VA health care eligibility reform could expand the 
types of services provided and allow veterans lacking 
supplemental insurance access to needed services; (5) the four 
legislative proposals reviewed could more than double the 
demand for VA outpatient services, cause VA to ration care, and 
force VA to seek larger appropriations to preserve its safety-
net mission; (6) alternative approaches including limiting the 
number of eligible veterans and range of benefits added or 
increasing cost sharing could preserve VA's ability to provide 
specialized services; (7) although the American Legion proposal 
incorporates all three of these approaches and is a basis for 
future reform proposals, changes need to be made to reduce the 
number of veterans covered, exempt VA from most federal 
contracting laws, and designate VA as a Medicare provider; and 
(8) one option to reduce the number of veterans who would be 
eligible under the proposal and target those veterans who have 
low incomes and lack supplemental insurance, would be to limit 
VA benefits for veterans with no service-related disabilities.

VA Health Care: Improving Veterans' Access Poses Financial and Mission-
        Related Challenges (GAO/HEHS-97-7, Oct. 25, 1996)

    VA runs one of the nation's largest health care delivery 
systems, including more than 170 hospitals and nearly 400 
clinics, over one-half of which are free-standing clinics. 
Veterans must often travel long distances, however, to receive 
care at these facilities. VA has a policy encouraging its 
hospitals to improve access to care for eligible veterans. As a 
result, many hospitals have either planned or established new, 
free-standing outpatient clinics, known as ``access points.'' 
Access points provide primary care to veterans and generally 
refer those needing specialized services or inpatient stays to 
VA hospitals. This report examines VA's policy for establishing 
access points. GAO discusses the legal, financial, and mission-
related implications of VA's efforts to establish access 
points.

VA Health Care: Need for Brevard Hospital Not Justified (GAO/HEHS-95-
        192, Aug. 29, 1995)

    VA assumed control of the former Naval Hospital in Orlando, 
Florida, in June 1995. VA plans to convert the hospital into a 
nursing home while continuing to operate an existing outpatient 
clinic. VA also plans to build a new hospital and nursing home 
in Brevard County, 50 miles from Orlando. GAO concludes that 
VA's conversion of the former Orlando Naval Hospital into a 
nursing home and construction of a new hospital and nursing 
home in Brevard County is not the most prudent and economical 
use of its resources. These construction projects are based on 
questionable planning assumptions that may result in the 
unneeded expenditure of federal dollars. Specifically, VA did 
not adequately consider the availability of hundreds of 
community nursing home beds and unused VA hospital beds as well 
as potential decreases in future demand for VA hospital beds. 
VA could achieve its goals in Central Florida by using existing 
capacity.

VA Health Care: Opportunities for Service Delivery Efficiencies Within 
        Existing Resources (GAO/HEHS-96-121, July 25, 1996)

    VA, which operates one of the nation's largest health care 
systems, faces increasing pressure to contain or reduce 
spending as part of governmentwide efforts to balance the 
budget. This report discusses ways VA could operate more 
efficiently and reduce the resources needed to meet the needs 
of veterans in what is commonly referred to as the mandatory 
care category. GAO addresses (1) VA's forecasts of future 
resource needs, (2) opportunities to run VA's system more 
efficiently, (3) differences between VA and the private sector 
in efficiency incentives, and (4) recent VA efforts to 
reorganize its health care system and create efficiency 
incentives. GAO concludes that successful implementation of a 
range of reforms, coupled with reduced demand for services, 
could save the VA health care system billions of dollars during 
the next 7 years. The success of these efforts, however, 
depends on introducing efficiency incentives at VA that have 
long existed in the private sector.

VA Health Care: Opportunities to Significantly Reduce Outpatient 
        Pharmacy Costs (GAO/HEHS-97-15, Oct. 11, 1996)

    All pharmacies run by VA provide medications and medical 
supplies that are available over the counter through other 
local outlets. The most frequently dispensed over-the-counter 
products include (1) medications, such as aspirin and insulin; 
(2) dietary supplements, including Sustacal and Ensure; and (3) 
medical supplies, such as alcohol prep pads, lancets, and 
glucose test strips. Unlike VA, public and private health plans 
cover few, if any, over-the-counter products for their 
beneficiaries. VA pharmacies dispensed over-the-counter 
products more than 15 million times during fiscal year 1995 at 
an estimated cost of $165 million, including handling costs of 
$48 million. VA recovered about $7 million through veterans' 
copayments, or about four percent of its total over-the-counter 
costs. Although many veterans shared a modest portion of the 
costs and some paid the full amount, most veterans paid 
nothing. GAO suggests several ways that VA could cut costs 
associated with dispensing over-the-counter products or boost 
revenues from copayments. First, VA could more narrowly define 
when to provide over-the-counter products. Second, VA could 
more efficiently dispense over-the-counter products and collect 
copayments. Third, VAfacilities could further reduce the number 
of over-the-counter products available to veterans on an outpatient 
basis. Finally, the Congress could expand copayment requirements.

VA Health Care: Physician Peer Review Identifies Quality of Care 
        Problems But Actions to Address Them Are Limited (GAO/HEHS-95-
        121, July 7, 1995)

    Physician peer review--physicians reviewing the work of 
other physicians--is crucial to ensuring that quality care is 
provided to patients. An essential element of peer review is 
management support for actions recommended by the peer review 
process. Without such support, peer review is meaningless 
because no action is taken on the peer reviewers' 
recommendations. This report examines the relationship between 
problem identification and problem resolution in VA physician 
peer review. GAO discusses (1) how the results of VA peer 
review are being used in reprivileging and disciplining doctors 
with performance problems; (2) what the impediments to 
effective peer review are; and (3) whether VA is taking steps 
to identify, follow up on, and report to state medical boards 
and the National Practitioner Data Bank on the actions of those 
physicians who are not performing in accordance with 
professional standards.

VA Health Care: Retargeting Needed to Better Meet Veterans' Changing 
        Needs (GAO/HEHS-95-39, Apr. 21, 1995)

    Many veterans have health care needs that are not 
adequately met through current health care programs, including 
VA's health care system. About one-third of the nation's 
homeless are veterans, nearly one-half of whom have serious 
mental problems, suffer from substance abuse, or both. The 
homeless have limited access to health care services and may 
not seek medical treatment. About 38 percent of male and 25 
percent of female Vietnam veterans with post-traumatic stress 
disorder have not sought treatment. About 91,000 low-income, 
uninsured veterans with no apparent health care options 
indicated in a 1987 VA survey that they had never used VA 
health facilities because they were unaware that they were 
eligible or they had concerns about the quality or 
accessibility of VA health care. VA cannot adequately address 
many of these health care needs because (1) it relies primarily 
on direct delivery of health care services in VA facilities, 
(2) its complex eligibility and entitlement provisions limit 
the services that veterans can obtain from VA facilities, and 
(3) space and resource limitations prevent eligible veterans 
from obtaining covered services. This report presents several 
options for restructuring VA's health care system to enable it 
to better meet the health care needs of veterans.

VA Savings Options (GAO/HEHS-95-165R, May 18, 1995)

    GAO reviewed several options for achieving budgetary 
savings in VA's health care system without adversely affecting 
the current level of services provided to low-income or 
disabled veterans. GAO noted that VA could achieve health care 
cost savings by (1) shifting care from VA hospitals to 
alternative settings, such as ambulatory care; (2) adopting 
state veterans' home charging policies; (3) authorizing estate 
recovery programs; (4) increasing copayments for health 
services; (5) reducing or eliminating care for veterans with 
high incomes; (6) delaying VA hospital construction projects; 
(7) increasing the use of community nursing homes as an 
alternative to new VA nursing homes; (8) strengthening 
veterans' income verification requirements; (9) changing VA 
dispensing practices for prescription drugs; (10) eliminating 
the dispensing of over-the-counter drugs; (11) recovering the 
full costs of services provided to nonveterans; (12) 
consolidating its mail service pharmacies; (13) consolidating 
underutilized services in nearby VA medical centers; (14) 
suspending locality-based pay adjustments; and (15) 
restructuring its ambulatory care system.

VA's Florida Network Planning (GAO/HEHS-95-160R, May 16, 1995)

    GAO addressed a series of questions related to VA's 
acquisition and intended use of the Naval Hospital in Orlando, 
Florida. GAO noted that (1) the VA Integrated Planning Model is 
based upon veterans' ages, average lengths of hospital stays, 
and number of patients treated in selected medical services; 
(2) VA used its model to project veterans' inpatient, 
outpatient, and nursing home needs for the year 2005; (3) VA 
did not consider the number of VA hospitals per square mile per 
capita in making its construction planning decisions for 
central Florida and significantly overestimated the number of 
hospital beds it would need in 1995; (4) it is unclear why 
Florida's hospital utilization rates are far below the national 
rates; (5) the veteran population is expected to decline in 
Florida and the nation over the next 15 years, while the total 
population in these areas is expected to increase; (6) there 
are waiting periods for certain elective medical treatments in 
central Florida VA hospitals due to staffing reductions; and 
(7) the VA Integrated Planning Model adequately accounts for 
the aging nature of the veteran population.

VA Health Care: Travis Hospital Construction Project Is Not Justified 
        (GAO/HEHS-96-198, Sept. 3, 1996)

    Pursuant to a congressional request, GAO provided 
information on VA's planned construction of an outpatient 
clinic and additional bed space at the David Grant Medical 
Center, focusing on (1) whether the project could be adequately 
justified and (2) whether there are cost-effective alternatives 
to planned hospital construction. GAO found that (1) VA planned 
construction of additional bed space and an outpatient clinic 
at Travis Air Base appears to be unjustified; (2) VA has not 
revised its construction plans to reflect the changes that have 
occurred in the health care marketplace and advances in medical 
practices and technology that have reduced the demand for 
hospital beds in northern California; (3) VA has not considered 
whether its construction plans will negatively affect 
surrounding community hospitals; (4) the veteran population in 
northern California is expected to decline by 25 percent 
between 1995 and 2010 and may not be large enough to support a 
new outpatient clinic; (5) VA is adequately meeting the health 
care needs of Northern California Health Care System veterans; 
(6) although VA clinics have experienced some space 
constraints, they have had no problem in placing veterans 
needing hospital care and using community hospitals for medical 
emergencies; (7) alternatives to VA construction plans include 
modifying VA hospital referral patterns, expanding use of other 
military and VA hospitals, granting VA more authority to 
contract for lower cost community hospital services, or 
allowing it to purchase a local Air Force hospital for use as a 
hospital or outpatient clinic; (8) VA Sierra Pacific Network 
officials are evaluating the best way to meet veterans' future 
health care needs, make better use of VA facilities, and 
increase the use of private and other public facilities; and 
(9) Congress' decision on whether to fund the construction plan 
will significantly affect the alternatives and options that can 
be implemented.

VA Health Care: Trends in Malpractice Claims Can Aid in Addressing 
        Quality of Care Problems (GAO/HEHS-96-24, Dec. 21, 1995)

    From fiscal year 1990 to fiscal year 1994, malpractice 
claims against VA medical centers have steadily increased, from 
678 to 978, with payments made to claimants totaling more than 
$200 million. In 1992, VA entered into an agreement with the 
Armed Forces Institute of Pathology (AFIP) to analyze trends in 
VA malpractice claims. VA's quality assurance staff, however, 
are making only limited use of the information being developed 
by AFIP. Although malpractice claim information is available 
from DOD, it is not comparable to the malpractice data that VA 
collects. The main reason for the lack of comparability is the 
absence of a standard data collection format. Nonetheless, GAO 
found that DOD information may be useful to VA to draw 
comparisons in areas in which malpractice claims are being 
generated, such as incidents related to surgery, diagnosis, and 
medication.

Veterans' Benefits: Basing Survivors' Compensation on Veterans' 
        Disability Is a Viable Option (GAO/HEHS-95-30, Mar. 6, 1995)

    In 1993, VA's Dependency and Indemnity Compensation (DIC) 
program paid benefits totaling $2.7 billion to about 276,000 
surviving spouses of service members who had died on active 
duty and surviving spouses of some disabled veterans. These 
benefits were paid under the Veterans' Benefits Act of 1992, 
which changed the basis for DIC benefits from the military rank 
of the deceased service member or veteran to a flat rate for 
all surviving spouses. This report (1) estimates DIC 
recipients' total income and determines the kinds and the 
amounts of benefits received from other programs, (2) 
determines the financial impact on surviving spouses of the 
deaths of totally disabled veterans and of veterans who were 
receiving supplemental payments because they had multiple 
severe disabilities and could not care for themselves, and (3) 
assesses alternative ways to set DIC benefits.

Veterans' Benefits: Better Assessments Needed to Guide Claims 
        Processing Improvements (GAO/HEHS-95-25, Jan. 13, 1995)

    Slow claims processing and poor customer service have long 
been recognized as serious problems for VA. As early as 1990, 
VA began encouraging its regional offices to improve their 
claims processing system, but processing times and backlogs 
have increased rather than decreased. At the end of fiscal year 
1994, nearly 500,000 claims awaited a VA decision. About 65,000 
of these were initial disability compensation claims. On 
average during fiscal year 1994, veterans waited more than 7 
months for their initial disability claims to be decided and, 
if approved, payments to begin; some waited much longer. This 
report discusses VA's current plans to change regional office 
claims processing and assesses VA's plans to determine the 
effectiveness of those changes.

Veterans' Benefits: Effective Interaction Needed Within VA to Address 
        Appeals Backlog (GAO/HEHS-95-190, Sept. 27, 1995)

    Veterans often wait months for VA to decide their 
compensation and pension claims. In addition, the 40,000 
veterans who appeal VA's decisions each year wait much longer--
more than 2 years for a final decision, according to agency 
officials. GAO found that VA's appeals process is increasingly 
bogged down, and the outlook for the future is not bright. 
Legislation and court rulings have expanded veterans' rights 
but also expanded VA's adjudication responsibilities. VA is 
having difficulty integrating these responsibilities into its 
already complex and unwieldy adjudication process. Since 1991, 
the number of appeals awaiting board action has risen by 175 
percent and the average processing time has increased by more 
than 50 percent. Studies by GAO, VA, and others have 
recommended the need for autonomous organizations in VA to work 
together to identify and resolve problems. Yet GAO found that 
problems continue to go unidentified and unresolved. Unless VA 
clearly defines its adjudication responsibilities, it will be 
unable to determine whether it has the resources to meet those 
responsibilities and whether new solutions may be needed, 
including laws amending VA's responsibilities or reconfiguring 
the department.

Veterans' Benefits: VA Can Prevent Millions in Compensation and Pension 
        Overpayments (GAO/HEHS-95-88, Apr. 28, 1995)

    Despite its responsibility to ensure accurate benefit 
payments, VA continues to overpay veterans and their survivors 
hundreds of millions of dollars in compensation and pension 
benefits each year. VA has the ability to prevent millions of 
dollars in overpayments but has not done so because it has not 
focused on prevention. For example, VA does not use available 
information, such as when beneficiaries will become eligible 
for Social Security benefits, to prevent the overpayments from 
occurring. Furthermore, VA does not systematically collect, 
analyze, and use information on the specific causes of 
overpayments that will help it target preventive efforts.

Veterans Compensation: Offset of DOD Separation Pay and VA Disability 
        Compensation (GAO/NSIAD-95-123, Apr. 3, 1995)

    DOD uses separation pay to induce people to serve in the 
military despite the risk of involuntary separation. The 
Congress authorized special separation pay to minimize the use 
of involuntary separations in the ongoing force drawdown. Pay 
offsets prevent service members from receiving dual 
compensation for a single period of service. Repealing offsets 
for separation and disability pay would cost the federal 
government an estimated $435 million for those service members 
who separated during fiscal years 1995 to 1999. A repeal would 
cost about $799 million if it was made retroactive to fiscal 
year 1992, when the special separation pay program began. 
Separation and disability pay offsets have not significantly 
undermined the voluntary separation incentive. According to 
DOD, the bulk of the drawdown since fiscal year 1992 has been 
accomplished through voluntary separations. DOD requires the 
services to inform separating service members about the offset.

Veterans' Health Care: Facilities' Resource Allocations Could Be More 
        Equitable (GAO/HEHS-96-48, Feb. 7, 1996)

    VA confronts the challenge of equitably allocating more 
than $16 billion in health care appropriations across a 
nationwide network of hospitals, clinics, and nursing homes. 
The challenge is made greater by the changing demographics of 
veterans. Although nationally the veteran population is 
declining, some veterans have relocated from the Northeast and 
the Midwest to southern and southwestern states in the past 
decade, offsetting veteran deaths in these states. VA has tried 
for years to implement an equitable resource allocation 
method--one that would link resources to facility workloads and 
foster efficiency. The need for such a system has become more 
urgent in recent years because of the demographic shift in 
veterans and the dramatic changes in health care resulting from 
increasingly limited resources. The resource allocation system 
can help VA achieve this goal by forecasting workload changes 
and providing comparative data on facilities' costs. 
Nonetheless, VA has not taken steps to overcome several 
barriers that can prevent it from acting on the data the system 
produces. If the system is to live up to its potential, several 
changes must be made, including linking resource allocation to 
VA's strategic plan, conducting a formal review and evaluation 
of facility cost variations, evaluating the basis for not 
allocating funds through resource planning and management, and 
using resource planning and management to overcome differences 
in veterans' access to care.

Veterans' Health Care: VA's Approaches to Meeting Veterans' Home Health 
        Care Needs (GAO/HEHS-96-68, Mar. 15, 1996)

    In fiscal year 1994, VA provided home health care to more 
than 40,000 veterans at a cost of $64 million to VA and 
millions more to Medicare. By providing them with home health 
care, VA allows these veterans to continue living at home and 
in their communities, rather than receive care in institutions. 
Veterans need home health care for various reasons. Some 
veterans have chronic health problems, such as heart disease, 
and require periodic visits, while others have been discharged 
from VA medical centers following surgery and need dressings 
changed or medications administered. The number of veterans 
needing home health care is expected to grow as the veteran 
population ages and as VA discharges patients from its 
hospitals to reduce the costs of hospitalization. This report 
provides information on (1) the characteristics and the 
services of the home health care programs that VA uses, (2) the 
available data on program costs, and (3) the way in which VA 
ensures that veterans receive quality service.

Vocational Rehabilitation: VA Continues to Place Few Disabled Veterans 
        in Jobs (GAO/HEHS-96-155, Sept. 3, 1996)

    Pursuant to a congressional request, GAO reviewed VA's 
vocational rehabilitation program, focusing on (1) the 
percentage of rehabilitated veterans, (2) the services 
provided, (3) the characteristics of clients served, (4) the 
cost of rehabilitation, and (5) VA's efforts to improve program 
effectiveness. GAO found that (1) the VA vocational 
rehabilitation program continues to focus on training and 
higher education, but it places few veterans in jobs; (2) from 
1991 to 1995, VA rehabilitated only about 8 percent of eligible 
veterans, while 51 percent continued to receive program 
services; (3) those program participants with a serious 
employment handicap declined from 40 percent to 29 percent over 
the last 5 years and those with a 10-to-20 percent disability 
increased from 34 percent to 42 percent; (4) over 90 percent of 
program applicants were male and had completed high school and 
almost 25 percent had taken some college courses; (5) VA spent, 
on average, about $20,000 on each employed veteran and $10,000 
on each program dropout; (6) over one-half of VA rehabilitation 
costs were for veterans' subsistence allowances; (7) state 
vocational rehabilitation agencies rehabilitated 37 percent of 
eligible individuals, while the remaining individuals continued 
to receive state program services; (8) the state vocational 
rehabilitation programs provided a wide range of rehabilitation 
services, and a majority of their clients were severely 
disabled; (9) almost 60 percent of the state program applicants 
were male and had completed high school, and 17 percent had 
completed some college courses; (10) the state programs spent, 
on average, about $3,000 on each rehabilitated client and about 
$2,000 on each dropout, none of which covered clients' living 
expenses; (11) VA established a design team in 1995 to improve 
program effectiveness, primarily by increasing the percentage 
of suitably employed veterans, improving staff job finding and 
placement skills, and developing a data management system; and 
(12) VA plans to implement these program changes in fiscal year 
1997.

VHA's Management Improvement Initiative (GAO/HEHS-96-191R, Aug. 30, 
        1996)

    Pursuant to a congressional request, GAO examined VA's 
progress in implementing management improvement initiatives to 
its health care system, administered by the Veterans Health 
Administration (VHA). GAO noted that (1) VA has concentrated 
its efforts on implementing those initiatives aimed at reducing 
centrally funded activities while deferring most of the more 
significant recommendations and (2) VA addressed the 1995 and 
1996 budget reductions mainly through across-the-board cuts. In 
an August 20, 1996, letter, VA commented to GAO that the agency 
is making considerable progress toward implementing those 
initiatives still appropriate.

                             [Enclosure II]

  Calendar Years 1995 and 1996 Testimonies on Issues Affecting Older 
                               Americans

    GAO testified 69 times before congressional committees 
during calendar years 1995 and 1996 on issues relating to older 
Americans. Of these testimonies, 2 were on education and 
employment, 35 on health, 3 on housing, 20 on income security, 
and 9 on veterans and DOD issues.

                    Education and Employment Issues

Department of Labor: Rethinking the Federal Role in Worker Protection 
        and Workforce Development (GAO/T-HEHS-95-125, Apr. 4, 1995)

    Although the Department of Labor has accomplished much over 
the years, its current approaches to worker protection are 
dated and frustrate both workers and employers. What is needed 
is greater service orientation, improved communication, greater 
access to compliance information, and expanded meaningful input 
into the standard-setting and enforcement processes. By 
developing alternative regulatory strategies that supplement 
and even replace its current labor-intensive compliance and 
enforcement approach, Labor can carry out its responsibilities 
in a less costly, more effective manner. Similarly, in the 
workforce development area, the government's job training 
effort consists of a patchwork of federal programs with similar 
goals, conflicting requirements, overlapping populations, and 
questionable outcomes. The roughly $20 billion appropriated in 
fiscal year 1995 for job training assistance to adults and out-
of-school youth was distributed to 15 agencies, including 
Labor, and supported 163 separate programs. This situation 
suggests that a major overhaul and consolidation of the 
programs are needed.

Senior Community Service Employment: Program Delivery Could Be Improved 
        Through Legislative and Administrative Actions (GAO/T-HEHS-96-
        57, Nov. 2, 1995)

    The Labor Department's Senior Community Service Employment 
Program finances part-time minimum-wage community service jobs 
for about 100,000 poor elderly Americans. GAO found that Labor 
distributes program funds through noncompetitive grants to 10 
national organizations, called national sponsors, and to state 
agencies. These national sponsors and state agencies, in turn, 
use the grant funds to finance local employment projects run by 
community service host agencies, such as libraries, nutrition 
centers, and parks, that directly employ older Americans. GAO 
found that the relative distribution of funds to the national 
sponsors and state agencies along with Labor's method of 
implementing the hold-harmless provisions have resulted in the 
distribution of funds among and within states that bear little 
relationship to actual need. GAO also found that, under Labor's 
regulations, expenditures that GAO believes to be 
administrative in nature may be charged to another cost 
category, allowing grantees to exceed the statutory 15-percent 
limit on administrative costs.

                             Health Issues

Blue Cross and Blue Shield: Change in Pharmacy Benefits Affects Federal 
        Enrollees (GAO/T-HEHS-96-206, Sept. 5, 1996)

    Of the 400 health plans available to federal workers, the 
Blue Cross and Blue Shield plan is the largest, covering nearly 
42 percent of the 4 million federal enrollees. To control drug 
costs, Blue Cross and Blue Shield recently began requiring 
federal enrollees to pay 20 percent of the price of 
prescriptions purchased at participating retail pharmacies. 
Previously, federal enrollees did not have to pay anything for 
prescription drugs. Enrollees may continue to receive drugs 
free of charge, however, if they buy them through the plan's 
mail-order program. Members of Congress and retail pharmacies 
have raised concerns about the quality of mail-order services 
and the effect of the change on the business of retail 
pharmacies that serve plan enrollees. To provide pharmacy 
services to its federal employee health plan, Blue Cross and 
Blue Shield contracts with two pharmacy benefit managers (PBM): 
PCS Health Systems, Inc., which provides retail prescription 
drug services, and Merck-Medco Managed Care, Inc., which 
provides mail-order drug services. This testimony discusses (1) 
Blue Cross and Blue Shield's reasons for the benefit change, 
(2) how it was implemented, (3) the change's effect on retail 
pharmacies, and (4) the extent to which PCS and Merck-Medco 
have met their contract requirements for services provided to 
the federal health plan.

Community Health Centers: Challenges in Transitioning to Prepaid 
        Managed Care (GAO/T-HEHS-95-143, May 4, 1995)

    As states move to prepaid managed care to control costs and 
improve access for their Medicaid clients, the number of 
participating community health centers continues to grow. 
Medicaid prepaid managed care is not incompatible with health 
centers' mission of delivering health care to medically 
underserved populations. However, health centers face 
substantial risks and challenges as they move into these 
arrangements. Such challenges require new knowledge, skills, 
and information systems. Centers lacking expertise and systems 
face an uncertain future, and those in a vulnerable financial 
position are at even greater risk. Today's debate over possible 
changes in federal and state health programs heightens the 
concern over the financial vulnerability of centers 
participating in prepaid managed care. If this funding source 
continues to grow as a percentage of total health center 
revenues, centers must face building larger cash reserves while 
not compromising services to vulnerable populations.

Consumer Health Informatics: Emerging Issues (GAO/T-AIMD-96-134, July 
        26, 1996)

    Technology has increased the amount of health information 
available to the public, allowing consumers to become better 
educated and more involved in their own health care. Government 
and private health care organizations rely on a variety of 
technologies to disseminate health information on preventive 
care, illness and injury management, treatment options, post-
treatment care, and other topics. This report discusses 
consumer health informatics--the use of computers and 
telecommunications to help consumers obtain information, 
analyze their health care needs, and make decisions about their 
own health. GAO provides information on (1) the demand for 
health information and the expanding capabilities of 
technology; (2) users' and developers' views on potential 
systems advantages and issues surrounding systems development 
and use; (3) government involvement--federal, state, and 
local--in developing these technologies; and (4) the status of 
related efforts by HHS. As part of this review, GAO surveyed 
consumer health informatics experts and presents their views on 
issues that need to be addressed when developing consumer 
health information systems.

Employer-Based Health Plans: Issues, Trends, and Challenges Posed by 
        ERISA (GAO/T-HEHS-95-223, July 25, 1995)

    As the movement for comprehensive federal health care 
reform has lost steam, the focus of reform has shifted to the 
states and private market. States remain concerned about the 
growing number of persons lacking health coverage and about 
financing health plans for poor persons. Employers have become 
increasingly aggressive in managing their health plans and have 
adopted various managed care plans and innovative funding 
arrangements. However, ERISA effectively blocks states from 
directly regulating most employer-based health plans, although 
it allows states to regulate health insurers. GAO found that 
nearly 40 percent of enrollees in employer-based health plans--
44 million people--are in self-funded plans. The divided 
federal and state framework for regulating health plans 
produces a complex set of trade-offs. Self-funded plans, which 
are exempt from state regulation under ERISA, provide employers 
greater flexibility to design a health benefits package that 
may have been less feasible to provide under state regulation. 
At the same time, however, states are unable to extend 
regulations, such as solvency standards, preexisting condition 
clause limits, and guaranteed issue and renewal requirements, 
even indirectly, to enrollees in these self-funded plans.

Fraud and Abuse: Medicare Continues To Be Vulnerable to Exploitation by 
        Unscrupulous Providers (GAO/T-HEHS-96-7, Nov. 2, 1995)

    Most Medicare providers try to abide by program rules and 
strive to meet beneficiaries' needs. Nevertheless, Medicare is 
overwhelmed in its attempts to keep pace with, much less stay 
ahead of, those bent on cheating the system. GAO's recent 
investigations of Medicare fraud and abuse have implicated home 
health agencies, medical suppliers, pharmacists, rehabilitation 
therapy companies, and clinical laboratories. They are 
attracted by the high reimbursement levels for some supplies 
and services, and the few barriers to entry into this lucrative 
marketplace. Once engaged in these profitable activities, 
exploitative providers too often escape detection because of 
inadequate claims scrutiny, elude pursuit by law enforcement 
authorities because of the authorities' limited resources and 
fragmented responsibilities, and face little risk of speedy or 
appropriate punishment.

Fraud and Abuse: Providers Excluded From Medicaid Continue To 
        Participate in Federal Health Programs (GAO/T-HEHS-96-205, 
        Sept. 5, 1996)

    Although HHS' Office of Inspector General (OIG) has 
excluded thousands of health care providers from state Medicaid 
programs because they committed fraud or delivered poor care to 
beneficiaries, weaknesses in the OIG's process could leave such 
providers on the rolls of federal health programs for 
unacceptable periods of time. This puts at risk the health and 
safety of beneficiaries and compromises the financial integrity 
of Medicaid, Medicare, and other federal health programs. The 
weaknesses include (1) lengthy delays in the OIG's decision 
process, even in cases where a provider has been convicted of 
fraud or patient abuse and neglect; (2) inconsistencies among 
OIG field offices regarding which providers will be considered 
for nationwide exclusion; (3) states not informing the OIG 
about providers who agree to stop participating in their 
Medicaid programs even though the provider withdrew because of 
egregious patient care or abusive billing practices; and (4) 
how states use information from the OIG to remove excluded 
providers from state programs. Because of incomplete records in 
the OIG field offices, GAO could not reach a conclusion as to 
the magnitude of these problems.

Health Insurance Regulation: National Portability Standards Would 
        Facilitate Changing Health Plans (GAO/T-HEHS-95-205, July 18, 
        1995)

    Many Americans face discontinuity in their health care 
coverage when they change employers, and others do not change 
jobs because of concerns about losing health care coverage. GAO 
surveyed the status of federal and state insurance reforms and 
the number of individuals who would be affected by legislation 
to establish national portability standards. GAO found that 
federal and state laws reflect steps taken to improve the 
portability of health insurance, but the possibility remains 
that an individual's coverage would be reduced when changing 
jobs because most private health plans still require waiting 
periods before making people with preexisting conditions fully 
eligible for coverage. On the basis of existing data on the 
number of people who change jobs and studies on the effect of 
health insurance on job mobility, GAO estimates that up to 21 
million Americans would benefit from legislation waiving 
preexisting condition exclusions for individuals who have 
maintained continuous health care coverage.

Medicaid: Experience With State Waivers To Promote Cost Control and 
        Access to Care (GAO/T-HEHS-95-115, Mar. 23, 1995)

    The Congress has begun reexamining the $131 billion 
Medicaid program--one of the fastest growing components of both 
federal and state budgets. In 1993, Medicaid cost nearly $100 
billion more and served about 10 million more low-income 
residents than it did a decade ago. To contain exploding costs 
and enrollment, many states are seeking greater flexibility in 
implementing statewide Medicaid managed care programs. 
Currently, this flexibility is available only through the 
waiver authority established by section 1115 of the Social 
Security Act. Although many states have expressed interest in 
waivers, only four states have waivers in place. Two additional 
states have received federal approval, but their plans still 
must be ratified by state legislatures. States face significant 
challenges as they move from traditional fee-for-service 
systems into managed care. Specifically, the emphasis that 
states put on program implementation and oversight may affect 
whether states' managed care programs successfully contain 
costs while increasing access to quality health care.

Medicaid: Matching Formula's Performance and Potential Modifications 
        (GAO/T-HEHS-95-226, July 27, 1995)

    When the Medicaid program was established in 1965, a 
matching formula was developed to narrow differences likely to 
arise among Medicaid programs in wealthier and poorer states. 
By giving poorer states a higher federal match, it was believed 
that disparities would be reduced across states in (1) 
population groups and services covered in each state program 
and (2) the tax burden imposed by the financing of Medicaid 
relative to the size of the state's financial resources. GAO 
testified that the matching formula, with its reliance on per 
capita income as a measure of state wealth, has not 
significantly reduced wide differences in states' Medicaid 
programs or the tax burdens to support them. Large disparities 
persist in the coverage of population groups and types of 
services as well as in the burdens that state taxpayers bear in 
financing state programs. Modifying the formula could enhance 
the ability of federal payments to narrow program disparities.

Medicaid: Spending Pressures Drive States Toward Program Reinvention 
        (GAO/T-HEHS-95-129, Apr. 4, 1995)

    The $131 billion Medicaid program is at a crossroads. 
Between 1985 and 1993, Medicaid costs tripled and the number of 
beneficiaries rose by more than 50 percent. Medicaid costs are 
projected to rise to $260 billion, according to the 
Congressional Budget Office. Despite federal and state 
budgetary constraints, several states are exerting pressure to 
expand the program and enroll hundreds of thousands of new 
beneficiaries. The cost of expanded coverage, they believe, 
will be offset by the reallocation of Medicaid funds and the 
wholesale movement of beneficiaries into some type of managed 
care arrangement. This testimony examines (1) federal and state 
Medicaid spending, (2) some states' efforts to contain Medicaid 
costs and expand coverage through waiver of federal 
requirements, and (3) the potential impact of these waivers on 
federal spending and on Medicaid's program structure overall.

Medicaid: Spending Pressures Spur States Toward Program Restructuring 
        (GAO/T-HEHS-96-75, Jan. 18, 1996)

    Several factors, including federal mandates that expand 
eligibility, medical price inflation, and creative financing 
schemes, have boosted Medicaid costs. To contain these 
expenses, 22 states have recently sought waivers from federal 
regulations that limit their ability to run extensive managed 
care programs. Some of these states have required the 
enrollment of their acute care patients--primarily low-income 
women and children--into managed care programs and have 
expanded coverage to previously ineligible persons. Arizona, 
which runs a Medicaid managed care program under a federal 
waiver obtained more than 10 years ago, has lowered Medicaid 
spending by millions of dollars. It also leads the states in 
its development of information systems for collecting medical 
encounter data essential for assessing quality of care.

Medicaid: State Flexibility in Implementing Managed Care Programs 
        Requires Appropriate Oversight (GAO/T-HEHS-95-206, July 12, 
        1995)

    Requiring states to obtain waivers to broaden use of 
managed care may hamper their efforts to aggressively pursue 
cost-containment strategies. At the same time, because current 
program restrictions on managed care were designed to reinforce 
quality assurance, their absence requires the substitution of 
appropriate and adequate mechanisms to protect both Medicaid 
beneficiaries and federal dollars. Finally, the reinvestment of 
managed care savings to expand Medicaid coverage to several 
million additional persons suggests the need for up-front 
consultation with the Congress because of (1) the heavier 
financial burden such 1115 waivers may place on the federal 
government and (2) the issue of whether the U.S. Treasury 
should benefit from those savings.

Medicaid: Statewide Section 1115 Demonstrations' Impact on Eligibility 
        Service Delivery and Program Cost (GAO/T-HEHS-95-182, June 21, 
        1995)

    The growth of Medicaid, which accounted for $142 billion in 
federal and state outlays in 1994, is outpacing even the growth 
of Medicare. This is happening at a time when states are 
feeling pressured financially and are seeking ways to care for 
their uninsured populations. In response, states are, one by 
one, reinventing their Medicaid programs, using the authority 
of section 1115 waivers. Named for section 1115(a) of the 
Social Security Act, these waivers free states from some 
Medicaid restrictions on the use of managed care delivery 
systems. They also allow states to expand Medicaid-financed 
coverage to persons not normally eligible for Medicaid. This 
testimony presents a detailed look at Medicaid's growing 
expenditures, describes states' efforts to obtain section 1115 
waivers, and summarizes the expenditures forecast of programs 
operating with waivers.

Medicare: Adapting Private Sector Techniques Could Curb Losses to Fraud 
        and Abuse (GAO/T-HEHS-95-211, July 19, 1995)

    Medicare's loss of billions of dollars to fraud and abuse 
could be curbed by adopting such private sector techniques as 
competitive bidding, use of advanced software to detect gross 
overpayments, and preferred networks to better control costs. 
Medicare's losses stem from inappropriate pricing and 
inadequate scrutiny of claims for payments. Further, abusive 
and poorly qualified providers of medical services and supplies 
continue to participate in the program. These problems are not 
unique to Medicare. However, private payers are often able to 
react quickly, through a variety of management approaches, 
whereas Medicare's pricing methods and controls over 
utilization, which were consistent with health care financing 
and delivery when the program started, have not been adapted to 
today's environment.

Medicare: Allegations Against ABC Home Health Care (GAO/T-OSI-95-18, 
        July 19, 1995)

    In response to a congressional request, GAO investigated 
allegations against ABC Home Health Care, a home health agency 
(HHA), and its participation in the Medicare home health care 
program. In the Medicare program, providers may receive 
reimbursement for only those expenses that are reasonable in 
amount and related to patient care for eligible patients. 
Current and former employees told GAO that local ABC officer 
managers directed them to alter records to make it appear that 
patients continued to need home health visits. Additionally, 
managers directed employees to continue visiting patients who, 
in the employees' opinion, did not qualify for home health care 
because they no longer met Medicare rules defining homebound 
status. ABC also reportedly charged Medicare for the cost of 
acquiring other HHAs by paying owners a small sum up front and 
the balance in the form of salary under employment agreements, 
a practice that is inconsistent with Medicare regulations for 
reimbursement. Finally, according to former employees, some 
managers directed employees to market ABC and its services with 
the intent of charging Medicare for costs that were not 
reimbursable. GAO has shared information concerning possible 
illegal activities with appropriate law enforcement 
authorities.

Medicare Claims Billing Abuse: Commercial Software Could Save Hundreds 
        of Millions Annually (GAO/T-AIMD-95-133, May 5, 1995)

    With an investment of only $20 million in off-the-shelf 
commercial software, Medicare could save nearly $4 billion over 
5 years by detecting fraudulent claims by physicians--primarily 
manipulation of billing codes. On the basis of a test in which 
four commercial firms reprocessed samples of more than 20,000 
paid Medicare claims, GAO estimates that the software could 
have saved $603 million in 1993 and $640 million in 1994. GAO 
estimates that because beneficiaries are responsible for about 
22 percent of the payment amounts--mainly in the form of 
deductibles and copayments--Medicare could have saved them $134 
million in 1993 and $142 million in 1994. The test results 
indicate that only a small portion of providers are responsible 
for most of the abuses: fewer than 10 percent of providers in 
the sample had miscoded claims.

Medicare: Excessive Payments for Medical Supplies Continue Despite 
        Improvements (GAO/T-HEHS-96-5, Oct. 2, 1995)

    Despite improvements by HCFA in claims monitoring, problems 
in payments for medical supplies persist. The inflexibility of 
Medicare's fee schedule results in payment rates that are 
higher than wholesale and many retail prices. In addition, in 
the case of many part A claims, claims processing contractors 
do not know what they are paying for and in the case of part B 
claims, have not had a basis for questioning unreasonably high 
charges. Neither type of contractor has been able to test 
claims for possible duplicate payments. For these reasons, 
Medicare has lost hundreds of millions of dollars in 
unnecessary payments. By obtaining the legislative authority to 
modify payment rates in accordance with market conditions, 
requiring providers to itemize claims, and introducing the 
relevant medical policies before paying for new benefits, HCFA 
could reduce its dollar losses arising from medical supply 
payments. Contractors could avoid paying unreasonable charges 
and making duplicate payments.

Medicare: High Spending Growth Calls for Aggressive Action (GAO/T-HEHS-
        95-75, Feb. 6, 1995)

    The government faces strong obstacles to bringing Medicare 
expenditures under control. Broad-based payment system reforms 
have slowed overall spending, but Medicare growth rates remain 
higher than overall inflation. And although more reforms may be 
needed, their nature is the subject of much debate. There is 
less dispute, however, that Medicare pays too much for some 
services and supplies. Fiscal pressures have increasingly led 
private and state-government payers to negotiate discounts with 
providers and to manage the form and the volume of care. 
Medicare has not exercised its potential market power in 
similar fashion when buying some services, such as 
rehabilitation therapy. GAO suggests that the government change 
the reimbursement policies for these excessively costly 
services to ensure that it is acting as a prudent buyer. Also, 
greater vigilance over wasteful or inappropriate payments could 
better protect Medicare against fraudulent and abusive billings 
from providers.

Medicare: Increased Federal Oversight of HMOs Could Improve Quality of 
        and Access to Care (GAO/T-HEHS-95-229, Aug. 3, 1995)

    This testimony discusses problems that HCFA has had 
monitoring HMOs it contracts with to provide services to 
Medicare beneficiaries and ensuring that they comply with 
Medicare's performance standards. GAO found weaknesses in 
HCFA's quality assurance monitoring, enforcement measures, and 
appeal processes. Although HCFA routinely reviews HMO 
operations for quality, these reviews are generally perfunctory 
and do not consider the financial risks that HMOs transfer to 
providers. Moreover, HCFA collects virtually no data on 
services received through HMOs to enable HCFA to identify 
providers who may be underserving beneficiaries. In addition, 
HCFA's HMO oversight has two other major limitations: 
enforcement actions are weak and the beneficiary appeal process 
is slow. HCFA's current regulatory approach to ensuring good 
HMO performance appears to GAO to lag behind the private 
sector.

