[Senate Report 107-158]
[From the U.S. Government Publishing Office]




107th Congress                   SENATE             Rept. 107-158
  2d Session                                             Volume 2
_______________________________________________________________________
 
                  DEVELOPMENTS IN AGING: 1999 AND 2000-VOLUME 2

                               ----------                              

                                A REPORT

                                 of the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                              pursuant to

                 S. RES. 54, SEC. 17(c), MARCH 8, 2001

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

 


                  June 4, 2002.--Ordered to be printed


             DEVELOPMENTS IN AGING: 1999 AND 2000--VOLUME 2
_______________________________________________________________________
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                       SPECIAL COMMITTEE ON AGING

                  JOHN B. BREAUX, Louisiana, Chairman
PHARRY REID, Nevada                  LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin                 CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont           RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin       RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon                    SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas         MIKE ENZI, Wyoming
EVAN BAYH, Indiana                   TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware           JOHN ENSIGN, Nevada
DEBBIE STABENOW, Michigan            CHUCK HAGEL, Nebraska
JEAN CARNAHAN, Missouri              GORDON SMITH, Oregon
                    Michelle Easton, Staff Director
               Lupe Wissel, Ranking Member Staff Director
  



                         LETTER OF TRANSMITTAL

                              ----------                              

                                       U.S. Senate,
                                 Special Committee on Aging
                                              Washington, DC, 2002.
Hon. Dick Cheney,
President, U.S. Senate,
Washington, DC.
    Dear Mr. President: Under authority of Senate Resolution 54 
agreed to March 8, 2001, I am submitting to you the annual 
report of the U.S. Senate Special Committee on Aging, 
Developments in Aging: 1999 and 2000, volume 2.
    Senate Resolution 4, the Committee Systems Reorganization 
Amendments of 1977, 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 1999 and 2000 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,
                                          John B. Breaux, Chairman.







                            C O N T E N T S

                              ----------                              
                                                                   Page
Letter of Transmittal............................................   III
    Item 1. Department of Agriculture............................     1
        Cooperative Extension System.............................     1
        Agricultural Research Service............................     2
        Economic Research Service................................     3
        Food and Nutrition Service...............................     4
        Center for Nutrition Policy and Promotion................     7
        Food Safety and Inspection Service.......................     7
        Marketing and Regulatory Programs........................     8
    Item 2. Department of Commerce...............................     9
    Item 3. Department of Defense................................    17
    Item 4. Department of Education..............................    20
    Item 5. Department of Energy.................................    54
    Item 6. Department of Health and Human Services..............    60
        Administration for Children and Families.................    60
        Administration on Aging..................................    67
        Office of the Assistant Secretary for Planning and 
          Evaluation.............................................    92
        Centers for Disease Control and Prevention...............   102
        Food and Drug Administration.............................   129
        Health Care Financing Administration.....................   154
        National Institutes of Health............................   220
        Health Resources and Services Administration.............   275
        Office of Inspector General..............................   290
    Item  7. Department of Housing and Urban Development.........   295
    Item  8. Department of the Interior..........................   307
    Item  9. Department of Justice...............................   318
    Item 10. Department of Labor.................................   330
    Item 11. Department of State.................................   345
    Item 12. Department of Transportation........................   347
    Item 13. Department of the Treasury..........................   359
    Item 14. Commission on Civil Rights..........................   377
    Item 15. Consumer Product Safety Commission..................   379
    Item 16. Corporation for National Service....................   385
    Item 17. Environmental Protection Agency.....................   399
    Item 18. Equal Employment Opportunity Commission.............   400
    Item 19. Federal Communications Commission...................   430
    Item 20. Federal Trade Commission............................   445
    Item 21. General Accounting Office...........................   530
    Item 22. Legal Services Corporation..........................   628
    Item 23. National Endowment for the Arts.....................   629
    Item 24. National Endowment for the Humanities...............   648
    Item 25. Pension Benefit Guaranty Corporation................   654
    Item 26. Postal Service......................................   691
    Item 27. Railroad Retirement Board...........................   698
    Item 28. Small Business Administration.......................   704
    Item 29. Social Security Administration......................   705
    Item 30. Veterans' Affairs...................................   710


107th Congress                                            Rept. 107-158
 2d Session                      SENATE                        Volume 2
======================================================================

                  DEVELOPMENTS IN AGING: 1999 AND 2000

                                 VOLUME 2

                                _______
                                

                  June 4, 2002.--Ordered to be printed

                                _______
                                

    Mr. Breaux, from the Special Committee on Aging, submitted the 
                               following

                              R E P O R T

              Report from Federal Departments and Agencies

                          ITEM 1--AGRICULTURE

                              ----------                              


  COOPERATIVE STATE RESEARCH, EDUCATION AND EXTENSION SERVICE (CSREES)

    Since early 1999, USDA's CSREES has been working with 
families with older Americans in small towns and rural areas to 
make improved health care decisions. One of the strategies 
focuses on how 4-H Youth Technology Teams can help other 
Americans to bridge the Digital Divide. The program is known as 
Teens Teaching Internet Skills (TTIS). In a partnership with 
the Health Care Finance Administration, 4-H Technology 
Leadership Teams are helping families with older Americans to 
learn how to use the internet to improve the quality of 
decisions they make in choosing health care, housing and 
transportation. As a result of collaboration between young 4H 
member volunteers and older Americans, seniors are increasingly 
accessing internet web sites such as www.medicare.gov, 
www.seniors.gov and www.workers.gov.
    In 1999, 4-H Youth Technology piloted Teens Teaching 
Seniors State Teams in Maryland, Virginia, Connecticut, 
Florida, Iowa and Washington to test approaches to help older 
adults to gain Internet skills. At the National Youth 
Technology Conference, held in July 2000 in College Park, 
Maryland, more than 250 youth leaders from 29 States met and 
learned from the six original teams, and, since then, twenty-
nine States have taken the initiative to develop State action 
plans and to identify state youth technology leadership

teams that, when provided with proper resources, will be able 
to implement efforts for their own TTIS program. Many of the 
individual State action plans call for the establishment of 
Community Technology Centers to serve as learning centers where 
youth can take the role of mentors to adults in helping them 
become technologically literate. Many States are planning 
public-private partnerships to establish technology learning 
places in their communities. Today, 4-H Youth Technology teams 
are converting the digital into digital opportunity across the 
generations. Communities are now seeking support to grow these 
efforts especially in under-served communities.
    CSREES provided key leadership in the framing of a new 
national extension initiative ``Financial Security in Later 
Life,'' which will be implemented in FY 2001. The purpose of 
the initiative is to focus new resources of the Land-grant 
University System on research, resident education, and 
extension/outreach programs related to an aging population. 
Particular attention will be paid to retirement planning 
especially the potential financial effects of long term care on 
family finances. A significant contribution of USDA-CSREES will 
be partnership building with other Federal agencies, the 
financial services sector, foundations, and non-profit 
organizations. Work already is underway on training for 
extension educators, research on retirement issues of farm 
families, and an interactive web site for consumers on long 
term care decisions. It is expected the initiative will span 5 
years.

                  AGRICULTURAL RESEARCH SERVICE (ARS)

    The Department of Agriculture Research Service (ARS) 
conducts research at the Jean Mayer Human Nutrition Research 
Center on Aging (HNRCA) in Boston, Massachusetts, on behalf of 
older Americans. Center scientists are determining the ways in 
which diet and nutritional status influence the onset and 
progression of aging, employing experimental animals, tissue 
cultures, and human subjects for such studies. They are 
exploring the ways in which diet, alone and in association with 
other factors, can delay or prevent the onset of degenerative 
conditions commonly associated with the aging process. This 
research will determine nutrient requirements during aging and 
the ways in which an optimal diet, in combination with 
exercise, genetic, physiological, psychological, sociological 
and environmental factors, may provide health and vigor over 
the life span of man.
    Scientists at the HNRCA are addressing three general 
questions of central importance to this mission:
           How does nutrition influence the progressive 
        loss of tissue functions with aging?
           What is the role of nutrition in the genesis 
        of major chronic degenerative conditions associated 
        with the aging process?
           What are the nutrient requirements necessary 
        to maintain the optimal functional well-being of older 
        people?
    ARS is strengthening its integrated multidisciplinary human 
nutrition research program to develop means for promoting 
optimum human health and well-being through improved nutrition. 
ARS research is also seeking to improve understanding of the 
functional roles dietary patterns play in human health 
maintenance. The goals of the ARS Human Nutrition Initiative 
are to:
           Reduce health care costs and enhance the 
        quality of life.
           Improve the scientific basis for more 
        effective Federal food assistance programs.
           Generate a more nutritious food supply.
           Improve the resistance to acute infections 
        and immune disorder.
           Enhance the capacity to promote changes in 
        diet habits.
           Individualize dietary guidance for 
        nutritionally vulnerable groups within the United 
        States.
    The ARS Human Nutrition Initiative Focuses on Five Vital 
Concerns:
           Food, Phytonutrients, and Health
           Health Body Weight
           Brain Function/Resistance to Mental Decline
           Bone Growth and Protection from Osteoporosis
           Foods to Fight Infectious Disease
    Recent accomplishments include findings that fortification 
or folate has reduced the prevalence of low circulating folate 
and high homocysteine concentrations. The implementation of the 
FDA-mandated folic acid fortification of enriched grain 
products was completed by early 1998. Researchers at HNRCA 
assessed the impact of fortifi-cation on the folate status of 
adult Americans. They have conducted a long-term follow-up of 
folate and homocysteine concentrations in the population-based 
Framingham Heart Studies. This work indicated that the current 
levels of fortification were able to reduce the prevalence of 
low circulating folate and high homocysteine concentrations to 
levels seen in multivitamin supplement users. This was the 
first demonstration of the effectiveness of this important 
national program.
    Researchers at HNRCA in collaboration with Framingham 
Osteoporosis Study researchers evaluated associations between 
dietary vitamin K intake, apoE genotype, bone mineral density 
and rate of hip fracture among elderly men and women 
participating in the original cohort of the Framingham Health 
Study. Low vitamin K intakes were significantly associated with 
increased incidence of hip fractures in men and women. In 
contrasts, neither low intakes of vitamin K nor apoE4 allele 
were associated with low bone mineral density.

                    ECONOMIC RESEARCH SERVICE (ERS)

    The Economic Research Service identifies research and 
policy issues relevant to the elderly population from the 
perspective of rural development. Ongoing research looks at 
demographic and socioeconomic characteristics of the older 
population by rural-urban residence. Current research examines 
rural-urban differences in health and access to health care for 
the elderly, based on data from the Current Population Survey 
and National Health Interview Survey. In the past year, we 
participated in the Interagency Forum on Aging-Related 
Statistics, reviewed proposals for the Office of Rural Health 
Policy's Rural Health Analytic Research Center Cooperative 
Agreement Program, and contributed to the Conference Report 
from the National Rural Health Research Agenda Setting 
Conference.
    The following publications on the rural elderly have been 
prepared by ERS staff in the past year:
    Rogers, Carolyn C., ``Growth of the Oldest Old Population 
and Future Implications for Rural America,'' Rural Development 
Perspectives, Vol. 14, No. 3, October 1999.
    Rogers, Carolyn C., ``Changes in the Older Population and 
Implications for Rural Areas, RDRR-90, December 1999 (released 
Feb. 2000).
    Rogers, Carolyn C., ``The Graying of Rural America,'' Forum 
for Applied Research and Public Policy, December 2000.

                    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 1999, $18 billion in food 
stamps were provided to a monthly average of 18 million 
persons.
    Households with elderly members accounted for approximately 
20 percent of the total food stamp caseload. However, sinced 
these households were smaller on average and had relatively 
higher net income, they received only 8 percent of all benefits 
issued.

Brief description of accomplishments

    The FSP has been at the forefront of efforts to reduce 
hunger and food insecurity among the elderly. The initiatives 
include:
           Development of a guide titled ``Help for the 
        Elderly and Disabled: A Primer for Enhancing the 
        Nutrition Safety Net for the Elderly and Disabled'' 
        that was distributed to appropriate agencies and 
        organizations. The purpose of this guide is to: 1) 
        assist State policy makers and others in understanding 
        the special rules embedded in the Food Stamp Act of 
        1977 (as amended) and the FSP regulations for elderly 
        and disabled individuals, 2) assist States and others 
        in identifying participation barriers the elderly and 
        disabled face when seeking nutrition assistance through 
        the FSP, and 3) assist States and others in identifying 
        possible outreach activities to increase participation 
        among the elderly and disabled.
           Development of easily reproducible posters 
        and fliers as part of a public information campaign to 
        increase awareness of the FSP among target audiences, 
        including the elderly.
           Announcing the availability of $3 million 
        dollars in research grants to be awarded in January 
        2001 to improve FSP access through partnerships and new 
        technology. The purpose of the grants is to explore 
        various strategies to reach potentially eligible 
        households and to educate food stamp eligible persons 
        not currently participating in FSP about the benefits 
        of the Program and how to apply for these benefits. One 
        of the target populations for these grants is the 
        elderly.
    The Food and Nutrition Service (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. An independent 
evaluation of SCCAP was completed in January 2000 and showed 
that the rate of food stamp participation among SSI recipients 
in South Carolina increased from 38 percent in 1994 to 50 
percent in 1998 while the national rate decreased from 42 
percent to 38 percent during the same period. Net potential 
savings at the South Carolina Department of Social Services are 
estimated at $575,000 per year. Based on the success of the 
project, FNS agreed to extend SCCAP for a maximum of three 
additional years (through September 2000). During this time, 
Congress will have a chance to review the findings of the 
evaluation and determine whether the results warrant amending 
the Food Stamp Act so that South Carolina may continue to use 
the special provisions of SCCAP as part of its normal FSP 
operations.

               Commodity Supplemental Food Program (CSFP)


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

    The Commodity Supplemental Food Program provides 
supplemental foods, in the form of commodities, and nutrition 
education to infants and children up to age 6, pregnant, 
postpartum or breastfeeding 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, 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 1999, 
approximately $45 million was spent on the elderly component.

Brief description of accomplishments

    About 65 percent of total program spending provides 
supplemental food to approximately 270,000 elderly participants 
a month. Older Americans are served by 23 eligible State 
agencies.

        Food Distribution Program on Indian Reservations (FDPIR)


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

    The Food Distribution Program on Indian Reservations 
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.
    Approximately $27 million of total costs went to households 
with a lease one elderly person. (This figure was estimated 
using a 1990 study that found that approximately 39 percent of 
FDPIR households had at least one elderly individual).

Brief description of accomplishments

    This program serves approximately 15,000 households with 
elderly participants per month.

               Child and Adult Care Food Program (CACFP)


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

    The Child and Adult Care Food Program 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 
1999, $36 million was spent on the adult day care component.

Brief description of accomplishments

    The adult day care component of CACFP served approximately 
32 million meals and supplements to over 62,000 participants a 
day in fiscal year 1999.
    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 day 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 of 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.

             The Emergency Food Assistance Program (TEFAP)


Title and purpose 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.
    Approximately $17 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.

                Nutrition Program for the Elderly (NPE)


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

    The Nutrition Program for the Elderly 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 $141 million worth of cash and commodities.

Brief description of accomplishments

    In fiscal year 1999, over 247 million meals were reimbursed 
at a cost of almost $150 million. On a average day 
approximately 932,000 meals were provided.

            CENTER FOR NUTRITION POLICY AND PROMOTION (CNPP)

    On September 28, 2000, CNPP hosted a symposium titled 
``Nutrition and Aging: Leading a Healthy, Active Life.'' This 
is the fifth in a series of symposiums hosted by CNPP that has 
included topics such as Childhood Obesity, Breakfast and 
Learning in Children, and Dietary Behavior. The purpose of the 
symposiums is to provide participants with the latest available 
scientific information, to increase the awareness of important 
nutritional issues, and to examine how these issues influence 
nutrition policy.
    The following publication on the elderly have been prepared 
by CNPP staff in calendar years 1999-2000:
    Sahyoun, Nadine and Basiotis, P. Peter, ``Food 
Insufficiency and the Nutritional Status of the Elderly 
Population,'' Nutrition Insights, Insight #18, May 2000.
    Gaston, Nancy W., Mardis, Anne, Gerrior, Shirley, Sahyoun, 
Nadine, and Anand, Rajen S, ``A Focus on Nutrition for the 
Elderly: It's Time to Take a Closer Look,'' `Nutrition 
Insights, Insight #14, July 1999.

                 FOOD SAFETY INSPECTION SERVICES (FSIS)


                   New Education Program for Seniors:

    With input from experts on aging, the Food Safety and 
Inspection Service has worked cooperatively with the Food and 
Drug Administration to produce a new educational program for 
seniors: a 14 minute video and accompanying publication both 
titled To Your Health, Food for Seniors.
    In developing this educational program, FSIS staff drew on 
the expertise of varied groups including the Administration on 
Aging, the National Institutes of Health, AARP and the State 
Units on Aging. As a result of those consultations, the program 
materials are targeted to address unique behaviors that can 
contribute to the risks of foodborne illness for seniors. They 
are also presented in formats designed to be ``senior 
friendly.'' The 17-page publication is printed in 14 point type 
to make reading easier to older eyes. The publication is 
presented in a large format--8\1/2\ by 11 inches--to make it 
easy to hold and use. The video presents information in a clear 
and concise manner with key points highlighted and repeated for 
emphasis. The video is broken into two segments, one addressing 
safe food handling at home and the other, food safety when 
eating out.
    The key food safety messages in the campaign--clean, 
separate, cook and chill--are drawn from the national food 
safety education campaign called Fight BAC! 
Support of these four key food safety messages is a goal of 
Healthy People 2010 and the new Dietary Guidelines for 
Americans.
    The educational program will be distributed early in 2001 
and will include distribution to the Administration on Aging's 
area offices and direct mail to more than 10,000 senior 
centers. The publication will also be available through the 
Consumer Information Center in Pueblo, CO. In all, more than a 
half a million copies of the publication and nearly 50,000 
copies of the video will be distributed.

                On-going Food Safety Advice for Seniors:

    To help communicate the importance of safe food handling 
for seniors--and their special risks--all press releases issued 
by FSIS include a box with safe food handling advice for at-
risk audiences. This advice is also routinely featured in video 
news releases as well as feature stories. The Food Safety 
Education staff also develops special features and fact sheets 
designed to help educate seniors about safe food handling--
available through the FSIS web site: http://www.fsis.usda.gov/
oa/pubs/consumerpubs.htm

                   MARKETING AND REGULATORY PROGRAMS

    The Agricultural Marketing Service facilitates the 
accessibility of agricultural products to older Americans by 
promoting and developing wholesale, collection, farmers, and 
direct markets. The support provided for these markets has made 
fresh, nutritious foods available in communities where older 
Americans have previously not had access to such products. The 
number of farmers markets has increased from 1,755 in 1994 to 
over 2,800 in 2000.

                     ITEM 2--DEPARTMENT OF COMMERCE

                              ----------                              


     UPDATES TO THE DEVELOPMENTS IN AGING REPORT FOR 1999 AND 2000

    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, in the 
United States and abroad. All of the items included in this 
report were released by the U.S. Census Bureau during calendar 
years 1999 and 2000.
    The items listed are available to the public in a variety 
of formats including print, electronic data bases, 
microcomputer diskettes, and CD-ROM. Many of these products can 
be found on the Internet at the Census Bureau's Web site at: 
.
    1. Population, Housing, and International Reports.--Three 
of the Census Bureau's major report series (Current Population 
Reports, Current Housing Reports, and 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 socioeconomic 
characteristics, such as income, health insurance coverage, 
need for assistance with activities of daily living, and 
housing situation. Data on the elderly around the world also 
are found in these 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, agencies of the United Nations, and the 
Organization for Economic Cooperation and Development.
    Additionally, the Census Bureau's population projection 
program and Special Studies Report series contain 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 after each decennial census. Included in these 
materials are information and data on the numbers and 
characteristics of persons 65 years of age and older.
    3. Data Base on Aging/National Institute on Aging 
Products.--The data provide a summary of analytical studies and 
other ongoing international aging products. Reports are based 
on compilations of data obtained from statistical offices of 
individual countries, various international organizations, and 
estimates and projections prepared at the Census Bureau. This 
work is funded by the National Institute on Aging.
    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.--In addition to the major products 
listed separately, we include a list of other data products 
that contain demographic and socioeconomic information on the 
elderly population.

           1. POPULATION, HOUSING, AND INTERNATIONAL REPORTS


                               Population

                                                           Report Number
Series P-20 (Population Characteristics):
    Regularly recurring reports in this series contain data from 
      the Current Population Survey. Topics include 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 and older.
    School Enrollment--Social and Economic Characteristics of 
      Students: October 1997......................................   516
    The Foreign-Born Population in the United States: March 1999..   519
    Geographical Mobility 1997 to 1998............................   520
    School Enrollment--Social and Economic Characteristics of 
      Students: (Update) October 1998.............................   521
    Computer Use in the United States: October 1997...............   522
    Voting and Registration in the Election of November 1998...... 523RV
    The Hispanic Population in the United States: March 1998......   525
    Fertility of American Women: June 1998........................   526
    The Hispanic Population in the United States: March 1999......   527
    Educational Attainment in the United States: March 1999.......   528
    The Asian and Pacific Islander Population in the United 
      States: March 1999..........................................   529
    The Black Population in the United States: March 1999.........   530
    Geographical Mobility (Update): March 1998 to March 1999......   531
    The Older Population in the United States: March 1999.........   532
Series P-23 (Special Studies):
    Information pertaining to methods, concepts, or specialized 
      data is furnished in these publications. Reports in this 
      series contain data on mobility rates, home ownership rates, 
      and the Hispanic population for both the general and older 
      populations.
    Profile of the Foreign--Born Population in the United States..   195
    Trends in Premarital Childbearing.............................   197
    Coresident Grandparents and Grandchildren.....................   198
    Centenarians in the United States............................. 199RV
    Geographical Mobility: 1990-1995..............................   200
    Poverty Among Working Families: Findings From Experimental 
      Poverty Measures 1998.......................................   203
Series P-25 (Population Estimates and Projections):
    Population estimates data include monthly estimates of the 
      total U.S. population; annual midyear estimates of the U.S. 
      population by age, sex, race, Hispanic origin (nativity was 
      added for the 1998 series of estimates); States by age and 
      sex; and population totals for counties, metropolitan areas, 
      and approximately 36,000 cities and other local governments. 
      The estimates for counties appeared in Series P-26 during 
      the 1970s and 1980, as did estimates for the approximately 
      36,000 local governments during the 1980s. Estimates for 
      Puerto Rico and the outlying areas were published in Series 
      P-25 through the 1980s. Estimates of the population for 
      Puerto Rico, outlying areas, and United States and state 
      housing unit estimates are available in the P-25 series and 
      more recently in press releases mentioned in this 
      publication. At present, most estimates formerly published 
      in the P-25 series are released only through the Internet, 
      with future plans to archive annual estimates data on CD-
      ROM.
    Projections of the United States and state populations are 
      also included in the P-25 series. Beginning in the 1980's, 
      projections are available not only by age and sex, but also 
      by race and Hispanic origin. There also can be occasional 
      research/developmental reports in this series. The Census 
      Bureau's plan for releasing projections include CD-ROM and 
      the Internet.
    Population Trends in Metropolitan Areas and Central Cities....  1133

     Population Estimates available on the Census Bureau's Web site

National Population Estimates:
    Annual Population Estimates--Median and Mean Age; 5-year Age 
      Groups; Sex; and Special Age Categories for Selected Years 
      from 1990 to 2000. July 1 dates, plus the most recent month 
      for which data are available.
    Annual Population Estimates by Age, Sex, Race and Hispanic 
      Origin; Median Age; Sex; Race (White; Black; American 
      Indian, Eskimo, and Aleut; and Asian and Pacific Islander); 
      Hispanic (of any race) and Non-Hispanic by Race for Selected 
      Years 1990 to 2000. July 1 dates, plus the most recent month 
      for which data is available.
    Population by Nativity--National Population Estimates by 
      Nativity from 1990-1999 (Includes age).
State Population Estimates (Includes: U.S. Regions, Divisions, and 
  States):
    1990 to 1999 Annual Time Series of State Population Estimates 
      by Age and Sex; By 5-Year Age Groups and Sex, Selected Age 
      Groups and Sec, and Single Year of Age and Sex, Median Ages: 
      1990 and 1999.
    1990 to 1999 Annual Time Series of State Population Estimates 
      by Race and Hispanic Origin: By Age, Sex, Race, and Hispanic 
      Origin.
County Population Estimates:
    1990 to 1999 Annual Time Series of County Population Estimates 
      by Age, Sex, Race and Hispanic Origin: By Age, Sex, Race, 
      Hispanic Origin, and Selected Age Groups.
Household and Housing Unit Population Estimates:
    Housing Units, Households, Households by Age of Householder, 
      and Persons per Household for States: 1998 Estimates, 1990 
      Census, 1990 to 1998 Percent Change, 1990 to 1998 Numeric 
      and Percent Change, 1998 Percent Distribution of Households 
      by Age of Householder, 1990 to 1998 Annual Time Series.

                         Population Projections

National Population Projections:
    The Population Projections Program produces projections of the 
      United States resident population by age, sex, race, 
      Hispanic origin, and nativity. The projections are based on 
      assumptions about future births, deaths, and international 
      migration. Although alternative series are produced, the 
      preferred, or middle series, is most commonly used. The 
      Census Bureau releases new national population projections 
      periodically.
Press Releases Available on Population Projections:
    (NP-T3) Projections of the Total Resident Population by 5-Year 
      Age Groups and Sex with Special Age categories: Middle 
      Series, 1999 to 2100.
    (NP-T4) Projections of the Total Resident Population by 5-Year 
      Age Groups, Race, and Hispanic Origin with Special Age 
      categories: Middle Series, 1999 to 2100.
    (NP-D1-A) Annual Projections of the Resident Population by 
      Age, Sex, Race, and Hispanic Origin: Lowest, Middle, 
      Highest, and Zero International Migration Series, 1999 to 
      2100.
    (NP-D1-B) Quarterly Projections of the Resident Population by 
      Age, Sex, Race, and Hispanic Origin: Middle Series, January 
      1, 1999 to January 1, 2101.
    (NP-D2) Projections of the Foreign-Born Population by Age, 
      Sex, Race, and Hispanic Origin: Lowest, Middle, Highest 
      Series, 1999 to 2100.
    (NP-D5) Components of Change: Component Assumptions of the 
      Resident Population by Age, Sex, Race, and Hispanic Origin: 
      Lowest, Middle, Highest Series, 1999 to 2100.
    Population Pyramids: Total Population by 5-Year Age Groups: 
      1990, 2000, 2025, 2050, 2100.
Series PPL (Population Paper Listings):
    This series of reports contains estimates of population and 
      projections of the population by age, sex, and origin. Other 
      topics appear as well some of which address issues related 
      to aging.
    The Asian and Pacific Islander Population in the United 
      States: March 1998 (Update).................................   113
    Computer Use in the United States: October 1997...............   114
    Profiles of the Foreign-Born Population in the United States: 
      1997........................................................   115
    Fertility of American Women: June 1998........................   116
    The Foreign-Born Population in the United States: March 1998..   117
    Geographical Mobility: March 1997 to March 1998...............   118
    School Enrollment--Social and Economic Characteristic of 
      Students: October 1998 (Update).............................   119
    Voting and Registration in the Election of November 1998......   120
    Foreign-Born Population in the United States: March 1999......   123
    The Hispanic Population in the United States: March 1999......   124
    Educational Attainment in the United States: March 1999.......   125
    Foreign-Born People in the United States: March 1995..........   127
    Foreign-Born People in the United States: March 1996..........   128
    Foreign-Born People in the United States: March 1997..........   129
    The Black Population in the United States: March 1999 (Update)   130
    The Asian and Pacific Islander Population in the United 
      States: March 1999 (Update).................................   131
    Geographical Mobility: March 1998 to March 1999...............   132
    The Older Population in the United States: March 1999.........   133
    Geographical Mobility: 1990-1995..............................   137
    Who is Minding the Kids? Child Care Arrangements Fall 1995....   138
Technical Working Papers Series:
    This series contains papers of a technical nature on various 
      topics, which have been written by staff of the Population 
      Division of the Census Bureau. 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.
    ``Are There Differences in Voting Behavior Between Naturalized 
      and Native-born Americans?'' by Loretta E. Bass and Lynn M. 
      Casper, Issued 1999.........................................    28
    ``Historical Census Statistics on the Foreign-born Population 
      of the United States: 1850-1990 by Campbell J. Gibson, 
      Issued February 1999........................................    29
    Women's Labor Force Attachment Patterns and Maternity Leave: A 
      Review of the Literature by Kristen E. Smith and Amara 
      Bachu, Issues January 1999..................................    32
    Evaluation of Relationship, Marital Status, and Grandparents 
      Items on the Census 2000 Dress Rehearsal by Charles Clark 
      and Jason Fields, Issued April 1999.........................    33
    Unbinding the Ties: Edit Effects of Marital Status on Same 
      Gender Couples by Jason Fields and Charles Clark, Issued 
      April 1999..................................................    34
    Racial-Ethnic and Gender Differences in Returns to 
      Cohabitation and Marriage: Evidence from the Current 
      Population Survey by Philip N. Cohen, Issued May 1999.......    35
    How Does POSSLQ Measure Up? Historical Estimates of 
      Cohanitation  by Lynne M. Casper, Philip N. Cohen, and Tavia 
      Simmons, Issued May 1999....................................    36
    Is Childlessness Among American Women on the Rise? by Amara 
      Bachu, Issued May 1999......................................    37
    Population Projections of the United States, 1999 to 2100: 
      Methodology and Assumptions by Frederick Hollmann, Tammany 
      Mulder, and Jeffrey Kallan, Issued January 2000.............    38
    What Do We Know About the Undercount of Children? by Kristin 
      K. West and J. Gregory Robinson, Issued August 1999.........    39
    Measures of Help Available to Households in Need: Their 
      Relation to Well-being, Welfare, and Work by Kurt J. Bauman 
      and Barbara Downs, Issued May 2000..........................    42
    Have We Reached the Top? Educational Attainment Projections of 
      the U.S. Population by Jennifer Cheeseman Day and Kurt J. 
      Bauman, Issued May 2000.....................................    43
    The Effects of Work and Welfare on Living Conditions in Single 
      Parent Households, by Kurt J. Barman, Issued August 2000....    46
Series SB/CENBR (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.
    Women in the United State: A Profile..........................  00-1
    Coming to America: A Profile of the Nation's Foreign-Born.....  00-2
    From the Mideast to the Pacific: A Profile of the Nation's 
      Asian Foreign-Born Population...............................  00-4
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.
    Child Support for the Custodial Mothers and Fathers: 1995.....   196
    The Changing Shape of the Nation's Income Distribution: 1947-
      1998........................................................   204
    Experimental Poverty Measures.................................   205
    Money Income in the United States: 1998.......................   206
    Poverty in the United States: 1998............................   207
    Health Insurance Coverage: 1998...............................   208
    Money Income in the United States: 1999.......................   209
    Poverty in the United States: 1999............................   210
    Health Insurance Coverage: 1999...............................   211
    Child Support for the Custodial Mothers and Fathers: 1997.....   212
Series P-70 (Household Economic Studies):
    These data are from the Survey of Income and Program 
      Participation (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 and older.
    Financing the Future: Postsecondary Students, Cost, and 
      Financial Aid...............................................    60
    Extended Measures of Well-Being: Meeting Basic Needs..........    67
    Dynamics of Economic Well-Being: Program Participation, Who 
      Gets Assistance?............................................    69

                                 Housing

These data are from the American Housing Survey. The survey 
    presents data on apartments; single-family homes; mobile 
    homes; vacant housing units; age, sex, and race of 
    householders; housing and neighborhood quality; housing 
    costs; equipment and fuels; and size of housing units. 
    Reports are present data on homeowner's repairs and 
    mortgages, rent control, rent subsidies, previous units of 
    recent movers, and reasons for moving. A wall chart 
    accompanies each report.
Series H-170 (Housing Characteristics for Selected Metropolitan 
  Areas):
    A separate report present data for individual metropolitan 
      areas for the same characteristics shown in Series H-150. 
      Eleven to 13 metropolitan areas are interviewed each year. 
      They are surveyed on a rotating basis, with a total of 48 
      metropolitan areas being surveyed within a 6-year period.

                         2. DECENNIAL PRODUCTS

    Centenarians in the United States: 1990, Connie Krach and 
Victoria A. Velkoff, Current Population Reports, Series P-23-
199, Washington, DC 1999.
    State Chartbook on Aging, forthcoming. This report presents 
state-level data for the population aged 65 and older for 
several key indicators; population, race and ethnic group, 
marital status, living arrangements, and poverty. Most of the 
data are from the 1990 Census of Population and Housing for the 
United States.

       3. DATA BASE ON AGING/NATIONAL INSTITUTE ON AGING PRODUCTS

    The following reports, articles, and book chapters are 
based on information contained in the International DataBase on 
Aging and other related holdings of the International Programs 
Center, Population Division, Census Bureau. This work is 
carried out with the support of the National Institute on Aging 
and is intended to highlight the present and future worldwide 
dimensions of aging and portray the diversity among nations.
    ``Gender Stereotypes: Data Needs for Aging Research.'' 
Victoria A. Velkoff and Kevin Kinsella. International Aging, 
Spring 1998, Vol. 24, No. 4, pp. 18-38.
    ``Russia's Aging Population'' Victoria A. Velkoff and Kevin 
Kinsella. In Russia's Torn Safety Nets, Mark G. Field and 
Judyth L. Twigg, eds. St. Martin's Press, New York, 2000.

                            Work in Progress

    An Aging World 2000, forthcoming. This report gives a 
cross-national comparison of aging in 52 study countries. It 
focuses on both the demographic aspect of aging in these 
countries and the socioeconomic impact of aging. The report 
highlight projected trends into the 21st century for the 
world's older population.
    Aging in Africa, forthcoming. This report examines the 
demographic and socioeconomic characteristics of the older 
population in Sub-Saharan Africa and will highlight the impact 
of HIV/AIDS on the older populations in these countries.
    World Population Profile: 2000, forthcoming. This report 
provides comprehensive demographic data for all countries and 
regions of the world. There are two special focus sections in 
the report, ``Child Mortality in the Developing World'' and 
``Focus of the AIDS Pandemic in the 21st Century.''

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

    The Census Bureau is one of the convening agencies in the 
Federal Interagency Forum on Aging-Related Statistics. The 
Forum, begun in the mid-1980s, was the first-of-its-kind effort 
to coordinate data and efforts of different government 
agencies. The Forum currently is being managed by staff of the 
National Center for Health Statistics, with the support of the 
National Institute on Aging.
    The Forum encourages cooperation among federal agencies in 
the development, collection, analysis, and dissemination of 
data pertaining to the older population. Through coordinated 
approaches, the Forum extends the use of limited resources 
among agencies through joint problem-solving, identification of 
data gaps, and improvement of statistical information bases on 
the older population, which are used to set project priorities 
of individual agencies.
    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, in 1999, the Census Bureau published a 
report entitled DataBase News in Aging, which includes 
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 report, which is produced in 
hard copy and is available on the Census Bureau's Internet 
site.
    In 2000 the Forum produced the report, Older Americans 
2000: Key Indicators of Well-Being. This report described the 
overall status of the U.S. population 65 and over. It compiled 
data to focus on several important areas in the lives of older 
people--including economic status, health status, health risks 
and behaviors, and health care.

                           5. OTHER PRODUCTS

    Profile on Racial and Ethnic Diversity Among Older 
Americans, forthcoming. This report focuses on racial and 
ethnic differences in America's older population using data 
from the Current Population Survey (CPS).

                        American Housing Survey

    Computer data tapes and CD-ROM are available for the 1997 
survey efforts. The survey is designed to provide information 
on the housing situation in the United States. Information is 
available by age.

           CPS and Survey of Income and Program Participation

    Data for both surveys are available in electronic media.

Statistical Abstract of the United States: 1999

    As the National Data Book, these annually released products 
contain an enormous collection of statistics on social and 
economic conditions in the United States. Selected 
international data also are included. The abstract appears in 
both print and CD-ROM versions.

International DataBase

    The International Data Base (IDB) is a computerized data 
bank containing statistical tables of demographic and 
socioeconomic data for all countries of the world. Most 
demographic information comes from country-specific estimates 
and projections made by the Census Bureau's International 
Programs Center. Country-specific data on social and economic 
characteristics are obtained from censuses and surveys or from 
administrative records. Country files are regularly updated as 
new information becomes available. Selected information from 
the IDB is highlighted in the Census Bureau's various 
international reports and publications mentioned previously.

                     ITEM 3--DEPARTMENT OF DEFENSE

                              ----------                              


                           Eldercare Support

    Military members and their families face unique challenges 
when facing Eldercare issues. Military members and families are 
often stationed far away from elderly relatives who may need 
their assistance. These demands seem to be increasing as life 
expectancies increase. Military families often find themselves 
trying to deal long-distance, even from overseas, with finding 
quality, affordable care for elderly family members. The 
situation is often further complicated by military family 
separations that are the norm of military life.
    In the 1999 Department of Defense Survey of active duty 
members, of those responding to the survey, we estimate that 
4.1 percent of the force has caregiver responsibilities for 
elderly loved ones. Of the 4.1 percent, 72 percent of those 
indicated that they have responsibility for one elder person, 
23.5 percent indicated responsibility for 2 elderly persons, 
and 4.5 percent indicated responsibilities for 3 or more.
    The Information and Referral (I&R) function of the 
Department of Defense Family Support programs is a critical 
source of information to families struggling to balance the 
demands of military life with the need to ensure the well-being 
and safety of elderly parents and loved-ones. Internet 
resources have proved to be a valuable tool for family support 
specialists who can research information and help military 
families start on the right path in sifting through this 
mountain of information. The I&R specialists often use the 
Eldercare Locator which directs them to appropriate local 
resources. The I&R specialists will filter a quantity of 
information in order to assist the inquiring service member 
with the appropriate resource and advice. While the assistance 
family support I&R specialists can provide is limited, they 
make every effort to connect military families with the best 
and most reliable resources for making informed choices.
    The I&R specialists often receive inquiries about making an 
elderly loved one a legal dependent of the service member. The 
specialists will caution the member to carefully consider this 
option since the elderly loved one may lose state benefits if 
they relocate with the service member. In addition, if they 
become a legal dependent of the military person, they are not 
eligible for TRICARE.
    The Family Centers also have a number of useful pamphlets 
and handouts on eldercare which 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 which draw thousands of military retirees and their 
families. For these seminars, staff bring in experts to present 
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.

                              Health Care

    TRICARE is the health plan for uniformed services 
beneficiaries. It is a regionally organized managed care 
program that integrates the military health facilities of the 
Army, Navy and Air Force and supplements the care these 
facilities offer with civilian networks of providers. TRICARE 
offers three choices for health care delivery: TRICARE Prime, 
TRICARE Extra, and TRICARE Standard. TRICARE Prime, a voluntary 
enrollment option, offers patients the advantage of primary 
care management, assistance in making specialty appointments, 
and additional preventive and primary care services. For 
eligible beneficiaries, TRICARE Prime generally is the least 
expensive option.
    TRICARE Extra allows eligible beneficiaries to receive an 
out-of-pocket discount when using preferred network providers. 
Eligible beneficiaries who do not enroll in TRICARE Prime may 
participate in Extra on a case-by-case basis just by using 
network providers. Beneficiaries selecting TRICARE Extra do 
incur deductibles and co-payments. TRICARE Standard offers 
comprehensive healthcare coverage from any authorized provider. 
Beneficiaries selecting this option incur deductibles and co-
payments at a slightly higher rate than those selecting TRICARE 
Extra.
    All active duty members enroll in TRICARE Prime without 
cost to the member. Family members, survivors and retirees 
under the age of 65 may enroll in TRICARE Prime. Retirees and 
their family members pay a small enrollment fee and all 
eligible beneficiaries except active duty members incur nominal 
co-payments for care received from network providers. Care 
received in military medical facilities is without cost to 
beneficiaries; for those not enrolled in TRICARE Prime, care in 
military medical facilities is received on a space available 
basis.
    During this reporting period, the law stipulated that 
military retirees and their families up to age 65 are eligible 
for the three TRICARE options. Military retirees and their 
dependents over the age of 65 may not participate in TRICARE, 
but they are eligible for care in military medical facilities 
on a space available basis. Included in this space available 
coverage are prescription drugs provided the needed medications 
are on the facility's formulary. Additionally, the Department 
of Defense sought ways to enhance its services to its over-65 
beneficiaries through a number of demonstration programs. 
Specifically, the Department tested alternatives to expand 
healthcare coverage to Medicare-eligible beneficiaries through 
Medicare reimbursement of military medical facilities, opening 
access to the Federal Employee Health Benefit Program, 
expanding pharmacy options, and offering supplemental coverage 
to Medicare.
    Implemention of the Floyd D. Spence National Defense 
Authorization Act of fiscal year 01 will directly impact these 
demonstration programs and significantly change the healthcare 
coverage offered by the Department of Defense to its Medicare 
eligible beneficiaries. This new legislation is the most 
dramatic modification to military health care coverage since 
the establishment of the Civilian Health and Medical Program of 
the Uniformed Services in 1965. By April 2001, the Department 
of Defense will offer these senior beneficiaries the same 
prescription drug benefit enjoyed by other uniformed services 
beneficiaries. They will continue to use the military 
pharmacies with no cost for medications; and on April 1, 2001, 
they will be entitled to use the mail order pharmacy program, 
network retail and non-network retail pharmacies. Medications 
through these sources will require a nominal copayment of $3 
for generic and $9 for branded medications; by mail order 
patients may receive up to a 90-day supply for this amount, and 
in the network retail pharmacies they may receive up to a 30-
day supply for this amount. The non-network retail pharmacies 
will cost a bit more. Also in the next year, senior 
beneficiaries will become eligible for TRICARE for Life 
benefits, the most significant of which is the secondary pay 
program. Beginning October 1, 2001, TRICARE will supplement 
Medicare benefits of these uniformed services beneficiaries, 
and, in most cases, with no additional claims processing 
required by the patient. To participate, these beneficiaries 
must be eligible for Medicare Part A and enrolled in Medicare 
Part B. They may continue to seek care from their Medicare 
providers and have TRICARE pick up the cost of their 
deductible, co-payments and other costs not paid by Medicare. 
TRICARE will also cover any TRICARE benefit that Medicare does 
not offer. Out-of-pocket expenses for these dual eligible 
beneficiaries will be a nominal co-payment for medications and 
Medicare Part B fees. This legislation brings to the senior 
military retirees and their dependents a health benefit that is 
unparalleled. It provides low-cost access to an extraordinary 
range of healthcare benefits, and offers choice in selection of 
providers. This legislation brings healthcare coverage by the 
Department of Defense as an entitlement to our senior 
beneficiaries.



                      ITEM 5--DEPARTMENT OF ENERGY

                              ----------                              


                              Introduction

    The Department of Energy (DOE) is a leading science and 
technology agency whose research supports our nation's energy 
security, national security, and environmental quality and 
contributes to a better quality of life for all Americans. DOE 
owns and manages more than 50 major installations located in 35 
states, employing approximately 10,000 federal workers and 
100,000 contract workers.
    Science is at the center of DOE's work, performed in its 27 
laboratories and other scientific user facilities and in the 
nation's universities. DOE supports breakthrough research in 
energy sciencesand technology, high energy physics, global 
climate change, genome mapping and the bio-sciences, 
superconducting materials, accelerator technologies, 
environmental sciences, and super-computing. DOE also supports 
science and mathematics education from the K-12 level through 
post-doctoral work.
    In support of the nation's energy security, DOE promotes 
development of clean, secure, sustainable energy resources, 
works to increase the diversity of energy supplies and fuel 
choices, and maintains the Strategic Petroleum Reserve.
    In fulfilling its national security mission, DOE assures 
the safety and reliability of the U.S. nuclear weapons 
stockpile without underground testing and supports U.S. non-
proliferation, arms control, and nuclear safety objectives 
world-wide.
    In meeting its environmental quality mission, DOE is 
responsible for cleaning up the environmental legacy left at 
sites where, for some 50 years, the nation's nuclear weapons 
were designed and manufactured.

                       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, 
2000 about 4.9 million homes had been weatherized with federal, 
state, and utility funds; of these, an estimated 2.0 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. At 
current prices, a weatherized low-income household now saves 
approximately $250 per year, about one-third of its space 
heating costs. Program benefits are further described in the 
Progress Report of the National Weatherization Assistance 
Program, available through the National Technical Information 
Service, 703/487-4650, 5285 Port Royal Road, Springfield, VA 
22161.
    States implement the program through community-based 
organizations. DOE and its state and community partners 
weatherize approximately 70,000 single- and multi-family 
dwellings each year. The program awarded $133 million in Fiscal 
Year 1999 and $135 million in Fiscal Year 2000 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 
Fiscal Year 1999, $32 million wasappropriated for the program 
and in Fiscal Year 2000, $33 million. 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.
    Some projects target the elderly specifically, such as 
Louisiana's low-income/handicapped/elderly/Native American 
outreach program which provides energy related assistance 
through a joint venture with utilities. The elderly also 
benefit from broader programs that provide energy audits, 
hands-on energy conservation workshops, and low-interest loans 
for homeowners. These can result in significant personal energy 
savings. Energy efficiency improvements in local and state 
buildings and services also indirectly benefit the elderly by 
freeing up state and local government tax revenues for non-
energy needs, as do energy efficient schools which place less 
of a burden on property taxes.

                Information Collection and Distribution

    The Energy Information Administration collects and 
publishes comprehensive data on energy consumption through the 
Residential Energy Consumption Survey (RECS). The RECS is 
conducted in households quadrennially and collects data from 
individual households throughout the country, including those 
headed by elderly individuals. Along with household and housing 
unit characteristics data, the RECS also collects the actual 
billing data from the households' fuel suppliers for a 12-month 
period.
    The results of the RECS are analyzed and published by the 
Energy Information Administration. The most recent survey data 
are from the 1997 RECS and are published on the Internet at 
http://www.eia.doe.gov/emeu/recs. The 1997 RECS public use data 
files are also available at this site. These files will include 
demographic characteristics of the elderly such as age, marital 
status and household income, as well as estimates of 
consumption and expenditures for electricity, natural gas, fuel 
oil, kerosene, and liquefied petroleum gas used in elderly 
households.
    In the 1997 RECS, 28.5 million, or 28 percent of all U.S. 
households, were headed by a person 60 years of age or older. 
Of these elderly households, 44 percent were one-member 
households (12.4 million people living alone) and 44 percent 
contained two people. In 19 percent of the two-member elderly 
households both members were under the age of 65; in 21 percent 
of these households, only one member was younger than 65; and 
in 60 percent, both members were over the age of 65. 
Comparisons of elderly versus non-elderly households reveal 
that:
           The 1997 household income of elderly 
        households was generally lower than that of non-elderly 
        households. Nearly a quarter, 23 percent, of elderly 
        households had incomes of less than $10,000, compared 
        to 9 percent of the non-elderly households. Only 12 
        percent of the elderly households had incomes of 
        $50,000 or more, compared to 34 percent of the non-
        elderly households. Of the 14.7 million U.S. households 
        whose income was below the poverty line, 37 percent 
        were headed by a person 60 years of age or older.
           Despite having lower household incomes, the 
        elderly households were more likely to own their 
        housing unit, 80 percent, than were non-elderly 
        households, 63 percent. The elderly were also more 
        likely to live in a single-family house, 76 percent, 
        than were non-elderly households, 71 percent.
           Elderly households are less likely to have a 
        personal computer or a modem connecting that computer 
        to the Internet or e-mail networks than are households 
        headed by persons less than 60 years of age. Among 
        elderly households, 14 percent have a personal computer 
        compared to 43 percent of the non-elderly households. 
        Only 7 percent of elderly households have a modem 
        connection compared to 26 percent of the non-elderly 
        households.
           Elderly households are only marginally less 
        likely to have a microwave oven, 79 percent, than are 
        non-elderly households, 85 percent.
    Analysis of the 1997 RECS data shows that consumption 
patterns differed between the elderly and non-elderly for some 
uses of energy. The elderly used more energy to heat their 
homes 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 in 1997 was $708. 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 58 percent of total energy consumption 
        and about 37 percent of total energy expenditures in 
        elderly households were for space heating. On the other 
        hand, appliances accounted for 23 percent of 
        consumption and 45 percent of total expenditures in 
        elderly households. Energy costs for appliances are 
        much higher relative to consumption than are energy 
        costs for space heating because virtually all 
        appliances are powered by electricity, the most 
        expensive energy source, whereas space heating is 
        largely provided by other, less expensive, energy 
        sources.

                       Research Related to Aging

    Through fiscal year (FY) 2000, the Office of Environment, 
Safety and Health (EH) sponsored research to further 
understanding of the human health effects of radiation. As part 
of this research program, DOE sponsored epidemiologic studies 
concerned with understanding health changes over time. Lifetime 
studies of humans constitute a significant part of EH's 
research; and 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, 
as well as some basic research on 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 non-
exposed 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 FY 2000.
    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 follow up 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 
contract 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.
    A recent study indicated that workers who were 
occupationally exposed to radiation for the first time at age 
45 or older might be more sensitive to health effects than 
workers who were exposed at younger ages. However, very few 
workers at DOE fit this profile. This finding is very 
preliminary and further research and analyses are being 
conducted to see if these results can be duplicated.
    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 1940's through 
the 1960's. The 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 like 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 Sciences Division within the Office of Biological and 
Environmental Research, Office of Science, carries out a 
Congressional mandate to develop beneficial applications of 
nuclear and other energy related technologies, including 
research on aging.
    The Aging Research involves study of a brain chemical, 
dopamine (DA), and its function in humans as they age. It has 
long been recognized that age brings a significant decline in 
the function of the brain DA system, 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 age-related 
losses in brain DA activity in cerebral function and to 
investigate mechanisms involved with the loss of DA function in 
normal aging. The results of these studies to date have shown 
that healthy volunteers with no evidence of neurological 
dysfunction do experience a decline in parameters of DA 
function, which are associated with a 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 the dopamine system in 
the elderly.

            ITEM 6--DEPARTMENT OF HEALTH AND HUMAN SERVICES

                              ----------                              


                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. In the 
welfare reform legislation, Section 103 of Title I of Public 
Law 104-193 gives states the authority to transfer up to 30 
percent of their Temporary Assistance to Needy Families (TANF) 
grant to SSBG and the Child Care Development Block Grant 
programs. The Balanced Budget Act of 1997 (Public Law 105-33) 
provided that the TANF transfer to SSBG would be up to 10 
percent of a State's TANF grant. The Transportation Equity Act 
of 1998 (Public Law 105-178) reduced the amount available for 
transfer from TANF to SSBG to 4.25 percent beginning in Fiscal 
Year 2001.
    Under the SSBG, Federal funds are available without a 
matching requirement. In fiscal year 2000, a total of $1.775 
billion was allotted to States. Of that amount, $425 million 
was delayed for funding until September 29, 2000. $1.909 
billion was appropriated for these activities in fiscal year 
1998. 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, 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 1998, the list below indicates 
the number of States providing certain types of services to the 
aged under the SSBG.

Services:                                           Number of States \1\
    Home-Based Services \2\.............................              36
    Adult Protective Services...........................              31
    Transportation Services.............................              19
    Adult Day Care......................................              25
    Health Related Services.............................              14
    Information and Referral............................              16
    Home Delivered......................................              17
    Congregate Meals....................................               9
    Adult Foster Care...................................              13
    Housing.............................................               9
---------------------------------------------------------------------------
\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. States also provide 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 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 a 
Department of Health and Human Services block grant program 
administered by the Office of Community Services (OCS) in the 
Administration for Children and Families (ACF).
    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 
Community Opportunities, Accountability, and Training and 
Educational Services Act of 1998, the NIH Revitalization Act of 
1993 (P.L. 103-43), and the Human Services Amendments of 1994 
(P.L. 103-252). In fiscal year 1999, all 50 states, the 
District of Columbia, five territories, and 130 tribes and 
tribal organizations received grants amounting to approximately 
$1.2775 billion, including $175 million in emergency 
contingency funds, and $2.2 million in re-allotted funds from 
FY 1998.
    In FY 2000, $1.1 billion is available. In addition, $300 
million in emergency contingency funds are available if the 
President decides to release some or all of the funds because 
of weather, supply shortages, or other energy emergencies. 
Federally-recognized and state-recognized Indian tribes, 
including Alaska native villages, may apply for direct LIHEAP 
funding. The amount to be reserved from a state's allotment for 
a direct grant to a tribe will be based on the ratio of 
eligible tribal households to total eligible households in the 
state, or a larger allotment amount agreed on by the tribe and 
state. Of the $1.1 billion appropriated for FY 2000, $27.5 
million is earmarked for leveraging incentive awards, to reward 
grantees that add non-Federal resources to help low income 
households meet their home heating and cooling needs. Up to 25 
percent of the leveraging incentive awards, or $6,875,000, will 
be used to fund grants to LIHEAP grantees under the Residential 
Energy Assistance Challenge Option Program (REACH) to develop 
innovative programs to reduce the energy vulnerability of 
LIHEAP-eligible households.
    LIHEAP 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.\3\ Most households in which one or more persons 
are receiving benefits from the Temporary Assistance to Needy 
Families (TANF) block grant, Supplemental Security Income, Food 
Stamps or need-tested veterans' benefits, may be regarded as 
categorically eligible for LIHEAP.
---------------------------------------------------------------------------
    \3\ 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 1998, about 34 percent of households 
receiving assistance with heating costs included at least one 
person age 60 or over, as estimated by the March 1998 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.
    The 1998 reauthorization retains legislation from the 1994 
reauthorization that specifically allows grantees to target 
funds to vulnerable populations, mentioning by name ``frail 
older individuals'' and ``individual with disabilities''. No 
new initiatives commenced in 1999 or 2000 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 (Title VI, Subtitle B, Public Law 97-35 as 
amended; and the Coats Human Services Reauthorization Act of 
1998 105-285) is authorized through fiscal year 2003. 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 1997 and 1998--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 1998 requires that states assure a portion of the grant 
funds will be used to support activities for elderly low-income 
individuals as part of their State Application and Plan 
submitted to OCS. Following the 1994 reauthorization, local 
community action agencies began to include a description of how 
linkages will be developed to fill identified gaps in services 
through information, referral, case management, and follow-up 
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 $491.9 million in fiscal year 1999. For fiscal year 2000, 
$521.5 million was appropriated. Of this amount, $3.3 million 
is available for federally and state-recognized tribes. A total 
of $8.4 million is available for training and technical 
assistance.

              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: 7/97-6/30/2002; FY '97--$82,680
    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: 7/97-6/30/2002; FY '97--$82,680
    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: 7/97-6/30/2002; FY '97--$82,680.
    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.

                  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: 7/97-6/30/2002; FY '97--$82,680.
    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.

         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: 7/92-6/30/1999; FY '97--$82,680
    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.

 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: 7/97-6/30/2002; FY '97--$82,680
    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 consumers 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. 1453, (809) 754-4377
    Project Period: 7/97-6/30/2002; FY '97-$82,680
    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.

                  CREATIVE CHOICES FOR HEALTHY LIVING

    Grantee: University-Affiliated Program Department of 
Pediatrics, Univ. of Arkansas for Medical Sciences.
    Project Director: Judith Holt, Ph.D ((501) 682-9900
    Project Period: 7-97-6/30/2002, FY '97--$82,680
    The UAP of Arkansas' Training Initiative Project, Creative 
Choices for Healthy Living, will focus on persons who are aging 
with developmental disabilities, their access to appropriate 
services and supports within the community. Specifically, it 
will enhance the health and well-being of older persons with 
developmental disabilities and other members of the aging 
community; enhance the skill and competencies of community 
trainers to provide the training identified by the community 
action plan; expand the project into new communities; develop 
and disseminate preserve training modules for undergraduate and 
graduate courses; disseminate project training modules for use 
in other settings state- and nation-wide; and evaluate the 
project's effects.

          MEETING THE NEEDS OF A CULTURALLY-DIVERSE POPULATION

    Grantee: Department of Pediatrics, Children's Hospital Los 
Angeles
    Project Director: Irma Castaneda, Ph.D (213) 669-2300-9900
    Project Period: 7/1/97-6/30/2002, FY '97--$82,680
    Develop and implement an interdisciplinary training program 
with a special emphasis on the multicultural aspects of aging 
and developmental disabilities which is integrated into 
Department's curriculum for a minimum of one primary or 
secondary consumer, and two graduate students per year. Will 
integrate material on multicultural aging and developmental 
disabilities into existing gerontology certificate programs. 
Provide training and consultation on the integration of content 
related to multicultural aging and developmental disabilities 
to four university departments. Provide training to a total of 
100 health care providers, community support personnel, and 
family members on the changing health and social needs of aging 
individuals with developmental disabilities from ethnic 
minority groups.

                        ADMINISTRATION ON AGING


                               Section I.


                           1. Reauthorization

    On November 13, 2000, President Clinton signed into law 
legislation (P.L. 106-501) to reauthorize the Older Americans 
Act. The amended Act, last reauthorized in 1992, will provide 
essential home and community-based services to millions of 
older Americans across the United States. In addition, for the 
first time ever, it will provide under the National Family 
Caregiver Support Program much needed support to families who 
are caring for their loved ones who are ill or who have 
disabilities.

              2. National Family Caregiver Support Program

    In 1999, President Clinton announced the Administration on 
Aging proposal to create the National Family Caregiver Support 
Program (NFCSP). The NFCSP is one of four LTC initiatives 
proposed in the FY 2000 Administration budget to help families 
sustain their efforts to care for an older relative who has 
serious chronic illness or disability. Under this Older 
Americans Act program, State Units or Offices on Aging, working 
in partnership with local Area Agencies on Aging, community 
service providers, and consumer organizations, will be expected 
to put in place at least five program components:
           Individualized information on available 
        resources to support caregivers;
           Assistance to families in locating services 
        from a variety of private and voluntary agencies;
           Caregiver counseling, training, and peer 
        support to help them better cope with the emotional and 
        physical stress of dealing with the disabling effects 
        of a family member's chronic condition;
           Respite care provided in the home, at an 
        adult day care center, or over a weekend in a nursing 
        home or residential setting such as an assisted living 
        facility; and
           Limited supplemental services to fill a 
        service gap that cannot be filled in any other manner.
    The NFSCP program was enacted as part of the Older 
Americans Act Amendments of 2000 (P.L. 106-501) signed into law 
on November 13, 2000. Full start-up funding for the program, as 
proposed at $125 million, has been provided for FY 2001.
    The basis underlying the program is simple: family 
caregivers need help. Families, not social service agencies or 
government programs, are the mainstay underpinning long term 
care (LTC) for older persons in the United States. According to 
the most recent National Long Term Care Survey (1994), more 
than seven million persons are informal caregivers providing 
unpaid help to older persons who live in the community and have 
at least one limitation in their activities of daily living. 
These caregivers include spouses, adult children, and other 
relatives and friends. Of the older persons receiving paid and 
unpaid assistance, 95 percent have family and friends involved 
in their care. Paid home care is the exception, not the rule, 
for the great majority of older persons with disabilities.
    The degree of caregiver involvement has remained fairly 
constant for more than a decade, bearing witness to the 
remarkable resilience of the American family in taking care of 
its older persons. This is despite increased geographic 
separation, greater numbers of women in the workforce, and 
other changes in family life. Thus, family caregiving has been 
a blessing in many respects. It has been a budget-saver to 
governments faced annually with the challenge of covering the 
health and LTC expenses of persons who are ill and have chronic 
disabilities. If the work of caregivers had to be replaced by 
paid home care staff, the estimated cost would be $45-95 
billion per year.

                         3. Longevity Symposium

    The 21st century presents many opportunities and challenges 
for the Aging Network--medical and technological advances, home 
and community-based care options, the need to prepare for a 
long life, and the need to implement evidence-based and 
culturally-responsive services to ensure that American elders 
receive the most effective assistance. The Administration on 
Aging convened a symposia series which highlighted the agency's 
commitment to helping the Aging Network prepare for the myriad 
of issues that come along with the gift of longevity.
    The first symposium, Longevity in the New American Century, 
convened in March 1999, was designed to identify the most 
potent, most promising research findings on issues important to 
older Americans and their families. Based upon these research 
findings, the Administration on Aging and other agencies and 
organizations will be able to make strategic decisions and 
build outcome-oriented programs for older Americans. The 
speakers invited to share information at this symposium were 
asked to provide specific ideas for an evidence-based, outcomes 
agenda in relation to the issues of caregiving, information and 
technology, diversity, consumer protection, economic security, 
and health.
    The second symposium, Building the Network on Aging 
Toolkit, convened in May 2000, focused on the presentation of 
evidence-based, outcomes-oriented strategies that can directly 
be used to develop and strengthen policies, programs and 
services. The primary purpose of this second symposium was to 
bridge the gap between research and practice. The speakers 
presented tools and methods that are essential components of 
programs for family caregiver support, cultural competent 
service delivery, the elimination of health disparities, life 
course planning, the application of new technologies, and for 
the measurement of program outcomes.