Medicare Managed Care: Enrollment Growth Underscores Need to Revamp HMO 
        Payment Methods (GAO/T-HEHS-95-207, July 12, 1995)

    Rapid growth in the number of Medicare beneficiaries in 
HMOs increases the urgency of correcting rate-setting flaws 
that result in unnecessary Medicare spending. By not tailoring 
its HMO capitation payment to how healthy or sick HMO enrollees 
are, HCFA cannot realize the savings that private-sector payers 
capture from HMOs. Two lessons can be learned from GAO's review 
of ways to fix Medicare's HMO capitation payments. First, a 
multipronged approach to rate setting makes sense. The large 
disparities in market conditions between states call for 
solutions keyed to market conditions. Second, with respect to 
achieving the promise of such initiatives, details matter. How 
these strategies are designed and implemented could mean the 
difference between success and failure. GAO believes that in 
the short term, HCFA can overcome its capitation problem by 
introducing a better health status risk adjustor. HCFA should 
also promptly test competitive bidding and other promising 
approaches to setting HMO rates that reduce Medicare costs.

Medicare Managed Care: Program Growth Highlights Need to Fix HMO 
        Payment Problems (GAO/T-HEHS-95-174, May 24, 1995)

    (This testimony is similar to our July 12, 1995, testimony 
summarized above.)

Medicare: Millions Can Be Saved by Screening Claims for Overused 
        Services (GAO/T-HEHS-96-86, Feb. 8, 1996)

    Medicare contractors routinely pay hundreds of millions of 
dollars in Medicare claims without first determining if the 
services provided are necessary. GAO reviewed payments to 
doctors for six groups of high-volume medical procedures--
ranging from eye examinations to chest X rays--that accounted 
for nearly $3 billion in Medicare payments in 1994. GAO also 
surveyed 17 contractors to determine if they had used medical 
necessity criteria in their claims processing to screen for 
these six groups of procedures. For each of the six groups, 
more than half of the 17 contractors failed to use automated 
screens to flag claims for unnecessary, inappropriate, or 
overused treatments. These prepayment screens could have saved 
millions of taxpayer dollars now wasted on questionable 
services. Problems with controlling payments for widely 
overused procedures continue because HCFA lacks a national 
strategy to control these payments. HCFA now relies on 
contractors to focus on procedures where local use exceeds the 
national average. Although this approach helps reduce local 
overuse of some procedures, it is not designed to control 
overuse of a procedure nationwide.

Medicare: Modern Management Strategies Could Curb Fraud, Waste, and 
        Abuse (GAO/T-HEHS-95-227, July 31, 1995)

    Medicare's vulnerability to provider exploitation of its 
billing system stems from a combination of factors: (1) higher 
than market rates for some services, (2) inadequate checks for 
detecting fraud and abuse, (3) superficial criteria for 
confirming the authenticity of providers billing the program, 
and (4) weak enforcement efforts. Various health care 
management techniques help private payers avoid these problems, 
but Medicare generally does not use these techniques. The 
program's pricing methods and controls over utilization have 
not kept pace with changes in health care financing and 
delivery. To some extent, the predicament inherent in public 
programs--the uncertain line between adequate managerial 
control and excessive government intervention--helps explain 
the dissimilarity in the ways in which Medicare and 
privatehealth insurers run their respective ``plans.'' GAO believes 
that a viable strategy for remedying the program's weaknesses consists 
of adapting the health care management approach of private payers to 
Medicare's public payer role. This would entail (1) more competitively 
developed payment rates, (2) beefed-up fraud and abuse detection that 
uses modern information systems, and (3) more rigorous criteria for 
granting authorization to bill the program.

Medicare: Modern Management Strategies Needed to Curb Program 
        Exploitation (GAO/T-HEHS-95-183, June 15, 1995)

    (This testimony is similar to our July 31, 1995, testimony 
described above.)

Medicare: Opportunities Are Available to Apply Managed Care Strategies 
        (GAO/T-HEHS-95-81, Feb. 10, 1995)

    Although the private sector quickly embraced managed care 
as an effective way to control the growth of health care costs, 
Medicare has moved more slowly. GAO believes that Medicare 
could benefit from the experience of the private sector and 
should test such managed care strategies as competitive bidding 
for HMOs. Using market power to negotiate with HMOs over price 
and increasingly over quality and the production of report-
card-type information, large employers are becoming more 
prudent and sophisticated purchasers of health care. The 
particulars of these efforts may not be directly transferable 
to the federal government, but their goals of using incentive-
based solutions to contain costs, guarantee quality, and inform 
consumers are worthy of consideration and testing.

Medicare: Private Payer Strategies Suggest Options to Reduce Rapid 
        Spending Growth (GAO/T-HEHS-96-138, Apr. 30, 1996)

    Improvements to Medicare's traditional fee-for-service 
program could yield much-needed savings. With better 
management, this program, which now serves about 90 percent of 
beneficiaries, could run more efficiently while continuing to 
provide good service to the nation's elderly. This means 
allowing Medicare to use tools similar to those used by private 
payers to manage health care costs. Negotiated discounts, 
competitive bidding, preferred providers, case management 
utilization reviews--these and other tools allow private payers 
to use market forces to control health care costs. Most, 
however, are not authorized for general use by HCFA, which runs 
Medicare. This results in a publicly financed program that pays 
higher-than-market rates for some goods and services and 
sometimes pays without question for improbably high bills. 
Recent HCFA efforts and pending legislation to address these 
problems appear promising. In addition, HCFA should test the 
feasibility of applying management strategies in high-cost, 
high-utilization areas. Finally, the Congress needs to give HHS 
the flexibility to make prompt price adjustments.

Medicare: Private Sector and Federal Efforts to Assess Health Care 
        Quality (GAO/T-HEHS-96-215, Sept. 19, 1996)

    HCFA now estimates that 4.3 million Medicare beneficiaries 
are enrolled in HMOs. Enrollment is believed to be growing at a 
rate of 100,000 new members per month. This testimony discusses 
ways to ensure that quality care is provided to the Medicare 
beneficiaries joining these HMOs. HCFA, which runs Medicare, 
finds the potential cost savings associated with managed care 
attractive. Concerns have been raised, however, that the cost 
control strategies employed by HMOs could undermine the quality 
of care. This testimony discusses (1) quality assessment 
methods used by large corporate purchasers of health insurance 
from HMOs, (2) quality assessment methods used by HCFA in 
administering the Medicare HMO program, (3) quality assessment 
methods HCFA plans for the future, and (4) what both corporate 
purchasers and HCFA are doing to share information about 
quality with employees and Medicare beneficiaries.

Medicare: Rapid Spending Growth Calls for More Prudent Purchasing (GAO/
        T-HEHS-95-193, June 28, 1995)

    Last year, federal spending for Medicare totaled $162 
billion--more than $440 million a day. In March 1995, the 
Congressional Budget Office estimated that these outlays would 
approach $350 billion by 2002. In 2005, they could exceed $460 
billion unless changes are made. This testimony discusses ways 
in which the Medicare program could avoid excessive or 
unnecessary spending. GAO examines areas of rapid spending 
growth and ways to conserve program dollars--mainly by revising 
reimbursement policies and better controlling unwarranted use 
of services.

Medicare: Reducing Fraud and Abuse Can Save Billions (GAO/T-HEHS-95-
        157, May 16, 1995)

    Medicare is overwhelmed in its efforts to keep pace with, 
much less stay ahead of, those bent on cheating the system. 
Various factors converge to create a particularly rich 
environment for profiteers. These include the following: (1) 
weak fraud and abuse controls to detect questionable billing 
practices, (2) few limits on those who may bill--companies 
using post office box numbers have qualified to bill the 
program for virtually unlimited amounts--and (3) overpayment 
for services. This testimony describes how providers exploit 
the system, why they are able to do so, and what steps Medicare 
has taken and what remains to be done to protect the program 
and the taxpayers against fraudulent reimbursement schemes and 
abusive billing practices.

Medicare Transaction System: Strengthened Management and Sound 
        Development Approach Critical to Success (GAO/T-AIMD-96-12, 
        Nov. 16, 1995)

    HCFA is developing a critical new claims-processing system, 
the Medicare transaction system (MTS), to replace the nine 
systems now used by Medicare. MTS' goal is to better protect 
program funds from waste, fraud, and abuse; allow better 
oversight of Medicare contractor operations; improve service to 
beneficiaries and providers; and cut administrative expenses. 
The weaknesses in HCFA's development of MTS stem from a lack of 
a disciplined management process; a process in which 
information systems and technology should be managed as 
investments. Not managing MTS in this way has led to system 
design and development proceeding despite (1) difficulties in 
defining requirements, (2) a compressed scheduled containing 
significant overlap of system-development phases, and (3) a 
lack of reliable information on costs and benefits. These risks 
in the development of MTS can be substantially reduced if HCFA 
adopts some of the best practices that have proven effective in 
other organizations: managing systems as investment, changing 
information management practices, creating line manager 
ownership, better managing resources, and measuring 
performance.

Pharmacy Benefit Managers: Early Results on Ventures With Drug 
        Manufacturing (GAO/T-HEHS-96-85, Feb. 7, 1996)

    Recently, some of the largest drug companies have merged or 
formed alliances with some of the largest PBMs. PBMs manage the 
prescription drug part of health insurance plans covering 
millions of Americans. These ventures gained attention not only 
because of their size but because of concerns that the PBMs 
would automatically give preference to their manufacturer 
partners' drugs over those made by competitors. The results of 
GAO's analysis of PBM formularies--a list of preferred 
prescription drugs by therapeutic class, often with cost 
designations--indicate that continued oversight of mergers and 
alliances between pharmaceutical manufacturers and PBMs is 
warranted to ensure competition in the marketplace. For 
example, the changes in Medco's formulary that appear to favor 
Merck drugs do not necessarily show that Medco automatically 
gave preference to Merck drugs over those of competitors. 
However, the formulary changes support the Federal Trade 
Commission's decision to continue monitoring the Merck/Medco 
merger and other such ventures.

Prescription Drug Pricing: Implications for Retail Pharmacies (GAO/T-
        HEHS-96-216, Sept. 19, 1996)

    Congressional hearings during the late 1980s highlighted 
the fact that the prices that consumers paid for prescription 
drugs were increasing more rapidly than the rate of inflation. 
In 1990, the Congress tried to control prescription drug 
expenditures by significantly changing the way that Medicaid 
pays for outpatient drugs. Vertical integration in the 
pharmaceutical market later became a concern, particularly 
mergers between large drug companies and PBMs. This testimony 
responds to the following three questions: How and why has the 
process by which drugs get from manufacturers to patients 
changed? What have been the consequences for retail pharmacies 
of changes in this process? What general strategies are retail 
pharmacies undertaking or proposing to respond to an 
increasingly competitive environment?

Prescription Drugs and the Elderly: Many Still Receive Potentially 
        Harmful Drugs Despite Recent Improvements (GAO/T-HEHS-96-114, 
        Mar. 28, 1996)

    GAO's analysis of 1992 data found that 17.5 percent of 
nearly 30 million Medicare recipients were still being 
prescribed drugs that were generally unsuitable for their age 
group. Although this is an improvement over the almost 25 
percent reported for 1987 data, the inappropriate use of 
prescription drugs remains a major health problem for the 
elderly. Insufficient coordination of patient drug therapies 
and weaknesses in communication between providers, pharmacists, 
and patients have compounded the problem. Inappropriate 
prescribing practices and the ensuing drug use have caused many 
elderly persons to suffer harmful effects that, according to 
FDA, have resulted in hospitalizations costing $20 billion 
annually. The costs are partly covered by Medicare and 
Medicaid. States, advocacy groups, and physician and pharmacy 
organizations have, however, taken steps to reduce 
inappropriate drug use. In addition, managed care, pharmacy 
benefit management, and other coordinated health care systems 
have features designed to reduce inappropriate prescription 
drug use among the elderly.

Prescription Drugs: Implications of Drug Labeling and Off-Label Use 
        (GAO/T-HEHS-96-212, Sept. 12, 1996)

    Physicians use a drug ``off-label'' when they prescribe an 
FDA-approved drug for treatments other than those specified on 
the label. GAO testified that off-label prescribing is 
prevalent and presents various problems for policymakers at 
different times. As it stands now, the problem is that the drug 
industry believes that labels overly constrain its ability to 
promote its products. This problem can be solved either by 
relying on sources in addition to the label to define 
appropriate promotion or by improving the process for updating 
the label. These two options are not necessarily mutually 
exclusive and both have benefits and drawbacks.

Status of Medicare's Federal Hospital Insurance Trust Fund (GAO/T-HEHS-
        96-94, Feb. 29, 1996)

    This testimony focuses on GAO's ongoing review of the 
status of Medicare's Federal Hospital Insurance (part A) Trust 
Fund. GAO discusses (1) when the administration became aware 
that the trust fund had an operating deficit--that is, cash 
outlays exceeded cash receipts--of $36 million for fiscal year 
1995 and how the information was disseminated and (2) what the 
status is of current projections regarding the trust fund.

                             housing issues

Housing and Urban Development: Limited Progress Made on HUD Reforms 
        (GAO/T-RCED-96-112, Mar. 27, 1996)

    Despite the promise of reform, reinvention, and 
transformation initiatives aimed at solving problems at the 
Department of Housing and Urban Development (HUD), much more 
remains to be done. HUD is very much an agency in limbo, and 
few of the proposals in its reinvention blueprint have been 
adopted. This testimony addresses HUD's difficulties in 
addressing (1) its long-standing management shortcomings, (2) 
its portfolio of multi- and single-family housing insured by 
the Federal Housing Administration, (3) budget and management 
problems plaguing the public housing program, (4) the spiraling 
cost of assisted housing programs, and (5) the need for 
consensus on HUD reforms.

Housing and Urban Development: Public and Assisted Housing Reform (GAO/
        T-RCED-96-22, Oct. 13, 1995)

    Current federal housing programs are seen as overly 
regulated and leading to warehousing of the poor, and the 
Congress is asking state and local governments to assume a 
larger role in defining how the programs work. The Congress is 
now reconsidering the most basic aspects of public housing 
policy--whom it will house, the resources devoted to it, the 
amount of existing housing stock that will be retained, and the 
rules under which it will operate. These statements provide 
GAO's views on legislation pending before Congress--S. 1260 and 
H.R. 2406--that would overhaul federal housing policy. GAO 
testified that the two bills contain provisions that will 
likely improve the long-term viability of public housing, such 
as allowing mixed incomes in public housing and conversion of 
some public housing to housing vouchers or tenant-based 
assistance when that makes the most sense. GAO also supports 
provisions to significantly beef up HUD's authority to 
intervene in the management of troubled housing authorities, 
but GAO cautions that questions remain about the reliability of 
the oversight system that HUD uses to designate these agencies 
as troubled.

Multifamily Housing: Issues and Options to Consider in Revising HUD's 
        Low-Income Housing Preservation Program (GAO/T-RCED-96-29, Oct. 
        17, 1995)

    HUD's program for preserving low-income housing seeks to 
maintain the affordable low-income housing that was created 
mainly under two federal housing programs during the 1960s and 
1970s. Under these programs, when owners received HUD-insured 
mortgages with 40-year repayment periods, they entered into 
agreements with HUD that imposed affordability restrictions, 
such as limits on the income level of tenants and on the rents 
that could be charged at the properties. After 20 years, 
however, owners had the right to pay off their mortgages in 
full without prior HUD approval and terminate the affordability 
restrictions. The preservation program has proven to be complex 
and costly, prompting recommendations from HUD and others to 
change or repeal the program. This testimony focuses on (1) how 
the current preservation program works, (2) the status of 
preservation-eligible projects, (3) concerns that have been 
raised about the program, and (4) options for revising the 
program.

                         INCOME SECURITY ISSUES

Congressional Retirement Issues (GAO/T-GGD-95-165, May 15, 1995)

    The retirement benefits provided by the Civil Service 
Retirement System for Members of Congress are generally more 
generous than those provided for other federal employees. The 
major differences are found in the eligibility requirements for 
retirement and the formulas used to calculate benefits. The 
Member benefit formula applies to congressional staff, but they 
are covered by the general employee retirement eligibility 
requirements. Law enforcement officers and firefighters may 
retire earlier than general employees and are covered by a more 
generous benefit formula than are general employees. Under the 
Civil Service Retirement System, the provisions for air traffic 
controllers fall between those for law enforcement officers and 
firefighters and those for general employees. Many of the 
advantages afforded to Members of Congress and congressional 
staff under the Civil Service Retirement System were continued 
under the Federal Employees Retirement System, which covers 
workers hired in 1984 and thereafter. But under the Federal 
Employee Retirement System, provisions for law enforcement 
officers, firefighters, and air traffic controllers are very 
similar to provisions for Members.

Disability Insurance: Broader Management Focus Needed to Better Control 
        Caseload (GAO/T-HEHS-95-164, May 23, 1995)

    Rising numbers of applicants for disability benefits have 
increased workloads at SSA and led to growing backlogs of 
claims. As a result, applicants are waiting longer to find out 
if they have been awarded benefits. Applicants wait almost 90 
days to learn whether they have been awarded benefits, while 
persons who appeal their claims to SSA's administrative law 
judges wait more than a year. These long waits can impose 
substantial hardship on applicants, particularly those with 
limited incomes and no medical insurance. SSA has undertaken 
several short-term initiatives to address the backlog problem. 
It has also begun a long-term effort to redesign its disability 
determination process. GAO shares congressional concerns that 
these changes may sacrifice decisional accuracy for faster 
processing. SSA is also addressing its workload increases while 
dealing with substantial resource constraints. Nonetheless, SSA 
needs to focus more attention on terminating benefits for those 
who are no longer eligible and encouraging beneficiaries to 
return to work. SSA, now an independent agency, also needs to 
provide more data and advice to the Congress on matters 
affecting disability insurance policy.

Federal Downsizing: The Administration's Management of Workforce 
        Reductions (GAO/T-GGD-95-108, Mar. 2, 1995)

    The Federal Workforce Restructuring Act of 1994 requires 
the federal government to eliminate about 270,000 positions 
between 1993 and 1999. To accomplish this downsizing without a 
reduction-in-force, the act allows federal agencies to offer 
buyouts to employees who agree to resign or retire by March 31, 
1995. This testimony discusses (1) the administration's 
compliance with the act, including which positions are counted 
toward full-time-equivalent reductions and from what baseline, 
and whether savings from the reductions are being used to pay 
for the Violent Crime Control and Law Enforcement Act of 1994; 
(2) the targets of workforce downsizing; and (3) how the 
workforce reductions are being managed.

Federal Downsizing: The President's Fiscal Year 1996 Budget and Its 
        Compliance With the Federal Workforce Restructuring Act of 1994 
        (GAO/T-GGD-95-105, Mar. 30, 1995)

    GAO's analysis of the President's fiscal year 1996 budget 
shows that government agencies are well on their way to 
achieving the downsizing goals mandated by the Federal 
Workforce Restructuring Act. Although payroll savings will no 
doubt accrue from these reductions, some of the projected 
savings may be offset by costs associated with what agencies do 
with the work previously done by separated employees. To the 
extent that work is shifted to other employees, contracted out, 
or transferred to other agencies, downsizing's true savings to 
taxpayers may be reduced.

Federal Downsizing: The Status of Agencies' Workforce Reduction Efforts 
        (GAO/T-GGD-96-124, May 23, 1996)

    The downsizing of the federal workforce is ahead of the 
schedule set by the Workforce Restructuring Act. At the same 
time, the administration has called on agencies to restructure 
their workforces by reducing management positions. These jobs 
have yet to be reduced to the extent called for by the National 
Performance Review. With regard to future workforce reductions, 
GAO found that in terms of absolute numbers--and given 
historical quit rates--the remaining employment ceilings called 
for by the act probably could be achieved governmentwide 
through attrition. Nevertheless, some agencies may be forced to 
downsize more than others. In such situations, buyouts or 
reductions in force (RIF) may be necessary. GAO found that 
buyouts offer greater savings than RIFs, except when employees 
affected by a RIF do not bump and retreat and are eligible to 
retire.

Federal Retirement Issues (GAO/T-GGD-95-111, Mar. 10, 1995)

    This testimony focuses on ongoing GAO work on two issues 
involving federal employee retirement programs. First, GAO 
compares the retirement provisions for Members of Congress and 
congressional staff in the Civil Service Retirement System and 
the Federal Employees Retirement System with the provisions 
applicable to other employees covered by these systems. Second, 
GAO analyzes retirement programs in the private sector and 
state government.

Federal Retirement System Financing (GAO/T-GGD-95-197, June 28, 1995)

    Federal retirement system financing is a complex issue. 
This testimony seeks to bring some perspective to the subject 
by describing how the government finances its retirement system 
and by describing the budget implications of the financing 
methods being used and possible changes to these methods. GAO 
concentrates on the Civil Service Retirement System and the 
Federal Employees Retirement System because they are the 
largest retirement programs for federal workers.

Financial Management: Interior's Efforts to Reconcile Indian Trust Fund 
        Accounts and Implement Management Improvements (GAO/T-AIMD-96-
        104, June 11, 1996)

    Although the Department of the Interior has brought to a 
close its project to reconcile the Indian trust funds, tribal 
accounts were never fully reconciled because of missing records 
and the lack of an audit trail in Interior's automated 
accounting systems. In addition, the 1996 report package that 
Interior provided to each tribe on the reconciliation results 
did not explain or describe the many changes in reconciliation 
scope and methodologies or the procedures that had been planned 
but were not implemented. As a result, the limitations of the 
reconciliation were not evident. Also, because of cost 
considerations and the potential for missing records, 
individual Indian trust fund accounts were not included in the 
reconciliation project. Indian tribes have raised concerns 
about the scope and the results of the reconciliation process. 
The vast majority of tribes have yet to decide whether to 
accept or dispute their account balances. If Interior cannot 
resolve the tribes' concerns, a legislated settlement process 
could be used to settle disputes over account balances. 
Interior has taken steps during the past 3 years to correct 
these long-standing problems with the accuracy of the Indian 
trust fund accounts, but these efforts will take years to 
complete. Moreover, the existing trust fund management and 
accounting systems cannot ensure accurate trust fund accounting 
and asset management. The appointment of a Special Trustee for 
American Indians was an important step in establishing high-
level leadership at Interior for Indian trust fund management.

Means-Tested Programs: An Overview, Problems, and Issues (GAO/T-HEHS-
        95-76, Feb. 7, 1995)

    Nearly 80 means-tested programs have been created over the 
years for low-income people. In fiscal year 1992, the federal 
government spent about $208 billion on these programs to meet 
the needs of poor Americans of all ages. The many means-tested 
programs are costly and difficult to administer. On the one 
hand, the programs sometimes overlap one another; on the other 
hand, they are often so narrowly focused that service gaps 
hinder clients. GAO notes that although advanced computer 
technology is essential to the programs operating efficiently, 
it is not being effectively developed or used. Due to their 
size and complexity, many of these programs are vulnerable to 
waste, fraud, and abuse. Moreover, the welfare system is often 
difficult for clients to use effectively. Finally, 
administrators have not articulated clear goals and objectives 
for some programs and have not collected data on how well the 
programs are working.

Overview of Federal Retirement Programs (GAO/T-GGD-95-172, May 22, 
        1995)

    This testimony describes how the federal retirement systems 
work, the benefits they provide, and how they compare with 
private sector programs. GAO concentrates on the Civil Service 
Retirement System and the Federal Employees Retirement System 
because they are the largest retirement systems for federal 
civilian personnel. GAO describes the history of the two 
retirement systems and discusses four issues that are often 
raised in connection with federal retirement: (1) retirement 
eligibility provisions, (2) benefit formulas, (3) COLAs, and 
(4) system financing.

Social Security Disability: Management Action and Program Redesign 
        Needed to Address Long-Standing Problems (GAO/T-HEHS-95-233, 
        Aug. 3, 1995)

    SSA has serious problems managing its Disability Insurance 
(DI) and Supplemental Security Income (SSI) programs. First, 
the lengthy and complicated decisionmaking process results in 
untimely decisions, especially for those who appeal, and shows 
troubling signs of inconsistency. Second, SSA has a poor record 
of reviewing beneficiaries to determine whether they remain 
eligible for benefits and an even worse record of providing 
rehabilitation to help move people off the disability rolls and 
into employment. This reinforces the public perceptions that 
SSA pays disability benefits to persons who are not entitled to 
them. Third, SSA needs to make better decisions about work 
capacity to restore public confidence and to better serve 
beneficiaries. Although these problems are serious, solutions 
do exist. GAO believes that relatively quick action could be 
taken to reduce inconsistent decisionmaking, step up review of 
beneficiaries who may be able to return to work, and improve 
rehabilitation outcomes. In some cases, SSA has the authority 
to take action, in others, decisionmakers may need to rethink 
the goals and objectives of the disability programs.

Social Security: Federal Disability Programs Face Major Issues (GAO/T-
        HEHS-95-97, Mar. 2, 1995)

    This testimony discusses the reasons for the tremendous 
growth in federal disability programs during the past 10 years, 
including program factors and social changes. GAO also comments 
on the impact of fraud and abuse on this growth and its effect 
on program integrity. In addition, GAO notes legislative 
reforms included in the Social Security Independence Act last 
year that tried to improve program integrity. Finally, GAO 
discusses weaknesses in SSA's efforts to return DI and SSI 
beneficiaries to work.

Social Security: Disability Programs Lag in Promoting Return to Work 
        (GAO/T-HEHS-96-147, June 5, 1996)

    On average, SSA pays over $1 billion in cash payments to DI 
and SSI beneficiaries each week. Although these payments 
provide a measure of income security, they do little to enhance 
the work capacities and promote the economic independence of 
recipients. Societal attitudes have shifted, and current law, 
such as the Americans With Disabilities Act, promotes economic 
self-sufficiency among the disabled. A growing number of 
private companies are exploring ways to return people with 
disabilities to the workforce. Moreover, medical advances and 
new technologies provide greater opportunities for people with 
disabilities to work. This testimony discusses how the 
structure of the DI and SSI programs impedes recipients' return 
to work and how strategies used in other disability systems 
could help restructure the programs to encourage recipients to 
return to work.

Social Security Administration: Effective Leadership Needed to Meet 
        Daunting Challenges (GAO/T-OCG-96-7, July 25, 1996)

    With a staff of 64,000, SSA runs the largest federal 
program--Social Security--as well as the largest cash welfare 
program--SSI. The agency's expenditures totaled $363 billion in 
fiscal year 1995, almost one-fourth of the $1.5 trillion 
federal budget. This testimony discussed the difficult 
challenges facing SSA in the coming decades: taking part in the 
debate over future financing of Social Security; encouraging 
disability recipients to return to work; reducing fraud and 
abuse; and managing workforce and technology investments so 
that SSA can meet the needs of America's retired, disabled, and 
poor.

SSA Benefit Statements: Statements Are Well Received by the Public But 
        Difficult to Comprehend (GAO/T-HEHS-96-210, Sept. 12, 1996)

    The personal earnings and benefit estimate is a six-page 
statement produced by SSA that supplies information about a 
worker's yearly earnings on record at SSA; eligibility for 
social security retirement, survivor, and disability benefits; 
and estimates of these benefits. SSA has tried to improve the 
statement, and the public has found it to be helpful for 
retirement planning. However, the statement falls short in 
clearly communicating the complex information that readers need 
to understand concerning SSA's programs and benefits. For 
example, the document's design and organization make it 
difficult for readers to locate important information. Readers 
are also confused by several important explanations, such as 
who in their family is also eligible for benefits and how much 
these family members might receive. SSA is considering 
redesigning the statement, but only if this effort reduces 
printing costs. This approach overlooks hidden costs, such as 
(1) inquiries from people who do not understand the statement 
and (2) the possibility that a poorly designed statement can 
undermine public confidence.

SSA Disability Reengineering: Project Magnitude and Complexity Impede 
        Implementation (GAO/T-HEHS-96-211, Sept. 12, 1996)

    Given the high cost and lengthy processing times of SSA's 
current disability claims process, the agency needs to continue 
its redesign efforts. SSA's redesign plan is proving to be 
overly ambitious, however. Some initiatives are also becoming 
more complex as SSA expands the work required to complete them. 
The agency's approach is likely to limit the chances for the 
project's success and has delayed implementation: testing 
milestones have slipped and support for the redesign effort has 
waned. In addition, the increasing length of the overall 
project and specific initiatives heighten the risk of 
disruption from turnover among key executives. GAO believes 
that as SSA proceeds with its redesign project it should focus 
on key initiatives, starting first with those that will quickly 
and significantly reduce claims processing time and 
administrative costs.

Supplemental Security Income: Noncitizens Have Been a Major Source of 
        Caseload Growth (GAO/T-HEHS-96-88, Feb. 6, 1996)

    Noncitizens are among the fastest growing groups receiving 
benefits from the SSI program, which provides means-tested 
benefits to eligible blind, elderly, or disabled persons. 
Noncitizens represent nearly one-third of aged SSI recipients 
and 5.5 percent of disabled recipients. About two-thirds of 
noncitizen SSI recipients live in three states--California, New 
York, and Florida. On the whole, noncitizens are more likely to 
receive SSI than citizens, but this may be true primarily for 
refugees and asylum seekers. Adult children of aged immigrants 
and others who say they are willing to financially support them 
sometimes do not. Eventually, many of these aged immigrants 
receive SSI. Also, some translators help noncitizens to 
fraudulently obtain SSI disability benefits.

Supplemental Security Income: Noncitizen Caseload Continues to Grow 
        (GAO/T-HEHS-96-149, May 23, 1996)

    (This testimony is similar to our February 6, 1996, 
testimony summarized above. Since the data used was updated 
from that used in the February testimony, the May testimony is 
summarized below.)
    Noncitizens are one of the fastest growing groups of 
recipients of SSI benefits. They represent nearly one-third of 
aged SSI recipients and about 6 percent of disabled recipients. 
Although the growth rate for noncitizen caseloads has slowed, 
it is still higher than that for citizens, and the percentage 
of noncitizens relative to other SSI recipients continues to 
rise. About two-thirds of noncitizen recipients--roughly 
520,000--live in three states: California, New York, and 
Florida. On the whole, noncitizens are more likely to receive 
SSI than are citizens, but this may be primarily true for 
refugees and asylum seekers. Adult children of aged immigrants 
and others who say they are willing to financially support them 
sometimes do not. Eventually, some of these older immigrants 
receive SSI. Also, some translators have helped noncitizens to 
fraudulently obtain SSI disability benefits

Supplemental Security Income: Recent Growth in the Rolls Raises 
        Fundamental Program Concerns (GAO/T-HEHS-95-67, Jan. 27, 1995)

    This testimony discusses the growth of SSI rolls and 
changes in the characteristics of SSI recipients. Last year, 
SSA paid nearly $22 billion in federal benefit payments to 
about 6.3 million aged, blind, and disabled SSI recipients. 
Since 1986, payments have risen by $13.5 billion, more than 
doubling. Benefits for the disabled accounted for nearly 100 
percent of this increase. Since 1986, the number of disabled 
SSI recipients under age 65 has increased an average of more 
than 8 percent annually, adding nearly 2 million younger 
recipients to the rolls, while the number of aged and blind 
recipients has remained level. The trend toward younger 
beneficiaries, coupled with low exit rates from the program, 
means that costs will continue to burgeon in the near term. 
Without a slowing in the growth of this younger population, SSI 
will become even more costly. Since 1991, three groups--
disabled children, legal immigrants, and adults with mental 
problems--have accounted for nearly 90 percent of the SSI 
caseload growth. Of the 2 million mentally disabled adults, 
roughly 100,000 are disabled mainly by drug addiction or 
alcoholism. The dramatic increases pose fundamental questions 
about eligibility standards, accountability, and program 
effectiveness.

Supplemental Security Income: Recipient Population Has Changed As 
        Caseloads Have Burgeoned (GAO/T-HEHS-95-120, Mar. 27, 1995)

    The SSI program provides means-tested income support 
payments to eligible aged, blind, or disabled persons. Last 
year, more than 6 million SSI recipients received nearly $22 
billion in federal benefits and more than $3 billion in state 
benefits. SSI is one of the fastest growing programs, with 
program costs soaring 20 percent annually during the past 4 
years. This testimony focuses on factors contributing to 
caseload growth, characteristics of SSI recipients, and ways to 
improve SSI.

                        VETERANS' AND DOD ISSUES

Defense Health Care: TRICARE Progressing, but Some Cost and Performance 
        Issues Remain (GAO/T-HEHS-96-100, Mar. 7, 1996)

    DOD's nationwide managed health care program--TRICARE--
represents a sweeping reform of the $15 billion per year 
military health care system. TRICARE seeks to improve access to 
care and ensure high-quality, consistent health care benefits 
for the 1.7 million active-duty service members and some 6.6 
million nonactive-duty beneficiaries. It also seeks to preserve 
choice for nonactive-duty beneficiaries by allowing them to 
choose whether to enroll in TRICARE Prime, which resembles an 
HMO; use a preferred provider organization; or use civilian 
health care providers under a fee-for-service arrangement. 
Despite initial beneficiary confusion caused by education and 
marketing problems, early implementation of the program is 
progressing consistent with congressional and DOD goals. 
Measures may be necessary, however, such as gathering cost and 
access-to-care data, to help the Congress and DOD better assess 
the program's future success. In addition, retirees, who make 
up half of those eligible for military health care, remain 
concerned about TRICARE's effect on their access to medical 
services.

VA Health Care: Approaches for Developing Budget-Neutral Eligibility 
        Reform (GAO/T-HEHS-96-107, Mar. 20, 1996)

    Reforming eligibility for health care benefits offered by 
VA would pose a major challenge even with unlimited resources. 
But with the Congress and VA facing mounting pressure to limit 
VA health care spending as part of governmentwide efforts to 
reduce the deficit, this challenge has become even greater. 
This testimony discusses (1) the problems that VA's current 
eligibility and contracting provisions create for veterans and 
providers, (2) the relationship between inappropriate 
admissions to VA hospitals and VA eligibility provisions, (3) 
proposals to reform VA eligibility and contracting rules and 
their potential impact on the deficit, and (4) options for 
achieving budget-neutral eligibility reform.

VA Health Care: Challenges and Options for the Future (GAO/T-HEHS-95-
        147, May 9, 1995)

    VA lags far behind the private sector in improving the 
efficiency of its hospitals. During the past decade, GAO has 
highlighted a series of management problems limiting VA's 
ability to (1) improve the efficiency and the effectiveness of 
its hospitals and (2) shift more of its inpatient care to less 
costly ambulatory settings. Although VA plans a major 
reorganization and other initiatives to improve its management 
capabilities, GAO remains concerned that some of the actions 
may not go far enough. Even if it improves the efficiency of 
its hospitals, VA is at a crossroads in the evolution of its 
health care system. The average daily workload in its hospitals 
dropped about 56 percent during the past 25 years, and further 
decreases are likely. At the same time, however, demand for 
outpatient care, nursing home care, and some specialized 
services is expanding, taxing VA's ability to meet veterans' 
needs. GAO concludes that a complete reevaluation of the VA 
health care system is needed. Absent such an effort, use of VA 
hospitals will likely continue to decline to a point at which 
VA's ability to provide quality care and support its secondary 
missions will be jeopardized.

VA Health Care: Efforts to Improve Veterans' Access to Primary Care 
        Services (GAO/T-HEHS-96-134, Apr. 24, 1996)

    VA runs one of the nation's largest health care systems, 
including 173 hospitals and 220 clinics. Last year, VA spent 
about $16 million serving 2.6 million veterans. This testimony 
focuses on VA's efforts to increase veterans' access to health 
care. GAO discusses legal, financial, and equity-of-access 
issues facing VA managers as they try to establish new access 
points--a VA clinic or a VA-funded or VA-reimbursed private 
clinic, group practice, or individual practitioner that is 
geographically separate from the parent facility. Access points 
are intended to provide primary care to all veterans and refer 
those needing specialized services or inpatient stays to VA 
hospitals.

VA Health Care: Issues Affecting Eligibility Reform (GAO/T-HEHS-95-213, 
        July 19, 1995)

    In this testimony GAO summarizes the results of a number of 
reviews that have detailed problems in administering VA's 
outpatient eligibility provisions; compared VA benefits and 
eligibility to those of other public and private health 
benefits programs; and assessed VA's role in a changing health 
care marketplace. In summary, veterans' eligibility for VA 
health care has evolved over time in terms of both the types of 
veterans eligible for care and the services they are eligible 
to receive. VA has gone from a system primarily covering 
hospital care for veterans with war-related injuries to a 
system covering a wide array of hospital and other medical 
services for both wartime and peacetime veterans and veterans 
both with and without service-connected disabilities. VA now 
has multiple categories of veterans eligibility based on a 
number of factors.

VA Health Care: Opportunities to Increase Efficiency and Reduce 
        Resource Needs (GAO/T-HEHS-96-99, Mar. 8, 1996)

    With a fiscal year 1995 appropriation of $16.2 billion, the 
VA health care system faces mounting pressure to contain or 
reduce spending as part of governmentwide efforts to reach a 
balanced budget. This testimony addresses (1) VA's forecasts of 
future resource needs, (2) opportunities to run the VA system 
more efficiently, (3) differences between VA and the private 
sector in terms of initiatives to become more efficient, and 
(4) recent VA efforts to reorganize its health care system and 
create incentives to operate more efficiently.

VA Health Care: Opportunities to Reduce Outpatient Pharmacy Costs (GAO/
        T-HEHS-96-162, June 11, 1996)

    VA allows its doctors to prescribe over-the-counter 
products because concerns have been raised that some veterans 
may lack the money to buy needed items. VA requires 
prescriptions as a way to control veterans' access to over-the-
counter products in VA pharmacies. In fiscal year 1995, for 
example, VA pharmacies dispensed analgesics, such as aspirin 
and acetaminophen, nearly 3 million times. The benefits package 
that most VA facilities offer for over-the-counter products is 
more generous than that available from other health plans. VA 
also provides other features, such as free over-the-counter 
product mail service and deferred credit for copayments owed, 
that are not common in other plans. GAO makes several 
suggestions for reducing the amount of money VA spends to 
dispense over-the-counter products. First, VA staff could more 
strictly adhere to statutory eligibility rules. Second, VA 
could more efficiently dispense over-the-counter products and 
collect copayments. Third, VA facilities could further reduce 
the number of over-the-counter products available to veterans 
on an outpatient basis. Finally, the Congress could expand 
copayment requirements.

Veterans' Benefits Modernization: Management and Technical Weaknesses 
        Must Be Overcome If Modernization Is to Succeed (GAO/T-AIMD-96-
        103, June 19, 1996)

    If the Veterans Benefits Administration (VBA) is to reduce 
operating costs and improve critical service to nearly 27 
million veterans and their dependents, it needs to streamline 
its business processes and take more advantage of information 
technology. However, VBA is experiencing many of the classic 
management and technical problems that have prevented federal 
agencies from reaping the benefits of substantial investment in 
information technology. This testimony discusses the steps VBA 
needs to take in the following three areas to improve its 
chances for success: (1) creating a credible business strategy 
and supporting an information resources management plan; (2) 
developing a better investment strategy for choosing and 
managing its portfolio of information technology projects in a 
more disciplined, businesslike way; and (3) strengthening its 
technical ability to develop software applications that are 
critical to its efforts to control costs and improve service to 
veterans.

Veterans' Health Care: Challenges for the Future (GAO/T-HEHS-96-172, 
        June 27, 1996)

    With a budget of $16.6 billion and a network of hundreds of 
hospitals, outpatient clinics, and nursing homes, VA's health 
care system provides medical services to more than 26 million 
veterans. VA has sought to fundamentally change the way in 
which it runs its health care delivery and financing systems. 
It has also sought authority to significantly expand 
eligibility for health care benefits and to both buy health 
care services from and sell them to the private sector. This 
testimony discusses (1) changes in the veterans population and 
the demand for VA health care services; (2) how well the 
existing VA system, and other public and private health 
benefits programs, meet the health care needs of veterans; (3) 
steps that could be taken, using existing resources and 
legislative authority, to address veterans' unmet health care 
needs and increase equity of access; (4) how other countries 
have addressed the needs of an aging and declining veteran 
population; and (5) approaches for preserving VA's direct 
delivery system, alternatives to preserving the direct delivery 
system, and combinations of both.





                  ITEM 22--LEGAL SERVICES CORPORATION

                              ----------                              


                          Service to the Aging

    The Legal Services Corporation (LSC) was created by 
Congress in 1974 to provide access to civil legal aid to low-
income Americans. The Corporation receives an annual 
appropriation from Congress. In 1996, LSC funded some 275 local 
legal aid programs across the country, serving every county in 
the nation.
    Legal services clients are as diverse as our nation, 
encompassing all races and ethnic groups and ages. The problems 
that bring people to local legal services offices arise out of 
everyday life. Usually they relate to matters of family law, 
housing, employment, government benefits, or consumer 
disagreements. Frequently they represent matters of crisis for 
clients and their families. The possible consequences may be as 
serious as the loss of a family's only source of income, 
homelessness, or the breakup of a family.
    In 1996, LSC-funded programs served 152,420 Americans over 
the age of 60. Older Americans represented 11 percent of the 
clients served by legal services programs. Because of their 
special health, income, and social needs, older people often 
require legal assistance, especially in coping with the 
government-administered benefits on which many depend for 
income and health care.
    Some local legal services programs have special elderly law 
units, but every program provides services to the elderly. Most 
LSC programs are listed in the blue or yellow pages of the 
phone book, usually listed under ``Legal Aid'' or ``Legal 
Services.'' You can also get a referral by calling LSC at (202) 
336-8800; going to the LSC web site (www.lsc.gov); or writing 
to Public Affairs, LSC, 750 First St., NE, Washington, DC 
20002.

                ITEM 23--NATIONAL ENDOWMENT FOR THE ARTS

                              ----------                              


   Summary of Activities Relating to Older Americans Fiscal Year 1997

                              introduction

    The National Endowment for the Arts holds as its guiding 
principle that the authentic experience of the arts should be 
available to the broadest public, including people of all ages. 
Through its grants programming and technical assistance, the 
Arts Endowment works to ensure the continued involvement of 
older adults in the arts as artists, teachers, mentors, 
volunteers, students, patrons and consumers. The wisdom, energy 
and creative potential that older Americans bring to the arts 
are part of our cultural heritage.

                        office of accessability

    Located in the Endowment's Partnership, Planning and 
Stabilization Division, the AccessAbility Office is the 
advocacy and technical assistance arm of the Arts Endowment 
that works to make the arts fully accessible to older adults, 
individuals with disabilities and people living in 
institutions. Through a wide variety of efforts, the 
Coordinator of this one-person office develops partnerships 
with grantees, private groups and other Federal agencies to 
better educate and assist access to the arts for the targeted 
populations. The focus is inclusion, opening up existing 
programs, and outreach to citizens who would not otherwise have 
opportunities to be involved in the arts.
    In addition to administering projects featured in this 
report, the Coordinator organizes and conducts panels and 
workshops for the arts community and organizations representing 
older or disabled people to better educate them concerning the 
value of making the arts accessible. During this reporting 
period, the Coordinator organized seminars for the National 
Council on Aging, the American Association of Museums, the 
Cleveland Arts Festival, Build Boston Conference, Dance 
Umbrella Festival, and the Southeastern Museum Conference. 
Further, she traveled to Natchez, Mississippi to assist 
Signature Works, the largest employer of people who are blind 
in the country, to assist them in developing ceramic and 
sculpture programs for its employees with the future 
possibility of marketing their art as one of its products.

           national database on the arts and older americans

    As a result of the Arts Endowment's work with the 1995 
White House Conference on Aging, this aging supported the 
creation of the first National Database on the Arts and Older 
Americans that was undertaken by the National Council on Aging 
(NCoA). This unique database should open the way to better 
communication between networks of arts organizations and aging 
groups to assist quality arts programming for, by and with 
older Americans. The database includes 536 agencies and 
individuals that are administering a wide variety of arts 
programming involving older adults. Of these, 328 are arts 
groups and the remainder consist of aging or educational 
agencies. The listings include program profiles and contact 
information. NCoA is presently working to post the database 
through its website.

      sense and sensitivity: a regional symposium on the arts and 
                             accessibility

    The Arts Endowment worked with Arts Midwest in Minnesota, a 
regional arts group that encompasses a nine state area, to 
convene a symposium that addressed access to the arts for older 
and disabled people. Convened in Milwaukee, Wisconsin on 
September 15-17, 1997, approximately 180 artists and arts 
administrators participated in the meeting to better educate 
themselves on making their own activities more available to 
older and disabled individuals; and educating their 
constituents about access issues.
    Over 35 acknowledged leaders in the arts and accessibility 
communities led workshops that focused on: design; performing 
and visual arts; outreach to people in institutions including 
nursing homes; and technology that is making the arts more 
accessible such as audio description and assistive listening 
systems.
    For example, Julie Bailey from the Iowa Arts Council 
presented their highly successful program, I Card, which 
involves 85 local arts councils and community agencies that 
work together to provide free or discounted admission for low 
income individuals and families to attend arts events 
throughout the state. Further, Patricia O'Mally from the 
Chicago Department of Aging discussed her agency's Renaissance 
Court, an arts program in downtown Chicago that includes a 
first rate gallery which showcases the work of artists over age 
55.
    This symposium represents the fourth in a series of 
regional access meetings over the past seven years sponsored by 
the National Endowment for the Arts.

                       careers in the arts forum

    The Arts Endowment developed a cooperative agreement with 
the John F. Kennedy Center for the Performing Arts to convene a 
national forum on ``Careers in the Arts'' that will take place 
at the Kennedy Center on June 14-16, 1998. This first-ever 
forum will bring together 230 artists, art technicians, art 
administrators, rehabilitation professionals and 
representatives of government agencies to focus on employment 
and education issues relating to individuals with disabilities 
in a wide variety of arts careers.
    A 17-member planning committee, composed of select 
leadership from the fields of the arts, rehabilitation and 
education, met at the Kennedy Center on September 21-23, 1997 
to develop a vision and shape for the forum, as well as, 
provide invaluable guidance on its objectives and program.
    This effort grew out of a series of interagency agreements 
that the Arts Endowment initiated with the U.S. Department of 
Education and the U.S. Department of Health and Human Services. 
The Federal agencies are joining with the Endowment in 
supporting the Forum to address their common concerns: the need 
for increased educational and career opportunities in the arts 
for people of all ages with disabilities; identifying obstacles 
and strategies to overcome them; and developing recommendations 
to advance arts careers for people with disabilities.

                            universal design

    The first collection of 37 Universal Design Exemplars, that 
represent examples of design excellence in the fields of 
architecture, graphic design, industrial design, interior 
design and landscape architecture, was supported by the Arts 
Endowment as highlighted in last year's report to the Special 
Committee. Universal design goes beyond codes and standards to 
create excellent design is usable by everyone throughout their 
lifespan. The collection is organized in a slide presentation 
with descriptive text, and is intended to encourage and assist 
the understanding and practice of this important design 
concept.
    On April 21, 1997, the AccessAbility Office worked with 
nine Endowment interns to organize and present the collection 
to staff from eight Federal agencies, including the Department 
of Justice and the Government Services Administration. Audience 
members found it to be comprehensive and said that they gained 
increased understanding concerning universal design and its 
importance to their respective fields.
    The Arts Endowment plans to support a second collection in 
1998 that will be disseminated to designers, city planners and 
others on CD Rom.

                         ARTS ENDOWMENT FUNDING

    Endowment supported programs are aimed at benefitting 
Americans of all ages. In addition, some projects specifically 
address older adults. For example:

Dance

    The Boston Dance Umbrella of Cambridge, Massachusetts 
received funding to support the 1997 International Festival of 
Wheelchair Dance, which took place June 2-14, 1997 in Boston. 
This unprecedented gathering featured performances, workshops, 
lecture/demonstrations, seminars, a conference, and a full 
program of education and community outreach activities. The 
Festival included both disabled and non-disabled artists who 
are developing this relatively new art form. Dance Umbrella 
collaborated with Very Special Arts Massachusetts and Axis 
Dance Troupe from Oakland, California to plan, implement and 
evaluate this highly successful project.
    Professional Flair Inc. of Cleveland, Ohio received funds 
to support the expansion of its dance troupe, Cleveland Ballet 
Dancing Wheels, to accommodate the increased demand for its 
lecture demonstrations. This pioneering dance company, that 
showcases dancers with disabilities, will add a second 
performing troupe of professional dancers with and without 
disabilities to present programs geared to a number of 
different audiences, such as nursing homes, schools, and 
colleges.

Folk arts

            Fellowships
    Seven National Heritage fellowships were awarded to artists 
fifty-five years and older in recognition of their outstanding 
contributions to the traditional arts. These artists include an 
acadina spinner & weaver, a North American sarod player & raga 
composer, two bluegrass musicians, an African American quilt 
maker, as well as the following:
    Charles Brown is a West coast Blues pianist and singer 
originally from Texas City, Texas. His sophisticated approach 
blends classical music technique with the blues and jazz. Brown 
was one of ``The Three Blazers,'' whose sound epitomized the 
relaxed West Coast piano trio style and integrated a blues 
quality to the music. He toured with artists such as Fats 
Domino, Bill Doggett, Roy Brown, and Amos Milburn, and was 
inducted into the Blues Foundation's Blues Hall of Fame in 
1977.
    Wenyi Hua, a Chinese Kunqu opera singer, was born in 
Shanghai, China and lives in Arcadia, CA. Her gesticulation, 
diction, and beautiful voice earned her many honors. In 1978, 
she joined the Shanghai Kun Opera Company and later became its 
director in 1985. In 1986, she received China's highest 
artistic honor, the Plum Blossom Award for her performance in 
the play ``Yun Zan Ji'' (The Jade Hairpin). Chinese opera 
scholar Dr. Pertel Jain describes her artistry, ``Wenyi Hua is 
a rare theater performer who transcends the boundaries of the 
form, reaching a profound understanding of dramatic character 
which is almost spiritual in nature.''
    Francis Whitaker is a Blacksmith/Ornamental Ironworker from 
Wodurn, Massachusetts. At sixteen, he dropped out of high 
school to become an apprentice with a premier ornamental 
blacksmith, Samuel Yellin, in Philadelphia. Whitaker said,: 
``The first time I shaped a piece of hot iron, I was hooked. 
There's magic to it.'' After working for a general contractor 
for seven years, he opened his own shop in 1933, during the 
depths of the Depression. He spent 20 years teaching across the 
United States and founded the Francis Whitaker Blacksmith 
School at the Rocky Mountain School. Whitaker received the 1995 
Colorado Governor's Award for Excellence in Arts and an 
Honorary Doctorate in Humane Letters from the University of 
Colorado.
    The Los Reyes de Albuquerque of New Mexico received funding 
to support a year-long series of performances of traditional 
New Mexican Hispanic music for children, older people, homeless 
individuals, and institutionalized people. This non-profit 
organization is the result of the efforts of the folk group of 
Los Reyes de Albuquerque which was founded some thirty-three 
years ago. The purpose of the Los Reyes de Albuquerque 
Foundation is to preserve, promote and perpetuate the 
traditional Hispanic music and songs of northern New Mexico and 
southern Colorado.

Media arts

    The Film Arts Foundation of San Francisco, California, 
received funding to support the production of a documentary 
film by Allie Light and Irving Saraf about the work of seven 
imaginative people with physical disabilities. 
``Dreamwalkers'', the film's working title, explores each 
person's concept of motion through thought, fantasy, and 
dreams. Combining cinema verite footage of the subjects with 
dramatizations and visualizations of their thoughts, which have 
been shared through interviews, the film portrays their lives.

Museum

    The Wichita Art Museum of Wichita, Kansas, received funding 
to support the expanded use of its Art Resource Center, a new 
museum facility that serves as a lending library of audio-
visual materials about the visual arts for teachers, parents 
and community groups. The Center opened in 1995 and acquired 
over 13,000 constituents in less than twelve weeks. This 
Resource Center is the only one of its kind in the state that 
reaches out to include parents, day care providers, recreation 
leaders, senior center participants and other community groups 
in its activities.

Theater

    The Stagebridge Theater of Oakland, California received 
funding to support its intergenerational arts and literacy 
project, Storybridge, where low-income older adults interact 
with at-risk children through a program of story telling in the 
schools and various community venues. Its goal is to develop 
literacy skills for young and old, particularly at-risk 
elementary age children and low-income, minority elders. All 
facets of their programs include curriculum guides and 
materials. Storybridge presents three inventive programs: The 
first is entitled, ``Grandparents Tales,'' which features a 
play performance about grandparents from different cultures and 
is performed by a multicultural cast of older actors. The 
second program, ``Senior Storytellers in the Schools,'' 
recruits and trains older adults to be storytellers in Oakland, 
Berkeley and San Francisco schools. The third is a storytelling 
assembly in which Stagebridge tours its experienced ``band of 
elder storytellers'' to local schools where students in small 
groups hear multiple pairs of storytellers.

Visual arts

    The Clay Studio of Philadelphia, Pennsylvania received 
funding to support the circulation of the ``Claymobile,'' a 
ceramics class in a van that travels to inner city and low 
income Philadelphia communities. The van goes to specific 
locations such as cultural centers, programs for older adults, 
after-school programs, homeless shelters, summer camps and 
schools. The Claymobile contains a complete stash of equipment 
and materials necessary to teach a class and transport the 
finished pieces back to the Clay Studio for firing. This art 
program broadens access to quality arts classes and increases 
the participation of many populations who are undeserved in the 
arts.
    The Little City Foundation of Palatine, Illinois received 
funding to support a two-phase exhibition of artwork created by 
people with developmental disabilities in the Chicago 
metropolitan area. The exhibitions include drawings, paintings, 
sculptures, prints, and performance works. The purpose of this 
effort its to bring more public attention to the art of 
individuals with developmental disabilities. This both 
increases the market for their work and attracts additional 
people with disabilities to the Foundation's programs. The 
project also intends to encourage purposeful discussion about 
the disability culture and the use of art as an important means 
of cultural self-expression.
    The Grass Roots Arts and Community Efforts (GRACE) of West 
Glover, Vermont received funding to promote a ``Twenty Years of 
GRACE--An Inside View,'' a collection of work and biographies 
of self-taught artists in northern rural Vermont, that will be 
published in May 1998. This 30-page book will celebrate the 
work of GRACE's participants as well as interpret its history, 
philosophy and methods of working for a broad audience. GRACE 
primarily works with artists who require long-term care. In 
nursing homes, town halls, day-care centers, and hospitals, 
participants are encouraged to work independently, exploring 
their own creative capabilities.

             ITEM 24--NATIONAL ENDOWMENT FOR THE HUMANITIES

 National Endowment for the Humanities Report on Activities Affecting 
             Older Americans in Fiscal Years 1995 and 1996

                           lifelong learning

    Grants awarded by the National Endowment for the Humanities 
support teaching, scholarship, and programs for the general 
public in history, literature, philosophy, and other 
disciplines of the humanities. The purpose that NEH exists to 
foster--the transmission of knowledge to succeeding 
generations, the creation of new knowledge, and the diffusion 
of cultural opportunity--are really manifestations of the same 
thing; they express our national commitment to, in the words of 
the Endowment's authorizing legislation, ``progress and 
scholarship in the humanities.'' In the American democratic 
context, that commitment has meant, among other things, 
ensuring a continuum of possibility for lifelong learning for 
everyone, of whatever age.
    Guaranteeing the availability of lifelong learning 
opportunities for older Americans in particular has never been 
a greater national priority than it is now. According to 
projections of the U.S. Census Bureau, the percentage of the 
population that is 65 or older, currently 12.5 percent, will 
rise to 18.5 percent by 2025. Living longer, older Americans 
are spending more years in retirement and enjoying better 
health as they do. Not only are older Americans more vigorous, 
but they are also better educated than ever before; 65 percent 
of Americans 65 or older have at least a high school diploma, 
14 percent have completed four years of college. Of course, the 
approaching retirement of the Baby Boom generation will only 
intensify these trends.
    Active engagement with learning can make retirement more 
productive and fulfilling, stimulating continued intellectual 
growth and interaction with others. But, learning is the task 
of a lifetime, not just of the retirement years. In a special 
paper prepared for the President's Committee on the Arts and 
the Humanities, Ronald J. Manheimer, director of the North 
Carolina Center for Creative Retirement at the University of 
North Carolina, Ashville, comments as follows:

          Most of the research findings in the field of 
        gerontology support the ``continuity theory of aging,'' 
        that people not only remain pretty much the same, in 
        terms of taste, interests and choice of activities from 
        earlier in adulthood, they become even more who they 
        were--preferences, like personality traits, 
        intensifying.

    School children whose earliest experience of literature 
will be more memorable because a favorite English teacher has 
attended a substantive summer study program; undergraduates 
whose understanding of history is grounded in the most current 
scholarship because those who teach that subject in America's 
colleges and universities have access to research fellowships 
and other opportunities for professional growth; and working 
adults who can find cultural enrichment in libraries and 
museums or on television in the communities where they live--
these are the ultimate beneficiaries of NEH grant programs that 
help sustain a continuum of lifelong learning opportunities for 
everyone. The benefits that Americans derive from these 
experiences will accrue throughout a lifetime, and not least 
during the years of retirement.

                            library programs

    During fiscal years 1995 and 1996, more than 40,000 NEH-
supported reading and discussion programs took place in more 
than 800 libraries and other community-based institutions 
nationwide. These activities are open to the general public, 
but the scholars and other specialists who direct them report 
especially strong participation by older Americans.
    Some reading and discussion programs are designed 
specifically for seniors. For example, in FY 1995 a grant of 
$70,000 enabled the National Council on the Aging to conduct 
reading and discussion programs in senior centers, nursing 
homes libraries, and veterans hospitals throughout the country. 
The project brought together scholars, veterans, factors and 
farm workers, teachers, and high school and college students to 
discuss ``Remember World War II.'' An anthology and discussion 
guide, developed with grant funds, provided the thematic and 
chronological focus for each discussion group, and was 
augmented by activities such as listening to tapes of radio 
broadcasts during the war. In FY 1996, the National Council on 
the Aging received $50,000 to conduct programs that encourage 
seniors to read and discuss literary autobiographies by authors 
of their own generation. Held at libraries and senior centers 
in six states and employing instructional materials developed 
under a previous NEH grant, the programs focused on 
autobiographical works by Richard Wright, Philip Roth, Maxine 
Hong Kingston, and Eudora Welty.
    Most NEH-supported reading and discussion programs are 
geared to intergenerational audiences, but all are well suited 
to the needs of older Americans, based as they are on locally 
available resources and activities that are intellectually 
stimulating without being physically demanding. Many of these 
library-based programs reach urban and rural communities that 
have few other sources of cultural enrichment. In FY 1996, the 
American Library Association received $400,000 to conduct a 
series of library-sponsored, radio call-in programs on 
Northwest and Southwest regional writing. Developed in 
coordination with radio stations in Albuquerque and Missoula, 
the programs were based on regionally significant works by such 
writers as Mark Twain, Rudolfo Anaya, Denise Chavez, Frank 
Waters, Lislie Silko, and James Welsh. More than 50 libraries 
in nine states distributed books and other educational 
materials toparticipating readers, who during the regular 
program broadcasts conducted live, on-air discussions with studio-based 
scholars via an 800 number.

                           museum exhibitions

    Museum attendance is now one of the most popular 
recreational activities in the United States. In New York, 
museums annually generate considerably larger audience figures 
than do all of the city's professional sports teams combined. 
That older Americans should be a part of this is not 
surprising; today's seniors are more active and better educated 
than ever before. According to a survey commissioned by the 
National Endowment for the Arts, 16 percent of adults 65 or 
older visited an art museum at least once during a 12-month 
period (1992), and 20 percent of the immediate post-retirement 
cohort aged 65 to 74 did so. Impressive as these figures are, 
they do not take account of additional numbers of older 
Americans who may have visited historical and other kinds of 
museums.
    At any time during FY 1995 and FY 1996, between 100 and 150 
different, NEH-funded museum exhibitions could be seen at over 
400 locations throughout the United States. Exhibitions 
supported by the Endowment are ideally suited to the needs of 
retirees living on a fixed income; museums agree as a condition 
of their NEH grant to set aside at least several admission-free 
hours each week.
    One of these exhibitions available to seniors free of 
charge was Splendors of Imperial China, which attracted 427,000 
visitors at its Metropolitan Museum of Art venue in New York, 
making it the world's biggest museum attraction in 1996. 
Incorporating approximately 350 objects from among the finest 
and most famous artworks in the Asian tradition--including 
paintings and calligraphy, and works in jade, bronze, and 
lacquer, many of them leaving China for the first time--the 
show provided a visually stunning and richly interpreted 
perspective on Chinese history and culture from the Neolithic 
period to the 18th century. After leaving New York, the show 
traveled to Washington, DC, Chicago, and San Francisco. In St. 
Louis, Meet Me at the Fair: Memory, History, and the 1904 
World's Fair Exhibition, supported with a $300,000 grant to the 
Missouri Historical Society, employed the family mementos and 
taped reminiscences of Fair participants, along with 
photographs, artifacts, and documents to examine the impact of 
this defining event on St. Louis' civic identity. After Louis 
Armstrong: A Cultural Legacy was shown during 1995 at the 
Queens Museum of Art in New York, a smaller version of the 
exhibition, also developed with NEH support and with a 
Smithsonian SITES grant, traveled during 1996 to seven other 
cities: Dallas; Chicago; Charleston; New Orleans; Rochester, 
New York; Savannah; and Washington, D.C.
    Seniors who do not happen to live near a major urban center 
can still see an engaging and thought-provoking exhibition. 
Barn Again!, examines that familiar agricultural structure as 
functional form, monument on the landscape, and symbol of 
community and country life. Developed by the Utah Humanities 
Council in cooperation with the humanities councils in Alabama, 
Georgia, Oregon, Ohio, West Virginia, Illinois, and Missouri, 
and with a $115,000 from NEH, the exhibition has been touring 
32 small rural museums and historical societies since 1996.

                        television documentaries

    Public television reaches virtually every community and 
home in the United States. During 1995 and 1996, millions 
nationally watched such NEH-funded documentaries as Ken Burns' 
12-hour series, The West; the eight-hour series, The Great War 
and the Making of the Twentieth Century; the four-and-a-half-
hour series FDR; and Ken Burns' Baseball, rebroadcast in 1995 
after this fall 1994 premier. For seniors who have limited 
mobility or who simply prefer to stay home, wholesome, serious 
viewing choices such as these are an especially welcome 
alternative to the usual fare of sitcoms and tabloid news 
offered on commercial television.

                            cultural tourism

    More and more Americans are discovering the special places 
in every region of the United States that attest to the history 
and cultural uniqueness of the American experience. NEH grants 
for site interpretation, and the historical and archival 
research that make it possible, continually reinforce this 
process of self-discovery, helping Americans make tangible 
connections with the past that is our common patrimony. Older 
Americans, the generation that has the biggest stake in the 
past and the time that the retirement years afford for travel, 
are enthusiastically joining the burgeoning ranks of cultural 
tourists. In 1992, according to the NEA-commissioned survey 
Arts Participation in America, 22 percent of American 65 or 
older visited an historical park at least once, and 29 percent 
of those between 65 and 74 did so.
    A few examples will suffice to show the range of NEH-
supported projects underway, in communities large and small, to 
reclaim our historic places. In FY 1996, an NEH grant of 
$150,000 enabled the Mississippi River Museum in Dubuque, Iowa, 
to begin interpretation of the riverfront site of the Dubuque 
Boat and Boiler Works, where Mississippi riverboats were built 
and launched for over 100 years. In FY 1995, the Florida 
Division of Historical Resources received $250,000 to interpret 
the site of the 17th-century Spanish mission at San Luis de 
Talimali. Based on more than a decade of work by archaeologists 
and historians, much of it supported by the Endowment, the 
fifty-acre historical park includes an audiovisual orientation, 
living history demonstrations, an interpretive trial through 
six excavation sites, and an exhibition explaining the current 
archaeological research. In FY 1995, the Lower East 
SideTenement Museum in New York opened an NEH-supported exhibition and 
tour program that interprets the authentically reconstructed interior 
of an actual tenement building and documents the lives of the Gumpertz 
and Baldizzi families, who lived there between 1865 and 1935.

                            senior scholars

    NEH grants support a number of long-term research projects 
in the humanities that have been directed and sustained over 
the years by some of the most eminent scholars in their field. 
Not a few of these renowned scholars are quite senior; yet 
despite their emeritus status they cheerfully persevere in the 
research work they know supremely well. Thus, Endowment support 
of senior scholars benefits the public in two ways; it enables 
uniquely qualified individuals to continue contributing 
authoritatively to the advancement of humane learning, and it 
incidentally furnishes the rest of us with inspirational 
examples of active engagement well past the traditional age of 
retirement. Anne Frior Scott of Duke University, editor of the 
Jane Addams papers; independent scholar Frederick Burkhardt, 
who is compiling an edition of the correspondence of Charles 
Darwin under the auspices of the American Council of Learned 
Societies; Dorothy Twohig of the University of Virginia, editor 
of the papers of George Washington; and Frederic Cassidy of the 
University of Wisconsin, editor of Dictionary of American 
Regional English--these are among the senior, but-still-active 
scholars whose work NEH research grants supported during fiscal 
years 1995 and 1996.
    Each year the Endowment chooses an exemplary scholar and 
teacher to deliver the Jefferson Lecture in the Humanities, the 
highest honor bestowed by the federal government for 
intellectual achievement. Not coincidentally, many of the 
scholars so honored have been among the most senior members of 
their profession. The 1995 Jefferson Lecturer was Vincent 
Scully, architectural historian and legendary teacher of 
generations of undergraduates at Yale University.

                           non-discrimination

    Older scholars have always been eligible to compete for 
Endowment support on the same basis as all other similarly 
qualified applicants. Accordingly, no information regarding age 
is requested from applicants, and funding application are 
evaluated and grants awarded exclusively on the basis of the 
merit of the proposed activities. Each year, numerous projects 
are funded that involve older persons as primary investigators, 
project personnel, or consultants. Each year, older persons 
serve on the NEH peer panels that evaluate grant applications 
for funding.
    NEH publications notify the public that the Endowment does 
not discriminate on the basis of age. The Endowment also has a 
special telephone number for the deaf and hearing impaired to 
use in requesting information. Alternative format publications 
concerning Endowment programs (i.e., audio tapes, large print) 
are also made available upon request. In addition, the 
Endowment maintains a site on the world wide web that provides 
information about current projects and grant application 
requirements. The Endowment encourages applicants to consider 
issues related to program as well as architectural 
accessibility in early planning stages of a project. Costs of 
exhibition and program accommodations for people with 
disabilities are generally eligible project costs.

                       state humanities councils

    In addition to activities benefiting older Americans that 
the Endowment supports directly, library programs, exhibitions, 
speakers bureaus, and other programs for the general public--
and in many cases, for older audiences in particular--are 
provided at the local level by the Endowment's affiliates, the 
state humanities councils. The Federal/State Partnership of the 
Endowment makes grants to humanities councils in 50 states, 
Puerto Rico, the Virgin Islands, the Marianas, and Guam. The 
special emphasis of the state humanities councils is to make 
focused and coherent education possible in places and by 
methods that are appropriate for adults.

                  ITEM 25--NATIONAL SCIENCE FOUNDATION

                              ----------                              


      National Science Foundation Report for Developments in Aging

    The National Science Foundation, an independent agency of 
the Executive Branch, was established in 1950 to promote 
scientific progress in the United States. The Foundation 
fulfills this responsibility primarily by supporting basic and 
applied scientific research in the mathematical, physical, 
environmental, biological, social, and engineering sciences, 
and by encouraging and supporting improvements in science and 
engineering education. The Foundation does not support projects 
in clinical medicine, the arts and humanities, business areas, 
or social work. The National Science Foundation does not 
conduct laboratory research or carry out educational projects 
itself; rather, it provides support or assistance to grantees, 
typically associated with colleges and universities, who are 
the primary performers of the research.
    The National Science Foundation is organized generally 
along disciplinary lines. None of its programs has a principal 
focus on aging-related research; however, a substantial amount 
of research bearing a relationship to aging and the concerns of 
the elderly is supported across the broad spectrum of the 
Foundation's research programs. Virtually all of this work 
falls within the purview of the Directorate for Social, 
Behavioral, and Economic Sciences and the Directorate for 
Engineering.

    directorate for social, behavioral, and economic sciences (sbe)

    The Directorate for Social, Behavioral, and Economic 
Sciences supports research in a broad range of disciplines and 
interdisciplinary areas through its Division of Social, 
Behavioral, and Economic Research. For example, sociological 
research is being supported which examines how the labor force 
participation and earnings of older Americans have been 
affected by recent economic trends; how Americans in their 50's 
cope with the dual pressures of supporting aging parents and 
grown children; how income distribution differs between the 
``young old'' and the ``old old,'' and how the degree of 
political activism of older Americans has changed over time in 
the twentieth century. Projects within anthropology are being 
supported to examine how economic development affects patterns 
of caring for dependent elderly, and with cognitive psychology 
to examine the extent to which knowledge acquired in youth is 
retained in later life.
    The SBE Directorate also supports several large-scale data 
gathering efforts which can be and have been used to study 
issues related to aging, although that is not their sole or 
even primary purpose. For example the Panel Study of Income 
Dynamics, which has been tracking a sample of more than 7,000 
American families since 1968, provides information on changing 
household composition, labor force participation, income, 
assets, and consumption patterns as individual respondents grow 
older. The General Social Survey, which has carried out sample 
surveys of the U.S. adult population more or less annually 
since 1972, contains several attitudinal items dealing with the 
status of, and care for, the elderly. These surveys enable 
researchers to examine how attitudes toward the elderly have 
changed over time and how age groups differ across a wide range 
of opinion areas. The National Election Survey, which has 
studied American elections since 1952, provides information on 
how attitudes regarding candidates and issues vary across age 
groups. The SBE Directorate is also supporting a project that 
will make available to researchers in a consistent and readily 
usable form public use microdata from the U.S. censuses from 
1850 through 1990. When completed, this project will make it 
possible to examine how the status and family relationships of 
older Americans have changed over the course of a century and a 
half.

                   directorate for engineering (eng)

    The National Science Foundation's Directorate for 
Engineering seeks to enhance long-term economic strength, 
security, and quality of life for the Nation by fostering 
innovation, creativity, and excellence in engineering education 
and research. This is done by supporting projects across the 
entire range of engineering disciplines and by identifying and 
supporting special areas where results are expected to have 
timely and topical applications, such as biotechnology and 
materials processing.
    Aging-related research is primarily supported within the 
Directorate for Engineering through the Biomedical Engineering 
and Research to Aid Persons with Disabilities programs. 
Research funded in this program relates to issues of aging and 
the elderly due to the propensity for the elderly to develop 
physical disabilities. Projects recently supported by this 
program include the following studies:
          Biophysical mechanisms of cartilage repair and 
        generation;
          Mechanisms of drug delivery in the treatment of 
        various diseases, including those associate with aging, 
        such as diabetes;
          Simple, noninvasive, quantitative methods to assess 
        postural instability associated with aging;
          Investigation of biodegradable polymer matrices to 
        support the growth of bone and the generation of bone-
        like tissues for application in osteoporosis;
          A variety of activities involving joint replacement, 
        including computer assisted design of orthopedic 
        surgery, cementing techniques, failure detection 
        techniques, and the pathophysiology of implant device-
        related infection;
          An image processing system for low vision people such 
        as those with age-related maculopathies;
          A visual speech articulation training aid for the 
        hearing impaired; and
          Undergraduate projects by student engineers to design 
        and fabricate custom designed devices and software for 
        disabled individuals.
    While these projects are not specifically directed toward 
problems of aging, all of these studies have potential for 
dealing with conditions prevalent among the elderly.

             ITEM 26--PENSION BENEFIT GUARANTY CORPORATION





                        ITEM 27--POSTAL SERVICE

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                   Programs Affecting Older Americans

                              vote by mail

    Many states have arranged for voting through the mail. This 
allows voters who are unable to visit a polling place, such as 
the elderly and physically impaired, to enjoy the convenience 
and security of voting through the mail.

                         carrier alert program

    Carrier Alert is a voluntary community service provided by 
city and rural delivery letter carriers who watch participants' 
mailboxes for mail accumulations that might signal illness or 
injury. Accumulations of mail are reported by carriers to their 
supervisors, who then notify a sponsoring agency, through 
locally developed procedures, for follow-up action. The program 
completed its 15th year of operation in 1997 and continues to 
provide a lifeline to thousands of elderly citizens who live 
alone.

                        delivery service policy

    The Postal Service has a long-standing policy of granting 
case-by-case exceptions to delivery regulations based on 
hardship or special needs. This policy accommodates the special 
needs of the elderly, handicapped, or infirm customers who are 
unable to obtain mail from a receptacle located some distance 
from their home. Information on hardship exceptions to delivery 
receptacles can be obtained from local postmasters.

               services available from your rural carrier

    Rural carriers continue to provide their customers with the 
retail services they have come to expect from the rural ``post 
office on wheels.'' Some of the retail services provided by 
rural carriers are registered and certified mail, accepting 
parcels for mailing, taking applications for money orders, and 
providing their customers with receipts for these services.
    Retail services are available to all customers served by 
rural carriers but are most beneficial to those individuals who 
are elderly or have a physical handicap which limits their 
ability to go to the post office for these important services. 
Rural carriers provide their customers with almost all retail 
services available from the post office 302 days per year.

                        parcel delivery policies

    For customers who are unavailable to receive parcels, but 
who normally are at home, we automatically redeliver the 
article on the following day. Additionally, if the mailer 
requests, uninsured parcels are left at customers' homes or 
businesses provided there is reasonable protection from the 
weather and theft. Both of these policies make it easier for 
customers to receive mail, and minimize the need for trips to 
the post office.

                             accessibility

    The Postal Service is subject to the Architectural Barriers 
Act of 1968. The resulting standards for the design, 
construction, and alteration of leased and owned facilities, 
are published in the Postal Service Handbook RE-4, Standards 
for Facility Accessibility by the Physically Handicapped.
    Significant progress continues to be made to increase the 
accessibility of the 36,000 Postal Service facilities. In 
Fiscal Year 1997, approximately $16 million were invested in 
accessibility projects, with most of it spent on retrofitting 
historic facilities. Also, 823 new facilities meeting the 
highest access standards were opened. Our commitment to 
barrier-free facilities is apparent as over $300 million has 
been spent in the last 10 years on accessibility projects. The 
Postal Service values its elderly customers and feel they will 
benefit from our efforts to make facilities more accessible.

                consumer education and fraud prevention

    The Postal Inspection Service endeavors to alert consumers 
and businesses to current crimes by attracting media attention 
to postal crime trends, publicizing positive law enforcement 
accomplishments, circulating media releases and hosting crime 
prevention presentations.
    In February 1997, the Inspection Service joined with the 
American Association of Retired Persons (AARP) and the Attorney 
General's Office of the State of New Mexico in a continuing 
public education initiative aimed at preventing telemarketing 
fraud. Volunteers from the Albuquerque area AARP, state and 
local consumer protection agencies, the New Mexico Attorney 
General's Office, and the Postal Inspection Service worked 
together to turn the tables on crooked boiler room operators. 
Using lists of previous victims of telemarketing fraud and 
names of seniors gleaned from commercial phone lists, 
volunteers telephoned 1,500 New Mexico residents to warn them 
of the dangers of telemarketing fraud.
    This same tactic, on a somewhat larger scale, was attempted 
with great media interest in Los Angeles in February 1998. 
Postal Inspectors teamed with FBI Special Agents and AARP 
members in a ``reverse boiler room'' operation underwritten by 
CellularOne of Los Angeles. Approximately 5,000 previous 
victims were contacted by phone and warned of possible renewed 
attempts by con artists to contact them by phone or mail.
    In New Jersey and Massachusetts, inspectors and local AARP 
volunteers formed partnerships to educate senior citizens about 
some of the fraudulent promotions which target the elderly 
through direct mail and telemarketing schemes. Senior 
volunteers were recruited to participate by collecting all 
questionable or suspicious unsolicited promotional mailings 
received during a specific period of time. Volunteers also kept 
a log of all unsolicited telemarketing calls received. 
Everything collected by the volunteers was turned over to 
inspectors for examination and follow-up attention. The results 
of the seniors' collection effort and the inspectors' 
preliminary investigations were publicized with media 
cooperation. This served to highlight drmatically the quantity 
of fraudulent solicitations which target senior citizens.
    At a joint press conference in September 1997, the Chief 
Postal Inspector, and members of the AARP, FTC and the 
Attorneys General Offices of Massachusetts and Arizona, via 
satellite, announced Operation Mailbox. This cooperative effort 
focused attention on unsolicited mailings received by seniors, 
including suspicious prize offerings, sweepstakes promotions 
and requests for charitable contributions. Senior volunteers 
collected hundreds of unsolicited mailings which were displayed 
dramatically at the press conference. Inspectors have been 
working with the other agencies to review the mail collected 
through Operation Mailbox and identify offers or solicitations 
which may require follow-up investigation.
    Senior victimization also was the topic of a Dateline NBC 
story which featured the Inspection Service's efforts to stop 
the flood of illegal foreign lottery mailings entering the 
United States. The story focused on the success inspectors have 
achieved in identifying illegal mailings at border entry 
points, with the assistance of the U.S. Customs Service, which 
has led to the seizure and destruction of over 4.5 million 
pieces of foreign lottery mail. The story also explored the sad 
tales of financial ruin suffered by many elderly victims of 
these schemes who seem easy prey to the allure of promised 
multi-million dollar jackpots.

                   injunctions and other civil powers

    In addition to the investigation of individuals or 
corporations for possible criminal violations, the Inspection 
Service can protect consumers from material misrepresentations 
through the use of several statutes. In less severe cases, 
operators of questionable promotions agree to a Voluntary 
Discontinuance. This is an informal promise to discontinue the 
operation of the promotion. Should the agreement be violated, 
formal action against the promoter could be initiated. In 
certain cases where a more formal action is better suited, a 
Consent Agreement is obtained. Generally, a promoter signs a 
Consent Agreement to discontinue the false representations or 
lottery charged in a complaint. If this agreement is violated, 
the Postal Service may withhold the promoter's mail pending 
additional administrative proceedings.
    The Postal Service (Judicial Officer) is empowered under 39 
U.S.C. (b)(2) to issue a Cease and Desist (C&D) Order which 
requires any person conducting a scheme in violation of Section 
3005 to immediately discontinue. C&D orders are issued as part 
of a False Representation order and, as a matter of course, are 
agreed to as a part of a Consent Agreement. Violators of C&D 
orders may be subject to civil penalties under 39 U.S.C. 3012. 
When more immediate relief to protect the consumer is 
warranted, the Postal Service has a number of effective 
enforcement options available. Title 39 U.S.C. 3003 and 3004 
enables the Postal Service, upon determining that an individual 
is using a fictitious, false, or assumed name, title, or 
address in conducting or assisting activity in violation of 18 
U.S.C. Sections 1302 (Lottery), 1341 or 1342 (Mail Fraud), to 
withhold mail until proper identification is provided and the 
person's right to receive mail is established.
    In those instances where a more permanent action is 
necessary, 39 U.S.C. 3007 allows the Postal Service to seek a 
Temporary Restraining Order detaining mail. By withholding 
service to the suspected violator, the extent of victimization 
is limited while an impartial judge reviews the facts and makes 
a final determination. If the judge decides that all mail 
pertaining to the promotion should be returned, then a False 
Representation Order, authorized under 39 U.S.C. 3005 is 
issued. In addition, U.S. District Judges may hold a hearing on 
alleged fraudulent activity, and issue a permanent injunction 
regarding the operation pursuant to 18 U.S.C. 1345.
    By requesting the court to withhold mail while a case is 
argued, Postal Inspectors have been successful in many cases in 
limiting the extent of victimization. Action under these 
statutes does not preclude criminal charges against the same 
target.

                       customer advisory councils

    In October 1988, the Postal Service introduced the concept 
of Customer Advisory Councils (CACs). The council concept was 
developed to encourage community interaction with local postal 
officials. CACs provide one more way for the Postal Service to 
listen to its customers. In 1995 the number of active councils 
grew to 1,778 nationwide, and almost 2,000 in Fiscal Year 1996.
    CAC membership usually includes up to 10 individuals who 
are representative of their community; small business owners, 
local government officials, university/college students, 
homemakers, and retired persons. Retired persons play an 
integral role in many of the council efforts, including 
``mystery shopping'' where members ``shop'' the various post 
offices, stations and branches to rate the cleanliness of the 
facility, clerk knowledge, courtesy, and other related aspects 
of our retail services. The valuable feedback received from 
councils is often used by local postal officials to improve 
service.