                        4. Priority Initiatives

                          Cultural Competence

    The Administration on Aging (AoA) recognizes that minority 
Americans often are at greater risk of poor health, social 
isolation, and poverty. Currently, minority elders comprise 
over 16.1 percent of all older Americans (65 years of age and 
older). In the future, this number is expected to increase 
dramatically. As a result, AoA has focused on educating the 
public and the aging network on cultural competence.
    Cultural competence is a set of congruent behaviors, 
attitudes, knowledge, and policies that come together in a 
practice and a service system that enables professionals to 
serve diverse clients. During calendar years 1999 and 2000, AoA 
has initiated the following activities to increase culturally 
competent practice:
           AoA's Longevity Symposia series, entitled 
        Longevity in the New American Century included a few 
        workshops focusing on cultural competence and the 
        minority aging experience. Included in the workshops 
        were new research, policy development ideas, and 
        suggestions for programs that promote equality in the 
        aging experience for minority elders;
           Collaboration with the Office of Minority 
        Health (OMH) on the May 2000 edition of Closing the 
        Gap, which focused on health issues and concerns for 
        minority older Americans;
           A Guide for Culturally Competent Practice 
        was developed for dissemination to providers of aging 
        services;
           Grants for applied research and 
        demonstration projects seeking to provide culturally 
        and linguistically competent services to Alzheimer's 
        Disease patients and their families in New York City, 
        Los Angeles, and San Francisco;
           Grants for a legal services hotline project 
        serving northern California;
           Grants for a resource center that 
        disseminates educational and best practice materials to 
        better equip minority and non-English speaking 
        consumers to combat waste and fraud in the Medicare and 
        Medicaid programs;
           Presentations by AoA staff at national 
        conferences and meetings on how to develop culturally 
        appropriate services to serve minority elders;
           AoA's website addition ``The Many Faces of 
        Aging: Resources to Effectively Serve Minority Older 
        Persons'' provides information on cultural competence.

             Eldertech--Technologies for Successful Aging:

    The number of older persons in the U.S. is estimated to 
increase from over 33 million today to 53 million in 2020. By 
2030, the demographic profile for the whole nation will be 
similar to the profile in the state of Florida today. 
Technologies that help to meet the challenges of aging, both 
for individual Americans as well as for the entire nation, will 
be increasingly valuable as the shift in demographics continue 
this century.
    In October 2000, the White House Office of Science and 
Technology Policy held a Forum on Technologies for Successful 
Aging. The Administration on Aging, as part of the cross-
Cabinet Steering Committee for this forum, played a key role in 
developing the agenda for the forum whose goal was to identify 
collaborative, technology transfer, and technology development 
and deployment opportunities for government, industry and 
academic communities that help to improve the independence, 
mobility, security, and health of aging Americans.
    In support of this goal, the 100 participants of the 
Conference began work to identify current and prospective 
barriers to those opportunities, mechanisms of support, and 
areas where additional research is needed. Specific topic areas 
included Health care and Assistive Devices, Regulatory and 
Technology transfer, Information and Technology, Mobility, 
Housing and the Workplace, and Consumer Protection, Security 
and Privacy issues. The Forum's overarching mission was to 
identify and prioritize recommendations that can be articulated 
as a set of near-term opportunities as well as long-term 
challenges to federal policymakers. The Intergovernmental 
Steering Committee continues to meet to follow up and formalize 
the steps that need to be taken in the coming months and years, 
and recommendations will be made to the incoming Administration 
to continue the work that has begun.

                       Mental Health Initiatives

    Companion Report to Surgeon General's Report on Mental 
Health
    AoA has authored a report that expands on the discussion of 
older adults and mental health contained in the 1999 Surgeon 
General's report. The AoA report focuses on challenges in the 
delivery of mental health services to older Americans, and 
highlights a number of supportive services that can provide 
vital assistance to older adults with mental health problems 
and their families. Release of this report is planned for 
January 2001.
    The report includes background information about the 
demographic characteristics of older Americans, the common 
stressors and adaptations that older persons face, and a brief 
summary of the findings from the Surgeon General's report. The 
report describes community mental health services, delivery of 
mental health services in primary and long-term care, and 
Medicare and Medicaid financing of mental health care. 
Supportive services discussed in the report include respite 
care, adult day services, support groups and peer counseling 
programs, wellness and health promotion programs, mental health 
outreach services, and caregiver programs. The discussion of 
each service includes its purpose, implementation models and 
examples, and research regarding effectiveness.
    Lastly, the report sets forth the challenges that must be 
addressed in order to provide effective community-based care to 
older persons with mental illnesses. Identified needs include: 
expanding prevention and early intervention services; 
increasing the number of professionals and paraprofessionals 
trained in geriatric mental health; providing adequate 
financing for mental health services; enhancing collaboration 
among delivery systems; improving access to mental health care; 
educating the public about mental illness and mental health 
treatment; expanding research on mental health issues in older 
adults; addressing the mental health needs of special 
populations; and encouraging consumer involvement.

           Alzheimer's Disease Demonstration Grants to States

    The Alzheimer's Disease Demonstration Grants to States 
Program (ADDGS) was established under Section 398 of the Public 
Health Service Act (P.L. 78-410) as amended by Public Law 101-
157 and by Public Law 105-379, the Health Professions Education 
Partnerships Act of 1998. Beginning in fiscal year (FY) 1999, 
the program was transferred within the Department of Health and 
Human Services from the Health Resources and Services 
Administration (HRSA) to the Administration on Aging (AoA).
    The ADDGS program's mission is to expand the availability 
of diagnostic and support services for persons with Alzheimer's 
disease, their families, and their caregivers. The 
Administration on Aging provides an added focus of reaching 
hard-to-serve and underserved people with Alzheimer's disease 
or related disorders (ADRDs).
    In general, the ADDGS projects demonstrate how existing 
public and private resources within States may be more 
effectively identified, utilized, and coordinated to enhance 
the educational and service delivery systems for persons with 
Alzheimer's disease, their families and caregivers. Under the 
Program, state grantees:
    Link public and non-profit agencies that develop and 
operate respite care, and other support, educational, and 
diagnostic services within the State to people who need 
services;
    Deliver services such as primary health care physician 
education and support services including respite care, home 
health care, personal care, day care, companion services, 
short-term respite care, and other forms of respite and 
supportive services to persons with ADRDs (at least 50 percent 
of the total grant must be spent on these activities);
    Improve access to home and community-based long-term care 
services for persons with Alzheimer's disease & their families;
    Provide individualized and public information, education, 
and referrals about 1) diagnostic, treatment and related 
services that are available; 2) sources of assistance to obtain 
such services, including entitlement programs; 3) legal rights 
of individuals and families affected by ADRD.
    In FY2000, AoA held a competitive grant award process, 
resulting in the issuance of grants to 16 states. Each grant 
has a 3-year project period and requires local match in the 
amounts of 25 percent (year 1), 35 percent (year 2), and 45 
percent (year 3). The general programmatic foci of the program 
are to:
           develop models of care for persons with 
        Alzheimer's disease, and
           improve the responsiveness of the home and 
        community based care system for persons with dementia.
    Projects are targeted to hard-to-reach populations 
including ethnic minorities, low income and rural families with 
Alzheimer's disease. The 16 states with ADDGS grants are 
Alaska, Arizona, Arkansas, California, Iowa, Maine, Minnesota, 
Nebraska, Nevada, New Hampshire, New Mexico, Rhode Island, 
Texas, Vermont, Virginia, and Wisconsin.

                        Managed Care Initiative

    In addition to the 16 new projects, 5 states have grants of 
$80,000 to fund services provided under the ADDGS Managed Care 
Initiative, an effort started in 1997 by HRSA. The Managed Care 
Initiative is designed to test the impact of community-based 
service interventions on primary care physician utilization 
rates by persons with Alzheimer's disease in a managed care 
environment.
    Organizations with FY 2000 ADDGS Managed Care Initiative 
Grants are:
           DC Office on Aging
           Florida Department of Elder Affairs
           Michigan Department of Community Health
           Ohio Department on Aging
           Oregon Senior and Disabled Services Division

               5. Reinventing the Administration on Aging

                        Performance Measurement

    AoA and the Aging Network have forged a partnership to 
utilize the tools provided by the Government Performance and 
Results Act (GPRA) to demonstrate to the Congress and the 
public the value of the programs administered under the Older 
Americans Act (OAA). GPRA has provided the Network the 
opportunity to use performance measurement to continuously 
document the results that service providers, Area agencies on 
Aging, State agencies on Aging, and AoA produce for older 
Americans. The reauthorized Older Americans Act reinforces the 
importance of measuring results, and directs AoA to develop 
performance outcome measures for Older Americans Act programs 
by December 2001. AoA and the Network have launched the 
Performance Outcomes Measures Project (POMP) to serve as a 
mechanism to identify and institutionalize indicators of 
results that will serve the long-term program improvement needs 
of the Network and Older Americans Act programs.
    Early in its second year of operation, the POMP is building 
on the consensus achieved by AoA's initiative to pull together 
selected network participants to identify a set of core areas 
and methods of performance measurement that can serve the aging 
community. With the assistance of accomplished researchers in 
the fields of gerontology and statistics, State and area 
partners from 16 States developed and tested performance 
measurement instruments that center on the needs and 
characteristics of the people they serve. Consistent with the 
best quality management practices in the field, POMP focuses 
primarily on customer assessment measures for core service 
areas, such as home care, transportation, and caregiver 
services. Pilot test users have found a high degree of 
satisfaction with services, and have also identified customer-
based recommendations for service improvement. For example, 
test findings for pilot areas indicate that transportation 
services are used most for doctor's appointments, and that 
expanded hours of service would be the most helpful change. 
State and area partners also tested nutrition assessment 
instruments for new clients and found that the nutritional risk 
of these individuals was very high. This indicates for test 
locations that nutrition services are targeted to the elderly 
who need the service most. Follow-up surveys of these same 
individuals will provide an indicator of the effects of Aging 
Network nutrition services on the nutritional status of these 
high-risk individuals after six months of program 
participation.
    Statistical methodologies that are useful to program 
administrators in the field are an added and promising feature 
of the AoA sponsored performance outcome measurement effort. 
The POMP survey methods and instruments have been designed to 
allow real people, working area agency staff and others, to 
conduct valid sample surveys of clients across an assortment of 
service areas. The materials and experiences of pilot agencies 
are being documented and have been proven to be replicable for 
a variety of agencies and programs.
    To support and enhance the indicators of program results 
that the performance outcome measurement partners are working 
to define, AoA is making use of ongoing administrative data to 
more fully illustrate and define the success of the Network in 
the service of elderly Americans. Ongoing administrative data 
from State and area agencies will be useful for demonstrating 
the effectiveness of these program entities in targeting 
services to those most vulnerable and in need. Existing 
administrative data will be useful for demonstrating the 
effectiveness of the Network in coordinating services and 
leveraging resources in support of the program objectives of 
the Older Americans Act.
    AoA and its program partners are committed to use 
performance measures to inform decision making that improves 
programs for older Americans. As AoA's performance measures 
mature, and trends in program performance emerge, AoA and the 
Network believe that these indicators of results, along with 
program evaluation and other management assessment tools, will 
be critical to program development in support of older 
Americans.

                            Policy Analysis

    For the first 30 years after enactment of the Older 
Americans Act (OAA) the major thrust of efforts undertaken by 
the Administration on Aging (AoA) was to support the 
development of a nationwide infrastructure with a capability to 
promote more comprehensive and coordinated home and community-
based services to vulnerable older individuals. A network of 
State and Area Agencies on Aging, as well as providers of 
supportive and nutrition services, has developed which 
leverages other sources of funds and coordinates with other 
agencies in addressing the needs of older individuals in 
greatest economic or social need, including older individuals 
with physical or mental impairments, living alone, with low 
income, minority status, or rural residence. The statutory 
basis for these efforts may be found in Titles III, VI, and VII 
of the OAA.
    More recently the focus has shifted to the responsibilities 
of the AoA to ``serve as the effective and visible advocate for 
older individuals within the Department of Health and Human 
Services and with other departments, agencies, and 
instrumentalities of the Federal Government by maintaining 
active review and commenting responsibilities over all Federal 
policies affecting older individuals'' (OAA Section 202(a)(1)). 
The OAA requires that the Assistant Secretary for Aging ``shall 
coordinate, advise, consult with, and cooperate with the head 
of each department, agency, or instrumentality of the Federal 
Government proposing or administering programs or services 
substantially related to the objectives of this Act, with 
respect to such programs or services'' (OAA Section 203(a)(1)). 
Additionally the OAA provides that ``The head of each 
department, agency, or instrumentality of the Federal 
Government proposing to establish programs and services 
substantially related to the objectives of this Act shall 
consult with the Assistant Secretary prior to the establishment 
of such programs and services.'' (OAA Section 203(a)(2)).
    To implement these statutory requirements, recently a 
policy unit has been established in areas defined in the 
Declaration of Objectives for Older Americans (OAA Section 101 
(1) ``An adequate income...''.), (2) ``The best possible 
physical and mental health.....''), (3) ``Obtaining and 
maintaining suitable housing......''). In the Economic Security 
policy area there will be review and analysis of legislation 
and regulations covering programs administered by the Social 
Security Administration, the U.S. Department of Labor, and 
other agencies; in the Housing policy area of programs 
administered by the U.S. Department of Housing and Urban 
Development and other agencies; in the Health policy area of 
programs administered by the Health Care Financing 
Administration, the Veterans Administration, the Substance 
Abuse and Mental Health Services Administration and other 
agencies. The policy analysts represent AoA at meetings with 
representatives of these departments and agencies and 
participate actively on work groups. They prepare analyses of 
reports, develop policy briefs, and advise senior officials on 
developments in their policy areas.

                        International Activities

    The AoA responds to requests for information from 
international organizations such as the United Nations, foreign 
governments, and agencies. It hosts international scholars, 
officials and practitioners who come to the U. S. to learn 
firsthand about America's response to population aging. In 1999 
and 2000, AoA staff briefed delegations from over 25 countries.
    The AoA participates in a number of collaborative efforts 
with other countries and with international organizations, such 
as the World Health Organization, to enhance aging programs and 
policies worldwide. The AoA has a signed agreement with the 
China National Committee on Aging of the People's Republic of 
China to share information and to develop collaborative 
activities.
    The Aging Core Group of the Health Working Group, U.S.-
Mexico Binational Commission.--The Commission promotes 
exchanges at the Cabinet level on a wide range of issues 
critical to U.S.-Mexico relations. The Aging Core Group is one 
of five areas of collaboration between the U.S. Department of 
Health and Human Services and the Mexican Ministry of Health. 
The U.S. side of the Core Group is led by the Assistant 
Secretary for Aging. A number of on-going exchanges of 
information, training and technical assistance have taken place 
to help both countries better address the special health needs 
of older people. In 1999 and 2000, in collaboration with the 
AoA, the Mexican Ministry of Health hosted invitational 
conferences to share models of care for the elderly; nutrition 
and the elderly; and prevention and control of chronic disease 
in the elderly.
    The International Year of Older Persons 1999.--The AoA 
coordinated the U.S. government's activities for the 
International Year of Older Persons (IYOP). A Federal Committee 
for the IYOP (the ``Committee'') was created and chaired by the 
Assistant Secretary for Aging. The Committee consisted of over 
40 governmental agencies and departments.
    The IYOP was formally launched by the reading of a message 
from President Clinton by HHS Secretary Donna E. Shalala on 
October 19, 1999, at a gathering at the U.S. Department of 
Agriculture. Guests included Cabinet heads and representatives, 
international delegates and senior advocates in Washington, 
D.C. A special video message was delivered from US Senator John 
Glenn (D-OH) upon his return to space on October 29 as a NASA 
researcher. Gubernatorial proclamations of the IYOP within 
their states were displayed.
           In June 1999, the AoA and the Committee 
        convened the invitational symposium Coming of Age: 
        Federal Agencies and the Longevity Revolution. The 
        symposium brought together some 300 senior 
        administrators from across the Executive Branch to 
        examine and address the policy and program implications 
        of our rapidly aging American society. The goal of the 
        symposium was to establish a foundation for the 
        advancement of the federal policy and program agenda 
        related to older Americans and their families in the 
        21st century. Discussions were organized around the 
        major themes of economic security, aging in place, 
        older people as a resource, health promotion and care, 
        and disability and long-term care.
           An IYOP website was established on the AoA 
        home page and became a major international source of 
        information on the IYOP.
           The IYOP culminated with an event entitled 
        ``Positive Aging: A Goal for the Next Millennium''--A 
        Day Celebrating the Culmination of The United Nations 
        International Year of Older Persons. The event was 
        hosted by the Committee and the US Committee 
        (representing non-governmental aging associations). The 
        program included a federal and a business panel and an 
        award ceremony for communities that have celebrated the 
        IYOP.
    The Federal Committee on Aging Issues.--With the close of 
the IYOP, the Committee continues its work as the Federal 
Committee on Aging Issues. The Assistant Secretary for Aging 
continues to chair the Committee. The Committee continues to 
share information among members and to examine ways of 
implementing recommendations from the 1999 symposium, Coming of 
Age: Federal Agencies and the Longevity Revolution.
    International Plan of Action on Aging, 2nd World Assembly 
on Aging.--Working together with the Committee, AoA is 
coordinating the federal government's input to the revised 
International Plan of Action. The revised Plan will be 
presented for discussion at the 2nd World Assembly on Aging, to 
be held under the UN auspices in 2002.
    International Conference on Rural Aging.--Under Title IV of 
the Older Americans Act, the Administration on Aging funded 
West Virginia University to put on the first international 
conference on rural aging: Rural Aging: A Global Challenge. The 
West Virginia University Center on Aging is now a UN Programme 
on Aging Advisory Site on Rural Aging. Representatives of 40 
nations attended the five-day conference held in June 2000 in 
Charleston, West Virginia. Policy recommendations on worldwide 
rural aging were adopted. They will become the basis of a Rural 
Aging Plan of Action to be included in the revised UN 
International Plan of Action on Aging.

             Work Force Plan of the Administration on Aging

    AoA's workforce planning initiative was completed here at 
headquarters in December, 1999 and in our regional offices in 
November, 2000. The plan highlights the Administration on 
Aging's vision of itself to be actualized by the year 2005, 
identifies competencies of its present workforce and areas for 
staff development, and focuses on organizational competency 
gaps to be addressed in the recruitment of staff in the future.
    In the last few months AoA has recruited approximately 
twenty new employees, following the indicators, conclusions, 
and recommendations contained in our workforce plan, and we 
will continue to use the workforce plan as the basis for our 
recruitment and staff development efforts in the future. The 
workforce plan indicates that the agency's present allocation 
of staff to the organizations support functions or 
infrastructures (i.e. grants, budget and finance, personnel, 
and training, IRM, and general administrative functions) are 
adequate for the size of the agency. The staffs performing 
these functions also are younger, with less seniority within 
the agency, and tend to have received technical training 
specific to their particular jobs. On the other hand AoA's 
workforce plan highlights the fact that an overwhelming number 
of the almost one hundred employees the agency has lost since 
1993 have been program staff. That trend will continue unabated 
over the next five years, when a 60 percent turnover in staff 
is anticipated because of retirements.
    AoA has recently filled a vacant management position which 
oversees our regional operations and a planning and evaluation 
officer position, but the vast majority of the new recruits are 
policy analysts and program analysts with extensive experience 
in applying research methodologies, evidence-based principles 
and qualitative and quantitative approaches to policy 
formulation and development and to the design, implementation, 
and evaluation of programs and services. AoA has recruited 
policy analysts with a thorough, in-depth knowledge of the 
following public policy areas, as they relate to older people: 
home and community based long term care, healthcare, housing, 
economic security, and mental health. The newly hired program 
analysts will concentrate on program design, technical 
assistance, and implementation in the following program areas: 
home and community based long term care/housing, elder rights/
legal services, public health promotion, and consumer 
protection.
    A few of these analysts have been assigned the task of 
serving as mentors to the two Presidential Management Interns 
(PMI) recruited by the agency this summer. Next year and in 
subsequent years, AoA will be in a position to concentrate on 
recruitment of staff at the GS 9 entry level of the PMI 
program, the Outstanding Student program, and the Student Co-op 
program and anticipate being able to employ each year at least 
four to six staff from these programs to replace program staff 
retiring.

                             Regional Teams

    As part of the new vision for the Administration on Aging, 
The Assistant Secretary on Aging directed the Regional Offices 
in 1999 to establish teams, including multi-regional teams, to 
help advance AoA's priorities in the areas of public/private 
partnerships, diversity, customer service and financial 
management. The teams made significant progress during 1999 and 
2000.
    The Boston (Region I) and New York (Region II) Offices 
worked together on a team to foster public/private 
partnerships. As it's first project, the team established a 
partnership with the Federal Deposit Insurance Corporation 
(FDIC) and the Women's Institute for a Secure Retirement 
(WISER) to help mid-life and elderly women, especially low-
income and minorities, understand and prepare to meet their 
everyday economic and financial needs at progressive states of 
aging. The partnership has produced a financial literacy 
program known as Power 2000 Take Control of Your Financial 
Future. The program includes a training manual with a suggested 
curriculum, materials that can be duplicated, resource guides 
and information on how to conduct a local workshop. To promote 
the program, AoA, FDIC and WISER identify and stimulate 
opportunities for presentations to the Aging Network, the 
banking network and other community-based groups, all of whom 
are asked to serve as catalysts in promoting the financial 
literacy program in their localities. Local partnerships are 
then formed among the partners and other federal, state and 
local organizations to serve as facilitators, resources and/or 
faculty in conducting Power 2000 presentations locally. The 
program was successfully piloted during 2000 in New York City 
and in one rural community in Upstate New York. Based on the 
results of the pilot, the partnership plans to roll out the 
program in 2001 to AoA regions nationwide.
    The San Francisco Office (Region IX) team is focused on 
policy issues related to diversity and aging. The team has 
developed a new section of the AoA web site, www.aoa.gov, ``The 
Many Faces of Aging: Resources to Effectively Serve Minority 
Older Persons,'' to help increase access to programs and 
services for older minority Americans and their caregivers. The 
site was launched in December, 2000 and includes a range of 
health and aging resources for and about minorities and diverse 
aging populations; demographic snapshots and statistics; and 
laws and executive orders related to ensuring improved access 
and culturally appropriate services. The site highlights 
various approaches to develop culturally and linguistically 
responsive services for minority older persons. The Dallas-
Atlanta (Regions IV and VI) team has been building a diversity 
website that will offer state-specific data on minority 
populations. These two initiatives were developed response to 
the growing diversity of the aging population. Currently, 
minority elders comprise over 16.1 percent of all older 
Americans (65 years of age and older). In the future, their 
numbers are expected to increase dramatically. Between 1999 and 
2030, the older minority population 65+ is projected to 
increase by 217 percent, compared with 81 percent for older 
white population.
    The Denver Office (Region VIII) team is focused on customer 
service, including the establishment of internal performance 
outcome measures for employee participation and performance. 
The Denver team has developed a comprehensive orientation 
manual for all new AoA employees. The manual provides 
background information on the Department of Health and Human 
Services, AoA, the Older Americans Act and the Aging Network, 
as well as information on internal operating policies and 
procedures. The manual will be issued in January 2001.
    The Denver team also has developed several tools for AoA's 
external customers. The ``Compendium of Grant Resources for 
Native American Elders Programs'' was developed in partnership 
with the Community Resource Center in Denver and the National 
Committee to Preserve Social Security and Medicare. The 
Compendium contains resources on funding, publications, 
resource agencies, profiles of funders and internet resources 
targeted to Native Americans. The Compendium project was 
initiated in Region VIII when Tribal Elders Programs requested 
additional funding information from the regional office to 
augment moneys received under Titles VI and III of the Older 
Americans Act. ``Cyberspace Resources on Retirement'' is a 
publication that identifies internet links on retirement and 
financial planning, health, quality of life and other baby 
boomer issues. The publication was a result of a creative 
partnership among the Develop Denver Office, the Community 
College of Denver, American Association for Retired Persons, 
and the National Committee to Preserve Social Security and 
Medicare.
    The Chicago (Region V) and Kansas City (Region VII) Offices 
have collaborated on establishing a fiscal management team 
comprised of representatives from all the regional offices and 
the AoA central office in Washington. The team serves as the 
focal point within AoA on all grantee related fiscal matters. 
The team ensures the provision of timely, consistent, uniform 
and accurate fiscal policy and technical assistance to the 
state units on aging, Native American programs, and the area 
agencies on aging. During 2000, the team developed a manual for 
AoA project officers, and drafted several technical assistance 
documents that will be used to implement the 2000 Amendments to 
the Older Americans Act, including the National Family 
Caregiver Support Program.
    The Seattle (Region X) Office team is looking at the issue 
of active aging, including the opportunities and challenges 
associated with creating meaningful roles for older people. 
There is a growing body of research which suggests that both 
the individual and the nation as a whole can benefit from older 
people being actively engaged in activities which allow them to 
make meaningful contributions to their families, their 
communities and the larger society. This issue will take on 
great significance as the baby boom generation ages. As a first 
step in exploring this issue, the Seattle team is reviewing the 
literature to identify what we know about the key factors and 
dynamics associated with active aging.

                               Section II


                         1. Summary of Reports

                          State Program Report

    Each year, the Administration on Aging (AoA) awards Older 
Americans Act (OAA) funds to every state based primarily on the 
relative size of the state's elderly population.
    Each State Unit on Aging (SUA), in turn, relies upon Area 
Agencies on Aging (AAAs)to partner with a diverse set of home 
and community service providers in getting supportive, 
nutrition, and related services to older persons. (Several 
states with relatively small populations combine the SUA and 
AAA functions into a single agency). The following is summary 
information on the clients, services, expenditures and staffing 
of OAA programs for fiscal year 1998 (most recent data 
available).

Clients

    Older Americans Act programs served nearly 6.5 million 
persons 60 years of age and older in FY 1998. While services 
are open to all older Americans, efforts are made to focus on 
those with the greatest economic and social need. Thus, OAA 
program participants have incomes below the poverty level at a 
rate nearly four times that of the total population in this age 
group. Nearly one-third of these individuals live in rural 
areas, compared to less than one-quarter of the total 
population age 60 and above. Participants in OAA service 
programs were members of racial or ethnic minority groups at a 
level nearly one-third higher than the total elderly 
population. OAA minority clients had incomes below the poverty 
level at a rate more than twice that of the minority elderly 
population overall.

Services

    Older Americans Act programs provided nearly 20 million 
units of personal care, homemaker and chore services in FY 
1998. During the same period, OAA programs provided almost 130 
million home delivered meals and 114 million congregate meals. 
Older persons received over 45.7 million trips to medical 
services, grocery stores, and other community services through 
OAA transportation programs. Over 13 million units of 
information and assistance services were provided to older 
persons and those acting on their behalf.

Expenditures and Staffing

    State Units on Aging and Area Agencies on Aging generated 
nearly $2 billion in state and local funds to supplement the 
$678 million in OAA dollars they received from AoA in FY 1998. 
Many SUAs also administered other programs for the elderly such 
as Medicaid home and community based waivers and state funded 
support services. There were 3,285 SUA staff and another 37,174 
staff at the AAA level working together to administer the much 
needed services provided through OAA funds. These figures 
include over 16,000 volunteers.

                        Ombudsman Program Report

    State Long Term Care Ombudsmen are advocates for residents 
of nursing homes, board and care homes, assisted living 
facilities and similar adult care facilities. They work to 
resolve problems of individual residents and to bring about 
changes at the local, state and national levels to improve 
care. While most residents receive good care in long-term care 
facilities, far too many are neglected, and other unfortunate 
incidents of psychological, physical and other kinds of abuse 
do occur. Thus, thousands of trained volunteer ombudsmen 
regularly visit long-term care facilities, monitor conditions 
and care, and provide a voice for those unable to speak for 
themselves.
    Begun in 1972 as a demonstration program, the Ombudsman 
Program today is established in all states under the Older 
Americans Act, which is administered by the Administration on 
Aging (AoA). Local ombudsmen work on behalf of residents in 
hundreds of communities throughout the country. Detailed 
information on the program for 1998 (the latest year for which 
reports are available) follows.

Cases and Complaints

    In FY 1998, ombudsmen nationwide opened 136,424 cases and 
closed 121,686 cases involving 201,053 individual complaints, 
most of which were filed by residents or friends and relatives 
of residents. Eighty-two percent of cases were in nursing home 
settings; 17 percent involved board and care, assisted living 
and similar facilities; and one percent were in non-facility 
settings. The top five nursing home complaints were in 
categories involving poor resident care, lack of respect for 
residents and physical abuse. Seventy-two percent of nursing 
home complaints and 67 percent of board and care complaints 
were resolved or partially resolved to the resident's or 
complainant's satisfaction.

Program Funding

    FY 1998 program funding totaled $47,404,557, $4.35 million 
more than in FY 1997. While program funding rose in FY 1998, it 
was relatively level for the period FY 1995 to 1998. Resources 
are still inadequate to meet the need for ombudsman services 
and volunteer coverage in all facilities covered by the 
program. About 58 percent of the program funding was from 
federal sources, especially Title III of the OAA; states 
provided about 28 percent of funding; 14 percent was from 
private sources.

Local Programs, Staffing and Volunteers

    There were 587 local and regional ombudsman programs in FY 
1998, essentially the same as in FY 1997; most of these 
programs were located in area agencies on aging. The number of 
paid ombudsman staff increased from 887 full-time equivalents 
(FTEs) in FY 1997 to 927 FTEs in FY 1998, with 679 paid staff 
working full-time on the program. The number of volunteers who 
are trained and certified to investigate complaints increased 
from 6,795 in FY 1997 to 7,359 in FY 1998. Most state ombudsman 
programs are located in state agencies on aging, but programs 
in 15 states are located in other types of organizational 
settings, a slight increase since FY 1997.

   Report on the American Indian, Alaskan Native and Native Hawaiian 
                                Program

    The Office for American Indian, Alaskan Native and Native 
Hawaiian programs serves as the focal point within the AoA for 
the operation and assessment of Native American programs 
authorized under Title VI and oversight of the Native American 
Elders Resource Centers authorized under Title IV. The Office 
Director continues to serve as the effective and visible 
advocate on behalf of older Native Americans, coordinates 
activities with other Federal departments and agencies, 
collects and disseminates information related to the problems 
of older Native Americans, and promotes coordination between 
the administration of Title III and Title VI.

Title VI--Grants for Native Americans

    Under Title VI of the OAA, the AoA annually awards grants 
to provide supportive and nutritional services for older 
American Indians, Alaska Natives and Native Hawaiians.
    Title VI, Grants to Indian Tribes, was added to the OAA in 
the 1978 amendments and was expanded by the 1987 Amendments to 
include Native Hawaiians.
    In Fiscal Year 2000 grants totaling $18,457,000 were 
awarded to 225 American Indian and Alaska Native Tribal 
Organizations, and two organizations serving Native Hawaiians, 
to provide congregate and home-delivered meals and a variety of 
supportive services. As required by the OAA, 90 percent of the 
funds went to the Tribal organizations and 10 percent went to 
the Native Hawaiian organizations.
    Nutrition services are a major component of Tribal Title VI 
programs. Native elders receive nearly three million congregate 
and home-delivered meals annually. Most program sites provide 
hot congregate meals four to five times a week. Home-delivered 
meals are delivered five times a week for elders who generally 
are in poorer health, are more functionally impaired, get out 
of their homes less often, and need in-home supportive 
services. Most programs provide modified diets for diabetics, 
or others who might be on low-fat, low-cholesterol, and low-
sodium diets. Several programs provide special nutrition 
services such as meals for homeless older persons an evening 
meal option for home-delivered meal participants, and weekend 
home-delivered meals.
    In addition to providing meals, nutrition education, 
screening, and counseling, Title VI programs are important 
resources for social interaction and supportive services. For 
example, congregate meal programs provide Native elders with 
important opportunities to meet with friends, participate in 
recreation and other activities, and take trips to other elder 
programs or state and national meetings. Other vital supportive 
services can include outreach, family support, legal 
assistance, and transportation to meal sites, doctor's 
appointments, and grocery shopping. Most programs offer health-
related services, such as podiatry screening and blood pressure 
monitoring.

Tribal Listening Session

    President Clinton signed an Executive Memorandum on April 
29, 1994 affirming that the United States government maintains 
the unique relationship with Indian Tribes founded on the 
principle of government-to-government relations. Consistent 
with this relationship, the AoA hosted a Tribal Listening 
Session on August 8, 2000 in Washington, DC with Tribal leaders 
throughout the country. The Session focused on issues affecting 
the lives of Indian elders. There were over 100 participants 
representing Tribes nationally. The Listening Session allowed 
for an open dialogue addressing four priority areas: 1) policy 
directions; 2) capacity building; 3) health care; and 4) long-
term care. Recommendations were made by the participants in 
these four areas and are currently being reviewed and 
addressed.

National Resource Centers

    Since 1994, AoA has awarded grants to two universities to 
establish National Resource Centers for Older American Indians, 
Alaska Natives, and Native Hawaiians. The University of 
Colorado at Denver and the University of North Dakota at Grand 
Forks provide culturally competent health care resources, 
community-based long term care information, and related 
services. They serve as the focal points for developing and 
sharing technical information and expertise for American Indian 
organizations, Native American communities, educational 
institutions, and professionals and others working with Native 
elders.

Interagency Task Force on Older Indians

    The 1987 Amendments in Section 134(d) directed the 
Commissioner on Aging to establish a permanent Interagency Task 
Force on Older Indians, with representative of federal 
departments and agencies who work to improve services to older 
American Indians. This Task Force was established in Fiscal 
Year 1990. Task Force members focus on three areas of concern: 
health, transportation, and data. The Task Force recommends 
ways to improve interagency collaboration, enhance services, 
and identify problems or barriers that prevent or diminish 
collaboration.

                      Discretionary Grants Program

    The Administration on Aging supports a number of 
demonstration programs, national resource centers, and related 
discretionary grant projects under the authority of Title IV of 
the Older Americans Act, the Health Insurance Portability and 
Accountability Act, and the Public Health Services Act. The 
principal AoA discretionary grants program efforts are 
summarized below:

Health Care Fraud and Abuse Control Program Activities

    The General Accounting Office estimates that billions of 
Medicare and Medicaid dollars are lost each year to waste, 
fraud and abuse. The AoA has played an active role in the 
ongoing effort to address this serious national problem through 
the enactment of P.L. 104-209, the Omnibus Consolidated 
Appropriations Act of 1997. Language contained in Title IV of 
the Older Americans Act directs the AoA to establish community-
based projects that utilize the skills and expertise of retired 
professionals in identifying and reporting waste, fraud and 
abuse. The projects are designed to recruit and train retired 
professionals, such as doctors, nurses, teachers, lawyers, 
accountants, and others to work in their communities and in 
local senior centers to help identify deceptive health care 
practices, such as over billing, overcharging, or providing 
unnecessary or inappropriate services. These senior volunteers 
undergo several days of training reviewing health care benefit 
statements and outlining steps individuals can take to protect 
themselves.
    AoA also receives funding under the Health Insurance 
Portability and Accountability Act of 1996 to work in 
partnership with the Health Care Financing Administration, the 
Office of Inspector General, the Department of Justice, and 
others in a coordinated effort to combat and prevent waste, 
fraud, and abuse in Medicare and Medicaid. The AoA's efforts 
under this initiative have been to: 1) train professionals who 
provide services to older Americans about how to recognize and 
report potential instances of waste, fraud, and abuse; 2) 
support the work of four technical assistance resource centers 
which provide outreach activities to rural, isolated, or 
limited English-speaking individuals; 3) develop consumer 
education materials in English, Spanish, and Chinese; and 4) 
convene annual national and regional conferences which bring 
together government officials, health care professionals, aging 
service providers, and older Americans to share common 
strategies and practices.
    Working in partnership with partners at the federal, state, 
and local levels, the Medicare error rate has been reduced by 
more than 40 percent over the past three years, and billions of 
dollars of improper payments have been returned to the Medicare 
and Medicaid programs.
    Over the past three years, the AoA's projects supported by 
Title IV of the Older Americans Act and the Health Insurance 
Portability and Accountability Act have a commendable track 
record:
           They have trained more than 40,000 
        volunteers and aging service professionals to serve as 
        community resources and educators.
           These volunteers and professionals in turn 
        have conducted more than 25,000 community education 
        events and one-on-one counseling sessions, directly 
        educating more than one million beneficiaries.
           The projects also held more than 2,500 media 
        events, reaching more than an estimated 45 million 
        people.
           During this time period, more than 2,300 
        complaints have been referred to health care providers, 
        Medicare contractors, the Office of Inspector General, 
        or other appropriate entities for follow-up 
        investigation and correction.
           While it has not been possible to document 
        the results of all the cases referred by the AoA's 
        grantees, nearly $58 million in savings have been 
        documented as being directly related to the efforts of 
        the projects.
           The heightened awareness of beneficiaries 
        checking their Medicare Summary Notices and Explanation 
        of Medicare Benefit statements has contributed to a 42 
        percent reduction in the Medicare error rate since the 
        projects have been in operation.

Pension Information and Counseling Program

    Now located in 14 states (Arizona; California; Connecticut; 
Illinois; Maine; Massachusetts; Michigan; Minnesota, Missouri; 
New Hampshire; New York; Rhode Island; Vermont; and Virginia), 
the pension counseling demonstration projects supported by AoA 
since 1993 have assisted over 10,000 older Americans with 
pension problems. The projects have been instrumental in 
recouping over $30 million in pension claims. Each of the 
pension counseling projects brings its own unique model to the 
program. Some projects operate with full-time lawyers, others 
rely on highly trained volunteers to provide assistance. The 
projects provide a range of services, from answering pension 
questions to providing legal assistance to obtain promised 
pension benefits.
    Each of the demonstration projects offers several basic 
services:
           Counseling and assistance to older 
        individuals and their families who need help in 
        determining their rights and in following the process 
        for filing claims or complaints related to pension and 
        other retirement benefits;
           Information on sources of pension and other 
        retirement benefits;
           Referrals to attorneys, actuaries, legal 
        services and other advocacy programs;
           Outreach programs to provide information, 
        counseling, assistance and referral regarding pension 
        and other retirement benefits with special emphasis on 
        outreach to women; minority; rural, and low-income 
        retirees.
    The Pension Rights Center in Washington, DC, with financial 
assistance from the Administration on Aging, provides technical 
assistance to individual pension projects, state and area 
agencies on aging, and legal services providers on pension 
issues, and encourages these groups to coordinate their 
activities with other federal agencies. The Center also 
provides training for staff and volunteers working in pension 
demonstration projects.

Elder Rights and Legal Assistance Program

    AoA support for model projects and resource centers under 
its Elder Rights and Legal Assistance Program is summarized 
below:

                  (1) Statewide Senior Legal Hotlines

    Model legal hotlines, utilizing paid, specially-trained, 
and experienced lawyers, are designed to provide unlimited free 
legal advise to all state residents age 60 and older, 
regardless of their level of income or resources. The hotlines 
also provide legal briefs and related assistance such as 
document reviews and calls/letters to third parties, but only 
when there is a likelihood that this would resolve the problem. 
Services are provided statewide by means of toll-free telephone 
lines. Currently, AoA is supporting senior legal hotlines in 
northern California, Georgia, Hawaii, Indiana, Iowa, Kentucky, 
Maine, Maryland, Michigan, New Hampshire, Tennessee, 
Washington, and West Virginia.

             (2) National Legal Assistance Support Projects

    The Older Americans Act mandates the support, under Title 
IV, of a national system of legal assistance support activities 
to State and Area Agencies on Aging which will assist them in 
developing an elder rights system and in providing, developing 
and supporting legal assistance for older people. In the 1992 
amendments to the Older Americans Act, legal assistance was 
made an integral part of the new Title VII, Vulnerable Elder 
Rights Protection program. As a result, AoA expanded the role 
of the national system to encompass elder rights systems 
development. Five (5) national level providers of legal support 
and assistance are now being funded by AoA through 2001.

         (3) National Resource Centers to Protect Elder Rights

    Two centers active nationwide (the National Center on Elder 
Abuse and the National Long Term Care Ombudsman Resource 
Center) have been funded by AoA since 1993 to provide findings, 
products, information, training, and technical assistance that 
would help to safeguard the rights of older persons living in 
residential and institutional settings.

Reach 2010 for the Elderly

    In FY 2000, the AoA joined with the Centers for Disease 
Control and Prevention to strengthen the scope of the 
departmental initiative to eliminate health disparities among 
racial and ethnic minority populations by mounting REACH 2010 
for the Elderly. This major collaborative effort has the goal 
of improving the health status of older racial and/or ethnic 
minority persons. Four projects were funded to support 
community coalitions in their groundbreaking initiatives to 
reduce health care disparities in the areas of heart disease, 
diabetes, and immunization. The Reach 2010 grantees are as 
follows:
           Boston Public Health Commission
           The Latino Education Project
           Special Services for Groups
           National Indian Council on Aging

Other Significant Discretionary Program Efforts

    Other noteworthy AoA-supported discretionary programs and 
projects include the Alzheimer's Disease Demonstration Grants 
to States Program, the Family Friends/Volunteer Senior Aides 
program, the National Eldercare Locator, minority aging model 
projects, and home and community based long term care 
demonstration projects.

                          2. Program Direction

 ----------------------------------------------------------------------------------------------------------------
                                                              FY 1999            FY 2000            FY 2001
----------------------------------------------------------------------------------------------------------------
Supportive Services & Centers..........................       $309,957,000       $310,020,000       $325,082,000
Congregate Meals.......................................        374,261,000        374,336,000        378,412,000
Home-Delivered Meals...................................        112,000,000        146,970,000        152,000,000
Preventive Health Services.............................         16,123,000         16,120,000         21,123,000
State and Local Innovations/Projects of National                18,000,000         31,156,000         37,678,000
 Significance..........................................
Grants to Native Americans.............................         18,457,000         18,457,000         23,457,000
Vulnerable Older Americans.............................         12,181,000         13,179,000         14,181,000
Alzheimer's Disease....................................          5,970,000          5,968,000          8,970,000
Program Administration.................................         14,781,000         16,458,000         17,232,000
TOTAL, Budget Authority................................       $881,730,000       $932,664,000     $1,103,135,000
----------------------------------------------------------------------------------------------------------------

                                FY 1999

    In FY 1999, AoA programs were funded at a total of $881.7 
million, an increase of almost $11 million over FY 1998. The 
majority of this money was allotted by statutory formula to 
states and territories. Funding for the major supportive 
services and nutrition programs remained unchanged; increases 
were provided for several smaller AoA programs. Vulnerable 
Older Americans did receive an additional $3 million (+33%) to 
increase Ombudsman activities. AoA's sole discretionary grant 
program, State and Local Innovations and Projects of National 
Significance received $18 million, the largest increase, +$8 
million (+80%). In FY 1999 the number of projects funded under 
this discretionary authority increased from approximately 61 to 
105 and included the Eldercare Locator, Senior legal hotlines, 
pension counseling, and evaluation activities.

                                FY 2000

    In FY 2000, AoA programs were funded at a total of $932.7 
million, an increase of $51 million. Home-Delivered meals, one 
of AoA's two formula grant nutrition programs, received an 
additional $35 million, a +31 percent increase. Funding for 
AoA's other formula grant programs again remained static. The 
increase for Home-Delivered meals allowed grantees to provide 
nearly 166,000,000 meals to frail, home-bound elders. 
Vulnerable Older Americans also received a $1 million increase, 
again for the Ombudsman program. And once again, State and 
Local Innovations and Projects of National Significance 
received a large increase (73%) bringing the program level to 
over $31 million and funding approximately 70 new projects, 120 
projects total. Program Administration also received a nearly 
$2 million increase to fund staff increases and increased costs 
of facilities rental, automated systems support, travel, 
supplies and equipment.

                               THE FUTURE

    In FY 2001, the start of which covers the final three 
months in calendar year 2000, funding for Aging programs has 
increased significantly, to a total of $1.1 billion or $169 
million over the FY 2000 level. This includes $125 million for 
a new National Family Caregiver Support Program to provide 
support to the 7 million informal caregivers of older 
Americans. In addition, the FY 2001 budget includes increases 
for each of its core services and programs, including home-
delivered and congregate meals; preventive health; grants to 
Native Americans, programs which protect the rights of the 
vulnerable, as well as an increase for the Alzheimers Disease 
Demonstration Project Grants to States.

       Accomplishments of the Administration on Aging: 1999-2000


                Administration/Departmental Initiatives

    Since 1995, the Administration on Aging has been a partner 
in the Administration's Operation Restore Trust initiative, 
along with HCFA, the Office of the Inspector General, and the 
Department of Justice to combat waste, fraud and abuse in 
Medicare and Medicaid. AoA has trained state and local 
ombudsmen and volunteers, aging network personnel, including 
staff and volunteers of State and Area Agencies on Aging, 
health insurance counselors and other service providers to 
identify and report suspected fraud and abuse. In FY 2000, $10 
million in grants was awarded to 48 ``Senior Medicare Patrol 
Projects'' operating in 43 states plus the District of Columbia 
and Puerto Rico. These projects have trained approximately 
30,000 senior volunteers and aging network staff and educated 
650,000 beneficiaries to identify and report suspected cases of 
fraud and abuse.
    Reauthorization of the Older Americans Act (OAA) with 
inclusion of the National Family Caregiver Support Program, 
part of the Administration's Long Term Care Initiative unveiled 
in 1999, which will help hundreds of thousands of family 
members care for their older family members by providing 
respite care and supplemental services, information, 
assistance, training, support and counseling. FY 2001 funding 
for the National Family Caregiver Support Program is $125 
million.

                  Public Information/Customer Service

    Launching of AoA's web site in 1995, a major source of 
timely and useful information to older people, the national 
aging network, policymakers. AoA's web site has been expanded 
to include limited access web sites for the Federal 
Coordinating Committee of the International Year of Older 
Persons (1999); a limited Spanish web site containing resource 
and referral information to those interested in Hispanic aging 
and health issues, and an independent web site dedicated to 
providing and sharing information about the Administration on 
Aging's role in the Administration's effort to fight fraud, 
waste and abuse in Medicare and Medicaid. In FY 2000, a 
minority/aging issues limited access web site and an on-line 
caregivers guide called ``Because We Care'' was added.
    Institution in 1999 of a limited access list serve 
specifically devoted to national aging network of state and 
area agencies on aging responsible for the collection and 
reporting program performance data to the Administration on 
Aging. Through NAPISNEWS, customized information and technical 
assistance can be quickly disseminated and provided to 
appropriate staff throughout the country.
    Creation of a Congressional mandated National Aging 
Information Center to provide convenient access to a wide range 
of resources for those interested in aging issues and 
information. The Center serves the aging network, educators, 
researchers, practitioners and the general public.
    Establishment of AoA's national disaster assistance program 
to assist older persons and representatives of the aging 
network in recovery efforts from Presidentially declared 
disasters. Since 1993, the Administration on Aging in 
collaboration with its state and area agencies on aging, FEMA, 
and the Red Cross has provided approximately $17.5 million in 
disaster relief to thousands of older persons in immediate need 
of assistance.

                            Medicare+Choice

    Since 1998, AoA has worked in partnership with the Health 
Care Financing Administration (HCFA) to support Medicare+Choice 
(M+C) implementation. Through the Information and Referral for 
Medicare Beneficiaries Projects, AoA was able to provide funds 
to State Units on Aging (SUAs) to strengthen the capability of 
information and referral providers at the State, Area Agency 
and local levels to respond to inquiries regarding M+C. In 
addition, AoA worked in collaboration with it's National 
Information and Referral Support Center and HCFA to develop the 
Medicare+Choice Training Manual for Older Americans Act 
Information Referral & Assistance Programs. The manual was 
provided to State Units on Aging and Area Agencies on Aging to 
assist them in developing Medicare+Choice training and outreach 
activities. Over 15,000 information and referral specialists 
and other Aging Network staff have received training as a 
result of this collaborative effort.

                     National Symposia on Longevity

    The Administration on Aging convened two symposia during 
1999 and 2000 which focused on the implications of a long 
living society. The symposia were designed to increase public 
awareness of longevity, provide a forum for dialogue about the 
implications for research, policy, programs and services, and 
foster the development of partnerships and collaborations 
between a variety of organizations. The first symposium focused 
on the most potent and promising research findings related to 
caregiving, economic security, health, population diversity, 
consumer protection, information and technology and media 
relations. The second symposium bridged the gap between 
research and practice by providing the participants evidenced-
based, outcomes-oriented methods and tools that could be used 
to plan, develop and modernize services and programs for 
America's diverse and growing older population.

               Programs and Services for Older Americans

    The Older Americans Act continues to provide essential home 
and community services for older persons, and their family 
members such as nutrition, transportation, and legal 
assistance, through a national aging network of 57 State 
offices on aging, 655 area agencies on aging, 225 Tribal 
Organizations, service providers and volunteers.

                               Nutrition

    Release of a Congressionally mandated evaluation of the 
Elderly Nutrition Program under the Older Americans Act (OAA) 
to determine the effectiveness of the Elderly Nutrition Program 
in meeting the nutritional needs of older persons as well as 
meeting unmet needs. Key findings include determination that 
the highly successful OAA Elderly Nutrition program provides an 
average of one million meals per day to older Americans; 
between 80 and 90 percent of participants have incomes below 
200 percent of the DHHS poverty level, and more twice as many 
of the participants live alone.
    Establishment of the National Policy and Resource Center on 
Nutrition and Aging which focuses on providing information 
dissemination, training and technical assistance and policy 
analysis on issues related to nutrition and older persons.
    The Morning Meals on Wheels Program Initiative was launched 
in 20 communities across the United States. This is a 
partnership with General Mills Food service and the 
Administration on Aging to provide at-risk older Americans with 
additional food and nutrition security. Morning Meals on Wheels 
provides home elders with a morning meal delivered to their 
door in addition to their regularly scheduled noon meal.
    Alzheimer's Disease Demonstration Grants program was 
transferred from HRSA to AoA. Sixteen new ADDGS grants were 
funded in 2000, to expand support efforts for persons with 
Alzheimer's Disease and their caregivers.The program emphasizes 
outreach to under served populations and regions, program 
development, service delivery systems and information 
dissemination.
    AoA convened its first Tribal Listening Session to Native 
American elder issues. The session gave American Indians, 
Alaska Natives, and Native Hawaiian representatives the 
opportunity to discuss policy directions and capacity building 
in areas such as long term care, health promotion, and support 
services needed in the future. Greater numbers of Native 
Americans are living well into their 80's and 90's. AoA funds 
225 tribal organizations representing more than 300 American 
Indian and Alaska Native tribes and two organizations serving 
Native Hawaiians, through Title VI of the Older Americans Act.

                          Consumer Protection

    Release of the National Elder Abuse Incidence Study which 
found that more than one half million older Americans, mostly 
older women, suffered some form of abuse and neglect in 1996, 
most at the hands of their family members.
    Entered into Interagency Agreement with the Department of 
Justice to address the public safety and security needs of 
older Americans. Activities have included promotion of local 
and state TRIAD programs, which are efforts to increase 
cooperation between law enforcement and aging and social 
services providers to reduce criminal victimization.
    Funding a new National Center on Elder Abuse to be operated 
by the National Association of State Units on Aging in 
partnership with the other advocacy organizations to facilitate 
training and technical assistance between state and local 
service providers, including older Americans, working to 
prevent elder abuse.
    Establishment of Pension Counseling and Counseling program 
including 10 AoA-funded pension demonstration projects serving 
14 states and one technical assistance Project for a total of 
$3.3 million dollars. These projects have assisted 30,000 
retirees, older employees and their spouses or widows/widowers 
to determine whether or not they are receiving the amount of 
retirement benefits to which they are entitled. The project has 
recouped at least $21 million in pension benefits on behalf of 
their clients returning $7 for every $1 spent to older 
Americans. AoA also released results of a two-year 
Congressional study of the Pension Counseling Program, which 
found that basic pension counseling for older workers and 
retirees is needed, can be easily provided at a moderate cost 
by training volunteers, and can yield substantial individual 
and collective savings.
    Design and Implementation of the National Ombudsman 
Reporting System (NORS) to obtain needed detailed ombudsman 
complaint and program information in an effort to design policy 
and serve as a baseline against which to measure program 
outcomes in future years. Funding of the National Long Term 
Care Ombudsman Resource Center, which provides training and 
technical assistance to state and local ombudsmen across the 
country.
    Partnership with the Federal Deposit Insurance Corporation 
in the Financial Literacy, Y2K and Banking Campaign, a public 
awareness campaign to promote financial literacy in particular 
between women and low income and minority populations.

                  Promoting Health and Quality of Care

    AoA has awarded four demonstration grants to expand the 
Centers for Disease Control's Reach 2010 (Racial and Ethnic 
Approaches to Community Health 2010) initiative. This grants 
will permit four communities to develop science based, 
community demonstration projects to address health disparities 
in older, racial and ethnic minority populations.
    AoA and HCFA joined forces to improve the quality of care 
in nursing homes. Nearly one half million dollars has been 
dedicated to support 4 demonstration projects to educate and 
empower communities and families to improve nutrition and 
hydration, and prevent abuse of nursing home residents.

                               Management

    To develop the national core set of performance outcome 
measures for aging services required by the Government Results 
and Performance Act, AoA is building on performance outcome 
measures currently in use by state and area agencies. Seventeen 
State and Area Agency partners are working to address the 
elements of data collection; analysis and recommendations; 
pilot testing, and dissemination, utilization and mentoring 
activities.
    The Administration on Aging was one of the first in HHS to 
undertake a workforce planning process. In early 1999, it 
completed a workforce plan to identify requisite knowledge, 
skills, and abilities for management and staff to be able to 
formulate, implement and assess programs and policies related 
to older persons and their families. The workforce plan serves 
as a guide for the recruitment and hiring of new managers and 
staff.
    The Administration on Aging embarked upon the reorientation 
of its Central and Regional Office program and policy foci in 
order to respond more effectively to the growing numbers and 
the increasing diversity of older Americans and their families, 
baby boomers anticipating their older years, and of populations 
at greater risk of chronic illness, disability and economic 
security.

                        International Activities

    AoA chaired and led national federal activities for the 
International Year of Older Persons, designated by the UN for 
1999. As head of the Federal Committee for the International 
Year for Older Persons, AoA convened the first ever federal 
symposium ``Coming of Age: Federal Agencies and the Longevity 
Revolution.'' As part of the IYOP activities, the Assistant 
Secretary for Aging addressed the 54th Session of the United 
Nations General Assembly on the aging challenges of a longer 
living U.S. society.
    Joined as a partner with Sister Cities International, Inc. 
which joins aging professionals and volunteers in the US with 
their counterparts in other countries to provide technical 
assistance in meeting the needs of any population.
    The Administration on Aging is a principal partner in the 
US-Mexico Bilateral Commission Health Working Group convened as 
part of the 1996 Annual Meeting of the US-Mexico Bilateral 
Commission. AoA assists in the identification of public health 
issues that effect both countries including aging, migrant 
health, prevention of tobacco abuse, women's health, 
immunization, and substance abuse.
    AoA was a member of the 1999 World Health Day Advisory 
Committee. ``Healthy Aging'' was designated by the World Health 
Organization as the topic of World Health Day 1999. In the US, 
the theme ``Healthy Aging, Healthy Living - Start NOW! was 
selected by the American Association for World Health and the 
advisory committee as fitting since 1999 was IYOP.

                          Network Security/Y2K

    AoA was the first in the Department of Health and Human 
Services to achieve Y2K compliancy, and worked for two years 
with its national aging network of state and area agencies on 
aging to ensure they were ready for the year 2000.
    Security of AoA's computer network has been improved in 
response to the President's Decision Directive 63 concerning 
anticipated cyberterrorism.

     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 2000, ASPE undertook or participated in the 
following analytic and research activities which had a major 
focus on the elderly.

                      1. Policy Development--Aging

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. The 
primary goals of the Federal Forum were to provide federal 
agencies a venue for discussing aging-related data issues and 
concerns that cut across agency boundaries, facilitate the 
improvement of existing aging data bases and the development of 
new sources of information, improve the dissemination of 
information on aging-related research and data, and encourage 
cross-national research and data collection on population 
aging. The Federal Forum was instrumental in gathering support 
for several important surveys of the aging U.S. population 
(e.g., the Health and Retirement Survey, the survey of Assets 
and Health Dynamics Among the Oldest-Old, and the Second 
Longitudinal Study of Aging) and produced several stand-alone 
reports including Trends in the Health of Older Americans and 
65+ in the United States.

                 2. Research and Demonstration Projects

Panel Study of Income Dynamics

    University of Michigan, Institute for Social Research
    Principal Investigators: James N. Morgan, Greg J. Duncan, 
Martha S. Hill
    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 gathered 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--$200,00; 
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--150,000; FY96--205,000; 
FY97--100,000; FY98: $200,000
    End Date: Ongoing

1999 NLTCS/ICS: File Preparation and Preliminary Data Analysis

    MEDSTAT Group
    The purpose of this project is to prepare the 1999 NLTCS/
ICS data file for analysis and to perform some preliminary 
descriptive analyses. This is a necessary prerequisite for more 
detailed analyses, which will be used to update the ASPE 
booklet ``Informal Caregiving: Compassion in Action'' 
(published in 1998, based on 1995 NLTCS data).
    Funding: $49,452 (FY00)
    End Date: September 30, 2001

A Comparative Study of the Outcomes and Costs Associated with Medicare 
        Post-Acute Services in Skilled Nursing Facilities, 
        Rehabilitation Hospitals/Units, and Home Health Settings

    University of Colorado
    Using the outcome measurement instrument developed for 
patients suffering from a stroke (i.e., developed under the 
project Medicare Post-Acute Care: Quality Measurement), two 
projects have been combined to study the outcome and costs of 
Medicare post acute care services for Medicare beneficiaries 
who have suffered a stroke and are discharged from acute care 
hospitals to skilled nursing facilities (SNFs), rehabilitation 
hospitals/units (RFs), home health agencies (HHAs), or use 
multiple post-acute care settings. These studies will examine 
in a post-prospective payment system environment the: (1) 
demographic and health related characteristics of and assess 
the extent of overlap in stroke patients treated in each of the 
post-acute care settings; (2) patterns of service use and costs 
associated with the treatment of similar patients in each 
setting and across episodes of care; (3) outcomes across an 
episode of care for similar Medicare beneficiaries treated by 
each post acute provider type and those treated by multiple 
providers; (4) the relationship between outcomes for similar 
patients and differences in the mix and intensity of services 
provided, and level of reimbursement across post acute care 
providers and episodes of care; and (5) core measures that are 
most useful to incorporate into on-going reporting requirements 
to monitor outcomes in each post-acute care setting and across 
episodes of care.
    Funding: Total Award $1,593,536 (FY99 $898,956; FY00 
$694,580)
    End Date: August 28, 2003

Analyses of Changes in Elderly Disability Rates: Implications for 
        Health Care Utilization and Costs

    The Urban Institute
    The purpose of this project is to conduct analyses using 
the 1984 to 1999 National Long-Term Care Survey (NLTCS) and the 
Medicare Current Beneficiary Survey (MCBS) to understand the 
nature of recent declines in elderly disability rates and their 
implications for health care utilization and costs. 
Specifically, researchers at The Urban Institute are (1) 
decomposing changes in elderly disability rates using the 1984 
to 1999 NLTCS and exploring possible reasons for the decline, 
and (2) linking changes in elderly disability rates to the use 
of specific medical procedures (e.g., cataract surgery, 
coronary and joint replacement surgeries) and/or assistive 
technology. The MCBS is the primary data set for the latter 
analyses.
    Understanding the structure of the decline will give us our 
first clues as to the reasons for the overall decline, the 
likelihood that disability rates will continue to fall in the 
future, and its potential impact on health care spending. 
Current hypotheses for the decline include improvements in 
nutrition (including advances in food preparation and storage 
over the century), healthier life-styles (higher levels of 
physical activity, lower levels of drinking and smoking), 
better treatment of chronic diseases through medical procedures 
and pharmaceuticals, and use of assistive devices and 
technology. It is likely that future improvements in disability 
and changes in health care utilization and spending will be 
heavily dependent on which of these hypotheses is correct. For 
example, if declines in disability rates are due primarily to 
improvements in IADLs or equipment use and reflect 
environmental changes rather than improvements in the intrinsic 
health of the elderly population, then the declines observed 
over the last decade may not continue into the next century and 
may have limited impact on acute health care spending. This 
project is a first step in understanding the policy 
implications of the changes that we are observing in elderly 
disability rates.
    Funding: $254,409 (FY99 $179,409; FY00 $75,000)
    End Date: December 31, 2001

Analyses of Residential Transition of Older Americans.