                        national consumers week

    The Postal Service has sponsored an annual Consumer 
Protection Week since 1977. Since 1980, the Postal Service has 
scheduled its observance to coincide with the National 
Consumers Week sponsored by the U.S. Office of Consumer 
Affairs. Postmasters and facility managers are urged to sponsor 
special activities to educate customers about postal products 
and services as well as Postal Inspection Service efforts to 
protect consumers from perpetrators of fraudulent schemes and 
other postal crimes. In conjunction with open houses and 
special gatherings scheduled during National Consumers Week, 
brochures are distributed to warn consumers about mail fraud 
and misrepresentations of products and services sold by mail. 
Helpful information about proper addressing of mail, packaging 
parcels correctly, temporary address changes, sending valuables 
through the mail, and how to report service problems are made 
widely available through planned events. As medical fraud and 
work-at-home schemes have traditionally ranked at the top of 
fraudulent promotions, the focus of material distributed is 
frequently directed toward alerting senior citizens of these 
other schemes.

                Stamps by Automated Teller Machine (atm)

    Stamps by ATM is one of the Stamps to Go Services and a 
convenient way to purchase stamps at a bank's automated teller 
machine. A specially designed sheetlet of 18 First-Class stamps 
is dispensed at the touch of a button. The cost is debited from 
your checking or savings account, treated like a cash 
withdrawal. Because many ATMs are accessible 24 hours a day, 
our customers are able to do banking and buy postage stamps at 
their convenience.

                             stamps by mail

    Stamps by Mail is another one of the Stamps to Go Services 
that allows postal customers to purchase postal products such 
as booklets, sheets, coils, postal cards, and stamped 
envelopes, by ordering through the mail.
    The Stamps by Mail program benefits a wide variety of 
people and is particularly beneficial to elderly or shut-in 
customers who cannot travel to the post office. Stamps by Mail 
provides order forms incorporated in self-addressed postage-
paid envelopes to customers for their convenience in obtaining 
products and services without having to visit a Postal Service 
retail unit. The form is available in lobbies or from the 
customer's letter carrier. The customer fills out the order 
form and returns it to the carrier or drops it in a collection 
box. Orders are normally returned to the customer within 2 or 3 
business days.

                            stamps by phone

    Stamps by Phone is a convenient program that is intended to 
target business, professional, and household customers who are 
willing to pay a service charge for the convenience of ordering 
by phone and paying by credit card (VISA or Master Card) to 
avoid trips to the post office. The customer calls the (1-800-
STAMPS-24) toll-free number, 24 hours a day, 7 days a week, and 
orders from a menu of postal products. There is no minimum 
amount and customers will receive their order within 3 to 5 
business days.

                 window automation at retail facilities

    The Postal Service is installing automated retail systems 
called Point of Service One at the service windows in retail 
facilities in all medium to large cities. These terminals use 
video screens to display information about each transaction for 
the customer. The screens show mailing options, value added 
services, required mailing forms, total amount due, and change 
from the amount tendered. The display of this type of 
information is useful to many customers with hearing 
impairments, including some older Americans.

                     alternate postal retail sites

    Alternate postal retail sites include contract Postal 
Units, and stamp consignment outlets (grocery stores, etc.). By 
providing retail services at alternate sites, the Postal 
Service allows customers to combine postal errands with other 
errands ``one-stop'' shopping. This is particularly 
advantageous to the elderly.
    Contract postal units provide more convenient locations 
available for our customers to purchase stamps, which generally 
means less wait time for them to obtain these retail services. 
Purchasing stamps and postal money orders, registering a 
letter, and other postal errands, can be combined with a trip 
to the neighborhood shopping center. This is particularly 
advantageous to the elderly.

                         stamps on consignment

    The Postal Service consigns stamps to supermarkets, drug 
stores, and other large retail chains for resale to customers 
at no more than face value. This provides our customers who 
need stamps an alternative to window service. This is 
especially convenient for our elderly customers who may have 
limited access to transportation and can purchase stamps while 
at the grocery or drug store.

                ITEM 28--U.S. RAILROAD RETIREMENT BOARD

                              ----------                              


 Annual Report on Program Activities for the Elderly--FYS 1995 and 1996

    The U.S. Railroad Retirement Board is an independent agency 
in the executive branch of the Federal Government, 
administering comprehensive retirement-survivor and 
unemployment-sickness benefit programs for the Nation's 
railroad workers and their families under the Railroad 
Retirement and Railroad Unemployment Insurance Acts. The Board 
also has administrative responsibilities under the Social 
Security Act for certain benefit payments and railroad workers' 
Medicare coverage.
    Under the Railroad Retirement Act, the Board pays 
retirement and disability annuities to railroad workers with at 
least 10 years of service. Annuities based on age are payable 
at age 62, or at age 60 for employees with 30 years of service. 
Disability annuities are payable before retirement age on the 
basis of total or occupational disability. Annuities are also 
payable to spouses and divorced spouses of retired workers and 
to widow(er)s, divorced, or remarried widower(er)s, children, 
and parents of deceased railroad workers. Qualified railroad 
retirement beneficiaries are covered by Medicare in the same 
way as social security beneficiaries.
    Under the Railroad Unemployment Insurance Act, the Board 
pays unemployment benefits to railroad workers who are 
unemployed but ready, willing and able to work and pays 
sickness benefits to railroad workers who are unable to work 
because of illness or injury.

                       benefits and beneficiaries

    During fiscal year 1996, retirement and survivor benefit 
payments under the Railroad Retirement Act amounted to almost 
$8.1 billion, $54 million more than the prior year. The number 
of beneficiaries on the retirement-survivor rolls on September 
30, 1996, totaled 765,000. The majority (86 percent) were age 
65 or older.
    At the end of the fiscal year, 344,000 retired employees 
were being paid regular annuities averaging $1,187 a month. Of 
these retirees, 162,000 were also being paid supplemental 
railroad retirement annuities averaging $43 a month. In 
addition, approximately 188,000 spouses and divorced spouses of 
retired employees were receiving monthly spouse benefits 
averaging $471 and, of the 243,000 survivors on the rolls, 
205,000 were aged widow(er)s receiving monthly survivor 
benefits averaging $708. Some 9,000 retired employees were also 
receiving spouse or survivor benefits based on their spouse's 
railroad service.
    About 699,000 individuals who were receiving or were 
eligible to receive monthly benefits under the Railroad 
Retirement Act were covered by hospital insurance under the 
Medicare program at the end of fiscal year 1996. Of these, 
684,000 (98 percent) were also enrolled for supplementary 
medical insurance.
    Gross unemployment and sickness benefits paid under the 
Railroad Unemployment Insurance totaled $97.7 million during 
fiscal year 1996, while net benefits totaled $65.6 million 
after adjustments for recoveries of benefit payments, some of 
which were made in prior years. Total gross and net payments 
increased by approximately $4.8 million and $4.1 million, 
respectively, from fiscal year 1995. Unemployment and sickness 
benefits were paid to 36,000 railroad employees during the 
fiscal year. However, only about $0.02 million (less than 1 
percent) of the benefits went to individuals age 65 or older.

                               financing

    At the end of fiscal year 1996, the net position of all of 
the Railroad Retirement Board trust funds was $14.8 billion, 
with revenues for the year exceeding expenditures by $564.4 
million. Investment earnings of $1.1 billion during the year, 
including a capital gain of $148.9 million on the sale of 
investments, were a major portion of the increase in the net 
position of the trust funds.
    The Board's 1996 railroad retirement financial report to 
Congress, which addressed railroad retirement financing during 
the next 25 years, was generally favorable and reflected a 
continuing improvement over the previous 2 years. It concluded 
that, barring a sudden, unanticipated, large decrease in 
railroad employment, no cash-flow problems arise over the 
entire 25-year projection period. However, like previous 
reports over the last decade, the 1996 report also indicated 
that the long-term stability of the system, under its current 
financing structure, is still dependent on future railroad 
employment levels.
    The Board's 1996 railroad unemployment insurance financial 
report was also favorable, indicating that experience-based 
contribution rates will keep the unemployment insurance system 
solvent, even under the most pessimistic employment assumption.
    The Board's reports consequently did not recommend 
financing changes for the railroad retirement or unemployment 
insurance systems.

                              legislation

    Legislation enacted on March 29, 1996, provided an increase 
in the social security earnings limits. As a result, railroad 
retirement annuitants ages 65-69 who work after retirement can 
earn more without a reduction in their benefits.
    Legislation enacted on October 9, 1996, increased the 
railroad unemployment and sickness insurance daily benefit rate 
and revised the formula for indexing future benefit rates. It 
also reduced the waiting period for initial benefit payments 
and eliminated duplicate waiting periods in continuing periods 
of unemployment and sickness. In addition, the legislation 
applied an earnings tests to claims for unemployment and 
reduced the duration of extended benefit periods for long-
service employees. The provisions of the legislation were based 
on joint recommendations to Congress negotiated by rail labor 
and management in order to update the railroad unemployment 
insurance system so that its provisions are more comparable to 
those of most State programs.

                service and administrative improvements

    The Railroad Retirement Board has continued to improve 
agency operations and better serve its customers. An agency-
wide reorganization effected in fiscal year 1995 was developed 
further in 1996 to achieve greater flexibility and economies of 
scale by combining like functions, eliminating organizational 
barriers, reducing layers of management, improving supervisory 
ratios, and developing more consistent policy and procedures. 
During 1996, the Board also closed a number of its field 
offices as part of a continuing restructuring of its field 
operations. The Board, nonetheless, through greater utilization 
of telephone and itinerant service, continued to maintain its 
high level of beneficiary service.
    The Board's fiscal year 1996 performance in terms of its 
Customer Service Plan standards for responding to 
correspondence and paying lump-sum death benefits and 
unemployment and sickness claims improved over the previous 
year while performance in other areas declined. These dips in 
performance are not believed to be indicative of a trend.
    During 1996, the Board completed its 5-year management 
improvement plan, at less cost than anticipated after 
successfully meeting or exceeding every goal, many ahead of 
schedule. The plan, based on an agreement with the White House 
Office of Management and Budget, required the Board to reduce 
claims processing backlogs, enhance debt collection activities, 
expand fraud controls, improve tax accounting operations, 
enhance automated claims processing systems, and make other 
improvement in its administrative management operations.
    Consistent with its desire to provide easier access to 
internal policies, the Railroad Retirement Board completely 
revised its 10 Consolidated Board Orders which served as the 
basic management policies of the agency. The 10 orders of 334 
pages were reduced to 5 orders of 69 pages. The revision of 
these orders was also in accord with Executive Order 12861, 
which required each agency to reduce by at least 50 percent its 
internal management regulations.
    Initiatives designed to improve operations included the 
development of an information technology capital plan as well 
as a plan to renovate mainframe systems to incorporate new date 
standards which will function properly beyond the year 2000. An 
interagency agreement with the Social Security Administration 
allows direct system-to-system access to that agency's benefit 
and wage databases, and allows Social Security Administration 
systems direct access to Board databases in future phases of 
this initiative. Cost containment initiatives included plans to 
covert ground floor space at the agency's Chicago headquarters 
facility into retail developments and the move of the Chicago 
office of the National Railroad Adjustment Board to the 
Railroad Retirement Board's headquarters.

                      office of inspector general

    During fiscal year 1996, the Office of Inspector General 
continued its efforts to assist management in increasing the 
efficiency of agency programs. Twenty-three audits and 
evaluations issued during the year contained findings for 
improvement in both administrative and program operations. 
Investigative activities resulted in 135 criminal convictions, 
66 indictments/informations, 50 civil judgments and $4.1 
million in court ordered restitutions, fines, recoveries and 
prevention of overpayments. From these activities, about 
$701,000 was returned to the agency trust funds and $64,000 to 
the Medicare trust funds in fiscal year 1996.

                     public information activities

    The Board maintains direct contact with railroad retirement 
beneficiaries through its 53 field offices located across the 
country. Field personnel explain benefit rights and 
responsibilities on an individual basis, assist railroad 
employees in applying for benefits and answer any questions 
related to the benefit programs. The Board also relies on 
railroad labor groups and employers for assistance in keeping 
railroad personnel informed about its benefit programs.
    At informational conferences held for railroad labor union 
officials, Board representatives describe and discuss the 
benefits available under the railroad retirement-survivor, 
unemployment-sickness and Medicare programs, and the attendees 
are provided with comprehensive informational materials. During 
1996, 2,000 railroad labor union officials attended 42 
informational conferences held in cities throughout the United 
States. In addition, railroad labor unions frequently request 
that a Board representative speak before their meetings, 
seminars and conventions. In 1996, the Labor Member's Office of 
the Railroad Retirement Board was represented at 34 union 
gatherings attended by 4,421 railroad labor officials. Field 
personnel addressed 84 local union meetings with 4,794 members 
in attendance.
    At seminars for railroad executives and managers, Board 
representatives review programs, financing, and administration, 
with special emphasis on those areas which require cooperation 
between railroads and Board offices. The Board also conducts 
informational seminars on benefit programs for employees at the 
request of railroad management. During 1996, the Management 
Member's Office of the Railroad Retirement Board conducted 17 
seminars for railroad officials. It also conducted 13 pre-
retirement counseling seminars attended by railroad employees 
and their spouses, and 16 benefit update presentations.
    The Board's headquarters is located at 844 North Rush 
Street, Chicago, Illinois 60611-2092, phone (312) 751-4500. In 
addition, the Board maintains an Office of Legislative Affairs 
in Washington, DC as a liaison for dealing with Members of 
Congress on matters involving the Railroad Retirement and 
Unemployment Insurance Acts and legislative issues that affect 
the Board. The Office of Legislative Affairs is located at 1310 
G Street, NW, Suite 500, Washington, DC 20005-3004, phone (202) 
272-7742.

                 ITEM 29--SMALL BUSINESS ADMINISTRATION

    The SBA continues to create, implement and deliver 
technical and financial assistance programs for the benefit of 
the Nation's small business community. We currently do not have 
a program that gives specific focus to older Americans.
    However, the SBA is the sponsoring Federal agency for the 
Service Corps of Retired Executives (SCORE) program. SCORE is 
an organization of nearly 12,000 business men and women who 
volunteer their time and expertise to provide management 
counseling and training to small business owners and people 
just starting a new business. They have extensive business 
experience, either as entrepreneurs and business owners or as 
former corporate executives. SCORE counseling is confidential 
and free of charge and is provided at more than 700 locations 
in the United States and its territories.

                ITEM 30--SOCIAL SECURITY ADMINISTRATION

                              ----------                              


 Programs Administered by the Social Security Administration--Calendar 
                          Years 1995 and 1996

    The Social Security Administration (SSA) administers the 
Federal old-age, survivors, and disability insurance (OASDI) 
program (title II of the Social Security Act). OASDI is the 
basic program in the United States that provides income to 
individuals and families when workers retire, become disabled, 
or die. The basic idea of the cash benefits program is that, 
while they are working, employees and their employers pay 
Social Security taxes; the self-employed also are taxed on 
their net earnings. Then, when earnings stop or are reduced 
because of retirement in old-age, death, or disability, cash 
benefits are paid to partially replace the earnings that were 
lost. Social Security taxes are deposited to the Social 
Security trust funds and are used only to pay Social Security 
benefits and administrative expenses of the program. Amounts 
not currently needed for these purposes are invested in 
interest bearing obligations of the United States. Thus, 
current workers help to pay current benefits and, at the same 
time, establish rights to future benefits.
    SSA also administers the Supplemental Security Income (SSI) 
program for needy aged, blind, and disabled people (title XVI 
of the Social Security Act). SSI provides a federally financed 
floor of income for eligible individuals with limited income 
and resources. SSI benefits are financed from general revenues. 
In about 54 percent of the cases, SSI is reduced due to 
individuals' having countable income from other sources, 
including Social Security benefits.
    SSA shares responsibility for the black lung program with 
the Department of Labor. SSA is responsible, under the Federal 
Coal Mine Health and Safety Act, for payment of black lung 
benefits to coal miners and their families who applied for 
those benefits prior to July 1973 and for payment of black lung 
benefits to certain survivors of miners.
    Local Social Security offices process applications for 
entitlement to the Medicare program and assist individuals with 
questions concerning Medicare benefits. Overall Federal 
administrative responsibility for the Medicare program rests 
with the Health Care Financing Administration, HHS.
    Following is a summary of beneficiary data and selected 
administrative activities for calendar year 1996.

     i. old-age, survivors, and disability insurance benefits and 
                             beneficiaries

    At the beginning of 1996, about 96 percent of all jobs were 
covered under the Social Security program. It is expected that, 
under the present law, this percentage of jobs will increase 
slightly through the end of the century. The major groups of 
workers not covered under Social Security are Federal workers 
hired before January 1, 1984 and State and local government 
employees covered under a retirement system for whom the State 
has not elected Social Security coverage.
    At the end of December 1996, 43.7 million people were 
receiving monthly Social Security cash benefits. Of these 
beneficiaries, 26.9 million were retired workers, 3.4 million 
were dependents of retired workers, 6.1 million were disabled 
workers and their dependents, 7.4 million were survivors of 
deceased workers and 653 were persons receiving special 
benefits for uninsured individuals who reached age 72 some 
years ago.
    The monthly amount of benefits being paid at the end of 
December 1996 was $29.4 billion. Of this amount, $21.3 billion 
was payable to retired workers and their dependents, $3.4 
billion was payable to disabled workers and their dependents, 
$4.7 billion was payable to survivors, and $0.1 million was 
payable to uninsured persons who reached age 72 in the past. 
(The cost of these special benefits for aged uninsured persons 
is financed from general revenues, not from the Social Security 
trust funds.)
    Retired workers were receiving an average benefit at the 
end of December 1996 of $745, and disabled workers received an 
average benefit of $704.
    During the 12 months ending December 1996, $347 billion in 
Social Security cash benefits were paid. Of that total, retired 
workers and their dependents received $232.9 billion, disabled 
workers and the dependents received $44.2 billion, survivors 
received $69.8 billion, and uninsured beneficiaries over age 72 
received $1.4 million.
    Monthly Social Security benefits were increased by 2.6 
percent for December 1995 (payable beginning January 1996) to 
reflect a corresponding increase in the Consumer Price Index 
(CPI).

      ii. supplemental security income benefits and beneficiaries

    In January 1996, SSI payment levels (like Social Security 
benefit amounts) were automatically adjusted to reflect a 2.6 
percent increase in the CPI. From January through December 
1996, the maximum monthly Federal SSI payment level for an 
individual was $470. The maximum monthly benefit for a married 
couple both of whom were eligible for SSI, was $705.
    As of December 1996, 6.6 million aged, blind, or disabled 
people received Federal SSI or federally administered State 
supplementary payments. Of the 6.6 million recipients on the 
rolls during December 1996, about 2.1 million were aged 65 or 
older. Of the recipients aged 65 or older, about 678,000 were 
eligible to receive benefits based on blindness or disability. 
About 4.5 million recipients were blind or disabled and under 
age 65. During December 1996, Federal SSI benefits and 
federally administered State supplementary payments totaling 
slightly over $2.4 billion were paid.
    For calendar year 1996, $28.3 billion in benefits 
(consisting of $25.3 billion in Federal funds and $3.0 billion 
in federally administered State supplementary payments) were 
paid.

               iii. black lung benefits and beneficiaries

    Although responsibility for new black lung miner claims 
shifted to the Department of Labor (DOL) in July 1973, SSA 
continues to pay black lung benefits to a significant, but 
gradually declining, number of miners and survivors. (While DOL 
administers new claims taken by SSA under part C of the Federal 
Coal Mine Health and Safety Act, SSA is still responsible for 
administering part B of the Act.)
    As of December 1996, about 131,000 individuals (102,000 age 
65 or older) were receiving $53 million in black lung benefits 
which were administered by the Social Security Administration. 
These benefits are financed from general revenues. Of these 
individuals, 21,000 miners were receiving $9 million, 86,000 
widows were receiving $37 million, and 24,000 dependents and 
survivors other than widows were receiving $6 million. During 
calendar year 1996 SSA paid out black lung payments in the 
amount of $655 million. About 21,000 miners and 86,000 widows 
and wives were age 65 or older.
    Black lung benefits increased by 1.8 percent effective 
January 1996. The monthly payment to a coal miner disabled by 
black lung disease increased from $427.40 to $435.10. The 
monthly benefit for a miner or widow with one dependent 
increased from $641.10 to $652.70 and with two dependents from 
$748.00 to $761.50. The maximum monthly benefit payable when 
there are three or more dependents increased from $854.40 to 
$870.20.

                     iv. communication and services

    SSA's public information initiatives are aimed at more than 
44 million Social Security beneficiaries, more than six million 
SSI recipients and about 148 million workers currently paying 
into the system. SSA seeks to ensure that current and future 
beneficiaries are aware of programs, services, and their rights 
and responsibilities.
    In 1995 and 1996, SSA planned public information outreach 
activities to help educate the public about Social Security. A 
public service campaign was conducted in conjunction with SSA's 
60th anniversary in 1995. The campaign was promoted through 
print media, as well as radio and television, and informed the 
public about Social Security's disability and survivors 
benefits programs. The media donated more than $4 million in 
advertising space.
    Subjects covered through public information messages 
included changes in the law affecting drug addicts and 
alcoholics, welfare recipients and disabled children. Messages 
were placed in the form of news releases, radio and television 
public service announcements and publications such as Social 
Security Today, a newsletter distributed to national 
organizations.
    SSA produces a wide range of publications on all Social 
Security programs. More than 100 consumer booklets and fact 
sheets keep the public informed about the programs and policies 
affecting them. Many publications also are available in 
Spanish. All are available through the agency's FAX Catalog, as 
well as on the Internet at SSA's web site, http://www.ssa.gov. 
Also, SSA's Public Information Distribution Center provides 
materials directly to external groups and organizations.
    The agency released several new videos designed to inform 
the public about Social Security. One, ``The Evolution of 
Social Security,'' highlights the history of the program. 
Another video was produced to accompany the SSA Teacher's Kit, 
which was marketed directly to more than 17,000 secondary 
schools. In addition to these video products, SSA spends a 
package of radio public service announcements on Social 
Security themes to 5,000 radio stations once a year.
    SSA also conducted a series of focus groups around the 
country to assess the public's knowledge of the Social Security 
program and to obtain their opinions on ways to increase public 
understanding and confidence.

          v. summary of legislation that affects ssa, 1995-96

P.L. 104-103 (H.R. 2924), An Act to Guarantee the Timely Payment of 
        Social Security Benefits in March 1996, signed on February 8, 
        1996
    Provides the Secretary of the Treasury authority to issue 
obligations of the United States equal to the aggregate monthly 
Social Security benefits payable in March 1996. Because such 
obligations would not be subject to the debt ceiling, the 
Secretary could issue new Federal debt obligations in order to 
obtain the cash necessary to cover Social Security benefits 
payments in March. The exemption terminated on March 15, 1996.
P.L. 104-115 (H.R. 3021), An Act to Guarantee the Continuing Full 
        Investment of Social Security and Other Federal Funds in 
        Obligations of the United States, signed on March 12, 1996
    Extended, from March 15, 1996, through March 30, 1996, the 
authority (enacted in P.O. 104-103) to issue obligations of the 
United States equal to the aggregate monthly Social Security 
benefits payable in March 1996.
P.L. 104-121 (H.R. 3136), the Contract With America Advancement Act of 
        1996 (Includes the Senior Citizens' Right to Work Act of 1996), 
        signed on March 29, 1996
            Denial of disability benefits to drug addicts and 
                    alcoholics
    Prohiits disability insurance (DI) and Supplemental 
Security Income (SSI) eligibility to individuals whose drug 
addiction and/or alcoholism (DAA) is a contributing factor 
material to the finding of disability. This provision applies 
to individuals who file for benefits on or after the date if 
enactment. For beneficiaries who, as of March 29, 1996, were 
already receiving DI and/or SSI benefits based on DAA 
materiality, this provisionbecame effective on January 1, 1997, 
SSA was required to: 1) notify DAA beneficiaries of new provisions by 
June 27, 1996; and 2) complete new medical determinations by January 1, 
1997, for affected beneficiaries who requested such a determination 
within 120 days after the date of enactment.
    Applies special representative payee requirements to DI or 
SSI beneficiaries who have a DAA condition, as determined by 
the Commissioner, and who are incapable of managing benefits. 
SSA is to refer these individuals to the appropriate State 
agency for treatment. In addition, allows certain 
organizational payees to collect a $50 monthly fee from 
beneficiaries who have a DAA condition.
    Provided an additional appropriation of $50 million for 
each of fiscal years 1997 and 1998 to carry out on a priority 
basis activities relating to the treatment of drug and alcohol 
abuse under section 1933 of the Public Health Service Act.
            Continuing Disability Reviews
    Authorizes additional funds to SSA for fiscal years 1996 
through 2002 for the purpose of conducting Social Security 
disability insurance continuing disability reviews (CDRs) and 
SSI CDRs and disability redeterminations. This would be 
accomplished by increasing the amount of funds available for 
appropriations under the discretionary spending cap in the 
Budget Enforcement Act.
    Directs the Commissioner of Social Security to ensure that 
the funds made available pursuant to this provision are used, 
to the greatest extent practicable, to maximize the combined 
savings to the old-age, survivors, and disability insurance 
(OASDI), SSI, Medicare, and Medicaid programs.
    Requires the Commissioner to report annually, for fiscal 
years 1996 through 2002, to Congress on the amount of money 
spent on CDRs, the number of reviews conducted (by category), 
the disposition of such reviews (by program), and the estimated 
savings over the short-, medium-, and long-term for OASDI, SSI, 
Medicare, and Medicaid programs from CDRs which result in 
cessations, and the estimated present value of such savings.
            Chief actuary
    Establishes by statute in the Social Security 
Administration the position of Chief Actuary, to be appointed 
by, and report directly to, the Commissioner, and be subject to 
removal only for cause.
            Dependency test for stepchildren
    Provides that a stepchild has to be receiving at least one-
half support from the stepparent when the child's claim is 
filed to get benefits. (The option for finding dependency based 
on the child's living-with the stepparent was eliminated.) This 
provision is effective for benefits of individuals who become 
entitled for months after June 1996.
    If the natural parent and the stepparent of an entitled 
stepchild divorce, benefits to the stepchild based on the work 
record of the stepparent would terminate the month after the 
month in which such divorce becomes final. This provision is 
effective for final divorces occurring after June 1996.
            Increase in the earnings test annual exempt amount
    Gradually raises, beginning in 1996, the earnings limit for 
the retirement earnings test (RET) for beneficiaries who have 
attained normal retirement age to $30,000 by 2002 (compared 
with $14,640 for 2002 under prior law, based on the assumptions 
in the President's FY 1998 Budget). The applicable 1996 exempt 
amount under prior law was $11,520. Exempt amounts under P.L. 
104-121 (exempt amounts under prior law are also shown) are:

------------------------------------------------------------------------
                                                             Estimated  
                                           Exempt amount   exempt amount
                  Year                     under Public     under prior 
                                            Law 104-121         law     
------------------------------------------------------------------------
1996....................................         $12,500         $11,520
1997....................................          13,500          12,000
1998....................................          14,500          12,600
1999....................................          15,500          12,960
2000....................................          17,000          13,560
2001....................................          25,000          14,040
2002....................................          30,000          14,640
------------------------------------------------------------------------

    After 2002, the annual exempt amount will be indexed to 
growth in average wages.
    The substantial gainful activity (SGA) amount applicable to 
individuals who are statutorily blind is no longer linked to 
the RET exempt amount for individuals ages 65 to 69. Instead, 
the SGA amount for blind people will continue to be adjusted 
annually as under present law, i.e., based on the national 
average wage index.
            Benefit and tax statements
    Requires SSA to conduct a pilot study of the efficacy of 
providing title II beneficiaries with information about their 
Social Security benfits and taxes. The study will involve a 
sample of retirement beneficiaries whose entitlement began in 
or after 1984 and continued for a period of at least 5 years. 
SSA will send each beneficiary one statement with estimates of 
the aggregate covered earnings of the insured person, the 
aggregate Social Security taxes (including the employer share 
paid on those earings), and the total amount of benefits paid 
on the insured person's record.
    Requires the study to be conducted within a 2-year period 
beginning as soon as practicable in 1996 and a report on its 
results be provided to Congress within 60 days of its 
completion.
            Investment of Social Security and Medicare trust funds
    Prohibits the Secretary of the Treasury from refraining 
from investing Social Security and Medicare trust fund monies 
in Federal securities, and from redeeming securities held by 
the trust funds, to avoid increasing or reducing outstanding 
public debt obligations. Effective March 29, 1996.
            Professional staff for the Social Security Advisory Board
    Authorizes the Social Security Advisory Board to appoint 
three professional staff employees, one of whom is to be 
appointed from among individuals approved by Advisory Board 
members who do not belong to the political party represented by 
the majority of the Board.
            Review of Federal regulations
    Requires that when Federal agencies promulgate certain 
regulations, including some of those issued by SSA, the agency 
must prepare a final regulatory flexibility analysis. The 
agencies must also provide the Chief Counsel for Advocacy of 
the Small Business Administration information on the potential 
impacts of the proposed rule on small entities and the type of 
small entities that might be affected. This provision does not 
apply to any proposed or final rule if the head of the agency 
cerifies that the rule will not, if promulgated, have a 
significant economic impact on a substantial number of small 
entities. The statute also provides for judicial review of 
agency compliance with this provision.

P.L. 104-134 (H.R. 3019), the Omnibus Consolidated Rescissions and 
        Appropriations Act of 1996, signed on April 26, 1996

            Debt collection
    Provides SSA with permanent debt collection authorities, 
including administratively offsetting other Federal benefit 
payments, offsetting Federal salaries, administrative 
garnishment of employees' pay, reporting delinquent debt to 
credit bureaus, using private collection agencies, and 
assessing late charges. The first $9000 per year of an 
individual's Federal benefit payments are exempt from 
administrative offset.
    Authorizes the collection of debts owed to the Federal 
Government by administrative offset against black lung benefits 
and benefits under title II of the Social Security Act.
            Electronic funds transfer (EFT)
    Requires recurring Federal payments, including Social 
Security and SSI benefits, to persons who begin to receive them 
after July 1996 to be paid by EFT. However, the head of each 
agency can waive the requirement for recipients who certify 
that they do not have a bank account or payment agent.
    All recurring Federal payments made after January 1, 1999, 
will be made by EFT, except that the Secretary of the Treasury 
may waive the requirement in certain circumstances.

P.L. 104-188 (H.R. 3448), the Small Business Job Protection Act of 1996 
        and the Minimum Wage Increase Act of 1996, signed on August 20, 
        1996

            Crews of fishing boats
    Treats crew members as self-employed (rather than 
employees) if (1) the crew of a vessel was normally composed of 
no more than 10 members, determined on the basis of the average 
size of the crew during the preceding four calendar quarters, 
and (2) under limited circumstances, the crew members received 
cash pay of not more than $100 per trip. The provision was 
effective January 1, 1994. It also applies to the period 1985-
1994, unless the remuneration had been treated as wages when 
paid.
            Employer-provided educational assistance
    Resinstates a provision that expired January 1, 1995, under 
which certain employer-provided educational assistance was 
excluded for Social Security and income tax purposes. The 
extension is extended, but only for courses that began before 
January 1, 1997. However, with respect to graduate level 
education, the exclusion does not apply to expenses relating to 
courses beginning after June 30, 1996.
            Retired members of the clergy
    Excludes from Social Security tax the rental value of a 
parsonage (or the parsonage allowance) and benefits from a 
church plan (as defined in the Internal Revenue Code) received 
by a retired member of the clergy. Applies to years beginning 
before, on, or after December 31, 1994.
            Newspaper deliverers
    Defines persons engaged in the business of distributing 
newspapers or shopping news as direct sellers for Social 
Security and income tax purposes--i.e., independent contractors 
(self-employed). Applies to services performed beginning 
January 1, 1996.
            Work opportunity tax credit
    Replaces the targeted jobs tax credit with the work 
opportunity tax credit for employers hiring individuals from 
one or more targeted groups. This includes disabled individuals 
referred to an employer upon completion of (or while receiving) 
rehabilitation services pursuant to an individualized written 
plan under a State plan for vocational rehabilitation services 
approved under the Rehabilitation Act of 1973.
    The provision applies to individuals who begin work for the 
employer after September 30, 1996.

P.L. 104-193 (H.R. 3734), the Personal Responsibility and Work 
        Opportunity Reconciliation Act of 1996, signed on August 22, 
        1996

                   Limited Eligibility of Noncitizens

Social Security benefits

    Prohibits the payment of Social Security benefits to any 
noncitizen in the U.S. who is not lawfully present in the U.S. 
(as determined by the Attorney General), unless the payment is 
made pursuant to a totalization agreement or treaty obligation.
    Applied for benefits based on applications filed on or 
after December 1, 1996.

SSI benefits

    Prohibits SSI eligibility for all qualified noncitizens 
except: \1\ Refugees (eligibility limited to the 5-year period 
after their arrival in the United States); asylees (eligibility 
limited to the 5-year period after the date they are granted 
asylum); noncitizens who have had deportation withheld under 
INA section 243(h) (eligibility limited to the 5-year period 
after the date their deportations are withheld; certain active 
duty Armed Forces personnel, honorably discharged veterans, and 
their spouses and dependent children; and lawful permanent 
residents who have earned 40 quarters of coverage for Social 
Security purposes. An individual under the age of 18 would be 
credited with all quarters of coverage earned by his or her 
parent, and a married individual (including widow(er)) 
generally would be credited with all quarters of coverage 
earned by his or her spouse during the marriage. However, for 
quarters earned after December 31, 1996, a quarter would not 
count as one of the required 40 if the noncitizen or person 
whose quarters are being credited to the noncitizen received 
federally funded public assistance during the quarter the work 
was done.
---------------------------------------------------------------------------
    \1\ This definition was amended by P.L. 104-208 (see description in 
section titled ``Provisions Related to Noncitizens''). Further 
significant changes were made by P.L. 105-33.
---------------------------------------------------------------------------
    In addition, with certain exceptions, noncitizens who enter 
the U.S. as lawful permanent residents after August 22, 1996, 
are ineligible for any Federal means-tested benefits (including 
SSI) for 5 years.
    Effective upon enactment. However, with regard to 
individuals on the SSI rolls at the time of enactment, requires 
the Commissioner to redetermine the eligibility of all 
noncitizens who may not meet the new eligibility categories 
within 1 year after enactment. If a qualified noncitizen is not 
in one of the new categories, his or her eligibility would end 
as the date of the redetermination.
    Required the Commissioner to notify all potentially 
affected beneficiaries on the SSI rolls of the provision by 
March 31, 1997.

Deeming of sponsors' incomes and resources

    For purposes of eligibility under SSI, deems the sponsors' 
(and sponsors' spouses') incomes and resources to the 
noncitizen until citizenship with the following exception:
          Deeming ends before citizenship in the case of lawful 
        permanent residents who earn 40 quarters of coverage. 
        Deeming for children and spouses of workers also could 
        end before citizenship if they are credited with 40 
        quarters, i.e., an individual under the age of 18 is 
        credited with all quarters of coverage earned by his or 
        her parent, and a married individual (including 
        widow(er)) generally is credited with all quarters of 
        coverage earned by his or her spouse during the 
        marriage. However, for quarters earned after December 
        31, 1996, a quarter will not count as one of the 
        required 40 if the noncitizen or person whose quarters 
        are being credited to the noncitizen received federally 
        funded public assistance during the quarter the work 
        was done.
    Effective for sponsored noncitizens who are admitted into 
the country under new, legally enforceable affidavits of 
support.

Requirements for affidavits of support for sponsorship

    Makes affidavits of support legally enforceable against the 
sponsor until the noncitizen becomes a U.S. citizen. The 
affidavit is enforceable for a period of 10 years after the 
noncitizen last received public assistance benefits, including 
SSI.
    Requires the agency that provides assistance to a 
noncitizen to request reimbursement from the sponsor for the 
assistance it provided. If the sponsor does not respond or is 
unwilling to make reimbursement within 45 days after the 
agency's request, the agency may take legal action against the 
sponsor. Allows the agency to hire individuals to collect 
reimbursement.
    Requires the Attorney General, in consultation with the 
Secretary of State and the Secretary of Health and Human 
Services, to develop a standard affidavit of support within 90 
days after the date of enactment. Also requires--effective with 
a date specified by the Attorney General which would be no 
earlier than 60 and no later than 90 days after development of 
the standard affidavit--that all newly signed affidavits be 
legally enforceable.

Reports to INS

    Requires the Commissioner to furnish to INS the name, 
address, and other identifying information of any individual 
that SSA knows is unlawfully in the United States. Such reports 
are required at least four times a year and upon request of 
INS. Also requires the Commissioner to ensure that State 
supplementary program agreements with States include provisions 
for the State also to furnish such information to INS at such 
times on persons whom the State knows are unlawfully in the 
United States.
    Effective upon enactment.

                          Childhood Disability

SSI eligibility based on childhood disability

    Eliminates the comparable severity standard and provides 
instead that a child under age 18 be considered under a 
disability if he/she has a medically determinable physical or 
mental impairment which results in marked and severed 
functional limitations and which can be expected to result in 
death or which has lasted or can be expected to last for a 
continuous period of not less than 12 months.
    Directs SSA to eliminate references to maladaptive behavior 
in the domain of personal/behavioral function in specified 
sections of the Listing of Impairments for children and to 
discontinue the use of an individualized functional assessment 
in evaluating a child's claim for benefits.
    These provisions are applicable to any individual who 
applies for SSI benefits based on disability, or whose claim is 
finally adjudicated, on or after the date of enactment, without 
regard to whether implementing regulations have been issued.

Current recipients

    Required SSA to notify recipients eligible for SSI benefits 
based on disability on enactment date and whose ligibility may 
be affected by the new childhood disability eligibility 
criteria, no later than January 1, 1997.
    Required SSA to redetermine the eligibility of such 
recipients, using the new childhood disability eligibility 
criteria, no later than 1 year after the date of enactment.
    Benefits for those recipients who did not meet the new 
childhood disability eligibility criteria terminated for the 
month beginning on or after the later of July 1, 1997, or the 
date of the redetermination.

Eligibility redeterminations and continuing disability reviews (CDRs)

    Requires CDRs: once every 3 years for recipients under age 
18 with impairments that are considered likely to improve; and 
not later than 12 months after birth for children for whom low 
birth weight is a contributing factor material to the 
determination of disability.
    Requires the representative payee of a recipient whose 
continuing eligibility is being reviewed to present evidence 
that the recipient is receiving treatment which is considered 
medically necessary and available, unless SSA determines that 
providing evidence of such treatment would be inappropriate or 
unnecessary. If the representative payee refuses, without good 
cause, to cooperate, SSA may change the payee if it is in the 
best interests of the child.
    Requires an eligibility redetermination, using the adult 
initial eligibility criteria, during the 1-year period 
beginning on a recipient's 18th birthday.
    Applies to benefits for months beginning on or after the 
date of enactment, without regard to whether implementing 
regulations have been issued.
    Repeals the requirement in the Social Security Independence 
and Program Improvements Act of 1994 (Public Law 103-296) that 
SSA (1) redetermine, using the adult eligibility criteria, the 
eligibility of one-third of the recipients who attain age 18 in 
or after May 1995 in each of fiscal years 1996 through 1998 and 
(2) submit a report regarding these reviews to the House 
Committee on Ways and Means and the Senate Committee on Finance 
not later than October 1, 1998.

Medical improvement review standard

    Makes conforming changes in the medical improvement review 
standard to reflect the new definition of disability for 
children who file for SSI benefits.
    Applicable with respect to benefits for months beginning on 
or after the date of enactment, without regard to whether 
implementing regulations have been issued.

Funding

    Authorized the appropriation of an additional $150 million 
in fiscal year 1997 and $100 million in fiscal year 1998 for 
the costs of processing CDRs and redeterminations.

Regulations

    Required SSA to issue regulations implementing the changes 
relating to benefits for disabled children within 3 months 
after enactment date.
    Directs SSA to submit final regulations pertaining to a 
child's eligibility for SSI disability benefits to the Congress 
at least 45 days before such regulations become effective.

Reports

    Required SSA to report to the Congress, not later than 180 
days following the date of enactment, on its progress in 
implementing the changes in the SSI disabled children's 
provisions.
    Requires GAO, not later than January 1, 1999, to study and 
report on the impact of the changes made by this Act on the SSI 
program and the extra expenses incurred by families of children 
receiving SSI benefits that are not covered by other Federal, 
State, or local programs.

                           other ssi changes

Prisoner reporting

    Provides for incentive payments from SSI program funds to 
State and local penal institutions and mental hospitals for 
furnishing information (date of confinement and certain 
identifying information) to SSA which results in suspension of 
SSI benefits ($400 for information received within 30 days of 
confinement or $200 for information received from 31 to 90 days 
after confinement).
    Applies to individuals whose period of confinement 
commences on or after the first day of the seventh month 
beginning after the month of enactment.
    Exempts SSI reporting agreements under which incentive 
payments are made from the computer matching provisions of the 
Privacy Act of 1974, as amended.
    Required the Commissioner to study and report to Congress 
(within 1 year of enactment) on the feasibility of prisoner 
reporting by courts and mandatory electronic reporting by 
correctional facilities and other institutions having incentive 
payment agreements with SSA for purposes of carrying out the 
suspension of benefits under the SSI program.
    Requires SSA to provide Congress (not later than October 1, 
1998) with a list of the institutions that are, and are not, 
providing information on inmates to SSA under the incentive 
payment provision.
    Authorizes SSA to provide, on a reimbursable basis, 
information obtained pursuant to SSI reporting agreements under 
which incentive payments are made to any Federal or Federally-
assisted cash, food, or medical assistance program for 
eligibility purposes.