    Urban Institute
    There are four main questions to be addressed in this 
project: (1) How do characteristics (both individual and 
environmental) of elderly persons residing in institutional 
settings differ from those residing in community-based 
settings? (2) How do these characteristics vary over time? (3) 
Are there differences in these characteristics between 
subgroups of institutionalized and non-institutionalized 
elderly? (4) What is the relationship between selected 
individual and environmental factors and the transition of the 
elderly between community and institutional residential 
settings? Data from six years of the Medicare Current 
Beneficiary Survey will be used to answer these questions. 
Understanding residential transitions will help staff in the 
Department improve surveys that monitor acute health and long-
term care use in different settings (e.g., the Medical 
Expenditure Panel Survey) and address outstanding long-term 
care policy issues (e.g., allocation of resources between 
community and institutional settings).
    Funding: Total Award $153,494 (FY00 $153,494)
    End Date: March 31, 2002

Assessment of Home Care Benefits Used by Holders of Private Long-Term 
        Care Insurance

    Life Plans, Inc.
    Most experts agree that long-term care insurance products 
must include both nursing home and home care benefits if they 
are to be commercially acceptable. Yet private insurers as well 
as public payers are concerned about their ability to control 
home care claims, particularly given the potential substitution 
of formal home care services for care provided by families. The 
purpose of this study was to collect detailed information on 
the experience of long-term care policy holders who have filed 
insurance claims to receive home care benefits and how their 
formal and informal service use compares to a comparable 
population of elderly persons without private insurance. 
Primary data collection involved face-to-face interviews with 
approximately 1,000 persons (500 disabled insurance claimants 
and 500 next-of-kin of those claimants) to collect information 
on functional and medical characteristics of claimants as well 
as formal and informal services use. The sample of claimants 
was drawn from the files of insurance companies that account 
for the majority of private long-term care policies now in 
force.
    Funding: $50,000
    End Date: March 1, 2000

Case Studies of Nursing Home Transition Programs

    Medstat Group
    The purpose of this project is to conduct case studies of 
Nursing Home Transition Programs in up to eight states (with 
possible additions depending on future grant awards). The 
programs being evaluated were developed and implemented with 
funding from an ongoing grant initiative sponsored by the 
Health Care Financing Administration (HCFA) and the Office of 
the Assistant Secretary for Planning and Evaluation (ASPE). A 
case study approach is proposed for two reasons: (1) the vast 
differences in state Medicaid programs, state long-term care 
infrastructures, and proposed nursing home transition programs; 
and, (2) the small number of nursing home residents expected to 
participate in the transition programs.
    Each case study will attempt to determine the most 
significant barriers faced by nursing home residents in 
returning to the community, and, to glean the relative success 
or failure of the strategies used by grantees to overcome these 
barriers. As HCFA and ASPE intend to continue making additional 
grants in this area, an evaluation of grantee activity will 
assist federal policy makers in further grant making, and state 
policy makers in developing transition programs.
    Funding: Total Award $300,006 (FY00 $300,006)
    End Date: February 1, 2002

Characteristics of Nursing Home Residents

    Hebrew Rehabilitation Center for Aging
    Caring for persons with disabilities in the least 
restrictive setting is a major long-term care policy objective. 
It is important to identify nursing home residents who could be 
discharged to the community if appropriate home and community-
based services were available. This project will analyze data 
from a new source--the Minimum Data Set (MDS)--in nine states. 
The MDS consists of assessments which have been conducted on 
all nursing home residents in selected States as part of a HCFA 
demonstration (and starting in the summer of 1998, the data 
will be collected in electronic form in all 50 States). We will 
learn much more about the medical conditions, functional needs, 
and specific services used by nursing home residents than was 
possible with previous data sets. We will also be able to study 
important subpopulations, especially the nonelderly. The policy 
implications of the findings will be assessed.
    Funding: Total Award $150,000 (FY98 $150,000)
    End Date: September 30, 2001

Evaluation of Practice in Care (EPIC)

    University of Colorado
    From 1989 to 1992, there was a 210 percent increase in 
Medicare expenditures for home health services. This increase 
in utilization has generated widespread policy interest in 
appropriate measures to control expenditures without 
compromising quality. Medicare home health has been the subject 
of considerable research, but the actual practice of home 
health care has not been extensively examined. This study will 
analyze ``episodes'' of care under the Medicare home health 
benefit, assess the actual practice of care, the extent to 
which there is variation in practice between acute and long-
term patients, and the factors that account for that variation. 
This study will also examine decision-making processes between 
patients, providers and physicians. What takes place during a 
visit and between visits as ``actual practice'' has never been 
measured. Furthermore, the function of decision-making by 
various parties has not been observed in ``actual practice.'' 
This effort to understand issues surrounding regional and 
practice variations of home health care delivery will aid the 
Department and the industry in combating fraud and abuse, as 
well as contribute valuable data to a future prospective 
payment system.
    Funding: Total Award $1,400,000 (FY97 $200,000)
    End Date: March 1, 2001

Informal Caregivers Supplement to the 1999 National Long-Term Care 
        Survey.

    Duke University
    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) has been involved in the past in designing a 
modest respite benefit for Medicare beneficiaries with 
Alzheimer's disease for inclusion in the President's budget. In 
1998, there is renewed interest in having proposals for respite 
services and other caregiver supports, on a broader scale, 
incorporated into the President's long-term care budget 
initiative. We are currently working with White House, OMB, and 
Treasury staff to explore the use of tax incentives to help 
informal caregivers be able to afford paid home care services 
as a supplement to their own informal efforts. In order to 
respond to these kinds of policy analysis requests, it is 
important for ASPE to look ahead and anticipate future data 
needs. In this case, the need is to have data collection 
mechanisms in place to track, over time, changes in the 
characteristics of informal caregivers of the disabled elderly, 
as we have to follow changes in the population of disabled 
elders themselves. ASPE supported the first and second Informal 
Caregiver's Supplement to the National Long-Term Care Survey in 
1982 and 1989 respectively. A third round of data collection on 
informal caregivers is now needed in order to remain up-to-
date.
    Family members typically initiate the process of nursing 
home placement for disabled elders when they feel that the 
disabled elder needs more help than can be provided in a home 
setting. Often families come to such a decision when one or 
more family caregivers have been providing upwards of 60 hours 
per week of unpaid assistance. This project will enable in-
depth analysis of the conflicts informal caregivers experience 
between employment and eldercare as well as provide information 
about the health status of caregivers and measures of caregiver 
stress and burden. These data can then be used in crafting 
policy initiatives to support caregivers and prevent 
``caregiver burnout'' which could result in premature 
institutionalization. It will help determine whether and to 
what extent caregivers' age, marital status, relationship to 
the care recipient, household income, employment, health 
status, and various measures of caregiver stress and burden are 
associated with greater or lesser use of supplemental formal 
care. We will also be able to measure the extent to which 
caregivers as well as the disabled elders themselves experience 
out-of-pocket spending for supplemental home care.
    Funding: Total Award $300,000 (FY98 $300,000)
    End Date: March 1, 2000

Long-Term Care Microsimulation Model

    Lewin Group
    This project will update and expand the capability of the 
Brookings/ICF Long-Term Care Financing Model, which currently 
takes a national sample of persons, ages them over time, and 
estimates their long-term care use and financing when they 
become elderly. It will incorporate results from recent surveys 
of nursing homes and home care utilization; e.g., the 1989 and 
1994 National Long-Term Care Surveys. The model will also be 
expanded to include acute care use and expenditures, and the 
period of simulation will be extended to 2030. The economic 
assumptions will be updated.
    The model will continue to be used to project future trends 
and to perform policy simulations, including expanded coverage 
for nursing home and home care, changes in Medicaid eligibility 
and services, and expanded enrollment in private long-term care 
insurance plans. It will also be used to estimate the impact of 
changing trends in disability and the combined burden of acute 
and long term care services on the elderly.
    Funding: $1,304,820 (FY97 $232,266; FY98 $211,709)
    End Date: December 31, 2000

Managed Delivery Systems for Medicare Beneficiaries with Disabilities 
        and Chronic Illnesses

    Mathematica Policy Research
    The last decade has brought tremendous changes in the 
health care system as payers and providers struggle to bring 
health care expenditures under control. The momentum to achieve 
a reformed, more managed U.S. health care system, one which 
seeks to bring costs under control while improving access to, 
continuity and coordination of care, appears unstoppable. 
However, it remains unknown how this transforming health care 
system will affect the health and well-being of people with 
significant disabilities and chronic illnesses. The Medicare 
program has lagged behind the private insurance market and even 
the Medicaid program in the proportion of its beneficiaries 
participating in managed care plans. In 1995, about 2.3 million 
older persons out of a total Medicare beneficiary population of 
25 million were enrolled in the Medicare Risk Program 
implemented under TEFRA. There is little information on the 
experience of older persons with disabilities in these and 
other managed care plans.
    The purpose of this study is to: (1) address the 
characteristics of elderly persons with chronic illnesses and 
disabilities that need to be accommodated in designing and 
operating managed delivery systems (MDS); (2) examine the 
issues that health care policy makers, plan administrators and 
providers need to consider in designing, operating, and 
monitoring MDS for the elderly with disabilities and chronic 
illness; (3) examine how MDS actually perform in meeting the 
needs of the elderly disabled; and (4) identify the factors 
that influence the success of MDS in meeting the needs of this 
population.
    Funding: Total Award $349,450 (FY97 $244,450; FY00 
$105,000)
    End Date: May 31, 2001

Medical Expenditure Panel Survey (MEPS) Nursing Home Component

    Medstat Group
    The Office of the Assistant Secretary for Planning and 
Evaluation (ASPE) and the Agency for Health Care Policy and 
Research (AHCPR) entered into this Interagency Agreement for 
the purpose of allowing ASPE and an ASPE contractor (The 
MEDSTAT Group) access to the Nursing Home Component of the 1996 
Medical Expenditure Panel Survey (MEPS) including the Community 
Caregiver Supplement. Through its contractor, ASPE will edit 
and prepare data files and analyze data from the MEPS Nursing 
Home Component and the Community Caregiver Supplement. The 
purpose of the ASPE-supported analyses is to better understand 
how to promote and improve home and community-based services as 
opposed to institutional services for persons with significant 
functional disabilities.
    End Date: July 1, 2000

Medicare Post-Acute Care: Quality Measurement

    Urban Institute
    This project developed four outcome measurement instruments 
and methods of data collection that could be used in future 
research to examine outcomes and costs associated with Medicare 
post-acute care (PAC) services for patients who have suffered a 
stroke, congestive heart failure(CHF), pneumonia, and back and 
neck conditions. These conditions were selected because of 
their prevalence within and across PAC settings. The 
instruments and the data collection methodology will be revised 
based on two field tests and technical expert input. The 
outcome measurement instrument developed for stroke patients 
will be used in other ASPE funded studies (i.e., A Comparative 
Study of the Outcomes and Costs Associated with Medicare Post-
Acute Services).
    Funding: Total Award $482,943 (FY97 $321,035; FY99 
$161,908)
    End Date: December 31, 2000

Monitoring the Health Outcomes for Disabled Medicare Beneficiaries

    Laguna Research Associates
    The Balanced Budget Act (BBA) of 1997 mandated major 
changes in home health payment requiring the implementation of 
a Prospective Payment System (PPS) by October 1999 (later 
delayed until October 2000) and an Interim Payment System (IPS) 
prior to the implementation of PPS. It also contained changes 
in eligibility and coverage for home health services. These 
changes, while intended to reduce Medicare home health costs, 
run the risk of reducing beneficiaries' access to appropriate 
care and adversely affecting health outcomes, especially for 
beneficiaries needing the most care (Komisar and Feder 1998, 
Smith and Rosenbaum 1998, MedPAC 1999, GAO 1998, Gage, 1998). 
Disabled Medicare beneficiaries are especially vulnerable.
    The purpose of this project is to study the impact of 
recent payment policy changes on disabled Medicare 
beneficiaries' satisfaction and quality of life with a view 
toward formulating inferences that will inform national home 
health care policy for the disabled. The study will build on a 
research project recently funded by the Home Care Research 
Initiative of The Robert Wood Johnson Foundation that examines 
the direct and indirect effects of the BBA changes. The 
project's main focus is to examine BBA impacts on Medicare 
beneficiaries' access to care, costs, satisfaction, and quality 
of care. Also examined will be the effects on agencies and on 
the overall health system.
    Funding: Total Award $150,000 (FY99 $150,000)
    End Date: September 30, 2001

National Study of Assisted Living for the Frail Elderly

    ``Assisted living'' refers to residential settings for 
people with disabilities which combine both housing and 
personal assistance services within a homelike or 
noninstitutional environment. The number of assisted facilities 
nationally is not known; estimates range from 8,000 to 30,000. 
Similarly, estimates for the number of frail elderly and other 
persons residing in such facilities range from 350,000 to 
1,000,000. This study will, among other things, generate a more 
reliable estimate of the number of these facilities and their 
residents. As assisted living options multiply, a challenge 
facing the Federal and State governments is how to regulate 
such arrangements, balancing consumer protection concerns 
(especially if public funds reimburse costs) with resident 
rights for self-direction, taking risks and maintaining 
accustomed lifestyles.
    The major purpose of this project is to analyze the role of 
assisted living within the current long-term care system from 
the perspective of consumers, owners/operators, workers, 
regulators, investors and other stakeholders, and to issue a 
report on its current status and future directions. The study 
will address several broad policy-relevant issues, including 
supply and demand trends; barriers; how closely practice 
parallels philosophy; the impact of key features on outcomes; 
and quality and accountability. The contractor will assist HHS 
and other Federal agencies in the formulation of regulatory and 
financing policy options for assisted living. A Technical 
Advisory Group has been established to provide guidance to the 
contractor.
    Funding: Total Award $2,025,000 (FY98 $350,000; FY99 
$75,000)
    End Date: June 30, 2000

``Cash and Counseling'' Demonstration/Evaluation.

    University of Maryland, Center on Aging
    This project, which is being done in collaboration with the 
Robert Wood Johnson Foundation, will employ a classical 
experimental research design (i.e., random assignment of 
participants to treatment and control groups) to test the 
effects of ``cashing out'' Medicaid-funded personal assistance 
services for the disabled. The demonstration will include 
elderly as well as younger disabled consumers. Two States are 
expected to participate in the demonstration. In these States, 
control group members will receive ``traditional'' benefits--
i.e., case managed home and community-based services, where 
payments for services are made to vendors--while treatment 
group members receive a monthly cash payment in an amount 
roughly equal to the cash value of the services they would have 
received under the traditional program.
    It is hypothesized that cash payments will foster greater 
client autonomy and that, as a result, consumer satisfaction 
will be greater. Consumers are expected to purchase a somewhat 
different mix of disability-related services and/or assistive 
technologies when they make the decisions and payments 
themselves than when case managers contract with vendors on 
their behalf. It is also hypothesized that States will save 
Medicaid monies (mostly in administrative expenses) from 
cashing out benefits. The analysis will consider the effects of 
the demonstration according to the varying characteristics of 
the consumers including age, disability, gender, family 
support, and other factors.
    Funding: Total Award $1,902,794 (FY97 $350,000; FY98 
$111,389; FY99 $250,000; FY00 $191,405)
    End Date: September 30, 2004

Synthesis and Analysis of Medicare Hospice Benefits

    Urban Institute
    The rapid rise in Medicare hospice expenditures, 
particularly on behalf of nursing home residents, has drawn the 
attention of a wide variety of health policy makers and the 
Office of the Inspector General (OIG). In a recent study, the 
OIG recommended ways to modify how Medicare and Medicaid pays 
for hospice services. Most experts agree that, however, that a 
larger study is needed to examine key hospice trends nationally 
and in selected States. This current study will collect 
additional information on the Medicare hospice benefit, 
including trends in utilization and expenditures, who is 
covered, and in which care settings. This information will help 
inform health policy makers as they consider alternative 
hospice benefit and payment designs.
    End Date: April 1, 2000
    Funding: Total Award $234,970.04 (FY97 $174,980.60; FY98 
$59,989.44)

Synthesis and Analysis of Medicare Post-Acute Care Benefits and 
        Alternatives

    Urban Institute
    This two-part project synthesized what was known about: (a) 
coverage and payment policies for post-acute care (PAC); (b) 
predictors of PAC use and nonuse and of the type, amount, and 
duration of PAC use; (c) PAC utilization including 
characteristics of PAC patients, patterns of PAC utilization, 
and geographic distribution of providers; (d) Medicare 
expenditures during the course of PAC episodes; (e) outcomes of 
patients in and across PAC settings; and (f) State policies 
designed to maximize Medicare PAC coverage.
    The first report, ``Medicare's Post-Acute Care Benefits: 
Background, Trends, and Issues to be Faced'', provides 
background on post-acute care expenditures and utilization, and 
Medicare policy changes that have contributed to these trends; 
the supply and changes in distribution of post-acute care 
providers; beneficiary, provider, and market characteristics 
associated with differential post-acute care provider use; and 
issues that need to be addressed regarding Medicare post-acute 
care services.
    The second report, ``Interviews with Provider and Consumer 
Groups, and Researchers and Policy Analysts'', summarizes 
discussions with key stakeholders regarding issues with 
Medicare's skilled nursing facility, home health, 
rehabilitation and long-term care hospital benefits. Many 
comments were raised regarding the impact of the changes 
enacted in the Balanced Budget Act on these benefits.
    Funding: Total Award $227,675.88 (FY97 $162,731; FY99 
$64,944.88)
    End Date: May 2000

The Contribution of Changes in Medication Use to Improvements in 
        Functioning among Older Adults

    Philadelphia Geriatric Center
    A possible explanation for the recently observed decline in 
the prevalence of disability in the U.S. elderly population is 
that better treatment of chronic diseases through medical 
procedures and pharmaceuticals has led to an improvement in 
functioning in the elderly population. Lending some credence to 
this hypothesis is research by Freedman and Martin (forthcoming 
in the American Journal of Public Health) that documents an 
increase in the prevalence of chronic health conditions such as 
arthritis, diabetes, stroke and heart disease during the same 
period that disability has fallen. They hypothesize that 
changes in the management of chronic disease--and changes in 
medication use in particular--have caused chronic health 
conditions to become less debilitating as their prevalence has 
increased.
    This project supplements an existing National Institute on 
Aging. Under that grant, the role of changes in the use of 
medications in explaining aggregate changes in functioning in 
the U.S. population aged 51-61 will be examined. The data sets 
for the analyses are the first (1992) and fourth (1998) waves 
of the Health and Retirement Survey (HRS), which provide 
nationally representative cross-sections of the 
noninstitutionalized population in this age range.
    Funding: Total Award $125,000 (FY00 $125,000)
    End Date: September 30, 2001

               CENTERS FOR DISEASE CONTROL AND PREVENTION


  National Center for Chronic Disease Prevention and Health Promotion

    CDC's National Center for Chronic Disease Prevention and 
Health Promotion (NCCDPHP) is involved in a wide array of 
chronic disease prevention and control activities on behalf of 
older Americans. NCCDPHP programs include musculoskeletal 
diseases (osteoarthritis, osteoporosis), cardiovascular health, 
Alzheimer's disease, urinary incontinence, the health care and 
long-term care needs of women and minorities, health status 
surveillance, physical activity promotion, disability 
prevention, diabetes management, cancer prevention and control, 
oral health, and the elimination of health disparities. Each is 
reviewed briefly below.

                               Arthritis

    Arthritis and other musculoskeletal diseases are prevalent 
and disabling chronic diseases, affecting approximately 38 
million persons in the United States. Data indicate that 49.4 
percent of persons 65 years and older have symptomatic 
musculoskeletal diseases and 11.6 percent of persons in this 
age group have arthritis as a major or contributing cause of 
activity limitation. Data are needed to describe the natural 
history of disease as well as to direct development of 
effective intervention efforts. To address the burden of 
arthritis, NCCDPHP:
           widely disseminated the National Arthritis 
        Action Plan--A Public Health Strategy. This plan was 
        released in November of 1998 and was developed under 
        the leadership of CDC, the Arthritis Foundation, and 
        the Association of State and Territorial Health 
        Officials. The plan proposes action in three major 
        areas: surveillance, epidemiology, and prevention 
        research; communication and education; and programs, 
        policies, and systems. It is designed to encourage 
        public health organizations, arthritis organizations, 
        and other interested organizations to work together at 
        the national, state, and local levels.
           analyzed the Arthritis Self-Help Course. 
        This analysis showed the course to be a cost-saving 
        intervention from both the societal and health care 
        system perspectives.
           determined the prevalence of hip and knee 
        osteoarthritis among whites and blacks in Johnston 
        County, NC, a rural, southern county. The Johnston 
        County Osteoarthritis Project is beginning follow-up of 
        3200 Caucasian and African-American residents of a 
        rural North Carolina county to determine factors 
        associated with the development and progression of hip 
        and knee osteoarthritis--the leading causes of 
        arthritis disability.

                          Alzheimer's Disease

    Chronic neurological diseases, conditions common among 
elderly, causes high levels of morbidity, disability, family 
stress, and economic burden. For example, the costs due to 
dementias were estimated at $24-$48 billion in 1985, and will 
increase as the population ages. However, the epidemiology of 
these conditions is poorly understood. NCCDPHP is studying the 
epidemiology of Alzheimer's Disease to determine disease rates, 
risk factors, and prevention factors.

                  Health Care and Long-term Care Needs

    The WISEWOMAN (Well-Integrated Screening and Evaluation for 
Women in Massachusetts, Arizona, and North Carolina) program is 
funded by NCCDPHP to determine whether adding other preventive 
services such as cardiovascular disease risk factor screening 
and intervention to the National Breast and Cervical Cancer 
Early Detection Program is effective in improving the health 
status of uninsured women age 50 and older.
    NCCDPHP conducted an assessment of long-term care needs 
among older adults in the Indian Health Service Santa Fe 
Service Unit, New Mexico. The objectives of the project were 
(1) to provide estimates of the population of functionally 
dependent adults age 55 and over within the Santa Fe Service 
Unit (SFSU) and distinguish clinically relevant subgroups; (2) 
to document the extent of informal care provided by family 
members to elders with chronic care needs; (3) to analyze the 
strengths and weaknesses of the current formal long-term care 
service system within the SFSU to accommodate the needs of the 
target population.
    NCCDPHP has initiated the EnPOWER project to improve 
prevention services in older women in HMO's. The project aims 
to enhance and promote preventive health services for older 
women in a managed care setting.

                       Health Status Surveillance

    NCCDPHP conducts surveillance of the health status of the 
elderly. Projects include:
           the publication of ``Surveillance for 
        Selected Public Health Indicators Affecting Older 
        Adults United States,'' Morbidity and Mortality Weekly 
        Report, December 17, 1999;
           the assessment of the prevalence of 
        electroconvulsive therapy on older adults by age, 
        gender, and ethnicity;
           the assurance of complete, timely, and 
        accurate cancer surveillance data at the state, 
        regional, and national levels;
           the generation of national and state 
        estimates of the prevalence and incidence of diabetes, 
        the processes and outcomes of care, and the costs of 
        care in the Medicare population;
           the use of several health-related quality-
        of-life measures in the state-based Behavioral Risk 
        Factor Surveillance System (BRFSS) to track quality of 
        life in the States; and
           determination of the feasibility of a 
        Medicare claims-based surveillance system for possible 
        adverse effects of folic acid food fortification among 
        persons with vitamin B12 deficiency.

                                 Cancer

    More than 30 percent of deaths from breast cancer in women 
over age 50 are preventable through widespread use of 
mammography screening for early detection. The National Breast 
and Cervical Cancer Early Detection Program targets underserved 
women, including older women with low income, and women of 
racial and ethnic minority groups. NCCDPHP currently funds the 
50 states, 4 U.S. territories, the District of Columbia, and 15 
American Indian/Alaska Native organizations through this 
program.
    NCCDPHP supports a project to generate information about 
attitudes towards prostate cancer screening and treatment. The 
project investigates (1) how quality of life is related to 
early detection and treatment; (2) whether screening for 
prostate cancer actually reduces mortality; and (3) the 
development of appropriate health messages for men and their 
families about prostate cancer screening and early detection.
    NCCDPHP sponsors a program promoting the early detection of 
colorectal cancer. The objectives of the project are (1) to 
promote awareness and use of colorectal cancer screening among 
health care providers and the public, especially the older 
population; (2) to support research that promotes the inclusion 
of colorectal cancer screening in quality measures applied to 
managed care organizations; and (3) to support the development 
of standards for screening sigmoidoscopy.

                         Cardiovascular Health

    Recognizing the immense burden of CVD, in FY1998, Congress 
made available funding to initiate a national, state-based CVD 
prevention program, starting with eight states, and in FY1999 
to expanded to eleven states. In FY2000, CDC will spend more 
than $25 million for the prevention and control of CVD and its 
disabling conditions. These activities include:
           Funding 5-6 additional states to implement 
        CVD prevention and control programs with environmental 
        interventions and policy strategies.
           Assisting states to better measure the 
        burden of CVD, monitor progress in reducing risk 
        behaviors, and determine the economic cost of the 
        disease.
           Funding state programs and research that 
        address racial and ethnic disparities in CVD.
           Enhancing CDC's National Standards 
        Laboratory to improve state laboratory capacity and 
        tailor screening procedures for youth, elderly and 
        minority populations.
    While strategies for preventing CVD (lipid management, 
hypertension control, diabetes awareness, smoking cessation, 
dietary modification, and physical activity behavior) exist, 
more efficient and practical methods for reaching low-income 
women and making prevention services available to them are 
needed. The NCCDPHP is collaborating with the University of 
North Carolina Prevention Center to produce a monograph that 
describes appropriate research and programmatic methods and 
protocols for integrating cardiovascular disease screening, 
intervention, and evaluation programs aimed at financially 
disadvantaged women. This monograph will include 
recommendations for laboratory tests, clinical measurements, 
interviews and surveys, field procedures, program tracking 
systems, and analytic plans. It will include practical examples 
of how to integrate CVD screening and intervention into 
existing health service programs that come from the experience 
of the WISEWOMAN (Well Integrated Screening and Evaluation for 
Women) projects in North Carolina, Massachusetts, and Arizona. 
This monograph will be written as a practical guide for state 
and local health departments for use in designing and adapting 
their own integrated prevention programs.

                                Diabetes

    The burden of diabetes is heavier among elderly Americans. 
More than 18 percent of adults over age 65 have diabetes. 
NCCDPHP funds diabetes control programs (DCP) in all 50 states, 
the District of Columbia, and eight U.S. affiliated island 
jurisdictions to effect changes and improvements in systems 
that care for and support people with diabetes. The primary 
goal of the DCPs is to improve access to affordable, high-
quality diabetes care and services. Priority is on reaching 
high-risk and disproportionately burdened populations which 
include the aged. NCCDPHP provides resources and technical 
assistance to state-based diabetes control programs to:
           determine the size and nature of diabetes-
        related problems and why they exist,
           develop and evaluate new strategies for 
        diabetes prevention,
           establish partnerships to prevent diabetes 
        problems,
           increase awareness of diabetes prevention 
        and control opportunities among the public, the health 
        care and business communities, and people with 
        diabetes, and
           improve access to quality diabetes care to 
        prevent, detect, and treat diabetes complications.

                              Oral Health

    In the United States, 30,000 new cases of oral and 
pharyngeal cancer will be diagnosed this year, and more than 
8,000 people will die of these largely preventable cancers. 
About 1 in 3 adults has untreated tooth decay and 25 percent of 
adults older than 65 years have lost all of their teeth. Only 
about half of people with diagnosed oral or pharyngeal cancer 
survive more than 5 years; among African American men, only 
about a third survive. People who do survive are at increased 
risk of developing additional cancers and frequently have the 
physical and psychological scars of what is one of the most 
disfiguring of all cancers.
    CDC is working with a consortium of public- and private-
sector organizations to develop a national program to prevent 
oral and pharyngeal cancers and to promote early detection and 
treatment, which can improve long-term survival. With its 
partners, CDC is also working to promote cessation of tobacco 
use, which especially when combined with heavy alcohol use is 
the major risk factor for more than 75 percent of oral and 
pharyngeal cancers in the United States.
    CDC is also working to
           Enhance surveillance of oral diseases using 
        state- and community-based data
           Support water fluoridation through 
        surveillance, training, and quality assurance
           Influence oral health policy and practice by 
        developing and distributing guidelines based on sound 
        science, e.g., infection control, fluoride use
           Develop a national alliance of partners to 
        prevent and control oral cancer
           Train dental and public health professionals 
        through residency and fellowship programs

                   Elimination of Health Disparities

    Chronic diseases disproportionately affect racial and 
ethnic minority populations in the U.S. The leading causes of 
death and disability (such as cardiovascular disease) are 
dramatically higher among these populations. Rates of death 
from stroke are 60 percent higher among African Americans than 
among whites. The prevalence in diabetes is higher among every 
racial and ethnic minority compared to whites of similar age. 
Among persons 65 years of age or older with one or more 
physician visits in the past year, influenza and pneumococcal 
vaccination levels among African Americans and Hispanics are 
substantially lower than those of whites. Death rates due to 
cancers, such as prostate and breast, are often higher among 
minorities as well.
    NCCDPHP administers the Racial and Ethnic Approaches to 
Community Health Program (REACH 2010), a major part of the 
President's Initiative on Race. The goal of this program is to 
eliminate disparities in health status experienced by racial 
minority and ethnic populations in key health areas (including 
cardiovascular disease, diabetes, and immunizations) by the 
year 2010. REACH demonstration projects are two-phase projects 
through which communities mobilize and organize their resources 
in support of effective and sustainable programs that will 
eliminate the health disparities of racial and ethnic 
minorities. These demonstrations require collaboration of both 
program and research experts for the purpose of identifying 
and/or developing successful community-based disease prevention 
and health promotion models that can be replicated for the 
ultimate goal of eliminating health disparities among racial 
and ethnic minorities. In Phase I, REACH communities are 
granted 12 months to develop a Community Action Plan (CAP). 
Phase II communities are granted four additional years of 
funding to implement and evaluate the CAP. Thirty-two community 
coalitions were funded in FY1999. The California Endowment 
contributed funding to support three additional organizations 
in the state of California identified through CDC's competitive 
process. In FY2000, 24 Phase II and 14 new Phase I communities 
were funded.
    Through an inter-agency agreement, NCCDPHP provided $1 
million to the Administration on Aging (AoA) to fund four 
demonstration projects focusing on health disparities among 
older racial and ethnic minority populations. In addition to 
the four projects funded directly by the AoA, other REACH 2010 
communities include activities that impact aging populations as 
well. Elderly-specific projects were:
           Boston Public Health Commission was funded 
        to address cardiovascular disease (CVD), diabetes, and 
        immunization in elderly African American communities.
           The Latino Education Project, Inc. was 
        funded to address CVD and late-stage diabetes among 
        rural and urban elders of Hispanic decent.
           Special Services for Groups, Inc. was funded 
        to lead six community coalitions to address CVH, 
        diabetes, and immunization disparities among 
        individuals of Southeast Asian decent.
           National Indian Council on Aging, Inc. was 
        funded to lead a community coalition focused on Indian 
        and Alaska native elders in nine states.
    NCCDPHP funding will support Phase I of demonstration 
projects. These projects serve as the foundation for Phase II 
projects. The AoA is responsible for funding Phase II of REACH 
2010 contingent upon availability of funds.
    Cardiovascular disease (CVD) continues to be the leading 
cause of death in the United States for women. African-American 
women are at particular risk, with coronary heat disease (CHD) 
and mortality rates 35.3 percent higher and stroke rates 71.4 
percent higher than for white women. Low socioeconomic status 
(SES) is also associated with higher CVD incidence and 
mortality. NCCDPHP is collaborating with the University of 
Alabama at Birmingham Prevention Research Center to produce the 
``Women's Wellness Sourcebook Module III Heart Disease and 
Stroke''. The Sourcebook is a culturally-appropriate training 
curriculum designed to promote CVD prevention among low SES 
minority women by teaching Community Health Advisors (CHAs) to 
conduct risk-reduction counseling.
    The Johns Hopkins University Prevention Research Center, in 
partnership with the NCCDPHP, is exploring how church-based 
programs in Baltimore can help prevent or control chronic 
diseases. Program components include weight control and 
nutrition, exercise and fitness, and smoking cessation, offered 
in the church by trained lay leaders; interwoven with the 
spiritual life and activities of the church, such as prayer 
groups, sermons, testimony, choir practice, and meals.
    The St. Louis University Prevention Research Center, 
another NCCDPHP-supported center, has collected and analyzed 
determinants of physical activity among 3,000 US women aged 40 
to 75 years, including 600 each from the following subgroups: 
African-American, Asian/Pacific Islander, American Indian/
Alaska Native, Hispanic,White, and low education (high school 
or less).

               Disability Prevention and Health Promotion

    NCCDPHP is collaborating with the AARP, the American 
College of Sports Medicine, the American Geriatrics Society, 
the National Institute on Aging, and The Robert Wood Johnson 
Foundation to create a ``National Plan to Increase Physical 
Activity Among Adults Aged 50 and Older.'' These partners 
hosted the ``Blueprint Conference'' on physical activity 
promotion in Washington, DC on October 30-31, 2000.
    NCCDPHP funds the Center for Health Promotion in Older 
Adults at the University of Washington at Seattle, School of 
Public Health to promote health among men and women aged 65 
years or older. The Center evaluates the presence of social 
networks and the influence of healthy eating and physical 
activity on elderly residents of public housing units. The 
Center also focuses on reducing disability and falls in older 
adults through interventions to improve physical activity, 
nutrition, and home safety.
    NCCDPHP is collaborating with the Administration on Aging 
(AOA) on a review of AOA's state and territorial aging agency 
health promotion programs.
    NCCDPHP is collaborating with the Association of State and 
Territorial Chronic Disease Program Directors to document 
chronic disease prevention and control program activities 
within state and territorial health departments.
    NCCDPHP released a monograph on quality of life and 
indicators of healthy days at the 15th National Conference on 
Chronic Disease Prevention and Control, November 29, 2000, in 
Washington, DC.
    NCCDPHP's Office on Smoking and Health provides web-based 
educational materials for people who want to quit smoking and 
for clinicians who want to help them. For older adults, 
quitting smoking is one of the most important health actions 
they can take. Materials include:
           You Can Quit Smoking
           Don't Let Another Year Go Up In Smoke: Quit 
        Tips
           Treating Tobacco Use and Dependence: A 
        Clinical Practice Guideline, Public Health Service
    NCCDPHP is studying the cost-effectiveness of different 
interventions designed to prevent osteoporosis in women who are 
perimenopausal or postmenopausal.
    The Health Promotion and Education Database and Cancer 
Prevention and Control Database contain aging-related health 
information useful for health care providers and program 
planners in state health and aging agencies. The databases 
include literature and programmatic information about disease 
prevention, health promotion, and health education information 
on nutrition, smoking cessation, cholesterol, high blood 
pressure, injury prevention, exercise, weight management, 
stress management, diabetes mellitus, and breast and cervical 
cancer screening. They are available through CDC's CDP (Chronic 
Disease Prevention) File CD-ROM, the Public Health Service's 
Combined Health Information Database (CHID) and CDC's WONDER 
system. CDP File is available from the Superintendent of 
Documents, Government Printing Office, Washington, DC 20402, 
202-512-1800 (Stock No. 717-145-00000-3). CHID can be accessed 
through most library and information services. CHID may be 
accessed via the Internet at http://chid.nih.gov. For more 
information about WONDER, contact CDC WONDER Customer Support 
at 404-332-4569.

                National Center for Environmental Health

    CDC's National Center for Environmental Health (NCEH) 
addresses the prevention of secondary conditions and promotion 
of health among the 54 million Americans with disabilities. The 
Center is analyzing NHIS and NHIS-Supplement on Aging data to 
identify the correlates of aging related to sensory impairments 
and to characterize disability in the above 55 age groups by 
race/ethnicity, gender, region, and activity limitation. These 
analyses will be included in the disability chapter of the 
upcoming MMWR Supplement on Aging.
    The NCEH environmental health laboratory is working to 
improve measurement of biochemical markers of bone loss to help 
physicians threat people with osteoporosis. The currently 
accepted gold standard for measuring bone status is a bone 
density test. However, such tests can only be repeated every 1-
2 years. The biochemical marker tests for bone loss can be 
performed more frequently to assess the success of treatments 
for osteoporosis.
    The NCEH environmental health laboratory also is 
collaborating on the Age-Related Eye Disease Study conducted by 
the National Eye Institute. The laboratory is testing patients 
participating in the study for levels of vitamins A, C, and E, 
carotenoids, retinyl esters, lipids, zinc, and copper. The 
laboratory is also assisting with genetic testings as part of 
this study.

                 National Center for Health Statistics

    CDC's National Center for Health Statistics (NCHS) is the 
Federal Government's principal health statistics agency. The 
NCHS data systems address the full spectrum of concerns in the 
health field from birth to death, including overall health 
status, morbidity and disability, risk factors, and health care 
utilization.
    The Center maintains over a dozen surveys and vital 
statistics data files that collect health information through 
personal interviews, physical examination and laboratory 
testing, administrative records, and other means. These data 
systems, and the analyses that result are designed to provide 
information useful to a variety of policy makers and 
researchers. NCHS frequently responds to requests for special 
analyses of data that have already been collected and solicits 
broad input from the health community in the design and 
development of its surveys.
    A broad range of data on the aging of the population and 
the resulting impact on health status and the use of health 
care are produced from these systems. For example, NCHS data 
have documented the continuing rise in life expectancy and 
trends in mortality that are essential to making population 
projections. Data are collected on the extent and nature of 
disability and impairment, limitations on functional ability, 
and the use of special aids. Surveys currently examine the use 
of hospitals, nursing homes, physicians' offices, home health 
care and hospice, and are being expanded to cover hospital 
emergency rooms and surgi-centers.
    In addition to NCHS surveys of the overall population that 
produce information about the health of older Americans, a 
number of activities provide special emphasis on the aging. 
They are described below.

                 The Second Longitudinal Study of Aging

    The Second Longitudinal Study of Aging (LSOA II) is a 
collaborative project of the National Center for Health 
Statistics and the National Institute on Aging. This 
prospective survey consists of a baseline interview, called the 
Second Supplement on Aging (SOA II), and two followup 
interviews fielded at two-year intervals. The SOA II interviews 
were conducted with a nationally representative sample of 9,447 
civilian noninstitutionalized Americans 70 years of age and 
over. It was fielded as part of the 1994 National Health 
Interview Survey and interviews were collected in-person 
between 1994 and 1996. The two reinterviews were administered 
by phone with these sample persons and have now been completed, 
one in 1997-1998 and one in 1999-2000.
    The LSOA II is designed primarily to measure changes in the 
health, functional status, living arrangements, and health 
services utilization of older Americans as they move into and 
through the oldest ages. Secondarily, the objective of the 
study is to provide a mechanism for monitoring the impact of 
proposed changes in Medicare and Medicaid and the accelerating 
shift towards managed care on the health status of the elderly 
and their patterns of health care consumption. Finally, the 
LSOA II replicates the first Longitudinal Study of Aging which 
was conducted ten years earlier between 1984 and 1990. To this 
end, questions concerning physical functioning and health 
status and their correlates which were part of the first LSOA 
are repeated in the LSOA 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 LSOA II questionnaire was been 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.
    The SOA II microdata were released to the public in 1998. 
The first followup is expected to be released in 2001 and the 
second follow up in 2003. These data, when used in conjunction 
with data from the LSOA, enable researchers 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 those who use the data with an opportunity to examine 
trends and determinants of ``healthy aging.'' Users of the LSOA 
and LSOA II data have typically consisted of researchers, both 
those in the Federal government and in university settings, 
policy planners, and agencies and organizations serving older 
persons.

         Health, United States, 1999 Health and Aging Chartbook

    In October 1999, the Health, United States, 1999 Health and 
Aging Chartbook was published. This special study on health and 
aging was part of the annual report on the nation's health 
submitted by the Secretary of the U.S. Department of Health and 
Human Services to the President and Congress. In 34 figures and 
accompanying text, it summarizes the health of older people in 
the United States at the end of the twentieth century, using 
nationally representative health surveys and vital statistics. 
Measures of health status, including mortality, the prevalence 
of chronic conditions, disability, oral health, hearing and 
visual impairments are presented in the volume. In addition, 
health care access and utilization measures such as hospital 
discharge rates, use of home health care services, and health 
insurance coverage are included. Special attention is paid to 
differences in health by age, sex, and race and ethnicity. The 
chartbook was distributed to all members of Congress and 
highlighted in a Congressional briefing sponsored by Senator 
Mikulski and Representative Hoyer.

                       Trends in Health and Aging

    Trends in Health and Aging is a major data dissemination 
project funded in part by the National Institute on Aging and 
located within NCHS's Office of Analysis, Epidemiology, and 
Health Promotion (OAEHP). Trends in Health and Aging draws upon 
the statistical resources of NCHS and other Federal statistical 
agencies to provide up-to-date information on health behaviors, 
health status, utilization and cost of care for the older 
population in the United States.

               Trends in Health and Aging Data Warehouse

    The core of the project is the Trends in Health and Aging 
Data Warehouse (DWHA). DWHA is intended for use by policy and 
program analysts, researchers and the general public. DWHA 
contains information from NCHS surveys and other data systems 
in a format easily accessible to users. The list of topics and 
measures grows based on users' suggestions and the data are 
updated as soon as new figures become available. The data 
warehouse became available to the public on the Internet in 
November 1999. It can be accessed at the following address: 
http://www.cdc.gov/nchs/agingact.htm. It serves as an important 
electronic resource for those seeking relevant national data on 
a host of issues related to future access to affordable health 
care and the enhancement of quality of life.
    In the DWHA trend data on the elderly population in the 
United States is organized under six general topic areas: 
demography (or population composition), vital statistics, 
health status and well-being, risk factors and health behavior, 
health care utilization, and health care expenditure.
    The target population is persons of 65 years of age and 
older, but the majority of the tables also contain data on 45-
64 year olds for comparison purposes and for representation of 
the baby boom generation. The indicators are presented by 5- or 
10- year age groups. Open-age intervals (for example, 65 and 
over) can be seen in a crude and age-adjusted form. Usually, 
for age adjustment the year 2000 standard residential 
population of the United States was used.
    The data are aggregated in interactive tables developed 
using a user-friendly dissemination tool, Beyond20/20. Tables 
prepared in Beyond20/20 are capable of presenting the data in 
the form of charts and maps by the exact variables needed by 
the user, and the data from the table can be extracted in 
formats acceptable by most software packages.
    Each table displays the selected measure(s) by sex, age 
interval, race or Hispanic origin for as many years as the data 
from the particular data system are available. Where possible, 
the tables present the information by States. Metadata 
accompanying each table provide important information on data 
sources, statistical methods used to get the information, and 
references to corresponding publications and supporting 
Internet sites.
    Examples of selected tables are as follows:

Demography (population composition)

    Population (number and percent of people, national and 
state estimates)

Vital Statistics

    Life Expectancy
    Mortality (national and state estimates)
    Living Arrangements

Health Status and Well-Being

    Self-assessed health
    Functional status of older adults
    Functional limitation
    Total tooth loss
    Mental health status of nursing home residents
    Selected chronic conditions

Risk Factors

    Immunization
    Current cigarette smoking
    Obesity
    Exercise

Health Care Utilization

    Nursing home use
    Hospital discharges
    All-listed procedures for hospital inpatients
    Several special web-based reports based on data from DWHA 
have been written and will be posted to the web site and 
available in hard-copy formats. The topics include trends in 
elderly mortality, oral health of older Americans, trends in 
vision and hearing, and trends in nursing home use.

               Federal Forum on Aging-Related Statistics

    The Forum was initially established in 1986, with the goal 
of bringing together Federal agencies with a common interest in 
database development and statistical compilation on issues in 
aging. The Forum has played a key role in improving aging-
related data by critically evaluating existing data resources 
and limitations, stimulating new database development, 
encouraging cooperation and data sharing among Federal 
agencies, and preparing collaborative statistical reports.
    During 1998, an organizing committee was established to 
coordinate the activities and goals of the Forum for 1999 and 
beyond. In addition to the Bureau of the Census, the National 
Center for Health Statistics, and the National Institute on 
Aging--the original core agencies--the members now include 
representatives from the Administration on Aging, the Bureau of 
Labor Statistics, the Health Care Financing Administration, the 
Office of Management and Budget, the Office of the Assistant 
Secretary for Planning and Evaluation, and the Social Security 
Administration.
    On August 10, 2000, the Federal Interagency Forum on Aging-
Related Statistics (Forum) released ``Older Americans 2000: Key 
Indicators of Well-Being.'' As one of the core members of the 
Forum, NCHS took the lead in producing, promoting, and 
disseminating this well received report. The report included 31 
key indicators carefully selected by the Forum to portray 
aspects of the lives of older Americans and their families. The 
report is divided into five subject areas: population, 
economics, health status, health risks and behaviors, and 
health care. The report can be accessed via the Forum's Web 
Site--http://www.agingstats.gov.

                 NHANES I Epidemiologic Follow-Up Study

    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 re-
interviews 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 follow-ups of the NHEFS population were 
conducted by telephone in 1986 (limited to persons age 55 and 
over at baseline), 1987, and 1992.
    Participant 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.

                           NHANES IV Planning

    The Fourth National Health and Nutrition Examination Survey 
began field operations in April of 1999. Although a wide range 
of the conditions assessed in NHANES IV are most common among 
the elderly, several components are particularly relevant to 
aging research:
           Muscle Strength, Impairment, and Disability: 
        All persons age 50+ will have measurement of isokinetic 
        muscle strength of knee extensors and flexors and all 
        persons age 60+ will have an assessment of ability and 
        time to get up from an armless chair five times and 
        time to perform a twenty foot walk at the usual speed. 
        Both sets of measures will provide important data on 
        physical impairment and function in the elderly and 
        will be correlated to other disability related self 
        reported items and other objective measurements 
        obtained in the survey.
           Lower Extremity Disease: For the first time, 
        the survey includes an evaluation of lower extremity 
        disease in persons age 40+, including Ankle-Brachial 
        Pressure Index measurement and assessment of peripheral 
        neuropathy. These data are especially important for 
        assessing the complications of diabetes and the 
        prevalence of peripheral vascular disease.
           Visual and Hearing Impairment: Vision (age 
        12+) and hearing (age 20+) are being assessed including 
        assessment of visual acuity, near vision (age 50+), 
        pure tone audiometry thresholds, and typanometry. 
        Sensory impairment is an important component of 
        functional impairment in the elderly.
           Bone Mineral Status: Bone mineral status is 
        being assessed including total bone mineral content and 
        bone mineral density by dual X-ray absorptiometry. 
        Osteoporosis is an important risk factor for hip 
        fractures in the elderly.
           Cognitive Function: Cognitive function is 
        being assessed in persons age 60+ with the Digit Symbol 
        Substitution Test.
           Balance and Vestibular Function: The 
        standard Romberg test of postural sway is being 
        assessed in all persons age 20+. Balance impairment is 
        related to the incidence of many fractures caused by 
        falling, especially hip fractures in the elderly.

                      Analysis of NHANES III Data

    NCHS is engaged in a range of projects analyzing data from 
NHANES III related to aging. These projects include:
           Prevalence of Disability and Risk Factors 
        Associated with Disability. NHANES III data will be 
        analyzed to assess the prevalence of physical and 
        functional limitation. It includes self reported data 
        obtained in the household interview and performance-
        based data obtained in the mobile examination center. 
        The risk factors associated with disability will be 
        assessed to provide a better understanding of the 
        etiology and treatment of disability in the elderly.
           Region of Birth and Cardiovascular Risk 
        Factors. NHANES III data will be used to assess early-
        life influences such as region of birth on the pattern 
        of risk factors for cardiovascular disease in later 
        life.
           Nutritional Intake among the Elderly. The 
        patterns of nutrient intake among adults age 60+ in 
        NHANES III will be analyzed.

                       Vital Statistics on Aging

    Information on mortality from the national vital statistics 
system plays an important role in describing and monitoring the 
health of both the institutionalized and non-institutionalized 
elderly population. The data include measures of life 
expectancy, causes of death, and age-specific death rate 
trends. The basis of the data is information from death 
certificates, completed by physicians, medical examiners, 
coroners, and funeral directors, used in combination with 
population information from the U.S. Bureau of the Census.
    Effective with mortality data for 1997, additional detail 
on the aging population was included in the official national 
life tables. For the first time life expectancy and other life 
table values for the population aged 85 to 100 years were shown 
in the annual life tables by incorporating information from the 
Medicare program on the mortality experience of the aged 
population with standard information from the vital statistics 
system.
    NCHS is expanding outreach to certifying physicians on 
proper completion of the cause-of-death section of the death 
certificate by designing material appropriate for diverse 
settings including professional meetings and electronic death 
certificates.
    Effective with mortality data for 1999, two important 
changes are being implemented for state and national mortality 
statistics: (1) causes of death are coded and classified by the 
Tenth Revision of the International Classification of Diseases 
(ICD-10), replacing ICD-9, which was used by the U.S. during 
1979-1998; and (2) the standard population used for age-
adjusting death rates is changed from 1940 to the year 2000 
population. The 1940 standard has been used for about 50 years. 
Use of ICD-10 affects the comparability of cause-of-death 
trends over time; the extent of the discontinuities is measured 
using a Comparability Study, results of which will be available 
at the time the 1999 mortality data are published in early 
2001. The new population standard for age-adjusting death rates 
affects the absolute level of death rates for many causes of 
death, in particular, deaths from chronic diseases; it also 
affects the relationship of mortality among the race groups. 
NCHS publications describe the extent and implications of these 
changes.

                    The National Health Care Survey

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

         Improving Self-Reports of Health Status by the Elderly

    The National Laboratory for Collaborative Research in 
Cognition and Survey Measurement of NCHS has conducted several 
cognitive research projects with elderly respondents. In 1998, 
Lab staff continued their investigation of recall and judgment 
issues that elderly respondents may have when answering 
questions regarding health status and quality of life. This 
project involved both in-house and extramural research. In-
house research is conducted by recruiting subjects to the NCHS 
Questionnaire Design Research Laboratory. Extramural research 
is conducted by the University of Maryland's Survey Research 
Center using split-ballot field experiments.

                     National Immunization Program

    CDC's National Immunization Program provides medical and 
epidemiologic expertise and collaborates with other CDC 
organizations and HHS agencies in developing strategies to 
enhance immunization coverage of adults, including influenza, 
pneumococcal, hepatitis B, measles, mumps, rubella, and 
varicella vaccines and combined tetanus and diphtheria toxoids. 
One of the greatest challenges we face is extending the success 
in immunization with children to the adult population.
    Immunization rates for influenza and pneumococcal disease 
are at record highs in persons 65 years of age or older. The 
Healthy People 2000 Objective for influenza vaccination in this 
age group has been achieved. It is estimated that in 1996-1997, 
about 19,500 deaths were prevented by influenza vaccination in 
persons in persons 65 years or older. In addition, increased 
use of pneumococcal vaccine between 1993 and 1997 saved almost 
$27 million in hospital costs alone.
    In spite of the progress that has been made, adult vaccines 
continue to be underutilized. Reasons for this include: 1) 
limited appreciation of the impact of adult vaccine-preventable 
diseases and missed opportunities to vaccinate during contacts 
with health-care providers; 2) failure to organize programs in 
medical settings that ensure adults are offered the vaccines 
they need; 3) doubts about the safety and efficacy of adult 
vaccines; 4) selective rather than universal approaches to 
vaccination; and 5) inadequate reimbursement for adult 
vaccination services.
    To overcome these challenges, CDC has taken a number of 
steps including:

                Testing Vaccine Safety and Effectiveness

    CDC is actively engaged in determining vaccine 
effectiveness. CDC and three health plans assessed the 
effectiveness of influenza vaccine in patients age 65 or older 
in preventing hospitalizations and deaths. Results showed that 
vaccination prevented 18-24 percent of the hospitalizations for 
pneumonia and 35-61 percent of all deaths. These findings 
support the concept that health plans should cover influenza 
vaccination, as well as actively promote the vaccine each fall.
    In January of 1999, CDC and others published a study on the 
safety of pneumococcal vaccination in the Journal of the 
American Medical Association, ``The Safety of Revaccination 
with Pneumococcal Polysaccharide Vaccine.''

                         Education and Training

    Enhancing education and training is a priority in adult 
vaccination efforts. CDC aired the first national video-
conference on adult immunization technical issues in June 1998 
and rebroadcast the presentation in June 1999. It was also 
broadcast in Spanish, with special efforts to promote it in all 
of the boarder states, Mexico, and the Caribbean.
    CDC and the Association of Teachers of Preventive Medicine 
developed and tested the ``What Works'' interactive software 
(CD ROM) program targeted at private primary care providers who 
provide health care services primarily for adults. This program 
focuses on strategies to increase immunization coverage levels 
among adults and technical issues relating to adult 
vaccinations.
    Immunization teaching materials for physicians were 
developed through a collaboration with CDC, Association of 
Teachers of Preventive Medicine, and the Department of Family 
Medicine at the University of Pittsburgh. The training 
materials are designed to be used by medical schools for 
students and residents. These products were published between 
April 1998 and April 1999 and include a Facilitators Guide, a 
Small Group Booklet, and a Reference Booklet.
    Two large print booklets were designed in 1999 to be 
distributed by health care providers to adult and senior 
patients. The focus of the booklets is to empower adults and 
seniors to take action for their own health. The vaccines 
presented include all immunizations important for adults of all 
ages. With the senior book emphasizing the vaccines for those 
diseases that can cause the most serious problems, i.e., 
influenza, pneumococcal disease, and adult tetanus and 
diphtheria among the elderly.

                            Recommendations

    CDC worked with the National Medical Association to develop 
a consensus document ``Adult Immunizations: Increasing 
Immunization Rates among African-American Adults'' published in 
1999. The document clearly demonstrates the need for improving 
vaccination in African-American adults and offers 
recommendations on how to do so.
    Task Force for Community Preventive Services included 
recommendations about successful interventions to increase 
coverage among adults in the published Guide to Community 
Preventive Services.
    The National Vaccine Advisory Committee and CDC published 
recommendations for vaccination of adults in non-traditional 
sites in the March 24, 2000 MMWR.
    Revision of Standards for Adult Immunization Practices, 
which were first developed in 1990, are under way. Revision 
began in 2000 and will be completed by December of 2001.
    The guide, ``Prevention and Control of Vaccine-Preventable 
Disease in Long-Term Care Facilities,'' was published in the 
September/October 2000 issue of the Journal of the American 
Medical Directors Association, and widely disseminated by CDC 
and HCFA to state health departments and nursing home 
directors.
    Authors from CDC published an article, ``Vaccine 
recommendations for Patients on Chronic Dialysis,'' in the 
March/ April 2000 issue of Seminars on Dialysis.

                            Standing Orders

    Dissemination of guidelines for health care providers is 
another important activity. CDC, in collaboration with the 
Advisory Committee on Immunization Practices and the Health 
Care Financing Administration, has recommended a key strategy 
called ``standing orders'' to improve influenza and 
pneumococcal vaccination levels in nursing homes throughout the 
country. A standing order enables nursing homes to provides 
these vaccinations to nursing home residents without an 
individual prescription.
    A project started in July of 1999 to evaluate the 
effectiveness of standing order programs to improve 
pneumococcal and influenza vaccination rates in nursing homes. 
It is a multi-state project (9 intervention, 5 control) to 
develop, implement and evaluate standing order programs and 
other immunization programs for influenza and pneumococcal 
vaccination among seniors in nursing homes funded by CDC 1 
percent Evaluation funds and the National Vaccine Program 
Office. It is run in collaboration with HCFA and Peer Review 
Organization (PRO).

                     Delivering Vaccines to Adults

    Since 1997, CDC immunization grant guidance has instructed 
grantees to assign at least 0.5 FTE to coordinate adult 
immunization activities; in CY 2000, 35 states reported having 
at least 0.5 FTE designated for this purpose. CDC has an annual 
influenza vaccine contract which many states use to purchase 
influenza vaccine for use by the state or local health 
departments. In 2000, CDC negotiated contracts for 2 million 
doses of influenza vaccine. Over 90 percent of local health 
departments deliver influenza vaccine, 85 percent deliver 
tetanus toxoid, 77 percent deliver hepatitis B vaccine, and 48 
percent deliver pneumococcal vaccine. Since 1997, CDC has 
conducted the Life Preserver campaign in collaboration with 
state health departments, to promote influenza and pneumococcal 
vaccination among persons with diabetes.

                           Understanding Gaps

    CDC commissioned an Institutes of Medicine (IOM) Report on 
the financing of vaccines. Calling the Shots: Immunization 
Policies and Practices found that ``additional funds are needed 
to purchase vaccines for uninsured and undersinsured adult 
populations within the states.'' Work is now being done to 
implement and respond to the recommendations.
    CDC also conducts research to better understand and improve 
adult vaccine delivery, including:
           Reviewing adult immunization activities in 
        the state immunization programs, 1997-99, to determine 
        best practices.
           Tested AFIX (Assessment, Feedback, 
        Incentive, and eXchange) methods, very successful for 
        childhood immunization, for physicians of Medicare 
        beneficiaries in New Jersey.
           Surveying African American physicians to 
        identify barriers to delivery of adult immunization, 
        and will use the results to design and evaluate a 
        provider-based intervention to improve vaccination 
        services.
           Designing and evaluating a multi-component 
        intervention in New Jersey to improve the use of 
        influenza and pneumococcal vaccination and cancer 
        screening (mammography and Pap testing) among African 
        American women enrolled in Medicare.

                    Improved Monitoring of Coverage

    Influenza and pneumococcal vaccination status is asked 
annually on the NHIS. In 1999, the BRFSS added a question on 
the type of place where influenza vaccination was received. 
Additionally, CDC has recommended standardization of 
pneumococcal vaccination questions in all relevant surveys 
(NHIS, BRFSS, HCFA's Medicare Current Beneficiary Survey). 
Hepatitis B vaccination status will be included on the 2000 
NHIS. CDC also worked with three HMO's to evaluate the 
feasibility of including a measure of pneumococcal vaccination 
among persons 65 years of age and older on HEDIS. Based on the 
results of this work, the measure has been approved for 
addition to HEDIS. CDC is also developing software suitable for 
assessing vaccination levels in adult patient practice 
settings.

                       2000-2001 Influenza Season

    The influenza season of 2000-2001 has posed new challenges 
to immunization efforts. In June, influenza vaccine 
manufacturers told federal public health officials to expect 
delays in flu vaccine shipments this flu season and possible 
shortages. This delay was due to a combination of factors 
including problems growing one of the virus strains used in 
vaccine and problems in the manufacturing process. Although all 
influenza vaccine is produced in the private-sector, and more 
than 90 percent distributed through the private-sector, CDC 
undertook a number of actions to minimize the adverse impact of 
delays. First, CDC contracted for up to 9 million doses of 
vaccine to be produced. This added production of additional 
influenza vaccine was done to make up for possible shortfalls 
experienced by some of the vaccine manufacturer and to help 
fill some gaps to vaccinate people at highest risk of 
complications of influenza. As a result, flu vaccine supplies 
were approximately what was distributed last year; however, a 
substantial amount of vaccine reached providers later than 
usual. Other actions taken to alleviate problems related to the 
delay in influenza vaccine availability included CDC's 
initiation of a media campaign to educate providers and the 
public regarding the recommendations for this year's influenza 
season, development of a web-based system to facilitate the 
exchange and redistribution of vaccine and ongoing 
communications with health care providers and partners to keep 
them informed of influenza vaccine availability.

                National Center for Infectious Diseases

    Infectious diseases remain a serious problem in the U.S. 
Pneumonia and influenza remain the sixth leading cause of death 
in the United States and septicemia has risen dramatically 
during the past three decades to become the 11th leading cause 
of death. Chronic liver disease, a substantial proportion of 
which is due to hepatitis C virus, is the 10th leading cause of 
death in the U.S. Pneumonia and septicemia are also 
contributing and precipitating factors in the deaths of many 
Americans with other illnesses, especially cardiovascular 
diseases, cancer, and diabetes. Infectious diseases have a 
disproportionate impact on older Americans, 65 years old and 
older. Quality of life also declines for millions of older 
Americans as a result of infectious illnesses. Prevention and 
control of infectious diseases will enhance and lengthen the 
lives of older Americans, make them more productive, and reduce 
associated medical costs.
    CDC emphasizes surveillance and training to prevent and 
control hospital-acquired and other institutionally acquired 
infections in elderly patients. Additionally, CDC staff 
provides education regarding infection control to care 
providers at nursing home and patient care conferences. This 
education focuses on patient care treatment and procedures 
associated with the highest risk of infection. Through the 
National Nosocomial Infections Surveillance (NNIS) system, 
special infection risks of elderly patients have been 
identified. According to NNIS, over half of the hospital-
acquired infections occur in elderly patients, although these 
patients represent about one-third of all discharges from 
hospitals. The use of certain devices, such as urinary 
catheters, central lines, and ventilators, are associated with 
high risk of infection in all types of patients. In elderly 
patients, the risk of infection is high even when a device is 
not used, suggesting that infection control must address other 
risk factors such as lack of mobility and poor nutrition, in 
addition to device use.

                          Monitoring Influenza

    Although delivering the influenza vaccine to persons at 
risk is a critical step in preventing illness and death from 
influenza, immunization is only part of the prevention 
equation. Other CDC efforts to combat influenza in the elderly 
include: (1) improving domestic surveillance through the 
sentinel and state health department laboratory surveillance 
networks; (2) conducting studies to better define the 
immunological response of the elderly to influenza vaccines and 
to natural infection; (3) conducting immunological studies 
involving laboratory and clinical evaluation of inactivated and 
live attenuated influenza vaccines in an effort to identify 
improved vaccine candidates; (4) increasing surveillance of 
influenza in the People's Republic of China and other countries 
in the Pacific Basin to better monitor antigenic changes in the 
virus; (5) improving methodologies for rapid viral diagnosis; 
(6) using recombinant DNA techniques to develop influenza 
vaccines that may protect against a wider spectrum of antigenic 
variants; and (7) providing laboratory training in the People's 
Republic of China, other Pacific Basin countries, and Latin 
America to develop and expand capacity for the diagnosis and 
detection of antigenic changes in the virus.

                    Preventing Pneumococcal Disease

    Pneumococcal pneumonia causes an estimated 7,500-12,500 
deaths each year; about 60 percent of these are in persons 65 
years old and older. Prevention of pneumococcal disease in the 
elderly requires widespread application of effective 
immunization. CDC is currently evaluating the emergence of 
drug-resistant pneumococcal strains through laboratory-based 
surveillance and is actively promoting increased vaccine use in 
the elderly and other groups at risk. New vaccines under 
development , including conjugate and common protein antigen 
approaches, offer the potential for improved prevention of 
pneumococcal disease in the elderly. Improved use of current 
vaccine, as well as evaluation of new tools, are critical to 
decrease illness and death from pneumococcal infections in the 
elderly.

                      Other Respiratory Infections

    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 treated with antiviral drugs. It 
is important to define the role of these viruses and risk 
factors for these infections among the elderly. CDC is working 
to define the disease burden associated with respiratory 
syncytial virus and parainfluenza virus infections in the 
elderly and helping to develop vaccination strategies for 
respiratory syncytial virus.

        Healthcare-acquired Infections and Adverse Health Events

    The Institute of Medicine (IOM) has reported that 
preventable adverse events associated with healthcare result in 
98,000 deaths and $29 billion in additional healthcare costs 
annually. Overall, 3-4 percent of all patients suffered a 
healthcare related adverse event. The elderly are 
disproportionately affected by such adverse events.
    Existing technology and knowledge can prevent many adverse 
events but prevention strategies have not been widely and 
successfully implemented. However, some successes have 
occurred. For example in 2000, CDC reported that bloodstream 
infections among patients in U.S. intensive care units, most of 
whom are elderly, declined by 32 percent to 43 percent during 
the 1990's (MMWR 2000:49;149-153). This success is due to 
improved efforts in infection control in U.S. hospitals, to 
technological advances, and to improved patient care. CDC is 
embarking on a 5 year plan to substantially reduce bloodstream 
infections in other healthcare settings such as cancer and 
dialysis centers, respiratory infections in long term care 
patients, infections following surgery, and infections due to 
antimicrobial resistant organisms. CDC has increased its focus 
on the use of new information technologies to improve 
efficiency, developed new collaborations with both private 
sector partners and public sector partners, and expanded its 
work in non-hospital settings (long-term care, home health 
care, cancer centers, dialysis centers) where a substantial 
portion of healthcare for the elderly is provided. Regarding 
antimicrobial resistance, CDC, through the Chicago 
Antimicrobial Resistance Project (CARP) is currently evaluating 
the impact of infection control strategies on the prevention of 
antimicrobial resistance in hospitals and long-term care 
facilities.

                     Group B Streptococcus Disease

    Group B streptococcus (GBS) is a major cause of invasive 
bacterial disease in elderly persons in the U.S. To document 
the magnitude of GBS disease in the elderly and develop 
preventive measures, CDC established population-based 
surveillance for GBS disease and case control studies to 
identify risk factors. An analysis of active surveillance data 
from 1993-1998 that was published in the New England Journal of 
Medicine in 2000 showed that the incidence of disease in adults 
 65 years old in 1998 was 20.1/100,000 population 
and the case fatality ratio was 15 percent compared to 8 
percent in adults 15-64 years old. Consistent with findings 
from earlier surveillance, the incidence of disease in black 
adults was approximately twice that in non-black adults. These 
data, along with serotype data on adult invasive GBS isolates, 
will be utilized to develop and evaluate vaccines and to 
promote the prevention and treatment of GBS disease in the 
elderly population.

                           Foodborne disease

    Foodborne disease is of particular concern in the elderly, 
who typically can have higher illness and death rates from 
foodborne pathogens than younger persons. Of particular concern 
are Salmonella enteritidis infections, often caused by 
undercooked eggs, and Escherichia coli O157:H7 infections, 
often caused by undercooked hamburger. CDC is working with USDA 
and FDA to encourage use of pasteurized eggs in nursing homes 
and thorough cooking of hamburger meat.
    Listeriosis is a severe bacterial foodborne infection that 
particularly affects the elderly, as well as pregnant women and 
immunocompromised person. CDC is participating in the 
interagency federal control plan for listeriosis, that includes 
enhanced surveillance, investigation of sporadic cases and of 
outbreaks to determine the sources, so that control measures 
can be targeted, and increased efforts to educate persons at 
higher risk in prevention measures.

                    Preventing Legionnaires' Disease

    An estimated 8,000-18,000 cases of Legionnaires' disease 
occur each year in the United States. Legionnaires' disease is 
a severe form of pneumonia caused by the bacterium, Legionella 
spp. Between 5-30 percent of persons contracting Legionnaires' 
disease die depending on underlying risk factors. The elderly, 
particularly those with underlying chronic diseases, are at 
greatest risk. Although attack rates are low, legionnaires' 
disease can be transmitted when susceptible persons are exposed 
to mists that come from a water source (e.g., air conditioning 
cooling towers, whirlpool spas, showers) contaminated with 
Legionella bacteria. Novel prevention strategies are focusing 
on the use of new disinfectants in water systems that may have 
the potential for greatly reducing the occurrence of 
legionnaires' disease. In addition, CDC is developing improved 
surveillance systems to better.

                        Gastrointestinal Disease

    Studies using information from national data bases show 
that of all age groups, the elderly (70 years old) 
have the highest rates of hospitalizations and deaths 
associated with diarrhea in the United States. 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 and studies needed to confirm this hypothesis 
are now underway. These studies should lead to a better 
understanding of ways to prevent gastrointestinal disease in 
the elderly. The recent identification of rotavirus as a cause 
of epidemic diarrhea in the elderly suggests that one approach 
to control may involve use of vaccines currently used for young 
children. Further study is now needed to determine the 
importance of rotavirus to gastrointestinal disease in the 
elderly.

                       Other Infectious Diseases

    It is becoming increasingly evident that infections play a 
major role in causing or contributing to some chronic diseases. 
Some of these conditions result from infection acquired at a 
younger age (including liver cancer and cirrhosis related to 
chronic hepatitis B or hepatitis C, stomach and duodenal ulcers 
or gastric cancer from Helicobacter pylori), while others 
develop from exposures later in life. CDC is actively promoting 
and pursuing ways to prevent initial infection and the chronic 
consequences of such infections. Microbes are also suspected 
but not yet proven as triggers of still other chronic 
conditions. CDC is developing research activities that identify 
and define these relationships. The potential to use infection 
control in the prevention or treatment of infections that 
produce chronic disease can improve the quality and length of 
life for many elderly persons.

           National Center for Injury Prevention and Control

    CDC's National Center for Injury Prevention (NCIPC) is 
involved in a wide array of activities to promote enhanced 
mobility and independent living among older Americans by 
preventing injuries and injury-related disabilities. Our 
research and programmatic efforts that target older Americans 
focus on falls prevention, understanding issues affecting older 
drivers, and preventing elder abuse. We also support two 
organizations focusing broadly on unintentional injury 
prevention among older Americans:
           The National Resource Center on Aging and 
        Injury was established at the end of FY1999 with the 
        San Diego State University. The Resource Center applies 
        cutting edge technology to collecting, organizing, 
        evaluating, and disseminating information about 
        preventing unintentional injuries among older adults. 
        In FY2000 the Resource Center established a repository 
        of over 1,000 resource items; developed an interactive 
        web site (www.olderadultinjury.org) with a searchable 
        data base; and provided information to over 636,000 
        people, including health care professionals, care 
        givers, and other individuals concerned about reducing 
        injuries among older adults.
           The Edward R. Roybal Institute for Applied 
        Gerontology in Los Angeles, CA is funded to develop 
        training materials for community organizations and 
        agencies that serve Hispanic and other minority older 
        adults in East Los Angeles. These materials enable 
        organizations to conduct outreach and educational 
        programs, and to integrate unintentional injury 
        prevention activities into their existing service 
        delivery programs.

                            Falls Prevention

    National studies show that one-third of the people over 65 
living at home will fall each year, and for people over 80, 
this rate increases to 40 percent. Falls are the second leading 
cause of injury deaths among persons aged 65 84 years and the 
leading cause among persons aged 85 years and older. Of all 
fall injuries, hip fractures produce the greatest morbidity and 
mortality. Approximately 250,000 hip fractures occur each year 
and half of those who sustain hip fractures never regain their 
former level of functioning.
    Falls are the leading cause of traumatic brain injury (TBI) 
among older people, accounting for more than half of TBIs among 
older men and more than three-fourths among older women. TBI is 
an important and under-recognized public health problem among 
older people. NCIPC analyzed population-based data for 1997 
from Arkansas, Colorado, and South Carolina (NCIPC-funded 
states conducting TBI surveillance), and found that among 
people 65 years of age or older who experience TBI, an 
estimated 1 in 3 men and 1 in 10 women have a fatal outcome.

Disseminating What Works

    A Tool Kit to Prevent Senior Falls, developed in 1999 by 
NCIPC, is a comprehensive collection of health education 
materials and assessment tools designed to reduce falls and 
related injuries among older adults. In FY2000 the Tool Kit was 
distributed to over 14,500 organizations and agencies concerned 
with preventing injuries among older adults. Pfizer 
Pharmaceuticals is mass producing these materials for 
distribution to their customers.
    NCIPC developed U.S. Fall Prevention Programs for Seniors: 
Selected Programs Using Home Assessment and Modification in 
November 2000. This document fully describes 18 comprehensive 
fall prevention programs as well as contact information for 21 
additional programs. These programs are intended to be used as 
models by agencies or organizations that want to develop fall 
prevention programs for older adults.

Fall Prevention Programs

    In September 2000, NCIPC funded the State of California to 
conduct a fall prevention demonstration program for community-
dwelling older adults that includes three strategies: increased 
physical activity, medication review, and home assessment and 
safety modifications. This is the first demonstration of a 
combined program of several proven prevention strategies.
    NCIPC funded fire/fall prevention programs in September 
2000 that target older adults in North Carolina, Minnesota, 
Maryland, Virginia and Arizona. These programs implement a pre-
developed program curricula for preventing fire and fall-
related injuries among older adults utilizing home visits, 
group presentations, and other innovative outreach strategies.

Gathering Better Data on Falls

    In order to understand more about fall risk factors and how 
falls occur locations, circumstances, predisposing and enabling 
factors, especially for sub-population groups (such as the 
oldest old, minorities), NCIPC is supporting the expansion of 
the National Electronic Injury Surveillance System of the 
Consumer Product Safety Commission to collect information about 
fall injuries from hospital emergency departments. We are also 
funding the 2nd Injury Control And Risk Survey, a national 
injury survey that will include information related to fall 
risk factor prevalence and fall prevention behaviors among 
seniors.

Research on Falls Prevention

    NCIPC conducts research by NCIPC scientists, and through a 
peer-reviewed, investigator-initiated grants program in 
universities and other research institutions across the 
country.
    In an NCIPC study using National Hospital Discharge Survey 
data, we analyzed hip fracture hospitalization rates occurring 
between 1988 and 1996, and found that hip fracture 
hospitalization rates for older women increased 40 percent 
while the rates for men remained stable. Over 95 percent of hip 
fractures were caused by falls.
    Previous extramural research on reduction of falls in 
nursing homes has shown promising results in reducing falls by 
as much as 19 percent. Research has also identified the 
following modifiable risk factors: inactivity and muscle 
weakness, over medication, and environmental hazards. Less well 
understood are other risks, e.g., impaired vision and types of 
footwear. To improve our knowledge in one of these areas, NCIPC 
is consulting with the Atlanta, GA Veteran's Administration 
hospital to study footwear and falls. Current extramural 
research grants relating to falls prevention include:
    Project Title: ``Hip Fracture Prevention from Falls in the 
Elderly''
    Project Director: Wilson Hayes, Ph.D.
    Institution: Beth Israel Hospital; Orthopedic Biomechanics 
Laboratory; Boston, MA
    The goals of this project are to understand the 
biomechanics of hip fractures among the elderly, to resolve 
uncertainties regarding the relative importance of trauma 
severity and age-related bone loss, and to design a protective 
pad to be worn over the hips and test its acceptability to 
potential users.
    Project Title: ``An Assessment of Fall Prevention/Safety 
Practices in Tennessee Nursing Homes''
    Project Director: Wayne Ray, Ph.D.
    Institution: Vanderbilt University School of Medicine; 
Nashville, Tennessee
    This study tests the hypothesis that the Tennessee Fall 
Prevention Program (TFPP), a reduces falls that result in 
serious injuries. TFPP is a statewide, safety practices 
training program for nursing home staff. Investigators are 
conducting a randomized controlled trial of an estimated 112 
nursing homes with a combined population of approximately 9,000 
residents. The primary analysis is assessing program 
effectiveness by comparing rates of falls resulting in serious 
injuries in intervention and control facilities. If effective, 
the TFPP could provide a model for feasible, cost-effective 
injury prevention programs in long-term care settings.
    Project Title: ``Antidepressants and the Risk of Falls''
    Project Director: Wayne Ray, Ph.D.
    Institution: Vanderbilt University School of Medicine; 
Department of Preventive Medicine; Nashville, Tennessee
    The investigator is conducting a retrospective, inception 
cohort study of an estimated 2,500 new antidepressant users and 
2,500 nonusers for the period of 7/1/93 through 6/30/95. The 
study is being conducted in nursing homes because residents 
have the highest prevalence of depression and antidepressant 
use, are particularly vulnerable to tricyclic antidepressants 
adverse effects, and have the highest rates of falls and 
related injuries. Study findings are expected to further injury 
control by providing information clinicians need to choose 
pharmacotherapy that minimizes risk of falls.
    Project Title: ``Biomechanics of Injury Prevention During 
Falls''
    Project Director: Stephen Robinovitch, Ph.D.
    Institution: Simon Fraser University; Office of Research 
Services; Burnaby, Brit. Col. Canada
    Considerable evidence now exists that fall severity, as 
defined by the configuration and velocity of the body at 
impact, is a stronger predictor than bone density of hip 
fracture risk. Data also suggest that specific protective 
responses exist for reducing fall severity and fracture risk, 
including braking the fall with the outstretched hands, and 
absorbing energy in the lower extremity muscles during descent. 
This study is designed to better define the biomechanical and 
neuromuscular variables that govern safe landing during a fall, 
and to identify the neuromuscular variables governing the 
efficacy of the protective responses as the basis exists for 
designing exercise-based interventions for reducing hip 
fractures in the elderly and other fall-related injuries.
    Project Title: ``Hip Fracture Reduction with the Penn State 
Safety Floor''
    Project Director: Donald Streit, Ph.D.
    Institution: Pennsylvania State University; Center for 
Locomotion Studies; Pennsylvania
    This proposal builds upon previous work in which a dually 
stiff floor intended to reduce the incidence of hip fractures 
in the elderly was successfully designed and developed. The 
Penn State Safety Floor (PSUSF) is stiff to loads typical of 
everyday activities but yields when forces such as those 
encountered during falls occur. Laboratory testing and finite 
element modeling have shown the floor to be capable of reducing 
the impact force of a fall by 28 percent investigators are now 
validating these promising initial results by conducting a 
carefully controlled study designed to directly demonstrate 
that hip fractures can be reduced by the use of the floor. In 
addition, investigators are monitoring a double occupancy room 
in a local nursing home where the floor is installed to 
demonstrate the livability of the floor.

                             Older Drivers

    In 1999, 7,088 people 65 years and older died in motor 
vehicle crashes. People 65 years and older represented 13 
percent of the population in 1999 and 17 percent of motor 
vehicle deaths. By 2030, elderly people are expected to 
represent 20 percent of the population. Once they're in 
crashes, elderly people are more susceptible than younger 
people to medical complications following motor vehicle 
injuries. Little is known about how the physical changes that 
accompany the aging process and diagnosed medical conditions 
effect driving performance. For example, there is some evidence 
to suggest that Parkinson's disease may impair driving, 
although the evidence is weak. More needs to be known about the 
connection between specific medical conditions and adverse 
driving outcomes.
    NCIPC has analyzed fatal and nonfatal injury data to assess 
trends over time in motor vehicle-related deaths to older 
persons. The rate of both fatal and nonfatal motor vehicle-
related injury increased during the study period. Rates 
increased as age increased, and men had rates twice as high as 
women. NCIPC collaborated with the University of California, 
San Diego to explore why older drivers stop driving. This study 
found that medical conditions were the most commonly given 
reason for stopping, and vision loss was the most common 
problem.
    NCIPC is also conducting research through peer-reviewed, 
investigator-initiated grants program in universities and 
research institutions across the country. Research grants 
relating to older drivers include:
    Project Title: ``Time Since License Renewal and Motor 
Vehicle Crash Risk Among Older Drivers''
    Project Director: Thomas D. Koepsell, M.D, M.P.H.
    Institution: University of Washington, Department of 
Epidemiology
    States vary considerably with regard to how long a driver's 
license remains valid before it must be renewed. Although some 
states shorten the time between renewals for older drivers, 
most do not. The time between license renewal for older drivers 
is a public policy choice, balancing the risk of crashes due to 
drivers who have become impaired against the cost and 
inconvenience of more frequent renewal checks. The aim of this 
project is to determine the relationship between crash risk and 
time since last license renewal for drivers 65 years and older. 
Investigators hypothesize that longer time periods since last 
renewal will be significantly associated with a higher crash 
risk, compared to drivers with more recent renewals. The long 
term objective is to guide public policy related to license 
renewal for older drivers in the United States, by determining 
the degree to which decreasing the interval between renewals 
for older drivers may lessen the risk of crash.
    Project Title: ``Elderly Driver Referral Project''
    Project Director: James McKnight, Ph.D.
    Institition: National Public Services Research Institute; 
Landover, MD
    The proposed study attempts to ascertain relationships 
between the capabilities of drivers and their safety of 
operation in order to enable license administrators to initiate 
licensing actions that minimize the threat from those who 
cannot operate safely while preserving the mobility of those 
who can. The psychophysical capabilities of the entire sample 
are being assessed through a battery of test measures designed 
specifically to tap capabilities shown to relate separately to 
age and highway accidents. The relationships obtained in this 
manner are applied to (1) improve the methods of detecting 
drivers whose abilities may be diminished by age, (2) develop 
tests to validly assess drivers' ability to drive safely, and 
(3) formulate licensing actions capable of achieving an optimum 
balance between safety and mobility.
    Project Title: ``Longitudinal Study of Elderly Drivers''
    Project Director/Lead Investigator: Jane Stutts, PhD;
    Other Investigators: Richard Stewart, PhD; Carol Hogue, 
PhD.
    Institution: University of North Carolina at Chapel Hill, 
Highway Safety Research Center
    A prospective cohort study is underway to assess the impact 
of selected functional impairments and medical conditions on 
the safety of older drivers. Drivers ages 65 and above coming 
in to renew their licenses were asked to participate in the 
study which involved a series of visual and cognitive 
functional assessments, along with a survey to gather 
information on self-reported medical conditions, use of 
medications, and driving habits. During the 1\1/2\ year data 
collection period, a total of 5,438 license renewal applicants 
were identified by the license examiners as potential study 
participants. Of these, 3,238, or 60 percent, elected to 
participate in the study. Participant and non-participant cases 
were linked with the North Carolina driver history files, and 
initial data analyses were carried out examining the role of 
various cognitive and visual functional impairments in recent 
prior crash involvement and in current driving exposure. Follow 
up analyses are planned in the project's final year to examine 
the usefulness of the driver functional assessments in 
predicting future crash involvement.
    In addition to these efforts, supplemental funding was made 
available by NCIPC to link North Carolina driver history data 
to data collected by UNC's Sheps Center for Health Services 
Research as part of an earlier study examining changes in 
health status and costs associated with Medicare-reimbursed 
screening and health promotion services. This ``add-on'' effort 
permitted further analyses of associations between motor 
vehicle crashes and injuries and a broad range of health 
measures in a separate population of elderly NC residents.

                              Elder Abuse

    Abuse of elderly persons is on the rise in the U.S. In 
1996, the National Elder Abuse Incidence Study reported 550,000 
incidents of abuse among elderly persons. There are no federal 
requirements for elderly protective services, nor are there 
regulations on training staff who provide protective services 
or for those investigating alleged cases of elder abuse. State 
protective services for the elderly vary widely; some are 
merged with children's services while others are separate.
    CDC's NCIPC and Public Health Practice Program Office have 
awarded a grant to the University of Iowa to evaluate the 
implementation and impact of state adult protective service 
statutes and regulations on the conduct of elder abuse 
investigations and outcomes. This study is expected to increase 
CDC's knowledge and understanding of state regulations related 
to elder abuse. Research findings from this study also will aid 
in the standardization of definitions in legislation and 
healthcare, and inform public health law practitioners about 
elder abuse reporting at the state level.

                   U.S. FOOD AND DRUG ADMINISTRATION


                              Introduction

    According to the U.S. Census Bureau, America's population 
aged 65 or older grew by 74 percent between 1970 and 1999, from 
20 million to almost 35 million people. As the percentage of 
older Americans 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.
    Some of the challenges associated with older Americans, 
such as multiple drug interactions, food safety, different 
physiological characterizations and reactions to drug regimens, 
and the need for better medical device design for home self-
diagnostics and therapies, will become more acute. These 
challenges will require greater inclusion of the elderly in 
clinical testing for drugs, medical devices, and other FDA-
regulated products. Further, the increasing educational needs 
of the elderly will require more focused educational programs, 
including specific dietary information and foods targeted to 
their nutritional requirements. The elderly population and food 
service workers who prepare food for the elderly also will 
require special education initiatives concerning proper food 
handling because as the population ages it becomes more 
susceptible to foodborne diseases. Some of the major 
initiatives that are underway are described below.

                                Mission

    The FDA is a regulatory consumer protection Agency. FDA's 
mission is to promote and protect the public health by 
providing timely clearance of safe and effective products and 
monitoring products for continued safety after they are in use. 
The Agency's primary responsibilities are to ensure that: (1) 
foods are safe, nutritious, wholesome, and honestly labeled; 
(2) cosmetics are safe and properly labeled; (3) all drug 
products used for preventing, diagnosing, and treating disease 
are safe and effective, and information on their proper use is 
available; (4) biological products (blood and blood products, 
test kits, vaccines and antigens, therapeutic agents, and other 
biologicals) are safe, potent, and effective for the 
prevention, diagnosis, and treatment of disease; (5) medical 
devices are safe, effective, and properly labeled, and the 
public is not exposed to excessive radiation from medical, 
industrial, and consumer products; (6) animal drugs, devices, 
and feeds are safe and effective; and (7) food from animals 
that are administered drugs are safe for human consumption.
    FDA accomplishes its mission through enforcement of the 
Federal Food, Drug, and Cosmetic Act and subsequent 
regulations. FDA's current areas of emphasis are to implement 
the Food and Drug Administration Modernization Act of 1997, to 
strengthen the Agency's science-base, and to implement the 
Administration's initiatives on food safety and blood safety.

                        Leveraging Partnerships

    Leveraging is the creation of relationships and/or formal 
agreements with others outside the FDA that will ultimately 
enhance FDA's ability to meet its public health mission. By 
choosing to work with other organizations that share our public 
health and safety goals, FDA can significantly amplify its 
public health impact, leverage the intellectual capital of 
others, and make wise use of its resources. FDA has formed many 
leveraging partnerships with other government agencies, 
regulated industry, academia, health providers, consumers, and 
national and community based organizations to help the Agency 
meet its public health responsibilities. As part of the 
Agency's long-standing tradition of involving the public in its 
activities, FDA is forging new relationships with organizations 
in the aging network on national and grassroots levels. The 
Agency has been quite successful with its collaborations, and 
FDA intends to expand and build upon this foundation in 
developing new partnerships. During 1999 and 2000, the Agency 
conducted a variety of activities intended to establish and 
strengthen two-way communication between FDA and its 
constituencies. These activities included national and local 
consumer roundtables, meetings with organizations, stakeholder 
meetings, and public meetings.

                          Public Participation

    FDA has processes that provide access to decision-making 
and information programs by its stakeholders. FDA's 
stakeholders include industry, small business, consumers, and 
health professionals. Stakeholders may interact with FDA policy 
makers, express opinions, or ask for information to address 
specific concerns. FDA provides balanced opportunities for 
public access to the pre- and post-market regulatory processes 
in addition to timely education and information.
    FDA convened a series of national and local roundtables and 
stakeholder meetings with consumers, health professional 
associations, and community-based organizations. These forums 
provide opportunities for the Agency to dialogue with diverse 
groups on the FDA Modernization Act and an array of regulatory 
and health policy issues. One of the issues addressed was risk 
management associated with the use of medical products, a 
significant matter of interest for the older American 
community.

                           Advisory Committee

    The Agency continues its efforts to involve older Americans 
to serve on its advisory committees by working with aging 
organizations to help identify potential candidates. Advisory 
committees have served an important role at FDA for many 
decades. FDA's advisory committees help the Agency make sound 
decisions based on good science in its review of regulated 
products. Advisory committees consist of individuals who are 
recognized as experts in their field from many different 
sectors including medical professionals, scientists and 
researchers, industry leaders, consumer representatives, and 
patient representatives. While advisory committee 
recommendations are valuable, all final decisions related to a 
regulated product are made by FDA. Currently there are 32 
advisory committees serving the Agency.

                              Health Fraud

    Health fraud is the deceptive promotion and distribution of 
false and unproven products and therapies to diagnose, cure, 
mitigate, prevent, or treat disease. 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 are often 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, 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. The Agency also evaluates 
its efforts to 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. Currently, 
FDA is leveraging resources with the Federal Trade Commission 
(FTC) in an effort to target Internet health fraud. This 
initiative, ``Operation Cure-All,'' is aimed at false and 
misleading claims, fraudulent and unproven ``miracle'' cures.
    FDA has worked with the National Association of Attorneys 
General 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, 
the U.S. Postal Service, 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.
    The Internet poses new and challenging problems to Agency 
efforts to prevent health fraud. Snake oil salesmen of the past 
have abandoned their wagons to hop on the Internet with offers 
of eternal youth and potions for the prevention, treatment and 
cure of many diseases. FDA recently seized and destroyed 
Chuifong Black Pills, offered as an Asian herbal treatment for 
the cure of arthritis. Analysis of the pills showed they 
contained several prescription drugs that may pose a serious 
health hazard, especially to consumers who were combining 
Chuifong with their own prescribed medications.
    FDA recently worked with State of California officials to 
stop the distribution of an unapproved diabetic drug imported 
from China. This herbal product, marketed under several names, 
contained the prescription diabetic drug, glyburide. There was 
at least one report of an adverse reaction that required 
medical treatment. FDA published a brochure in cooperation with 
many health care organizations, designed to warn consumers 
about buying medical products online. FDA continues to work 
with the U.S. Customs Service and state law enforcement 
agencies to prevent the Russian product Corvalolum from 
entering the United States. Corvalolum contains dangerous 
levels of Phenobarbital.
    Unapproved new drugs offered as treatments for cancer 
continues to be marketed illegally. FDA took action against 
Laetrile, a fraudulent cancer cure marketed by two firms. The 
Agency obtained a consent decree of permanent injunction 
against one firm and the second firm is under a preliminary 
injunction as of September 2000.
    Another unapproved new drug, hydrazine sulfate, also 
marketed illegally as a treatment for cancer, may cause serious 
adverse effects. Studies have shown that hydrazine sulfate is 
not effective and that it may actually decrease survival time. 
The Agency is taking steps to stop the distribution of this 
product.

                       Office of Consumer Affairs

    The FDA's Office of Consumer Affairs (OCA) seeks consumer 
participation in Agency policy-making and ensures that FDA 
decision-makers hear consumer concerns before completing policy 
decisions. OCA's primary functions include encouraging public 
participation and consumer education and outreach. OCA 
routinely includes older Americans in their public 
participation, education, and outreach initiatives, as well as 
the recruitment process for consumer representatives. OCA 
continues to work with its Agency counterparts, as well as its 
constituents, to ensure consumer involvement in Agency 
processes.
    One method the Agency uses to ensure that FDA gets 
consumers' points of view is by including consumer 
representatives on Agency advisory committees. The role of the 
consumer representative is to (1) represent the consumer 
perspective on issues and actions before the advisory 
committee; (2) serve as a liaison between the committee and 
interested consumers, associations, coalitions, and consumer 
organizations; and (3) facilitate dialogue with the advisory 
committees on scientific issues that affect consumers.
    OCA co-sponsored a variety of consumer roundtables and 
consumer education programs that highlighted issues of 
importance to older Americans. For example:
           OCA in conjunction with FDA's Office of 
        Regulatory Affairs, Pacific Region, convened three 
        public forums. These forums entitled, ``Public Input on 
        Public Health, FDA Listens to You, A Town Hall 
        Meeting'' were held in May 1999 in Oakland, California; 
        Los Angeles, California; and Portland, Oregon. The 
        purpose of the forums was to provide an opportunity for 
        FDA's primary stakeholders, U.S. consumers, to have an 
        open dialogue with FDA's senior policy makers about 
        their consumer protection concerns. Some of the topics 
        addressed were safety and labeling of dietary 
        supplements, access to clinical trials, health fraud, 
        and food safety.
           On October 26, 1999, ``FDA's Consumer 
        Roundtable'' was held in Houston, Texas. This meeting 
        provided an opportunity for consumer to engage in an 
        open dialogue with senior Agency officials on how FDA 
        can work with consumers and community organizations to 
        manage and communicate the risk and benefits of drug 
        products.
           On April 27, 2000, a consumer roundtable 
        ``FDA Celebrates Alliances with Hispanic Communities: 
        Moving Forward'' was held in San Diego, California. 
        This roundtable established interaction between the 
        public and Agency officials on how the Agency can work 
        with the community to manage and communicate the risks 
        and benefits associated with drug products.
           On December 13, 2000, a discussion was held 
        in Washington, D.C. between senior FDA officials, 
        consumer leaders, and consumers to discuss key public 
        health and consumer protection priorities for the 
        Agency. The purpose of this roundtable was to 
        strengthen consumer involvement in the Agency's process 
        for assessing how it is currently directing its 
        consumer protection responsibilities and determining 
        whether there is a need to redirect or shift priorities 
        to better meet those responsibilities.

                        Office of Public Affairs

    The FDA's Office of Public Affairs (OPA) is the agency's 
primary point of contact for the news media. It also manages 
the agency's website at www.fda.gov and develops information 
materials on FDA-related public health and consumer protection 
activities. While working very closely with the different 
centers within the agency, OPA has published a number of FDA 
Consumer magazines, articles, press releases, and talk papers 
that focus on topics of interest and concern to older 
Americans.
    The agency website has a page dedicated to older Americans 
entitled ``FDA Information for Older People.'' This site gives 
information regarding buying medicines online, seniors and food 
safety, and linkages to other organizations outside of FDA with 
information of interest to older Americans. This webpage also 
has numerous articles and other publications with information 
for older Americans on a wide range of health issues such as:
           Arthritis: Timely Treatments for an Ageless 
        Disease
           Help Your Arthritis Treatment Work (Spanish 
        Version)
           Preventing Colon Cancer
           FDA Sets Higher Standards for Mammography
           Lung Cancer
           Prostate Cancer: No One Answer for Testing 
        or Treatment
           Health Claim for Foods That Could Lower 
        Heart Disease Risk
           Keeping Cholesterol Under Control
           Taking Charge of Menopause
           Taking Time to Use Medicines Wisely
           How to Spot Health Fraud

                    Office of Special Health Issues

    The FDA's Office of Special Health Issues (OSHI) serves the 
public by answering their questions about the Agency's 
activities related to HIV/AIDS, cancer, and other diseases. 
OSHI works with patients and their advocates to encourage and 
support their active participation in the formulation of FDA 
regulatory policy. Additionally, OSHI (1) serves as a channel 
through which patient issues and viewpoints can be brought to 
the attention of FDA medical and regulatory staff; (2) ensures 
a comprehensive and timely response to individuals with 
questions and concerns related to life-threatening diseases and 
other special health issues; (3) participates in the 
development of national policies and practices concerning HIV/
AIDS, cancer, and issues related to special populations; and 
(4) provides FDA representation to scientific and policy 
meetings related to life-threatening diseases and other special 
health concerns.

                        Office of Women's Health

    The FDA's Office of Women's Health (OWH) serves as a 
champion for women's health both within and outside the Agency. 
To meet its goals OWH (1) ensures that FDA's regulatory and 
oversight functions remain gender sensitive and responsive; (2) 
works to correct any identified gender disparities in drug, 
device, and biologics testing and regulation policy; (3) 
monitors the progress of priority women's health initiatives 
within FDA; (4) promotes an integrative and interactive 
approach regarding women's health issues across all the 
organizational components of the FDA; and (5) forms 
partnerships with government and non-government entities, 
including consumer groups, health advocates, professional 
organizations, and industry, to promote FDA's women's health 
objectives.
    OWH has developed a number of initiatives to further its 
inclusion of older Americans in their programs such as:
           Take Time To Care (TTTC) encouraged women 
        nationwide to educate themselves and their families 
        about using medicines wisely. Educational grassroots 
        programs were developed with 80 national organizations 
        and cosponsored by the National Association of Chain 
        Drugstores (20,000 community pharmacies). Their efforts 
        coupled with nearly 100 media outlets brought the FDA 
        message to 26 million readers and viewers. For these 
        efforts, the Health Care Quality Alliance (97 health 
        care associations) selected TTTC as a recipient of the 
        prestigious Pinnacle Award, which annually ``recognizes 
        pioneering contributions and exemplary leadership in 
        medication use quality improvement.''
           Breast Cancer Awareness Month--In 
        collaboration with the Center for Devices and 
        Radiological Health the FDA/OWH sent a letter to all 
        10,000 certified mammography facilities inviting them 
        to showcase the availability of our Mammography Today 
        brochure and distribute a one-page abbreviated version 
        of the brochure to inform patients about their new 
        rights.
           Pink Ribbon Sunday--OWH sponsored activities 
        of the FDA Public Affairs Specialists in Houston, 
        Dallas, and Atlanta to conduct ``Pink Ribbon Sunday'' 
        activities that encourage ``women of color'' to get 
        screened. In the city of Houston alone, 153 churches 
        participated and reached about 110,000 people with FDA 
        materials. The Public Affairs Specialists received the 
        American Cancer Society's ``Partner of Courage Award.''
           Breast Cancer Videotape--OWH developed a 
        Breast Cancer ``Early Detection Saves Lives'' videotape 
        to encourage churches to sponsor screening and 
        educational activities. The videotape will be given to 
        the Public Affairs Specialists, and the National Cancer 
        Institute for distribution through their clearinghouse.
           New Publications--(1) Created a quarterly 
        newsletter for our stakeholders focusing on FDA 
        actions, meetings and activities of interest to women. 
        (2) Published the first FDA history document describing 
        the agency's role in protecting women's and the 
        public's health over the last 100 years. The milestones 
        presented highlight specific actions taken by the 
        agency so that all Americans can enjoy safer, healthier 
        lives.
           OWH Website--Redesigned the OWH website that 
        became a recipient of the ``Hot Site Award.''

            Other Outreach Projects (for delivery in FY2001)

           OWH will work in partnership with the 
        American Pharmaceutical Association Foundation and the 
        National Wholesale Druggists' Association Healthcare 
        Foundation to promote distribution of TTTC medicine 
        tips in hospitals. Hospital-based pharmacies will 
        encourage consumers to play a role in managing risks 
        associated with medication use as in-patients and out-
        patients.
           In December 2000, the Emergency Nurses 
        Association (ENA) announced to its 25,000 members its 
        decision to adopt TTTC as a national campaign. ENA will 
        distribute ``My Medicines'' brochures in emergency 
        settings, hospital auxiliaries, civic meetings, and 
        retirement homes.
           OWH funded a grant for the translation of 
        materials about cervical and breast cancer screening 
        for Asian-American Pacific-Islander communities through 
        a website coordinated by APANet.
           OWH funded a bi-regional women's health 
        conference in DHHS Regions II and III for health 
        professionals and consumers to raise awareness about 
        health disparities found in minority communities.
           OWH funded the development of a multi-media 
        Women's Health Care Trainer's Kit and Consumer Guide to 
        assist women in planning for screenings and preventing 
        illnesses.
           OWH funded a ``Read the Label'' project that 
        will use graphics to provide instructions for non-
        English readers in a variety of Asian languages. This 
        model may then be applied to other language groups.

                 Office of Orphan Products Development

    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. From 1983--when the Orphan Drug Act was 
passed--through the end of 2000, 216 products to treat small 
populations of patients were approved by FDA.
    By the end of 2000 there were 856 designated orphan 
products. One hundred thirty-two of these designated orphan 
products (15 percent) represent therapies for diseases 
predominately affecting older Americans. Seventy-five are for 
treating rare cancers in the elderly, such as ovarian cancer, 
pancreatic cancer, and metastatic melanoma. Twenty-two  of the  
orphan  products  designated  for treating elderly populations 
are for rare neurological diseases, such as amyotrophic  
lateral sclerosis  (ALS), and advanced  Parkinson's disease. 
Twenty-nine 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 product grants had their beginning in 1983 as 
one of the incentives provided by the Orphan Drug Act. This 
program 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 grant 
program have contributed to the marketing approval of twenty-
eight 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, such as 
women, children, or the elderly. Under the orphan drug program, 
disease populations are small and in many instances the firms 
themselves are very small. The goal of the Orphan Drug Act is 
to bring to market products for rare diseases or conditions. In 
so doing, orphan product development promotes research and 
labeling of drugs for use by and for special populations. The 
orphan products grant program has funded more than 42 studies 
aimed at treatment of diseases affecting adults and older 
adults.

             The National Center for Toxicological Research

    The National Center for Toxicological Research's (NCTR) 
mission is to conduct peer-reviewed scientific research that 
supports and anticipates the FDA's current and future 
regulatory needs. This involves fundamental and applied 
research specifically designed to define biological mechanisms 
of action underlying the toxicity of products regulated by the 
FDA. This research is aimed at understanding critical 
biological events in the expression of toxicity and at 
developing methods to improve assessment of human exposure, 
susceptibility, and risk.
    NCTR has worked with the National Institute on Aging (NIA) 
in the past to study the role caloric restriction plays in the 
aging process and what affect a reduced caloric diet has on 
disease etiology. The Interagency Agreement with the NIA 
terminated in 1999 with the animals that were raised in support 
of this work being transferred to Harlan Sprague Dawley, a 
commercial laboratory animal breeder. 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 affects the 
normal aging process. Since 1999 the only studies that have 
been continuing are a collaborative study with the University 
of Tennessee at Memphis designed to determine if the 
physiological, metabolic, and molecular changes that occur with 
caloric restriction in rodents are similar in humans, and 
additional rodent studies to measure how different levels of 
caloric restriction might influence body changes.
    Although the work over the last several years has 
concentrated on the mechanisms of toxic interaction in the body 
and the role caloric restriction has on this process, studies 
with calorically restricted animals have repeatedly shown that 
caloric restriction extends the life span of animals. How this 
affects aging is still in question; however, the research being 
conducted in this area is continuing to chip away at the 
problem of how diet affects the aging process, and what 
elements or lack thereof in the human diet may help to extend 
human life.

                                Medwatch

    MedWatch, the FDA's voluntary Medical Products Reporting 
and Safety Information Program, serves both healthcare 
professionals and the medical product-using public. MedWatch 
strives to educate health professionals about the critical 
importance of being aware of, monitoring for, and reporting 
adverse events and product problems to FDA and/or the 
manufacturer, as well as to ensure that new safety information 
is rapidly communicated to the medical community, thereby 
improving patient care. The purpose of the MedWatch program is 
to enhance the effectiveness of postmarketing surveillance of 
medical products as they are used in clinical practice and to 
assist in rapidly disseminating information about significant 
health hazards associated with these products. Health 
professionals, as well as consumers, are encouraged to report 
serious adverse reactions and product problems associated with 
FDA-regulated products to the Agency.
    Older Americans are generally more susceptible to adverse 
events because of the probability they will use more 
medications and medical device products.

               Center for Devices and Radiological Health

    The FDA's Center for Devices and Radiological Health (CDRH) 
promotes and protects the health of the public by ensuring the 
safety and effectiveness of medical devices and the safety of 
radiological products. Medical devices include products ranging 
from mechanical heart valves to ophthalmic lasers to pregnancy 
test kits products that are intended for use in the diagnosis 
of disease or other conditions, or in the cure, mitigation, 
treatment or prevention of disease. Radiation-emitting 
electronic products include such things as microwave ovens, 
televisions, sunlamps, medical and baggage inspection x-ray 
machines, and laser products such CD and DVD players, light 
shows and bar code scanners. CDRH provides information to 
consumers, including older Americans, regarding medical devices 
and radiation-emitting products to enhance their ability to 
avoid risk, achieve maximum benefit, and make informed 
decisions about the use of such products.

                              Mammography

    Because a woman's risk for breast cancer increases as she 
gets older, the need to have a regularly scheduled mammogram is 
critical to ensure early detection. Congress enacted the 
Mammography Quality Standards Act of 1992 (MQSA) to ensure that 
all women have access to quality mammography for the detection 
of breast cancer in its earliest, most treatable stages.
    As of April 28, 2000, there were 9,994 MQSA-certified 
mammography facilities in the United States and its 
territories. All of these facilities are subject to clinical 
accreditation by outside expert bodies, and certification and 
inspection by FDA to ensure compliance with quality standards.
    Older women are the focus of this effort:
           CDRH targets older Americans for particular 
        outreach efforts. Groups such as AARP have been on our 
        mailing list to receive mammography information and 
        Mammography Matters (our newsletter) since the 
        inception of our program.
           CDRH has collaborated extensively with FDA's 
        Offices for Women's Health, Consumer Affairs, Public 
        Affairs, and Special Health Issues, and they have 
        distributed educational materials about mammography to 
        their constituents, including newsletter editors.
           Older Americans were included in the 
        outreach about the availability of the 1-800-4-Cancer 
        hotline. Callers to this number can locate FDA-
        certified mammography facilities in their areas, get 
        answers to questions about breast cancer, and request 
        publications.
           Consumer representatives with ties to senior 
        advocacy groups are members of our National Mammography 
        Quality Assurance Advisory Committee.

                          Hospital Bed Safety

    FDA continues its work to reduce the hazards associated 
with patient entrapment in hospital beds. Patient entrapment 
with hospital bedside rails can occur in hospitals, nursing 
homes and at home. The FDA continues to receive reports of 
death and injury when patients become entangled or trapped 
between the mattress and bed rail or in the bed rail openings. 
The patients most at risk for entrapment are frail, elderly or 
confused.
    FDA initiated and is an active member of The Hospital Bed 
Safety Work Group, which most recently met in Chicago on 
October 24-25, 2000. The Hospital Bed Safety Work Group is made 
up of representatives of the federal government, national 
health care organizations, manufacturers of hospital beds and 
medical researchers. To date, the work group has primarily 
focused on raising awareness of the entrapment hazard and 
educating caregivers and family members on the problems 
associated with bed rail use. The work group recently issued an 
educational brochure, ``A Guide to Bed Safety,'' that 
highlights the benefits and risks of bed rails, ways to meet a 
patient's need for safety, and patient or family concerns about 
bed rail use. This brochure and the work of The Hospital Bed 
Safety Work Group are available on the FDA web site for bed 
safety at: http://www.fda.gov/cdrh/beds/. Planned work includes 
developing clinical guidance for caregivers on appropriate bed 
rail use and developing a measurement tool for clinical 
facilities to determine if an entrapment hazard exists with 
their beds.

               Treatment for Benign Prostatic Hyperplasia

    On October 11, 2000, FDA sent a Public Health Notification 
to alert the medical community of the potential for serious 
injuries from microwave thermotherapy for benign prostatic 
hyperplasia (BPH). Although the use of microwave thermotherapy 
for the treatment of BPH has been demonstrated to be safe and 
effective, FDA is concerned about reports of unexpected 
procedure-related complications that have occurred since the 
marketing of these devices. The letter identified several 
factors that may have contributed to the injuries and made 
recommendations to avoid injury.

                        Medical Device Approvals

Heart and Cardiovascular System

           The AngioJet System, approved on March 15, 
        1999, removes blood clots from blocked heart arteries 
        or bypass grafts prior to angioplasty. The device will 
        provide an alternative treatment to so-called clot-
        busting drugs, and will be particularly useful for 
        patients in whom these drugs cannot be used.
           On November 6, 2000, FDA approved the Cordis 
        CheckmateTM System and the Novoste Beta-
        CathTM System, both of which use catheters 
        to deliver radiation inside a coronary stent, following 
        the opening of a blocked artery. The radiation helps 
        reduce the risk of new tissue growth inside the 
        coronary stent and the resulting narrowing of the 
        artery.
           FDA continues to review and approve for 
        marketing improved versions of heart valves, 
        pacemakers, implanted cardioverter defibrillators and 
        other cardiac devices that will help many older 
        Americans live longer, more comfortable lives.

Vision

           Verteporfin for injection (Visudyne), the 
        first therapy to slow vision loss in people with 
        classic ``Wet Age-Related Macular Degeneration (AMD)'' 
        was approved on April 13, 2000. AMD, a retinal disease 
        causing severe and irreversible vision loss, is a major 
        cause of blindness in individuals older than 60 years 
        in the Western World.

Cancer

           Approved on April 19, 1999, the T-SCAN 2000 
        is intended for use as a follow-up step to mammography 
        for patients whose mammograms are ambiguous. The device 
        has the potential to reduce the number of negative 
        biopsies, thus saving women worry about breast lesions 
        that turn out to be non-cancerous.
           Approved January 31, 2000, the Senographe 
        2000D is the first mammography system that produces 
        digital images on a solid state receptor instead of 
        analog images on a radiographic film. Unlike 
        radiographic film, digital images can be electronically 
        stored and transferred, so that a specialist at a 
        remote location can evaluate them. The images also can 
        be manipulated to correct for under- or over-exposure. 
        Early diagnosis remains the best weapon against breast 
        cancer, which annually affects 185,000 women, 46,0000 
        of whom die of the disease. Most women who get breast 
        cancer are over 50 years of age. The approval of 
        digital mammography benefits older Americans because 
        the ability to manipulate computer images means fewer 
        call-backs for additional imaging, which can be 
        difficult for older Americans who often depend on 
        others for their transportation.
           FDA allowed continued marketing of two types 
        of saline-filled breast implants that had been approved 
        for breast reconstruction and for breast augmentation 
        in women 18 years or older. This decision was made 
        following the conclusion of clinical studies involving 
        9,000 women and the recommendations of our expert 
        advisory committee. Many women feel that breast 
        reconstruction is an essential part of their recovery 
        after mastectomy because of breast cancer.
           The Optical Biopsy System is a laser system 
        that improves a physician's ability to identify 
        suspicious growths in the colon. It is operated through 
        an endoscope and can be used to evaluate polyps less 
        than 1 cm in diameter. This device was approved on 
        November 15, 2000.
           Another device, FocalSeal-L Surgical 
        Sealant, was approved on May 30, 2000, for sealing air 
        leaks in lungs following the removal of cancerous 
        tumors. FDA reviewed the sealant, which is ``painted'' 
        on the lung and activated by light, on an expedited 
        basis because of its potential importance for patients 
        with lung cancer.
           Levulan Kerastick (aminolevulinic acid HCI) 
        for Topical Solution, 20 percent is to be used in 
        conjunction with photodynamic therapy for treatment of 
        actinic keratoses (AKs) (pre-cancerous skin lesions) of 
        the face or scalp. AKs are rough, scaly, red or brown 
        patches that begin on the surface of the skin. They are 
        mostly found among individuals with light complexions 
        affecting more than 50 percent of elderly fair-skinned 
        persons in hot, sunny climates. This product was 
        approved on December 6, 1999.

Diabetes

           The Continuous Glucose Monitoring System, 
        approved on June 16, 1999, provides physicians with 
        continuous measures of tissue glucose levels in adults 
        with diabetes.
           Apligraf is intended to be used on patients 
        who have not responded well to standard methods of 
        treating foot ulcers. Approved on June 20, 2000, 
        Apligraf is a cellular, bi-layered skin substitute 
        produced from bovine collagen and cells derived from 
        human infant foreskins. Many diabetics have difficulty 
        healing and might benefit from this product.

Pneumonia

           A laboratory test for detecting 
        Streptococcus pneumoniae, one of the bacteria that is a 
        leading cause of pneumonia was approved on August 30, 
        1999. Pneumonia can be a life-threatening disease for 
        the elderly.

Hearing Loss

           Vibrant Soundbridge is a surgically 
        implanted hearing device intended to help adults with 
        moderate to severe nerve hearing loss. Approved on 
        August 31, 2000, this device is an alternative for 
        people who have not been helped by hearing aids. About 
        20 percent of Americans--more than 56 million--
        experience some nerve deafness by the age of 55.

                                Research

    Gender effects on coronary arteries and balloon 
angioplasty.--FDA scientists have established a large animal 
cardiovascular research program to develop and study models of 
cardiovascular disease, vascular injury, and long-term vascular 
implant performance. FDA scientists are using the laboratory to 
study effects of gender and hormonal state on the function and 
mechanical properties of coronary arteries and on the response 
of arteries to balloon injury. More than 75 subjects have been 
studied and the results thus far will be announced at the FDA 
Science Forum in February 2001. The motivation for the study is 
the observed greater incidence of cardiovascular death in 
postmenopausal women and men of all ages compared to 
premenopausal women.
    Early detection of diabetes-related eye diseases.--One of 
the most threatening aspects of diabetes is the development of 
visual impairment due to cataract formation, diabetic 
retinopathy, and glaucoma. In many cases, diabetes-related 
ocular pathologies go undiagnosed until visual function is 
compromised. In order to develop techniques for early cataract 
detection, FDA scientists are studying the progression of 
diabetes in a unique animal model and monitoring the changes in 
the lens using a safe, nondestructive dynamic light scattering 
technique.
    Ultrasonic measurement of bone density.--FDA has approved 
several ultrasound bone densitometers, which are used in the 
assessment of osteoporosis, and more applications for these 
devices are in progress. Because this is a new technology, 
there is little standardization between devices, and the 
technology is likely to continue evolving. FDA scientists are 
investigating the ultrasonic measurements (backscatter, 
attenuation, and sound speed) on 50 women ranging in age from 
50-90. The objective is to investigate the diagnostic utility 
of the backscatter measurement for diagnosis of osteoporosis. 
Preliminary experiments conducted on bone samples in vitro 
increased understanding of how and why ultrasound bone 
sonometry is effective and should, therefore, lead to better 
review of these devices.
    Acoustic detection of cavitation near heart valves.--
Transient cavitation--the formation and collapse of tiny 
bubbles in the blood--has been observed near operating 
mechanical heart valves. Cavitation can damage the valve and 
break down the blood cells. FDA is conducting studies to 
determine if the broad-spectrum acoustic energy that occurs 
when the bubbles collapse might be used to detect cavitation by 
``listening'' with a hydrophone to the noise produced by valve 
closing when cavitation is present.
    Electromagnetic interference with electronic implants.--
CDRH scientists have conducted studies to help determine the 
risk of various magnetic fields to electronic implanted medical 
devices. Magnetic fields from various types of electrical 
equipment can interfere with the proper operation of implanted 
medical devices, such as cardiac pacemakers and defibrillators, 
and spinal cord stimulators. CDRH engineers have completed 
magnetic and electric field mapping of eight electronic article 
surveillance systems. A special laboratory environment was 
required to conduct this study. CDRH's three-dimensional 
electromagnetic field-strength mapping apparatus was relocated 
to a new laboratory and the required support structure was 
designed and constructed using non-magnetic components; a walk-
through metal detector was obtained from the Federal Aviation 
Administration. The results of these tests were published in 
the September-October 1999 issue of Compliance Engineering.
    Standards Development.--CDRH scientists have participated 
heavily in the development of performance standards for many 
types of devices of interest to older Americans. These include 
standards for devices to relieve the consequences of arthritis 
such as total orthopedic joints and mobility aids such as 
wheelchairs, as well as devices to assist the cardiovascular 
system such as pacemakers, heart valves, and cardiovascular 
stents. CDRH currently supports more than 500 domestic and 
international standards development efforts.

                                Website

    CDRH's website provides consumer information on many topics 
of interest to older Americans such as mammography, newly 
approved medical devices, and reducing user error. There are 
also webpages devoted to LASIK, the popular laser surgery for 
improving vision, and the safety of hospital beds. CDRH's 
website can be found at http://www.fda.gov/cdrh/index.html.

                              Publications

           ``Mammography Today: Questions and Answers 
        for Patients on Being Informed Consumers--Better 
        Treatments Save More Lives''
           ``FDA Sets Higher Standards for 
        Mammography''
           Mammography Matters newsletter
           ``A Guide to Bed Safety; Bed Rails in 
        Hospitals, Nursing Homes and Home Health Care: The 
        Facts''
           ``Breast Implant Risks''
           ``Breast Implants An Information Update--
        2000''

CDRH FDA & HHS Press Releases, Fact Sheets, Public Health Notifications 
               and Statements Related to Older Americans

           FDA Approves New Device To Remove Blood 
        Clots From Coronary Arteries (Angio-jet)--March 15, 
        1999
           FDA Approves New Breast Imaging Device (T-
        Scan)--April 19. 1999
           Potential Cross-Contamination Linked to Hem 
        odialysis Treatment--May 1999
           Laser Facts--June 1999
           FDA Clears Quick New Lab Test for Pneumonia 
        Antigen--August 30, 1999
           Consumer Update on Mobile Phones--October 
        20, 1999
           Temporomandibular Joint Implants: A Consumer 
        Information Update--November 1999
           First Drug Device Combined Treatment for 
        Certain Pre-Cancerous Skin Lesions Approved--December 
        6, 1999
           FDA Statement about ColorMax Eyeglass 
        Lenses--December 21, 1999
           FDA Approves First Digital Mammography 
        System--January 31, 2000
           Risks of Burns from Eruption of Hot Water 
        Overheated in Microwave Ovens--March 8, 2000
           Microwave Oven Radiation--March 8, 2000
           FDA Alerts Health Professionals and 
        Consumers to a Nationwide Recall of Clinipad Antiseptic 
        Sterile Products--March 10, 2000
           FDA Approves Treatment for Wet Macular 
        Degeneration--April 13, 2000
           Two Firms Get FDA Approval To Continue 
        Marketing Saline-Filled Breast Implants--May 10, 2000
           FDA Approves New Surgical Sealant For Lung 
        Cancer--May 30, 2000
           FDA Approves New Product For Diabetic Foot 
        Ulcers--June 20, 2000
           Risk of Electromagnetic Interference with 
        Medical Telemetry Systems--July 10, 2000
           Serious Injuries from Microwave 
        Thermotherapy for Benign Prostatic Hyperplasia--October 
        11, 2000
           FDA Approves New Implanted Hearing Device--
        October 23, 2000
           FDA Approves Two New Devices To Help Reduce 
        the Risk of Repeat Coronary Stent Re--Narrowing (In-
        Stent Restenosis)--November 6, 2000
           FDA Approves New Device To Help Distinguish 
        Harmless from Pre-Cancerous Growths in Colon--November 
        15, 2000
           Court Orders Refund to Purchasers of Gas 
        Grill Igniters Marketed for Pain Relief--November 30, 
        2000

                Center for Drug Evaluation and Research

    The mission of FDA's Center for Drug Evaluation and 
Research (CDER) is to promote and protect the public health by 
helping to ensure that safe and effective drugs are available 
to the American public including older Americans. FDA is 
continuing to make drugs safer for older Americans, who consume 
a large share of the nation's medications. Adults over age 65 
buy 30 percent of all prescription drugs and 40 percent of all 
over-the-counter (OTC) drugs.

                          Public Participation

    CDER continues to maintain its long-standing tradition of 
involving the public in its activities. On June 28 and 29, 
2000, FDA held a public meeting to get input and opinions on 
the type of drugs for which it would be appropriate to switch 
from prescription status to OTC status. Many of the drugs 
discussed were drugs commonly used by the aging population in 
America. For example, one part of the meeting focused on 
cholesterol-lowering drugs and whether they should be 
considered as candidates for OTC drug status. The meeting 
attracted considerable attention from consumer and patient 
groups, as well as industry, and was covered by C-Span.

                     OTC Labeling Changes Campaign

    Many older Americans find the print on OTC labels too small 
to be legible. In 1997, FDA issued a proposal to establish a 
standardized format for the labeling of OTC drug products and 
provided over 7 months for interested persons to comment on the 
OTC labeling proposal. The Agency received more than 1,800 
comments from health professionals, students, professional 
organizations, trade associations, manufacturers, consumers, 
and consumer organizations. An overwhelming majority of the 
comments supported the Agency's initiative to standardize the 
format of OTC drug product labeling and to make the labeling 
easier to read and understand by requiring a minimum type size, 
user-friendly headings, and other well-accepted visual cues. 
The regulations became effective on April 16, 1999. In many 
cases, OTC drugs with the new labeling will begin appearing on 
the shelves by 2002. The remainder of more than 100,000 OTC 
drugs will be required to adopt the new labeling within the 
next six years. CDER reached more than 17 million people with a 
print campaign and 137 million listeners with radio Public 
Service Announcements notifying them of the OTC labeling 
changes.

                   Materials, Outreach, and Exhibits

    The FDA continually strives to establish an ongoing 
dialogue between the Agency and its constituents on important 
public health problems and issues. Of recent interest is the 
use of the Internet by the public to buy medical products. Many 
consumers, including older Americans or those who cannot leave 
their homes, benefit from the convenience and privacy of this 
new option. The safe use of the Internet by consumers is 
threatened, however, by fraudulent or disreputable Internet 
pharmacies that sell products illegally. CDER prepared a 
brochure, a newspaper article, and a print Public Service 
Announcement designed to inform the public about the potential 
dangers of buying medical products on the Internet, and to 
increase consumer awareness about the problems related to 
online drug purchases. This information is available on FDA's 
website on www.fda.gov.
    In addition, the Agency actively participated in outreach 
activities including a two-day national workshop with the 
National Patient Safety Foundation to address the safe use of 
medical products from the consumer and patient perspectives. 
Held in March 2000, one of the goals of the meeting was to 
stimulate a national dialogue about safe medical treatment 
among consumer groups and health professional organizations. 
Following the meeting, CDER produced four videotaped 
presentations to be used during future public meetings about 
safe medical treatments. In May 2000, CDER provided an exhibit 
at the First National Conference of the American Society of 
Aging and the National Council of the American Association of 
Retired Persons in Orlando, Florida.
    Finally, CDER has prepared several brochures specifically 
for older Americans. Titles include: ``AgePage, Medicines: Use 
Them Safely,'' ``Reducing Your Risk of Heart Attack or Stroke 
with Aspirin Therapy: Know the Facts,'' and ``Be an Active 
Member of Your Health Care Team.''

             Postmarket Drug Surveillance and Epidemiology

    CDER's Office of Postmarketing Drug Risk Assessment is 
responsible for receiving, entering into a database, and 
analyzing reports sent to the Agency on adverse reactions to 
drugs. In 1999, there were approximately 261,000 reports 
entered into CDER's Adverse Event Reporting System. For 2000, 
the approximate number increased to 300,000. Reports 
representing patients aged 65 years or older numbered 54,000 
(21 percent of total for 1999) and 52,000 (17 percent of total 
for 2000). These percentages are similar to those reported in 
the past.

                           Geriatric Labeling

    On December 11, 1998, the Agency made public a draft 
publication entitled: ``Guidance for Industry on the Content 
and Format for Geriatric Labeling.'' This guidance discusses 
the following issues related to the submission of geriatric 
labeling: 1) who should submit revised labeling; 2) 
implementation dates; 3) description of the regulation and 
optional standard language in proposed labeling; 4) content and 
format for geriatric labeling; and 5) applicability of user 
fees to geriatric labeling supplements. Comments submitted to 
the proposed rule currently are being addressed by the Agency.

                             Generic Drugs

    During 1999-2000, FDA's Office of Generic Drugs approved 
699 abbreviated new drug applications. These drug products are 
often substantially less expensive and provide a safe and 
effective alternative to brand-name products. Many of these 
approvals represent the first time a generic drug was made 
available for products of special interest to older Americans 
such as doxazosin mesylate capsules used in the treatment of 
enlarged prostate and hypertension, paclitaxel injection used 
in the treatment of various ovarian and breast cancers, and 
digoxin tablets used in the treatment of heart failure. These 
and other recently approved generic drug products could save 
the American public and federal government millions of dollars. 
In July 1998 the Congressional Budget Office (CBO) published a 
report: How Increased Competition from Generic Drugs Has 
Affected Prices and Returns in the Pharmaceutical Industry. The 
CBO estimated that in 1994, purchasers saved between $8 billion 
to $10 billion on prescriptions at retail pharmacies by 
substituting generic drugs for their brand-name counterparts.

              Center for Food Safety and Applied Nutrition

    While the American food supply is among the safest in the 
world, there are still too many Americans stricken by illness 
every year caused by the food they consume, and some mostly the 
very young, elderly, and the immune compromised die every year 
as a result. The FDA's Center for Food Safety and Applied 
Nutrition (CFSAN) promotes and protects the public health and 
economic interest by striving to be a leader in food safety, 
protecting consumers from economic fraud, promoting sound 
nutrition, and encouraging innovation. The following programs 
and activities demonstrate the center's commitment to provide 
benefits for older Americans.

                CFSAN's Outreach and Information Center

    CFSAN's new Outreach and Information Center (O&IC) 
considerably expanded access and assistance to all consumers 
throughout the country, especially older consumers. Expanding 
coverage of the live toll-free Information Line, 1-888-SAFEFOOD 
(10:00-4:00) was particularly beneficial since a large 
proportion must rely on the telephone for information. Of the 
55,000 calls received, a majority were from older persons 
seeking information on a variety of food and cosmetic-related 
issues. With more now having access to computers, we have seen 
a steady increase in the number of older consumers requesting 
food safety information through CFSAN's electronic-mail system. 
However, we also responded to more that 2500 written letters, 
again a majority from older persons. Most notably, older 
consumers are the single largest group requesting FDA/CFSAN 
publications and other materials. The O&IC and the Consumer 
Education Staff have developed workshops, served as presenters, 
provided materials and staffed exhibits at conferences 
throughout the country, with a particular focus on providing 
information to older consumers.

           Food Safety Campaign Aimed at Seniors is Launched

    ``To Your Health! Food Safety for Seniors'' is a new 
educational program developed by CFSAN's Food Safety Initiative 
staff and the U.S. Department of Agriculture's Food Safety and 
Inspection Service. The materials focus on seniors because they 
are one of the more susceptible populations for developing 
foodborne illness. And once they become sick, they face the 
risk of more serious health problems, even death.
    The 14-minute video and companion publication were designed 
in cooperation with a variety of senior advisors including 
representatives from the Administration on Aging, the State 
Units on Aging, and the National Institutes of Health. In 
format and design, the materials are tailored to seniors. The 
publication features large type to make easy reading for older 
eyes. The graphics are colorful and bold. The video contains 
portraits of other seniors. Through them, we learn about safe 
food handling at home and food safety when eating out. This 
program is not targeted to seniors who are living in nursing 
homes or assisted-living facilities where all meals are 
provided.
    A comprehensive, nationwide distribution plan is underway 
for the 550,000 publications and 47,000 videos produced. Health 
educators and program leaders at more than 10,000 senior 
centers; 5,000 county extension offices; 5,000 county health 
departments 1,000 area offices of aging; 50 state extension and 
health departments; as well as 50 national organizations 
representing seniors will be receiving the materials. FDA's 
Public Affairs Specialists will be complementing this 
distribution with their own outreach activities. Individual 
consumers can receive a free copy of the publication by 
contacting the Consumer Information Center in Pueblo, Colorado. 
A small supply of publications and videos are in stock. If you 
would  like a  copy of  the publication,  please  contact  
Laura Fox, FSI Education Team, at 202-260-0574; or by e-mail to 
[email protected]. The video will shortly be on the CFSAN 
Intranet.