Modify the effective date of applications

    Provides that an individual's application for SSI benefits 
is effective on the first day of the month following the date 
on which the application is filed, or following the date on 
which the individual first becomes eligible, whichever is 
later. The amendment, in effect, eliminates prorated payments 
for the month of application by providing that the first month 
for which benefits can be paid is the month after the month in 
which the application is filed.
    Permits the issuance of an emergency advance payment in the 
month the application is filed to an individual who is 
presumptively eligible and has a financial emergency.
    Requires that the emergency advance payment be repaid 
through proportional reductions in the individual's SSI 
benefits over a period of not more than 6 months.
    Effective for applications filed on or after the date of 
enactment.

Reduction in cash benefits payable to institutionalized individuals 
        whose medical costs are covered by private insurance

    Limits to not more than $30 a month SSI cash benefits 
payable to children under age 18 who are in medical 
institutions receiving payments (with respect to that 
individual) under any health insurance policy issued by a 
private provider of such insurance.
    Effective with respect to benefits for months beginning 90 
or more days after the date of enactment.

Installment payments of large past-due SSI payments

    Requires SSA to pay in installments retroactive SSI benefit 
amounts that equal or exceed 12 times the monthly Federal 
benefit rate (FBR) plus the monthly State supplemental level. 
Payments are to be made in no more than three installments at 
6-month intervals. The first and second installment generally 
cannot exceed 12 times the FBR ($5,640 based on 1996 rates) 
plus any Federally administered State supplement. Any remaining 
retroactive benefits will be paid in the third installment.
    Provides that where an individual has incurred debts for 
food, clothing, shelter, or medical expenses or has current or 
anticipated expenses for medical needs or the purchase of a 
home, the maximum amount of an installment payment may be 
increased by the total amount of these debts and expenses.
    Provides that the installment payment requirements do not 
apply to an individual who is terminally ill or who is 
currently ineligible for benefits and likely to remain so for 
the next 12 months.
    Effective with respect to past-due benefits payable after 
the third month following the month of enactment.

Dedicated savings accounts

    Requires the representative payee of a disabled or blind 
child to establish a bank account to maintain retroactive SSI 
benefits that exceed 6 times the FBR (smaller retroactive 
benefit amounts may also be placed in such accounts once 
established).
    Allows funds in the account to be used only for the 
following expenses: medical treatment, education or job skill 
training; or, if related to child's impairment, personal needs 
assistance, special equipment or housing modifications, therapy 
or rehabilitation, other items or services related to the 
child's impairment which SSA determines appropriate.
    Provides that unauthorized expenditures constitute 
misapplication of benefits and are recoverable by SSA from the 
child's representative payee.
    Requires SSA to establish an accountability system to 
monitor these accounts under which payees are required to 
report on the use of these funds.
    Provides that these accounts are excluded from resource 
counting and that interest earned is excluded from income.
    Effective with respect to payments made after the date of 
enactment.

Denial of benefits for fugitive felons and probation and parole 
        violators/exchange of information with law enforcement officers

    Denies eligibility for SSI with respect to any month during 
which an individual is fleeing to avoid prosecution for a 
felony, fleeing to avoid custody or confinement after 
conviction of a felony, or violating a condition of probation 
or parole imposed under State or Federal law.
    Requires SSA to provide upon written request of any 
appropriate agency, the current address, SSN, and photograph 
(if applicable) of any SSI recipient, provided that the 
requesting law enforcement officer furnishes the name of the 
recipient and other identifying information and notifies SSA 
that the recipient: is fleeing to avoid prosecution for a 
felony, or custody or confinement after a felony conviction; or 
is violating a condition of probation or parole; and has 
information that is necessary for the officer of the agency to 
conduct the officer's official duties and the location or 
apprehension of the recipient is within the officer's official 
duties.
    Effective upon enactment.

Denial of SSI benefits for 10 years to individuals who have 
        misrepresented residence in order to obtain benefits in two or 
        more states

    Denies SSI benefits for a period of 10 years to an 
individual convicted in Federal or State court of having made a 
fraudulent statement or representation with respect to his or 
her place of residence in order to receive benefits 
simultaneously in two or more States.
    Effective upon enactment.

Annual report on the SSI program

    Requires the Commissioner to report to the President and 
Congress regarding the SSI program, not later than May 30 of 
each year, including: a comprehensive description of the 
program; historical and current data on allowances and denials, 
including number of applications and allowance rates for 
initial determinations, reconsideration determinations, 
administrative law judge hearings, appeals council reviews, and 
Federal court decisions; historical and current data on 
characteristics of recipients and program costs, by recipient 
group (aged, blind, disabled adults, and disabled children); 
historical and current data on prior enrollment by recipients 
in public benefit programs, including State programs funded 
over Part A of title IV of the Social Security Act and State 
general assistance programs; projections of future numbers of 
recipients and program costs, through at least 25 years; 
information on the number and outcomes of redeterminations and 
continuing disability reviews, utilization of work incentives, 
administrative and other program costs, State supplementation 
program operations; summaries of relevant research; and a 
historical summary of statutory changes to the SSI law.
    Provides that each member of the Social Security Advisory 
Board be permitted to include their views on the SSI program in 
the annual report.
    Effective upon enactment.

                     use of social security numbers

Social Security card

    Required the Commissioner of Social Security to develop a 
prototype of a counterfeit-resistant Social Security card that: 
is made of durable, tamper-resistant material (e.g., plastic); 
employs technologies that provide security features (e.g., 
magnetic stripe); and provides individuals with reliable proof 
of citizenship or legal resident alien status.
    Required the Commissioner of Social Security to study and 
report on different methods of improving the Social Security 
card application process, including: evaluation of the cost and 
workload implications of issuing a counterfeit-resistant Social 
Security card for all individuals over a 3-, 5-, and 10-year 
period; evaluation of the feasibility and cost implications of 
imposing a user fee for replacement cards and cards issued to 
individuals who apply for such a card prior to the scheduled 3-
, 5-, and 10-year phase-in options.
     Required the Commissioner to submit the report and a 
facsimile of the prototype card to the Congress within 1 year 
of the date of enactment.

Expansion of the Federal Parent Locator Service

    Requires HHS to transmit to SSA, for verification purposes, 
certain information about individuals and employers maintained 
under the Federal Parent Locator Service in an automated 
directory to be known as the National Directory of New Hires. 
SSA is required to verify the accuracy of, correct, or supply 
to the extent possible, and report to HHS the name, SSN, and 
birth date of each individual regarding whom HHS maintains 
information for purposes of the Federal Parent Locator Service 
and the employer identification number of each such employer. 
SSA will be reimbursed by HHS for the cost of this verification 
service.
    Effective upon enactment.

Collection and use of SSNs for use in child-support enforcement

    Provides that State child support enforcement procedures 
require that the SSN of any applicant for a professional 
license, commercial driver's license, occupational license, or 
marriage license be recorded on the application. The SSN of any 
person subject to a divorce decree, support order, or paternity 
determination or acknowledgement will be placed in the 
pertinent records. SSN's also must be placed in the records 
relating to the death and recorded on death certificates.
    Effective upon enactment.

Earned Income Tax Credit (EITC)

    Provides that, in order to be eligible for the EITC, an 
individual must include on his or her tax return a Social 
Security number assigned to the individual which was not 
assigned solely for nonwork purposes as well as, where 
applicable, a Social Security number meeting the aforementioned 
requirement for his or her spouse.
    Effective for taxable years beginning after 1995.

P.L. 104-208 (H.R. 3610), An Act Making Omnibus Consolidated 
        Appropriations for FY 1997, signed on September 30, 1996

    This omnibus budget bill includes six FY 1997 
appropriations measures and contains SSA's FY 1997 
appropriation. The bill also includes the Illegal Immigration 
Reform and Immigrant Responsibility Act of 1996. Included in 
the immigration reform section of H.R. 3610 were the following 
provisions of interest to SSA:

                   provisions related to noncitizens

Definition of ``qualified alien''

    Amends section 431 of P.L. 104-193 to add to the list of 
six specific immigration categories that comprise the 
definition of ``qualified alien,'' the following new category:
          Aliens and their children who have been battered or 
        subjected to extreme cruelty by a spouse or parent or a 
        member of the spouse's or parent's family living in the 
        same household as the alien if the alien has a petition 
        for adjustment of immigration status approved or 
        pending and the Attorney General determines that there 
        is a substantial connection between such battery or 
        cruelty and the need for benefits. A noncitizen would 
        not be considered to be a qualified alien for any month 
        in which the noncitizen lives in the same household as 
        the individual responsible for the battery or extreme 
        cruelty.
    Note.--In order to be eligible for SSI, a ``qualified 
alien'' would also have to meet the noncitizen SSI eligibility 
criteria under P.L. 104-193.

Sponsorship deeming

    Amends section 421 of P.L. 104-193 to add the following two 
exceptions to sponsor-to-immigrant deeming:
          Requires that if a noncitizen is indigent and the 
        agency makes a determination for a 12-month period that 
        without SSI benefits the noncitizen is unable to obtain 
        food and shelter taking into account the noncitizen's 
        income and cash, food, housing, and other assistance 
        provided by any individual including the sponsor, then 
        only the amount of income and resources actually 
        provided the noncitizen by the sponsor is counted for 
        deeming purposes. In all cases in which such 
        determinations are made, the agency is required to 
        report the names of the noncitizens and their sponsors 
        to the Attorney General.
          Provides that deeming would not apply for a 12-month 
        period if noncitizens or their children have been 
        battered or subjected to extreme cruelty by family 
        members. The deeming exemption period (with regards to 
        the sponsor batterers income and resources only) is 
        extended if the battering or cruelty has led to an 
        order from a judge, an Administrative Law Judge (ALJ), 
        or the Immigration and Naturalization Service (INS), 
        and the benefit-paying agency determines that the need 
        for benefits has a substantial connection to the 
        battery or cruelty. The deeming exemption does not 
        apply for any month in which the noncitizen lives in 
        the same household as the person responsible for the 
        battery or extreme cruelty.
    These provisions are effective for noncitizens whose 
sponsors execute legally enforceable affidavits of support (see 
below).

Affidavits of support

    Replaces the affidavit of support provisions in P.L. 104-
193 with the following:
          Requires that affidavits of support be made contracts 
        under which the sponsor agrees to provide support at an 
        annual income that is not less than 125 percent of the 
        poverty line. Affidavits of support are made legally 
        enforceable against the sponsor by the sponsored 
        immigrant, and the Federal, State, local governments, 
        or other entity which provide the sponsored noncitizen 
        any means-tested public benefit. These affidavits are 
        required to include the sponsors' agreement to support 
        the noncitizens until they become U.S. citizens or 
        until they (or, under certain conditions, their spouses 
        or individuals who claimed them as dependents on their 
        income tax return) have worked 40 quarters in the 
        United States, whichever is earlier.
          Requires the agency to request reimbursement from the 
        sponsor for assistance provided the noncitizen. If 45 
        days after the reimbursement request, the sponsor is 
        unresponsive or unwilling to make reimbursement, the 
        agency has 10 years to take legal action against the 
        sponsor. Allows the agency to hire individuals to 
        collect reimbursement.
    The Attorney General, in consultation with the Secretary of 
Health and Human Services (HHS), was required to develop a 
standard affidavit of support within 90 days after enactment 
and the provision was effective no earlier than 60, and no 
later than 90, days after enactment.

Study of noncitizens who are not ``qualified aliens'' receiving SSI on 
        another's behalf

    Required that the General Accounting Office within 180 days 
of enactment submit a report to Congress and the Department of 
Justice on the extent to which means-tested benefits are being 
paid to noncitizens acting as representative payees who are not 
``qualified aliens''.

Reports of earnings of noncitizens not authorized to work

    Effective beginning with FY 1996, requires the Commissioner 
to report to Congress, no later than 3 months after the end of 
each fiscal year, the aggregate number of Social Security 
numbers (SSNs) issued to noncitizens not authorized to work, 
but under which earnings were reported.
    Required the Commissioner to transmit to the Attorney 
General, within 1 year of enactment, a report on the extent to 
which SSNs and Social Security cards are used by noncitizens 
for fraudulent purposes.

Maintaining information on noncitizens

    Authorizes the Attorney General to require any noncitizen 
to provide his/her SSN for purposes of inclusion in any record 
maintained by the Attorney General or INS. Effective on the 
date of enactment.

Ineligibility of noncitizens not lawfully present for social security 
        benefits

    Prohibits payment of Social Security benefits to any 
noncitizen in the U.S. for any month during which the 
noncitizen is not lawfully present in the U.S. (as determined 
by the Attorney General).
    Effective for benefits based on applications filed on or 
after the first day of the first month that begins at least 60 
days after the date of enactment.

            Improvements in identification-related documents

Birth certificate requirements

    Prohibits Federal agencies from accepting copies of 
domestic birth certificates that do not conform to standards 
set forth in Federal regulations. The President was to select 
one or more Federal agencies to develop appropriate standards 
for birth certificates and include them in a final regulation 
to be promulgated no later than 1 year after the date of 
enactment. The regulation shall: provide for certification by 
the issuing agency; provide for use of safety paper, the seal 
of the issuing agency, and other features designed to resist 
tampering, counterfeiting, and duplicating for fraudulent 
purposes; not require a single design to be used by all States; 
and accommodate the differences between States in the manner 
and form in which birth records are stored and birth 
certificates are produced.
    The restriction on the acceptance of birth certificates by 
Federal agencies applies to birth certificates issued after the 
day that is 3 years after promulgation of the regulation.
    Requires the Department of Health and Human Services (HHS) 
to provide grants: to encourage States to develop the 
capability to match birth and death records, within each State 
and among the States, and to note the fact of death on the 
birth certificates of deceased persons (fosucing first on 
individuals born after 1950); and for projects in 5 States to 
demonstrate the feasibility of a system by which State vital 
statistics records will reflect in-State deaths within 24 hours 
of that office's acquiring death information from persons 
required to report such information.
    Required HHS to submit a report to Congress within 1 year 
of enactment on ways to reduce birth certificate fraud, 
including any use of a birth certificate to obtain an SSN or 
State or Federal identification or immigration document.
    Effective upon enactment.

Driver's license requirements

    Prohibits Federal agencies from accepting for any 
identification-related purpose a driver's license, or 
comparable identification document, issued by a State, unless 
the license: has an application process that requires the 
presentation of such evidence of identity as is required by 
regulations published by the Secretary of Transportation within 
1 year of enactment; is consistent with regulations that 
require security features designed to limit tampering, 
counterfeiting, photocopying, and use of the license or 
document by imposters; and contains the SSN which can be read 
visually or by electronic means. (This requirement does not 
apply if the State does not require the SSN to appear on the 
license; requires every applicant for a license to submit his/
her SSN; and requires State verification with SSA that the SSN 
is valid.)
    The restriction on acceptance of drivers licenses by 
Federal agencies would be effective beginning October 1, 2000.

Development of prototype of counterfeit-resistant social security card

    Required the Commissioner of Social Security, within 1 year 
of enactment, to develop a prototype of a counterfeit-resistant 
Social Security card that: is made of durable, tamper-resistant 
material (e.g., plastic); employs technologies that provide 
security features (e.g., magnetic stripe); and provides 
individuals with reliable proof of citizenship or legal 
resident noncitizen status.
    Requires the Commissioner of Social Security and the 
Comptroller General each to study and report to Congress on 
different methods of improving the Social Security card 
application process, including: evaluation of the cost and 
workload implications of issuing a counterfeit-resistant Social 
Security card for all individuals over a 3-, 5-, and 10-year 
period; and evaluation of the feasibility and cost implications 
of imposing a user fee for replacement cards and cards issued 
to individuals who apply for such a card prior to the scheduled 
3-, 5-, and 10-year phase-in options.

                            other provisions

Employment verification

    Requires three specific pilot programs to begin no later 
than 1 year after enactment and end no later than 4 year after 
the pilot begins.
    Provides for employers to participate voluntarily in any 
one of the pilots.
          Basic Pilot--employers in five of the seven States 
        with the highest estimated population of noncitizens 
        not lawfully present are to confirm, through a toll-
        free telephone line or other electronic media system 
        established by the Attorney General, the identify and 
        employment eligibility of the individual based on SSN 
        and immigration document (if applicable).
          Citizen Attestation Pilot--an employer would not 
        confirm identify or work authorization for individuals 
        attesting that they are citizens. This pilot would 
        operate only in States with a driver's license that 
        contains a photograph and has been determined by the 
        Attorney General to have security features/reliable 
        means of identification.
          Machine-readable Document Pilot--an employer would 
        confirm an individual's identify and work authorization 
        by means of a machine-readable SSN on a driver's 
        license. This pilot would apply to individuals who do 
        not attest citizenship and would operate only in States 
        with a driver's license that contains a photograph and 
        has been determined by the Attorney General to have 
        security features/reliable means of identification.
    Requires SSA to advise whether the name and SSN match SSA 
records and whether the SSN is valid for employment. In cases 
of tentative non-confirmation, the Attorney General in 
consultation with SSA and the INS must provide a secondary 
verification process to confirm (or not) the validity of the 
information provided.

Verification of alien student eligibility for post-secondary federal 
        student financial assistance

    Required the Secretary of Education and the Commissioner of 
Social Security jointly to submit to Congress within 1 year of 
enactment of the legislation a report on the Department of 
Education computer matching program for student loan, grant, or 
work assistance purposes. The report was to include: an 
assessment of the effectiveness of the computer matching 
program, and a justification for such assessment; the ratio of 
successful matches under the program to inaccurate matches; and 
such other information as the Secretary and the Commissioner 
jointly consider appropriate.

                ITEM 31--DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


      ACTIVITIES ON BEHALF OF OLDER VETERANS FOR FISCAL YEAR 1995

                            I. Introduction

    The Department of Veterans Affairs has the potential 
responsibility for a beneficiary population of more than 26 
million veterans whose median age is approximately 57 years. 
Over thirty-three percent of the veteran population is age 65 
and older. By the year 2005, over four and a half millions 
veterans will be 75 years or older.
    This demographic trend will require VA to redistribute its 
resources to meet the different needs of this older population. 
Historically, older persons are greater users of health care 
services. The number of physician visits, short-term hospital 
stays, and number of days in the hospital all increase as the 
patient moves from the fifth to seventh decade of life.
    VA has developed a wide range of services to provide care 
in a variety of institutional, non-institutional, and community 
settings to ensure that the physical, psychiatric and 
socioeconomic needs of the patient are met. Special projects, a 
variety of innovative, medically-proven programs and individual 
VA medical center (VAMC) initiatives have been developed and 
tested that can be used for veteran patients and adapted for 
use by the general population.
    VA operates the largest health care system in the Nation, 
encompassing 173 hospitals, 131 nursing home care units, 39 
domiciliaries, and 391 outpatient clinics. Veterans are 
alsoprovided contract care in non-VA hospitals and in community nursing 
homes, fee-for-service visits by non-VA physicians and dentists for 
outpatient treatment, and support for care in 77 State Veterans Homes 
in 39 States. As part of a broader VA and non-VA network, affiliation 
agreements exist between virtually all VA health care facilities and 
nearly 1,000 medical, dental, and associated health schools. This 
affiliation program with academic health centers results in almost 
109,000 health profession students receiving education and training in 
VAMCs each year.
    In addition to VA hospital, nursing home and domiciliary 
programs, VA is increasing the number and diversity of non-
institutional extended care programs. The dual purpose is to 
facilitate independent living and keep the patient in a 
community setting by making available the appropriate 
supportive medical services. These programs include Hospital-
Based Home Care, Community Residential Care, Adult Day Health 
Care, Psychiatric Day Treatment and Mental Hygiene Clinics, and 
Homemaker/Home Health Aide Services.
    The need for both acute and chronic hospitalization will 
continue to rise as older patients experience a greater 
frequency and severity of illness, as well as a different mix 
of diseases, than younger patients. Cardiovascular diseases, 
chronic lung diseases, cancers, psychiatric, and mental 
disorders, bone and joint diseases, hearing and vision 
disorders, and a variety of other illnesses and disabilities 
are all more prevalent in those persons age 65 and older.

               II. Geriatrics and Extended Care Programs

                          va nursing home care

    Nursing Home Care Units (NHCU), which are based at VA 
medical centers, provide skilled nursing care and related 
medical services. An inter-disciplinary approach to care is 
employed, which encourages diverse professional staff, working 
together, to meet the multiple physical, social, psychological, 
and spiritual needs of the patients. Nursing home patients 
typically require a prolonged period of care and/or 
rehabilitation services to attain and/or maintain optimal 
functioning.
    In fiscal year 1995, more than 33,000 veterans were treated 
in 131 VA nursing homes, generating a total average daily 
census (ADC) of almost 13,600.
    VHA is continuing to offer NHCU staff educational programs 
to enhance the care of the mentally ill nursing home patient. 
Interest in the use of the Patient Assessment Instrument 
(Minimum Data Set) remains high. While the use of this 
instrument is not mandated, many facilities have reported plans 
to adopt it.

                      community nursing home care

    This is a community-based, contract program for veterans 
who require skilled or intermediate nursing care when making a 
transition from a hospital setting to the community. Veterans 
who have been hospitalized in a VA facility for treatment, 
primarily for a service-connected condition, may be placed at 
VA expense in community facilities for as long as they need 
nursing care. Other veterans may be eligible for community 
placement at VA expense for a period not to exceed 6 months. 
Selection of nursing homes for a VA contract requires the prior 
assessment of participating facilities to ensure they meet our 
standards of care. Follow-up visits are made to veterans by 
teams from VA medical centers to monitor patient programs and 
quality of care.
    In September, 1995, VA issued a request for proposals (RFP) 
to corporate level, multi-state nursing home providers for bids 
to provide nursing home care to veterans with a minimum level 
of guaranteed expenditures. Responses to the RFP were received 
in January, 1996. Up to six multi-state contracts are expected 
to be established by mid-1996. This initiative is expected to 
result in reduced administrative costs (and potentially per 
diem costs), improvement of VA's access to nursing home beds, 
and more consistent quality of care.
    In fiscal year 1995, 27,000 veterans were treated in the 
program. The number of nursing homes under contract was 3,500 
and the average daily census of these homes was 8,300.

                          va domiciliary care

    Domiciliary care in VA facilities provides necessary 
medical and other professional care for eligible ambulatory 
veterans who are disabled by disease, injury, or age and are in 
need of care but do not require hospitalization or the skilled 
nursing services of a nursing home.
    The domiciliary offers specialized interdisciplinary 
treatment programs that are designed to facilitate the 
rehabilitation of patients who suffer from head trauma, stroke, 
mental illness, chronic alcoholism, heart disease and a wide 
range of other disabling conditions. With increasing frequency, 
the domiciliary is viewed as the treatment setting of choice 
for many older veterans.
    Implementation of rehabilitation-oriented programs has 
provided a better quality of care and life for veterans who 
require prolonged domiciliary care and has prepared increasing 
numbers of veterans for return to independent or semi-
independent community living.
    Special attention is being given to older veterans in 
domiciliaries with a goal of keeping them active and productive 
as well as integrated into the community. The older veterans 
are encouraged to utilize senior citizens and other resources 
in the community where the domiciliary is located. Patients at 
several domiciliaries are involved in senior center activities 
in the community as part of VA's community integration program. 
Other specialized programs in which older veterans are involved 
include Foster Grandparents, Handyman Assistance to senior 
citizens in the community, and Adopt-A-Vet.
    In fiscal year 1995, 18,100 veterans were treated in 40 VA 
domiciliaries resulting in an average daily census of 5,713. Of 
these numbers, approximately 3,410 veterans and an average 
daily census of more than 1,300 were admitted to the 
domiciliaries for specialized care for homelessness. This 
latter group had an average age of 43 years, while the overall 
average age of domiciliary patients was 59 years.

                              state homes

    The State Home Program has grown from 10 homes in 10 states 
in 1888 to 77 state homes in 39 States. Currently, a total of 
22,510 beds is authorized by VA to provide hospital, nursing 
home, and domiciliary care. VA's relationship to state veterans 
homes is based upon two grant programs. The per diem grant 
program enables VA to assist the states in providing care to 
eligible veterans who require domiciliary facilities. The other 
VA grant program provides up to 65 percent federal funding to 
states to assist in the cost of construction or acquisition of 
new domiciliary and nursing home care facilities, or the 
expansion, remodeling, or alteration of existing facilities.

                              hospice care

    VA has developed programs that provide pain management, 
symptom control, and other medical services to terminally ill 
veterans, as well as bereavement counseling and respite care to 
their families. The hospice concept of care is incorporated 
into VA medical center approaches to the care of the terminally 
ill. All VA medical centers have appointed a hospice 
consultation team, which is responsible for planning, 
developing, and implementing the hospice program.

                        hospital-based home care

    This program provides in-home primary medical care to 
veterans with chronic illnesses. The family provides the 
necessary personal care under the coordinated supervision of a 
hospital-based interdisciplinary treatment team. The team 
prescribes the needed medical, nursing, social, rehabilitation, 
and dietetic regimens, and provides the training of family 
members and the patient in supportive care.
    Seventy-five VA medical centers are providing hospital-
based home care (HBHC) services. In fiscal year 1995, home 
visits were made by health professionals to an average daily 
census of 5,000 patients.

                         adult day health care

    Adult Day Health Care (ADHC) is a therapeutically-oriented 
ambulatory program that provides health maintenance and 
rehabilitation services to veterans in a congregate setting 
during the daytime hours. ADHC in VA is a medical model of 
services, which in some circumstances may be a substitute for 
nursing home care. VA operated 13 ADHC centers in fiscal year 
1995, with an average attendance of 450 patients. VA also 
continued a program of contracting for ADHC services at 83 
medical centers. The average daily attendance in contract 
programs was 419 in fiscal year 1995.

                       community residential care

    The Community Residential Care home program provides 
residential care, including room, board, personal care, and 
general health care supervision to veterans who do not require 
hospital or nursing home care but who, because of health 
conditions, are not able to resume independent living and have 
no suitable support system (e.g., family, friends) to provide 
the needed care. All homes are inspected by a multidisciplinary 
team prior to incorporation of the home into the VA program and 
annually thereafter. Care is provided in private homes that 
have been selected by VA, at the veteran's own expense. 
Veterans receive monthly follow-up visits from VA health care 
professionals. In fiscal year 1995, an average daily census of 
9,200 veterans was maintained in this program, utilizing 
approximately 2,100 homes.

              homemaker/home health aide services (H/HHA)

    In fiscal year 1995, VA initiated a pilot program of 
health-related services for veterans needing nursing home care, 
implementing provisions of Public Law 101-366. These services 
are provided in the community by public and private agencies 
under a system of case management provided directly by VA 
staff. For the purpose of the initiative, health-related 
services are defined as homemaker/home health aide services 
only.
    One hundred eighteen VAMCs were purchasing H/HHA services 
in fiscal year 1995 for approximately 4,200 veterans.

           Geriatric Evaluation and Management Program (GEM)

    The Geriatric Evaluation and Management (GEM) Program 
includes inpatient units, outpatient clinics, and consultation 
services. A GEM Unit is usually a functionally different group 
of beds (ranging typically in number from 10 to 25 beds) on a 
medical service or an intermediate care unit of the hospital 
where an interdisciplinary health care team performs 
comprehensive geriatric assessments. The GEM unit serves to 
improve the diagnosis, treatment, rehabilitation, and discharge 
planning of older patients who have functional impairments, 
multiple acute and chronic diseases, and/or psychosocial 
problems. GEM clinics provide similar comprehensive care for 
geriatric patients not in need of hospitalization as well as 
provide follow-up care for older patients to prevent their 
unnecessary institutionalization. A GEM program also provides 
geriatric training and research opportunities for physicians 
and other health care professionals in VA medical centers. 
Currently, there are 130 GEM Programs.
    Results from a controlled, randomized study of GEM efficacy 
that was conducted at the VA Medical Center Sepulveda, CA, and 
published in the New England Journal of Medicine in 1984, 
showed significant benefits such as improved survival, 
decreased rehospitalization rates, improved functional status, 
and decreased nursing home placement following admission to GEM 
units.

              Care of the Acute and Critically ILL Elderly

    In 1995, VA Headquarters completed its third printing of a 
supplemental guide for medical center staff who care for the 
acutely-ill veteran (Geriatric Pocket Pal). This guide is used 
by residents, nurses, and allied health personnel in all VA 
medical centers. Many requests have been received from non-VA 
clinical staff for this popular VHA publication, developed by 
VA Headquarters and field staff. The Geriatric Pocket Pal was 
revised in November, 1994, to include updated reference 
materials and incorporate additional information.

                              Respite Care

    Respite Care provides planned, periodic, short-term care 
for a disabled person in order to temporarily relieve the 
caregiver from the physical and emotional burden of providing 
the needed care and supervision. VA provides respite care by 
admitting a veteran to a hospital or nursing home bed for up to 
thirty days a year. This institutionally-based program not only 
supports this caregiver's role in caring for the veteran at 
home, but also provides an opportunity for VA staff to evaluate 
and treat the veteran's health care needs and offer guidance to 
the caregiver in the home treatment plan.

                Alzheimer's Disease and Other Dementias

    VA's program for veterans with Alzheimer's disease and 
other dementias is decentralized throughout the medical care 
system, with coordination and direction provided by the Office 
of Geriatrics and Extended Care. Veterans with these diagnoses 
participate in all aspects of the health care system including 
outpatient programs, acute care programs and extended care 
programs. Approximately 56 medical centers have established 
specialized programs for the treatment of veterans with 
dementing illnesses. Policy guidance concerning a continuum of 
dementia services to be provided in VA's health care networks 
is currently under development.
    In order to advance knowledge about the care for veterans 
with dementia, VA investigators conduct basic biomedical, 
applied clinical and health services research, much of which 
occurs at VA's Geriatric Research, Education and Clinical 
Centers (GRECCs), and which is supported through the Office of 
Research and Development. Rehabilitation Research and 
Development Service develops and evaluates new technologies and 
techniques designed to minimize disability associated with 
dementia. Continuing education for staff is provided through 
training classes sponsored by GRECCs and VA's continuing 
education field units.
    VA Headquarters has disseminated a variety of dementia 
patient care educational materials in the form of publications 
and videos to all VA medical centers. In fiscal year 1990, all 
VA libraries received a revised edition of guidelines for 
diagnosis and treatment of dementia, a series of 21 dementia 
caregiver education pamphlets developed by the Minneapolis 
GRECC, and 3 videotapes on Alzheimer's disease developed by the 
Bedford Division of the Boston GRECC. In fiscal year 1993, VA 
libraries received a series of 3 geriatric health care 
videotapes that are relevant to dementia patient care. In 
addition, a comprehensive instructional program, ``Keys to 
Better Care,'' was made available to all VA medical centers 
through regional audiovisual delivery sites. This 14-part 
training package for health care providers caring for patients 
with Alzheimer's Disease and other dementias addresses a wide 
range of issues related to quality care and it is being used 
extensively by VA staff. Also, an audiovisual videotape on 
rehabilitation of the cognitively-impaired patient, produced by 
the Northeast VA Learning Resources Service, was made available 
at all VA libraries.
    During 1990 and 1991, VA Headquarters surveyed a sample of 
VA medical centers with established inpatient units for 
patients with dementia. A summary report of these dementia unit 
site visits was published by VA in September, 1993, and has 
been disseminated widely throughout the VA system and to the 
non-VA community. The report details the organization and 
delivery of inpatient services to dementia patients from 
admission to discharge. Results of these site visits will aid 
in planning future dementia programs and services, with 
information addressing such issues as dementia unit staffing 
patterns, programming, and overall organization.
    In fiscal years 1994 and 1995, VA conducted teleconferences 
that featured national experts on Alzheimer's disease. 
Presented were state-of-the-art strategies for diagnosis and 
treatment of this devastating disease from a primary care 
perspective. Staff at both VA and non-VA sites, including State 
Veterans Homes, participated in these educational 
teleconferences.
    As a further development, a joint VA/University Health 
System Consortium (UHC) technical advisory group has been 
working since July, 1995, on an updated clinical guideline for 
the identification and assessment of dementia. The guideline, 
which will emphasize the role of primary care clinicians in the 
diagnostic process, will be distributed throughout the VA and 
UHC systems.
    Also, in fiscal year 1995, a comprehensive Center for 
Alzheimer's Disease and Other Neurodegenerative Disorders was 
begun at the Oklahoma City VA Medical Center. The goal of the 
Center is to develop and evaluate a rural health model for the 
coordinated care of patients with Alzheimer's disease or other 
degenerative neurological disorders in the state of Oklahoma. 
Using an interdisciplinary, case-management approach, the 
Center provides patient services, including outpatient 
diagnosis, treatment and follow-up care, as well as support for 
family and other caregivers of veterans with these disorders. 
The use of telemedicine technology is being explored to enhance 
communication among providers in distant settings. 
Collaborative relationships between VA, state and local 
community organizations will be coordinated to meet the 
community service needs of these patients and their families. 
Relevant staff education, training, and research activities 
will also be developed.

      Geriatric Research, Education, and Clinical Centers (GRECCs)

    The Geriatric Research, Education, and Clinical Centers 
(GRECCs) assume an important role in further developing the 
capability of the VA health care system to provide cost-
effective and appropriate care to older veterans. First 
implemented in 1975, GRECCs are designed to enhance the 
system's capability to develop state-of-the-art care in 
geriatrics through research, education, and clinical care. The 
goals of the GRECCs are to develop new knowledge regarding 
aging and geriatrics, to disseminate that knowledge through 
education and training to health care professionals and 
students, and to develop and evaluate alternative models of 
geriatric care.
    GRECCs have developed many innovative approaches to educate 
and train VA clinical staff who care for elderly veterans. 
GRECC staff have continued to expand their outreach education 
and training to provide expertise to VA staff, particularly in 
the area of geriatric evaluation and management. Also, GRECCs 
have developed individual topic-specific education programs for 
the networks they serve and have collaborated with other GRECCs 
to present this information to clinical staff in other networks 
as well. This provides a significant number of clinical staff 
with the state-of-the-art information on specific issues 
concerning care of the elderly.
    Each GRECC has developed an integrated program of basic and 
applied research, education, training, and clinical care in 
selected areas of geriatrics. Current focal areas include 
cardiology and prevention of cardiovascular disease; cognitive 
and motor dysfunction andneurobiology; endocrinology, 
swallowing disorders, metabolism and nutrition; geropharmacology; 
immunology, cancer and infectious diseases; osteoporosis and arthritis; 
falls; exercise physiology; geriatric rehabilitation; sensory 
impairment; depression; bio-ethical aspects of medical decision-making 
in the elderly; and cost-effective and quality of geriatric care. Using 
an integrated approach, the GRECCs are developing practitioners, 
educators, and researchers to help meet the need for training health 
care professionals in the field of geriatrics; providing information 
for, as well as establishing models on, cost-effective approaches to 
care of the elderly; and researching better methods to diagnose and 
treat health care problems of the older person, as well as finding 
answers to fundamental questions on the processes and consequences of 
aging.
    At present there are 16 GRECCs. They are located at the 
following VA medical centers: Ann Arbor, MI; Baltimore, MD; 
Bedford and Brockton/West Roxbury, MA (2 divisions); Durham, 
NC; Gainesville, FL; Little Rock, AR; Madison, WI; Miami, FL; 
Minneapolis, MN; Palo Alto, CA; San Antonio, TX; St. Louis, MO; 
Salt Lake City, UT; Seattle/American Lake, WA (2 divisions); 
Sepulveda, CA; and West Los Angeles, CA. Public Law 99-166, 
``Veterans Administration Health Care Amendments of 1985,'' 
increased from 15 to 25 the maximum number of facilities that 
the VA Secretary may designate for GRECCs.

                    III. Office of Clinical Programs

                              Primary Care

    As VHA transitions from an acute, inpatient-based system of 
care to an outpatient, primary case-based system of care, 
opportunities for collaboration between geriatrics and primary 
care are being maximized. Most physicians in geriatrics come 
from an internal medicine background with a strong emphasis on 
primary care and an interdisciplinary team approach to patient 
care. As medical centers implement primary care, one of the 
primary care teams is in the area of geriatrics. Development of 
geriatric primary care is one of the goals now being 
highlighted and encouraged as special training teams are 
assisting medical centers in implementing primary care.
    Two VHA publications, Sharing Innovations Among VA 
Clinicians and VA Innovations in Ambulatory Care, have been 
distributed to VHA providers. They highlight new ways of 
improving patient care and satisfaction. These books contain 
specific information about geriatric-aged patients and new 
techniques to meet their needs.

                            Medical Service

    Medical Service in VAMCs serves as the primary source of 
physicians for the care of all veterans, including elderly 
patients. Due to the aging of the population, Medical Service 
is increasingly involved in all aspects of the delivery of 
health care to the aged. Acute and intermediate medical wards, 
coronary and intensive care units, nursing homes and outpatient 
clinics are all seeing an increased proportion of elderly 
patients with acute and chronic illnesses. While some care is 
provided specifically by geriatricians, as the population ages, 
all internists are seeing an older veteran population.
    Some subspeciality areas are particularly impacted, such as 
cardiology, endocrinology (diabetes), rheumatology and 
oncology. Medical Service provides necessary subspecialty care 
in inpatient and outpatient settings in addition to 
participating in Geriatric Fellowship Training, GRECCs, 
Geriatric Evaluation and Management (GEM) Programs, Hospice, 
Respite, Nursing Home, and Hospital-Based Home Care. The 
specialized care that is required by the elderly has been 
recognized by Medical Service at a number of medical centers, 
by their establishment of a Geriatric Medicine Section, which 
emphasizes clinical care, as well as coordinating research and 
education efforts related to geriatrics.
    Age alone is less frequently used as a determinant of an 
individual patient's care. Geriatric patients undergo invasive 
diagnostic procedures as well. For example, the Sunbelt is 
experiencing an increasingly heavy cardiac catheterization 
workload. The average age of patients treated in coronary and 
intensive care units is increasing, producing a concomitant 
demand for cardiac rehabilitation and physical fitness programs 
that are targeted to the frail elderly and the physically 
handicapped of all ages. The special interest and involvement 
of Medical Service in geriatrics has also resulted in 
participation by internists in such programs as Adult Day 
Health Care, as well as in research problems in nutrition and 
treatment by hypertension.
    Smoking cessation has been shown to benefit even elderly 
patients. Thus, the role of Preventive Medicine for this 
patient population has expanded. The Medical Service has been 
active in implementing preventive strategies in smoking 
cessation, immunization (influenza and pneumococcal vaccines), 
and colorectal screening (for cancer). Lipid control is an 
emerging area that may benefit this population.
    Participation in evaluation and treatment of elderly 
patients by interdisciplinary teams during intermediate-length 
hospital stays will be an increasingly important role for the 
physicians of the Medical Service.

                          Social Work Service

    Meeting the biopsychosocial health care needs of an aging 
population of veterans and caregivers continues to be a major 
priority of Social Work Service and the Veterans Health 
Administration. The need to be competitive in a challenging and 
changing health care environment, as well as cost-effective and 
efficient in addressing the social components of health care, 
has led to a re-examination of social work priorities and their 
relevance to the VA health care mission, with special reference 
to the needs of chronically ill, older veterans. Without a 
support network of family, friends, and community health and 
social services health care gains would be lost and VHA acute 
care resources would be over-burdened. It is frequently not the 
degree of illness that determines the need for hospital care, 
but rather the presence or absence of family and community 
resources.
    The expansion of homemaker/home health aide services is 
evidence of the importance of non-institutionalized support 
networks in maintaining the veteran in the community. Social 
workers continue to coordinate discharge planning and to serve 
as the focal point of contact between the VA medical center, 
the veteran patient, family members, and the larger community 
health and social services network. The veteran and family 
members have, in many respects, become the ``unit of care'' for 
social work intervention. It is this ``customer'' focus which 
will undergird social work programming for vulnerable 
populations, including older veterans who are demanding that 
VHA be more responsive and sensitive to their psychosocial 
needs and those of their caregivers.
    The role of the caregiver as a member of the VA health care 
team and as a key player in the provision of health care 
services continues to be a major area of social work practice 
and will continue to be in the immediate future. This is 
consistent with the recognition that 80 percent of nursing care 
is provided in the home by family, neighbors, etc., and that 
the family, ordinarily the veteran's spouse, is the key 
decision-maker concerning health insurance issues, and, most 
probably, access to health and community support services.
    As VHA transitions from an acute care to a primary care/
community interactive health care delivery system, Social Work 
Service has placed increased emphasis on its pivotal role in 
community services coordination, development, and integration. 
The development of a ``seamless garment of care,'' with case 
management services as its centerpiece, is being given 
increased emphasis by Social Work Service and its National 
Committee. The National Committee functions in an advisory 
capacity concerning social work and systems issues, priorities, 
and practice concerns. While case management services have been 
a central component of social work practice in VHA, this 
service modality is being ``re-discovered'' by the VA health 
care system as an essential component of services provided to 
``at-risk'' veterans and their caregivers. Case management, 
also known as ``care coordination,'' was identified in 
veterans' discussion groups as a very important ingredient in 
meeting the veterans' health care needs and those of their 
caregivers. During 1995 and beyond, VHA, and particularly 
Social Work Service, will be challenged to expand case 
management services in concert with other community providers 
and to provide a perspective that addresses this critical 
ingredient of care in terms of its absolute relevance to 
successful health care outcomes. In a revitalized and 
reconfigured VA health care system, issues of coordination, 
access, cost, and appropriateness of VA and community services 
will be determined not only by the needs of the customers, but 
also by the experience and expertise of the providers.
    Older veterans, including those from some minority groups 
such as Native Americans, are at significant risk for the 
development of health care problems related to geographic 
isolation, economic deprivation, and cultural barriers. The 
Interagency Task Force on Older Indians continues to address 
issues of concern related to the provision of services to a 
population that has been underserved by the Federal sector. The 
Department of Veterans Affairs, represented by Social Work 
Service, has been an active member of this consortium.