                    Program Priority Accomplishments

    The following is a listing of program priority 
accomplishments for CFSAN. Each of these accomplishments 
addresses an action taken by the Agency to enhance the lives of 
consumers while protecting the U.S. food supply and promoting 
public health. With an increase in the variety of foods and the 
number of convenience items that are currently available to 
consumers in the market place a number of public health 
concerns have evolved, especially for older Americans because 
of their greater susceptibility to illnesses. The 
accomplishments listed below will address some of those 
concerns.
           Nutrition, Health Claims, and Labeling--
        CFSAN published a final rule authorizing a health claim 
        for soy protein and heart disease (21 CFR 101.82) on 
        October 26, 1999. CFSAN completed the evaluation of two 
        additional health claim petitions within statutory 
        timeframes. One petition was for sterol esters and 
        heart disease. The other was for stanol esters and 
        heart disease. The agency issued an interim final rule 
        authorizing these health claims on September 8, 2000 
        (65 FR 54686)(21 CFR 1010.83).
           Food Safety Report--In accordance with 
        Senate Report 106-80, in consultation with the U.S. 
        Department of Agriculture, prepared a report to 
        Congress on how to educate the public about the safety 
        of our food supply.
           Public Meeting--Held a public meeting in 
        Chicago, Illinois on July 21, 2000 to discuss the use 
        of term ``fresh'' in the labeling of foods processed 
        with alternative non-thermal technologies. The purpose 
        of this meeting was to solicit views on whether the use 
        of the term ``fresh'' is truthful and non-misleading on 
        foods processed with these alternative technologies and 
        on what type of criteria FDA should use when 
        considering the use of the term with future 
        technologies.
           Enforcement Procedures--CFSAN established 
        procedures to evaluate food label complaints and 
        respond to significant or precedent setting 
        discrepancies in food labeling.
           Safety Issues--Contracts were arranged with 
        the National Academy of Science's Institute of Medicine 
        to establish a scientific framework for assessing the 
        safety of dietary supplements, and to apply that 
        framework to several specific dietary supplement 
        products.
           Ephedra--Published three Federal Register 
        notices announcing the availability of new adverse 
        event reports and related information on dietary 
        supplements containing ephedrine alkaloids, and 
        announcing withdrawal of the provisions of the 
        ephedrine alkaloids proposed rule relating to the 
        dietary ingredient level and duration of use limit for 
        these products (65 FR 17474-17510; April 3, 2000). 
        Participated in a public meeting on August 8-9, 2000 
        sponsored by the Public Health Service, to discuss the 
        available information about the safety of dietary 
        supplements containing ephedrine alkaloids.
           Health Claim Regarding Fiber and Colorectal 
        Cancer--On October 10, 2000 issued a final 
        determination on a second of the four Pearson claims. 
        FDA determined that the proposed health claim about 
        dietary fiber and reduced risk of colorectal cancer 
        could not be authorized because the results of studies 
        about dietary fiber consistently showed a lack of 
        relationship between dietary fiber supplements and the 
        risk of colorectal cancer. Neither could the claim be 
        qualified because the suitable evidence against the 
        claim outweighed the evidence for it.
           Health Claim Regarding Omega-3 Fatty Acids 
        and Coronary Heart Disease--On October 31, 2000 issued 
        a final determination on the third of four Pearson 
        claims. FDA is using its enforcement discretion to 
        allow a qualified claim about the use of omega-3 fatty 
        acids in dietary supplements and the reduced risk of 
        coronary heart disease. The qualified claim applies to 
        daily intakes that do not exceed three grams per person 
        per day from conventional food and dietary supplement 
        sources.
           Claims for Mitigation of Disease--Following 
        a public meeting on May 26, 2000 denied a petition 
        requesting authorization of a health claim concerning 
        the relationship between dietary supplements containing 
        saw palmetto and benign prostatic hyperplasia (BPH). 
        FDA's response noted that claims about effects on 
        existing diseases do not fall within the scope of the 
        health claim provisions of the Act and therefore may 
        not be the subject of an authorized health claim.
           Health Claim Petitions--CFSAN continues to 
        meet its statutory obligations for health claims for 
        dietary supplements. CFSAN denied, by operation of the 
        statue (on December 1, 1999) and formally on May 26, 
        2000 a health claim for saw palmetto extracts and 
        symptoms of BPH. CFSAN also denied on January 11, 2000 
        a petition for vitamin E and heart disease due to lack 
        of significant scientific agreement to support the 
        claim.
           Dietary Supplement Strategic Plan--On 
        January 3, 2000 the Dietary Supplement Strategic Plan 
        was distributed to stakeholders and posted on the web 
        page. The plan establishes a clear program goal to 
        have, by the year 2010, a science-based regulatory 
        program that fully implements the Dietary Supplement 
        Health and Education Act of 1994, and that provides 
        consumers with a high level of confidence in the 
        safety, composition, and labeling of dietary 
        supplements products.
           Bottled Water Feasibility Study--Solicited 
        comments on the draft feasibility study in the Federal 
        register of February 22, 2000 (65 FR 8718) and 
        published in the Federal register of August 25, 2000 
        (65 FR 51833), a final report on the feasibility of 
        appropriate methods of informing customers of the 
        contents of bottled water, as required by the Safe 
        Drinking Water Act Amendments.
           Advisory Committee--A standing Dietary 
        Supplement Subcommittee was officially added to the 
        restructured Food Advisory Committee on June 26, 2000. 
        A request for membership nominees having the requisite 
        scientific expertise to serve on the new subcommittee 
        appeared in the Federal Register on July 28, 2000 (65 
        FR 46463).
           Biotechnology--On May 3, 2000 made a public 
        announcement on plans to strengthen the regulatory 
        approach for bioengineered foods. Three initiatives 
        were announced: (1) Development of a proposed rule 
        requiring that developers of bioengineered foods notify 
        the agency before they market such products; (2) the 
        addition of scientists to the Food Advisory Committee 
        that have expertise in biotechnology; and (3) the 
        development of labeling guidance to assist 
        manufacturers who wish to voluntarily label their foods 
        being made with or without the use of bioengineered 
        ingredients.
           Food Allergens--Held meetings at 14 
        locations to raise consumer and industry awareness to 
        the presence of allergens in foods and on labeling 
        approaches to identify the presence of allergens.
           Food Safety Initiative--Completed 
        development of the survey instrument for the Food 
        Safety Consumer Survey Cycle IV. The survey is used to 
        monitor the impact of food safety initiatives and to 
        identify consumer education needs.
           Dietary Supplements--Communicated dietary 
        supplement enforcement policies and procedures to the 
        general public, FDA field offices, health care 
        professionals, and industry. The Agency met with 
        several organizations to share information concerning 
        dietary supplement enforcement policies and procedures.
           CFSAN--FDA & HHS Press Releases, Talk 
        Papers, Fact Sheets and Statements
                    7/1/99--New Egg Safety Steps Announced, 
                Safe Handling Labels and Refrigeration will be 
                Required
                    7/9/99--Consumers Advised of Risks 
                Associated with Raw Sprouts
                    7/10/99--FDA Issues Nationwide Health 
                Warning about Sun Orchard Unpasteurized Orange 
                Juice Brand products
                    10/1/99--FDA Issues Nationwide Public 
                Health Advisory about Contaminated Pet Chews
                    10/20/99--FDA Approves New Health Claim for 
                Soy Protein and Coronary Heart Disease
                    10/25/99--FDA Issues Guidance to Enhance 
                Safety of Sprouts
                    11/16/99--FDA Issues Warning About Sun 
                Orchard Fresh Squeezed Unpasteurized Orange 
                Juice
                    11/19/99--Sun Orchard Adds an Additional 
                Production Code to its unpasteurized Orange 
                Juice Recalled Because of Possible Health Risk
                    12/23/99--Nationwide Recall of Certain 
                Royal Baltic Brand Smoked Fish Products Due to 
                Potential Health Risk
                    1/5/00--FDA Finalizes Rules for Claims on 
                Dietary Supplements
                    1/10/00--Royal Baltic expands Nationwide 
                Recall of Smoked Fish Products Due to Potential 
                Health Risk
                    1/27/00--FDA Issues Nationwide Warning on 
                Felix's, Trader Joe's, Delicioso, and the 
                Carryout Cafe Brands of 5 Layer Dip because of 
                Possible Health Risk
                    2/10/00--FDA Public Health Advisory: Risk 
                of Drug Interactions with St. John's Wort and 
                Indinavir and Other Drugs
                    5/26/00--FDA Advises Consumers About Fresh 
                Produce Safety
                    9/5/00--FDA Authorizes New Coronary Heart 
                Disease Health Claim for Plant Sterol and Plant 
                Stanol Esters
                    9/8/00--FDA Database of Foodborne Illness 
                Risk Factors Released
                    11/21/00--FDA Warns Against Consuming 
                Dietary Supplements Containing Tiratricol
                    11/24/00--FDA Announces Nationwide Recall 
                of Certain Soups Due to Potential Health Risk 
                From Botulism
                    11/30/00--FDA Finalizes Safe Handling 
                Labels and Refrigeration Requirements for 
                Marketing Shell Eggs

                                Website

    CFSAN's website has an informational page entitled, 
``Seniors and Food Safety.'' This page gives a broad spectrum 
of information about foodborne illness, food preparation and 
storage and additional links for seniors. Also on CFSAN's 
website is another informational page entitled, ``Information 
for Women Over 65 Years Old.'' This site has links to 
information on food, nutrition, cosmetics, publications for 
older consumers, mammography and medications from the agency as 
well as links to other federal government agencies.

                     Center for Veterinary Medicine

    The FDA's Center for Veterinary Medicine (CVM) regulates 
the manufacture and distribution of food additives and drugs 
that will be given to animals. These include animals from which 
human foods are derived, as well as food additives and drugs 
for pet (or companion) animals. CVM is responsible for 
regulating drugs, devices, and food additives given to, or used 
on, over one hundred million companion animals, plus millions 
of poultry, cattle, swine, sheep, and minor animal species. 
(Minor animal species include animals other than cattle, swine, 
chickens, turkeys, horses, dogs, and cats.)
    Pets are very important to all people including the 
elderly. CVM has approved drugs that may make it easier for 
elderly to keep their pets. CVM approved two drugs to treat two 
different behavioral problems affecting some dogs--Clomicalm 
Tablets (clomipramine hydrochloride) to be used as part of a 
comprehensive behavioral management program for separation 
anxiety in dogs greater than six months of age, and Anipryl 
Tablets to control the clinical signs associated with canine 
Cognitive Dysfunction Syndrome (CDS).
    Separation anxiety is a complex behavior disorder displayed 
when the owner or someone the dog is attached to leaves the 
dog. Dogs with separation anxiety may exhibit one or more of 
the following symptoms: barking, destructive behavior, 
excessive salivation, and inappropriate elimination.
    Anipryl Tablets can control the clinical signs associated 
with CDS, an age-related deterioration typified by multiple 
cognitive impairments that affect the dog's ability to function 
normally. Behavioral changes associated with CDS include 
disorientation, decreased activity level, abnormal sleep wake 
cycles, loss of house training, decreased or altered 
responsiveness to family members, and decreased or altered 
greeting behavior.

                       Public Affairs Specialists

    Public Affairs Specialists (PASs) are located throughout 
the country in FDA field offices. PASs participate in diverse 
outreach activities to update and educate the Agency's 
stakeholders on a multitude of important public health issues. 
PASs also respond to consumer questions about the Agency, its 
authorities, activities, and the products it regulates.The 
Agency has established networks and communication channels to 
reach the national and local aging network with consumer-
oriented information. By working with a variety of external 
constituencies--consumers, patients, health professionals, 
academia and scientific organizations, industry, women's 
organizations, minority groups, and the international 
community--FDA is able to form the collaborations and 
cooperative arrangements to significantly extend its outreach 
to older consumers.
    PASs have conducted a variety of community-based programs 
in 1999-2000 to address the health concerns and information 
needs of older Americans. The Agency also exhibits at major 
annual meetings of national organizations, as well as at 
community events and local health fairs sponsored by grassroots 
organizations. The topics that were addressed by field 
programs, exhibits, training activities, and speeches were food 
labeling, food safety, safe use of medications, health fraud, 
clinical trials, dietary supplements, drug approval, food and 
drug interactions, and buying prescription drugs on the 
Internet.
           PAS (San Juan, Puerto Rico) participated in 
        a day long health fair targeting older persons and 
        members of the AARP.
           PAS (Houston, Texas) participated in an 
        exhibit at the American Health Association ``Living 
        Longer-Living Well'' seminar. The event was designed to 
        guide women in taking wellness to heart by providing 
        health information on diet, stress reduction, 
        nutrition, and how disease affects the heart.
           PAS (San Francisco, California) worked with 
        the local hospitals to provide workshop materials for 
        its ``Senior Medication Awareness Training Program.''
           PAS (New Orleans, Louisiana) staffed an 
        exhibit at the ``4th Annual Mayor's Senior Summit.''
           PAS (New Orleans, Louisiana) participated in 
        a ``Community Resources Sharing Forum'' sponsored by 
        the New Orleans Elder Action Coalition. The purpose of 
        the forum was to bring together key community leaders 
        to share information, ongoing programs, concerns, and 
        ideas. The PAS prepared FDA information packages.
           PAS (Philadelphia, Pennsylvania) gave a 
        health fraud presentation to older Americans, older 
        American organizations, industry, and other federal 
        agencies.
           PAS (Denver, Colorado) gave a presentation 
        on FDA's role and responsibilities in drug approval to 
        older Americans at the ``Prescription for Your Future'' 
        conference.
           PAS (Indianapolis, Indiana) gave a 
        presentation to a group of older Americans on FDA and 
        good nutrition for the elderly.
           PAS (New Orleans, Louisiana) gave a 
        presentation on prevention and treatments for 
        osteoporosis and arthritis.
           PAS (San Juan, Puerto Rico) gave a 
        presentation about the safe use of medications to a 
        group of retired consumers.
           PAS (Parisippany, New Jersey) participated 
        in the 7th and 8th Annual Congressional Senior Expo. 
        Congressman Bob Franks sponsored this event in the hope 
        of connecting senior citizens of Central New Jersey 
        with the organizations and programs designed to serve 
        them.PASs regularly speak with media representatives, 
        give interviews and provide background information for 
        newspaper, magazine, newsletters, and television and 
        radio reporters.
           PAS (Parisippany, New Jersey) worked with 
        the Glaucoma Foundation in developing an article on how 
        FDA reviews drugs and medical devices.
           PAS (San Francisco, California) conducted an 
        on-camera interview with a local NBC station on how to 
        spot health fraud, a part of a series covering 
        fraudulent products and the elderly.
           PAS (San Francisco, California) delivered a 
        food safety speech on the local Cable Network that 
        included information on microbiology, with a focus on 
        the four messages of the ``Fight BAC'' program.
           PAS (New Orleans, Louisiana) taped a 30-
        minute interview with the WSM Radio News Director on 
        the topics food safety for the holidays, drug 
        approvals, and stockpiling drugs.
    For the last three years, CFSAN in cooperation with FDA's 
Office of Regulatory Affairs has funded grassroots food safety 
education projects proposed by FDA PASs emphasizing:
           The Fight BAC! Campaign materials developed 
        by the Partnership for Food Safety Education;
           National Food Safety Education Month;
           Populations at severe risk from foodborne 
        illness (young children, older Americans, immuno-
        compromised individuals);
           People of low literacy or who primarily 
        speak languages other than English; and
           Safe handling and preparation of raw shell 
        eggs and egg dishes.
    The following projects geared toward older Americans were 
funded by CFSAN in cooperation with FDA's Office of Regulatory 
Affairs:
           Development of education packets on Listeria 
        monocytogenes for use in training health professionals 
        working with at-risk populations in New York;
           An island-wide campaign stressing egg safety 
        targeting at-risk populations, food service and retail 
        workers, and health professional in Puerto Rico;
           Food safety and food allergy workshops in 
        Pennsylvania and Delaware for hospital, nursing home, 
        day care centers, and church food prepares;
           Development and testing of methods for 
        improved communication of food recall and food safety 
        messages for at-risk populations;
           Expansion of the train-the-trainer volunteer 
        program for senior food safety education to cover the 
        entire state of Florida; and
           Food safety workshops for food preparers in 
        nursing homes, meals-on-wheels programs, and other 
        elderly nutrition sites in Douglas County, Wisconsin.