                Rehabilitation Research and Development

    The mission of the Rehabilitation Research and Development 
(Rehab R&D) Service is to investigate and develop concepts, 
products and processes that promote greater functional 
independence and improve the quality of life for impaired and 
disabled veterans. Aging, particularly the aging of persons 
with disabilities, is a high priority of the service. Efforts 
in this area include:
          A national VA program of merit-reviewed, 
        investigator-initiated research, development and 
        evaluation projects targeted to meet the needs of aging 
        veterans with disabilities;
          Support of a Rehabilitation Research and Development 
        Center on Aging at Decatur, Georgia, VA Medical Center; 
        and
          Transfer into the VA health care delivery system of 
        developed rehabilitation technology and dissemination 
        of information to assist the population of aging 
        veterans and those who care for them.
    In addition to specific projects on aging, may of the 
investigations supported through the Service's nationwide 
network of research at VAMCs and at four Rehabilitation 
Research and Development Centers have relevance for impairments 
commonly associated with aging.
    Some samples of investigator-initiated studies currently 
being carried out are:
          A Low-Vision Enhancement System (LVES);
          Liquid Crystal Dark-Adapting Eyeglasses;
          Electronic Travel Aid for the Blind;
          Non-Auditory Factors Affecting Hearing Aid Use in 
        Elderly Veterans;
          The Influence of Strength Training on Balance and 
        Function in the Aged; and an
          Epidemiologic Study of Aging in Spinal Cork Injured 
        Veterans.
    The Rehab R&D Center on Aging is structured around five 
interdisciplinary research sections to address the multi-
dimensional nature inherent in problems of aging and 
disability: Environmental Research; Vision Rehabilitation; 
Neuro-Physiology; Engineering and Computer Science; and Social, 
Behavioral, and Health Research. Areas of study include:
          Design-related problems that affect the quality of 
        life of older people, including least restrictive 
        environments, falls, independence and safety;
          Orientation and mobility for the blind, low vision, 
        and rehabilitation outcomes measurement for older 
        persons with visual impairment;
          The neurologic and physiologic changes that accompany 
        aging and behavioral coping problems; and
          Development and application of new technologies to a 
        variety of prototypes for the design of assistive 
        devices and assistive software.

             Physical Medicine and Rehabilitation Medicine

    Physical Medicine and Rehabilitation Service (PM&RS) 
strives to provide all referred older veterans with 
comprehensive assessment, treatment and follow-up care for 
psychosocial and/or physical disability affecting functional 
independence and quality of life. The older veterans's 
abilities in the areas of self-care, mobility, endurance, 
cognition and safety are evaluated. Therapists utilize physical 
agents, therapeutic modalities, exercise and the prescription 
of adaptive equipment, to facilitate the veterans' ability to 
remain in the most independent life setting. Rehabilitation 
personnel provide education to the veterans and their families 
around adjustment to their disability or physical limitations 
and instruct them in techniques to maintain independence 
despite disability.
    Over 6,000 veterans per year receive treatment and are 
discharged from inpatient rehabilitation programs at 
approximately 65 medical centers. There is a growing number of 
subacute rehabilitation programs being established at medical 
centers across the nation. The subacute setting affords us the 
ability to provide less intense rehabilitative services for the 
older veteran, aimed at promoting an individuals' integration 
back into the community. On both acute and subacute 
rehabilitation units, physicians, usually board certified 
physiatrists, lead interdisciplinary teams of professionals to 
focus on outcomes of functional restoration, clinical 
stabilization, or avoidance of acute hospitalization and 
medical complications.
    A uniform assessment tool, the Functional Independence 
Measure (FIM), is being implemented throughout the VA 
rehabilitation system. Patients are evaluated on 18 elements of 
function at the time of admission, regularly during treatment 
and at discharge. Application of FIM results to quality 
management activity will assist local and national 
rehabilitation clinicians and managers to maximize effective 
and efficient rehabilitation care delivery. An administrative 
data base called the Uniform Data System for Medical 
Rehabilitation (UDS/mr) will monitor outcomes of care and 
increase accuracy of developing predictors and ideal methods of 
treatment for the older veteran with various diagnoses. As part 
of a national contract with UDS/mr, 65 facilities with 
rehabilitation bed units provide data and receive outcome 
reports as part of the national and international UDS/mr data 
bank.
    Rehabilitation therapists are leading and participating in 
innovative treatment, clinical education, staff development and 
research. Rehabilitation professionals work within homebound 
health care; independent living centers; Geriatric Evaluation 
and Management Units; Adult Day Health Care; Day Treatment 
Centers; Domiciliaries; Interdisciplinary Team Training 
Programs; Geriatric Research, Education, and Clinical Centers 
(GRECCs); and hospice care programs.
    Driver training centers are staffed at 40 VA medical 
centers to meet the needs of aging and disabled veterans. With 
the growing numbers of older drivers, the Department of 
Veterans Affairs has put emphasis on the training of the mature 
driver. Classroom education, updates in laws and defensive 
driving techniques are supported with behind-the-wheel 
evaluation by trained specialists.

                            Nursing Service

    Care of the elderly veteran continues to be one of the 
highest priorities for Nursing Service. Nurses at every level 
of the organization are committed to providing leadership in 
the clinical, administrative, research, and educational 
components of gerontological nursing.
    Professional nurses function as part of interdisciplinary 
teams to coordinate and provide care in settings beginning with 
Geriatric Evaluation and Management Programs (GEMs) and 
progressing along many care settings including ambulatory care, 
acute care, long-term care, and community agencies. 
Gerontological nurse practitioners and clinical nurse 
specialists provide primary care and continuity of care as 
clinical care managers and coordinators of care.
    Preventive care and health promotion incentives continue to 
preserve independence, foster self-care, improve productivity, 
and enhance the quality of life by improving the health status 
of aging veterans. Proper screening, education, and referral of 
elderly veterans are vital activities to meet their health care 
needs in the least restrictive environment. Nurses in wellness 
clinics and other ambulatory care settings provide supervision, 
screening, and health education programs to assist veterans in 
maintaining healthy lifestyles.
    Nurses play a key role in restoring the functional 
abilities of aging veterans with chronic illnesses and 
disabilities. Programs for the physically disabled and 
cognitively impaired have been established and are administered 
by nurses and nurse practioners in home care, ambulatory care 
settings, and inpatient units. Treatment programs are goal-
directed toward physical and psychosocial reconditioning or 
retraining of patients with biological and 
psychosocialdisturbances. Patient and family teaching is a major part 
of each program. Family and significant others have a key role in 
providing support to aging veterans and are assisted in learning and in 
maintaining appropriate caregiver responsibilities. VA nurses 
contribute to planning and implementing health care services for the 
elderly in the community-at-large. They serve on task forces and 
participate in self-help and support groups related to specific 
diseases such as Alzheimer's. Nurses are also advisors to local health 
planning councils, and they share VA educational activities and 
research seminars with other health care professionals.
    Nursing leaders continue to collaborate with schools of 
nursing to offer positive learning experiences in both 
undergraduate and graduate nursing education. Nursing schools 
are encouraged to focus more attention on programs in 
geriatrics, rehabilitation, and chronic care. Graduate nursing 
students receive clinical experience in Geriatric Evaluation 
and Management Programs, Nursing Home Care Units, and Hospital 
Based Home Care Programs. Nursing Service is committed to 
leadership that will ensure the patient care needs of aging 
veterans are addressed. The preceptorship training program for 
the position of Associate Chief or Supervisor Nursing Home Care 
Unit is on hold until the need for nurses in these positions 
has been determined. The interdisciplinary approach to reduce 
poly-pharmacy continues, with several nursing home care units 
reporting successful programs.
    Nursing Service continues to support restraint-free 
environments throughout the VA health care system. Several 
VAMCs report a variety of successful strategies to reduce the 
use of restraints, including a successful interdisciplinary 
approach to understanding, evaluating, and developing 
alternatives to physical restraints. Disciplines involved 
include Nursing, Medicine, Pharmacy, Dietetics, Recreation, 
Rehabilitation, and Social Work. Strategies that contribute to 
restraint reduction include an electronic wandering alert 
system, a gait training program, education of family members, 
greater use of volunteers and use of hospital beds with egress 
alarms.
    Many medical centers across the VA system have developed 
new initiatives to improve the quality of care for aging 
veterans. Many such interventions have improved the quality of 
life of patients as well as the quality of care. Some of these 
include the following:
    An interdisciplinary autonomy committee to create an 
environment in which resident autonomy is enhanced and promoted 
while meeting the therapeutic needs.
    A variety of unique approaches to meet nutrition needs of 
aging patients in long-term care settings. Successful 
interventions included interdisciplinary total quality 
improvement teams for nutrition support and care, an 
interdisciplinary progressive self-feeding program and a dining 
together program.
    The use of Tai-Chi to promote health and improve the 
quality of life for the institutionalized aging patient. 
Preliminary data suggest improvement in physical functioning 
and improved scores on mental status tests for dementia 
patients.
    An enhanced Geriatric care project developed to provide a 
safe user friendly therapeutic environment while promoting an 
environment conducive to wellness. Outcomes of the project 
include the following:
          A safe and protective area for wandering patients;
          Greater patient participation, communication, and 
        socialization through the use of outdoor activities;
          Enhanced customer and staff satisfaction.
    The use of primary care to reduce admissions and length of 
stays for nursing home patients in acute care settings. The use 
of multidisciplinary teams to provide Geriatric Primary Care 
for the frail elderly and those over the age of 75.
    An innovative program designed to prevent and/or minimize 
the effects of bed rest utilizing a mobility program called 
VIPS (Volunteer in Professional Service). The program was 
designed to increase routine ambulating of patients utilizing 
trained volunteers. Outcomes of the program include enhanced 
mobility, return of patient to a less restrictive environment, 
and increased companionship and socialization for patients with 
limited mobility.
    Research is needed to advance health care for older persons 
and to improve gerontological nursing practice. Nursing 
research is urgently needed to improve the quality of care in 
the following areas:
          Urinary incontinence;
          Common eating patterns, programs, and nutrition;
          Falls;
          Enhancing socialization skills;
          Care of Alzheimer's patients;
          Wandering behavior;
          Dementia;
          Exercise and mobility;
          Medications, including effectiveness of psychotropic 
        medications, and types and incidence of medication 
        abuse among the elderly;
          Health promotion;
          Frail elderly in the home setting;
          Alternatives to institutional care; and
          Coping mechanisms of patients, families, and 
        caregivers.
    Studies are needed to enhance the quality of life for aging 
female veterans in a health care system largely focused on a 
male model of care. Osteoporosis is a serious metabolic bone 
disease which affects post-menopausal women to a greater degree 
than men. Women veterans who served during and prior to the 
Korean and Vietnam Wars are a prime risk group for this 
disease. Timely application of research findings to clinical 
care in all practice settings will improve the quality of care 
and quality of life to aging veterans.

                       nutrition and food service

    Medical nutrition care saves money, improves patient 
outcomes and enhances the quality of life for our older 
veterans. To better serve the veteran and identify nutritional 
needs, many VA health care professionals are now using 
Determine Your Nutritional Health Checklist and Level I and II 
Nutrition Screen developed by the American Dietetic 
Association, American Academy of Family Physicians and National 
Council on Aging National Screening Initiative. The Checklist 
or Level I Screen identifies those at high risk for poor 
nutritional status, while Level II Screen provides specific 
diagnostic nutritional information. The National Screening 
Initiative emphasizes educating the physician in nutritional 
care. The booklet, Incorporating Nutrition Screening and 
Interventions into Medical Practice, has been nationally 
disseminated to doctors. This information complements the 
handbook, Geriatric Pocket Pal, developed in collaboration with 
the Office of Geriatrics and Extended Care.
    Many medical centers have Geriatric Nutrition Specialist 
positions. Dietitians in these positions have developed easy-
to-read educational materials for their audience and shared 
this information with other medical centers. Several medical 
centers are providing outreach services for the elderly in 
their community. For example, the Bronx VAMC provides outreach 
to local senior centers, and the Dallas VAMC has bi-monthly 
visits by their health screening team to facilities in their 
area. A variety of nutrition education programs have been 
offered for health care providers and patients.
    Nutrition and Food Service continues to provide guidance on 
quality care. Several practice guidelines have been distributed 
to all the medical centers to ensure quality care for our 
elderly. In addition, Tomah VAMC has developed 
interdisciplinary guidelines for the care of dysphagia. The 
clinical indicator to ensure that the patient not only receives 
food, but also is fed, was distributed to all medical centers. 
Northampton VAMC developed an indicator for high-risk geriatric 
patients who are overweight.

                          Office of Dentistry

    Dental care for the geriatric patient involves restoration 
of function through rehabilitation of the dentition, and 
elimination of pain and suffering attributable to oral disease. 
It is important that older adults are able to effectively 
masticate a variety of foods so that convalescence after 
surgery, chemotherapy, or other significant medical 
interventions is expedited.
    Interpersonal skills, which are highly dependent upon 
physical appearance, as well as effective communication, can be 
enhanced by improving the teeth's appearance and by properly 
aligning and restoring the anterior teeth to maintain clarity 
of speech. The goals of dental care are consistent with those 
of all disciplines involved in geriatrics--to maximize function 
and foster independence in living. Dentistry should be an 
integral part of any comprehensive health care program for the 
elderly.
    The nature of dental disease in late life--chronic and 
often asymptomatic even in advanced stages, aggravated by 
coexistent medical problems, and perceived as a low priority by 
health funding agencies--requires an increased emphasis on 
preventive services. Innovative, individualized, preventive 
dental programs are often necessary for each patient. 
Preventive modalities include the use of home-applied fluoride 
solutions, anti-microbial mouth rinses, specially fabricated 
tooth brushes, instruction to family or care givers on oral 
hygiene techniques, and more frequent dental examinations. 
These are low-cost yet effective measures that can obviate the 
need for future expensive or invasive dental care. VA has been 
a world leader in developing preventive dental therapies and 
field testing them for clinical efficacy.
    Oral cancer is a disabling and disfiguring disease that 
primarily affects middle-aged and older adults. Ninety-five 
percent of cases occur in those over 40. Alcohol, tobacco, and 
advanced age are important risk factors in the development of 
this disease. Early detection of frequently asymptomatic 
lesions can significantly reduce the disease's morbidity. 
Through a long-standing program of oral screening examinations, 
VA dentists have been able to expeditiously detect incipient 
oral cancers. Such interventions minimize the need for ablative 
surgery, which often results in swallowing and eating 
difficulties. Early detection can also significantly reduce 
mortality rates.
    Most VA Medical Centers have established Geriatric 
Evaluation and Management (GEM) programs. Dental Services 
contribute to the GEM's interdisciplinary team effort by 
conducting admission oral assessments, collaborating on 
treatment planning, providing specialty consultations and 
needed care, and preparing summaries of oral care protocols to 
be maintained after discharge. Oral examinations conducted 
during GEM admissions commonly identify problems previously 
undetected that can impede chewing efficiency, safe swallowing, 
and clearly articulated speech. Interdisciplinary treatment 
planning takes advantage of the synergy associated with group 
efforts. Patients are rehabilitated more rapidly with properly 
staged and coordinated care. New problems and unexpected 
outcomes are better addressed by geriatric interdisciplinary 
teams. For matters involving the oral-dental complex, dentistry 
has responded with timely assessment, definitive diagnosis, and 
recommended treatment. At discharge a review of the patient's 
response to treatment, plan for maintenance, and guidance for 
future care are prepared. The GEM Program has been an ideal 
environment for dentistry to demonstrate its relative merit and 
range of contributions to the interdisciplinary team.
    The VA Program Guide: Oral Health Guidelines for Long Term 
Care Patients developed by the Offices of Dentistry, Clinical 
Affairs, and Geriatrics and Extended Care, continues to serve 
as the primary handbook for management of the multidisciplinary 
oral health efforts. It describes the goals, implementation, 
and monitoring of oral care provision for patients in VA long 
term care programs.
    The impact of VA programs in geriatric dentistry is not 
limited to its own health care system, but extends to a broader 
level. VA dentistry is represented on both National Institute 
of Dental Research (NIDR) reviews and a U.S. Surgeon General's 
workshop on oral health promotion and disease prevention. The 
American Association of Dental Schools (AADS) has an ongoing 
Geriatric Education Project that has developed curricular 
guidelines for teaching concepts in gerontology and geriatrics 
to dental and dental hygiene students. VA dentists have been 
noteworthy contributors to these efforts to define geriatric 
educational objectives and identify resource materials for 
dental faculty members.
    I response to the 1993 research agenda setting conference 
``Oral Health for Aging Veterans--Making a Difference: 
Priorities for Quality Care,'' emphasis is not being directed 
to improving outcomes for geriatric dental interventions. VA 
researchers and clinicians in a variety of settings are 
assessing the risk/benefit ratio of specific treatment 
modalities to determine which are the most effective. These 
efforts represent a fundamental shift from research involving 
process to that which measures actual outcomes, and as such 
will be more useful to clinicians.
    In summary, the Office of Dentistry continues to support 
efforts that will benefit older veterans in three general 
areas. First, optimizing the quality of dental care received by 
elderly patients as VA facilities is a priority. Second, 
education in geriatric oral health will continue to be made 
available to patients, dental staff, and non-dental care 
providers such as nurses, physicians, and family members. 
Third, research with promise to broaden our understanding of 
oral disease and its treatment in older adults will be 
encouraged.

                   Office of Research and Development

    In fiscal year 1995 the total Research and Development 
Program (which includes the medical, health services and 
rehabilitation research programs) expenditure on aging-related 
research was $13.2 million, or 8.6 percent of the total 
research appropriation. These funds supported 123 research 
projects. VA investigators were supported by an additional 
$14.6 million from extra VA sources to conduct aging-related 
research (these funds supported 192 projects).

                      va medical research service

    As the health care needs of the veteran population change, 
so must the areas of research and development funded by the VA 
Medical Research Service (VAMRS). Currently, half the veteran 
population (approximately 13.2 million) is over age 56. An 
estimated 37 percent of veterans (approximately 9 million) will 
be 65 or older by the end of the decade. In response, VAMRS has 
devoted substantial resources to medical problems common in 
this population, including dementia, prostate cancer, other 
cancers and heart disease. VA investigators have advanced the 
study of neurobiology in Alzheimer's disease, hormone 
regulation in prostate cancer, larynx preservation in advanced 
laryngeal cancer, and drug therapy or vitamin supplementation 
for prevention of heart disease and stroke.
    Age-related dementia is a major health concern of the 
elderly, affecting 10 percent of people over 65. VHA predicts 
that 600,000 veterans will suffer from dementia by the year 
2000. VAMRS spent over $4 million on studies of Alzheimer's 
disease and other dementias in fiscal year 1995, and an 
additional $17.7 million in research grants were obtained from 
non-VA sources. Among the nearly 300 investigator-initiated VA 
research projects in this area are the following:
    Dr. George Bartzokis is the West Los Angeles VA Medical 
Center is using magnetic resonance imaging (MRI) to test 
hypothesis that patients with Alzheimer's disease have 
increased iron in several brain regions. Post-mortem studies 
have found elevated iron levels in the brains of these 
patients, so iron may play an important role in the development 
of the disease. Dr. Bartzokis' ongoing research suggests that 
MRI may be useful in diagnosing and treating Alzheimer's 
disease.
    Dr. Douglas Galasko of the San Diego VA Medical Center is 
investigating proteins in cerebrospinal fluid as possible 
biological markers for Alzheimer's disease. If such markers are 
confirmed, they could lead to earlier diagnosis and treatment 
of the illness.
    Dr. Maurice Dysken of the Minneapolis VA Medical Center is 
conducting a special research initiative under which 
neuropsychological tests are administered to subjects 80 and 
older. Although cognitive impairment and other problems 
experienced by the younger elderly have received increasing 
attention, data on those 80 and older are sparse.
    Osteoporosis is a crippling disease that affects millions 
of postmenopausal women. The long hospitalizations and extended 
nursing home care for patients suffering bone fractures is 
estimated at $10 billion per year in the United States. VAMRS 
devoted more than $1.4 million to research on osteoporosis last 
year. Total grants to VA investigators for osteoporosis 
research exceeded $4 million and funded more than 70 projects.
    Among those studying osteoporosis are Dr. Stavros Manolagas 
and Dr. Robert Jilka of the Little Rock VA Medical Center. They 
have discovered that the lack of estrogen that occurs with the 
completion of menopause causes an overproduction of bone 
scavenger cells called osteoclasts. Their work, begun at the 
Indianapolis VA Medical Center, opens the door to new therapies 
for female veterans.
    Other world-recognized investigators studying osteoporosis 
include Dr. Norman Bell of the Charleston VA Medical Center, 
Dr. Gregory Mundy of the South Texas Veterans Health Care 
System, and Dr. David Baylink and Dr. John Farley of the Loma 
Linda VA Medical Center. Dr. Baylink's group is conducting 
multiple projects aimed at improving understanding of the 
unequal changes in the rates of bone formation and bone 
resorption in postmenopausal women. Dr. Bell studies the 
relationship between vitamin D and bone and is currently 
participating in clinical studies of drugs for treating 
osteoporosis.

                Health Services Research and Development

    Health Services Research and Development (HSR&D) is an area 
of research designed to enhance veterans' health by improving 
the quality and cost effectiveness of the care provided by the 
Department of Veterans Affairs (VA). The focus of VA HSR&D is 
on (1) advancing the state of knowledge about health services 
in VA and the nation and (2) disseminating that knowledge for 
practical use. The large number of aging veterans and their 
increasing health care needs make this population particularly 
important for HSR&D to study. The Service's four major program 
areas emphasized aging during Fiscal Year 1995 and are:
    (1) The Investigator Initiated Research (IIR) program 
encourages and supports projects proposed and conducted by VA 
researchers, clinicians, and administrators from throughout the 
Nation. In this intramural program of HSR&D, VA staff conduct 
merit reviewed and approved projects in VA Medical Centers with 
oversight and advice from Headquarters. The IIR program also 
includes career development, which encourages interested 
clinicians and researchers to pursue careers in VA by 
guaranteeing salary support.
    Forty-four percent of the 52 HRS&D investigator-initiated 
projects addressed questions important to aging veterans. Six 
new projects were initiated in Fiscal Year 1995 that impact 
aging veterans. Projects included studies of cardiac 
procedures: appropriateness and necessity of cardiac procedure 
use after acute coronary artery bypass graft (CABG) surgery; 
and tow studies addressing utilization of cardiac procedures 
(carotid endarterectomy and CABG) in black veterans. One study 
is assessing risk factors for patients who may suffer the 
adverse affects of drug treatment for tuberculosis and another 
study is developing a reliable and valid health status measure 
for skin disease to improve outcomes of care.
    Ongoing geriatric related investigations included studies 
of social factors in the occurrence of cardiac events; home 
measurement of peak expiratory flow rate in Chronic Obstructive 
Pulmonary Disease; the effects of exercise training on frail, 
elderly veterans; Simulated Presence Therapy, a new non-
pharmacologic technique, to reduce problem behaviors in 
patients with Alzheimer's disease; the potential demand for 
bone marrow transplantation, resource use, and effectiveness; 
and malnutrition among elderly patients.
    Eight IIR projects related to aging were completed in 
Fiscal Year 1995. These projects included studies of the 
benefits of arthritic knee joint rehabilitation; risk 
assessment for cardiac complication after non-cardiac surgery; 
and evaluation of home oxygen programs as compared to 
outpatient facility programs; factors that influence mortality 
and impatient health care utilization one year following 
admission to a medical intensive care unit (ICU); the impact of 
polypharmacy use on health related quality of life; the 
effectiveness of managed care for improving the health status 
and quality of care of aging veterans; rehospitalization 
following surgery; pressure ulcer development in long-term 
care; and institutional long-term care and hospital 
utilization.
    (2) The HSR&D Cooperative Studies in Health Services (CSHS) 
projects are multi-site health services research studies based 
on the model of VA's Cooperative Studies Program. Because of 
VA's health care system size, complexity, and data 
availability, it offers unique opportunities to conduct large-
scale research projects, such as the CSHSs. These studies are 
expected to yield more definitive findings than may be 
available in other health care research environments. Three 
Centers for Cooperative Studies in Health Services provide 
scientific, technical, and management support to the CSHS 
investigators. One new CSHS project is determining the cost and 
outcome of telephone care. Five ongoing CSHS projects relevant 
to the concerns of the aging population are continuing. As a 
result of funding constraints, only one of two new CSHS 
Geriatric Evaluation and Management (GEM) trials that began 
preparations in Fiscal Year 1994 was allowed to continue in 
Fiscal Year 1995.
    (3) The HSR&D Field Program is a cadre of core VA staff 
assigned to a network of selected medical centers. In 1995, the 
Service provided funding for nine ongoing HSR&D Field Programs. 
In support of program objectives, Fields Program staff conduct 
independent research projects and collaborate with community 
institutions.
    Field Programs serve as Centers of Excellence in selected 
areas of expertise in health services research. Four of these 
programs have aging as one of their primary research foci. The 
Northwest Center for Outcomes Research in Older Adults, the 
HSR&D Field Program at Seattle VAMC, continues to examine 
issues related to aging, including the magnitude and costs of 
prevention strategies for diabetic foot problems; and the 
impact of rehabilitation services on inpatients newly diagnosed 
with a disabling disorder. The Midwest Center for Health 
Services and Policy Research at Hines VAMC in Illinois 
emphasized gerontology and rehabilitation issues. The HSR&D 
Field Program in Bedford, Massachusetts, is a Center for Health 
Quality, Outcome and Economic Research and has a strong 
interest in advance directives and health related quality of 
life issues. Another HSR&D Field Program, the Center for the 
Study of Healthcare Provider Behavior at the Sepulveda VAMC, 
has a strong interest in health care quality and outcomes 
within both VA and non-VA health systems.
    In addition to these Field Program investigations during 
Fiscal Year 1995, HSR&D Service provided core support funding 
for the Normative Aging Study (NAS), a multidisciplinary and 
longitudinal investigation of human aging, and the Dental 
Longitudinal Study, a companion study addressing oral health 
and risk factors for oral disease in an aging population.
    (4) The Special Projects Program encompasses the HSR&D 
Service Directed Research (SDR) Program, the Management 
Decision Research Center (MDRC), and special activities such as 
conferences and seminars. Special projects may include 
evaluation research, information syntheses, feasibility studies 
and other research projects responsive to specific needs 
identified by Congress, other federal agencies, or Department 
of Veterans Affairs executive and management staff. This is a 
centrally directed program of health services research 
conducted by VA field staff, VA Headquarters staff, and/or 
contractors engaged to analyze specific problems.
    Five ongoing HSR&D Service Directed Research projects focus 
on issues relevant to the aging veteran population. These 
projects include an evaluation of the diagnosis, treatment, and 
outcomes of veterans hospitalized for acute ischemic stroke; 
and a study of health related quality of life. Additionally, 
three SDR projects are focusing on prostate cancer to include 
an assessment of the impact of an educational intervention on 
patient preferences of prostate cancer treatment; an 
investigation of familial patterns in prostate cancer; and 
preference in patients suffering from advancing metastatic 
prostate cancer.
    As a result of the HSR&D Service initiative on women's 
health, six new SDR projects were funded in 1995 that also are 
expected to benefit aging female veterans. These projects 
address issues of access to VA care; cancers of the 
reproductive system as it relates to military experience and 
Post Traumatic Stress Disorder; quality of life; long-term 
care; workforce participation, health insurance and health care 
use; and development of a Registry of Women Veterans.
    Six SDR projects were completed in Fiscal Year 1995. They 
include an examination of the nursing home minimum data set for 
use in VA extended care facilities; an interactive videodisc 
project to increase physician discussion of advance directives 
with patients; an assessment of the impact of patient education 
on prostate cancer screening decisions; a study of breast 
cancer among women veterans; a study of the care of acute 
myocardial infarction patients; and a special project examining 
racial differences in cardiac care.
    In addition to these special research initiatives, primers 
are being developed by the HSR&D Service Management Decision 
and Research Center (MDRC) to explain the fundamentals of a 
specific health services research or health care related issue 
relevant to VA's efforts to deliver high quality care. The 
first primer on primary care was released in September, 1995. 
The second primer on Technology Assessment in VA is expected to 
be released in mid-1996. Two additional primers are in the 
planning stage, one on Outcomes and the other on Program 
Evaluation for Managers.
    Management briefs are a new effort from MDRC. The purpose 
of the management brief is to provide managers with a concise 
overview of HSR&D study findings in a particular area as well 
as describe the potential impact and possible implementation 
strategies and resources for managers. Examples include 
``Primary Care: Accessible, Continuous, Comprehensive and 
Coordinated,'' and ``Caring for the Elderly Veteran` Commitment 
to Quality.''
    In Fiscal Year 1995, the MDRC, through its management 
consultation program, conducted five studies at the request of 
the Office of Geriatrics and Extended Care. Three were 
completed in Fiscal Year 1995 and two have continued into 
Fiscal Year 1996. Two studies, one a policy analysis and the 
other an evaluation of the nursing home enhanced prospective 
payment system, provided information about alternative rate 
structures for contracting with community nursing homes to 
maximize veteran access to high-quality long-term care while 
containing costs for the Department. A third study is analyzing 
the differences in costs between VA nursing home care units and 
rates charged by community nursing homes to understand the 
reasons for the differences. A fourth study assessed the extent 
of subacute care being provided in VA facilities, and in 
community nursing homes. A sixth study evaluated the 
effectiveness of the homemaker/home health aide program across 
the system.

                      Office Academic Affiliations

    All short- and long-range plans for VHA that address health 
care needs of the Nation's growing population of elderly 
veterans include training activities supported by the Office of 
Academic Affiliations (OAA). The training of health care 
professionals in the area of geriatrics/gerontology is an 
important component for a variety of programs conducted at VA 
medical centers in collaboration with affiliated academic 
institutions. Clinical experiences with geriatric patients is 
an integral part of health care education for the almost 
109,000 health trainees, including 34,000 resident physicians 
and fellows, 22,000 medical students, and 53,000 nursing and 
associated health students. These residents and students train 
in VA medical centers annually as part of affiliation 
agreements between VA and nearly 1,000 health professional 
schools, colleges, and university health science centers. 
Recognizing the challenges presented by the ever-increasing 
size of the aging veteran population, the OAA has made great 
strides in promoting and coordinating interdisciplinary 
geriatric and gerontologic programs in VA medical centers and 
in their affiliated academic institutions.
    The Office of Academic Affiliations, in VHA, supports 
selected geriatric education and training activities through 
the VA fellowship and residency programs for physicians and 
dentists.

Geriatric medicine

    The issue of whether or not geriatrics should be a separate 
medical specialty or a subspecialty was resolved in September 
1987, when the Accreditation Council for Graduate Medical 
Education (ACGME) approved Geriatric Medicine as an area of 
special competence. Effective January 1988, the American Board 
of Internal Medicine and the American Board of Family Practice 
specified procedures for the certification of added 
qualifications in geriatric medicine. VA played a critical role 
in the development and recognition of geriatric medicine in the 
United States, and since 1989, any VA medical center may 
conduct training in geriatrics providing an ACGME-accredited 
program is in place.
    The demand for physicians with special training in 
geriatrics and gerontology continues unabated because of the 
rapidly advancing numbers of elderly veterans and aging 
Americans. The VA health care system offers clinical, 
rehabilitation, and follow-up patient care services as well as 
education, research, and interdisciplinary programs that 
constitute the support elements that are required for the 
training of physicians in geriatrics. This special training was 
accomplished through the VA Fellowship Program in Geriatrics 
from Fiscal Year 1978-89 and through specialty residency 
training since Fiscal Year 1990. In Fiscal Year 1995, VA 
supported 92 physicians receiving advanced education in 
geriatrics.
    These educational programs are designed to develop a cadre 
of physicians committed to clinical excellence and to becoming 
leaders of local and national geriatric medical programs. Their 
dedication to innovative and thorough geriatric patient care is 
expected to produce role models for medical students and for 
residents. The curriculum incorporates clinical, 
pharmacological, psychosocial, education, and research 
components that are related to the full continuum of treatment 
and health care of the elderly.
    During its 17-year history, the program has attracted 
physicians with high quality academic and professional 
backgrounds in internal medicine, psychiatry, neurology, and 
family practice. Their genuine interest in the well-being of 
elderly veterans is apparent from the high VA retention rate 
after completing the fellowship training. Many of the fellows 
have published articles on geriatric topics in nationally 
recognized professional journals, and several fellows have 
authored or edited books on geriatric medicine and medical 
ethics. The number of recipients of important awards and 
research grants (AGS/Pfizer, AGS/Merck, Kaiser, National 
Institutes on Aging, and VA) increases each year.
    The VA fellowship alumni continue to represent the largest 
single agency contribution to the pool of trained geriatricians 
in the United States.

Geriatric dentistry

    The VA Dentist Geriatric Fellowship Program ended in June 
1994. It proved to be an excellent recruitment source for 
dentists uniquely trained in the care of the elderly. 
Approximately thirty of these graduated fellows currently serve 
as staff dentists throughout the VA system. Others have assumed 
leadership positions in geriatric dentistry at academic 
institutions. They have enhanced patient care and other 
geriatric initiatives at their own as well as regional medical 
centers, and have also contributed to the geriatric efforts at 
affiliated health centers and in the community. Nationally, 
former fellows have made significant contributions to the 
professional literature and are actively involved in geriatric 
dental research.
    In July 1982, a two-year Dentist Geriatric Fellowship 
Program commenced at five medical centers affiliated with 
Schools of Dentistry. The goals of this program are similar to 
those described for the Physician Fellowship Program in 
Geriatrics. In Fiscal Year 1988, the number of training sites 
increased to six for a final 3-year cycle. As of June 1994, 52 
Geriatric Dentistry Fellows had completed their special 
training.
    The format of these fellowships, however, has changed from 
predesignated sites in geriatric dentistry to individual awards 
in dental research. Candidates from any VA medical center with 
the appropriate resources may now compete for postdoctoral 
fellowships for dental research. In Fiscal Year 1995, nine 
fellows participated.

Geriatric psychiatry and geriatric neurology

    In Fiscal Years 1990 and 1991, the Department of Veterans 
Affairs established the 2-year Fellowship Programs in Geriatric 
Psychiatry and Geriatric Neurology to develop a cadre of 
physicians with expertise in two areas; (1) specialized 
knowledge in the diagnosis and treatment of elderly patients 
with dementia and other psychiatric/neurological problems; and 
(2) innovative teaching and research skills for academic 
potential. In Fiscal Year 1995, VA supported 30 Geriatric 
Psychiatry Fellows and eight Geriatric Neurology Fellows.
    The American Board of Psychiatry developed criteria for 
ACGME-accredited training in geriatric psychiatry; and the 
approval of Geriatric Psychiatry became official in September, 
1993. VA expects to continue funding for fellow-level training 
at the current fellowship sites during the transition to 
accredited program status. This is another example of VA's 
initiative in establishing programs in areas of need. In Fiscal 
Year 1996, any accredited VA training site could request 
positions in Geriatric Psychiatry as part of the residency 
allocation.

               nursing and associated health professions

Interdisciplinary team training program

    The Interdisciplinary Team Training Program (ITTP) is a 
nationwide systematic educational program that is designed to 
include didactic and clinical instruction for VA faculty 
practitioners and affiliated students from three or more health 
professions such as physicians, nurses, psychologists, social 
workers, pharmacists, and occupational and physical therapists. 
The ITTP provides a structured approach to the delivery of 
health services by emphasizing the knowledge and skills needed 
to work in an interactive group. In addition, the program 
promotes an understanding of the roles and functions of other 
members of the team and how their collaborative contributions 
influence both the delivery and outcomes of patient care.
    The ITTP has been activated at 12 VA medical centers. Two 
sites located at VA Medical Centers (VAMCs) Portland, Oregon; 
and Sepulveda, California, were designated in 1979. Three 
additional VA sites at Little Rock, Arkansas; Palo Alto, 
California; and Salt Lake City, Utah, were selected in 1980; 
and VAMCs Buffalo, New York; Madison, Wisconsin; Coatesville, 
Pennsylvania; and Birmingham, Alabama, were approved in 1982. 
In the spring of 1983, three sites were selected at VAMCs 
Tucson, Arizona; Memphis, Tennessee; and Tampa, Florida.
    The purposes of the ITTP are to develop a cadre of health 
practitioners with the knowledge and competencies required to 
provide interdisciplinary team care to meet the wide spectrum 
of health care and service needs for veterans, to provide 
leadership in interdisciplinary team delivery and training to 
other VA medical centers, and to provide role models for 
affiliated students in medical and associated health 
disciplines. Training includes the teaching of staff and 
students in selected priority areas of VA health care needs, 
e.g., geriatrics, ambulatory care, management, nutrition, etc.; 
instruction in team teaching and group process skills for 
clinical core staff; and clinical experiences in team care for 
affiliated education students with the core team serving as 
role models. During Fiscal Year 1995, more than 185 students 
from a variety of health care disciplines were provided 
monetary support at the 12 model ITTP sites.

Advanced practice nursing

    Advanced Practice Nursing, i.e., master's level clinical 
nurse specialist and nurse practitioner training, is another 
facet of VA education programming in geriatrics. The need for 
specialty trained graduate nurses is evidenced by the 
sophisticated level of care needed by VA patient populations, 
specifically in the area of geriatrics. Advanced nurse training 
is a high priority within VA because of the shortage of such 
nursing specialists who are capable of assuming positions in 
specialized care and leadership.
    The master's level Advanced Practice Nursing Program was 
established in 1981 to attract specialized graduate nursing 
students to VA and to help meet needs in the VA priority areas 
of geriatrics, rehabilitation, psychiatric/mental health, adult 
health and critical care, all of which impact on the care of 
the elderly veteran. Direct funding support is provided to 
master's level nurse specialist students for their clinical 
practicum at the VA medical centers that are affiliated with 
the academic institutions in which they are enrolled. During 
Fiscal Year 1995, 146 master's level advanced practice nursing 
student positions were supported: 34 in geriatrics, 4 in 
rehabilitation, 32 in psychiatric/mental/health, 32 in critical 
care, and 44 in adult health/medsurgery.

VA gerontological nurse fellowship program

    Gerontological nursing has been a nursing specialty since 
the mid-1960's. As society changes, particularly in terms of 
the demographic trends in aging, more attention is being 
focused on both the area of gerontological nursing and the 
education of nurses in this specialty. Doctoral level nurse 
gerontologists are prepared for advanced clinical practice, 
teaching, research, administration, and policy formulation in 
adult development and aging.
    In Fiscal Year 1985, a two-year nurse fellowship program 
was initiated for registered nurses who were doctoral 
candidates with dissertations focused on clinical research in 
geriatrics/gerontology. The first competitive review was 
conducted in 1986. One nurse fellow was selected for the Fiscal 
Year 1986 funding cycle. Since that time, two nurse fellowship 
positions have been available for selection at approved VA 
medical center sites each fiscal year.
    Initial appointments for nurse fellows are for one year. 
Reappointments of one additional year are subject to 
satisfactory first year's performance evaluation.

Expansion for associated health training in geriatrics

    A special priority for geriatric education and training is 
recognized in the allocation of associated health training 
positions and funding support to VA medical centers hosting 
GRECCs and to VA medical centers (non-ITTP/GRECC sites) 
offering specific educational and clinical programs for the 
care of older veterans. In Fiscal Year 1995, a total of 20 
associated health students received funding support in the 
following disciplines: Social Work, Psychology, Audiology/
Speech Pathology, Clinical Pharmacy, Advanced Practice Nursing, 
Dietetics, and Occupational Therapy.

Health professional scholarship program

    The Scholarship Program was established in 1980 and funded 
from 1982 through 1985 to assist in providing an adequate 
supply of nurses for the VA and the Nation. Beginning in 1988, 
the Scholarship Program was reactivated to provide scholarships 
to students in full-time nursing and physical therapy 
baccalaureate and master degree programs in certain specialties 
specified by VA.
    By Fiscal Year 1990, additional scholarships were available 
to students enrolled in baccalaureate and master's degree 
occupational therapy programs, and students enrolled in their 
final year of associate degree nursing programs. In Fiscal Year 
1992, scholarships were available for students enrolled in 
master's degree nurse anesthetist programs. Beginning in 1994, 
Respiratory Therapy scholarships became available through this 
program.
    Since the beginning of the program, 530 awards have been 
given to students studying for advanced master's degrees, 
including 481 in nursing, 40 in nurse anesthesia, and 9 in 
occupational therapy and physical therapy. Of this number, 301 
students have completed degrees and fulfilled their obligations 
by working as professionals in VA medical centers. Of these 301 
professionals, 206 are still employed by VA. The remaining 
students are in the process of completing their degrees, 
completing their service obligations, or beginning their 
service obligation in the near future.

Learning resources

    The widespread education and training activities in 
geriatrics have generated a broad spectrum of requirements for 
learning resources throughout the VA system. Local medical 
media services continue to provide thousands of audiovisual 
products that meet educational and clinical needs in the areas 
of geriatrics and gerontology. Local library services continue 
to perform hundreds of on-line searches on data bases such as 
MEDLINE and AGELINE (availablethrough Bibliography Retrieval 
Services), and continue to add books, journals, and audiovisuals on 
topics related to geriatrics and aging. Employee education staff have 
produced and/or sponsored a number of satellite programs on Alzheimer's 
disease and other dementias. Taped copies of three of these satellite 
programs (``Diagnosis and Treatment of Alzheimer's Disease,'' ``Dental 
Care of Cognitively Impaired Older Adults: Prioritizing Service 
Needs,'' and ``Progressive Aphasia: Overview and Case in Point'') can 
be obtained from the local Library Service at every VA medical center.

Employee education

    In support of VA's mission to provide health care to the 
aging veteran population, education and training continues to 
be offered to enhance VA medical center staff skills in the 
area of geriatrics. These educational activities are designed 
to respond to the needs of VA health care personnel throughout 
the entire Veterans Health Administration. Annually, funding is 
provided for employee education and distributed to two levels 
of the organization for support of continuing education 
activities in priority areas.
    First Level.--Funds are provided directly to each of the VA 
medical centers to meet the continuing education needs of its 
employees. VA Headquarters also allocates funds for VAMC-
initiated programs to allow health care facilities, with 
assistance from the Employee Education Network, to conduct 
education programs within the facility to meet locally-
identified training needs. VAMC-initiated funds were used to 
support 23 separate activities specifically having geriatrics 
as the primary content.
    Second Level.--The Office of Employee Education, through 
the Employee Education Network, meets education needs by 
conducting programs at the regional and local medical enter 
level. Examples of recent programs are:
          Dementia, Depression, and Addiction;
          JCAHO-Long Term Care Standards;
          Alzheimer's and Dementia;
          Nursing Role in Caring for the Older Adult;
          Geriatric Treatment Update;
          Suicide and Depression in the Elderly;
          Identification and Treatment of Depression in the 
        Elderly;
          Issues Facing Older Women;
          Elder Abuse;
          Myths of Aging;
          Geropharmacology; and
          Geriatric Care--Unresolved Problems.
    Employee education programs are also conducted in 
cooperation with the GRECCs, which received $276,835 in 
training funds in Fiscal Year 1995 to support their identified 
needs. This collaborative effort ensures the efficient use of 
existing resources to meet the increasing demands for training 
in geriatrics/gerontology.
    In response to systemwide training needs, a National 
Training Program on ``Long Term Care in Psychiatric Hospitals'' 
was held.
    In addition, funds were provided to support continuing 
education experiences for the Geriatric Fellows and the 
Interdisciplinary Team Training Program staff members.
    The Office of Employee Education continues to work 
cooperatively with the Office of Geriatrics and Extended Care. 
A collaborative initiative was the printing and distribution of 
the updated ``Geriatric Pocket Pal,'' a supplemental reference 
guide for clinicians.

                 VII. Veterans Benefits Administration

                   Compensation and Pension Programs

    Disability and survivor benefits such as pension, 
compensation and dependency and indemnity compensation 
administered by the Veterans Benefits Administration (VBA) 
provide all, or part, of the income for 1,700,469 persons age 
65 or older. This total includes 1,238,957 veterans, 443,666 
surviving spouses, 15,845 mothers and 2,001 fathers.
    The Veterans' and Survivors' Pension Improvement Act of 
1978, effective January 1, 1979, provided for a restructured 
pension program. Under this program, eligible veterans receive 
a level of support meeting a national standard of need. 
Pensioners generally receive benefits equal to the difference 
between their annual income from other sources and the 
appropriate income standard. Yearly cost of living adjustments 
(COLAs) have kept the program current with economic needs.
    This Act providers for a higher income standard for 
veterans of World War I or the Mexican border period. This 
provision was in acknowledgement of the special needs of the 
Nation's oldest veterans. The current amount added to the basic 
pension rate is $1,867 as of December 1, 1995.

                    Veterans Services program Staff

    VBA Regional Office personnel maintain an active liaison 
with local nursing homes, senior citizen homes, and senior 
citizen centers in an effort to ensure that older veterans and 
their dependents understand and have access to VA benefits and 
services.
    Generally, regional office staff visit these facilities as 
needed or when requested by the service providers. VA pamphlets 
and application forms are provided to the facility management 
and social work staff during visits and through frequent use of 
regular mailings. State and area agencies on the aging have 
been identified and are provided information about VA benefits 
and services through visits, workshops and pre-arranged 
training session. Senior citizen seminars are conducted for 
nursing home operations staff and other service providers that 
assist and provide service to elderly patients. Regional office 
staff regularly participate in senior citizens fairs and 
information events, thereby visiting and partipating in events 
where the audience is primarily elderly citizens. VBA staff 
also visit places where senior citizens congregate such as 
malls, churches, and special luncheons or breakfasts to advise 
veterans of their benefit entitlements. Regional office 
outreach coordinators continue to serve on local and state task 
forces and represent VA as members of special groups that deal 
extensively with the problems of the elderly.

      ACTIVITIES ON BEHALF OF OLDER VETERANS FOR FISCAL YEAR 1996

                            I. Introduction

    The Department of Veterans Affairs has the potential 
responsibility for a beneficiary population of more than 26 
million veterans whose median age is approximately 57 years. 
Over thirty-three percent of the veteran population is age 65 
and older. By the year 2005, over four and a half million 
veterans will be 75 years or older.
    The demographic trend will require VA to redistribute its 
resources to meet the different needs of this older population. 
Historically, older persons are greater users of health care 
services. The number of physician visits, short-term hospital 
stays, and number of days in the hospital all increase as the 
patient moves from the fifth to seventh decade of life.
    VA has developed a wide range of services to provide care 
in a variety of institutional, noninstitutional, and community 
settings to ensure that the physical, psychiatric and 
socioeconomic needs of the patient are met. Special projects, a 
variety of innovative, medically-proven programs and individual 
VA medical center (VAMC) initiatives have been developed and 
tested that can be used for veteran patients and adapted for 
use by the general population.
    VA operates the largest health care system in the Nation, 
encompassing 173 hospitals, 133 nursing home care units, 40 
domiciliaries, and 398 outpatient clinics. Veterans are also 
provided care in non-VA hospitals and in community nursing 
homes, fee-for-service visits by non-VA physicians and dentists 
for outpatient treatment, and support for care in 89 State 
Veterans Homes in 42 States. As part of a broader VA and non-VA 
network, affiliation agreements exist between virtually all VA 
health care facilities and nearly 1,000 medical, dental, and 
associated health schools. This affiliation program with 
academic health centers results in almost 107,000 health 
profession students receiving education and training in VAMCs 
each year.
    In addition to VA hospital, nursing home and domiciliary 
care programs, VA is increasing the number of diversity of non-
institutional extended care programs. The dual purpose is to 
facilitate independent living and to keep the patient in a 
community setting by making available the appropriate 
supportive medical services. These programs include Home-Based 
Primary Care, Community Residential Care, Adult Day Health 
Care, Psychiatric Day Treatment and Mental Hygiene Clinics, and 
Homemaker/Home Health Aide Services.
    The need for both acute and chronic hospitalization will 
continue to rise as older patients experience a greater 
frequency and severity of illness, as well as a different mix 
of diseases, than younger patients. Cardiovascular diseases, 
chronic lung diseases, cancers, psychiatric and mental 
disorders, bone and joint disease, hearing and vision 
disorders, and a variety of other illnesses and disabilities 
are all more prevalent in those age 65 and older. VA continues 
efforts to improve the outcomes of care for elderly patients 
with complex problems by supporting Geriatric Research, 
Education and Clinical Centers and specialized clinical 
services such as Geriatric Evaluation and Management Programs.

                   II. Veterans Health Administration

                    office of patient care services

    During this fiscal year, the Office of Patient Care 
Services reorganized to form ten strategic healthcare groups. 
Each of these functional groups has contributed significantly 
to VA's efforts on behalf of older veterans.

Primary and Ambulatory Care Strategic Healthcare Group (SHG)

    The Office of Primary and Ambulatory Care and the Office of 
Geriatrics and Extended Care continue to maximize collaboration 
in transforming the veterans health care system from a bed-
based, hospital inpatient system to one rooted in ambulatory 
care. Physicians who specialize in geriatrics often come from 
an internal medicine background that includes a strong emphasis 
on primary care and an interdisciplinary team approach to 
patient care. Assistance in continuing development of geriatric 
primary care programs is one of the options offered by Primary 
Care Education and Consultation Teams.
    VHA's National Primary Care Strategic Education Committee 
has charged a work group with developing a field facility 
educational module specifically designed for integrating 
geriatrics and primary care. Other completed modules available 
to geriatricians for further developing their geriatric primary 
care programs include: Managing Change; Strategic Planning; 
Team Development; Customer Service; Patient and Family 
Education; Information Management; Performance Measures; Ethics 
and Legal Issues; and Medical Faculty Development.

Dentistry

    Oral/Dental care for the geriatric patient involves 
restoring function of the dentition, and elimination of pain 
and suffering attributes to oral disease. It is important that 
older adults are able to effectively masticate a variety of 
foods so that convalescence after surgery, chemotherapy, or 
other significant medical interventions is expedited.
    Interpersonal skills, which are highly dependent upon 
physical appearance, as well as effective communication, can be 
enhanced by improving the patient's appearance and by properly 
aligning and restoring the anterior teeth to maintain clarity 
of speech. The goals for oral/dental care are consistent with 
all disciplines involved in geriatrics--to maximize function 
and foster independence in living. Dentistry needs to be an 
integral part of any comprehensive health care program for the 
elderly.
    The nature of dental disease is often chronic and often 
asymptomatic even in advanced stages. It can be aggravated by 
coexistent medical problems, and perceived as a low priority by 
health care funding agencies. Innovative, individualized, 
preventive dental care programs are necessary for each patient. 
Preventive modalities can include the use of home-applied 
fluoride solutions, anti-microbial mouth rinses, specially 
fabricated tooth brushes, instruction to family or care givers 
on oral hygiene techniques, and more frequent dental 
examinations. These are low cost yet effective measures that 
can reduce the need for future expensive or invasive dental 
care. VA has been a world leader in developing preventive 
dental therapies and field testing them for clinical efficacy.
    Oral cancer is a disabling and disfiguring disease that 
primarily affects middle-aged and older adults. Ninety-five 
percent of cases occur in those over 40. Alcohol, tobacco, and 
advanced age are important risk factors in the development of 
this disease. Early detection of frequently asymptomatic 
lesions can significantly reduce the disease's morbidity. 
Through a long-standing program of oral screening examinations, 
VA dentists have been able to expeditiously detect incipient 
oral cancers. Such interventions minimize the need for ablative 
surgery, which often results in disfigurement and difficulties 
in swallowing and eating. Early detection also reduces 
mortality rates.
    Most VA Medical Centers have established Geriatric 
Evaluation and Management (GEM) Programs. Dental Services 
contribute to the GEM's interdisciplinary team effort by 
conducting admission oral assessments, collaborating on 
treatment planning, providing specially consultations and 
needed care, and preparing summaries or oral care protocols to 
be maintained after discharge. Oral examinations conducted 
during GEM admissions commonly identify problems that can 
impede chewing efficiency, safe swallowing, and clearly 
articulated speech. Interdisciplinary treatment planning takes 
advantage of the synergy associated with group efforts. 
Patients are rehabilitated more rapidly with properly staged 
and coordinated care. New problems and unexpected outcomesare 
better addressed by geriatric interdisciplinary teams. For matters 
involving the oral-dental complex, dentistry has responded with timely 
assessments, definitive diagnosis, and recommended treatment. At 
discharge a review of the patient's response to treatment, plan for 
maintenance, and guidance for future care is prepared. The GEM Program 
has been an ideal environment for dentistry to demonstrate its relative 
merit and range of contributions to the interdisciplinary team.
    The VA Program Guide, ``Oral Health Guidelines for Long-
Term Care Patients'' developed by the Office of Patient Care 
Services, Dentistry and Geriatrics and Extended Care, continues 
to serve as the primary handbook for management of the 
multidisciplinary oral health efforts. It descries the goals, 
implementation, and monitoring of oral care provision for 
patients in VA long-term care programs.
    The impact of VA programs in geriatric dentistry is not 
limited to its own health care system, but extends to a broader 
level. VA dentistry is represented on both National Institute 
of Dental Research (NIDR) reviews and a U.S. Surgeon General's 
workshop on oral health promotion and disease prevention. The 
American Association of Dental Schools (AADS) has an ongoing 
Geriatric Education Project that has developed guidelines for 
teaching concepts in gerontology and geriatrics to dental and 
dental hygiene students. VA dentists have been noteworthy 
contributors to these efforts to define geriatric educational 
objectives and identify resource materials for dental faculty 
members.
    VA dentists have been active participants in recent 
projects involving both basic research and health services 
research. One investigator has developed measures to assess the 
relationship between oral health and overall quality of life in 
older patients. Another has surveyed VA dental services to 
determine the effectiveness of smoking cessation interventions. 
Finally, research is ongoing to discover biological markers for 
the detection of oral cancer.
    In summary, VA's Office of Dentistry continues to support 
efforts that will benefit older veterans in three general 
areas. First, optimizing the quality of dental care received by 
elderly patients at VA facilities is a priority. Second, 
education in geriatric oral health will continue to be made 
available to patients, dental staff, and non-dental care 
providers such as nurses, physicians, and family members. 
Thirds, research with promise to broaden our understanding of 
oral disease and its treatment in older adults will be 
encouraged.

Hospital Based Acute Care Strategic Healthcare Group (SHG)

    Hospital Based Acute Care serves as the primary source of 
physicians for the care of all veterans, including elderly 
patients. Due to the growing proportion of older veterans, 
Hospital Based Acute Care is increasingly involved in all 
aspects of the delivery of health care to this patient 
population. Acute and intermediate medical wards, coronary and 
intensive care units, and outpatient clinics are all seeing an 
increased proportion of elderly patients with acute and chronic 
illnesses. While some care is provided specifically by 
geriatricians, as the population ages, all internists are 
seeing an older veteran population.
    Some subspecialty areas are particularly impacted, such as 
cardiology, endocrinology (diabetes), rheumatology and 
oncology. Hospital Based Acute Care provides necessary 
subspecialty care in inpatient and outpatient settings in 
addition to participation in Geriatric Evaluation and 
Management (GEM) Programs, Hospice, Respite, Nursing Home, 
Adult Day Health Care and Home-Based Primary Care. The 
specialized care required by elderly patients with complex 
problems has been recognized by Hospital Based Acute Care at a 
number of medical centers by their establishment of Geriatric 
Medicine Sections which emphasize clinical care, as well as 
coordinate research and education efforts related to 
geriatrics.
    Age alone is less frequently used as a determinant of an 
individual patient's care. Geriatric patients undergo invasive 
diagnostic procedures as well. For example, the Sunbelt is 
experiencing an increasingly heavy cardiac catheterization 
workload. The average age of patients treated in coronary and 
intensive care units is increasing, producing a concomitant 
demand for cardiac rehabilitation and physical fitness programs 
that are targeted to the frail elderly and the physically 
handicapped of all ages. The special interest and involvement 
of Hospital Based Acute Care in geriatrics has also resulted in 
participation of internists in research studies such as 
nutrition problems in the elderly and treatment of 
hypertension.
    Smoking cessation has been shown to benefit even elderly 
patients. Thus, the role of Preventive Medicine for this 
patient population has expanded. Hospital Based Acute Care 
staff have been active in implementing preventive strategies in 
smoking cessation, immunization (influenza and pneumococcal 
vaccines), and colorectal screening (for cancer). Lipid control 
is an emerging area that may benefit this population.
    Participation in evaluation and treatment of elderly 
patients by interdisciplinary teams during intermediate-length 
hospital stays will be an increasingly important role for 
physicians in the Hospital Based Acute Care Strategic 
Healthcare Group.

Geriatrics and Extended Care Strategic Healthcare Group (SHG)

    Geriatrics and Extended Care has developed an extensive 
continuum of clinical services including specialized and 
primary geriatric care, residential rehabilitation, community-
based long-term care, and nursing home care. The shared purpose 
of all geriatrics and extended care programs is to prevent or 
lessen the burden of disability on older, frail, chronically 
ill patients and their families/caregivers, and to maximize 
each patient's functional independence.
    The following is a description of VA's geriatrics and 
extended care programs and activities within each.
            VA nursing home care
    VA nursing home care units (NHCU), which are based at VA 
facilities, provide skilled nursing care and related medical 
services. Patients in NHCUs may require shorter or longer 
periods of care and rehabilitation services to attain and/or 
maintain optimal functioning. An interdisciplinary approach to 
care is utilized in order to meet the multiple physical, 
social, psychological and spiritual needs of patients.
    In fiscal year 1996, more than 35,900 veterans were treated 
in VA's 133 NHCUs. The average daily census of patients 
provided on these units was 13,605.
    VA is continuing to offer NHCU staff educational programs 
to enhance the care of the mentally ill nursing home patient. 
Interest in the use of the Resident Assessment Instrument/
Minimum Data Set remains high, and while not mandated, many 
NHCUs have adopted it.
            Community nursing home care
    This is a community-based contract program for veterans who 
require skilled nursing care when making a transition from a 
hospital setting to the community. Veterans who have been 
hospitalized in a VA facility for treatment, primarily for a 
service-connected condition, may be placed at VA expense in 
community facilities for as long as they need nursing home 
care. Other veterans may be eligible for community placement at 
VA expense for a period not to exceed 6 months. Selection of 
nursing homes for a VA contract requires the prior assessment 
of participating facilities to ensure quality services are 
offered. Follow-up visits are made to veterans by staff from VA 
medical centers to monitor patient programs and quality of 
care.
    VA has added multi-state contracts (MSC) to the Community 
Nursing Home (CNH) Program. Multi-state and single state 
nursing home contracts have been developed to reduce the 
administrative and direct care costs while improving access to 
nursing home care for veterans. Administrative costs associated 
with maintaining 3,200 separate nursing home contracts and the 
annual inspection process will be reduced. Direct care costs 
are expected to be reduced by providing a more competitive rate 
for nursing home care. Access to community nursing homes will 
be improved by adding nursing homes, adding specialized 
services in selected nursing homes, and guaranteeing placement 
within 48 hours.
    In September 1996, VA awarded 6 multi-state contracts and 
one single state contract to corporations for quality community 
nursing home care in 1,053 facilities. This includes new 
contracts with 588 nursing homes. Multi-state contracts have 
been awarded to: Beverly Health Care and Rehabilitation 
Services; Vencor; Sun Health Care Group; Genesis Health 
Ventures; Integrated Health Services; and, Unicare Health 
Facilities/Park Associates. A single state contract was awarded 
in California to Harmony, Inc. Together, these corporations 
span 43 states.
    In fiscal year 1996, 26,201 veterans were treated in the 
CNH program. The number of nursing homes under contract was 
3,200 and the average daily census of veterans in these homes 
was 7,379.
            VA domiciliary care
    Domiciliary care in VA facilities provides necessary 
medical and other professional care for eligible ambulatory 
veterans who are disabled by disease, injury, or age and are in 
need of care but do not require hospitalization or the skilled 
nursing services of a nursing home.
    The domiciliary offers specialized interdisciplinary 
treatment programs that are designed to facilitate the 
rehabilitation of patients who suffer from head trauma, stroke, 
mental illness, chronic alcoholism, heart disease and a wide 
range of other disabling conditions. With increasing frequency, 
the domiciliary is viewed as the treatment setting of choice 
for many older veterans.
    Implementation of rehabilitation-oriented programs has 
provided a better quality of care and life for veterans who 
require prolonged domiciliary care and has prepared increasing 
number of veterans for return to independent or semi-
independent community living.
    Special attention is being given to older veterans in 
domiciliaries with a goal of keeping them active and productive 
as well as integrated into the community. The older veterans 
are encouraged to utilize senior centers and other resources in 
the community where the domiciliary is located. Patients at 
several domiciliaries are involved in senior center activities 
as part of VA's community integration program. Other 
specialized programs in which older veterans are involved 
include Foster Grandparents, Handyman Assistance to senior 
citizens in the community, and Adopt-A-Vet.
    In fiscal year 1996, 19,229 veterans were treated in 40 VA 
domiciliaries resulting in an average daily census of 5,521. Of 
these numbers, approximately 3,410 veterans and an average 
daily census of more than 1,500 were admitted to the 
domiciliaries for specialized care for homelessness. The 
average age of this latter group was 43 years, while the 
overall average age of domiciliary patients was 59 years.
            State homes
    The State Home Program has grown from 10 homes in 10 states 
in 1888 to 89 state homes in 42 States. Currently, a total of 
23,248 State home beds is authorized by VA to provide hospital, 
nursing home, and domiciliary care. VA's relationship to State 
veterans homes is based upon two grant programs. The per diem 
grant program enables VA to assist the states in providing care 
to eligible veterans who require domiciliary, nursing home or 
hospital care. The other VA grant program provides up to 65 
percent federal funding to States to assist in the cost of 
construction or acquisition of new domiciliary and nursing home 
care facilities, or the expansion, remodeling, or alteration of 
existing facilities.
    In fiscal year 1996, State veterans homes provided care to 
6,095 veterans in the domiciliaries and 20,260 in the nursing 
homes. The average daily census of veteran patients was 3,349 
for domiciliary care and 12,749 for nursing home care.
            Hospice care
    VA has developed programs that provide pain management, 
symptom control, and other medical services to terminally ill 
veterans, as well as bereavement counseling and respite care to 
their families. The hospice concept of care is incorporated 
into VA medical center approaches to the care of the terminally 
ill. All VA medical centers have appointed a hospice 
consultation team, which is responsible for planning, 
developing, and implementing the hospice program.
            Home based primary care
    This program, formerly called Hospital Based Home Care, 
provides in-home primary medical care to veterans with chronic 
illnesses. The family provides the necessary personal care 
under the coordinated supervision of a hospital-based 
interdisciplinary treatment team. The team prescribes the 
needed medical, nursing, social, rehabilitation, and dietetic 
regimens, and provides the training of family members and the 
patient in supportive care.
    Seventy-five VA medical centers are providing home based 
primary care (HBPC) services. In fiscal year 1996, home visits 
were made by VA health professionals to an average daily census 
of 5,100 patients.
            Adult Day Health Care
    Adult Day Health Care (ADHC) is a therapeutically-oriented, 
ambulatory program that provides health maintenance and 
rehabilitation services to veterans in a congregate setting 
during the daytime hours. ADHC in VA is a medical model of 
services, which in some circumstances may be a substitute for 
nursing home care. VA operated 14 ADHC centers in fiscal year 
1996 with an average attendance of 373 patients. VA also 
continued a program of contracting for ADHC services in 83 
medical centers. The average daily attendance in contract 
programs was 613 in fiscal year 1996.
            Community Residential Care/Assisted Living
    The Community Residential Care/Assisted Living program 
provides residential care, including room, board, personal 
care, and general health care supervision to veterans who do 
not require hospital or nursing home care but who, because of 
health conditions, are not able to resume independent living 
and have no suitable support system (e.g., family, friends) to 
provide the needed care. All homes are inspected by a 
multidisciplinary team prior to incorporation of the home into 
the VA program and annually thereafter. Care is provided in 
private homes that have been selected by VA, and is at the 
veteran's own expense. Veterans receive monthly follow-up 
visits from VA health care professionals. In fiscal year 1996, 
an average daily census of 9,300 veterans was maintained in 
this program, utilizing approximately 2,100 homes.
            Homemaker/Home Health Aide (H/HHA)
    In fiscal year 1996, VA provided homemaker/home health aide 
services for veterans needing nursing home care. These services 
are provided in the community by public and private agencies 
under a system of case management provided directly by VA 
staff.
    One hundred eighteen VAMCs were purchasing H/HHA services 
in fiscal year 1996 for approximately 1,500 veterans on any 
given day.
            Geriatric Evaluation and Management
    The Geriatric Evaluation and Management (GEM) Program 
includes inpatient units, outpatient clinics, and consultation 
services. A GEM Unit is usually a functionally different group 
of beds (ranging typically in number from 10 to 25 beds) on a 
medical service or an intermediate care unit of the hospital 
where an interdisciplinary health care team performs 
comprehensive, multidimensional evaluations on a targeted group 
of elderly patients who will most likely benefit from these 
services. The GEM unit serves to improve the diagnosis, 
treatment, rehabilitation, and discharge planning of older 
patients who have functional impairments, multiple acute and 
chronic diseases, and/or psychosocial problems. GEM clinics 
provide similar comprehensive care for geriatric patients not 
in need of hospitalization as well as provide follow-up care 
for older patients to prevent their unnecessary 
institutionalization. A GEM program also provides geriatric 
training and research opportunities for physicians and other 
health care professionals in VA facilities. Currently, there 
are 121 GEM Programs.
            Respite care
    Respite care is a program designed to relieve the spouse or 
other caregiver from the burden of caring for a chronically 
disabled veteran at home. This is done by admitting the veteran 
to a VA hospital or nursing home for planned, brief periods of 
care. The long range benefit of this program is that it enables 
the veteran to live at home with a higher quality of life than 
would be possible in an institutional setting. It may also 
provide the veteran with needed treatment during the period of 
care in a VA facility, thus maintaining or improving functional 
status and prolonging the veteran's capacity to remain at home 
in the community. Nearly all VA facilities have a respite care 
program.
    A formal evaluation of the program, issued in 1995, found a 
high level of satisfaction with the Respite Care Program by 
family caregivers. The evaluation also found a high level of 
enthusiasm for the program by medical center staff delivering 
the care.
            Alzheimer's disease and other dementias
    VA's program for veterans with Alzheimer's disease and 
other dementias is decentralized throughout the medical care 
system, with coordination and direction provided by the 
Geriatrics and Extended Care Strategic Healthcare Group in VA 
Central Office. Veterans with these diagnoses participate in 
all aspects of the health care system, including outpatient, 
acute care, and extended care programs. Approximately 56 
medical centers have established specialized programs for the 
treatment of veterans with dementing illnesses. Policy guidance 
concerning a continuum of dementia services to be provided in 
VA's health care networks is currently under development.
    In order to advance knowledge about the care for veterans 
with dementia, VA investigators conduct basic biomedical, 
applied clinical, health services, and rehabilitation research, 
much of which occurs at VA's Geriatric Research, Education and 
Clinical Centers (GRECC's), and which is supported through the 
VA office of Research and Development as well as extramural 
sources. In fiscal year 1996, VA investigators were involved in 
approximately 200 funded research projects on Alzheimer's 
disease and other dementias.
    Continuing education for staff is provided through training 
classes sponsored by GRECCs and VA's continuing education field 
units. In addition, VHA has disseminated a variety of dementia 
patient care educational materials in the form of publications 
and videotapes to all VA medical centers. These include 
guidelines for the diagnosis and treatment of dementia, 
videotapes concerning the management of Alzheimer's disease in 
home and health care settings, videotapes on other geriatric 
health care topics relevant to dementia patient care, and 
videotapes of VA satellite teleconferences on diagnosis and 
treatment of dementia. In addition to these VA-developed 
materials, VA has also purchased and distributed to VA regional 
libraries for use on a circulating basis throughout the VA 
system a comprehensive instructional program, ``Keys to Better 
Care,'' for health care providers caring for persons with 
Alzheimer's disease and related disorders. Other dementia 
program planning and resource materials have been distributed 
to all VA medical centers, including a report on program 
characteristics of a sample of VA inpatient dementia units.
    In fiscal year 1996, VA conducted its second nationwide 
satellite teleconference with national experts presenting 
strategies for diagnosis and treatment of dementia from a 
primary care perspective. In addition, a set of previously-
disseminated 21 dementia caregiver education pamphlets 
developed by the Minneapolis GRECC became available via the 
Internet on the home page established by the Bedford Division 
of the Boston GRECC (http://med-www.bu.edu/alzheimer/). Also in 
fiscal year 1996, a new videotape on natural feeding techniques 
in Alzheimer's disease developed by the Bedford GRECC was 
distributed to all VA medical centers. In addition, a joint VA/
University Healthsystem Consortium (UHC) technical advisory 
group is working on an updated clinical guideline for primary 
care practitioners on the identification and assessment of 
dementia. This guideline, which is nearing completion, will be 
distributed throughout the VA and UHC systems. Another project 
currently under development is an Alzheimer's caregiver CD-ROM. 
This interactive, multimedia program will provide basic 
information on Alzheimer's disease, a staging tool, and stage-
specific strategies for care. This effort is being directed by 
the VA Education Center in Minneapolis.
    The comprehensive Center for Alzheimer's Disease and Other 
Neurodegenerative Disorders at the Oklahoma City VA Medical 
Center completed its second year of development during fiscal 
year 1996. The center is progressing toward a goal to develop 
and evaluate a rural health care model for the coordinated care 
of patients with Alzheimer's disease or other degenerative 
neurological disorders in the state of Oklahoma, using an 
interdisciplinary, case-management approach.
            Geriatric Research, Education, and Clinical Centers
    Geriatric Research, Education and Clinical Centers (GRECCs) 
are designed to enhance the VA's capability to develop state-
of-the-art care for the elderly through research, training and 
education, and evaluation of alternative models of geriatric 
care. First established by VA in 1975, the current 16 GRECCs 
continue to serve an important role in further developing the 
capability of the VA health care system to provide cost-
effective and appropriate care to older veterans.
    GRECCs have established many interrelationships with other 
programs to avoid fragmentation and duplication of efforts. 
Important examples include the GRECCs coordination with VA's 
Health Services Research and Development (HSR&D) Field Programs 
and other research programs within VA and at affiliated health 
science centers; coordination with VA Employee Education 
Centers and Cooperative Health Manpower Education Programs, as 
well as with Geriatric Education Centers at affiliated 
universities; and coordination with clinical programs and 
quality improvement efforts at each host VA facility and 
throughout the VA network in which each GRECC is located.
    In fiscal year 1996, GRECCs made a number of contributions 
to the field of aging and care of the elderly. Examples include 
the discovery of an Alzheimer's gene by researchers at the 
Seattle, Washington GRECC; the development and dissemination by 
the Bedford division of the Boston, Massachusetts GRECC of a 
video on Natural Feeding Techniques for Alzheimer's Patients 
for training of staff and students; and an evaluation by the 
Miami, Florida, GRECC of an interdisciplinary model of care for 
patients with prostate cancer.

Mental Health Strategic Healthcare Group (SHG)

    Although the reported prevalence of mental illness among 
the elderly varies, conservative estimates for those age 65 
years or older include a minimum of 5 percent with Alzheimer's 
disease or other dementias and an additional 15 to 30 percent 
with other disabling psychiatric illnesses. If we use the 30 
percent estimate, 2.3 to 2.7 million veterans can be expected 
to need psychogeriatic care at any given time during the first 
two decades of the next century. Mental Health Services 
throughout VA have continued to provide care to older veterans 
through a growing continuum of acute, subacute, and long-term 
hospital programs, residential care, and both clinic and 
community-based programs in each of the 22 new Veterans 
Integrated Services Networks (VISNs). During a 1992 survey of 
VA mental health programs, 192 psychogeriatric programs in 87 
VA medical centers were identified. Some of the specific 
activities in fiscal year 1996 are noted below:
            Integrated psychogeriatric patient care
    This 55 page VHA Program Guide (1103.22) was published 
March 26, 1996, for primary care and mental health 
professionals engaged in care of the elderly with mental health 
problems. These guidelines, developed by a national VA 
Psychogeriatric Field Advisory Group over a period of five 
years, describe a continuum of programs for elderly 
psychogeriatric patients including suggestions for treatment 
modalities, organization, space, equipment, staffing, 
education, research, and quality management in addition to an 
overall introduction to the subject. It is recommended as a 
resource for clinicians serving elderly veterans and non-
veterans alike.
            UPBEAT (Unified Psychogeriatric Biopsychosocial Evaluation 
                    and Treatment)
    UPBEAT, a $2 million demonstration project currently in 10 
VA facilities, is exploring clinical and economic outcomes as a 
result of screening elderly patients in acute VA medical and 
surgical hospital settings for depression, anxiety, and 
substance abuse. Following an interdisciplinary psychogeriatric 
team evaluation, case managers follow-up patients with positive 
symptoms. Early findings suggest no fewer readmissions but 
lower bed days of care and, consequently, significantly lower 
overall costs, as compared to a ``usual care'' group.
            Treatment guidelines for major depressive disorders
    This algorithm-based treatment guideline for both primary 
care practitioners and mental health specialist was developed 
last year by a multidisciplinary group of VA and non-VA 
professionals to enhance the uniformity and quality of VHA's 
clinical interventions. A special depression screening exam for 
veterans over 60 years of age and annotations regarding 
pharmacological treatment of elders are major features of the 
new guidelines. In addition, treatment of veterans with 
substance abuse and post-traumatic stress disorder (PTSD) is 
included. The Guideline built upon similar efforts published by 
the American Psychiatric Association and the Agency for Health 
Care Policy and Research (AHCPR) in 1993, and the VA Medical 
Advisory Panel (Pharmacologic Management of Depression) in 
1996. A ``Version I'' draft is being field tested at 30 VA 
medical centers and sent to all VA facilities and a ``Version 
II'' will be made available after feedback from the field test 
is incorporated.
            Clinical research
    A MEDLINE search of medical research publications since 
1990 on geriatric psychiatry in VA settings revealed 122 
articles, of which 56 dealt exclusively with elderly veterans. 
Of these, 21 addressed post-traumatic stress disorder (PTSD) 
including studies of ex-prisoners of war, 14 primarily alcohol 
abuse and its detection; 9 Alzheimer's and related diseases; 
and the rest, other aspects of medical or mental illness.

Physical Medicine and Rehabilitation Strategic Healthcare Group (SHG)

    Physical Medicine and Rehabilitation Therapy strives to 
provide all referred older veterans with comprehensive 
assessment, treatment and follow-up care for psychosocial and/
or physical disability affecting functional independence and 
quality of life. The older veteran's abilities in the areas of 
self-care, mobility, endurance, cognition and safety are 
evaluated. Therapists utilize physical agents, therapeutic 
modalities, exercise and the prescription of adaptive 
equipment, to facilitate the veteran's ability to remain in the 
most independent life setting. Rehabilitation personnel provide 
education to the veteran and family members about adjustment to 
a disability or physical limitations and instruct them in 
techniques to maintain independence despite disability.
    There are approximately 65 comprehensive inpatient medical 
rehabilitation programs (both acute and subacute) within the 
Veterans Health Administration. There are a growing number of 
subacute rehabilitation programs being established at medical 
centers across the nation. The subacute rehabilitation setting 
affords us the ability to provide less intense rehabilitation 
services for the older veteran, aimed at promoting an 
individual's integration back into the community. On both acute 
and subacute rehabilitation units, physicians, usually board 
certified physiatrists, lead interdisciplinary teams of 
professionals to focus on outcomes of functional restoration, 
clinical stabilization, or avoidance of acute hospitalization 
and medical complications.
    A uniform assessment tool, the Functional Independence 
Measure (FIM) is being implemented throughout the VA 
rehabilitation system. Patients are evaluation on 18 elements 
of function at the time of admission, regularly during 
treatment and at discharge. Application of FIM results to 
quality management activity will assist local and national 
rehabilitation clinicians and managers to maximize effective 
and efficient rehabilitation care delivery. An administrative 
data base called the Uniform Data System for Medical 
Rehabilitation (UDS/mr) monitors outcomes of care and increases 
the accuracy of developing predictors and ideal methods of 
treatment for the older veterans with various diagnoses. 
Through a national contract with UDS/mr, facilities with 
inpatient rehabilitation programs provide data and receive 
outcome reports as part of a national and international USD/mr 
data bank.
    Rehabilitation therapists are leading and participating in 
innovative treatment, clinical education, staff development and 
research. Rehabilitation professionals work within Home-based 
Primary Care Programs, Independent Living Centers, Geriatric 
Evaluation and Management Units, Adult Day Health Care, Day 
Treatment Centers, Domiciliaries, Interdisciplinary Team 
Training Programs, Geriatric Research, Education, and Clinical 
Centers (GRECCs), and Hospice Care Programs. Applying 
principles of health education and fitness, rehabilitation 
staff develop and provide programs aimed at promoting health 
and wellness for the aging veteran.
    Driver training centers are staffed at 40 VA medical 
centers to meet the needs of aging and disabled veterans. With 
the growing numbers of older drivers, the VA has put emphasis 
on the training of the mature driver. Classroom education, 
updates in laws and defensive driving techniques are supported 
with behind-the-wheel evaluation by trained specialists.
            Recreation therapy
    Provided that adequate preventive and support services are 
made available, older individuals can enjoy full and satisfying 
lives. Studies have shown that isolation leads to depression, 
and depression is the most common mental disorder affecting 20% 
of persons aged 65 and older. Also, the highest suicide rate in 
America is among persons aged 50 and over.
    The Department of Veterans Affairs (VA) Recreation 
Therapists are an integral part of interdisciplinary teams in 
the treatment of illnesses in the elderly. Whether the patient 
is in-patient,out-patient, residential or independent living, 
therapeutic recreation services focus on restoring or maintaining 
optimum independent living and quality of life. Recreation Therapists 
assist patients in the following ways:
          Promote physical health through therapeutic exercises 
        and gross motor activities;
          Enhance mental functioning through the use of reality 
        orientation, sensory stimulation, remotivation therapy 
        and challenging therapeutic activities;
          Use behavioral approaches to help older persons 
        replace maladaptive behaviors with effective functional 
        skills; and
          Provide leisure skills training programs within the 
        patients' range of abilities and facilitate community 
        integration through the use of existing resources.
    Since 1983, VA's Recreation Therapy Service has held the 
National Veterans Golden Age Games (NVGAGs) for the benefit of 
veterans age 55 and older. Sports and recreation are vital 
components of rehabilitative medicine within VA medical 
facilities, where recreation therapy plays an important role in 
the lives of older patients.
    The NVGAGs serve as a showcase for the preventive and 
therapeutic medical value that sports and recreation provide in 
the lives of all older Americans. Participants compete in a 
variety of events that include but are not limited to, 
swimming, tennis, shuffleboard, horseshoes, croquet, bowling 
and bicycle races.
    The NVGAGs are co-sponsored by VA and the Veterans of 
Foreign Wars. Financial support is also provided by numerous 
corporate sponsors and hundreds of local volunteers provide on-
site assistance each year.
    The 1996 NVGAGs were hosted by the VA Medical Center in 
Loma Linda, California. The 1997 program will be held in 
Leavenworth, Kansas, during the week of July 27-August 2.