                  HEALTH CARE FINANCING ADMINISTRATION


                             HCFA Projects

    Evaluation System for Medicare+Choice
    Prj #: 500-95-0047/06
    Start Date: 09/16/1998
    End Date: 09/15/2001
    Funding: $746,887
    Vehicle: Task Order
    PI: Lyle Nelson, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Brigid Goody, Sc.D
    Description: The Balanced Budget Act of 1997 (P.L. 105-33) 
makes several changes that affect the eligibility criteria for 
and payment to health plans contracting with HCFA to provide 
services to Medicare beneficiaries. The concurrent 
implementation of several initiatives could have unintended 
effects on the managed care choices available to Medicare 
beneficiaries, as well as on the additional benefits provided 
to beneficiaries and on the quality of care delivered to 
beneficiaries enrolled in health plans. The purpose of this 
task order is to design and implement a strategy for tracking 
and evaluating managed care performance both nationwide and 
within specific markets across the country during the 
implementation of the Medicare+Choice provisions. Dimensions of 
performance to be tracked include beneficiary access to managed 
care options, as well as the cost and quality of services 
delivered to beneficiaries by managed care organizations.
    Status: Data preparation and analyses are ongoing. The 
contractor has prepared exploratory case studies of 12 markets 
and an interim report containing information on 69 markets 
representing 74 percent of Medicare managed care enrollees. 
Dimensions of performance included in these reports are the 
availability of Medicare managed care organizations, enrollment 
and disenrollment, and the variation and generosity of benefit 
offerings. The principal findings of these preliminary analyses 
indicate that early experience under varies substantially 
across markets, especially with respect to contract nonrenewals 
and the availability and generosity of prescription drug 
benefits. Future analyses will include additional years' data 
and expand the dimensions of performance to include access and 
quality, provider behavior, and financial viability.
    Next Generation Medicare Managed Care Payment System
    Prj #: 500-00-0025/01
    Start Date: 09/30/2000
    End Date: 04/28/2002
    Funding: $635,897
    Vehicle: Task Order Contract
    PI: Stuart Gutterman
    Awardee: Urban Institute, The
    PO: Leslie M. Greenwald, Ph.D.
    Description: The purpose of this project is to design a 
possible next generation payment methodology--currently called 
the Direct Model--for the Medicare+Choice program. This study 
will prepare a conceptual paper that describes and 
operationalizes HCFA's proposed general approach. As of January 
1, 2000, 10 percent of Medicare+Choice plans total capitated 
payments are based on the Principle In-Patient Diagnostic Cost 
Group (PIP-DCG) risk adjustment methodology. Future years will 
see an increase in the proportion of payments based on risk 
adjustment, with a comprehensive risk adjustment methodology 
due to take effect in January 2004. The movement of the 
Medicare+Choice program towards increased emphasis on health 
status risk adjusted payments--though an improvement over 
current demographic adjusted payments in terms of potential 
accuracy and ability to address selection bias--still has a 
significant drawback: it is based on FFS practice patterns and 
costs. Two possible steps could be taken to separate Medicare 
managed care payments from their traditional fee-for-service 
basis. The first could be considered an interim approach, and 
would address the problem of basing managed care payment on FFS 
practice patterns. If a full encounter data model were 
implemented, and if a complete set of data were mandated 
(sufficient to support recalibration), risk adjuster weights 
could be re-estimated using managed care encounter data (rather 
than the FFS data used in the models development). In this way, 
risk score weights and resulting predicted payments would 
reflect actual managed care practice patterns instead of FFS 
practice patterns. The remaining residual of FFS in the 
approach would be FFS prices, which would be assigned to the 
managed care encounter data in the absence of reliable 
information on actual managed care costs. In the longer term, 
HCFA could move to what could be called a direct payment model. 
Under this direct model, managed care payments would move away 
(all or in part) from their current county FFS basis. In this 
direct payment approach, risk adjustment models could be 
calibrated using either a combination of fee-for-service and 
managed care encounter data, or managed care data alone. But 
rather than converting enrollee expenditure estimates from risk 
adjustment methodologies to a risk adjustment factor (i.e. 
figures such as 1.05, indicating the estimated expenditures of 
an individual relative to others), the risk adjustment model 
would simply predict expected expenditures for that individual. 
Then, this risk based estimated expenditure (inflated to the 
payment year from the model calibration year) would be 
multiplied by a geographic price index to adjust for local 
price differences. In all likelihood, these price indexes would 
continue to be based on prices observed in fee-for-service. It 
might be possible however, in the future, to estimate both the 
risk adjusted estimated expenditures and price indexes based on 
costs/prices observed in managed care (or a combination of 
managed care and fee-for-service). These concepts, however, are 
not possible to implement today, when actual costs for managed 
care services are all but unknown, and most national health 
specific price indexes are considered weak. This model presumes 
that the risk adjuster method would account sufficiently for 
practice pattern variability. In addition, this change would 
require agreement on the extent of parity between Medicare's 
expenditures for beneficiaries enrolled in fee-for-service 
versus managed care. This direct model could be summarized as 
follows: Direct payment (Individuals Risk Based Estimated 
Expenditures) x (Geographic Price Input). This possible future 
approach for Medicare may seem extreme at first glance. But 
because BBA had mandated that county rates by blended with a 
national rate, there is already a move toward national pricing. 
The direct model is perhaps a logical extension of this policy.
    Status: In progress.
    Survey of Medicare Beneficiaries Who Were Involuntarily 
Disenrolled from HMOs that Withdrew from Medicare or Reduced 
their Service Areas
    Prj #: 500-95-0061/10
    Start Date: 09/30/2000
    End Date: 02/28/2002
    Funding: $470,000
    Vehicle: Task Order
    PI: Bridget Booske
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute
    PO: Gerald Riley
    Description: In January 1999 and January 2000 about 100 
HMOs withdrew from the Medicare program or reduced their 
service areas. Over 300,000 Medicare beneficiaries were 
disenrolled involuntarily each year, and had to enroll in 
another HMO or go to fee-for-service (FFS). Many of these 
disenrollees did not have another managed care plan available 
to them. These beneficiaries had no choice but to go to FFS. 
Most HMOs that participate in Medicare offer additional 
benefits outside the regular Medicare benefit package. Extra 
benefits commonly include low copayments, prescription drugs, 
unlimited hospitalization, and preventive services. Many 
beneficiaries have come to rely on the extra benefits they 
receive from their HMO, particularly prescription drugs. 
Replacing the benefits through Medigap insurance is usually 
very expensive, and may be unaffordable for some. Joining 
another HMO or going to FFS may also force many beneficiaries 
to change doctors, creating dissatisfaction and disrupting 
existing patterns of care. There has therefore been concern 
among policymakers about the impact of the recent HMO 
withdrawals on the beneficiary population. There have been two 
efforts to assess the impact of the January 1999 withdrawals 
and service area reductions on beneficiaries. The first, based 
on survey results indicated that although most disenrollees 
fared relatively well after their HMO withdrew from Medicare, 
many experienced a reduction in supplemental benefits, an 
increase in premiums, and/or disruption in their care 
arrangements (Kaiser Family Foundation, 1999). Problems were 
disproportionately experienced by disabled beneficiaries, 
racial and ethnic minorities, the poor and near-poor, and those 
reporting fair or poor health. The second effort covered 
enrollee notification; information and assistance in exploring 
new insurance options; what option beneficiaries selected; 
changes in benefits and costs; problems encountered; and 
satisfaction. HCFA anticipates that additional withdrawals may 
occur in 2001 and subsequent years. It is desirable to know the 
impact on beneficiaries if a significant number of additional 
withdrawals occurs in 2001. In this project we will mount a 
survey that asks about the experience of beneficiaries whose 
plans withdraw from Medicare or reduce their service areas in 
January, 2001. A draft survey instrument has been developed. 
This project will: finalize the instrument; develop an OMB 
clearance package; identify an appropriate sample from Medicare 
administrative records; administer the survey; edit and clean 
the data; analyze the survey responses; prepare a final report; 
prepare and deliver a clean data file to HCFA for use in 
further analyses. Beneficiaries will be asked what insurance 
arrangements they made after their plan withdrew from Medicare 
or reduced its service area; how their benefits and out of 
pocket costs were affected by new arrangements necessitated by 
their plan's withdrawal; and whether they had to change 
doctors. The universe from which the survey sample will be 
drawn is the Medicare population enrolled in managed care plans 
that either terminate their risk contracts or reduce their 
service areas in January, 2001. In the case of plans that 
reduce their service areas, enrollees that live in areas from 
which the plan withdraws will be eligible for the survey. The 
survey sample must be drawn from 2 strata: persons who live in 
geographic areas where at least one managed care plan is still 
available under Medicare after January, 2001; and areas where 
no Medicare managed care plans are available after January, 
2001. Approximately 1,500 completed surveys must be produced 
for each stratum. The survey must be conducted by mail with 
telephone followup, and will consist of 20-30 questions.
    Status: Research Triangle Institute is performing the work 
under this task order with over 90 percent of the funds 
assigned to their subcontract.
    Updating the Johns Hopkins University ACG/ADG Risk 
Adjustment Methods for Medicare Contracting
    Prj #: 500-00-0060
    Start Date: 09/29/2000
    End Date: 03/31/2001
    Funding: $272,902
    Vehicle: Contract
    PI: Jonathan Weiner
    Awardee: Johns Hopkins University, School of Public Health
    PO: Jesse Levy
    Description: This contract will allow HCFA to better assess 
and evaluate the Johns Hopkins University ACG/ADG model as an 
option for a potential Medicare+Choice payment system. Johns 
Hopkins will revise, extend and recalibrate the ADG/ACG model 
using recent Medicare data. They will provide HCFA with the 
updated software and a recalibration. Earlier work by Johns 
Hopkins for HCFA updated the ACG/ADG Risk Adjustment Method for 
application to Medicare risk contracting. In that project, 
Hopkins developed two diagnosis-based risk adjustor models. 
Work on these alternatives to the then existing demographic-
only risk adjustment models was concluded in 1996. In further 
work entitled AApplying JHU ACG/ADG Risk Adjustment Methods to 
Medicare Risk Contracting, Johns Hopkins further developed 
their model for Medicare purposes. This concluded in early 
2000.
    Status: This project is getting underway.
    Applying the Clinically Detailed Risk Information System 
for Cost (CD-RISC) to Medicare+Choice Payments
    Prj #: 500-95-0056/12
    Start Date: 09/29/2000
    End Date: 09/12/2001
    Funding: $245,934
    Vehicle: Task Order
    PI: Emmitt Keeler
    Awardee: RAND Corporation, The
    PO: John Robst
    Description: This project will provide technical consulting 
and analytic services to assess and evaluate the Clinically 
Detailed Risk Information System for Cost (CD-RISC) model as an 
option for a potential Medicare+Choice payment system. The 
project will calibrate the CD-RISC model on Medicare dataCwhich 
may involve the need to make adjustments to the model as it 
currently stands--and provide HCFA with the up to date software 
and calibration. During earlier work funded by HCFA CD-RISC was 
developed to potentially apply to capitation payments for the 
under-65 population. This model has not yet been calibrated or 
tested on Medicare beneficiaries and expenditures. In response 
to our mandate from the Balanced Budget Act of 1997, HCFA has 
implemented a risk adjustment method for Medicare+Choice 
payments. That method relies on inpatient data only. For a 
number of reasons, we believe methods that draw upon data from 
outpatient care delivery sites as well as inpatient sites are 
preferable to this model. We have announced that we plan to 
implement a model that draws upon diagnoses from multiple sites 
of care in 2004. We are now in the process of evaluating 
different candidates among the models that have been developed 
to see which ones perform the best. To make sure we have 
sufficient choices available, we are funding further 
development of contending models this one included.
    Status: In progress.
    Evaluation of the Competitive Pricing Demonstration--Phase 
I
    Prj #: 500-95-0048/07
    Start Date: 06/30/1999
    End Date: 08/29/2001
    Funding: $458,288
    Vehicle: Task Order
    PI: Gregory C. Pope & Steven Garfinkel (RTI)
    Awardee: Health Economics Research, Inc.
    PO: Brigid Goody, Sc.D
    Description: Section 4011 of the Balanced Budget Act of 
1997, which establishes authority for HCFA to test competitive 
pricing for Medicare+Choice organizations mandates that 
``...the Secretary shall closely monitor and measure the impact 
of the project on the price and quality of, and access to, 
Medicare covered services, choice of health plans, changes in 
enrollment, and other relevant factors.'' The purpose of this 
phase of the evaluation of the Competitive Pricing 
Demonstration is to provide HCFA with timely feedback on the 
implementation and operational experience of each demonstration 
site. A case study methodology will be used to develop both 
qualitative and quantitative information required to assess the 
strengths and weaknesses of the demonstration. The types of 
questions to be answered during this phase include:
          How was the bidding process implemented?
          How did the plans react to the process?
          Can the process be improved?
          How smoothly was the demonstration implemented in 
        each site?
          Were there operational problems for each of the 
        stakeholders and, if so, how were they resolved?
          How effective were the Area Advisory Committees in 
        their responsibilities to advise on implementation 
        issues? What lessons were learned that could ease 
        implementation in other sites or on a nationwide basis?
    Status: The contractor is currently completing a case study 
of the advisory committee process. Since the implementation of 
the demonstration has been delayed until January 2002, further 
evaluation activities are being delayed. This delay will force 
a change in this contract.
    Evaluation of the Medical Savings Account Demonstration
    Prj #:500-95-0057/06
    Start Date: 09/28/1998
    End Date: 09/27/2003
    Funding: $6,546,119
    Vehicle: Task Order
    PI: Ken Cahill
    Awardee: Barents Group, LLC/Westat
    PO: Renee Mentnech
    Description: This project evaluates the Medical Savings 
Account (MSA) Demonstration. It compares the experience of MSA 
enrollees with other Medicare beneficiaries. The contractor 
will also act as a coordinator between HCFA and the 
demonstration participants, including beneficiaries and health 
plans, in order to ensure that accurate, reliable, and complete 
data are collected.
    Status: In progress.
    Evaluation of the Medicare Choice Demonstration
    Prj #:500-92-0011/06
    Start Date: 09/01/1995
    End Date: 09/30/2000
    Funding: $1,591,240
    Vehicle: Delivery Order
    PI: Lyle Nelson, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Renee Mentnech
    Description: HCFA is in the process of implementing the 
Medicare Choices Demonstration to test the feasibility and 
desirability of new types of managed care plans for Medicare 
such as integrated delivery systems and preferred provider 
organizations. This evaluation project provides a detailed 
assessment of the overall demonstration project, which looks 
specifically at beneficiary experiences in the demonstration, 
cost and use of services within the demonstration sites, and 
quality of care issues. The evaluation provides some insights 
into whether the greater range of managed care options offered 
in this demonstration would be more appealing to the Medicare 
beneficiaries, and whether issues such as biased selection, 
high rates of disenrollment, and dissatisfaction exist. In 
addition, the evaluation project provides continuous monitoring 
of the demonstration sites, including a comprehensive case 
study of each of the managed care plans in the demonstration. 
This part of the evaluation activities focuses on the 
implementation experience and operational feasibility of the 
new managed care plans, as well as how plans interact with 
carriers and HCFA.
    Status: The contractor has completed site visits to assess 
the implementation difficulties the plans have encountered. The 
first and second interim implementation reports are available. 
A survey of plan enrollees and a fee-for-service comparison 
group has also been completed. The survey focuses on reasons 
for enrolling and disenrolling, enrollees' understanding of 
their plans, and the enrollees' perceptions of access, quality, 
and satisfaction. A final report is expected in the summer of 
2000.
    Department of Defense Subvention Demonstration Evaluation
    Prj #:500-95-0056/06
    Start Date: 09/03/1998
    End Date: 03/02/2002
    Funding: $1,411,439
    Vehicle: Task Order
    PI: Dana Goldman, Ph.D.
    Awardee: RAND Corporation, The
    PO: Leslie M. Greenwald, Ph.D.
    Description: Under the demonstration, enrollment in the 
Department of Defense's (DoD) Senior Prime plan is offered to 
military retirees over age 65 who live within 40 miles of the 
primary care facilities of one of the six sites, have recently 
used military health facility services, and are enrolled in 
Medicare Part B. The Senior Prime plans must meet all relevant 
requirements for Medicare+Choice plans. Medicare makes a 
capitation payment to DoD for each enrollee, and DoD must 
maintain a level of effort for health care services to all 
retirees who are also Medicare beneficiaries, whether or not 
they choose to enroll, that is based on fiscal year 1996 DoD 
experience. The evaluation seeks to answer the basic question: 
can DoD and Medicare implement a cost-effective alternative for 
delivering accessible and quality care to military-Medicare-
eligible beneficiaries? The evaluation will seek the answer by 
examining issues in four basic areas:
          Enrollment demand.
          Enrollee benefits.
          Cost of the program.
          Impacts on other DoD and Medicare beneficiaries.
    RAND is conducting a process evaluation and a quantitative 
analysis for the demonstration sites and a set of control 
sites.
    Status: The final report from the evaluation was delivered 
in April 1999. It is available from the National Technical 
Information Service (NTIS) (accession number PB 99 149056). The 
Interim Report conveying results of the process evaluation of 
the demonstration start-up period was delivered in July 1999.
    Second Generation of Social Health Maintenance Organization 
Demonstration
    Period: November 1996 Extended 30 months after the Report 
to Congress is submitted.
    Funding: Waiver-only.
    Grantees: See below.
    Description: In accordance with section 2344 of Public Law 
98-369, the concept of a social health maintenance organization 
(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 (BBA) of 1990 authorized the 
expansion of the S/HMO 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 also 
provided an opportunity to test more geriatrically-oriented 
models of care. Six organizations in the project were selected 
to participate. Only one plan is operational, The Health Plan 
of Nevada. The Balanced Budget and Refinement Act of 1999 
extended the demonstration until 18 months after the submission 
of the SHMO transition Report to Congress. The Benefits 
Improvement and Protection Act of 2000 further extended the 
demonstration another 12 months, for a total of 30 months after 
the submission of the SHMO transition Report to Congress.
    Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las 
Vegas, NV 89114.
    Period: September 1995-December 2001
    Funding: $1,811,184
    Contractor: Abt Associates Inc, 55 Wheeler Street, 
Cambridge, MA 02138
    Investigator: Henry Goldberg
    Site Development and Technical Assistance for the Second 
Generation Social Health Maintenance Organization Demonstration
    Prj #:500-93-0033
    Start Date: 09/27/1993
    End Date: 12/30/2000
    Funding: $2,251,123
    Vehicle: Contract
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota, School of Public Health, 
Institute for Health Services Research
    PO: Thomas Theis
    Description: In January 1995, HCFA selected six 
organizations to participate in the Second Generation Social 
Health Maintenance Organization (S/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 
S/HMO model, which was initiated as a demonstration in 1985. 
Although similar services are provided under both of these 
demonstrations, the Second Generation S/HMO Demonstration 
features a greater emphasis on geriatric care and a more 
inclusive case-management system. Another distinguishing 
characteristic of the project is its 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 at San Francisco, are providing 
technical assistance and support in the development, 
implementation, and operation of the Second Generation S/HMO 
Demonstration.
    Status: The developmental phase of the Second Generation S/
HMO Demonstration began in January 1995. Since that time the 
University of Minnesota and the University of California at San 
Francisco have been providing technical assistance to the 
organizations participating in the project. They have also 
developed a questionnaire that is being used to determine a 
beneficiary's capitated payment rate, a series of geriatric 
protocols is being used to help physicians identify and treat 
certain health conditions, and a care coordination assessment 
instrument is being used to assist case managers with care 
planning. These technical assistance contractors have made site 
visits during this time to review the progress of the S/HMO 
site. They are also assisting a contractor in preparing a S/HMO 
Transition Report to Congress. The Health Plan of Nevada (HPN) 
began enrolling beneficiaries in the demonstration in November 
1996. HPN enrollment at the end of 1999 was over 35,000 
members.
    Second Generation Social Health Maintenance Organization 
Demonstration: Florida
    Prj #:99-C-90874/4
    Start Date: 05/01/1998
    End Date: 06/30/2000
    Funding: $150,000
    Vehicle: Cooperative Agreement
    PI: Charlie Liem
    Awardee: Florida Department of Elder Affairs
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Florida State Department of Elder Affairs (DEA) with funds to 
purchase technical assistance and to support planning 
activities for a second generation social HMO. The goal of this 
project is to study the feasibility of implementing a Second 
Generation Social HMO in Florida and, should this prove 
feasible, to develop the specifications needed for the State to 
issue an RFP.
    Status: Department of Elder Affairs staff are taking the 
lead in coordinating planning activities and have assembled a 
task force comprised of consumers, providers, and 
representatives from the Maryland State Department of Health 
and Mental Hygiene to guide the planning process. They have 
obtained Medicare and Medicaid claims data and are linking 
these data in an effort to devise a rate-setting mechanism that 
will work for plans that enroll a disproportionate share of 
frail elderly.
    Second Generation Social Health Maintenance Organization 
Demonstration: Maryland
    Prj #:99-C-90868/3
    Start Date: 04/30/1999
    End Date: 06/30/2000
    Funding: $109,211
    Vehicle: Cooperative Agreement
    PI: Martin Wasserman, MD
    Awardee: Maryland Department of Health and Mental Hygiene
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Maryland State Department of Health and Mental Hygiene (DHMH) 
with funds to purchase technical assistance and to support 
planning activities for a second generation social HMO. The 
state has sub-contracted this work to the Center for Health 
Plan Development and Management (CHPDM) at the University of 
Maryland in Baltimore County. The goal of this project is to 
study the feasibility of implementing a Second Generation 
Social HMO in Maryland and, should this prove feasible, to 
develop the specifications needed for the State to issue an 
RFP.
    Status: The State has hired staff to coordinate planning 
activities and has assembled a task force comprised of 
consumers, providers, and representatives from the Department 
of Health and Mental Hygiene to guide the planning process. 
They have obtained Medicare and Medicaid claims data and are 
linking these data in an effort to devise a rate-setting 
mechanism that will work for plans that enroll a 
disproportionate share of frail elderly.
    Evaluation of the Evercare Demonstration Program
    Prj #:500-96-0008/02
    Start Date: 09/26/1997
    End Date: 03/25/2001
    Funding: $1,544,142
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Leslie M. Greenwald, Ph.D.
    Description: For each EverCare site, of which there are 
five, two comparison groups will be selected--nonparticipating 
residents in EverCare site nursing homes and residents in 
nonparticipating nursing homes operating in EverCare 
demonstration cities.
    Status: Site visits have been made to EverCare and non-
EverCare facilities in each of the participating sites. The 
information gathered was developed into a paper that has been 
submitted to the gerontologist for review.
    Age Well Option (now referred to as TLC)
    Prj #:18-P-90748/1
    Start Date: 05/01/1997
    End Date: 04/30/2002
    Funding: $600,000
    Vehicle: Grant
    PI: Lewis A. Lipsitz, M.D.
    Awardee: Hebrew Rehabilitation Center for the Aged
    PO: Renee Mentnech
    Description: Community care and educational protocols are 
used to test the hypothesis that clients can be educated and 
empowered to more actively participate in their own health care 
planning, decisionmaking, and chronic disease management. The 
populations studied are individuals living in the Hebrew 
Rehabilitation Center for the Aged and those living in 
subsidized housing in the Boston community. Educational 
protocols are used to test the hypothesis that clients can be 
educated and empowered to more actively participate in their 
own health care planning, decisionmaking, and chronic disease 
management.
    Status: In progress.
    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.
    Description::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 SeniorHealth 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. 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 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 continued 
to collaborative projects with other organizations in the San 
Francisco Bay area. A pilot agreement with the Institute on 
Aging (IOA) was completed and the two organizations have 
entered into a venture agreement in which IOA established an 
adult day health center, operating it under the rules of the 
program of All-Inclusive Care for the Elderly (PACE) protocol. 
The site is in the Richmond area of San Francisco. On Lok 
provides quality assurance oversight as well as marketing and 
enrollment support. IOA receives a portion of On Lok's 
capitation via the HCFA demonstration and a portion is retained 
by On Lok to cover administrative expenses. The Balanced Budget 
Act of 1997 authorized coverage of PACE under the Medicare 
program. Under the Benefits Improvement and Protection Act of 
2000, this demonstration has until November 24, 2002 to 
transition to operational
    Status:. This date can be extended one year as a State 
election.
    Evaluation of the Program of All-Inclusive Care for the 
Elderly (PACE)
    Prj #:500-96-0003/04
    Start Date: 04/23/1997
    End Date: 06/30/2000
    Funding: $238,917
    Vehicle: Task Order
    PI: David Kidder, Ph.D.
    Awardee: Abt Associates, Inc.
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: The Evaluation of the Program of All-inclusive 
Care for the Elderly (PACE) consists of both qualitative and 
quantitative components. The purpose of the qualitative 
component is to examine, in detail, the structure and process 
of case management as well as to gain a better understanding of 
the factors that drive interdisciplinary team decisionmaking in 
the PACE model. Since enrollment in PACE has been lower than 
originally expected, except for On Lok, the first part of the 
quantitative part of the evaluation of PACE is examining the 
decision to participate in PACE. This is particularly important 
given the anomaly of under-enrollment in virtually all long-
term care alternatives, as well as the policy interest in 
encouraging increased use of managed care. In the evaluation, 
the process by which people come to participate in PACE is 
modeled. The ``refusers,'' or those who apply to PACE and pass 
the initial screening eligibility criteria but do not actually 
enroll in the program, serve as the comparison group for the 
evaluation of the impact of PACE. The impact evaluation of PACE 
is addressing a broad range of questions including:
          Does the government spend less on PACE clients than 
        it would have spent on them in the absence of PACE?
          Does the PACE program spend no more on PACE clients 
        than the capitation amount?
          Does PACE alter the mix of services provided?
          Does the quality of life and satisfaction with 
        services increase for participants and family members?
          Does PACE impact the presence and amount of formal 
        in-home care, formal care outside the home, informal 
        in-home care and informal care outside the home?
          How does PACE affect the health status and functional 
        status of PACE participants?
    Status: All of the data collection for this project has 
been completed and the contractor is analyzing the impact of 
PACE on Medicare costs. A final report, entitled ``The Impact 
of PACE on Participant Outcomes,'' has been received. Briefly, 
this study found that compared to the comparison group:
          PACE enrollees had much lower rates of nursing home 
        and inpatient hospital utilization, and higher rates of 
        ambulatory care.
          PACE enrollees reported better health status and 
        quality of life.
          PACE participants had lower mortality rates.
    The benefits of PACE appeared to be magnified for those 
participants with high levels of physical impairment. Work 
continues on the study of the cost effectiveness of PACE.
    Actuarial Assessment of PACE Enrollment Characteristics in 
Developing Capitated Payments
    Prj #:500-95-0061/09
    Start Date: 09/30/2000
    End Date:
    Funding: $120,460
    Vehicle: Task Order
    PI: James Robertson
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: The purpose of this is to investigate the 
impact of a number of the Program for All-Inclusive Care for 
the Elderly (PACE) specific issues on financial risk and 
payments and then to formulate alternative payment options, 
which would result in a reasonable approach for Medicare 
payments to PACE. The BBA requires the PACE program to be paid 
using the risk adjustment method developed for Medicare+Choice 
programs, but adjusted for factors specific to the PACE 
program. PACE is expected to differ from M+C plans in a number 
of attributes: enrollment size, group bias, dual Medicaid 
capitation, and mortality rates. An actuarial assessment is 
needed to explore the risk characteristics related with these 
factors and to formulate options that use this information in a 
capitated payment system. The project will explore the 
following issues related to PACE payments: (1) The Problem of 
Small Numbers--The volatility of a PACE site's average actual 
Medicare service costs for a period depends upon the site's 
census. Enrollment size could influence: (a) setting the 
minimally viable number of PACE organizations in a geographic 
area, (b) setting the minimum enrollment size for a viable PACE 
site, and (c) establishing financial reserve requirements, 
which may be considered by licensing agencies in assessing 
financial viability. Large sites should exhibit more stable 
per-member-per-month costs from period to period than smaller 
sites. So, all else being equal, smaller sites will be more 
likely than large sites to experience significant strains on 
their financial status. In the insurance industry, this 
exposure is managed through reinsurance agreements or minimum 
surplus requirements. The actuarial topic of ruin theory may be 
applied to determine the formula for the minimum surplus level 
to assure that the probability of a site's financial ruin is 
less than some maximum tolerance. (2) Biased Groups--Related to 
the problem of small numbers, PACE organizations enroll an 
inherently biased group of beneficiaries. Available studies 
suggest that PACE enrollees are sicker, frailer, and more 
costly than the average Medicare beneficiary is. It is not 
clear whether these higher costs are driven by enrollment into 
PACE after a precipitating event, or if these costs are ongoing 
as a result of enrolling patients with chronic/persistent 
illnesses. Either bias would likely act to increase the 
financial risk assumed by PACE organizations particularly in 
light of the assumption of a random draw in Medicare+Choice, 
where payment is based on the average. However, the rate 
setting implications are different. If PACE is enrolling 
beneficiaries at a high point their expenditure pattern, then 
remaining expenditures prior to enrollment could overstate 
average costs. On the other hand, paying average cost will 
underpay given the lingering effects of the precipitating event 
and higher costs in the last year of life. What is the most 
appropriate Arisk adjuster or other method of modifying 
capitation rates to account for these biases? (3) Medicaid 
Capitation--Ignoring the adequacy of the Medicaid rates, does a 
jointly capitated payment model reduce the financial risk to a 
PACE organization? This could occur if services provided by 
Medicare result in lower Medicaid costs. (4) Higher Mortality--
PACE organizations have experienced higher mortality rates, 
estimated at roughly 20 percent per year. A prospective model 
is used in Medicare+Choice payments; however, the mortality is 
much lower, estimated at 3 percent. If a prospective risk 
adjustment model is used, payments will be adjusted in 
subsequent years only on living enrollees. Given the 
differential rates in mortality, would a prospective payment 
model adjusted for higher mortality result in lower financial 
risk to a PACE organization?
    Status: Payments for medical services furnished by PACE 
organizations are fully capitated by Medicare and Medicaid. A 
variant of this capitated approach is used by Medicare to pay 
Medicare+Choice organizations, which generally have much larger 
numbers of Medicare participants than PACE organizations. 
Because of their unique niche, total reliance on capitated 
payments (Medicare and Medicaid), lower enrollee levels, and 
higher mortality rates, PACE organizations may have a higher 
level of financial risk than Medicare+Choice plans. In order to 
assess the potential risk elements as well as to help determine 
implications for policy purposes, an actuarial evaluation and 
assessment of payment rates for PACE will be performed under 
this project. Available studies suggest that PACE enrollees are 
sicker, frailer, and more costly than the average Medicare 
beneficiary. It is not clear whether these higher costs are 
driven by enrollment into PACE after a precipitating event, or 
if these costs are ongoing as a result of enrolling patients 
with chronic/persistent illnesses. Either bias would likely act 
to increase the financial risk assumed by PACE organizations 
particularly in light of the assumption of a random draw in 
Medicare+Choice, where payment is based on the average. This 
project will assess the financial risk that PACE organizations 
incur as a result of their smaller enrollment numbers, biased 
populations, and higher mortality. Risk will be characterized 
in enrollment level tiers and compared and contrasted to the 
risk characteristics of larger health delivery organizations. 
Simulations and the actuarial theory of ruin will be used in 
this assessment. The impact of joint capitated funding streams 
(Medicare and Medicaid) also will be modeled. Available claims 
data and data sets from other studies will be analyzed under 
this contract.
    Community Nursing Organization Demonstration
    Period: September 1992--December 31, 2001
    Contractors: See below.
    Description: 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 multi speciality clinic. All CNO sites underwent a 1-year 
development period and began a 3-year operational period in 
January 1994. The Balanced Budget Act of 1997 extended the 
demonstration through December 31, 1999. The Balanced Budget 
and Refinement Act of 1999 extended the demonstration through 
December 2001 and inlcuded a budget neutrality requirement for 
the payment rates. The Benefits Improvement and Protection Act 
of 2000 removes the budget neutrality reqirement but will 
reduce projected payment rates by 15 percent for the New York 
site, and 10 percent for the three other sites. Actuarial 
adjustments will also be made for October through December 2000 
and for calendar year 2001. 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: Care Clinic Association, 307 East Oak, Suite 3, 
P.O. Box 718, Mahomet , IL 61853.
    Contractor:Visiting Nurse Service of New York, 107 East 
70th Street, New York, NY 10021-5087
    Aditional Analyses of Community Nursing Organization (CNO) 
Demonstration Data
    Prj #: 500-95-0062/09
    Start Date: 09/29/2000
    End Date: 01/19/2001
    Funding: $204,637
    Vehicle: Task Order
    PI: Steven Pizer
    Awardee: Abt Associates, Inc.
    PO: James Hawthorne
    Description: The Community Nursing Organization (CNO) 
Demonstration was mandated by the Omnibus Budget Reconciliation 
Act of 1987, although actual enrollment did not commence until 
12/17/93. The demonstration was originally authorized for three 
years but in 1996 it received a one-year extension from HCFA, 
followed by a two-year extension through the Balanced Budget 
Act of 1997. The demonstration was scheduled to end on 12/31/
99, but received another two year extension from Congress in 
the Balanced Budget Refinement Act of 1999 (BBRA). It is now 
scheduled to run until 12/31/01. Abt Associates was contracted 
to design and conduct an evaluation of the first phase of the 
demonstration. The Abt Phase I evaluation included 
beneficiaries randomized through September 1995. It addressed 
the experience of these beneficiaries through the beginning of 
1997. The main findings were that the CNO intervention did not 
significantly improve care and that capitation payments to the 
CNO's were significantly higher than expenditures for the same 
package of services provided to the control groups but paid for 
on a fee-for-service basis. Because of language in the BBRA, 
which requires that the remainder of the demonstration be 
budget neutral, and the findings from the Abt evaluation, HCFA 
notified the CNO sites that their capitation payments will be 
reduced. The CNO sites and Congressional staff contend that the 
payment reductions are such that the CNOs will be required to 
cease operations. As a result of requests from the CNO sites 
and Congressional staff, several meetings took place to discuss 
the future of the demonstration and the budget neutrality 
requirement. The CNO sites and Congressional staff question the 
validity of the Abt evaluation and have requested that 
additional analyses be conducted. The CNO sites and 
Congressional staff are particularly concerned about the fact 
that in a 1998 Interim Report by the evaluation contractor, the 
expenditures for the treatment and control groups were 
different than the expenditure amounts in the Final Evaluation 
Report. Several important methodological changes were made in 
the Final Report, including the elimination from the analysis 
of participants from the treatment group who enrolled after 
randomization stopped, the addition of 6 more months of data, 
and the use of an inflation adjustment that was not applied to 
the data in the Interim Report. The CNO sites and Congressional 
staff want to know the extent to which each of these 
methodological changes affected the expenditure amounts in the 
Final Report. They want to have a better understanding of the 
reasons behind the changes between the Interim and Final 
Reports. When the evaluation contractor conducted the work for 
the Final Report, they re-constructed the files from scratch, 
which means the Final Report was not simply an update of the 
analyses in the interim report. Therefore, to fully understand 
the differences between the Interim and Final Report and answer 
their questions and concerns, additional programming and 
analyses will be necessary.
    Phase II Evaluation of Community Nursing Organization (CNO) 
Demonstrations
    Prj #: 500-95-0062/10
    Start Date: 09/20/2000
    End Date: 09/19/2002
    Funding: $246,367
    Vehicle: Task Order
    PI: Steve Pizer
    Awardee: Abt Associates, Inc.
    PO: James Hawthorne
    Description: This project is for the design and 
implementation of the Phase II evaluation of this ongoing 
demonstration. The Community Nursing Organization (CNO) 
Demonstration was mandated by the Omnibus Budget Reconciliation 
Act of 1987 although actual data collection for the project did 
not commence until 12/17/93. The demonstration was originally 
authorized for three years but in 1996 it received a one-year 
extension (from HCFA)(followed by a two-year extension 
authorized in the Section 10019 of the Balanced Budget Act of 
1997). The demonstration was scheduled to end on 12/31/99 but 
(in Section 532 of the Balanced Budget Refinement Act of 
1999(BBRA)) it received another two year extension from 
Congress and is now scheduled to run until 12/31/01. Abt 
Associates won a competitive contract to design and conduct an 
evaluation of the first phase of the demonstration. The Abt 
(Phase I) evaluation covers the operation of the demonstration 
from January, 1994 to July, 1997. In addition to extending the 
demonstration, Congress mandated a second evaluation of the 
demonstration which is this Phase II Evaluation. A final report 
of this evaluation is to be delivered to Congress no later than 
7/1/01. This new/extended evaluation will provide for longer 
term follow-up of early participants and will also include 
assessment of the effects of the CNO intervention on later 
participants whose data were not available for the Abt 
evaluation. This second evaluation will require the use of HCC 
concurrent, risk adjusted estimates of Medicare expenditures 
for Medicare beneficiaries who participated in the 
demonstration as well as for a new comparison group. The 
calculation of the risk adjuster scores is being contracted 
separately and the resulting data will be made available to 
this Phase II Evaluation.
    Study of Pharmaceutical Benefit Management
    Prj #: 500-97-0399
    Start Date: 09/28/2000
    End Date: 07/13/2001
    Funding: $299,695
    Vehicle: Contract
    PI: Michael Keagan
    Awardee: PriceWaterhouse Coopers, LP
    PO: Peri H. Iz, Ph.D.
    Description: This study is an extension of an earlier HCFA 
ORD research (500-95-0065/02). Completed in 1996, this early 
study remains valuable for its description of the industry 
functions and the origins. However, most information contained 
in the early study is no longer current. This industry has 
undergone major stages of evolution during the past five years. 
While the industry size has grown impressively in size, there 
has been an increasing concentration of market power. The 
pharmacy benefit management (PBM) industry is becoming a 
dominant player in the administration of pharmaceutical 
benefits. It seems certain that the PBM sector will play a 
significant role in administering the Medicare program in case 
a drug benefit is added to Medicare. This study will 
systematically examine this growing PBM industry from a 
potential client's perspective.
    Status: The project is in the start-up phase.
    Evaluation of Programs of Coordinated Care and Disease 
Management
    Prj #: 500-95-0047/09
    Start Date: 09/30/2000
    End Date: 09/29/2005
    Funding: $3,018,839
    Vehicle: Task Order
    PI: Randolph Brown
    Awardee: Mathematica Policy Research
    PO: Barbara Silverman, MD
    Description: This project will design and conduct the 
evaluation of a group of Congressionally mandated demonstration 
programs and two HCFA-initiated demonstration programs. These 
programs will test various methods of managing care in the fee-
for-service Medicare environment. Attempts to demonstrate the 
effectiveness of programs of care coordination or management 
are complicated not only by wide variations in program staff, 
funding mechanisms, interventions and stated goals, but by the 
evaluator's definition(s) of effectiveness. Despite the 
widespread acceptance of the concept of care coordination, 
studies of the effectiveness of various approaches, including 
those conducted in Medicare beneficiary populations, have 
yielded mixed results. The results of a Medicare demonstration 
of case management in a fee-for-service environment carried out 
from October 1992 through November 1995 are demonstrative of 
the difficulties inherent in defining and evaluating the 
effectiveness of these programs. The three programs studied 
varied widely in their target populations and the nature of the 
interventions attempted; although all were associated with 
increased client satisfaction, none appeared to improve 
outcomes or reduce costs. A major defect in the three programs 
studied was a lack of active involvement of the primary care 
provider in the case management intervention. HCFA continues to 
investigate the potential of care coordination or case 
management to improve care quality and control costs in the 
Medicare fee-for-service program. Section 4016 of the Balanced 
Budget Act of 1997 (Public Law 105-33) required the Secretary 
to design a demonstration of approaches to coordinated care of 
chronic illnesses in up to nine separate sites. As required by 
Congress, an evaluation of best practices in coordinated care 
and a study of demonstration design options has been conducted. 
A solicitation informing interested parties of the intent to 
conduct this demonstration is expected in late Spring, 2000. 
Demonstration sites will be funded for a period of four years. 
A separate demonstration, the Medicare Case Management 
Demonstration, focuses on programs of case management specific 
to diabetes and congestive heart failure. This evaluation is to 
assess the effectiveness of various strategies for coordinating 
care in the fee for service (FFS) Medicare environment, in a 
total of 11 demonstration sites. The participating 
demonstration sites will vary considerably by a number of 
factors, including corporate structure, types of medical 
conditions addressed, scope of patient care covered, 
beneficiary eligibility, source of comparison data. However, 
the sites have in common the goal of improving quality and 
reducing cost of health care received by chronically ill 
Medicare beneficiaries through any or all of the following: 1. 
Individualized plans of care that take into account the 
beneficiaries medical and social needs. 2. Improved 
beneficiaries access to treatment and prevention services, 
including services that may not otherwise be available through 
the traditional Medicare fee-for-service program (such as 
medications, home visits, transportation, and health 
education). 3. Involvement of a care Acoordinator@ 
or Amanager@ in the beneficiary medical care 
depending on the design of the program, this individual may 
exercise considerable control over the beneficiary's medical 
care, or may function in an adjunct role, assisting patients in 
making and keeping medical appointments, complying with 
treatment recommendations and accessing other needed resources 
4. Simplified processes for contacting providers to allow for 
rapid resolution of new problems that otherwise might require 
emergency care 5. Increased beneficiaries (or where applicable, 
family members or caregivers) understanding of their medical 
problems, in order to improve compliance with treatment plans. 
6. Improved information sharing between health care providers 
in order to insure that patients receive appropriate care in a 
timely fashion, reduce duplicative or unnecessary care, and 
avoid unnecessary emergency care and hospitalizations. The goal 
of this evaluation is to identify those characteristics of the 
programs of coordinated care under study that have the greatest 
impact on health care quality and cost, and to identify the 
target populations most likely to benefit from such programs. 
The demonstration programs to be studied as a part of this 
evaluation will vary widely with respect to the demographics, 
medical and social situations of the target population, 
intensity of services offered, interventions under study, 
type(s) of health care professionals delivering the 
interventions, and other factors. Furthermore, sites may be 
added to the demonstration as it progresses. For these reasons, 
the evaluator will be required to establish a basic framework 
for analysis that can be tailored to the requirements of each 
demonstration site, and will allow for between-site comparisons 
at the intervals and at the completion of the evaluation.
    Status: In progress.
    Aging in Place: A New Model for Long-Term Care
    Prj #: 18-C-91036/7
    Start Date: 06/18/1999
    End Date: 06/17/2003
    Funding: $1,169,406
    Vehicle: Cooperative Agreement
    PI: Karen Dorman Marek, PhD, MBA, RN
    Awardee: Curators of the University of Missorui, Office of 
Sponsored Program Administration, University of Missouri--
Columbia, Sinclair School of Nursing
    PO: Barbara Silverman, MD
    Description: The goal of the ``Aging in Place'' model of 
care for frail elderly is to allow elders to remain in their 
homes as they age, rather than requiring frequent moves to 
allow for more intensive care if and when it becomes necessary. 
The University of Missouri's Sinclair School of Nursing is in 
the process of implementing such a model. Although a planned 
element of the program is a new senior housing development, the 
program currently targets elderly residents of existing 
congregate housing. The University has received a grant in the 
amount of $2 million in support of the evaluation of this model 
of care.
    Status: A first-year award was made to the applicant 
subject to revision of the study design and work plan according 
to terms and conditions established by the review panel. HCFA 
staff met with the Principal Investigator and other members of 
the research team at a kick-off meeting on September 1, 1999, 
at which time a revised work plan and budget were submitted. As 
a result of changes to the study plan, the applicant requested 
an increase in the first-year award with a corresponding 
reduction in the Years 2-4 awards and no change in the total 
budget. This change was approved.
    Study of Medicare Payments in HPSA's
    Prj #: 500-95-0056/11
    Start Date: 09/21/1999
    End Date: 07/29/2001
    Funding: $240,323
    Vehicle: Task Order
    PI: Donna Farley
    Awardee: RAND Corporation, The
    PO: William Buczko, Ph.D.
    Description:Medicare includes a number of special payment 
provisions aimed at maintaining beneficiary access to needed 
services in areas where there is a scarcity of physicians and 
providers. These areas are designated by the Health Resources 
and Services Administration and are called Health Professional 
Shortage Areas (HPSAs). This project compiles data on trends in 
payment amounts, services, and recipients that have been 
provided by Medicare over the past decade, project future 
trends, and suggests and assesses alternatives to the current 
set of special payment provisions for HPSAs. It will review the 
value of all Medicare payments to HPSAs for services provided 
in, or to residents of, such areas. The methodology used to 
designate such areas is undergoing proposed changes which are 
expected to be finalized in the year 2000. This project will 
inform HCFA about the importance of several Medicare special 
payment policies for HPSAs and aid in the assessmentof them and 
of alternatives.
    Status: In progress.
    Evaluation of Competitive Bidding Demonstration for DME and 
POS
    Prj #: 500-95-0061/03
    Start Date: 09/30/1998
    End Date: 05/15/2003
    Funding: $2,315,249
    Vehicle: Task Order
    PI: Sarita Karon
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute/Northwestern Univ.
    PO: Ann Meadow, Sc.D.
    Description: HCFA has mounted a demonstration to test the 
feasibility and effectiveness of establishing Medicare fees for 
durable medical equipment (DME) and prosthetics, prosthetic 
devices, orthotics and supplies (POS) through a competitive 
bidding process. The fundamental objective of competitive 
bidding is to use marketplace competition to establish market-
based prices and to select DME suppliers. The Balanced Budget 
Act of 1997 (BBA) authorized competitive bidding demonstrations 
for Part B services (except physician services), and the 
current project is being conducted under that authority. The 
initial site of the demonstration is Polk County, Florida. 
Competitively bid product categories in Polk include oxygen 
supplies and equipment, enteral nutrition, surgical dressings, 
urological supplies, and hospital beds. Medicare contracts with 
winning suppliers commenced in October 1999. Section 4319 of 
the BBA specifically mandates evaluation studies addressing 
competitive bidding impacts on expenditures, quality, access, 
and diversity of product selection. This task order will study 
these and other outcomes of the demonstration. The evaluation 
will use several types of research designs, such as multiple 
time series analysis and pre-test/post-test comparisons. The 
results of the evaluation will help HCFA decide how to conduct 
any future competitive bidding activities.
    Status: Data collection activities have begun. A pre-
demonstration survey of oxygen users and users of other medical 
supplies was fielded in two Florida counties (Polk and Brevard) 
in March 1999. The results suggested beneficiaries were highly 
satisfied with the services and products delivered by their 
Medicare suppliers. A followup survey is to be conducted during 
CY 2000. Two site visits in 1999 were conducted as part of the 
evaluation's case study activities, focusing on administrative 
and market outcomes. Other evaluation activities now in the 
planning stages include claims analyses, focus groups, fee-
schedule analyses, and additional surveys. The first annual 
evaluation report is scheduled for release in early CY 2001.
    Assessment of Medicare Prescription Drugs and Coverage 
Policies
    Prj #: 500-00-0024/01
    Start Date: 09/30/2000
    End Date: 02/28/2002
    Funding: $202,527
    Vehicle: Task Order
    PI: Thomas Hoerger
    Awardee: Research Triangle Institute
    PO: Peri Iz
    Description: The purpose of this task is to assemble and 
analyze recent fee-for-service and managed care plan data on 
Medicare spending for prescription drugs, as well as comparable 
data from other public and/or private payers. Using these data, 
the project will estimate possible financial effects of 
alternative Medicare payment policies for drugs currently 
covered by statute. This study will estimate current 
expenditures and possible savings from alternative 
reimbursement policies based on different discount rate and 
price schedules used by other payers, as well as examine other 
purchasing polices including competitive bidding and rebate 
mechanisms. In fiscal year 1997, Medicare's limited 
prescription drug benefits represented approximately 5 percent 
($2.8 billion of the $56.4 billion) of the total Medicare Part 
B expenditures. The majority of this drug spending is provided 
on an inpatient basis or related to the End Stage Renal Disease 
program. While not the most significant source of spending 
under Medicare, Part B spending for these limited prescription 
drugs exceeds spending for lens surgery, ambulance services, or 
oxygen. Until recently, Medicare paid for these limited 
prescription drugs based on reasonable charge determinations 
for covered prescription drug products found in the published 
Average Wholesale Price (AWP). Medicare paid 63 percent of the 
amounts billed for prescription drug products and their 
dispensing. A recent report from the Office of the Inspector 
General (OIG) concluded, however, that Medicare's payments for 
22 drugs in 1996 had an average mark-up of 41 percent over what 
physicians and suppliers paid for the drugs. By contrast, 
Medicare recognized only 49 percent of submitted charges for 
all other billed Part B services. The Balanced Budget Act of 
1997 changed Medicare's payment amount from 100 percent to 95 
percent of the AWP. According to several OIG reports, public 
programs such as Medicare have been paying too much for 
prescription drugs relative to what pharmacies actually spend 
for brand name products. For example, the prevailing Medicaid 
discount rate has been 10 percent, whereas actual acquisition 
discounts average over 18 percent. For generic products, the 
disparity is thought to be larger. Medicaid recoups a 
substantial portion of prescription drug payments through 
rebates from manufacturers. Also, drug manufacturers frequently 
provide special discounted prices for drugs used by the 
Department of Defense, the Department of Veterans Affairs, and 
certain Department of Health and Human Services health care 
programs. In 1997, it was estimated that 68 percent of Medicare 
managed care plan benefit packages included broadened benefits 
for prescription drugs, and that some of these managed care 
options were offered at no additional premium to beneficiaries. 
Such managed care plans offering these options may receive 
substantial discounts and/or rebates from manufacturers either 
by negotiation or by use of pharmacy benefit management firms 
who conduct price negotiations on behalf of plans. Medicare 
would like to know in greater detail how its payment policy for 
prescription drugs compares with the policies of other payers 
and purchasers. But data for making such comparisons are not 
readily available. HCFA does obtain detailed, product specific 
data from state Medicaid programs that are used to calculate 
rebate obligations of manufacturers. Under the terms of the 
Medicaid rebate agreements, however, such data are held in 
confidence and could not be used for this study. Hence, the 
purposes of this study are twofold:
          Data Collection (Task 1): the contractor will seek 
        and obtain available drug payment system information 
        from other non-Medicare organizations.
          Comparative Analysis (Task 2): the contractor will 
        compare current Medicare covered prescription drug 
        reimbursement levels to those found in the data 
        gathered, and prepare an analytical report.
    Status: In progress.
    Examine the Effects of Providing a Outpatient Prescription 
Drug Benefit
    Prj #:HCFA-00-0046
    Start Date: 01/20/2000
    End Date: 02/28/2001
    Funding: $15,000
    Vehicle: Simplified Acquisition
    PI: Ralph Monaco
    Awardee: InterIndustry Economic Research Fund
    PO: Edgar Peden
    Description: This project analyzes the macro-economic 
effects related to the introduction of a new public program, 
specifically an outpatient prescription drug benefit for 
Medicare.
    Status: In progress.
    Evaluation of the Nursing Home Case-Mix and Quality 
Demonstration
    Prj #:500-94-0061
    Start Date: 09/30/1994
    End Date: 09/01/2000
    Funding: $2,980,219
    Vehicle: Contract
    PI: Robert J. Schmitz, Ph.D.
    Awardee: Abt Associates, Inc.
    PO: Edgar A. Peden
    Description: Using data from the Nursing Home Case-Mix and 
Quality (NHCMQ) Demonstration, HCFA is evaluating the new 
practice of paying skilled nursing facilities (SNF) for 
Medicare skilled nursing services on a prospective basis. Prior 
to July 1, 1998, SNFs were reimbursed on a retrospective basis 
for their reasonable costs. Since that date, however, following 
methods used in the NHCMQ demonstration, a new prospective 
methodology has been implemented. Under this methodology, 
patients are classified into resource utilization groups which 
are then used to calculate each facility's case mix. HCFA then 
pays facilities for each covered day of care, to the case mix 
of patients residing there on any given day. Though some costs 
will continue to be
    Status: Interim analyses of admitting patterns and select 
outcomes have been undertaken, and visits to demonstration and 
nondemonstration facilities have been completed which should 
help in understanding provider response to the payment 
demonstration. Data base construction and analysis of the third 
phase of the demonstration, which bundled skilled therapy 
services into the prospectively-paid routine rate has been 
completed. This primary data collection activity was completed 
in July 1999. MDS assessments were matched to Medicare SNF and 
hospital claims and to HCFA Provider-of-Service records to 
create the analytic data base for the project. Current analytic 
activities center around assessing and revising the draft final 
report. Of special interest is the analysis of primary data 
regarding the provision of professional therapy services in 
both demonstration sites and comparison sites.
    Case-Mix Adjustment for a National Home Health Prospective 
Payment System
    Prj #:500-96-0003/02
    Start Date: 07/26/1996
    End Date: 09/30/2000
    $Funding $3,416,984
    Vehicle: Task Order
    PI: Henry Goldberg
    Awardee: Abt Associates Inc.
    PO: Ann Meadow, Sc.D.
    Description: The primary focus of this study is to 
understand existing variation in home health resource patterns 
and to use this information to develop a case-mix adjustment 
system for a national home health prospective payment system 
(PPS). In this study, the Outcomes and Assessment Information 
Set (OASIS), which has been developed for outcome-based quality 
assurance and improvement for Medicare home health agencies, is 
being examined to see whether items included in this instrument 
will be useful for case-mix adjustment. Detailed information, 
including information on resource utilization and additional 
items needed for case-mix adjustment not included on OASIS, has 
been collected from participating agencies. (Arizona, 
California, Florida, Illinois, Massachusetts, Pennsylvania, 
Texas, Wisconsin.)
    Status: Ninety agencies were recruited and trained from 
eight States in the spring and summer of 1997. All agencies 
began data collection on a 6-month cohort of new admissions to 
home care beginning in October 1997. Data collection ended in 
the spring of 1999. Analysis to date has resulted in a viable, 
clinically coherent system of 80 case-mix groups that explains 
more than 30 percent of the variation in resource use on a 
development sample drawn from the cohort members. Resource use 
is measured for 60-day periods of care, to conform to the 
planned unit of payment under the forthcoming national PPS. 
Selected OASIS assessment items, collected at the start of 
care, are used in the grouping system. The case-mix items fall 
into three major domains: clinical factors, functional-status 
factors, and utilization factors. Within each domain, a 
parsimonious set of items is summarized into a score for the 
patient. In two of the domains, scores are partitioned into 
four levels corresponding to high, moderate, low, and minimal 
impact, based on the relationship of the score to resource 
utilization. In the third domain, scores are partitioned into 
five impact levels. A patient's combination of levels on all 
three domains identifies the group into which the patient is 
classified for purposes of case-mix adjusting the prospective 
payment amount. Under this system, the patient's case mix 
classification is updated at the end of the payment period to 
reflect the actual amount of home therapy services received 
during the 60-day payment period. This information is necessary 
to arrive at a final score for the utilization domain. Results 
of the study to date are described in two reports:
          Case-Mix Adjustment for a National Home Health 
        Prospective Payment System: First Interim Report, July 
        1998 (revised December 1998).
          Case-Mix Adjustment for a National Home Health 
        Prospective Payment System: Second Interim Report, 
        September 24, 1999.
    Additional reports on model validation results refinement 
related analysis and OASIS case-mix data verfication are 
expected in 2001.
    Maximizing the Cost Effectiveness of Home Health Care: The 
Influence of Service Volume and Integration with Other Care 
Settings on Patient Outcomes
    Prj #:17-C-90435/8
    Start Date: 09/01/1994
    End Date: 09/30/2000
    Funding: $1,496,245
    Vehicle: Cooperative Agreement
    PI: Peter W. Shaughnessy, Ph.D.
    Awardee: Center for Health Policy Research, University of 
Colorado
    PO: Ann Meadow, Sc.D.
    Description: 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 it 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, and that 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 these hypotheses, a 
sample of 3,600 patient records is being analyzed from agencies 
in 20 States stratified into high, medium, and low-volume 
categories based on annual visits per beneficiary. Trained data 
collectors at each agency recorded patient health status and 
service information between HHC admission and discharge to 
assess patient outcomes and costs within the HHC episode. Long-
term, self-reported outcomes are being measured from telephone 
interview data at HHC admission and from 6-month follow ups. 
These primary data concerning patient status and outcomes will 
be combined with Medicare claims data over the episode of care 
to study the relationship between service volume in HHC and 
both patient outcomes and costs.
    Status: Study Paper 1, Research Design Update, which 
summarized the research design and its evolution from the 
original proposal, was finalized in September 1998. Primary 
data collection ended in late 1998. An interim report on a 
subsample of 1,000 patients (February 1999) described case mix 
and volume relationships. Separately for the four common 
conditions (congestive heart failure, stroke, surgical hip 
procedures, and open wounds), a high- and low-volume group was 
selected by taking the highest and lowest 45 percent of the 
arrayed cases within each condition. Two-sample tests for mean 
differences in case mix characteristics and volume were 
performed to compare the two volume groups within each 
condition. The median volume (defined as number of visits until 
discharge or first inpatient admission) differed by a factor of 
about four to nine, depending on the condition. For home health 
aide services, mean volume differed by a factor of between 30 
and 47. Many case mix indicators were measured at the start of 
care. Of these, few demographic indicators differed between the 
volume groups within condition. But limitations in activities 
of daily living (ADLs) were significantly greater for the high-
volume groups, these patients had a greater prevalence of 
chronic conditions, and their institutional utilization within 
the 14 days prior to admission was less likely to be an acute-
care hospital, indicating the more post-acute nature of the 
low-volume groups. This general case mix difference is 
consistent with the greater use of aide services for high-
volume patients. Preliminary analyses of outcomes suggested 
relatively few differences in outcomes by volume. This result 
may mean that the additional services delivered to the high-
volume group helped equalize outcomes between more severely ill 
and less severely ill patients. Risk-adjusted analyses planned 
for later in the study are necessary to further explore this 
possibility.
    Evaluation of Phase II of the Home Health Agency 
Prospective Payment Demonstration
    Prj #:500-94-0062
    Start Date: 09/30/1994
    End Date: 09/30/2000
    Funding: $3,528,408
    Vehicle: Contract
    PI: Barbara Phillips, Ph.D.
    Awardee: Mathematica Policy Research, Inc.
    PO: Ann Meadow, Sc.D.
    Description: This contract is evaluating Phase II of the 
Home Health Agency (HHA) Prospective Payment Demonstration, 
under which HHAs are paid on a prospective basis for an episode 
of care reimbursed by the Medicare program. (Phase I tested 
per-visit prospective payment for HHAs.) Ninety-one agencies 
from five states--California, Florida, Illinois, Massachusetts, 
and Texas--were randomly assigned to either the treatment group 
(prospective payment system (PPS) method, 48 agencies) or the 
control group (conventional cost-based reimbursement, 43 
agencies). The agencies phased into the demonstration at the 
beginning of their 1996 fiscal year. Treatment-group agencies 
can reduce the cost of care they provide during a 120-day 
payment period by reducing visits, changing the mix of visits 
to make less costly visits a larger proportion of visits, 
reducing per-visit costs, or some combination of all three. The 
cost-reducing activities raise the possibility that quality of 
care might deteriorate under episode-based payment. Quality 
impacts, along with cost, utilization, and qualitative, 
behavioral effects, are the focus of the evaluation. 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.
    Status: Interim findings from the evaluation, based 
primarily on the first 8 to 15 months of demonstration 
operations, are described in following documents:
          Transition Within a Turbulent System: An Analysis of 
        the Initial Implementation of the Per-Episode Home 
        Health Prospective Payment Demonstration, August 6, 
        1997.
          Preliminary Report: The Impact of Prospective Payment 
        on Medicare Home Health Quality of Care, January 30, 
        1998.
          Preliminary Report: The Impact of Prospective Payment 
        on Medicare Home Health Use--Promising Results for a 
        Future Program, July 22, 1998.
          The Impact of Prospective Payment on Medicare Service 
        Use and Reimbursement During the First Demonstration 
        Year, December 1998.
          Preliminary Report: The Impact of Prospective Payment 
        on the Cost per Episode: Striking the Balance Between 
        Decreasing Use and Increasing Cost, July 22, 1999.
    Findings from the first 2 years of the evaluation are 
described in additional reports forthcoming in calendar year 
2000. Findings from the interim analysis of cost impacts 
suggest that, on average, prospective payment reduced the cost 
of care during the 120-day episode period by $419 or 13 
percent. The impact on cost was similar across different types 
of agencies, except that small agencies (less than 30,000 
visits in year before the demonstration) exhibited a 
significantly smaller effect than large agencies. Findings from 
the utilization study suggest that the per-episode group of 
HHAs was able to reduce the number of visits provided during 
the 120-day episode period by 17 percent and the time from 
admission to discharge by 15 percent. The proportion of 
patients receiving care in each home health discipline changed 
little under episode payment. The utilization findings 
generally applied to agencies regardless of size, nonprofit 
status, affiliation status (hospital or freestanding), or use 
pattern (i.e., whether the agency provided more or less than 
the average number of visits during a base year, given its case 
mix).
    The reduction in visits has not led to compensating 
utilization in other parts of the health care system. An 
analysis of utilization and reimbursement for Medicare-covered 
services other than home health found that prospective payment 
did not affect the use of or reimbursement for such services 
during the 120-day episode period. An investigation of 
spillover effects in settings not covered by Medicare similarly 
found no compensating utilization. For example, prospective 
payment did not affect the likelihood of receiving 
nonresidential services such as personal care aides and adult 
day care, based on results from a patient survey.
    These findings suggest that a reduction in home health 
utilization at the level observed under the demonstration does 
not adversely affect care quality or shift costs to services in 
other settings. Other interimanalyses of quality impacts found 
few differences in patient outcomes between treatment and 
control agencies, and when differences were found, they were 
small. Analysis of claims data indicated that PPS patients have 
significantly lower emergency room use. There were no 
significant differences due to PPS in any other outcomes 
studied from the claims data, including institutional 
admissions for a diagnosis related to the home health care and 
mortality. Results from the first patient survey on client 
satisfaction suggested that both treatment and control group 
clients were generally satisfied. On three specific components 
of satisfaction with agency staff, treatment-group clients were 
found to be somewhat less satisfied than control group clients, 
although satisfaction levels were quite high in both groups. 
Measures of health and functional outcomes from the survey 
offered equivocal evidence for small negative effects of 
prospective payment in a few of the functional outcomes. These 
results are preliminary and require further study in a planned 
follow-up survey. Half of the treatment agencies selected for 
case study early in the demonstration reported plans for 
specific initiatives to reduce per-episode costs spurred by 
their participation in the demonstration project. From the case 
studies, the evaluators concluded that treatment agencies were 
not planning to change their behavior in ways that threatened 
access or quality of care.
    Subsequent evaluation reports will focus on utilization, 
cost, and quality effects beyond the 120-day episode period. 
There will be further case-study results on agency response to 
the demonstration and an extension of previous work on cost 
impacts to include an analysis of agencies' financial 
performance. Finally, supplementary analyses will consider the 
representativeness of the demonstration sample and the patient 
selection behavior of agencies.
    Medicare Post-Acute Care: Evaluation of BBA Payment 
Policies and Related Changes
    Prj #:500-96-0006/04
    Start Date: 09/21/2000
    End Date: 09/20/2002
    Funding: $636,557
    Vehicle: Task Order
    PI: Brian Burwell
    Awardee: MEDSTAT Group, LLC
    PO: Philip Cotterill
    Description: The purpose of this project is to study the 
impact of BBA and other policy changes on Medicare utilization 
and delivery patterns of post-acute care. Post-acute care is 
generally defined to include the Medicare covered services 
provided by skilled nursing facilities (SNFs), home health 
agencies, rehabilitation hospitals and distinct part units, 
long term care hospitals, and outpatient rehabilitation 
providers. The changes in post-acute care payment policy 
enacted in the late 1990's (mostly in the 1997 Balanced Budget 
Act (BBA) with some subsequent modifications) were made one-by-
one to most types of post-acute care. However, a beneficiary's 
post-acute care needs, can often be met in alternative provider 
settings. Hence policy changes for one post-acute care modality 
may have ramifications for other post-acute and acute care 
services. Understanding the interrelationships among post-acute 
care delivery systems is critical to the development of 
policies that encourage appropriate and cost-effective use of 
the entire range of care settings. The results of this work may 
be useful in refining policies for individual types of post-
acute care, as well as in developing a more coordinated 
approach across all settings. Medicare utilization and 
expenditures for post-acute care increased dramatically in the 
1990's prior to the passage of the BBA. Many of the changes 
enacted in the BBA were in reaction to the experience of the 
early 1990's and were aimed at controlling the decade's 
fiscally disturbing expenditure trends. Even before passage of 
the BBA, administrative actions (such as Operation Restore 
Trust (ORT)) were taken to tighten the enforcement of coverage 
guidelines and reduce abuses that were perceived to be 
significant contributory factors to the runaway growth of the 
early 1990s. Chief among the BBA changes was the mandate for 
implementation of prospective payment systems to replace 
retrospective cost-based payment for all the major post-acute 
care providers. Among the BBA policies whose impacts to be 
considered in this project are the following: the Interim 
Payment System (IPS) for home health agencies; the SNF 
prospective payment system; the revised inpatient hospital 
transfer policy for 10 DRGs; the new cost limits and rebased 
target amounts for rehabilitation hospitals and distinct part 
units; and the outpatient therapy limits. Study Overview--In 
general, the appropriate evaluation design is a Adifferences in 
differences@ model that estimates differential 
effects over time as a function of differential degrees of 
impact. In this initial project, analyses will compare changes 
between the pre-BBA period of the 1990's and a post-BBA year, 
such as 1999. For the most part, the studies should focus on 
the interrelationships among the various post-acute care 
settings. However, in some cases, changes affecting a single 
type of post-acute care may warrant special analysis. The model 
needs to be applied flexibly to include a variety of 
beneficiary, provider, and market area analyses. In addition, 
analyses may involve data for individual years, as well as 
changes between years. Since the impacts of policy changes not 
yet implemented will continue to be of interest for many years, 
the analyses developed under this project are expected to use 
and refine methods that can be applied in future evaluation 
research. Analytically, this is a challenging project due to 
the numbers of provider types and policy changes involved. The 
staggered and overlapping temporal implementation of the 
changes further complicates the effort. The proposed analyses 
are not necessarily expected to be able to attribute causality 
to effects detected, nor are they expected to disentangle the 
effects of one policy change from the effects of another. In 
general, it will only be possible to determine net effects of 
all changes relevant to a specific analysis. However, in 
choosing time periods, attention will be paid to the policies 
that could be expected to impact behavior during the period of 
analysis. The project will utilize secondary data sources, 
primarily HCFA claims data. Claims for all relevant types of 
services will need to be linked with beneficiary enrollment 
information to create Aepisodes@ of care by 
beneficiary. At least 2 such episode files will be required, 
one for a pre-BBA year such as 1995 or 1996 and another for a 
post-BBA year such as 1999. In addition the project will design 
a strategy for monitoring and evaluation of impacts across 
post-acute care settings. We are interested in distinguishing 
between the needs for regular monitoring of impacts across 
post-acute care settings and more detailed evaluation studies. 
We are especially interested in defining data requirements for 
monitoring sentinel events that would serve as alerts for more 
in-depth evaluation. The strategy will define data requirements 
for monitoring and evaluation activities, taking into 
consideration the data available for individual care modalities 
and the need to integrate data across modalities in as timely 
and efficient a manner as possible.
    Status: In developmental phase.
    Design of an Integrated Post-Acute Care System
    Prj #: 500-96-0008/04
    Start Date: 09/30/1997
    End Date: 10/31/2001
    Funding: $829,428
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Frederick G. Thomas, III, CPA, MS, MBA
    Description: HCFA intends to create an infrastructure of 
post-acute and long-term care delivery and payment systems that 
are better integrated and more flexible in meeting the needs of 
beneficiaries with chronic illnesses and disabilities. The 
transition from our current benefit and provider-based system 
to a beneficiary-centered system requires several elements:
          An assessment tool that can be used and shared across 
        provider types.
          More flexible benefit packages.
          Funding based on beneficiary health and functional 
        needs.
          Case management that involves formal and informal 
        caregivers in care planning and supports and 
        encourages, where appropriate, beneficiaries to direct 
        their own care.
    Additional work that incorporates beneficiary preferences 
into outcome measures, as well as further attempts to 
differentiate outcomes by post-acute-care modality for 
different patient conditions, is also needed. The purpose of 
this project is to design several elements needed in a more 
integrated system--an assessment tool, potential case 
management models, appropriate payment systems, and outcome 
measures that cross settings and incorporate beneficiary 
preferences, with the ultimate intent of pilot testing and 
refining these elements in a demonstration. A second purpose of 
this project is to design an optional demonstration that tests 
the feasibility and effectiveness of creating a more integrated 
post-acute-care system.
    Status: Work has begun on developing potential case-
management models, as well as an assessment instrument.
    Effects of Telemedicine on Accessibility, Quality, and Cost 
of Health Care
    Prj #:18-P-90332/5
    Start Date: 07/01/1994
    End Date: 09/30/2001
    Funding: $644,086
    Vehicle: Grant
    PI: F. W. Womack
    Awardee: University of Michigan
    PO: Joel Greer, Ph.D.
    Description: This project evaluated the effect of 
telemedicine systems on accessibility, quality, and cost of 
health care. A detailed methodology for evaluating telemedicine 
was developed by a panel of experts and implemented in existing 
telemedicine programs at the Medical College of Georgia (MCG) 
Telemedicine Center and Mountaineer Doctor Television (MDTV) at 
the Health Sciences Center, West Virginia University (WVU). 
Included in the evaluation design was a quasi-experimental 
survey study of clients and providers in selected experimental 
and control communities and a case-control study to compare the 
content, process, and outcomes of episodes of care with and 
without telemedicine. The project plan had three goals:
    Development of a detailed methodology for a comprehensive 
evaluation of the effects of telemedicine on accessibility, 
utilization, quality, and cost of health care, using a panel of 
experts on quality, economics, clinical medicine, and 
technology. Implementation and testing of the evaluation design 
at the MCG Telemedicine Center. Extending the evaluation design 
to MDTV at WVU.
    The general hypothesis guiding this research was that 
telemedicine will improve accessibility to health care, enhance 
the quality of care delivered, and contain costs.
    Status: The final report is being prepared.
    Maximizing the Effective Use of Telemedicine: A Study of 
the Effects, Cost Effectiveness, and Utilization Patterns of 
Consultation via Telemedicine
    Prj #: 18-C-90617/8
    Start Date: 09/01/1995
    End Date: 09/28/2002
    Funding: $2,198,968
    Vehicle: Cooperative Agreement
    PI: Jim Grigsby, Ph.D. and Robert E. Schlenker, Ph.D.
    Awardee: Center for Health Policy Research, University of 
Colorado
    PO: Joel Greer, Ph.D.
    Description: This project is evaluating the medical 
effectiveness, patient and provider acceptance, and costs 
associated with telemedicine services, as well as their impact 
on access to care in rural areas. The demonstration involves 
ten rural hospitals, one rural referral hospital, and one urban 
hospital. Planned services for the demonstration include 
interactive video consults for teleradiology, telepathology, 
and, where available, telesonography, electrocardiography, and 
fetal monitoring strips. Payment for related physician services 
is expected to be made under a waiver of Medicare payment 
regulations. The goal of he project is to evaluate whether 
specialty telemedicine services provided by hospital networks 
produce change with respect to medical effectiveness, patient 
and provider satisfaction, cost, and access. Hypotheses include 
telemedicine improving differential diagnoses and treatment, 
patients and providers being as satisfied with telemedicine as 
with on-site services, telemedicine services being less costly 
than on-site services, and telemedicine improving access to a 
wider range of health care services.
    Status: The evaluation design has been completed and the 
instrument approved by the Office of Management and Budget. 
Data collection has begun.
    Evaluation of the Informatics, Telemedicine, and Education 
Demonstration
    Prj #: 500-95-0055/05
    Start Date: 09/30/2000
    End Date: 07/29/2004
    $Funding $1,419,493
    Vehicle: Task Order
    PI: Judith Woodridge/Stephen Zuckerman
    Awardee: Urban Institute, The
    PO: Carol Magee
    Description: Section 4207 of the Balanced Budget Act of 
1997 (BBA97) instructs the Secretary to establish a single, 4-
year demonstration project using an eligible health care 
provider telemedicine network. The demonstration involves the 
application of high-capacity computing and advanced 
telemedicine networks to the task of improvement of primary 
care and prevention of health complications in Medicare 
beneficiaries with diabetes mellitus. These beneficiaries must 
reside in medically underserved rural or medically underserved 
inner-city areas. The statute also mandates that the Secretary 
submit a final Report to Congress (RTC) that: AY shall include 
an evaluation of the impact of the use of telemedicine and 
medical informatics on improving access of Medicare 
beneficiaries to health care services, on reducing the costs of 
such services, and on improving the quality of life of such 
beneficiaries. Submission of the RTC is mandated by August 31, 
2004 (6 months after the conclusion of the demonstration). The 
purpose of this project is to evaluate the impact of the 
Informatics, Telemedicine, and Education Demonstration Project 
and to provide input into the RTC. The Informatics, 
Telemedicine, and Education Demonstration project is using 
specially modified home computers, or home telemedicine units 
(HTU) linked to a Clinical Information System (CIS) maintained 
by Columbia Presbyterian Medical Center. The HTUs in patients' 
homes allow video conferencing, access to health information 
and access to medical data. Computerized devices read blood 
sugar levels, check blood pressure, take pictures of skin and 
feet for signs of infection, and screen for other factors that 
affect the management of diabetes. These data are fed 
electronically to the data system at Columbia. The CIS provides 
storage of clinical data for use in the development and 
application of patient care guidelines and clinical standards. 
Full-time nurse case-managers monitor the data and intervene if 
the data from a patient vary from guidelines. Patients receive 
feedback, including clinical data such as blood glucose levels, 
care reminders and suggestions on how to maintain good health. 
Health information specific to diabetes is to intervention 
group participants on a specially developed website (under 
development) in both low literacy and regular versions in both 
Spanish and English.
    The demonstration project is being conducted as a 
randomized, controlled clinical trial. Half of the participants 
are receiving the intervention, consisting of an HTU and 
electronic services within a case-manager environment (as 
detailed above), and half continue to receive usual care for 
their diabetes. The demonstration consists of 2 components: an 
urban component conducted in northern Manhattan, and a rural 
component, conducted in upstate New York. Participants can have 
either Type I or Type II diabetes, and both males and females 
will be included. There are no racial or ethnic exclusions to 
participation. Demonstration participants are being recruited 
into the study over approximately 1 year. Once recruited and 
randomized, each participant will remain in the demonstration 
for 2 years. After completion of their time in the 
demonstration, participants will be phased out over 
approximately 1 year. Outcome data will be collected from all 
participants at three visits (visit 1 [baseline], visit 2 [one 
year follow-up], and visit 3 [two year follow-up]). The primary 
health outcome measures to be collected as part of the 
demonstration are glycosylated hemoglobin levels, blood 
pressure levels, and lipid levels. Other important outcomes 
include receipt of recommended diabetes-specific health care 
services (dilated eye exam, foot exams), other recommended 
preventive services, smoking cessation in the subset of 
participants who smoke, and satisfaction with care.
    Impact of the telemedicine intervention on health outcomes 
will be evaluated by comparing mean and adjusted mean levels of 
glycosylated hemoglobin, blood pressure, and lipids in the 
intervention and the control groups. There will be two separate 
analyses. The first is an internal analysis of the randomized 
clinical trial to be conducted by the Columbia University 
consortium analysts. The clinical trial analysis is primarily 
focused on the impact of the telemedicine intervention on 
health outcomes and clinical care of the participants. The 
second evaluation, which is the this project, is to assess the 
financial impact of the of the demonstration. This evaluation 
is independent of Columbia's internal analysis. This financial 
inpact evaluation will focus on whether the home telemedicine 
intervention can increase access to care for Medicare 
beneficiaries in medically underserved areas; whether the use 
of the intervention would reduce health care costs; and whether 
the physicians who are part of demonstration are representative 
of the physician population serving Medicare beneficiaries. 
More specifically, the questions to be addressed are:
        What is the impact of the use of telemedicine and 
        medical informatics on:
        access of Medicare beneficiaries to health care 
        services?
        reducing the costs of health care services to Medicare 
        beneficiaries?
        improving the quality of life of Medicare 
        beneficiaries?
        In addition, issues to be addressed may include:
        costs of the telemedicine intervention, with attention 
        to both technology and service costs of the 
        intervention
        estimation of the cost-effectiveness of the 
        telemedicine interventiondifferences in the physicians 
        who participate in the demonstration from those who do 
        not participate.
    Status: This project is subcontracted to Mathematica Policy 
Research.
    Design and Simulation of Alternative Medigap Structure
    Prj #: 500-95-0059/07
    Start Date: 09/30/1999
    End Date: 07/29/2001
    Funding: $588,984
    Vehicle: Task Order
    PI: Lisa Maria Alecxih
    Awardee: Lewin Group, The
    PO: John Robst
    Description: While Medicare benefits are extensive, like 
many insurance products, the program has deductible and co-
insurance requirements as well as limitations on payments to 
providers. On average, basic Medicare benefits alone cover 
about half the personal health care expenditures of aged 
beneficiaries (Laschober and Olin, 1996). Because of these 
``gaps'' in coverage, many beneficiaries choose to purchase a 
supplemental policy, often called ``Medigap.'' The project will 
compile premium data on existing standard Medigap premiums, 
formulate alternative standard benefit packages, and estimate 
premium costs of these alternative packages. From this 
analysis, the current and alternative Medigap options will be 
compared.
    Though Medicare supplemental coverage has been available 
since nearly the inception of the Medicare program itself, 
prior to the enactment of the Social Security Disability 
Amendments of 1980, such insurance products were regulated only 
by States. Increasing concerns regarding the confusing array of 
different Medigap products, questionable marketing and sales 
practices, sales of overlapping and duplicative coverage, and 
low loss ratios prompted Congress in 1980 to establish Federal 
standards for Medigap plans. Most States adopted the standards, 
which were developed by the National Association of Insurance 
Commissioners. Continued concern regarding marketing abuses and 
confusion among beneficiaries eventually prompted Congress to 
mandate Medigap policy standards. As a result of the Omnibus 
Budget Reconciliation Act of 1990, effective in 1992, newly 
issued Medigap policies have been required to conform to one of 
ten standardized benefit packages. The law also mandated other 
standards, including minimum loss ratios and a guaranteed open 
enrollment period for new Medicare enrollees. Despite many 
changes in the Medicare programsince the early 1990s, the basic 
benefit structure of Medicare supplemental insurance has 
remained unchanged. This project will examine possible updated 
Medigap benefit structures, and compare these alternatives to 
the premiums and benefit structures of currently available 
supplementary coverage, as well as Medicare+Choice options.
    Status: In progress.
    Health status and Medical Treatment of the Future Elderly: 
Implications for Medicare Program Expenditures
    Prj #:500-95-0056/09
    Start Date: 06/30/1999
    End Date: 06/15/2001
    Funding: $1,582,650
    Vehicle: Task Order
    PI: Dana Goldman, Ph.D., and Michael Hurd, Ph.D.
    Awardee: RAND Corporation, The
    PO: Linda Greenberg, Ph.D.
    Description: This project is designed to develop 
demographic-economic models to project how changes in health 
status, disease, and disability among the next generation of 
the elderly will affect future Medicare spending. The goal of 
this task order is to enable HCFA actuaries and policymakers to 
simulate the impact of changes in health and functional status, 
as well as changes in medical technology, on future costs to 
the Medicare program. The first aim of the model will be to 
answer the question: ``If the current trends in demographics 
continue, and if the future generation of the elderly face the 
same health status and health care environment as today's 
elderly, what will future health care costs be?'' The second 
aim of the model will be to serve as the simulation vehicle for 
evaluating ``what if'' scenarios to explore how various 
assumptions about changes in the health status of the elderly 
and the health care environment will affect Medicare and non-
Medicare costs.
    The models will focus on two key determinants of health 
spending: diseases (and the medical technology to treat them) 
and health status. RAND will use literature reviews and 
technical expert panels (TEPs) to guide the model development 
effort. The literature review effort will focus on five areas:
          Health and disability trends.
          New medical treatments.
          Effects of new technologies on morbidity and 
        mortality.
          Diseases most likely to affect the elderly's future 
        health expenditures.
          Past efforts to model health care expenditures.
    The first TEP--consisting primarily of physicians 
knowledgeable about treatments for the elderly--will identify 
conditions likely to affect expenditures by the future elderly. 
For each condition, the TEP will identify the emerging 
technologies and estimate likely consequences on mortality and 
morbidity. The second TEP--consisting primarily of social 
scientists and modelers--will help determine appropriate health 
status measures, methodologies, and data sets for estimating 
model parameters, and the best modeling techniques.
    RAND will use a microsimulation model to estimate future 
Medicare expenditures. The modeling efforts will consist of 
three components: a ``basic'' model, a ``health status'' model, 
and a ``what if'' model. The ``basic'' model will categorize 
the future elderly population by age and sex, then iteratively 
apply a transition matrix to calculate the status of the 
population at later time periods. This will serve as a useful 
benchmark for subsequent modeling efforts. The ``health 
status'' model will augment the basic model to explicitly 
include health status so that RAND can explore the possibility 
that changes may occur in the health status of the elderly and 
the treatment of particular health conditions among the 
elderly. RAND will use longitudinal datasets to estimate the 
transition rates--the probability that a person (or persons) 
with certain demographic characteristics and known health 
status will transition to another category with a different 
demographic and health status description over some time 
period. RAND will estimate the direct costs of health 
expenditures by fitting parametric models of the distribution 
of expenditures using existing data that link health status to 
spending. Finally, the ``what if'' model will explore changing 
the parameters of the health status model to reflect possible 
changes to the health care environment, including medical 
breakthroughs.
    Status: The project is well underway. In September 1999, a 
final design report was accepted. In the fall of 1999, project 
staff consulted with nationally-recognized geriatricians to 
discuss which disease groups and specific medical conditions 
should be covered by the medical TEPs. Members have been 
appointed to the medical and social science TEPs. Preliminary 
reviews of the literature are expected prior to theTEP 
meetings. Work on devising a micro-simulation model to estimate 
future Medicare expenditures is underway. Final project results 
are expected by December 2001.
    Retiree Health Benefits
    Prj #:500-95-0061/08
    Start Date: 09/30/2000
    End Date: 06/30/2002
    Funding: $249,971
    Vehicle: Task Order
    PI: Lauren McCormack
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute
    PO: Brigid Goody, Sc.D.
    Description: This project examines current employer-based 
health  insurance  coverage  for  Medicare-eligible  retirees,  
the prospects for continuation of this coverage and possible 
implications for the restructuring of the Medicare fee-for-
service and Medicare+Choice (M+C) programs. Although 
approximately one-third of aged Medicare beneficiaries have 
coverage under an existing employer-sponsored health insurance 
policy, the prevalence of coverage has declined and retiree 
cost-sharing requirements have increased in recent years. If 
current trends continue, the future of employer-sponsored 
coverage of Medicare eligible retirees is not encouraging. 
Declining employer-sponsored coverage could result in more 
Medicare beneficiaries purchasing individual Medigap policies, 
joining Medicare+Choice plans or going without supplemental 
coverage. As Medicare beneficiaries face paying more for 
services previously covered by retiree health insurance, the 
Medicare Program may come under increasing pressure to offer 
additional benefits, most notably outpatient prescription 
drugs.
    The project will consist of two parts. The first part will 
analyze existing secondary data to describe the types of 
coverage offered to Medicare-eligible retirees, the funding for 
this coverage and recent trends in coverage. The second part 
will be comprised of interviews aimed at understanding the 
prospects for future employer-sponsored coverage of this 
population, possible impacts of Medicare reform initiatives on 
this coverage and how the Medicare Program, both fee-for-
service and managed care, might be restructured to encourage 
continued coverage. Interviewees would, at a minimum, include 
employers, unions, business coalition/purchasing groups and 
outside consultants (insurance agents/brokers, third party 
administrators and professional benefits consultants).
    Status: Research Triangle Institute will perform this 
project under a subcontract
    Health Disparities: Longitudinal Study of Ischemic Heart 
Disease Among Aged Medicare Beneficiaries
    Prj #:500-95-0058/12
    Start Date: 09/22/2000
    End Date: 01/21/2002
    Funding: $282,157
    Vehicle: Task Order
    PI: Jerry Cromwell
    Awardee: Health Economics Research, Inc.
    PO: Linda Greenberg, Ph.D.
    Description: The purpose of this task order contract is to 
assess the use of Medicare covered services among Medicare 
beneficiaries with ischemic heart disease based on 
sociodemographic characteristics (e.g., race/ethnicity, sex, 
age, socioeconomic status). During the past few years, the 
Health Care Financing Administration (HCFA) has undertaken 
several efforts to strengthen the base of knowledge of health 
disparities among racial/ethnic groups. This project is one 
part of a larger HCFA and Department of Health and Human 
Services effort to address health disparities among Medicare 
beneficiaries. This will be done using a longitudinal database 
that links Medicare enrollment and claims data with small-area 
geographic data on income (e.g., U.S. Census data or other 
private data sources). Such information will be useful to 
compare the incidence of disease and the outcomes of diagnostic 
and surgical procedures for ischemic heart disease (IHD) across 
racial/ethnic groups, socioeconomic status, and geographic 
areas. The advantage of a longitudinal database is that it 
provides data at multiple time points during a person's life. 
Due to recent expansions in the race/ethnic coding in the 
Medicare enrollment database (EDB), it is now possible to 
examine health care access, utilization, and outcomes among 
minority groups.
    Status: In progress.
    Patterns of Injury in Medicare and Medicaid Beneficiaries
    Prj #:500-95-0060/04
    Start Date: 09/29/2000
    End Date: 09/30/2001
    Funding: $715,991
    Vehicle: Task Order
    PI: Deborah Garnick
    Awardee: Brandeis University
    PO: Rosemary Hakim, Ph.D.
    Description: This project is a descriptive study of the 
extent and impact of injuries in the Medicare and Medicaid 
populations, and to conduct in depth analyses on specific types 
of injuries. Unintentional injuries accounted for more than 
90,000 deaths in the US in 1997, making this the fifth leading 
cause of death overall. Intentional injuries, suicide and 
homicide, have resulted in more than 50,000 deaths annually 
since 1985. The impact on health care costs, income and 
productivity is significant. Injuries may be an even more 
important cause of mortality and morbidity among persons in 
vulnerable populations, which include the populations served by 
Medicare and Medicaid. While mortality data for injuries are 
available, data addressing the prevalence of morbidity due to 
injuries and the expenditures for related care are not 
available. The Medicare and Medicaid data are particularly well 
suited to assess morbidity due to injuries that are severe 
enough to come to medical attention.
    Status: In progress.
    Examining Gender and Racial Disparities Among Medicare 
Beneficiaries with Chronic Diseases
    Prj #:500-95-0058/15
    Start Date: 09/29/2000
    End Date: 09/28/2001
    Funding: $177,442
    Vehicle: Task Order
    PI: Deborah Dayhoff
    Awardee: Health Economics Research, Inc.
    PO: Marsha G. Davenport, M.D., M.P.H.
    Description: The purpose of this task order is to develop 
and complete an analytic study using the Medicare 
administrative claims files to expand HCFA's knowledge base in 
the area of women's health and chronic diseases. Chronic 
diseases contribute significantly to the morbidity and 
mortality of older Americans. Diseases such as arthritis, 
asthma, chronic obstructive pulmonary disease (COPD) and other 
respiratory conditions, cancers, diabetes, heart disease, 
hypertension, osteoporosis, and stroke comprise the major 
categories of chronic conditions affecting persons age 65 and 
older. Cardiovascular diseases (CVD), primarily heart disease 
and stroke, are the leading cause of death irrespective of 
gender or racial origin. However, for women, cardiovascular 
disease is responsible for more deaths than almost all of the 
leading causes of death, including cancer. The general category 
of cardiovascular diseases (CVD) includes not only heart 
diseases such as coronary heart disease, but also hypertension 
or high blood pressure and stroke. Until recently, death rates 
for coronary heart disease had declined. However, with the 
growing aged population, the slope of this decline has begun to 
level off.
    Another cardiovascular disease with a major impact on the 
aged population is stroke. Stroke is the third leading cause of 
death. Recent studies have identified disparities in treatment 
for heart disease both by gender and race/ethnicity. There are 
a growing number of racial and/ethnic groups in this country 
who appear to be disproportionately sharing the burden of these 
chronic diseases. Just as cardiovascular disease can result in 
disabilities, arthritis and osteoporosis are also diseases that 
cause disability and lost work days. As the population ages, 
the impact of this disease may have major ramifications for 
society as more and more persons become disabled. Osteoporosis 
is a potential cause of disabilities because this disease 
increases the risk of fracture. Data from the Medicare Current 
Beneficiary Survey (MCBS) showed that the percentage of 
Medicare beneficiaries reporting osteoporosis increased with 
increasing age. The study also found that a higher percentage 
of whites reported having had a hip fracture than nonwhites. A 
final category of diseases are the respiratory diseases. Asthma 
and COPD are among the 10 leading chronic conditions. It has 
been found that deaths due to asthma are more likely to occur 
in African Americans and Hispanics than among whites. In 
summary, chronic diseases are quite prevalent in the aged 
population. Little is known about the gender and racial 
differences in patterns of utilization and health outcomes for 
the Medicare population. Findings from this project will assist 
HCFA in targeting policies, programmatic changes, education, 
outreach, research and demonstration projects to achieve 
improved health outcomes for our female Medicare beneficiaries.
    Status: In progress.
    Health status and Quality of Life for Women with Diabetes: 
Data from the Medicare Current Beneficiary
    Prj #:500-96-0516/13
    Start Date: 09/30/2000
    End Date: 09/29/2001
    Funding: $92,490
    Vehicle: Task Order
    PI: Celia H. Dahlman [Fu Assoc's, Sub]
    Awardee: CHD Research Associates, Inc.
    PO: Marsha G. Davenport, M.D., M.P.H.
    Description: This task order will develop a database, 
create analytic files, and provide programming and analytic 
support for studies on beneficiaries with diabetes from the 
Medicare Current Beneficiary Survey (MCBS). These studies will 
focus on gender and racial/ethnic differences for respondents 
in the MCBS who reported having had a diagnosis of diabetes. 
Chronic diseases contribute significantly to the morbidity and 
mortality of older Americans. Diabetes is the seventh leading 
cause of death in this country. However, the true burden of 
diabetes is actually not known, because diabetes frequently 
goes undiagnosed. The Centers for Disease Control and 
Prevention (CDC) estimate that the number of persons with 
undiagnosed diabetes to be over 5 million. At the present time, 
it has been estimated that 10.3 million people have been 
diagnosed with diabetes in the United States. HCFA's Women's 
Health Workgroup developed an initiative on diabetes in 
response to the Department's interest in proposals for the 
Women's Living Long, Living Well and the Prevention 
Initiatives. Diabetes was identified as a disease that affected 
our beneficiaries across the life span and scope of all HCFA's 
programs (Medicare, Medicaid, and the State Children's Health 
Insurance Program). This project is designed to provide a 
mechanism for on-going analyses from the Medicare Current 
Beneficiary Survey (MCBS) and the Medicare administrative files 
that are linked for these survey participants. Through creating 
a database and analytic files, studies on Medicare 
beneficiaries with diabetes can be conducted using several 
years of data from the MCBS. Important issues related to 
health, health status, co-morbid conditions, functional status, 
disability, quality of life as well as costs and utilization of 
health care services can be examined. We plan to study at a 
minimum:
          Demographic characteristics of beneficiaries who 
        report a diagnosis of diabetes (age; gender; race/
        ethnicity; income; education; marital status; etc.)
          Health and functional status (activities of daily 
        living; instrumental activities of daily living)
          Health care services variables (usual source of care; 
        doctor and emergency room visits)
          Co-morbid health conditions ( heart disease; stroke; 
        blindness; amputations; etc.)
          Utilization of services from the link to the Medicare 
        administrative files for outpatient services; inpatient 
        hospitalizations; etc.
          Use of preventive services appropriate for diabetics 
        (immunizations; eye exams; foot care; etc.)
          Costs associated with preventive care and treatment 
        of Medicare beneficiaries with diabetes.
          Changes in coverage policies for diabetic treatment 
        and care.
    Status: In developmental phase.
    Improving Quality in Long-term Care
    Prj #:HCFA-99-0100
    Start Date: 04/01/1999
    End Date: 03/31/2001
    Funding: $50,000
    Vehicle: Purchase Order
    PI: Janet Corrigan, Ph.D.
    Awardee: National Academy of Sciences, Institute of 
Medicine, Board on Health Care Services
    PO: Sydney P. Galloway
    Description: HCFA provided funds to support a portion of an 
ongoing project in the National Academy of Sciences/Institute 
of Medicine (IOM). Our funding would sponsor an additional 
meeting of the project committee to further explore and 
deliberate on its findings and recommendations related to the 
definition and enforcement of regulatory standards, work-force 
problems, organizational capacity for quality improvement, and 
quality measurement/information strategies in long-term care 
situations.
    In 1986, IOM issued the report, Improving the Quality of 
Care in Nursing Homes, which was to serve as a foundation for 
the Nursing Home Reform Act of 1987. Since then, much has 
changed including attitudes about those using long-term care, 
ways of providing care, and strategies for assessing and 
improving the quality of care. In 1997, with primary funding 
from the Robert Wood Johnson Foundation, the IOM appointed an 
expert committee to examine a broader range of long-term care 
services, recipients, and quality improvement strategies than 
those considered in the 1986 report. Questions being 
investigated include:
          What are the demographic, health, and other 
        characteristics of individuals requiring long-term care 
        and how are they changing?
          What are the roles of the various long-term care 
        settings, and how do they relate to other components of 
        community care systems?
          What are the strengths and limitations of existing 
        methods and tools to measure, oversee, and improve 
        quality of care and the outcomes of long-term care?
          How can these methods and tools be improved?
          What is known about the current quality of long-term 
        care in different settings and the extent to which care 
        has improved or deteriorated in the last 10-15 years?
          What is known about the impact of long-term care 
        regulation, especially the Nursing Home Reform Act of 
        1987?
    After working for over a year, the IOM committee concluded 
that an additional meeting was needed given the complexity of 
the topics being considered and a number of recent developments 
in long-term care, including various initiatives by the 
Department of Health and Human Services. In particular, the 
committee directed that additional report text be drafted 
related to payment issues and research directions. This HCFA 
project provides the support to make this last portion of the 
work possible.
    Status: The final report is completed.
    Direct and Indirect Effects of the Changes in Home Health 
Policy and an Analysis of the Skill Mix of Medicare Home Health 
Services Before and After the Balanced Budget Act of 1997
    Prj #:HCFA-00-0108
    Start Date: 03/16/2000
    End Date: 03/23/2001
    Funding: $24,298
    Vehicle: Simplified Procurement
    PI: Nelda McCall
    Awardee: Laguna Research Associates
    PO: Sydney P. Galloway
    Description: This project provides partial support for a 
project primarily funded by the Robert Wood Johnson Foundation 
(RWJ). As part of this larger project, HCFA supplies needed 
data and receives the results of a special study. The major 
(RWJ) project examines three areas where impacts of the 
Balanced Budget Act (BBA) might fall B the Medicare 
beneficiary, home health care agencies, and the overall medical 
and long-term care system. Analysis based on the data HCFA 
supplies under this award, taken together, will help understand 
the overall pattern of impacts and be useful in formation of 
future reimbursement policy. The special study for HCFA looks 
at beneficiary access. This will analyze pattern of Medicare 
home health use before and after the implementation of the BBA. 
There is a focus on assessing whether changes occurred in the 
skill mix of types of visits received by home health users. It 
will examine whether differential effects have occurred for 
different categories of home health users and in different 
geographic areas.
    Status: The data have been accessed and the analysis are 
being prepared.
    Assessing Readiness of Medicare Beneficiaries to 
Participate in Informed Health Care Choices
    Prj #:17-C-90950/1
    Start Date: 08/17/1998
    End Date: 06/16/2000
    Funding: $63,192
    Vehicle: Cooperative Agreement
    PI: James O. Prochaska, Ph.D.
    Awardee: Pro-Change Behavior Systems
    PO: Sherry A. Terrell, Ph.D.
    Description: This study will adapt the investigator's 
transtheoretical model of health behavior change using the 
Medicare Current Beneficiary Survey (MCBS) data to predict a 
Medicare beneficiary's readiness to make an informed decision 
about his/her Medicare health insurance plan choice. The model 
is a mathematical algorithm that assigns/classifies a case to a 
stage of readiness to make a decision.
    Status: The research team has received MCBS data for 1995-
1997 from HCFA and prepared related analytic files. Once 1998 
MCBS files are available, the transtheoretical model can be 
applied.
    Analysis of Medicare Beneficiary Baseline Knowledge Data 
Using MCBS
    Prj #:500-95-0061/04
    Start Date: 06/16/1999
    End Date: 06/15/2002
    Funding: $229,123
    Vehicle: Task Order
    PI: James M. Robinson, Ph.D.
    Awardee: University of Wisconsin--Madison/Research Triangle 
Institute
    PO: Sherry A. Terrell, Ph.D.
    Description:The purpose of this project is to analyze 
Medicare beneficiary baseline knowledge data which have been 
previously collected through the Medicare Current Beneficiary 
Survey (MCBS). The program objective is to evaluate National 
Medicare Education Program (NMEP) print material (Handbook: 
1999 and Bulletin) and selected information distribution 
channels (print, Internet, 1-800-MEDICARE). The policy 
objective is to support HCFA strategic plan initiatives, 
contribute to Government Performance and Results Act program 
performance reporting, and provide feedback for monitoring and 
continuous quality improvement of NMEP informational materials 
directed to the Medicare population over time.
    Status: The project is in the first of two phases. An 
analysis plan has been approved for Phase I, MCBS data user 
agreements executed, and MCBS Access to Care files for 1995-
1997 and associated supplemental files have been received. 
Phase I data analyses have begun and several working measures 
of knowledge constructed. A report entitled ``A Knowledge Index 
Technical Note'' using Phase I data has been received and is 
under review. Phase II will extend Phase I analyses using MCBS 
1998 Access to Care files including special supplements--Round-
23 (beneficiary knowledge) and Round-24 (beneficiary needs).
    Survey and Evaluation of New Medicare Members of 
Medicare+Choice Plans
    Prj #:500-95-0047/07
    Start Date: 09/08/1999
    End Date: 09/07/2001
    Funding: $657,583
    Vehicle: Task Order
    PI: Merrile Sing, Ph.D.
    Awardee: Mathematica Policy Research, Inc
    PO: Peri Iz, Ph.D.
    Description: The purpose of this project is to design a 
survey for and collect data from Medicare beneficiaries who are 
new members of Medicare+Choice (M+C) plans and to evaluate the 
effectiveness of the National Medicare Education Program (NMEP) 
for these beneficiaries. The objective is to understand the 
special information needs of new Medicare members, their 
sources of information (who/where), their preferred 
distribution channels (how), their understanding of the basic 
(standard) Medicare program, their understanding of their 
particular M+C plan, and the impact NMEP activities may have on 
new members' decision to choose an M+C plan or change their 
plan. This project does not include the disenrollee population. 
The project will support HCFA strategic plan initiatives, 
contribute to Government Performance and Results Act program 
performance reporting, and provide feedback for monitoring and 
quality improvement to NMEP informational materials directed to 
the M+C population over time.
    Status: This project is in the start-up phase.
    Evaluation of the Home & Community-based Services Waiver 
Program
    Prj #:500-96-0005/03
    Start Date: 09/30/1998
    End Date: 03/29/2002
    Funding: $2,308,371
    Vehicle: Task Order
    PI: Lisa Maria Alecxih
    Awardee: Lewin Group, The
    PO: Renee Mentnech
    Description: The Home and Community-Based Services (HCBS) 
Waiver Program has been operating since 1981 and has 
experienced tremendous growth in recent years. The percent of 
Medicaid long-term care spending devoted to HCBS has increased 
from 10 percent to 19 percent (between the financial and 
beneficiary-level impacts of the program) in over a decade. The 
aim of this task order is to gain a better understanding of the 
broader HCBS waiver program and determine what programmatic 
mechanisms have been successful.
    Status: The project is ongoing.
    Study of the Impact of Boren Amendment Repeal on Medicaid 
Skilled Nursing Facilities
    Prj #:Other/CF-1999-1
    Start Date: 01/01/1999
    End Date: 12/31/2000
    Funding: $280,000
    Vehicle: Grant
    PI: Christine Bishop, Ph.D.
    Awardee: Brandeis University, Heller Graduate School, 
Institute for Health Policy
    PO: Paul J. Boben, Ph.D.
    Description:This project examines the impact of the repeal 
of the Boren Amendment through a study of the relationship 
between States' Medicaid payments to nursing homes and quality 
and access to care for Medicaid recipients. The results of this 
research will assist HCFA in preparing a report to Congress on 
the effects of Boren Amendment repeal, as mandated by the 
Balanced Budget Act of 1997. HCFA's participation in this 
project is primarily to supply the needed data and to supervise 
its use.
    Status: The research team has just begun looking at data 
from the Online Survey Certification and Reporting system and 
Skilled Nursing Facility Cost Report data bases maintained by 
HCFA. A report examining the relationship between State 
Medicaid reimbursements for skilled nursing facilities and 
access and quality of care for Medicaid eligibles is expected 
soon.
    Study of the Impact of Boren Amendment Repeal on Nursing 
Facility Services for Medicaid Eligibles
    Prj #:500-95-0060/03
    Start Date: 09/29/2000
    End Date: 10/10/2001
    Funding: $268,875
    Vehicle: Task Order
    PI: Christine Bishop
    Awardee: Brandeis University
    PO: Paul J. Boben, Ph.D.
    Description: The purpose of this project is to study of the 
impact of repeal of the Boren Amendment on Medicaid eligibles= 
access to Nursing Facility (NF) services and the quality of 
care available to them in those facilities. The results of the 
study will enable HCFA to submit the required Report to 
Congress. The Balanced Budget Act of 1997 (BBA) effected the 
repeal of a provision of Medicaid commonly known as the ABoren 
Amendment. The Boren Amendment provided lower limits on the 
amounts states could pay three types of institutional 
providers: hospitals, nursing facilities and intermediate care 
facilities for the mentally retarded (ICF/MR). State payments 
had to be sufficient to cover the cost of Aefficiently and 
economically operated facilities. The BBA also required HCFA to 
study the effect of this repeal of the Boren Amendment on 
access to care and quality of care provided to Medicaid 
eligibles in these facility types. A Report to Congress must be 
submitted by August 7, 2001. To partially fulfill this 
statutory requirement, HCFA entered into a collaborative 
arrangement with The Commonwealth Fund and Brandeis University 
to study the relationship between state Medicaid reimbursement 
policy and access to care and quality of care for Medicaid 
eligibles in NFs. The Commonwealth Fund provided financial 
support through a grant to Brandeis. HCFA's contribution has 
been technical guidance and data, and in exchange was promised 
a report that would have provided the basis for the Report to 
Congress. The research plan of the Brandeis/Commonwealth 
project relies on a number of strategies. First, survey data 
collected under a HCFA contract by Wichita State University and 
the University of California, San Francisco are used to track 
changes in states NF reimbursement policies in the aftermath of 
Boren Amendment repeal. Data from other sources--HCFA's OSCAR 
and Medicare SNF cost reports databases--are used to construct 
other variables that measure the relevant policy outcomes: 
access to NF services and quality of care in those facilities. 
Statistical methods are then used to determine what 
relationships exist (if any) between the outcome variables and 
state Medicaid reimbursement policy variables. Finally, 
additional qualitative information on state responses to Boren 
Amendment repeal is drawn from parallel research conducted by 
an independent researcher also working under a Commonwealth 
Fund grant and the Urban Institute through their Assessing the 
New Federalism Project. Phase I of the project (November 1998 
to December 2000) consists of a cross-sectional study of the 
relationship between state payment policy and the relevant 
outcome variables using data from 1996 (prior to Boren 
Amendment repeal). Phase II (January through December 2001) 
will expand the analysis to include data from 1999, allowing a 
study of changes since the repeal of the Boren Amendment. In 
November 1998, The Commonwealth Fund approved grant funding for 
Phase I, and Brandeis University researchers began work shortly 
thereafter. In January 1999 a Memorandum of Understanding was 
signed formalizing the collaborative relationship between HCFA 
and Brandeis University. On June 12, 2000, however, The 
Commonwealth Fund informed HCFA that they would not provide 
financial support for Phase II of the research. In order for 
the Report to Congress can be submitted in a timely fashion 
HCFA must now bring the research to completion.
    Status: This project is underway.
    Mauli Ola (Spirit of Life) Project
    Prj #:18-C-91142/9
    Start Date: 09/28/2000
    End Date: 09/27/2005
    Funding: $704,055
    Vehicle: Cooperative Agreement
    PI: Charman Akina
    Awardee: Waimanalo Health Center
    PO: Stephanie Monroe
    Description: A significant number of Native Hawaiians do 
not access medical services on a timely basis, even when such 
services are made available and affordable. Of those who do, 
their continues to be a significant rate of continued medical 
non-compliance. This appears to be the case even where patients 
demonstrate a basic understanding of the medical basis and 
management strategy of their illness. Simple, straightforward 
medical information and instruction are not, it seems, 
sufficient as behavior motivators to effect long-standing 
behavioral change in the Native Hawaiian population. It is this 
underlying behavioral motivation that the Waimanalo Health 
Center proposes to address in an integrated and comprehensive 
outreach and preventive health demonstration project. The 
Center proposes to significantly increase the number and 
intensity of personal and culturally relevant motivators to 
effect positive lifestyle changes. The Center would provide 
culturally relevant and medically sound outreach, screening, 
educational, and preventive health services for its entire 
service area.
    Status: This project is underway.
    State of Minnesota ``Senior Health Options (MSHO) Project
    Prj #:11-W-00024/5
    Start Date: 04/01/1995
    End Date: 12/01/2000
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Pamela Parker
    Awardee: Minnesota, Department of Human Services
    PO: Linda Frisch
    Description: 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 targeted the elderly dually-entitled 
population that resides in the seven-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 are being 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 is being treated 
as a health plan that contracts with HCFA to provide services, 
and provides those services through subcontracts with various 
appropriate providers. The State is continuing 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 will continue to apply 
to the overall demonstration and managing entity, which will be 
the State.
    Status: The State implemented the project in March 1997. It 
is currently ongoing.
    Multi-state Evaluation of Dual Eligibles Demonstrations
    Prj #:500-96-0008/03
    Start Date: 09/30/1997
    End Date: 09/29/2002
    Funding: $2,155,854
    Vehicle: Task Order
    PI: Robert L. Kane, M.D.
    Awardee: University of Minnesota
    PO: Noemi V. Rudolph
    Description: This evaluation is designed to assess the 
impact of dual eligible demonstrations in the States of 
Minnesota, Colorado, Wisconsin and New York. Analyses will be 
conducted for each State and across States. The quasi-
experimental design will utilize surveys, case studies, and 
Medicare and Medicaid data for analysis. Major issues to be 
examined include the use of a capitated payment strategy to 
expand services while reducing/controlling costs, the use of 
case management techniques and utilization management to 
coordinate care and improve outcomes and the goal of responding 
to consumer preferences while encouraging the use of 
noninstitutional care. A universal theme to be developed is the 
difference between managing and integration.
    Status: Beneficiary surveys have been completed in the 
Minnesota demonstration. Beneficiary surveys for the Wisconsin 
demonstration are planned to be conducted in early 2000. Two 
case study reports and the First Annual Report have been 
submitted to HCFA. The New York demonstration received its 
waivers in September 1999 and increased evaluation activities 
will soon be underway.
    Wisconsin Partnership Program
    Prj #:11-W-00123/05
    Start Date: 10/16/1998
    End Date: 12/31/2004
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Steve Landkamer
    Awardee: Wisconsin Division of Health and Family Services, 
Department of Health and Family Services
    PO: James Hawthorne
    Description: The State submitted an application t in 
February 1996 for Medicare and Medicaid demonstration waivers 
to establish a ``Partnership'' model of care for dually-
entitled nursing home-certifiable beneficiaries who are either 
under age 65 with physical disabilities or frail elders. This 
project is utilizing Centers for Independent Living in Madison 
and Eau Claire. This is believed to be the first site in the 
nation offering fully capitated Medicare and Medicaid services 
for people with physical disabilities. Waivers were approved on 
October 16, 1998 and one site (Elder Care--Madison) became 
operational on January 1, 1999. Community Care for the 
Elderly--Milwaukee expected to become operational on March 1, 
1999. Community Living Alliance--Madison and Community Health 
Partnership--Eau Claire expected to become operational in the 
spring of 1999. The ``Partnership'' model is similar to the 
Program for All-inclusive Care for the Elderly (PACE) model in 
the use of multidisciplinary care teams, prepaid capitation, 
and sponsorship by community-based service providers. Rather 
than the physician being co-located with the multi-disciplinary 
team, the Partnership program will enable participants to use a 
physician of their choice in the community who agrees to 
participate as a contractor with the Partnership plan. This 
model utilizes nurse practitioners and other multidisciplinary 
team members to provide continuity and coordination with the 
physicians who elect to participate. The Partnership also will 
rely less on adult day care centers than do PACE sites as the 
organizing focus for the provision of care. The model is 
proposed as a fully voluntary enrollment model for 1,200 
beneficiaries. All Medicare and Medicaid covered benefits are 
offered under full capitation for eligible participants who 
elect to enroll. Partnership sites for the frail elderly are 
the existing PACE sites in Milwaukee and Madison. The 
Partnership model for people with disabilities will utilize 
Centers for Independent Living in Madison and Eau Claire. The 
model for people with disabilities is believed to be the first 
site in the nation for fully capitated Medicare and Medicaid 
services for people with physical disabilities. Partnership 
sites for the frail elderly are the existing PACE sites in 
Milwaukee and Madison.
    Status: The four sites became operational in early 1999 and 
by the end of the year had a combined enrollment of over 700. 
An evaluation of the Partnership, under separate contract, 
began in mid-1999.
    Continuing Care Network Demonstration, Technical Assistance 
and Third Party Assessments
    Prj #:18-C-91101/2
    Start Date: 09/30/1999
    End Date: 03/05/2005
    Funding: $437,994
    Vehicle: Cooperative Agreement
    PI: Helena Temkin-Greener, PhD
    Awardee: Community Coalition for Long Term Care
    PO: Noemi V. Rudolph
    Description: This initial award is part of a multi-year 
technical assistance and third party assessment for the 
Continuing Care Network (CCN) demonstration project in Monroe 
County. Specific objectives include: (1) to analyze and compare 
the proposed HCFA Medicare+Choice capitation methodology with 
the CCN demonstration risk-adjusted payment model, (2) to 
assure the collection of assessment data and administer a 
subcontract with the independent assessor, (3) to design and 
empirically test a Medicare and Medicaid risk/savings sharing 
model, and (4) to examine CCN strategies for outreach/
education, marketing, and enrollment especially as it pertains 
to the frail and dual eligibles. Data sources will include: the 
Monroe County Medicare and Medicaid Database and the CCN 
demonstration database, surveys, assessments conducted by the 
independent assessor and by care plan nurses, interviews, and 
focus groups.
    Status: In progress.
    Continuing Care Network Demonstration
    Prj #:11-W-00126/2
    Start Date: 09/30/1999
    End Date:
    Funding: $0
    Vehicle: Waiver-only Project
    PI: Linda Gowdy
    Awardee: New York State Department of Health, Bureau of 
Continuing Care Initiatives
    PO: Noemi V. Rudolph
    Description: Medicare waivers were approved for this 
demonstration on September 1999. The CCN project, a 5-year 
demonstration, is designed to test the efficiency and the 
effectiveness of financing and delivery systems that integrate 
primary, acute and long term care services under combined 
Medicare and Medicaid capitation payments based on functional 
status. The CCNs will enroll, over a five-year period, at least 
10,000 Medicare-only and dually eligible beneficiaries who are 
65 or older in Monroe County, New York. This population will 
include those residing in nursing facilities, the nursing home 
certifiable living in the community, and the unimpaired. This 
is a voluntary program for both Medicare and dually eligible 
beneficiaries. The approval is the first to combine the 
authority under Section 402 of the Social Security Amendments 
with the authority of Sections 1915(a) and 1915(c). The State 
will amend the (Medicaid) State Plan to include a new class of 
managed care organizations that will allow them to capitate 
Medicaid service costs with home and community-based services 
and to pay the CCNs one capitated payment for each Medicaid 
enrollee. The State will also apply a parallel 1915(c) waiver 
to support case management and invoke spousal impoverishment 
protection for nursing home certifiable enrollees living in the 
community. A limited chronic care benefit of up to $2,600 per 
year (and not to exceed a $6,000 lifetime maximum) will be 
available to all that join the CCN as community-based 
unimpaired participants on enrollment. The DMS-1 assessment 
instrument, which is normally employed to assess nursing home 
certifiability in New York State, will be used to place 
enrollees who are nursing home certifiable in the community 
into one of the three rate cells based on level of impairment. 
An independent third party assessor will conduct initial and 
subsequent DMS-1 assessments, since the result of this 
assessment will be used for both care planning and rate cell 
determination.
    Status: In progress.
    Demonstration Project for Institutionalized Dually Eligible 
Persons
    Prj #:99-C-90869/3
    Start Date: 04/30/1999
    End Date: 06/30/2000
    Funding: $59,538
    Vehicle: Cooperative Agreement
    PI: Martin Wasserman, MD
    Awardee: Maryland Department of Health and Mental Hygiene
    PO: James Hawthorne
    Description: This Cooperative Agreement provides the 
Maryland State Department of Health and Mental Hygiene (DHMH) 
with funds to purchase technical assistance and to support 
planning activities to develop two demonstration projects to 
assist persons with physical disabilities who are under age 65 
to move from nursing facilities to community-based settings. 
The demonstrations would provide care coordination on a 
capitated basis and would emphasize consumer choice and 
direction. The demonstrations would depend on existing Medicare 
Managed Care Organizations (MCOs) to enroll eligible 
beneficiaries and to provide their medical care. The MCO's 
would sub-contract with community based organizations, such as 
Centers for Independent Living, to assist participants in 
obtaining appropriate support services in the community and to 
facilitate coordination of these services and the beneficiaries 
medical care. DHMH has sub-contracted the developmental work 
for this demonstration to the Center for Health Plan 
Development and Management (CHPDM) at the University of 
Maryland in Baltimore County.
    Status: DHMH has subcontracted the developmental work for 
this demonstration to the Center for Health Plan Development 
and Management at the University of Maryland in Baltimore 
County. The project has hired staff to coordinate planning 
activities and has assembled a task force comprised of 
consumers, providers, and representatives from DHMH to guide 
the planning process. The project is on schedule for the 
projected completion date of June 30, 2000.
    Multi-state Dual Eligible Data Base and Analysis 
Development
    Prj #:500-95-0047/03
    Start Date: 09/30/1997
    End Date: 09/30/2001
    Funding: $2,135,418
    Vehicle: Task Order
    PI: Don Lara
    Awardee: Mathematica Policy Research, Inc.
    PO: William D. Clark
    Description: This project will use available Medicare/
Medicaid-linked statewide data in 10-12 States to develop a 
uniform database that can be used by States and the Federal 
Government to improve the efficiency and effectiveness of the 
acute- and long-term-care services to persons eligible for both 
Medicare and Medicaid (dual eligible). It will also conduct 
analyses derived from these data to strengthen the ability to 
develop risk-adjusted payment methods and deepen the 
understanding of Medicare-Medicaid program interactions as they 
relate to access, costs and quality of service. Finally, it 
will recommend longer-range options that will improve the 
usefulness of the database for operational and policy purposes.
    Status: The project is constructing a multistate dual 
eligible database and using these data for analyses.
    Case Studies of Managed Care Arrangements for Dual Eligible 
Beneficiaries
    Prj #:500-95-0048/08
    Start Date: 08/26/1999
    End Date: 02/25/2001
    Funding: $367,135
    Vehicle: Task Order
    PI: Edith Walsh
    Awardee: Health Economics Research, Inc.
    PO: William D. Clark
    Description: The purpose of this project is to obtain 
greater knowledge of the dynamics of Medicare and Medicaid 
coordination of eligibility, benefits, and services at the 
health plan level. It will provide preliminary identification 
of issues that the Health Care Financing Administration, 
States, health plan contractors and beneficiaries should 
prioritize and address. It will identify exemplary and routine 
approaches implemented by health plans for further 
consideration and potential adoption by others. This project 
examines health plans including their provider networks, care 
management activities and beneficiary experiences. It will 
identify exemplary and routine approaches implemented by health 
plans for further consideration and potential adoption by 
others. In 1997, an estimated 6.7 million Medicare 
beneficiaries received some level of additional benefits 
through Medicaid buy-in at some point during the year. These 
dual eligible beneficiaries are estimated to represent 17 
percent of all Medicare beneficiaries in 1997, and are 
estimated to account for at least 28 percent of total Medicare 
expenditures. For Medicaid, enrollment and expenditure 
experience is strikingly similar. Dual eligible beneficiaries 
are estimated to represent 19 percent of total enrollment and 
35 percent of Medicaid expenditures, of which 57 percent is 
Federal match to States. The growing importance of the dually 
eligible population is magnified by the fact that the 
population of Americans over 80+, those most likely to become 
dually eligible due to frailty and impairment, is expected to 
grow by 100 percent for men and 50 percent for women by the 
year 2025. Beneficiaries dually entitled for Medicare and 
Medicaid obtain health insurance coverage from these programs 
in many combinations. They may be entirely in traditional fee-
for-service, Medicare+Choice risk contract plans with Medicaid 
benefits in fee-for-service, Medicaid managed care arrangements 
of varying definitions with Medicare fee-for-service, or in 
combinations of Medicare and Medicaid contractual arrangements 
within the same health plan organization. Some Federal 
demonstration health plans more consciously attempt to 
integrate Medicare and Medicaid financing at the plan level. It 
is believed that, through improved contractual arrangements, 
additional efficiencies in the organization and delivery of 
services may lead to improved health plan performance. The 
combined financing is intended to facilitate the integration of 
medical care, hospitalization, and post-acute services with 
community and/or residential supportive services and other 
benefits, including prescription drugs. The availability of 
this array of options varies considerably in health plans 
across the United States. Even though total enrollment and 
costs for services used by dual eligible beneficiaries in 
Medicare and Medicaid represents a substantial figure, the 
bifurcation of responsibility for this population results in a 
consideration of dual eligibility as a subset of each program 
subject to the statutory requirements of each. Rarely has a 
lens been applied to program changes mandated in either program 
that considers the impact of changes in one program and 
resulting consequences on the other. The Balanced Budget Act 
changes in Medicare home health payment and consequences for 
State Medicaid illustrates this point. Similarly, research that 
illuminates dual eligible issues often is focused on either 
Medicare or Medicaid, but rarely both. There are many reasons 
for this including data incompatibility, source of funding, and 
primary purpose of the research. This task order is one of a 
number of efforts intended to apply a lens to dual eligible 
issues as the central point of focus. In this study the 
dynamics of Medicare and Medicaid interactions at the health 
plan level are to be investigated. Given the difficulty in 
seeking to change both Medicare and Medicaid programs by 
Statute or through demonstration and program waivers in order 
to improve service delivery systems for dual eligible 
beneficiaries, it is essential to develop a more complete 
understanding of the way these programs interact at the 
provider and beneficiary level. While it is important to 
determine exemplary solutions to common problems that may have 
potential for replication by others, it is equally important to 
obtain a realistic portrait of the abilities and limitations of 
health plans in working with the Medicare and Medicaid programs 
to accomplish the facilitation, coordination, and integration 
of health and supportive services for dual eligible 
beneficiaries.
    Status: The project is in the start-up phase.
    Factors Associated with Low Mammography Rates among Elderly 
Blacks
    Prj #:20-P-90895/4
    Start Date: 09/27/1998
    End Date: 09/26/2000
    Funding: $240,035
    Vehicle: Grant
    PI: Alma R. Jones
    Awardee: Morehouse School of Medicine
    PO: Richard Bragg
    Description: The overall objective for the research is to 
provide information that will ultimately lead to reductions in 
breast cancer mortality among African American Medicare 
beneficiaries, 65 years old and older in Fulton County and 
DeKalb County, Georgia, by increasing the percentage of this 
population that is screened for breast cancer annually. The 
project will address the low mammography screening rates for 
African American, nonhealth-maintenance-organization Medicare 
beneficiaries in Fulton and DeKalb counties. The study will 
develop, field test, evaluate, and disseminate a model for 
identifying barriers to test breast cancer screening among 
various populations. The proposed study will build upon 
research previously performed by the breastcancer prevention 
research group at Morehouse. In this instance, a trial to 
increase the rate at which inner-city African American women of 
various ages obtain breast and cervical cancer screening was 
designed. Hence, the Principal Investigator wants to: Increase 
the knowledge of breast cancer and improve the attitude toward 
breast cancer screening. Increase the rate at which annual 
screening mammograms are secured in the study population.
    Status: This project, which was awarded under HCFA's grant 
program for Historically Black Colleges and Universities, is in 
progress.
    Health Promotion in the African American Community: A 
Computer-Based Nutrition Program
    Prj #: 20-P-91120/6
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $120,754
    Vehicle: Grant
    PI: JoAnn Blake
    Awardee: Prairie View A&M University
    PO: Richard Bragg
    Description: The purpose of the study is to investigate the 
effectiveness of a computer-based nutrition education program 
on the use of health promotion behaviors by African American 
adults in community settings as compared to traditional methods 
of instruction. An interactive multimedia computer program will 
be used to teach nutrition to African American adults. A 
research team of faculty and nursing students will implement 
project activities. The investigators plan to validate the 
feasibility of computer based intervention strategies and 
materials that are designed to teach African American adults 
about nutrition in a community setting when compared to 
traditional methods of instruction. The project goals are: (1) 
to form collaborative partnerships within minority communities 
in need of health promotion focusing on nutrition, (2) to 
examine the difference in outcomes of health education using a 
computer based delivery method when compared to traditional 
methods, and (3) to determine the feasibility of using a 
computer-based education program to teach health promotion to 
African American adults in urban community settings. A study 
population of 200 individuals will be recruited from the 
community. A two group pretest (Nutrition Survey and Health 
Promotions Lifestyle Program (HPLP) behavior rating scale)--
posttest design will be used. The software program will present 
information in a cultural relevant way that may be 
individualized to the subject. A panel of experts will review 
the program.
    The experimental group will complete the pretest that 
consists of a questionnaire on nutrition and the Health 
Promotion Lifestyle Profile. The pretest instruments are 
designed to determine baseline knowledge and use of health 
promotion behaviors. After the baseline data is collected, the 
experimental group will complete a multimedia interactive 
computerized nutrition program developed by the investigators. 
Instruction on nutrition in the areas of need identified by the 
computer program will be provided. The control group will 
complete the baseline data collection process, receive printed 
information in the form of pamphlets and will be provided with 
group instruction on nutrition. The researchers will be 
available to assist with use of the computers and completion of 
the data collection instruments. A body mass index will be 
calculated for all participants and the posttest will be 
administered 3 months and 6 months after the start of the 
project. The applicant will develop and test the computer 
program before using it with the experimental group.
    Status: Study is in development phase.
    Increasing Breast Cancer Screening in African American 
Women: A Community Pilot Project
    Prj #: 20-P-91123/4
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,990
    Vehicle: Grant
    PI: Margaret Hargreaves
    Awardee: Meharry Medical College
    PO: Richard Bragg
    Description: The study seeks to determine the extent to 
which breast cancer screening can be increased among low income 
and elderly African-American women living in the Nashville area 
(more specifically, around the East Nashville Family Health 
Care Group Practice -ENC), using a combination of culturally 
appropriate strategic approaches that are implemented through a 
coordinated community effort. The main goal is to develop, 
implement, and evaluate a culturally-sensitive multi-faceted 
pilot program that seeks to improve breast cancer screening 
knowledge (K), attitudes (A), and practices (P) in a high risk 
population of poor and elderly African American women. The 
specific objectives are: (1) to increase breast cancer 
knowledge (K) in the targeted risk groups by 20 percent above 
baseline; (2) to improve attitudes toward cancer screening (A) 
by at least 1 standard deviation above baseline values; (3) to 
increase the number of mammograms completed (P) among the 
targets risk groups by 20 percent above baseline rates; and (4) 
to improve the rate of early detection in the targeted risk 
groups by 20 percent above baseline levels. This 2 year project 
will involve a collaborative venture between Meharry's Cancer 
Control Research Unit, the East Nashville Family Health Care 
Group, the Community Coalition for Minority Health, the Middle 
Tennessee Breast and Cervical Cancer Screening Coalition, and 
other selected organizations and individuals in the East 
Nashville Community who have an interest in breast cancer 
prevention and control. The study has three phases: Phase 1: 
Planning, 1-6 months; Phase 2: Implementation, 7-22 months; and 
Phase 3: Evaluation, 9-24 months. Under Phase I four main 
activities are proposed to be conducted: These activities are: 
(1) Working with community organizations (becoming 
knowledgeable with how the East Nashville community is 
organized). (2) The development of an intervention program: (a) 
cluster profiling methodology, (b) social marketing 
methodology, and (c) stages of change methodology. (3) Training 
health educators for the project. (4) Baseline data collection 
KAP and barriers questionnaires administered. Random sample of 
at least 100 women selected from cluster profiles around the 
target area. Questionnaires will be administered by telephone.
    Status: Project is underway.
    Efficacy of a Culturally Sensitive Health Promotion Program 
To Improve Exercise and Dietary Behaviors in African American 
Elders with Hypertension
    Prj #: 20-P-91130/7
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $98,838
    Vehicle: Grant
    PI: Lucille Davis
    Awardee: Southern University and A&M College, School of 
Nursing
    PO: Richard Bragg
    Description: The project is to test the efficacy of a 
culturally sensitive health promotion program that seeks to 
improve exercise and diet, two behaviors important in 
controlling hypertension in African American elders with 
hypertension. The project will compare the impact of outcomes 
of; (1) knowledge, (2) efficacy expectations and outcomes 
(beliefs about performing exercise and dietary behaviors), and 
(3) stages of change on exercise and dietary behaviors of 
elders who participate in one of two versions of a health 
promotion program. One version would use a culturally sensitive 
health promotion videotape (HPV) and the other, a culturally 
sensitive health promotion self-care manual (HPM). These tools 
have already been developed under a previously funded project. 
The project will have a quasi-experimental design to test the 
efficacy of using culturally sensitive videotapes and self care 
manuals as part of a health education program to improve 
hypertension knowledge, efficacy, stages of change, and 
exercise behaviors in African American elders with 
hypertension. The first year will be conducted in Baton Rouge, 
LA and the second year in Jackson, MS, under the coordination 
of the two participating universities. The intervention will be 
conducted at public housing complexes and involve resident 
coordinators who would serve as liaison between participants 
and researchers. In Louisiana, the study population will be 
drawn from 6 housing complexes involving approximately 700 
units with a large proportion of older African Americans. In 
Mississippi, 498 units including 152 units exclusively for the 
elderly, and 346 units for multi-generational families will 
comprise the target population. The sample size will consist of 
150 African Americans, 50 individuals in each of the 3 groups. 
Buildings will be randomized to one of the three groups. 
Recruitment will involve meeting with staff and residents in 
the designated buildings. Strategies to prevent attrition will 
include weekly classes. Group one will use the videotape as 
part of a lecture-discussion and skill building class. Elders 
will also be given a copy of the videotape and instructions on 
its use between classes. This group will be given a copy of the 
manual and instructed on its use between classes. The control 
group will not receive the intervention.
    Provisions and incentives are incorporated into the design 
to assure retention of subjects and to control for potential 
intervention variability across sites. For example, a small 
stipend will be paid for each interview. Inclusion criteria for 
participating in the study are explicit and appropriate to the 
goals and objectives of the study. Data will be collected at 
baseline and remeasured at 3 and 6 months on 9 variables.
    Status: Project is in development
    A Population-Based Case Control Study of Ethnic Differences 
in the Utilization of Elective Hip or Knee Replacement Surgery 
for Arthritis
    Prj #: 25-P-90948/6
    Start Date: 09/30/1998
    End Date: 09/29/2000
    Funding: $250,000
    Vehicle: Grant
    PI: Agustin Escalante
    Awardee: University of Texas Health Science Center at San 
Antonio
    PO: Richard Bragg
    Description: This project examines the utilization of 
elective hip or knee replacements for arthritis among Hispanics 
and non-Hispanics in Bexar County, Texas. It directly assesses 
persons hospitalized for these procedures between February 1999 
and January 2000. The objectives of the project are to: Compare 
ethnic background between persons hospitalized for elective 
arthritis-related hip/knee replacement surgery and persons 
hospitalized for other reasons. Examine the association between 
socioeconomic status and acculturation and the likelihood of 
recipients of hip/knee replacements being Hispanics compared to 
others. Measure age-adjusted rates of elective replacement 
surgery. Investigate to what extent Bexar County residents who 
are Medicare and Medicaid beneficiaries undergo these elective 
procedures outside the county. First, a case-control study will 
be conducted comparing the ethnic background of recipients of 
an elective arthritis-related hip or knee replacement surgery 
against the ethnic background of age- and gender-matched 
controls hospitalized for other reasons. Second, population-
based utilization rates will be developed for these elective 
procedures using census-derived demographic information as the 
denominator population. Finally, the completeness of these 
estimates will be assessed using Medicare and Medicaid claims 
data to measure the extent to which Bexar County residents 
selected these elective procedures in hospitals outside their 
county of residence.
    Status: This project, which was awarded under the Hispanic 
Health Services Research Grant Program, is in progress.
    Cervical and Breast Cancer Screening for Post-Reproductive 
Age Hispanic Women Residing Near the U.S.-Mexico Border
    Prj #: 25-P-91062/9
    Start Date: 09/20/1999
    End Date: 09/19/2001
    Funding: $263,281
    Vehicle: Grant
    PI: Francisco A.R. Garcia, MD, MPH
    Awardee: University of Arizona, Arizona Board of Regents
    PO: Richard Bragg
    Description: The U.S.-Mexico border area in general and the 
Arizona (U.S.)-Sonora (Mexico) border area in particular has 
had a history of economic ties and the sharing of physical, 
economic ties, cultural, and health characteristics. The 
proposed study, which focuses on the border community of 
Douglass/Sulphur Springs Valley in Arizona, highlights the 
immense and unique health problems that plague the U.S.-Mexico 
border region. Some of the main contributing factors associated 
with the myriad of health problems in the region include: 
poverty, unavailability, and accessibility of preventive health 
and treatment services. Because there is a sparsity of research 
in the area that addresses the health of the population, as 
well as the dynamics associated with the etiology of prevalent 
diseases, there may very well be an underestimation of the 
incidence and prevalence of various diseases that seemingly 
disproportionately afflict the population. Of particular 
interest to the researchers is the preventive value of 
screening for cervical and breast cancers associated with 
Hispanic women who live in a border community (Douglass) on the 
U.S.,-Mexico border. Reports suggest that breast and cervical 
cancers may be two to three times higher for Mexican Americans 
than for non-Hispanic whites.
    The study proposes to address these problems by providing 
information on : (1) the prevalence of breast and cervical 
cancers, (b) barriers that affect access to and utilization of 
health care, including screening services; and (c) successful 
intervention strategies (involving health workers or 
promotoras) that increase participation in and and sustained 
involvement with breast and cervical cancer screening services. 
To achieve this, the researchers propose to develop culturally 
competent health promotion activities that will: (a) increase 
rates of routines breast and cervical disease screening, (b) 
promote disease prevention strategies, and (c) address the 
significant cultural and structural barriers faced by these 
women. This study will allow the researcher to address these 
problems by using a 2-year community-based cohort intervention 
study. Using data collected from a population-based cross-
sectional survey involving 600 women who will be interviewed, 
the study seeks to gather information relating to utilization 
and barriers to utilization of breast and cervical cancer 
screening services. Following the completion of the interview, 
the interviewer will assist the participant in scheduling a 
clinic visit to have a variety of screening tests (e.g., pelvic 
examination, including a pap smear; telecolposcopy; sampling 
for HPV infection; and breast examination. Instruments or 
questionnaires to be used in the study will be built from 
previous or existing questionnaires associated with earlier and 
ongoing projects that the PI and his research team are 
associated with.
    Status: In progress.
    Understanding the Role of Culture in the Access and 
Utilization of Telemedicine Health Services Among Hispanic, 
Native Americans and White Non Hispanic Populations
    Prj #: 25-P-91143/9
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,594
    Vehicle: Grant
    PI: Ana Maria Lopez
    Awardee: University of Arizona Cancer Center
    PO: Richard Bragg
    Description: This project will provide a profile of 
telemedicine service utilization by Mexican American, Navajo 
and Non Hispanic white patients. The study focuses on the 
health needs of rural Arizona residents, including some who 
live near the U.S. border. These residents face geographic 
barriers (distance) and supply barriers (lack of specialty 
care) to access to care. These problems are compounded by 
environmental hazard along the U.S. border and the lack of 
economic opportunity in rural areas in Arizona. The applicant 
provided a clear and compelling
    Description: of these problems through the use of 
statistics and multiple academic citations on health care in 
Arizona. The objectives of the study are to: (1) identify if 
telemedicine increases or decreases the number of clinic 
encounters between patient and clinician at the same rate for 
Mexican American, Navajo, and non-Hispanic White populations, 
(2) examine if telemedicine alters the type or complexity of 
the clinical encounter at the same level for these populations, 
(3) assess if telemedicine affects the cost of providing 
clinical services for the management of chronic and/or 
rehabilitative conditions at the same amount for these 
populations, (4) examine if telemedicine affects patient 
compliance (e.g., taking medications as prescribed, doing 
exercise as instructed, etc) at the same level for these 
populations, (5) assess if minority patients perceive that 
cultural competency is an important factor in the delivery of 
telemedicine services such that it may impact utilization of 
these services, and (6) examine how telemedicine impacts the 
quality of life for these populations.
    There are two goals that are offered for this study: (1) To 
provide a profile of telemedicine service utilization, and (2) 
to deepen and broaden the understanding of the role of culture 
in access and utilization of telemedicine health services. 
These goals will be achieved via the development and 
implementation of a patient satisfaction survey, a provider 
survey, and chart review. The project has access to a cohort of 
200 patients stratified by location. This research is tracking 
individuals within an existing service project. The enrollment 
is constrained by the scope of current services. It is 
estimated that 50 participants will be studied at each of the 
four sites for a total of 200 individuals. The ethnic 
distributions are assumed to be as follows: the population of 
Springerville is 100 percent non Hispanic white, the populaton 
of Ganado is essentially 100 percent Navajo, and the 
populations of Douglass and Nogales are approximately 80 
percent Mexican-American and 20 percent non Hispanic white. 
These population distributions result in an expectation for 
enrollment Mexican-Americans, 70 non Hispanic whites, and 50 
Navajo. The first three objectives will be evaluated from 
direct patient chart review and assessment of the discharge and 
billing code data. The compliance objective will be assessed 
using a simple survey technique. The final two objectives will 
be assessed via patient surveys. These surveys are based on an 
existing self-administered questionnaire that serves to measure 
patient satisfaction with telemedicine services in terms of 
quality of care.
    Status: Project is in development phase.
    A Systematic Approach to Improving Pap Smear Screening 
Rates Among
    Prj #: 25-P-91150/9
    Start Date: 09/25/2000
    End Date: 09/24/2001
    Funding: $124,450
    Vehicle: Grant
    PI: Helda L. Pinzon-Perez/Vera Kennedy
    Awardee: California State University, Fresno Foundation, 
College of Health and Human Services, Grants and Research
    PO: Richard Bragg
    Description: This project will identify barriers to Pap 
smear screening facing Hispanic/Latino women within a Medicaid 
managed care system. The American Cancer Society (ACS) criteria 
for Pap smear screening will be used: testing with the onset of 
sexual activity and repeat pap smears every 1-3 years at the 
physician's discretion. Hispanic/Latina populations are the 
ethnic groups with the highest incidence of cervical cancer, 
and it is increasing. Cervical cancer rates in the San Joaquin 
Valley are 10.6 new cases and 3.3 deaths per 100,000 women, 
i.e., 10 percent and 50 percent higher, respectively, than the 
state as a whole. A major reason for these high rates is under-
utilization of Pap smear screening. The goals of this project 
are: to identify the alterable barriers to Pap smear screening 
facing Hispanic/Latino women within a Medicaid managed care 
system; to measure the proportion of Latina women within a 
Medicaid managed care system who are screened for cervical 
cancer; and to design a comprehensive community-based outreach 
and health education intervention strategy to improve the 
cervical cancer screening rates among the Hispanic/Latina 
population. The results from this study will be used in the 
training of medical residents at the University of California 
San Francisco in Fresno and it will be shared and disseminated 
to other health care providers, which will enhance the ability 
of service providers to provide culturally competent training 
and services as well. The study will focus on the major aspects 
of care affecting Pap smear screening. The participants will be 
recruited from 4 large community health centers (urban vs. 
rural) that serve predominately Hispanics in the Central Valley 
and the Blue Cross Managed MediCaid system. The study design 
involves structured interviews (covering the above aspects of 
care) with a random sample of 300 with 100 from each of three 
groups of women: (1) seen by a physician + Pap smear within 3 
years, (2) seen by a physician + No Pap smear within 3 years, 
and (3) Not seen by a physician + No Pap smear within 3 years. 
A pilot study will be done with 30 women. A comprehensive 
community-based outreach and health education intervention 
strategy and prevention program will be compared (involving 
strategies such as call and recall system with incentives, 
``Consejeras'' community health workers, mailed reminders, 
discussion groups in native language, use of female providers 
and interpreters, provision of transportation, etc.) to improve 
pap screening rates among the target group of Hispanic women.
    Status: Project is in develpment phase.
    MassHealth: Senior Care Options Medicare Enrollment Broker
    Prj #: 500-00-0038
    Start Date: 09/28/2000
    End Date: 09/28/2001
    Funding: $170,289
    Vehicle: Contract
    PI: Marion E. Reitz
    Awardee: Maximus, Inc.
    PO: William D. Clark
    Description: This project involves demonstration-specific 
design development in Phase I. If awarded Phase II, the project 
will provide operational support for features being implemented 
in the MassHealth: Senior Care Options research/demonstration 
initiative sponsored by the Health Care Financing 
Administration (HCFA) and the Massachusetts Division of Medical 
Assistance (DMA). The Phase I consists of a developmental 
design phase culminating in the preparation of an Enrollment 
Broker Operations Protocol and the performance of operational 
system pilot tests. Phase II will implement the operational 
support activities. A decision to award
    Phase II is to be based on the feasibility of the proposed 
enrollment broker operational activities as described in the 
Enrollment Broker Protocol and the readiness of the contractor 
to perform such activities. Award of
    Phase II also is to be determined by the separate approval 
by HCFA and DMA of MassHealth: Senior Care.
    Status: Project is in development phase.
    Readmission and Access
    Prj #: 30-P-91022/7
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,600
    Vehicle: Grant
    PI: Cindy Hornberger
    Awardee: University of Kansas Medical Center
    PO: Carl Hackerman
    Description: The primary aim of this study is to determine 
the relationship between access to health services and heart 
failure outcomes among Kansans aged 65 years and older who were 
discharged with DRG 127 during 1995. Heart failure is the only 
major cardiovascular disorder that is increasing in incidence 
and prevalence as the population ages. Heart failure is the 
most common diagnosis related grouping billed to Medicare. A 
significant portion of these costs are due to repeated 
readmissions. Readmission rates for heart failure within the 
first 14 days to 1-year range from 12.5 to 47.5 percent. 
Readmission frequency and mortality are related to access, 
which includes (a) availability of services, such as distance 
to health care services, (b) individual and community social 
determinants of well being, such as income and educational 
levels, and (c) actual utilization of health services. The 
project will use Individual-level and ecological-level analyses 
to examine the relationships between the dependent variables of 
readmission rate and mortality, and the independent access 
variables using merged data sets. The access variables will 
include the availability of emergency and/or community 
hospitals. emergency transportation, specialty and/or primary 
care providers; the number of home health care visits; and 
county-level social determinants. The Medicare data come from 
the Kansas and Missouri peer review organizations. Other data 
sources include the Area Resource File; Kansas Kids Coalition, 
Inc.; the Kansas Hospital Association; and the Kansas Health 
Institute. Validity concerns regarding readmission rates, as an 
unbiased indicator of disease severity will be addressed. 
Statistical methods will include descriptive statistics, 
correlational studies, analyses of variance, and linear 
regression techniques.
    Status: In progress.
    Home Care Services: The Effect of Unmet Need on Health Care 
Utilization
    Prj #: 30-P-91010/9
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,600
    Vehicle: Grant
    PI: Lisa G. Matras-Schmidt
    Awardee: University of California, Department of Health 
Services
    PO: Carl Hackerman
    Description: The main objective of this study is to examine 
how the need for home care services and the service delivery 
mechanism itself affect the use of health care services among a 
population of Medicare-eligible elderly and disabled persons 
receiving home care. Home care is one of the fastest growing 
components of personal health expenditures. However, among 
persons receiving home care, there is still a considerable 
amount of unmet need--either a lack of, or insufficient help 
with, activities of daily living and instrumental activities of 
daily living. Moreover, different models of service delivery 
have been developed to provide home care. Both of these 
factors, unmet need and service delivery mechanism, can have 
significant impacts on costs of home care, as well as quality 
of life for home care recipients. However, the effect of these 
factors on the utilization of health services has not been 
included in past studies of home care programs. This research 
addresses the following: (1) Do persons with more unmet home 
care personal assistance needs utilize more health services 
than those with fewer unmet personal assistance needs and (2) 
Does the service delivery method of home care (client self-
directed versus home care agency model) affect health care 
utilization? Data come from two sources which will be linked 
together, (1) a survey of individuals receiving home care 
services through the California In-Home Supportive Services 
program and (2) Medicare claims data. Multiple regression 
analysis will be utilized to examine the effects of service 
delivery mechanism and unmet personal assistance needs on use 
of health services. In addition, a stratified analysis based on 
level of disability will be done in order to determine if the 
effects vary by degree of disability.
    Status: In progress.
    Customer Utilization of Prescription Drugs
    Prj #: 30-P-91007/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $19,171
    Vehicle: Grant
    PI: Julie M. Ganther
    Awardee: University of Wisconsin--Madison, School of 
Pharmacy
    PO: Carl Hackerman
    Description: The main objectives oft this study are to: (1) 
examine the effect of insurance on prescription drug 
utilization, (2) examine the effect of medical care preferences 
on prescription drug utilization, and (3) explore the 
interaction between medical care preferences and insurance 
coverage. The expansion of insurance coverage for prescription 
drugs may be one factor in the large growth in prescription 
drug expenditures over the past two decades. However, consumer 
preferences for treating health problems also may effect 
prescription drug utilization. Some consumers prefer to see a 
doctor and/or take a prescription drug almost any time they 
have a health problem while other consumers prefer to self-
treat most health problems. In addition to directly affecting 
prescription drug utilization, these preferences may influence 
the effect of insurance coverage on prescription drug 
utilization. For example, it is unlikely that consumers who 
prefer to avoid using prescription drugs would increase their 
utilization dramatically just because they had insurance 
coverage. Data will be collected via mail survey from a random 
sample of Wisconsin consumers age 50 and over. A two-part 
econometric model will be used to examine whether health 
insurance coverage and medical care preferences effect the 
number of prescriptions and the cost of prescriptions used in a 
30 day reference period. Medical care preferences will be 
measured using a 10--item scale. In order to account for 
possible selection bias in insurance choice, consumers will be 
asked to report the source of their prescription drug 
insurance. The analysis will be done separately for the 
respondents who received their insurance from a large employer. 
These insurance coefficients will be compared to the insurance 
coefficients for the entire sample to determine the magnitude 
of the selection bias.
    Status: In progress.
    Factors of and Variations in Hospitalization Rates among 
Elderly Nursing Home Residents: Searching for Indicators of 
Appropriate Levels of Acute Care
    Prj #: 30-P-91009/1
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,561
    Vehicle: Grant
    PI: Mary Ellen Whelan
    Awardee: University of Massachusetts-Boston
    PO: Carl Hackerman
    Description: This project aims to further the understanding 
of the interface between nursing homes and hospitals. It will 
closely examine one aspect of this care continuum, 
hospitalization among nursing home residents. The project 
involves an empirical investigation of the relative explanatory 
contribution of individual patient risk factors, facility-level 
structural factors and area market health delivery factors in 
explaining variations in hospital utilization rates among 
dually-eligible, nursing home residents in the state of 
Massachusetts. Using longitudinal data, all hospitalizations 
will be analyzed via multivariate regression techniques to help 
disentangle the influence of practice style differences from 
medical needs among nursing homes and to determine whether 
variations in transfer rates are associated with high (low) 
discretionary and/or certain ambulatory care sensitive 
conditions. In an attempt to curb burgeoning Medicaid 
expenditures associated with nursing home care, various state 
Medicaid cost containment strategies for nursing homes have 
been implemented. By and large, the payment policies enacted 
reflect prospective rate setting methodologies, meaning that 
Medicaid reimbursement to nursing homes is based on a capitated 
system, often with case-mix adjustment allowances, rather than 
an individual based or flat-rate cost strategy. Although 
research suggests that these changes in Medicaid reimbursement 
polices succeeded in improving access to nursing homes for 
certain heavy-care residents, policy concerns remain regarding 
the overall effects of these payment systems on health care 
accessibility.
    Status: In progress.
    Effect of Competition on Quality of Medicare
    Prj #: 30-P-91016/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,596
    Vehicle: Grant
    PI: Tiffany Radcliff
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: This research examines the relationship 
between market structure and quality of care using data that 
defines quality with conformity to accepted clinical practice 
guidelines. This project explores the role of competition in 
the provision of appropriate care once patients are admitted to 
hospitals with acute myocardial infarction.
    Price regulation within the U.S. health system is 
increasing. For example, during the 1980s the Health Care 
Financing Administration implemented the Prospective Payment 
System with predetermined and fixed hospital payment rates 
based on diagnosis codes. Movement from cost-based payment to 
external price regulation for health services has consequences. 
What happens to quality of care across different types of 
competitive environments when the price of health services is 
fixed by external regulation? Descriptive statistics and 
multivariate regression are used to test the following research 
hypotheses: 1. Under price regulation, quality of care will 
increase with the level of market competition. 2. Other 
factors, including whether the market is rural, will affect 
quality of care. Quality of care for urban residents will be 
higher than for rural residents. In this work the sample 
includes the majority of Medicare patients hospitalized with 
acute myocardial infarction during 1994-95. The quality 
indicators were abstracted from inpatient medical charts by 
Peer Review Organizations as part of the Health Care Financing 
Administration's Cooperative Cardiovascular Project. 
Competition will be measured using various definitions of 
market areas and measures of market competition.
    Status: In progress.
    Post Acute Care Use and Early Hospital Readmission of 
Hospitalized Elderly Medicare Patients
    Prj #: 30-P-91018/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,596
    Vehicle: Grant
    PI: Wen-Chieh Lin
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: The objective of this project is to 
investigate the variation in hospital discharge location and 
subsequent early hospital readmission attributable to patient, 
hospital, and market area characteristics for elderly Medicare 
patients. The Balanced Budget Act of 1997 (BBA) expanded the 
prospective payment system to post-acute care. The BBA also 
expanded the definition of transfer cases by treating discharge 
to post-acute care as hospital transfers (for selected 
Diagnostic Reimbursement Groups.) These expansions are likely 
to result in new patterns of post-acute care choice and 
utilization. Understanding the attributable variations of will 
provide information for reforming post-acute care services and 
policy options for bundling post-acute care payments in the 
future. The specific aims for this study are: (1) investigate 
patient, hospital, and market factors affecting hospital 
discharge location (a two-level (patient and hospital) 
hierarchical model will be established to investigate the 
variation in the probability of receiving a specific type of 
post-acute care for patients (a) within hospital-market and 
then (b) across hospital-market. The hospital and market area 
(county) characteristics are attached to the hospital.) (2) To 
investigate quality of care using early hospital readmission as 
the indicator (the similar structure of the two-level 
hierarchical model will be used to investigate this issue by 
including the post-acute care choice in the model.)
    Status: In progress.
    Improving Health Outcomes Using New Psychosocial Screens
    Prj #: 30-P-91025/2
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,595
    Vehicle: Grant
    PI: Deborah N. Peikes
    Awardee: Princeton University
    PO: Carl Hackerman
    Description: This study addresses a central challenge faced 
by the Medicare program, to control costs by reducing the 
demand for health services. This study characterizes critical 
sociodemographic, psychological, and social factors, which 
place people at risk for later illness so that appropriate 
interventions can be made to reduce those risks. It will 
identify key protective factors that contribute to the 
maintenance of long term health -information critical to 
increasing the number of disability-free years enjoyed by the 
population. The project uses the Wisconsin Longitudinal Survey 
(WLS), an extensive set of longitudinal data collected on 
roughly 10,000 Wisconsin high school graduates born in 1939. 
This cohort precedes the bulk of the baby boom generation by 
about a decade. The ``boomers'' are expected to tax the 
Medicare system in the coming years.
    Hence lessons gained from this sample can be used to target 
preventive efforts to reduce the amount of ill health faced by 
the younger baby boomers, and, in the process. lower Medicare 
expenditures. The project will isolate constellations of 
factors in the Wisconsin respondents' life histories, which 
predict health outcomes in later life. To do so, it will 
construct life histories which incorporate extensive survey 
information about adversity and advantage across multiple 
domains, occurring throughout life (e.g., early background and 
starting resources, educational and occupational attainment, 
job conditions, marriage and parenting, social support and 
participation in voluntary organizations). The integration of 
these multiple domains, organized around the person as the unit 
of analysis, constitutes a novel approach to explicating later 
life health status. It will then apply Boolean-logic analytic 
methodology to isolate key factors affecting health outcomes 
and utilization patterns.
    Status: In progress.
    Economic Impact of Outpatient Prescription Drug coverage on 
Total and Specific Health Expenditures and Service Use of 
Medicare Beneficiaries
    Prj #: 30-P-91017/5
    Start Date: 01/10/1999
    End Date: 01/09/2000
    Funding: $21,579
    Vehicle: Grant
    PI: Margaret Artz
    Awardee: University of Minnesota
    PO: Carl Hackerman
    Description: This research investigates the economic impact 
of outpatient prescription drug coverage for Medicare 
beneficiaries in terms of health care expenditure and service 
use. Prescription medications play a significant role in the 
health care regimens of the elderly and represent a significant 
portion of their out-of-pocket health care expenses. Medicare 
does not cover outpatient prescription drugs, yet little more 
than half of Medicare beneficiaries who purchase a supplemental 
insurance policy choose one with a prescription drug benefit. 
Specifically, this research will determine if those elderly 
possessing Medicare supplemental insurance with prescription 
coverage have lower total and specific health care expenditures 
 and/or  specific  health  care  use  compared  to elderly  
possessing either Medicare supplemental insurance without 
preseciption coverage or Medicare alone. Estimation of per 
capita differences in annual expenditures and service use will 
also be calculated. Generosity of the outpatient prescription 
drug coverage in terms of cost sharing is figured to play an 
important role in the expenditures spent and/or service used by 
the elderly.
    Status: In progress.
    Nursing Home Quality of Care: Time, Competition and Demand
    Prj #: 30-P-30238/4
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $30,669
    Vehicle: Grant
    PI: Virender Kumar
    Awardee: University of North Carolina at Chapel Hill, 
Office of Research Services, for Department of Health Policy 
and Administration
    PO: Carl Hackerman
    Description: The project assesses how competition and its 
influence on the chronic health care market, and the OBRA 87 
regulations affect the quality of nursing home care. Variation 
in competition over a twelve year time period and variation 
across the country will be used to identify how competition 
affects quality. Measures of quality will be health outcomes of 
individuals assessed through claims data. Three waves of the 
National Long-Term Care Survey will be used as a basis to 
identify individuals admitted to a nursing home for the study 
sample. The analysis will use simultaneous equation methods to 
derive consistent estimates of the Medicaid reimbursement rate, 
competition, and OBRA 87 effects on quality and accessibility 
of nursing home care. In this time of concerns about limited 
funds and the quality of nursing home care and accessibility to 
care for Medicaid beneficiaries, the topic is of great 
interest.
    Status: In progress.
    Access to Medicare Home Health Care in the Wake of the 
Balanced Budget Act
    Prj #: 30-P-30245/3
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $32,390
    Vehicle: Grant
    PI: Joan F Davitt
    Awardee: Bryn Mawr College, Graduate School of Social Work 
and Social Research
    PO: Carl Hackerman
    Description: Recent changes to the Medicare home health 
benefit have altered the way that home health care agencies 
will be reimbursed. It has been estimated that the new 
reimbursement system, referred to as the Interim Payment 
System, will reduce agency revenues by 15-22 percent. Such 
reductions may encourage agencies to alter the amount, duration 
or type of benefits provided to certain types of home health 
care patients. This study will investigate whether certain 
types of patients are experiencing reductions in access to care 
or in service receipt including: (1) not being admitted to home 
health services; (2) being discharged early; (3) receiving less 
services; or (4) receiving less expensive services. This study 
consists of a secondary analysis of data from the Medicare 
Current Beneficiary Survey (MCBS) Access to Care, Public Use 
File and HCFA claims files for the years 1996 and 1998. These 
will comprise the primary data sources for this study. The 
researcher will also obtain the Provider of Services Extract 
File from the OSCAR data base. The researcher will also conduct 
qualitative interviews with home health agency staff in an 
attempt to enhance the depth of understanding of these issues.
    Statistical analyses will allow the researcher to: 
determine whether this particular policy change is affecting 
access to care; to test hypotheses regarding utilization 
patterns; to understand which factors (such as patient 
characteristics, agency characteristics, and supply-side 
factors) are more predictive of specific utilization patterns; 
and to understand the explanatory power of sets of independent 
variables. Qualitative interview data will allow the researcher 
to understand agency practices post-IPS, providing greater 
sensitivity to contextual elements and provider perspectives. 
These interviews will also be used to check for validity in the 
interpretation of quantitative data and to identify provider 
practices that may not be reflected in the claims files. 
Information from this study will be shared with policy makers 
and home health agency providers and may be utilized to improve 
the design of the prospective payment system or to design 
necessary clinical criteria for reimbursement limit exemptions 
in home health care.
    Status: In progress.
    Outcomes and Reimbursement of Stroke and Hip Fracture 
Rehabilitation
    Prj #: 30-P-30247/2
    Start Date: 01/03/2000
    End Date: 01/02/2001
    Funding: $32,400
    Vehicle: Grant
    PI: Anne Deutsch
    Awardee: State University of New York at Buffalo, Sponsored 
Programs Administration, for School of Nursing
    PO: Carl Hackerman
    Description: Inpatient rehabilitation services for Medicare 
beneficiaries may be delivered in either rehabilitation 
hospitals/units or in skilled nursing facilities (SNF) and the 
distinctions between services provided in these 2 settings has 
narrowed in recent years. Given the differences in costs, it is 
of interest to compare functional outcomes of beneficiaries who 
have received rehabilitation services in comprehensive versus 
SNF-based settings after experiencing a hip fracture or stroke. 
The study sample will include Medicare beneficiaries who 
recently experienced a hip fracture or a stroke and were 
discharged from either a rehabilitation hospital/unit or a SNF 
that subscribed to the Uniform Data System for Medical 
Rehabilitation. This data system includes both admission and 
discharge measurements of functional status. The study will 
compare ability to perform motor functions, Medicare 
reimbursement data, rehabilitation length of stay; and total 
length of stay between beneficiaries in the 2 settings while 
adjusting for admission functional ability, age, co-morbid 
conditions, and a number of other demographic, diagnosis-
related, and health system related variables.
    Status: In progress.
    Healthy Aging Project
    Prj #: 500-98-0281
    Period: 10/30/1998-9/29/03
    Funding: $3.7 million
    Award: Cost reimbursement contract
    PI: Larry Rubenstein, M.D.
    Awardee: RAND, 1700 Main Street, Santa Monica, CA 90401
    PO: Pauline Lapin, Office of Clinical Standards and Quality
    Description: A key challenge to the health care system will 
be to determine how to prevent or slow the progression of 
disability in the senior population. There will be a total of 
76 million seniors living in the United States in 2030--a 
dramatic increase from the 35 million today. This population 
surge will substantially increase the demand for health care by 
older people, who experience much higher rates of morbidity and 
mortality than younger people. The Health Care Financing 
Administration (HCFA) developed the Healthy Aging Project to 
identify, test and disseminate evidence-based approaches to 
promote health and prevent functional decline in older adults. 
HCFA awarded RAND a five-year contract to produce reports 
synthesizing the evidence on how to improve the delivery of 
Medicare clinical preventive and screening benefits. RAND is 
also exploring how behavioral risk factor reduction 
interventions, such as smoking cessation, might be incorporated 
into Medicare.
    The first evidence report, Interventions that Increase the 
Utilization of Medicare-funded Preventive Services for Persons 
Aged 65 and Older, is an important guide for providers and 
health care systems seeking to improve the use of influenza 
immunizations, pneumococcal vaccinations, mammography, Pap 
tests and colon cancer screening. A key finding from this 
report is that organizational changes are effective in 
improving the delivery of preventive services. Standing orders 
are a type of organizational change that allow appropriate non-
physician staff to offer services, usually vaccinations, 
without an individual physician prescription. HCFA and the 
Centers for Disease Control and Prevention (CDC) are 
collaborating on a demonstration project to implement standing 
orders to increase influenza immunization rates in all of the 
nursing homes located in nine states. Medicare's quality 
improvement contractors, the peer review organizations or PROs, 
are working on this initiative.
    Another demonstration being conducted under the Healthy 
Aging Project tests the feasibility of implementing a smoking 
cessation benefit in Medicare. Three benefit options, including 
telephone counseling, are being compared to assess their 
effectiveness in promoting smoking cessation. HCFA commissioned 
an evidence report on smoking cessation, and this demonstration 
is based on that report and the U.S. Public Health Service 
clinical practice guideline on smoking cessation.
    HCFA is interested in comprehensive and systematic 
approaches to health promotion, which address both clinical 
prevention and behavioral risk factor reduction. Health risk 
appraisals with tailored feedback and follow-up are a promising 
tool for doing just that. HCFA has commissioned an evidence 
report on health risk appraisals, as well as chronic disease 
self-management, physical activity and falls prevention. RAND 
is synthesizing the evidence on these strategies and addressing 
the Medicare program and policy implications involved in 
testing them in Medicare demonstrations in its reports.
    HCFA coordinated the development of the Healthy Aging 
Project with the Agency for Healthcare Research and Quality 
(AHRQ). This project was designed to complement other 
Departmental initiatives, such as Healthy People 2010, and the 
U.S. Preventive Services Task Force. HCFA is conducting the 
Healthy Aging Project in collaboration with the AHRQ, the CDC, 
the Administration on Aging, and the National Institutes of 
Health.
    Status: Two evidence reports are currently available--
Interventions that Increase the Utilization of Medicare-funded 
Preventive Services for Persons Aged 65 and Older and 
Interventions to Promote Smoking Cessation in the Medicare 
Population. A pilot project testing the implementation of 
standing order interventions in nursing homes is being 
conducted in nine states. A demonstration to test the 
feasibility of implementing a Medicare benefit for smoking 
cessation will be conducted in seven states. Final revisions 
are being made to the evidence report on health risk appraisals 
and targeted interventions; this report should be available in 
the next few months. Reports on chronic disease self-
management, physical activity and falls prevention are 
currently in various stages of the evidence review process.

                     NATIONAL INSTITUTES OF HEALTH

    Older Americans are generally better off healthier and 
wealthier than ever before.\1\ A combination of factors, 
including the translation of critical research advances into 
prevention and treatment strategies and the advent of health 
and social welfare programs, have dramatically improved the 
quality of life for older people. Average life expectancy in 
the United States has at least doubled over the past century, 
from an average of 49 years in 1900 to age 76 at the turn of 
the century. The rate of disability among people age 85 and 
older substantially declined from the 1980s through the mid-
1990s, and currently a majority of people age 65 and older rate 
their health as good or excellent. Programs such as Social 
Security and Medicare have improved the fiscal well-being of 
older people in the United States, enabling many individuals to 
enjoy a healthy and active retirement.
---------------------------------------------------------------------------
    \1\ Federal Interagency Forum on Aging Related Statistics. Older 
Americans 2000: Key Indicators of Well Being 2000.
---------------------------------------------------------------------------
    Although the news is promising, good health is far from a 
universal reality for older Americans. The latest national 
surveys indicate that about one-fifth of people age 65 and 
older, more than 7 million people, report some disability. 
Chronic disease, memory impairment, and depressive symptoms 
affect large numbers of older people and the risk of such 
problems significantly rises with age. Nearly half of those age 
85 and older suffer from Alzheimer's disease.\2\ These millions 
of less fortunate older people struggle with daily activities 
as simple as bathing and dressing, with families and friends 
taking on the difficult and often costly role of caregiver. The 
outlook for aging minority groups is particularly troublesome 
given the obvious health disparities that research has shown 
exists between older white Americans and their minority 
counterparts.
---------------------------------------------------------------------------
    \2\ Evans, DA, Funkenstein HH, Albert MS, et al. Prevalence of 
Alzheimer's disease in a community population of older persons; higher 
than previously reported. JAMA 262: 2551-2556, 1989.
---------------------------------------------------------------------------
    An increasing interest in aging research is driven in part 
by a projected dramatic increase in the older population. 
According to the United States Census Bureau, by 2030 the 
population of people 65 years and older will double. The over-
85 group, often referred to as the ``oldest old,'' is the 
fastest growing segment of the older population and is 
projected to comprise 20 million people by the middle of this 
century. The implications of this dramatic increase in the 
aging population are numerous and research has an important 
role to play in providing solutions to the challenging issues 
posed by an aging society.
    Understanding the difference between advanced years that 
are active and independent and those that are characterized by 
frailty and dependence is at the heart of research supported by 
the National Institute on Aging (NIA), a component of the 
National Institutes of Health (NIH). The NIH is the principal 
biomedical research arm of the Federal government. The NIA, 
which was established by Congress in 1974, sponsors biomedical 
and behavioral research on the aging process and diseases and 
conditions affecting the elderly. NIA also leads the Federal 
research effort on Alzheimer's disease. Through independent, as 
well as collaborative, research efforts, the NIA and the other 
Institutes and Centers that comprise the NIH are working to 
reduce disability and disease and promote healthy lifestyles 
for older people.
    This report highlights a number of significant aging-
related research advances and activities supported or conducted 
by the NIH in 1999 and 2000. Section I of this report outlines 
key advances reported by the NIA for 1999 and 2000 in four 
major areas of research. Section II provides selected findings 
from some of the other NIH institutes involved in aging 
research. They are: National Institute on Mental Health (NIMH); 
National Eye Institute (NEI); Office of Research on Women's 
Health (ORWH); National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK); National Institute of Arthritis and 
Musculoskeletal and Skin Diseases (NIAMS); National Center for 
Complementary and Alternative Medicine (NCCAM); National 
Institute on Deafness and Other Communication Disorders 
(NIDCD); National Heart, Lung and Blood Institute (NHLBI); 
National Institute of Nursing Research (NINR); National Center 
for Research Resources (NCRR); National Institute of Child 
Health and Human Development (NICHD); National Library of 
Medicine (NLM); National Institute of Allergy and Infectious 
Diseases (NIAID); and National Institute of Neurological 
Disorders and Storke (NINDS).

            Section I--National Institute on Aging 1999-2000

    For 25 years, the NIA has led a national scientific effort 
to understand the mechanisms of aging and to extend healthy, 
active years of life for all Americans. This enterprise has 
rapidly expanded knowledge about the biological, behavioral, 
and social changes that occur with advancing age. Many of these 
advances have saved lives and prevented disability by 
contributing to improvements in public health and health care 
and enhancing physical and cognitive abilities in old age. 
Other discoveries have provided exciting insights into the 
secrets of aging and longevity. Through its support of training 
programs and research infrastructure, the NIA has provided 
critical tools to the next generation of investigators entering 
the field of aging research. Also, the NIA has maintained a 
variety of programs, including the Alzheimer's Disease 
Education and Referral Center and the NIA Information 
Clearinghouse, to communicate the results of aging research and 
related health information to the research community, health 
care providers, patients, and the general public, providing 
guidance on health care, health promotion and disease 
prevention for older people.
    Recent significant advances reported by the NIA can be 
categorized under four major headings: 1) Alzheimer's Disease 
and the Neuroscience of Aging; 2) Biology of Aging; 3) Reducing 
Disease and Disability and 4) Behavioral and Social Research.

           Alzheimer's Disease and the Neuroscience of Aging

    Alzheimer's disease (AD), the most common cause of dementia 
among older persons, is the result of abnormal changes in the 
brain that lead to a devastating decline in intellectual 
abilities and changes in behavior and personality. Tragically, 
as many as four million Americans now suffer from AD,\3\ and 
that number is expected to increase significantly as the baby 
boom generation reaches the age of greatest risk. Scientists do 
not yet fully understand what causes AD, but it is clear that 
the disease develops as a result of a complex cascade of 
events, influenced by genetic and non-genetic factors, taking 
place over time inside the brain with age being the most 
prominent risk factor. These events cause the brain to develop 
beta amyloid plaques and neurofibrillary tangles and lose nerve 
cells and the connections between them in a process that 
eventually interferes with normal brain function.
---------------------------------------------------------------------------
    \3\ Small, GW, Rabine, PV, Barry, PP, et. al. Diagnosis and 
treatment of Alzheimer's disease and related disorders. JAMA 16:1363-
1371, 1997.
---------------------------------------------------------------------------
    In the last decade, researchers have made tremendous 
strides toward solving the mystery of AD, improving 
understanding of its underlying molecular processes, developing 
innovative diagnostic tools, devising effective treatments, and 
testing prevention strategies. For example, the convergence of 
evidence from basic laboratory science and epidemiology studies 
has led to the identification of candidate interventions, such 
as vitamin E, estrogen, and anti-inflammatory agents, that may 
treat or prevent AD. In addition, advances in basic research 
have uncovered enzymes called secretases that are involved in 
the clipping of a normal cell surface protein to produce the 
amyloid peptide that forms the senile plaques found in the 
brains of AD patients. Identifying and understanding how these 
enzymes work will accelerate the development of interventions 
to specifically block their action and stop the development of 
AD plaques.
    As a result of these and other scientific discoveries, in 
1999, the NIA kicked off the NIH Alzheimer's Disease Prevention 
Initiative. The goals of this Initiative are to: invigorate 
discovery of new treatments, identify risk and preventative 
factors, enhance methods of early detection and diagnosis, 
advance basic science to understand AD, improve patient care 
strategies, and alleviate caregiver burdens. In 1999, the NIA 
launched the first large-scale AD prevention clinical trial 
supported by the NIH, the Memory Impairment Study (MIS). This 
study is evaluating vitamin E and donepezil (Aricept) over a 
three-year period for their effectiveness in slowing or 
stopping the conversion from mild cognitive impairment (MCI), a 
condition characterized by a memory deficit without dementia, 
to AD. It will be taking place at more than 70 sites in the 
U.S. Other ongoing or upcoming AD prevention trials will 
examine whether treatment with a variety of agents, such as 
anti-inflammatory drugs, estrogen, aspirin, vitamin E, 
antioxidants, or combined folate/B6/B12 supplementation can 
prevent development of AD. The effects of each of these agents 
on normal age-related decline will also be evaluated. 
Information about ongoing AD clinical trials supported by the 
NIA is now available on the Alzheimer's Disease Education and 
Referral Center home page, a service of the NIA, at: http://
www.alzheimers.org/.
    Advances in the field of AD research also have implications 
for other neurodegenerative disorders, such as Parkinson's 
disease. For example, advances in imaging techniques may one 
day enhance the ability of practitioners to detect early 
changes in the brain and intervene before symptoms of diseases 
progress. Building on the progress of NIA-supported research in 
the area of Alzheimer's disease and the neuroscience of aging, 
efforts will continue to identify critical diagnostic, 
treatment and prevention strategies for AD as well as other 
neurodegenerative diseases.