Nursing Strategic Healthcare Group (SHG)

    Nursing Service, in support of VHA's reorganization and 
``Prescription for Change'', continues to rank care of the 
elderly veteran as a major priority. Nurses at every level of 
the organization are committed to leadership in the clinical, 
administrative, research, and educational components of 
gerontological nursing. Powerful societal forces in both the 
federal government and the private sector require even a 
greater collaborative teamwork as nursing strives to integrate 
advances in the technology, information management, and 
participates in the transition from inpatient to outpatient 
healthcare within the managed care model.
    Nurses continue to participate in preventive care and 
health promotion initiatives, to preserve both the veterans' 
and their significant others' independence. Team approaches to 
improving the health status of aging veterans have fostered 
optimum levels of self-care, improved productivity, and 
enhanced quality of life. Health screening, education, primary 
care and referral of elderly veterans are critical functions 
necessary to evaluate healthcare needs and properly place the 
veteran in the most appropriate level of care. This may range 
from the environment of personal care in the home as the least 
restrictive setting to nursing home care as the most 
restrictive environment. Nurses in wellness clinics, mobile 
units and other ambulatory care settings provide supervision, 
screening and health educational programs to assist veterans 
and their significant others in fostering and maintaining 
healthy lifestyles.
    Effective utilization of Advanced Practice Nurses (APN) in 
the provision of healthcare services is a critical component of 
VHA's mission to provide primary care in a seamless system 
across a continuum of care. This continuum of care for aging 
veterans includes primary care, acute care, long-term care, 
rehabilitative care and mental health care. Nurses are a vital 
part of interdisciplinary teams that coordinate and provide 
care in settings such as Geriatric Evaluation and Management 
Programs (GEMs), ambulatory care, acute care, long-term care, 
mobile care units, and community agencies. Gerontological 
advanced practice nurses provide primary care and continuity of 
care in the role as clinical care managers, coordinators of 
care, and case managers. Through sustained patient 
partnerships, APNs provide health care for aging patients in 
diverse settings minimizing illness and disabilities and 
focusing on health promotion, disease prevention and health 
maintenance.
    Primary care may be provided to aging veterans by a 
physician or a nurse practitioner primary care provider and 
followed by a care team including psychiatry, psychology, 
social work, rehabilitative medicine and others. Primary care 
services are based on long-term care needs of aging patients 
including those with multiple and chronic medical problems, 
functional disabilities, cognitive impairments and weakened 
social support systems. Services are provided across the 
continuum from health promotion and disease prevention to 
screening for community services including hospice care 
evaluation.
    Nurses facilitate the restoration of functional abilities 
of veterans with chronic illnesses and disabilities. Programs 
for the physically disabled and cognitively impaired are 
administered by nurses and advanced practice nurses in settings 
representing ambulatory care, inpatient care and home care. 
Treatment programs and rehabilitation teams are goal-directed 
with physical and psychosocial reconditioning or retraining of 
patients. Patient and family teaching are a major part of each 
program. Family/significant others have a key role in providing 
support to veterans. Both are assisted in learning and in 
maintaining appropriate patient/caregiver rights and 
responsibilities. VA nurses contribute to planning, 
implementing and evaluating healthcare services for veterans in 
the community-at-large. They serve on task forces and 
participate in self-help and support groups. These include 
those related to specific diseases such as Alzheimer's, cancer, 
AIDS, diabetes, stroke, and spinal cord injury. VA nurses serve 
in a variety of roles in their work and private volunteer 
activities.
    Committed to leadership in education, VA nurses provide 
creative learning, experiences for both undergraduate and 
graduate nursing students. Nursing education initiatives 
including ``distance learning'' are being developed to provide 
skills and competencies necessary to function in primary and 
managed care settings. Students are able to work and study with 
VA nurses who have clinical and administrative expertise in 
aging and long-term care. These include nurses in various 
organizational and leadership roles. These collaborative 
experiences promote a culture and image of an agency that is 
committed to quality care and quality of life for aging.
    A recent national VA Nursing Home Care Unit (NHCU) study 
revealed that over the last three years there has been a 
significant decrease in restraint usage. Decreased restraint 
usage is attributed to interdisciplinary reassessment of the 
patient's treatment. Each patient/resident has a comprehensive 
interdisciplinary plan of care which facilitates reduced 
restraining usage. Resident outcomes include a decrease in the 
number of falls and injuries with an increase in residents' 
alertness, happiness, muscle strength, independence and pride. 
Nurses and other members of the interdisciplinary team are 
proud of these clinical outcomes as VA NHCUs strive to become a 
restraint free environment. Such an environment enhances 
resident behaviors in independence, decision making and 
socialization.
    Committed to research, VA nurses continue to change and 
reshape clinical nursing practices. Nursing research is 
improving care delivery and health promotion in the following 
areas:
          Alternatives to Institutional Care;
          Wound Care and Effectiveness of Treatment Regimens;
          Risk Assessment for Falls;
          Restraint Minimization and Interdisciplinary 
        Assessment Tool Effectiveness;
          Patient Education, Health Promotion and Maintenance; 
        and
          Clinical Pathways
    Timely application of research findings to clinical care in 
all practice settings will improve the quality care and quality 
of life to aging veterans. Quality of life is an essential 
component for evaluating the effects of nursing care in both 
research and clinical practice. Research by nurses as a 
discipline and in collaboration with other members of the 
health care team must focus on specific patient care outcomes 
including quality of life, effectiveness of care interventions, 
cost effectiveness and patient satisfaction.

Pharmacy and Benefits Management Strategic Healthcare Group (SHG)

    The Under Secretary for Health established the Pharmacy 
Benefits Management (PBM) Service line in FY 1996 to provide a 
focus within the Veterans Health Administration (VHA) 
concerning the appropriate use of pharmaceuticals in the health 
care of veterans. A secondary goal is to decrease the overall 
cost of health care through achievement of the PBM's primary 
goal. As the VHA transitions from an emphasis on inpatient care 
to ambulatory/primary care, pharmaceutical utilization will 
increase dramatically.
    VHA's PBM is organized around a group of field-based 
physicians called the Medical Advisory Panel (MAP). The MAP 
provides leadership and guidance to the PBM in addressing the 
four functions of the PBM. These functions are (1) to enhance 
the efficiency and effectiveness of the drug use process; (2) 
to enhance the distribution systems for pharmaceuticals used in 
both the inpatient and outpatient settings; (3) to consistently 
bring best pharmaceutical practices into the VA health care 
system, and (4) to maintain and enhance VA's drug pricing 
capabilities.
    The PBM serves a qualitative and quantitative role in 
addressing the needs of older veterans. In a patient population 
who frequently has co-morbidities and multiple drug therapies, 
the actions of pharmacists to improve the drug use process are 
essential in realizing the goal of the appropriate use of 
pharmaceuticals. In collaboration with other health 
professionals and the use of adjunct tools such as drug 
treatment guidelines, acute and chronic conditions facing 
geriatric patients are addressed in an efficient and effective 
manner with emphasis on the clinical condition as well as 
issues related to customer service and access.
    Substantial gains have occurred in addressing the 
timeliness of pharmaceutical services at VA medical facilities 
through the use of automated distribution systems for mail 
prescriptions and improved work flow processes for patients who 
present at pharmacy counters. In addition, serious discussion 
is underway to further improve customer service, access and 
clinical care for all veteran patients through entering into 
relationships with community-based pharmacists to act as 
nonresident members of the facility-based primary care team. 
While still in the conceptual stage this practice has the 
potential to accomplish quality patient care, improve access 
and customer service and improve on the efficiency of care 
delivery.

Allied Clinical Services Strategic Healthcare Group (SHG)

Nutrition and food service

    Medical nutrition care saves money, improves patient 
outcomes and enhances the quality of life for our older 
veterans. To better serve the veteran and identity nutritional 
needs, many VA health care professionals are now using 
Determine Your Nutritional Health Checklist and Level I and II 
Nutrition System developed by the American Dietetic 
Association, American Academy of Family Physicians and National 
Council on Aging National Screening Initiative. The Checklist 
or Level I Screen identifies those at high risk for poor 
nutritional status, while Level II Screen provides specific 
diagnostic nutritional information. The National Screening 
Initiative emphasizes educating the physician in nutritional 
care. The booklet, Incorporating Nutrition Screening and 
Interventions into Medical Practice, has been nationally 
disseminated to doctors. This information complements the 
handbook, Geriatric Pocket Pal, developed in collaboration with 
the Geriatrics and Extended Care SHG.
    Many medical centers have Geriatric Nutrition Specialists 
positions. Dietitians in these positions have developed easy-
to-read educational materials for their audience and shared 
this information with other medical centers. Several medical 
centers are providing outreach services for the elderly in 
their community. For example, the Bronx VAMC provides outreach 
to local senior centers, and the Dallas VAMC has bi-monthly 
visits by their health screening team to facilities in their 
area. Feeding dependency is highly associated with malnutrition 
among nursing hone residents. Silver Spoons is one of the 
successful programs instituted by the Miami VAMC nursing home 
aimed at intervention before severe nutritional problems 
develop in feeding dependent residents. The program uses 
volunteers to fee residents and to ensure adequate nutrition. 
This is an interdisciplinary program including dietary, 
nursing, voluntary, medical, recreation and dental services. 
The Brockton/West Roxbury VAMC developed a pureed product line 
to enhance the appearance, taste, quality and acceptability of 
foods for geriatric patients with dysphagia.
            Social Work Service
    Meeting the biopsychosocial health care needs of an aging 
population of veterans and caregivers continues to be a major 
priority of Social Work Service and the Veterans Health 
Administration. The need to be competitive in a challenging and 
changing health care environment, as well as cost-effective and 
efficient in addressing the social components of health care, 
has led to a re-examination of social work priorities and their 
relevance to the VA health care mission, with special reference 
to the needs of chronically ill, older veterans. Without a 
support network of family, friends, and community health and 
social services, health care gains would be lost and VHA acute 
care resources would be over-burdened. It is frequently not the 
degree of illness that determines the need for hospital care, 
but rather the presence or absence of family and community 
resources.
    The expansion of homemaker/home health aide services is 
evidence of the importance of non-institutionalized support 
networks in maintaining the veteran in the community. Social 
workers continue to coordinate discharge planning and to serve 
as the focal point of contact between the VA medical center, 
the veteran patient, family members, and the larger community 
health and social services network. The veteran and family 
members have, in many respects, become the ``unit of care'' for 
social work intervention. It is this ``customer'' focus which 
will undergird social work programming for vulnerable 
populations, including older veterans who are demanding that 
VHA be more responsive and sensitive to their psychosocial 
needs and those of their caregivers.
    The role of the caregiver as a member of the VA health care 
team and as a key player in the provision of health care 
services continues to be a major area of social work practice 
and will continue to be in the immediate future. This is 
consistent with the recognition that 80 percent of care of the 
elderly is provided in the home by family, neighbors, etc., and 
that the family, ordinarily theveteran's spouse, is the key 
decision-maker concerning health insurance issues, and, most probably, 
access to health and community support services.
    As VHA transitions from an acute care to a primary care/
community interactive health care delivery system, Social Work 
Service has placed increased emphasis on its pivotal role in 
community services coordination, development, and integration. 
The development of a ``seamless garment of care,'' with case 
management services as its centerpiece, is being given 
increased emphasis by Social Work Service and its National 
Committee. The National Committee published Social Work 
Practice Guidelines, Number 2: Social Work Case Management, in 
September 13, 1995. These standards are used as a starting 
point and part of the educational process that takes place at 
each medical center, as we move into interdisciplinary clinical 
paths and practice guidelines. The National Committee functions 
in an advisory capacity concerning social work and systems 
issues, priorities, and practice concerns. While case 
management services have been a central component of social 
work practice in VHA, this service modality is being ``re-
discovered'' by the VA health care system as an essential 
component of services provided to ``at-risk'' veterans and 
their caregivers. Case management, also known as care 
coordination, was identified in veterans' discussion groups as 
a very important ingredient in meeting the veterans' health 
care needs and those of their caregivers. During 1997 and 
beyond, VHA, and particularly Social Work Service, will be 
challenged to expand case management services in concert with 
other community providers and to provide a perspective that 
addresses this critical ingredient in health care in terms of 
its absolute relevance to successful health care outcomes. In a 
revitalized and reconfigured VA health care system, issues of 
coordination, access, cost, and appropriateness of VA and 
community services will be determined not only by the needs of 
the customers, but also by the experience and expertise of the 
providers.

Diagnostic Services Strategic Healthcare Group (SHG)

    The clinical services of Pathology and Laboratory Medicine, 
Radiology, and Nuclear Medicine constitute the Diagnostic 
Services Group. Each of these clinical services provides direct 
services to veteran patients and to clinician-led teams in 
ambulatory/primary care, acute care, mental health, geriatrics 
and long-term care, and rehabilitation medicine.
    Diagnostic Services' staff are educated on special care of 
the elderly. Pathology and Laboratory staff, for example, 
receive special training on phlebotomy with the elderly. In 
addition, normal values of various laboratory tests may be 
different in the elderly. These differences are incorporated 
into each VA facility's reference on normal ranges for tests.

Prosthetic and Sensory Aids Strategic Healthcare Group (SHG)

    The mission of the Prosthetic and Sensory Aids Service 
(PSAS) Strategic Healthcare Group is to provide specialized, 
quality patient care by furnishing properly prescribed 
prosthetic equipment, sensory aids and devices in the most 
economical and timely manner in accordance with authorizing 
laws, regulations and policies. PSAS serves as the pharmacy for 
assistive aids and PSAS prosthetic representatives serve as 
case managers for prosthetic equipment needs of the disabled 
veteran.
    Today, the majority of amputations performed in VA medical 
centers are a result of peripheral vascular disease and 
diabetes as opposed to traumatic amputations related to war 
injuries dating back to World War II. Elderly veterans make up 
roughly 90 percent of this patient population. For some of 
these elderly veterans, the transition to learning the mobility 
requirements of an artificial limb can be difficult. For 
others, the adjustment to a different type artificial limb due 
to the amputation of the residual limb or an amputation of 
another extremity can be just as traumatic. Prosthetic 
representatives exercise good logic in filling prosthetic 
prescriptions for both groups of veterans, taking into account 
the veteran's present quality of life, mobility, and 
dependence.
    PSAS is an integral member of health care teams providing 
prevention, treatment, and follow-up care to our aging veteran 
population. An example of this would be VHA's Preservation-
Amputation Care and Treatment (PACT) Program. It was 
established to provide a model of at-risk limb care which 
essentially expands the scope of care and treatment of veterans 
who are at risk for limb loss or who have sustained 
amputations. The PACT incorporates interdisciplinary 
coordination of surgeon, rehabilitation physician, nurse, 
podiatrist, therapist, and prosthetic/orthotic personnel to 
track every patient with amputations, or those at risk for limb 
loss, from the day of entry into the VA healthcare system, 
through all appropriate care levels, back into the community. 
There are 139 PACT Programs VA-wide.
    Some of the most common prosthetic appliances provided to 
elderly patients are artificial limbs, wheelchairs, braces, 
hospital beds, environmental controls, oxygen and respiratory 
equipment, eyeglasses, hearing aids, speech prostheses, talking 
machines, reading machines, home safety equipment, walking 
canes, crutches, and custom molded shoes.

Office of Research and Development

            Medical research
    Within the Office of Research and Development, the mission 
of Medical Research Service is to support and enhance patient 
care at VA health care facilities by seeking improvements in 
the prevention, diagnosis, and treatment of diseases and 
disorders. In order to focus efforts on medical problems most 
prevalent within the veteran population and establish 
priorities for future funding, the service has conducted a 
thorough review of its research portfolio. As a result of this 
study, aging has been established as one of the 17 priority 
areas for funding by Medical Research Service.
    Although the number of funded projects identified with a 
primary focus on aging remains relatively constant, research 
efforts with a secondary focus on aging include studies on a 
multitude of diseases and disorders affecting older veterans. 
Examples of such conditions are Alzheimer's Disease, prostate 
and other cancers, depression, heart disease, and Parkinson's 
Disease. Studies on these and other conditions which affect 
older veterans constitute a large portion of the Medical 
Research Service budget.
    Among the current efforts focusing on aging in research 
conducted by Gerard Schellenberg, Ph.D., Associate Director for 
Research, VA Puget Sound Geriatric Research, Education and 
Clinical Center (GRECC), who recently discovered the first 
human gene associated with aging. The gene causes a rare 
disorder, i.e., Werner's Syndrome, which results in premature 
aging. This important discovery follows a previous one by Dr. 
Schellenberg and colleagues--the discovery of an Alzheimer's 
gene which may allow a better understanding of the disease and 
lead to improved treatments.
            Health Services Research and Development
    Health Services Research and Development (HSR&D) is an area 
of research designed to enhance veterans' health by improving 
the quality and cost effectiveness of the care provided by the 
Department of Veterans Affairs. The focus of VA HSR&D is on (1) 
advancing the state of knowledge about health services in VA 
and the nation and (2) disseminating that knowledge for 
practical use. The large number of aging veterans and their 
increasing health care needs make this population particularly 
important for HSR&D to study. The Service's four major program 
areas emphasized aging during FY 1996, as described in the 
following pages.
    (1) The Investigator Initiated Research (IIR) program 
encourages and supports projects proposed and conducted by VA 
researchers, clinicians, and administrators from throughout the 
Nation. In this intramural program of HSR&D, researchers 
conduct merit reviewed and approved projects in VA Medical 
Centers with advice from VA Headquarters staff. The IIR program 
includes career development which guarantees salary support to 
clinicians and researchers interested in pursuing research 
careers in VA.
    Thirty-two percent of the 53 HSR&D IIR projects addressed 
questions important to aging veterans. Five newly initiated 
projects included an evaluation study of the effectiveness of 
screening for prostatic cancer; a controlled trial of a 
physical restoration intervention (SAFE-GRIP) to reduce the 
likelihood of falls in the elderly after hospitalization; a 
study of the differences in coronary angioplasty outcomes 
between veterans and non-veterans; a study of the impact of 
oral health conditions and quality of life in older veterans; 
and a study to improve the management of patients with chronic 
obstructive pulmonary disease.
    Ongoing geriatric related investigations included studies 
affecting veterans with cardiac related illnesses such as: 
appropriateness and necessity of cardiac procedure use after 
acute myocardial infarction; quality of life outcomes after 
coronary artery bypass graft (CABG) surgery; the role of social 
factors in the occurrence of cardiac events; and two studies 
addressing utilization of cardiac procedures (carotid 
endarterectomy and CABG) in Africian-American veterans.
    Researchers are examining pressure ulcer incidence rates as 
a measure for long-term care in VA facilities; examining 
strategies to improve the quality of nutritional care to 
elderly hospitalized patients; and developing reliable and 
valid health status measures for skin disease to improve 
outcomes of care.
    Five IIR projects related to aging were completed. These 
projects included a study of the magnitude, costs, treatment, 
and prevention strategies of diabetic foot problems; a study of 
quality of life outcomes after coronary artery bypass graft 
surgery; Simulated Presence Therapy (SPT), a new non-
pharmacologic technique to reduce problem behaviors in 
Alzheimer's disease patients; and the effects of exercise 
training on frail, elderly veterans. Also completed was a study 
of home monitoring of peak expiratory flow rates to detect 
early respiratory decompensation in patients with chronic 
obstructive pulmonary disease. This study revealed that home 
monitoring is feasible, and that symptoms and peak flows can be 
used to forecast respiratory status in three to seven days.
    (2) The HSR&D Cooperative Studies in Health Services (CSHS) 
projects are multi-site health services research studies based 
on the model of VA's Cooperative Studies Program for biomedical 
research. Because of VA's health care system size, complexity, 
and data availability, if offers unique opportunities to 
conduct large-scale research projects, such as the CSHS. These 
studies are likely to yield more definitive findings than may 
be available in other health care environments. Three Centers 
for Cooperative Studies in Health Services (CCSHS) provide 
scientific, technical, and management support to CSHS 
investigators. Examples of Cooperative Studies in Health 
Services projects relevant to the concerns of the aging 
population include: a comparison of the cost and effectiveness 
of team-managed Home Based Primary Care (HBPC) to customary 
care for severely disabled and terminally ill patients; and a 
study of whether the combination of inpatient care provided by 
Geriatric Evaluation and Management (GEM) Units and outpatient 
care provided by GEM Clinics as compared with usual care 
provided to hospitalized veterans will reduce mortality and 
enhance health-related quality of life for veterans. 
Researchers are examining which processes and structures of 
cardiac care are predictive of positive health outcomes; and 
comparing costs and health outcomes of telephone care to face-
to-face clinic visits. Funding ended for one project that 
tested whether providing discharged patients with ``rapid 
access'' to high quality primary car would affect health 
services utilization, health-related quality of life, patient 
satisfaction with care, and health care costs.
    (3) The HSR&D Field Program is a network of core VA staff 
assigned to selected medical centers. In 1996, the Service 
funded nine ongoing HSR&D Field Programs. Field Program staff 
conduct independent research projects and collaborate with 
community institutions in support of program objectives.
    Field Programs serve as Centers of Excellence in selected 
subject matter areas. Although some Field Programs have aging 
as one of their primary research foci, Field Programs have 
research interests in health care issues affecting aging 
veterans. The Northwest Center for Outcomes Research in Older 
Adults at Puget Sound Healthcare System examines issues 
affecting the elderly such as, improving the quality of 
ambulatory care, prevention and treatment for chronic 
illnesses, and long-term care. The Midwest Center for Health 
Services and Policy Research at Hines VAMC in Illinois 
continues to emphasize gerontology and rehabilitation issues. 
The Field Program in Bedford, Massachusetts, is a Center for 
Quality, Outcomes and Economic Research with interests in the 
quality of long-term care, cost effectiveness, health outcomes 
and health related quality of life issues. the Center for 
Health Services Research in Primary Care at Durham VAMC 
emphasizes research that enhances the delivery, quality and 
efficiency of primary care provided to veterans. The Center is 
focusing on topics such as access to health care for ethnic 
groups, process and outcomes of care relative to such diseases 
as stroke, diabetes and breast cancer, and cost-effective 
management of chronic diseases.
    In addition to supporting Field Program investigations, 
HSR&D Service provided core support funding for the Normative 
Aging Study (NAS), a multidisciplinary, longitudinal 
investigation of human aging, and the Dental Longitudinal 
Study, a companion study addressing oral health and risk 
factors for oral disease in an aging population.
    (4) The Special Projects Program encompasses the HSR&D 
Service Directed Research (SDR) Program, Management Decision 
Research Center (MDRC), and special activities such as 
conferences and seminars. Special projects may include 
evaluation research, information syntheses, feasibility 
studies, special initiatives and other research projects 
responsive to specific needs identified by Congress, other 
federal agencies, or Department of Veterans Affairs executive 
and management staff. This is a centrally directed program of 
health services research conducted by VA field staff, VHA 
Headquarters staff, and/or contractors engaged to analyze 
specific problems.
    Ongoing HSR&D Service Directed Research (SDR) projects 
focus on issues relevant to the aging veteran population. These 
projects include an evaluation of the diagnosis, treatment, and 
outcomes of veterans hospitalized for acute ischemic stroke; 
and a study of health related quality of life. Additionally, 
three SDR projects focus on prostate cancer. One assesses the 
impact of an educational intervention on patient preferences 
for treatment. Another investigates familial patterns in 
prostate cancer, and another studies patient preferences in 
advanced metastatic prostate cancer.
    Seven continuing projects related to women's health are 
expected to benefit aging female veterans. These projects 
address issues of access to VA care; cancers of the 
reproductive system relating to military experience and Post 
Traumatic Stress Disorder; quality of life; long-term care; 
workforce participation, health insurance and health care use; 
and development of a Registry of Women Veterans.
    Since many veterans, including older veterans, suffer from 
chronic diseases, VA researchers are looking for efficient and 
effective ways to manage their care. A new HSR&D Service 
Directed Research project is investigating the effectiveness of 
telecare in the management of diabetes.
    The Under Secretary for Health proposed the nursing 
research initiative to encourage new research on nursing topics 
and to expand the pool of nurse investigators within the 
Department ofVeterans Affairs. The Research and Development 
Office in collaboration with the Nursing Service staff implemented a 
research program that targets nursing investigators. This effort would 
invite research proposals for health services research, medical 
research and rehabilitation research. In 1995 Health Services Research 
Service issued a formal Request for Applications inviting nurses at VA 
medical centers to submit research proposals. The first nursing 
research project was funded in 1996 related to the psychophysiology of 
Post Traumatic Stress Disorder in female nurse Vietnam veterans. It is 
expected that this initiative will increase the number of projects 
related to aging veterans in fiscal year 1997.
    In addition to these special research initiatives, MDRC is 
developing primers to explain specific health services-related 
or health care-related issues relevant to VA's efforts at 
delivering high quality care. The first primer on Primary Care 
was released in September 1995. The second primer on Technology 
Assessment in VA was released in July 1996. Two forthcoming 
primers will be on outcomes and program evaluation for 
managers.
    Management Briefs and Practice Matters are new MDRC 
projects. The purpose of the Management Brief is to provide 
managers with a concise overview of HSR&D study findings in a 
particular research area as well as provide contact information 
and important citations. Practice Matters summarizes the 
results of important research within VA and promotes its 
application to managers by describing the potential impact and 
possible implementation strategies and resources.
    In FY 1996, the MDRC, through its Management Consultation 
Program conducted three studies at the request of the Office of 
Geriatrics and Extended Care. Two were completed including one 
study that analyzed the differences in costs between VA nursing 
home care units and community nursing homes; and a second study 
that assessed the extent of subacute care provided in VA 
facilities and community nursing homes. One ongoing study is 
evaluating the national multi-state nursing home contract 
initiative. The evaluation is assessing costs, access, quality 
of care and administration burden of new contracts. The MDRC 
also will conduct a Congressionally-mandated analysis of VA 
hospice care in 1997.
    Future HSR&D initiatives expected to increase research on 
aging relate to improving veterans access to VHA services; the 
effects of managed care on patient and system outcomes; 
alternative strategies for implementing evidence-based clinical 
practice guidelines; investigating ethnic and cultural 
variations in health care and designing interventions; and 
exploring gender differences in health care and evaluating 
interventions for improving women's health services in VA.

Rehabilitation Research and Development

    The mission of the Rehabilitation Research and Development 
(Rehab R&D) Service is to investigate and develop concepts, 
products and processes that promote greater functional 
independence and improve the quality of life for impaired and 
disabled veterans. Aging, particularly the aging of persons 
with disabilities, is a high priority of the service. Efforts 
in this area include:
          A national VA program of merit-reviewed, 
        investigator-initiated research, development and 
        evaluation projects targeted to meet the needs of aging 
        veterans with disabilities;
          Support of a Rehabilitation Research and Development 
        Center on Aging at Decatur, Georgia, VA Medical Center; 
        and
          Transfer into the VA health care delivery system of 
        developed rehabilitation technology and dissemination 
        of information to assist the population of aging 
        veterans and those who care for them.
    In addition to specific projects on aging, many of the 
investigations supported through the Service's nationwide 
network of research at VAMCs and at four Rehabilitation 
Research and Development Centers have relevance for impairments 
commonly associated with aging.
    Some examples of investigator-initiated studies currently 
being carrier out are:
          A Low-Vision Enhancement System (LVES);
          Liquid Crystal Dark-Adapting Eyeglasses;
          Upper Body Motion Analysis for Amelioration of Falls 
        in the Elderly;
          Non-Auditory Factors Affecting Hearing Aid Use in 
        Elderly Veterans;
          The Influence of Strength Training on Balance and 
        Function in the Aged; and an
          Epidemiologic Study of Aging in Spinal Cord Injured 
        Veterans.
    The Rehab R&D Center on Aging is structured around five 
interdisciplinary research sections to address the multi-
dimensional nature inherent in problems of aging and 
disability: Environmental Research; Vision Rehabilitation; 
Neuro-Physiology; Engineering and Computer Science; and Social, 
Behavioral, and Health Research. Areas of study include:
          Design-related problems that affect the quality of 
        life of older people, including least restrictive 
        environments, falls, independence and safety;
          Orientation and mobility for the blind, low vision, 
        and rehabilitation outcomes measurement for older 
        persons with visual impairment;
          The neurologic and physiologic changes that accompany 
        aging and behavioral coping problems; and
          Development and application of new technologies to a 
        variety of prototypes for the design of assistive 
        devices and assistive software.

Office of Academic Affiliations

    All short- and long-range plans for VHA that address health 
care needs of the Nation's growing population of elderly 
veterans include training activities supported by the Office of 
Academic Affiliations (OAA). The training of health care 
professionals in the area of geriatrics/gerontology is an 
important component for a variety of programs conducted at VA 
medical centers in collaboration with affiliated academic 
institutions. Clinical experiences with geriatric patients are 
an integral part of health care education for the almost 
107,000 health trainees, including 33,000 resident physicians 
and fellows, 20,000 medical students, and 54,000 nursing and 
associated health students. These residents and students train 
in VA medical centers annually as part of affiliation 
agreements between VA and nearly 1,000 health professional 
schools, colleges, and university health science centers. 
Recognizing the challenges presented by that ever-increasing 
size of the aging veteran population, the OAA has made great 
strides in promoting and coordinating interdisciplinary 
geriatric and gerontologic programs in VA medical centers and 
in their affiliated medical institutions.
    The Office of Academic Affiliations, in VHA, supports 
selected geriatric education and training activities through 
the VA fellowship and residency programs for physicians and 
dentists.
            Geriatric medicine
    The issue of whether or not geriatrics should be a separate 
medical specialty or a subspecialty was resolved in September 
1987, when the Accreditation Council for Graduate Medical 
Education (ACGME) approved Geriatric Medicine as an area of 
special competence. Effective January 1988, the American Board 
of Internal Medicine and the American Board of Family Practice 
specified procedures for the certification of added 
qualifications in geriatric medicine. VA played a critical role 
in the development and recognition of geriatric medicine in the 
United States, and since 1989, any VA medical center may 
conduct training in geriatrics providing an ACGME accredited 
program is in place.
    The demand for physicians with special training in 
geriatrics and gerontology continues unabated because of the 
rapidly advancing numbers of elderly veterans and aging 
Americans. TheVA health care system offers clinical, 
rehabilitation, and follow-up patient care services as well as 
education, research, and interdisciplinary programs that constitute the 
support elements that are required for the training of physicians in 
geriatrics. This special training was accomplished through the VA 
Fellowship Program in Geriatrics from Fiscal Year 1978-89 and through 
the specialty residency training since Fiscal Year 1990. In Fiscal Year 
1996, VA supported 104 physicians receiving advanced education in 
geriatric medicine and 19 physicians receiving advanced education in 
geriatric psychiatry. VA also supported 15 physicians pursuing post 
residency fellowship education in geriatric neurology and geriatric 
psychiatry.

                          Geriatric dentistry

    In July 1982, a two-year Dentist Geriatric Fellowship 
Program commenced at five medical centers affiliated with 
Schools of Dentistry. The goals of this program were similar to 
those described for the Physician Fellowship Program in 
Geriatrics. In Fiscal Year 1988, the number of training sites 
increased to six for a final 3-year cycle. As of June 1994, 52 
Geriatric Dentistry Fellows had completed their special 
training.
    The VA Dentist Geriatric Fellowship Program ended in 1994. 
It proved to be an excellent recruitment source for dentists 
uniquely trained in the care of the elderly. Approximately 
thirty of these graduated fellows currently serve as staff 
dentists throughout the VA system. Others have assumed 
leadership positions in geriatric dentistry at academic 
institutions. They have enhanced patient care and other 
geriatric initiatives at their own as well as regional medical 
centers, and have also contributed to the geriatric efforts at 
affiliated health centers and in the community. Nationally, 
former fellows have made significant contributions to the 
professional literature and are actively involved in geriatric 
dental research.
    Since the Dentist Geriatric Fellowship Program ended at 
designated VA sites, individual awards in dental research have 
been initiated. Candidates from any VA medical center with the 
appropriate resources may now compete for postdoctoral 
fellowships for dental research.
            Nursing and associated health professions
    Based on the demographics of its veteran patient 
population, all affiliation students receive experience in 
caring for the elderly. VA also has special programs which 
focus on geriatrics.
            Interdisciplinary Team Training Program
    The interdisciplinary Team Training Program (ITTP) is a 
nationwide systematic educational program that is designed to 
include didactic and clinical instruction for VA facility 
practitioners and affiliated students from three or more health 
professions such as physicians, nurses, psychologists, social 
workers, pharmacists, and occupational and physical therapists. 
The ITTP provides a structured approach to the delivery of 
health services by emphasizing the knowledge and skills needed 
to work in an interactive group. In addition, the program 
promotes an understanding of the roles and functions of other 
members of the team and how their collaborative contributions 
influence both the delivery and outcomes of patient care. 
Training includes the teaching of staff and students in 
selected priority areas of VA health care needs, e.g., 
geriatrics, ambulatory care, management, and nutrition; 
instruction in team teaching and group process skills for 
clinical core staff; and clinical experiences in team care for 
affiliated education students with the core team serving as 
role models.
    The ITTP, which began in 1978, has been activated at 12 VA 
medical centers: Birmingham, AL; Buffalo, NY; Coatesville, PA; 
Little Rock, AR; Madison, WI; Memphis, TN; Palo Alto, CA; 
Portland, OR; Salt Lake City, UT; Sepulveda, CA; Tampa, FL; and 
Tucson, AZ.
    The goal of ITTP is to develop a cadre of health 
practitioners with the knowledge and competencies required to 
provide interdisciplinary team care to meet the wide spectrum 
of health care and service needs for veterans, to provide 
leadership in interdisciplinary team delivery and training to 
other VA medical centers, and to provide role models for 
affiliated students in medical and associated health 
disciplines. During Fiscal Year 1996, more than 184 students 
from a variety of health care disciplines were provided funding 
support at the 12 ITTP sites.
            Advanced Practice Nursing Program
    Advanced Practice Nursing, i.e., master's level clinical 
nurse specialist and nurse practitioner training, is another 
facet of VA education programming in geriatrics. The need for 
specialty trained graduate nurses is evidenced by the 
sophisticated level of care needed by VA patient populations, 
specifically in the area of geriatrics. Advanced nurse training 
is a high priority within VA because of the shortage of such 
nursing specialists who are capable of assuming positions in 
specialized care and leadership.
    The master's level Advanced Practice Nursing Program was 
established in 1981 to attract specialized graduate nursing 
students to VA and to help meet needs in the VA priority areas 
of geriatrics, rehabilitation, psychiatric/mental health, 
primary care, medical-surgical and critical care, all of which 
impact on the care of the elderly veteran. Direct funding 
support is provided to master's level nurse specialist students 
for their clinical practicum at the VA medical centers that are 
affiliated with the academic institutions in which they are 
enrolled. During Fiscal Year 1996, 376 master's level advanced 
practice nurse student positions were supported.
            VA Predoctoral Nurse Fellowship Program
    Gerontological nursing has been a nursing specialty since 
the mid-1960's. As society changes, particularly in terms of 
the demographic trends in aging, more attention is being 
focused on both the area of gerontological nursing and the 
education of nurses in this specialty. Doctoral level nurse 
gerontologists are prepared for advanced clinical practice, 
teaching, research, administration, and policy formulation in 
adult development and aging.
    In Fiscal Year 1985, a two-year nurse fellowship program 
was initiated for registered nurses who were doctoral 
candidates with dissertations focused on clinical research in 
geriatrics/gerontology. The first competitive review was 
conducted in 1986. One nurse fellow was selected for the Fiscal 
Year 1996 funding cycle. Since that time, two nurse fellowship 
positions have been available for selection at approved VA 
medical center sites each fiscal year.
    In FY 1994, the program was changed to Predoctoral Nurse 
Fellowship to include all clinical areas that are relevant to 
the care of veterans.
            Expansion for associated health training in geriatrics
    A special priority for geriatric education and training is 
recognized in the allocation of associated health training 
positions and funding support to VA medical centers hosting 
GRECCs and to VA medical centers (non-ITTP/GRECC sites) 
offering specific educational and clinical programs for the 
care of older veterans. In Fiscal Year 1996, a total of 189 
associated health students received funding support in the 
following disciplines: Social Work, Psychology, Audiology/
Speech Pathology, Clinical Pharmacy, Advanced Practice Nursing, 
Dietetics, and Occupational Therapy.
            Geropsychology post-doctoral fellowship
    In FY 1993, the Office of Academic Affairs initiated a one 
year geropsychology post-doctoral fellowship program. The 
purpose of the program is to develop a cadre of highly trained 
geropsychologists who will contribute to the care of the 
elderly both within and outside the Department of Veterans 
Affairs. This pool of individuals should provide an excellent 
source of recruitment for future VA psychologists.
    One fellow is selected annually at each of the following 10 
VA Medical Centers: Brockton, MA; Cleveland, OH; Gainesville 
FL; Houston, TX; Knoxville, IA; Little Rock, AR; Milwaukee, WI; 
Palo Alto, CA; Portland, OR; and San Antonio, TX. These VAMCs 
have strong geriatric focus programs and accredited psychology 
internship programs.

Office of Employee Education

    In support of VA's mission to provide health care to the 
aging veteran population, education and training opportunities 
are offered to enhance the skills of medical center employees 
in the area of geriatrics. These educational activities are 
designed in response to the needs of health care personnel 
throughout the entire Veterans Health Administration. Annually, 
funding is provided for employee education and distributed to 
three major levels of the organization to support continuing 
education activities in priority areas.
    First Level.--Funds are provided directly to each VA 
medical center to meet the continuing education needs of their 
employees. In FY 1996, 383 individual episodes of training were 
received by medical center employees in the area of geriatrics. 
An additional 2,393 employees attended locally sponsored 
lectures, workshops and seminars. The total number trained 
through local funding represents 4.3% of the total number of 
individuals trained.
    Second Level.--The Office of Employee Education, through 
the Employee Education System meets education needs by 
conducting programs at the VA network and local medical center 
levels. In FY 1996, seven of the ten major employee education 
system sites conducted a total of 35 programs in the area of 
geriatrics. A total of 1,139 employees participated in these 
programs. Examples of some of the more recent programs include:
          Dementia, Depression, and Addiction;
          Alzheimer's and Dementia;
          Suicide and Depression in the Elderly;
          Issues Facing Older Women; and
          Myths of Aging.
    Level Three.--Employee education programs are also 
conducted in cooperation with the GRECCs. In FY 1996, the 
GRECCs received $253,304 in training funds to support their 
identified needs. This collaborative effort ensures the 
efficient use of existing resources to meet the increasing 
demands for training in geriatrics and gerontology.

Chief Information Office

            Library and audiovisual communication
    The widespread education and training activities in 
geriatrics have generated a broad spectrum of requirements for 
information throughout the VA system. Local library services 
continue to perform hundreds of on-line searches on databases 
such as MEDLINE and other bibliographic databases, and continue 
to add books, journals, and audio visuals on topics related to 
geriatrics and aging.
    The Satellite Television network carried four live 
broadcasts targeted to healthcare providers who work with aged 
patients. The topics included elder abuse, PTSD in the older 
adult, geriatric oral surgery and Alzheimer's Disease.
    The AV Software Delivery Program partnered with the 
Employee Education Network to produce and distribute two 
programs on videocassette explaining the VA Patient Assessment 
Instrument and Alzheimer's Feeding Techniques. Both are 
available in VA Library Services.

                 III. Veterans Benefits Administration

                        compensation and pension

    Disability and survivor benefits such as pension, 
compensation, and dependency and indemnity compensation 
administered by the Veterans Benefits Administration (VBA) 
provide all, or part, of the income for 1,672,173 persons age 
65 or older. This total includes 1,225,426 veterans, 430,864 
surviving spouses, 14,152 mothers and 1,731 fathers.
    The Veterans' and Survivors' Pension Improvement Act of 
1978, effective January 1, 1979, provided for a restructured 
pension program. Under this program, eligible veterans receive 
a level of support meeting a national standard of need. 
Pensioners generally receive benefits equal to the difference 
between their annual income from other sources and the 
appropriate income standard. Yearly cost of living adjustments 
(COLAs) have kept the program current with economic needs.
    This Act provides for a higher income standard for veterans 
of World War I or the Mexican border period. This provision was 
in acknowledgment of the special needs of the Nation's oldest 
veterans. The current amount added to the basic pension rate is 
$1,867 as of December 1, 1995.

                    veterans services program staff

    VBA Regional Office personnel maintain an active liaison 
with local nursing homes, senior citizen homes, and senior 
citizen centers in an effort to ensure that older veterans and 
their dependents understand and have access to VA benefits and 
services.
    Generally, regional office staff visit these facilities as 
needed or when requested by the service providers. VA pamphlets 
and application forms are provided to the facility management 
and social work staff during visits and through frequent use of 
regular mailings. State and area agencies on aging have been 
identified and are provided information about VA benefits and 
services through visits, workshops and pre-arranged training 
sessions. Senior citizen seminars are conducted for nursing 
home operations staff and other service providers that assist 
and provide service to elderly patients. Regional office staff 
regularly participate in senior citizens fairs and information 
events, thereby visiting and participating in events where the 
audience is primarily elderly citizens. VBA staff also visit 
places where senior citizens congregate such as malls, 
churches, and special luncheons or breakfasts to advise 
veterans of their benefit entitlements. Regional office 
outreach coordinators continue to serve on local and state task 
forces and represent VA as members of special groups that deal 
extensively with the problems of the elderly.

                             
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