                   1999 Selected Scientific Advances


           Alzheimer's Disease and the Neuroscience of Aging

    Age-associated memory loss might be reversible.--
Researchers have identified a process by which the normal 
primate brain degenerates with aging, and were able to show 
that this degeneration can be reversed by gene therapy. They 
found that cholinergic neurons in a specific area of the brain 
are most dramatically affected by aging. An actual count of 
brain cells in rhesus monkeys showed that very few cells are 
actually lost in the cerebral cortex with advancing age. In 
contrast, cholinergic neurons in another part of the brain (the 
basal forebrain) were found to shrink in size and to stop 
making regulatory chemicals, a change that seriously affects 
the ability to reason and store memories. Using skin cells from 
each individual monkey, researchers inserted a gene that makes 
human nerve growth factor (NGF) and then injected the modified 
cells into the brains of these monkeys. After three months, the 
cholinergic neurons of the monkeys with the NGF injections had 
an almost youthful appearance. The number of cells detected was 
restored to about 92 percent of normal for a young monkey, and 
the size of the cells was restored to within 3 percent of 
normal young values. Such gene transfer  approaches  restoring  
cellular  function  have  important implications for the 
treatment of chronic age-related neurodegenerative disorders, 
such as AD.
    Brain atrophy measured by imaging techniques predicts 
progression from MCI to AD.--Mild cognitive impairment (MCI) is 
characterized by a memory deficit, but not dementia. Compared 
to normal memory changes associated with aging, memory loss 
associated with MCI is more persistent and troublesome. Each 
year, 12-20 percent of people over age 65 with MCI develop AD, 
compared with 1-2 percent of people in this same age group 
without MCI. A study found that MCI can reliably be clinically 
defined and diagnosed. The ability to differentiate patients 
with MCI from healthy control subjects and persons with very 
mild AD hopefully will lead to useful, practical, and cost-
effective means to test drug interventions for AD. To help make 
these distinctions, researchers recently used magnetic 
resonance imaging (MRI) to determine volume measurements of the 
hippocampus, a region of the brain important for learning and 
memory, in patients with a clinical diagnosis of MCI. The 
hippocampus was selected for imaging because this brain 
structure plays a central role in memory function. Patients 
were assessed annually for approximately three years using both 
clinical and cognitive assessments. In older individuals with 
MCI, the smaller the hippocampus at the beginning of the study, 
the greater the risk of developing AD later. Imaging studies 
such as these can actually identify deviations from normal 
cerebral function or normal anatomy before a clinical diagnosis 
can be made. The ability to detect early disease will enable 
researchers to test the effectiveness of treatments or 
interventions designed to stop brain changes before clinical 
deterioration sets in.
    Normal cellular enzyme becomes a marker for AD.--
Researchers examining the brains of people who had died from AD 
found abnormally large amounts of a normal enzyme called casein 
kinase-1 (CK-1) in nerve cells inside cellular sacs (vacuoles) 
called granulovacuolar degeneration (GVD) bodies. Previous 
research had shown that these vacuoles tended to accumulate in 
the hippocampus. Looking for an enzyme that adds phosphate to 
tau molecule, a key protein in the development of dementia, the 
investigator found a 30-fold increase in one form of CK-1 
inside GVD bodies in the hippocampus. This finding enables 
researchers to use CK-1 as a molecular label for studying the 
vacuoles and forges a link between them and the plaques and 
tangles commonly studied in AD brains. Analysis of GVD bodies 
could provide valuable clues useful both for the diagnosis of 
AD and for gaining a better understanding of the disease.
    Study results show promise for developing treatment of 
early-onset AD.--Most early-onset AD is the result of mutations 
in one of two human presenilin genes, PS-1 and PS-2. Mutations 
in PS-1 are found in about 40 percent of people with familial 
(early onset) AD. Every known presenilin mutation affects the 
processing of amyloid precursor protein (APP) into smaller 
fragments, such as beta-amyloid peptide, the primary 
constituent of the distinctive plaques that accumulate in the 
brains of Alzheimer's patients. When scientists altered the 
amino acid sequence of the presenilin protein from its normal 
sequence in two critical locations, amyloid formation was 
reduced. Evidence indicates that mutated PS-1 protein may be 
able to clip the beta-amyloid fragment from APP. If true, the 
identification of the long-sought enzyme involved in producing 
neuritic plaques associated with AD should hasten development 
of drugs that inhibit the enzyme, blocking production of 
amyloid-beta in much the way cholesterol-lowering drugs work. 
These studies have implications for the treatment of AD and 
related disorders of amyloid accumulation. The challenge will 
be to develop drugs that reduce or alter the activity of 
presenilin, but do not completely eliminate it, since complete 
elimination of presenilin is lethal in mice, and presenilin is 
likely to have a similar essential function in humans.
    Gene causing a form of familial dementia may yield clues to 
AD.--A form of dementia that spans seven generations of members 
of the same family in England has been linked to a newly 
discovered, dominant gene, BRI, on chromosome 13. Familial 
British dementia (FBD), which has an onset at approximately age 
50, is characterized by progressive dementia, muscle 
spasticity, and loss of muscle tone due to disease of the 
cerebellum. The predominant pathological lesions are abnormal 
protein deposits in the brain, plaques in the vicinity of blood 
vessels, and neurofibrillary tangles. FBD is similar to AD 
because in both disorders the production of a small insoluble 
protein is a key feature. Further, the neurofibrillary 
pathology observed in both FBD and AD is identical. While much 
remains unknown about the BRI gene and the function of the 
protein that it produces, understanding how the gene defect 
causes the disease will lead to insights into the pathogenesis 
of other neurodegenerative diseases characterized by amyloid 
``deposition.'' Understanding how the genetically distinct 
disorder FBD develops will contribute to efforts to understand 
the development and progression of the more prevalent AD. 
Further, insights gained in FBD may aid the design and 
development of treatments intended to disrupt peptide 
aggregation and prevent the ensuing neurodegeneration not only 
in FBD and AD but also in other diseases such as those caused 
by infectious particles called prions.
    One form of the ApoE gene protects brain cells from 
injury.--The protein apolipoprotein E (ApoE) participates in 
the transport of serum  lipids  (fats)  and the  redistribution 
 of lipids  among  cells. Although the mechanism through which 
it works is unknown, the only accepted risk factor for sporadic 
late-onset AD is the ApoE4 structural  variant  of the  ApoE 
gene.  To test  the  hypothesis that ApoE3, but not ApoE4, 
protects against age-related neurodegeneration, researchers 
analyzed mice expressing similar levels of human ApoE3 or ApoE4 
in the brain. It was determined that ApoE3 protected the brain 
against excitotoxic injury but that ApoE4 did not. ApoE3, but 
not ApoE4, also protected against age-dependent 
neurodegeneration. This study presents compelling evidence to 
suggest that the presence or absence of a particular ApoE 
structural variant or isoform affects the way neurons respond 
to injury. These differences in the effects of ApoE isoforms on 
neuronal integrity may relate to the increased risk of AD and 
to the poor outcome after head trauma and stroke in humans. The 
significance of this finding is that it may help to explain how 
ApoE4 functions as a risk factor for the development of AD, 
and, if confirmed, might suggest useful therapeutic strategies 
that could be started in advance of any cognitive impairment in 
at-risk individuals.
    New mouse model produces tangles similar to those in AD.--
Developing mouse models with features of human AD is vital in 
helping researchers gain insights into the etiologies, 
mechanisms, and progression of AD. Mice implanted with human 
genes for beta-amyloid, the precursor to neuritic plaques, were 
developed in 1997. Now, for the first time, researchers have 
developed a transgenic mouse strain that expresses human tau 
genes and develops AD-like tau tangles. Unlike their litter-
mates that lack the tau gene, these genetically altered mice 
developed masses of abnormal tau filaments in nerve cells 
within the spinal cord, cerebral cortex, and brainstem, and in 
three other critical regions of the central nervous system, as 
well as undergoing nerve cell degeneration as they aged. While 
this new strain of transgenic mice does not completely model 
AD, they closely resemble human diseases that accumulate AD-
like tau deposits in the brain. The development of this mouse 
model will help researchers understand how tau produces disease 
in the brain, and together with other partial models of AD will 
move closer to developing effective preventive or treatment 
interventions against AD.
    Study finds that the hormone melatonin does not decrease 
with age.--Melatonin, a natural sleep inducer, is secreted by 
the pineal gland located deep within the brain. The hormone is 
produced at high levels during a person's normal sleeping hours 
and is lowest during the day. A number of factors, including 
light and many common medications, such as aspirin, ibuprofen, 
and beta-blockers, can affect melatonin secretion. In the past 
two decades, more than 30 reports have suggested that the level 
of night-time melatonin peak declines progressively with age. 
These reports have led to a proliferation of over-the-counter 
supplements aimed at augmenting melatonin levels in the 
elderly. A five-year study was recently completed that measured 
serum melatonin levels in 120 healthy men and 24 women aged 18-
81. The analysis found no statistically significant difference 
in night-time melatonin concentrations between the younger and 
older study participants. This outcome means that in most 
healthy people, concentration of melatonin probably does not 
decline with age, and aging probably does not affect the 
regulation of melatonin secretion.

                   2000 Selected Scientific Advances


           Alzheimer's Disease and the Neuroscience of Aging

    Use of Positron Emission Tomography (PET) Imaging to 
Identify Pre-symptomatic Decline in Brain Function.--The gene 
APOE- has been associated with increased risk of AD. 
Scientists have been increasingly interested in whether the 
brain and brain function of people who carry one or more copies 
of APOE-4 are different from those of individuals who 
do not carry the gene to ultimately see whether AD-like 
symptoms can be identified before the disease is diagnosed 
clinically. PET imaging can provide information on metabolic 
function of specific brain regions. Recent studies using PET 
show that, despite similarities in age, gender, education, 
family history of dementia, and baseline performance on memory 
and other cognitive tasks, individuals with the APOE-
4 gene(s) have reduced cerebral glucose metabolism in 
several areas of the brain compared to people who have none. 
The differences in metabolism were even greater two years after 
initial evaluation. Lower baseline metabolism at the start of 
the study predicted a greater cognitive decline in subjects at 
genetic risk for AD. Though longer follow-up studies are needed 
to determine how many of the APOE-4 carriers actually 
develop AD, these findings suggest that a combination of 
cerebral metabolic rate and genetic risk factors may be one way 
to help detect AD pre-clinically.
    In Vivo Detection of Amyloid Plaques.--Scientists have been 
searching for a marker to be used in living patients (in vivo) 
to identify amyloid plaques that may be present in brain long 
before clinical diagnosis of the disease. A new molecular probe 
has recently been developed that sensitively labels plaques in 
post mortem AD brain sections. This probe now has been shown as 
well to label plaques throughout the brain after intracerebral 
injection in living transgenic mice. This probe is a prototype 
for molecules that could be used for radiological imaging of 
plaques in the brains of living people, permitting monitoring 
of the development and progression of AD as well as the 
clearance of plaques in response to anti-amyloid therapies.
    Standardized Clinical Information Can Predict Conversion to 
AD.-- Researchers have identified components of a standardized 
clinical assessment instrument that also appear to predict 
which individuals with very mild impairment (symptoms) or 
``questionable'' AD have a high likelihood of converting to AD 
over time. The assessment instrument was the Clinical Dementia 
Rating (CDR), a clinical interview which stages AD from normal 
to severe based on six functional categories. After receiving a 
CDR rating of normal or questionable, participants were 
followed for three years to determine who converted to probable 
AD. Likelihood of progression to AD during follow-up was 
related to the sum of the scores in the six CDR categories. 
This score, combined with selected clinical interview 
questions, identified 89 percent of those questionable 
individuals who converted to AD in the study. These findings 
provide guidelines for using a clinical assessment to identify 
patients most likely to convert from questionable AD to AD, 
improving the possibility of earlier diagnosis and earlier 
implementation of available interventions.
    Identification of the Amyloid Forming Enzymes Offers New 
Targets for Drug Development.--Amyloid is a small peptide 
fragment produced as a result of snipping (cleavage) of the 
much larger amyloid precursor protein (APP) by two enzymes 
known as beta () and gamma () secretases. For 
years, scientists knew that something was snipping the APP into 
fragments and they even went so far as to name the suspect 
secretases. But no one had been able to physically and 
precisely identify the enzymes that did the actual clipping of 
APP until the past year, when the identities of the  
and  secretases at last were revealed.
    The identity of secretase was discovered simultaneously by 
several drug companies. However,  secretase has proven 
more elusive. Its activity was known to be affected by 
mutations in one of the genes (presenilin 1 or PS1) that cause 
AD in early onset families. PS1 was identified several years 
ago and structural evidence suggested it might actually be the 
 secretase. To test this possibility, scientists 
identified a radioactive molecule that binds tightly to the 
active site of the enzyme, thus labeling the enzyme molecules. 
They found that PS1 was the labeled protein, strongly 
suggesting that it itself is the  secretase. It is 
believed this line of research could lead to the discovery of 
drugs that inhibit the production of amyloid without inhibiting 
other essential functions these secretase enzymes might have. 
Ultimately, clinical trials on such secretase-inhibiting drugs 
will show whether this approach will work.
    Immunization Against Amyloid- Can Reduce Brain 
Amyloid- Deposition.--Recent studies in animal models 
have been important in understanding the etiology of AD and in 
testing potential new therapies. In transgenic mouse models 
showing extensive plaque formation with advancing age, 
researchers are now evaluating plaque-reducing drugs. The 
results of this research have been promising. In one 
breakthrough, pharmaceutical company scientists showed that 
repeated long-term injections of an amyloid vaccine can cause 
an immune response in test mice, nearly eliminating amyloid 
plaques and associated neuropathology, with no obvious 
toxicity. A number of NIH-funded scientists have confirmed and 
extended these observations. In a novel approach, one group 
administered the vaccine to mice nasally, and also induced an 
immune response. In that study, when young transgenic mice were 
repeatedly given the human amyloid- via the nasal 
route, the mice had a much lower amyloid burden at middle age 
than animals not receiving the vaccine. Interest in the vaccine 
approach heightened upon recent preliminary reports that 
amyloid vaccination prevents cognitive decline in another 
transgenic mouse model of AD, suggesting that a vaccine might 
indeed make a difference in the clinical symptoms of AD. Human 
trials are only now beginning to test both the safety and the 
efficacy of these vaccines as a possible therapy for people 
with AD.
    A New Model of Parkinson's Disease (PD).--There are many 
similarities among neurodegenerative diseases such as AD, PD, 
and other dementias, and research on one can provide valuable 
clues about the others. PD is a common age-related and 
progressive neurodegenerative disorder characterized by death 
of neurons that make the neurotransmitter dopamine. Loss of 
these neurons results in rigidity, tremor, slowed movement, and 
impaired gait. Another hallmark of PD is the formation of 
fibrous protein deposits, called Lewy bodies, in neurons. 
Mutations in the -synuclein gene have been linked to 
some forms of inherited PD and insoluble -synuclein 
accumulates in Lewy bodies, as well as in plaques in AD. A new 
-synuclein transgenic model has been developed, using 
the fruit fly Drosophila, that exhibits many essential features 
of human PD including age-dependent onset, progressive loss of 
dopamine neurons and motor function, and development of Lewy 
body-like pathology. This model will be useful in identifying 
underlying mechanisms mediating -synuclein toxicity 
and in identifying genes that modify the -synuclein 
mediated neurodegeneration, and which may play a role in the 
pathogenesis of PD. These transgenic flies may also be valuable 
in screening potential drugs affecting the onset and 
progression of PD.
    Ongoing Research Highlights Importance of Testing 
Interventions.--REACH (Resources for Enhancing Alzheimer's 
Caregiver Health) is a multi-site intervention trial, at six 
sites and a coordinating center, to conduct social and 
behavioral research on interventions designed to help 
caregivers of patients with AD and related disorders. REACH 
projects are testing such interventions as educational support 
groups, behavioral skills training programs, family-based 
interventions, environmental modifications, and computer-based 
information and communication services. Some 1,222 caregivers 
and care recipients have participated in the study, which 
includes large numbers of African Americans, Cuban Americans, 
and Mexican Americans. Data from the REACH study are just being 
analyzed.

                            Biology of Aging

    Research on the biology of aging has led to a revolution in 
aging research. This new gerontology investigates the 
progressive, nonpathological biological and physiological 
changes that occur with advancing age and the abnormal changes 
that are risk factors for or accompany age-related disease 
states. Progress is being made in understanding the gradual 
changes in structure and function that occur in the brain and 
nerves, bone and muscle, heart and blood vessels, hormones, 
nutritional processes, immune responses, and other aspects of 
the body. Research has begun to reveal the biologic factors 
associated with extended longevity in humans and animal models, 
such as fruit flies, roundworms and rodents. The ultimate goal 
of this effort is to develop interventions to reduce or delay 
age-related degenerative processes in humans. Areas of research 
include the effects of calorie restriction on various 
organisms, the identification of genes and genetic mutations 
that may be related to longevity, and the study of cellular 
function in human and animal models.

                   1999 Selected Scientific Advances


                            Biology of Aging

    Mitochondrial DNA mutations increase with aging.--One 
hypothesis of the cause of aging is the accumulation of 
mutations in mitochondrial DNA (mtDNA). Although earlier 
research has shown that a particular deletion mutation of 
mitochondrial DNA increases with age, it appeared that this 
mutation only occurred in less than 4 percent of mtDNA 
molecules. However the methods used to quantitate the level of 
this mutation would not have detected other deletions, so it 
was argued by some that the common deletion mutation 
represented the ``tip of the iceberg'' of mitochondrial 
mutations. Skeptics responded that this unproven hypothesis 
represented wishful thinking. By use of a sensitive method to 
look at point mutations in mitochondrial DNA, researchers found 
hard evidence that mtDNA point mutations increase with aging 
and mitochondria deteriorate as people age. These scientists 
show that one particular point mutation in the control region 
of the mtDNA occurs in a high proportion of the mtDNA molecules 
of more than 50 percent of people over the age of 65, but is 
absent in younger individuals. Because the mitochondria are the 
cellular sites for energy metabolism, deterioration of 
mitochondria could deprive cells of the energy they need to 
function and ultimately could lead to premature cell death.
    Caloric restriction prevents age-associated changes in gene 
expression.--Most multicellular organisms exhibit a progressive 
and irreversible physiologic decline during the aging process. 
The only intervention known to slow the intrinsic rate of aging 
in mammals is caloric restriction. Given 30 to 40 percent fewer 
calories than in usual feeding schedules, but fed all the 
necessary nutrients, rodents and other non-primate laboratory 
animals studied not only have lived far beyond their normal 
life spans but have reduced rates of several diseases, 
especially cancers. In a new study, the gene expression profile 
of the aging process was analyzed in skeletal muscle of mice. 
Of the 6347 genes surveyed by new micro-array techniques, only 
58 (0.9%) displayed a greater than twofold decrease in 
expression. Thus, the aging process is unlikely to be due to 
large, widespread alterations in gene expression. The major 
effect of caloric restriction seems to be to heighten animals' 
stress response in response to damage to proteins and other 
large molecules. Caloric restriction also completely or 
partially suppressed age-associated alterations in expression 
of a large proportion of genes. This is the first global 
assessment of the aging process in mammals at the molecular 
level. Potentially, gene expression profiles can be used to 
assess the biological age of mammalian tissues, providing a 
tool to evaluate experimental interventions.
    Link established between telomeres and mammalian aging.--
Telomeres are highly repetitive DNA sequences located at the 
end of chromosomes. They are essential for the stability of 
chromosomes and cell survival in a wide variety of organisms. 
In human cells grown in culture, telomere length shortens with 
each cell division and the progressive telomere shortening 
ultimately limits the ability of cells to divide. To test the 
possibility of a link between telomere shortening and aging of 
an organism, investigators have created genetically altered 
mice lacking telomerase, an enzyme that adds new telomeric DNA 
sequences to existing telomeres. In this transgenic model, 
telomeres progressively shortened throughout the lifespan, 
providing a unique opportunity to understand the cellular 
consequences and aging significance of telomere shortening in 
the living animal. Although loss of telomeres did not elicit a 
full spectrum of the classical symptoms of aging, age-dependent 
telomere shortening was associated with a shortened life span, 
reduced capacity to respond to physiological stress, slow wound 
healing, and an increased incidence of spontaneous cancers. As 
individuals age, older organs show a markedly diminished 
capacity to cope with acute and chronic stress. The telomerase-
deficient mouse provides a valuable model to study the role of 
telomere maintenance in cellular stress responses in the aging 
organism.

                   2000 Selected Scientific Advances


                            Biology of Aging

    Extension of Average Life Span of Nematodes by 
Pharmacological Intervention.--It is widely accepted that 
oxidative stress is a factor in aging. To date, however, it has 
not been demonstrated convincingly that natural anti-oxidants 
such as vitamins C and E or b-carotene extend life span in 
model experiments with mice, fruit flies, or nematodes (a kind 
of worm). Varied results have been obtained in genetically 
altered fruit flies over-expressing either superoxide dismutase 
(SOD) or SOD and catalase, enzymes that reduce oxidative 
damage. Now, an artificial compound, EUK-134, which mimics both 
SOD and catalase activity, has been shown to increase the 
average life span of nematodes by about 50 percent. EUK-134 
also reversed premature aging in a nematode strain subject to 
elevated oxidative damage. These results strongly suggest that 
oxidative stress is a major factor in rate of aging in the 
nematode, and that this rate can be slowed by pharmacological 
intervention. It may be that similar compounds could lessen 
oxidative stress in humans and delay or reduce age-related 
pathology.
    Cell Transplantation and Aging.--An alternative to tissue 
or organ transplantation that appears to have great potential 
is formation of functional tissue from cell transplants. Recent 
research has shown that isolated cow or human adrenal gland 
cells inserted into immunodeficient mice formed functional 
adrenal tissue that resembles normal adrenal gland. This 
approach may potentially be used for any organ, either to study 
its functional regeneration in a living organism with age or to 
therapeutically regenerate lost function as in a case, for 
example, when defective genes might be replaced in cells 
isolated from a patient and then placed back into the same 
patient for tissue regeneration. This technique can also reduce 
the need for immunosuppressive therapies and offers an 
alternative to stem cell therapies.
    Genetically Mimicking Caloric Restriction (CR) 
Significantly Extends Yeast Life Span.--CR has been shown to 
significantly extend life span in a variety of organisms. In 
organisms studied to date (yeast, nematodes, fruit flies, mice 
and rats), CR increased both mean and maximum life span, as 
well as significantly reducing signs of disease. In all species 
examined, the extended longevity and health of the animals was 
accompanied by changes in the regulation of energy metabolism. 
Recent research has determined that genetic manipulation of 
glucose availability, metabolism, and signaling pathways can 
mimic the longevity-extending effects of CR in the yeast model. 
This discovery makes the yeast model of aging and longevity a 
powerful tool for uncovering the underlying cellular and 
molecular mechanisms responsible for increased longevity and 
health span, with a view to developing effective interventions.
    CR Increases Neurotrophic Factor Production in the Brain 
and Protects Neurons.--Beyond extending life span, CR also 
reduces development of age-related cancers, immune and 
neuroendocrine alterations, and motor dysfunction in rodents. 
Recent animal model studies of neurodegenerative disorders 
provide the first evidence that CR can also increase resistance 
of neurons to age-related and disease-specific stresses. One 
possible mechanism is that the mild metabolic stress associated 
with CR induces cells to produce proteins that increase 
cellular resistance to disease processes. Indeed, CR increases 
production of one such protein, a neuronal survival factor, 
BDNF. BDNF signaling in turn plays a central role in the 
neuroprotective effect of CR. This work suggests that CR may be 
an effective approach for reducing neuronal damage and 
neurodegenerative disorders in aging, providing insight into 
the design of approaches that might mimic CR's beneficial 
consequences.
    Use of Gene Expression Microarrays in Aging Research.--
Aging is normally accompanied by changes in expression, or 
activity, of a large number of genes, but it is not clear which 
of these changes are critical in the aging process. Gene 
expression microarrays, which allow profiling the activity of 
many thousands of genes at once, provide an opportunity to 
obtain a more complete picture of what these changes are, and 
to design tests of whether these changes are causally 
associated with aging. In three recent studies, investigators 
looked at differences in gene expression patterns in young and 
old mouse skeletal muscle, liver, and brain tissue and also 
made several observations on changes brought about by caloric 
restriction. Though the data analyses are complex, some initial 
observations are: 1) aging results in lower levels of activity 
of metabolic and biosynthetic genes; 2) aging is accompanied by 
patterns of gene expression that are indicative of stress 
responses, including inflammatory and oxidative stress; 3) 
many, but not all, age-related changes in gene expression in 
mouse liver and skeletal muscle are slowed by caloric 
restriction; and 4) caloric restriction appears to increase 
expression of genes for repairing and/or preventing damage to 
cellular macromolecules. Microarray technology is proving to be 
an efficient approach to answering long-standing important 
questions about molecular mechanisms of aging and how these may 
be manipulated, for example, by calorie restriction. Profiling 
changes in gene activity may eventually provide useful 
biomarkers of the aging process itself, markers that might be 
important in assessing the effectiveness of strategies to 
retard aging-related processes.

                    Reducing Disease and Disability

    As life expectancy increases, there is an ever greater need 
to keep these additional years disease and disability-free. 
Research has shown that life-style and other environmental 
influences can profoundly impact outcomes of aging, and that 
remaining healthy and emotionally vital until advanced age is a 
realistic expectation. NIA-supported investigators at 
institutions across the nation, including those that are the 
recipients of Claude Pepper Older Americans Independence 
Centers awards, are helping to define optimal needs regarding 
diet, diet supplements, exercise, safety, and other factors. 
The goals are to ensure that endurance, strength, and balance 
are kept at the highest possible level and that the risks of 
disease, such as osteoporosis, cancer, and cardiovascular 
disease, and disability are kept to a minimum. In addition to 
its support of biomedical and behavioral research, the NIA is 
committed to helping reduce disease and disability by 
translating research findings into effective interventions, 
such as exercise, for the public. Toward this end, in 1999, the 
NIA published a free manual, Exercise: A Guide from the 
National Institute on Aging, the cornerstone of the Institute's 
ongoing campaign to encourage older people to exercise. The 
Guide is based on scientific evidence and is intended to help 
people design their own exercise program. Information about the 
Guide, and other NIA publications, is available on the NIA home 
page at: http://www.nih.gov/nia/health/.

                   1999 Selected Scientific Advances


                    Reducing Disease and Disability

    Delirium can be prevented in hospitalized older patients.--
Delirium, an acute confusional state, in older hospitalized 
older patients is associated with poor outcomes, and is a 
common, serious, and potentially preventable source of both 
prolonged illness and early death. Between 20-30 percent of all 
hospitalized elderly patients have episodes of delirium, 
resulting in treatment costs exceeding $4 billion per year in 
the U.S. Previous studies of delirium focused on the treatment 
of delirium rather than on primary prevention. A recent study 
done by researchers evaluated the effectiveness of a multi-
component strategy for the prevention of delirium. Study 
participants received either usual, standard hospital care or 
care under a multidisciplinary team of specialists that 
included staff nurses, recreational therapists, physical 
therapists, geriatricians, and trained volunteers. Patients in 
this study had one or more of six risk factors for delirium, 
including cognitive impairment, sleep deprivation, immobility, 
dehydration, or impaired vision or hearing. To address these 
risk factors, team members were trained to recognize and 
counteract the danger signs before confusion, agitation, and 
hallucinations set in. Interventions include making sure 
patients got enough fluids, taking them for walks, and 
providing warm drinks at bedtime to promote sleep. While 15 
percent of patients receiving standard hospital services 
experienced at least one episode of delirium, only 9.9 percent 
of those receiving the team approach experienced an episode. 
Once an initial episode of delirium had occurred, however, the 
intervention had no significant effect on the severity of 
delirium or the likelihood of recurrence. This study holds 
substantial promise for the prevention of delirium in 
hospitalized older patients. Further evaluation is needed to 
determine the cost effectiveness of intervention to prevent 
delirium and its effects on related outcomes, such as 
mortality, re-hospitalization, institutionalization, use of 
home health care, and long-term cognitive functioning.
    Predictors of healthy aging can be identified and 
interventions can reduce risk of disability.--There is a need 
to understand whether there are modifiable risk factors that 
can decrease the risk of disability and death with aging. A 
long-term study with Japanese-American men in Hawaii has shown 
that these men have one of the highest life expectancies of all 
Americans. Because a number of baseline measurements were taken 
of these men in midlife, from 45 to 68, it was possible to 
explore predictors of long life expectancy and prevention of 
physical disability. Among over 6500 healthy men at baseline, 
about 60 percent remained free of major illness and were not 
physically or cognitively impaired over the next 25 years. Data 
from mid-life that proved to be predictive of healthy aging 
included optimal blood pressure, low blood sugar and 
cholesterol levels, lack of obesity, lack of smoking, and 
strong hand grip. At an older age the men were examined to 
determine the presence of functional limitation and disability. 
Of various factors considered, mid-life hand grip strength was 
associated with less physical disability and faster walking 
speed. In a clinical trial, participants were randomized into 
intervention and control groups. At the end of one year after a 
regimen of increased physical activity and chronic-illness 
self-management, the intervention group experienced fewer 
hospitalizations and fewer total hospital days. Factors leading 
to a long and active life are of prime importance as the 
population ages worldwide. This study suggests that preventive 
and/or therapeutic interventions are most effective when 
initiated at younger ages, although the clinical trial results 
suggest that successful intervention can occur at older ages. 
Researchers will need to work with clinicians to develop 
strategies to address modifiable risk factors in order to 
promote healthy aging.
    Testosterone replacement men may have protective effects 
against age-related diseases.--Many older men have blood levels 
of testosterone well below the normal range for younger men. 
Earlier studies have shown that low testosterone levels may 
increase risk factors for disease and disability, including 
loss of bone (leading to osteoporosis and fractures), loss of 
muscle (causing decreased strength), and increases in body fat 
(increasing risks for diabetes and heart disease). In a 
recently completed clinical trial of men over 65 years old with 
low serum testosterone, study participants were given a 
testosterone or placebo skin patch for three years. Levels of 
testosterone in the treatment group rose to those generally 
found in younger men. Men with the lowest endogenous serum 
testosterone (3 micrograms per liter or less) prior to 
beginning the trial had significant increases in bone density 
in response to testosterone replacement. The testosterone 
treatment also increased lean body tissue and significantly 
decreased body fat. Study participants were monitored for 
possible adverse treatment effects, particularly on the 
prostate. Testosterone treatment did not increase symptoms of 
an enlarged prostate, such as impaired urinary function, nor 
was there statistically significant evidence that the 
administered testosterone increased the incidence of prostate 
cancer. The results of this study suggest that testosterone 
replacement could help protect many older men with low 
testosterone levels against common diseases of aging such as 
diabetes, heart disease, and osteoporosis. However the 
possibility that testosterone replacement could increase 
adverse events such as prostate diseases, though not observed 
in this small study, reinforces the need for well-designed 
larger studies as well as the development of strategies to 
minimize risks of testosterone therapy while still providing 
benefits.
    Postmenopausal estrogen use is associated with decreased 
arterial stiffness.--Arterial stiffness has been identified as 
a potential risk factor for cardiovascular disease. Earlier 
research has shown that estrogen may improve blood vessel 
pliability by altering the structure and function of vascular 
tissue, including smooth muscle cells. This study, conducted at 
examined the influence of age and current estrogen replacement 
therapy (ERT) on stiffness in the common carotid arteries (the 
main arteries that pass up the neck and supply blood to the 
head). The common carotid arteries of 172 women, 37 of whom 
were current users of ERT, were examined by ultrasound, and the 
degree of arterial stiffness was measured. Arterial stiffness 
was found to increase linearly with age, and was modestly 
related to other cardiac risk factors. The degree of stiffness 
was lower in women using ERT than in postmenopausal nonusers. 
Furthermore, the effects of age and ERT on the stiffness 
persisted after adjustments for other cardiovascular risk 
factors. Carotid stiffness was similar in ERT users, whether or 
not they also took progesterone. This study suggests that the 
cardiovascular protection seen in women using ERT may involve 
overall reduction of age-associated arterial stiffening.
    Chronic inflammation in the elderly predicts disability and 
early death.--Inflammation is a normal biologic response of the 
immune system to a number of different stimuli, including 
infections, allergens, and physical trauma. However, 
inflammation can become chronic and increase the onset and 
severity of a number of age-related disabilities and diseases. 
An indicator of this process is the elevation of a pro-
inflammatory protein, interleukin-6 (IL-6), which plays a 
central role in inflammation and increases with age. High 
circulating levels of IL-6 are associated with such diverse 
conditions as depression, heart failure, and arthritis. One 
study of nearly 1,700 men and women, ages 70 or greater living 
in North Carolina, measured IL-6 levels against a standardized 
test for depression. After controlling for age, race, and 
gender, IL-6 levels remained the only biologic variable 
significantly associated with depression. In another study in 
men and women 71 years or older, participants with the highest 
levels of interleukin-6 were almost twice as likely to develop 
mobility-disability and were about twice as likely to die 
within 5 years of the beginning of the study. It is known that 
IL-6 stimulates the synthesis of C-reactive protein, an 
indicator of systemic inflammation. When levels of both IL-6 
and C-reactive protein were elevated simultaneously, there was 
a 3-fold increased risk of mortality. Further studies are 
needed to improve our understanding of the complicated system 
of stimulus and response with regard to inflammation. These 
findings may broaden our understanding of the health correlates 
and consequences of chronic inflammation, as well as provide a 
new way to identify high-risk individuals to determine whether 
they would benefit from anti-inflammatory intervention.
    Behavioral training is more effective than drug therapy for 
urge urinary incontinence.--Approximately 15 million Americans 
adults have urinary incontinence (UI) with associated health 
costs estimated in a range of $16- $26 billion dollars 
annually. Urinary incontinence is especially a problem for 
women. Nearly 40 percent of community dwelling women age 60 
years and older suffer from some form of UI. While behavioral 
training and drug therapy have both been previously 
demonstrated to be effective treatments for urge urinary 
incontinence in older adults, drug therapy is commonly used as 
the first course of treatment. A recent clinical trial directly 
compared behavioral training (instrument-assisted pelvic muscle 
exercises to improve bladder control) to drug treatment for 
urge UI in older women and demonstrated that behavioral 
training was significantly more effective than drug therapy in 
reducing the episodes of accidental urine loss. Thus, 
behavioral training should be considered the first treatment 
option given the potential side effects of drug therapy, and to 
avoid further problems with drug interactions among older 
persons taking multiple medications.

                   2000 Selected Scientific Advances


                    Reducing Disease and Disability

    Fitness Affects Mortality Risk Regardless of Body Fat.--
Both obesity and being unfit increase risk for chronic disease 
and death. However, the interrelationship between fitness, body 
fat, and mortality has not been clear. Recent research suggests 
that it is fitness, not fat, that may count most. In one study, 
investigators followed men 30-83 years of age for an average of 
eight years, classifying participants according to body fat as 
well as relative fitness based on exercise testing. Not 
surprisingly, the study showed that the higher the level of 
fat, the lower the level of fitness. But what intrigued 
researchers most were data showing that, within each category 
of body fat, ``fit'' men were at lower risk of death. Most 
strikingly, among those more fit, obesity was not significantly 
related to risk of death. In another study, low fitness 
increased mortality risk in men approximately fivefold for 
cardiovascular disease, and threefold for all-cause mortality. 
These findings suggest that, beyond interventions focusing on 
weight-loss to prevent and treat obesity-associated conditions, 
there may also be important benefits for the obese from 
improved fitness.
    Stress Testing May Not Be Needed for Starting an Exercise 
Program.--The role of exercise stress testing and safety 
monitoring for older people who want to start an exercise 
program is unclear. Current guidelines for routine exercise 
stress testing may deter older people from beginning an 
exercise program, either because of the cost of testing or 
because it may lead people to believe that exercise poses 
higher risks than it actually does. The latest research 
suggests that, in the absence of cardiovascular 
contraindications, the benefits of exercise for the elderly, 
balanced against a somewhat minor increase in risk, may be 
sufficient for starting an exercise program without prior 
exercise stress testing.
    Commonly Prescribed Diuretic Protects Against 
Osteoporosis.--The lifetime risk of osteoporotic fracture in 
the U.S. is 40 percent in women and 13 percent in men. Because 
age-related bone loss increases susceptibility to fracture, 
strategies aimed at preserving bone mass are important. Large 
observational studies have consistently shown that the use of 
thiazide diuretics, usually prescribed to treat high blood 
pressure, is associated with higher bone density and about a 30 
percent lower risk of hip fracture. Investigators recently 
completed a clinical trial to directly test the effect of 
taking thiazides on bone density in older men and women with 
normal blood pressure. Among healthy older adults, low-dose 
hydrochlorothiazide did preserve bone density at the hip and 
spine. The modest effects observed over three years, if 
accumulated over 10-20 years, may explain the 30 percent 
reduction in hip fracture risk associated with thiazides in the 
earlier observational studies. The results of this trial 
suggest that low-dose thiazide therapy may have a role in 
strategies to prevent osteoporosis.
    Regulation of TGF- Type II Receptor and 
Atherosclerosis.--Atherosclerosis or narrowing of the arteries 
is the major risk factor for both heart disease and stroke and 
is a major complication after arteries have been surgically 
enlarged by balloon angioplasty. Throughout life, artery wall 
cells successfully repair injuries related to smoking, high 
blood pressure or cholesterol, making new cells to replace 
damaged ones. But constant exposure to such stresses eventually 
causes the artery wall cells to lose control of their 
replication. The growing mass of cells forms plaque, which 
eventually clogs the vessels and causes reduced blood flow. New 
research is helping to identify the complex series of cellular 
events causing cells to lose control of their division. In 
normal circumstances, a protein called TGF- prevents 
excessive cell division. It acts on the cells through binding 
to a protein receptor on the cell surface, the TGF- 
receptor, causing intracellular changes that stop cells 
dividing. In atherosclerotic lesions, it has been shown, 
unrestricted growth in some cells is caused by mutations in 
this receptor, inactivating it. Another way of preventing 
normal receptor function is to make too little TGF- 
receptor to be effective. One protein that inhibits the 
production of TGF- receptor is called Egr-1. This 
protein is found at very high levels in plaques, perhaps being 
induced by artery injury. Finding drugs to repress the activity 
of Egr-1 may be one way of keeping the key TGF- 
receptor functioning effectively to stop excessive cell 
division and prevent atherosclerosis.
    Exendin-4 as a Treatment for Type 2 Diabetes.--Type 2 
diabetes mellitus (DM) is caused by an inability of the beta 
cells of the pancreas to compensate for increasing insulin 
demands; consequently, blood glucose levels rise. Scientists 
are searching for compounds that act on the pancreatic beta 
cells to prevent this progressive rise in blood glucose. GLP-1, 
a gut peptide, can stimulate beta cells to produce more insulin 
even in type 2 DM; however, its biologic half-life is short and 
its effects quickly wear off. Exendin-4, a newly studied 
peptide analog of GLP-1, is long-lived and more potent than 
GLP-1, and has been shown to reduce blood glucose levels in 
rodents. A recent study conducted by researchers in the NIA 
intramural research program with small numbers of diabetic and 
non-diabetic humans demonstrated Exendin-4's efficacy in 
inducing insulin and normalizing blood sugar, even in 
diabetics. In the near future, an exendin-like drug possibly 
may become an effective treatment for type 2 DM.

                     Behavioral and Social Research

    A goal of NIA behavioral and social research is to maintain 
or enhance the health and well-being, including physical and 
cognitive function, of older individuals throughout the life 
span. For example, new interventions are being developed to 
encourage long-term changes in health behaviors that will lead 
to a reduced risk of disease and disability. Cognitive 
interventions are being tested to maintain cognitive function 
and retain independence. Components of the physical environment 
are being redesigned to match the skills and abilities of older 
persons, thus helping to prevent injuries and to improve 
performance of daily activities. Such human factors research 
has produced new and improved medical devices and treatment 
regimens, instructional designs, and product labeling. As the 
number of older people who are able and willing to work well 
into late adulthood increases, researchers are studying the 
physical and social barriers to their sustained participation 
in the workforce and the factors needed to enhance their skills 
and productivity. A related body of demographic research 
documents trends in health, disability, retirement, long-term 
care, and the economic aspects of aging, and uncovers their 
causes and inter-relationships.
    A major focus of ongoing research supported by the NIA 
Behavioral and Social Research (BSR) program involves tracking 
the declining chronic disability rate in the elderly U.S. 
population. First reported in 1997, researchers at Duke 
University found that between 1982 and 1994, the prevalence 
rates for chronic disability in the U.S. elderly population, 
age 65 and older, declined 3.6 percentage points, based upon 
data from the 1982, 1989, and 1994 National Long Term Care 
Surveys. The decline is highly significant statistically and 
occurred at nearly all levels of disability. In absolute terms, 
the differences in prevalence suggest that there were 
approximately 1.2 million fewer disabled people in 1994 than 
would have been predicted if the 1982 rates had remained the 
same; that is, 7.1 instead of 8.3 million people. Subsequent 
waves of the survey revealed that disability rates for older 
people have continued this downward movement. The NIA BSR 
program is supporting research to understand the dynamics of 
this trend with the goal of accelerating it in future years.

                   1999 Selected Scientific Advances


                     Behavioral and Social Research

    Social and productive activities confer survival advantages 
to the elderly.--When previous studies found that older people 
who remained active lived longer, scientists assumed that the 
survival advantage resulted from improved cardiopulmonary 
fitness attributable to physical activity. A new study from a 
research team suggests that social activities (church 
attendance, travel, etc.) and productive activities (gardening, 
community work, etc.) involving little or no enhancement of 
fitness lowered the risk of all-cause mortality over a 13-year 
period to a degree similar to that achieved by fitness 
activities (e.g., swimming, and walking). This study suggests 
that a wider range of mechanisms, both psychological and 
psychosocial, may be involved in the association between 
activity and mortality than had been previously thought. The 
finding has important implications for public policy and 
clinical practice. If confirmed, it suggests that clinicians 
might consider recommending a broader range of activity options 
for older patients.
    Centenarians live most of their lives in good health.--
Scientists have found preliminary evidence that many 
centenarians remain functionally independent for the vast 
majority of their lives and then experience a relative rapid 
decline near the end of their lives. Relative to others in the 
older population, they also appear to either experience a 
marked delay in the onset or, in some cases, escape diseases 
such as cancer and Alzheimer's disease. Scientists also find a 
strong familial component to extreme longevity. Siblings of 
centenarians tend to live longer compared to siblings of 
individuals who died in their mid-70's. This may be due in part 
to shared genetic traits among family members. Understanding 
the genetic and environmental factors responsible for 
centenarians' prolonged good health could provide insights for 
improving the health of all older people. Further work is 
needed to elucidate the genetic and environmental factors that 
contribute to centenarians' extreme longevity.
    Socioeconomic status and health disparities are strongly 
related over the life course.--There is a striking and well-
documented relationship between socioeconomic status, health, 
and longevity. People with higher incomes and more wealth tend 
to be healthier and to live longer. The causes of this 
relationship are largely unknown, but may be related to health 
behaviors and access to care. In a recent study done by 
researchers, African-American men were found to have lower life 
expectancy in disparate income groups than did white men in the 
same income groups for the years 1979 to 1989. African-American 
men with family incomes below $10,000 averaged 7.4 fewer years 
of life than black men in families with more than $25,000; 
among white men, the differential between the two income groups 
was 6.6 years. Less work has been focused on the effect of 
health events on subsequent income and wealth. The strong 
inter-relationship between health and wealth at older ages may 
be due, in large part, to the adverse economic impact of major 
health events. One major reduction in wealth appears to be 
reduced earnings that stem from taking early retirement or 
otherwise decreasing work. People who have heart attacks, 
strokes, or other acute health events are especially likely to 
reduce their work levels. There are equally large reductions in 
wealth among those with and without health insurance (although 
those with health insurance have lower out-of-pocket medical 
expenses), suggesting that health insurance does not fully 
protect people from the economic costs of major illnesses. This 
finding demonstrates how differences in health status can cause 
differences in economic circumstances. These results also 
suggest some direction for policy. They show, for example, that 
health insurance deals with only a small part of the economic 
cost of declining health. The much larger economic costs of 
decreased work and lost earnings might be more effectively 
addressed in other ways. To aid in understanding this causal 
relation between health and wealth, future clinical trials 
could include more economic content so that the impacts of 
health on economic status can be measured.
    Neighborhood and socioeconomic characteristics hamper 
progress in fitness.--Physical inactivity is a leading cause of 
both death and disability among older adults. Recent analyses 
from the Alameda County Study, which was conducted by 
investigators, show that socioeconomic variables such as 
neighborhood characteristics affect physical activity levels 
and thus may contribute to health disparities. Living in a poor 
neighborhood is associated with a decline in physical activity, 
even adjusting for age, individual income, education, smoking 
status, body mass index, and alcohol consumption. Other survey 
analyses reveal that poor weather and fear of crime were major 
barriers to exercise among low-income urban older adults, as 
was the lack of information from physicians and family/friends 
regarding the safety and benefits of exercise. These studies 
demonstrate the importance of designing physical activity/
exercise programs that can counter the negative effects of 
disadvantaged social conditions.

                     2000 Selected Science Advances


                     Behavioral and Social Research

    Mortality Continues to Decline in Industrialized 
Countries.--During the twentieth century, mortality rates have 
shown steady and significant declines in the G7 countries of 
Canada, France, Italy, Germany, Japan, the United Kingdom, and 
the U.S. Mortality decline has occurred most significantly in 
older populations due to decreases in deaths from heart attack, 
stroke, and cancer. Examining mortality data of the G7 
industrialized countries over the last five decades, 
researchers found that long-term patterns in mortality rates 
have continued to decline exponentially at a remarkably 
constant rate, without evidence of slowing. Therefore, official 
estimates of longevity in the G7 countries underestimate life 
expectancy and also understate the ratio of people 65 and older 
to working age people (20-64 year olds). By the year 2050, 
these ratios may be between 6 percent (UK) and 40 percent 
(Japan) higher than official projections. These findings have 
significant implications for public policy regarding future 
demands on health care, long-term care, retirement support, and 
other services.
    Emotional Vitality is associated with lower Mortality and 
Progression of Disability in Disabled Older Women.--Using data 
from the Women's Health and Aging Study, a longitudinal study 
of community-dwelling disabled women aged 65 years and older, 
researchers examined whether emotional vitality protects 
against progression of disability and mortality. At the start 
of this study, a substantial proportion of even the most 
disabled older women were identified as emotionally vital. 
Three years later, results showed that these upbeat, positive 
women did better than women who were not emotionally vital in 
maintaining physical function over time. These results suggest 
that helping older people maintain a high level of emotional 
vitality might play an important role in slowing or preventing 
a downward spiral in health status. Further study may be 
warranted of why and when positive emotions protect against 
health decline in older people.
    The Influence of Stereotypes on Cardiovascular Health and 
Cognitive Function.--Recent research indicates that exposure to 
negative beliefs about aging can contribute to adverse health 
outcomes, even when an individual is not consciously aware of 
such exposure. In this study, exposure to negative stereotypes 
elicited heightened cardiovascular stress (increased blood 
pressure and heart rate in older adults) in response to 
mathematical and verbal challenges designed to elicit a stress 
response. Positive messages about aging protected participants 
from a stress response. The older adults exposed to positive 
stereotypes also exhibited more confidence in their ability to 
perform computations than those exposed to negative 
stereotypes, and then outperformed them as well. These 
preliminary findings suggest that further research is need to 
examine the potentially powerful influence of stereotypes not 
only on the physical well being of older adults but also on 
their performance in tasks known to become progressively more 
difficult with age. Perhaps positive age-related stereotypes 
could be used to reduce cardiovascular responses to stress and 
to improve cognitive performance and daily function.

        Section II.--Research Sponsored by Other NIH Institutes


                  National Institute of Mental Health

    The National Institute of Mental Health (NIMH) program of 
research on aging includes studies in the basic sciences as 
well as research in neurobiology and brain imaging, clinical 
neuroscience, treatment assessment, psychosocial and family 
studies, and service systems research. Studies involve mental 
disorders with initial occurrence in late life as well as 
illnesses that begin in early adulthood but continue throughout 
the life course. Major areas of research focus are the 
psychiatric aspects of Alzheimer's disease and related 
dementias, depressive disorders, schizophrenia, anxiety 
disorders, and sleep disorders.

Alzheimer's Disease

    An estimated 4 million Americans age 65 and older suffer 
from Alzheimer's disease or other forms of dementia. An 
important area of NIMH research on Alzheimer's disease focuses 
on genetic factors. NIMH-supported researchers recently 
identified a new gene mutation strongly associated with the 
risk of developing late-onset Alzheimer's disease, the most 
common form of the brain disorder. Using the NIMH Genetics 
Initiative Alzheimer's disease sample (a collection of DNA 
samples and clinical information from hundreds of families in 
which more than one individual has Alzheimer's), and new 
methodology, the researchers found that a particular gene 
mutation, alpha-2 macroglobulin-2 (A2M-2), was significantly 
associated with Alzheimer's. Different teams of investigators 
are continuing to analyze the NIMH Genetics Initiative sample, 
and recent evidence has been found by three different groups to 
support linkage between genetic markers on chromosome 10 and 
Alzheimer's disease. Researchers are actively working to find 
the specific gene involved. These findings, if replicated, will 
offer important clues into the disease process and will help 
discern the role of additional genetic and environmental 
factors involved in creating vulnerability to the disease.

Depression

    Nearly 5 million of the 32 million Americans age 65 and 
older suffer from depression. Significantly, many late-life 
depressions are amenable to treatment. Recent NIMH-supported 
studies provide important information relevant to depression 
treatment in the elderly. One study compared treatment response 
among elderly depressed patients who had their first depressive 
episode early in life and those whose first episode occurred at 
age 60 or older. Although age at onset did not affect overall 
efficacy of treatment, patients who had experienced their first 
depressive episode early in life took 5-6 weeks longer to reach 
remission. This slower treatment response, combined with the 
increasing rates of suicide among the elderly, particularly 
among males, indicates that elderly depressed patients with 
early-onset illness need particularly careful management.
    Another study found that a combination of pharmacotherapy 
and psychotherapy is extremely effective in preventing 
recurrence of depression among the elderly. Older adults who 
received interpersonal therapy and an antidepressant medication 
during a three-year period were much less likely to experience 
recurrence than those who received medication only or therapy 
only. Positive long-term outcome, however, was less durable in 
individuals above age 70 than in those below this age.
    NIMH-supported research has suggested that, among depressed 
older adults, slower and less complete response to 
antidepressant treatment tends to be associated with 
cerebrovascular pathology, ventricular enlargement, and 
impairment of frontostriatal brain pathways. Patients with such 
brain pathology often also show particular clinical features, 
including psychomotor retardation, lack of insight, and 
impairment of higher-order executive functions. One recent 
study extended this picture by examining the prognostic value 
of executive dysfunction in older adults after their depressive 
symptoms had remitted with treatment. The presence of 
abnormalities of initiating behaviors and perseverating, but 
not memory impairment or other clinical features, predicted 
fluctuations in residual depressive symptoms and greater 
relapse and recurrence of depressive disorder. These clinical 
features thus can help identify patients who need particularly 
vigilant monitoring and follow-up. This body of research is 
leading to further studies on the role of specific prefrontal 
brain pathways in predisposing toward or perpetuating 
depressive symptoms and syndromes in elderly patients.

Suicide

    Older Americans are disproportionately likely to commit 
suicide. Comprising 13 percent of the population, they account 
for nearly 20 percent of all suicide deaths. The rate of 
suicide is particularly striking among white males aged 85 and 
older: in 1997, the most recent year for which statistics are 
available, the rate in this group was 65 per 100,000 - about 
six times the national U.S. rate of 10.6 per 100,000. 
Researchers interviewed families and associates of elderly 
individuals who committed suicide to determine the state of 
mind of such individuals just prior to their suicide. The 
investigators concluded that major depression was the most 
common predictor of suicide in this study population. At least 
70 percent of those who committed suicide had visited primary 
care providers within a month of the suicide. The findings 
point to the urgency of enhancing both the detection and 
adequate treatment of depression in primary care settings as a 
means of reducing the risk of suicide among the elderly. NIMH 
is currently funding a multi-site study in the elderly to test 
the effectiveness of an intervention aimed at improving the 
recognition of suicidal ideation and depression by primary care 
providers.

Sleep Disorders

    Insomnia and other sleep difficulties tend to be highly 
prevalent, chronic ailments among older adults that are most 
commonly managed clinically by prescribing hypnotic 
medications. However, long-term use of such medications can 
often complicate the sleep difficulties. NIMH-supported 
research has demonstrated that psychotherapy can also be used 
successfully to treat chronic primary insomnia in middle-aged 
to elderly individuals. Cognitive-behavioral therapy focused on 
sleep issues proved equal to the sleep medication temazepam in 
alleviating insomnia in older adults, and led to more enduring 
improvements in sleep at 12- and 24-month follow-ups. Combining 
the psychotherapy with medications did not yield advantages 
over the outcomes achieved with either treatment individually. 
Such results indicate that psychological interventions are 
useful techniques in treating sleep problems in late life and 
that, as in other disorders, older patients with chronic 
insomnia respond to psychotherapy comparably to younger adults.

                         National Eye Institute


Age-Related Macular Degeneration

    Age-related macular degeneration is the leading cause of 
blindness in patients over the age of 65. As the population in 
this country ages, this disease will have an even greater 
impact. The condition affects the retina and leads to varying 
degrees of vision loss depending on the form and severity of 
the disease. In initial phases, the disease causes reductions 
in the ability to read fine print and see in dim light. In the 
later stages of the disease, abnormal blood vessel growth takes 
place under the retina and causes severe vision loss resulting 
in an inability to drive, read, recognize faces, and perform 
other visual tasks of day to day living. While the disease has 
been recognized for many years, our understanding of the causes 
and reasons for progression of this disease are still limited. 
Work in humans with this conditions has indicated that certain 
proteins involved in growth of blood vessels are elevated in 
these patients and that one growth factor, vascular endothelial 
growth factor (VEGF), is consistently elevated in patients with 
abnormal blood vessels associated with age-related macular 
degeneration. For the first time, scientists at the National 
Eye Institute (NEI), using a system to manipulate the 
expression of VEGF have been able to cause development of 
abnormal blood vessels in rodent eyes that are identical in 
location and appearance to those seen in humans afflicted with 
the disease. This finding is important, because, to date, no 
animal model has been developed that mimics the disease in 
humans. Modeling this condition in animals will provide an 
invaluable research tool to study the causes and to test 
treatments for this condition. Because the model takes 
advantage of a stimulus known to occur in the human condition, 
a more precise understanding of the trigger factors for the 
growth of the blood vessels will be gained. Subsequently, these 
trigger factors can then be manipulated through various 
therapeutic mechanisms that should be directly applicable to 
patient care. By understanding and using this new model, 
scientists hope to develop better tools to treat patients with 
age-related macular degeneration.

Age-Related Cataract

    Visual impairment and blindness from cataract is an 
important public health problem throughout the world. Age-
related cataract accounts for about 16 million cases of 
blindness worldwide, about half of all cases of blindness. Most 
people with severe impairment from cataract are in the 
developing countries of Asia and Africa where barriers to 
cataract surgery are greatest. In the population-based 
Baltimore Eye Study and the Salisbury Eye Evaluation Project, 
cataracts were the leading cause of visual impairment (best 
corrected visual acuity in the better eye of worse than 20/40 
but better than 20/200) among older adults. In both studies, 
rates of blindness and visual impairment from cataract were 
higher in blacks than in whites. While surgical treatment for 
cataract is effective, the cost of the large number of 
procedures done each year is high. In the United States, 
cataract surgery is the most frequently performed surgical 
procedure in the Medicare program, with about 1.35 million 
cataract operations done each year at a cost of approximately 
3.4 billion dollars. The identification of modifiable risk 
factors or interventions that affect the development of 
cataract could have a large economic impact and reduce rates of 
blindness and visual impairment throughout the world. The Age-
Related Eye Disease Study (AREDS), sponsored by the NEI, is an 
ongoing multi-center study of the natural history of cataract 
and age-related macular degeneration. Data were collected at 
entry on a wide range of possible risk factors for cortical and 
nuclear cataracts, two of the most common types of cataract. 
Results from the study reinforce a growing consensus that 
smoking increases the risk of development of nuclear cataract 
and that higher levels of sunlight exposure increase the risk 
of cortical cataract. The identification of these potentially 
modifiable risk factors for cataract reinforces public health 
recommendations to avoid smoking and decrease exposure to 
sunlight.

Glaucoma

    Glaucoma is a group of eye disorders that share a distinct 
type of optic nerve damage that can lead to blindness. 
Approximately three million Americans have glaucoma, and as 
many as 120,000 are blind from this disease. Most of these 
cases can be attributed to primary open angle glaucoma, an age-
related form of the disease. Elevated intraocular pressure is 
frequently, associated with glaucoma, but definitive evidence 
supporting a casual effect has not been demonstrated 
experimentally. Scientists now have evidence that increases in 
intraocular pressure have a profound effect on ganglion cell 
survival. Optic nerve fibers from retinal ganglion cells 
connect to neurons in a part of the brain called the lateral 
geniculate nucleus (LGN). Neurons from the LGN relay 
information to the visual cortex for processing. Using a 
primate model of glaucoma, scientists showed that relatively 
moderate elevations of intraocular pressure cause loss of LGN 
neurons over an extended period of time. These data demonstrate 
that chronic elevation of intraocular pressure has a 
neurodegenerative effect on neurons critical for the 
integration and transmission of visual information.

Low Vision Education Program

    On October 19, 1999, the NEI announced the formal launch of 
its Low Vision Education Program. Low vision is broadly defined 
as a visual impairment, not corrected by standard glasses, 
contact lenses, medicine, or surgery, that interferes with the 
ability to perform everyday activities. Most people develop low 
vision because of eye diseases, such as cataracts; glaucoma; 
diabetic retinopathy; or age-related macular degeneration, the 
leading cause of severe visual impairment and blindness in 
Americans 60 years of age and older. Low vision primarily 
affects the growing population of people over age 65 and other 
higher risk populations, including Hispanics and African 
Americans who are likely to develop low vision at an earlier 
age. While lost vision usually cannot be restored, many people 
can learn to make the most of the vision that remains. The Low 
Vision Education Program will include a multimedia public 
service campaign and a traveling exhibit that will be displayed 
in shopping malls around the country. The program will provide 
communities nationwide with materials and technical support to 
increase awareness of local low vision services and resources.

                  Office of Research on Women's Health

    During 1999 and 2000, the Office of Research on Women's 
Heath (ORWH) supported a number of research activities with the 
NIA and other NIH ICs that specifically address the health of 
older Americans, including:

Study of Women's Health Across Nation II: (SWAN II)

    The goal of this research is to determine menopause-
specific physiological changes and their predictors and the 
impact of menopause on subsequent disease. SWAN consists of 
both cross sectional and longitudinal studies on the natural 
history of menopause and a characterization of endocrinology/
physiology of premenopause. Five ethnic groups are included - 
Caucasian, African American, Hispanic, Chinese, and Japanese.

Black Rural and Urban Caregivers Mental Health Functioning

    The purpose of this study is to assess the mental health 
and social functioning of rural and urban African-American 
women who provide unpaid care to an elder (65 years and older) 
by using a cross-sectional research design and random sample of 
elders.

Continuous Low-Dose Hormone Replacement Therapy (HRT) Combined with 
        Alendronate (ALN) in Postmenopausal Women

    The primary outcome measures from this research are spine 
bone mineral density and total hip bone mineral density as a 
result of receiving low-dose HRT, ALN, and both low-dose HRT 
and ALN. Total body bone mineral content and forearm bone 
mineral content will also be measured.

Comprehensive Treatment for Older Breast Cancer Patients

    The hypothesis of this study is that a comprehensive 
geriatric intervention integrated with oncological treatment 
may preserve the independence and quality of life of older 
breast cancer patients.

Exercise and Quality of Life in Older Women with Breast Cancer

    The primary aims of the study are to determine if: 1) A 
moderate exercise program, as compared to enhanced usual care, 
significantly improves the physical function and quality of 
life in older women with breast cancer; and 2) A psycho-
educational program, as compared to usual care, significantly 
improves physical functioning and quality of life in older 
women with breast cancer.

Gender Differences in Pain Responses of the Elderly

    This research will develop future strategies for pain 
treatment in elderly patients by increasing our understanding 
of the role of gender and hormone replacement on pain 
perception.

Menopausal Depression: Chronobiologic Basis

    This research is designed to provide information on 
possible mechanisms mediating the effects of reproductive 
hormones on mood and behavior and deriving relevant clinical 
treatment guidelines for menopausal women from this research. 
This proposal represents an extension of the investigators' 
previous work that led to the development of new hypotheses and 
treatment strategies.

NAS Panel on Risk and Prevalence of Elder Abuse and Neglect

    This panel evaluates the potential for pilot studies needed 
to develop instruments that can detect abusive behavior. The 
panel will also discuss issues related to confidentiality and 
data sharing, and make recommendations regarding the scope of a 
national research effort on elder abuse and neglect which will 
include institutionalized victims of abuse and neglect and 
issues related to data collection on victims suffering from 
dementia.

Estrogen and Cholinergic System Interactions in Aging

    The studies contribute important information on the 
mechanistic link between estrogen, cognition, and Alzheimer's 
disease in older women, and promote further interest in 
designing better therapeutic strategies.

Postmenopausal Estrogen Influences on Olfaction

    This study tests the hypothesis that hormone replacement 
therapy (HRT) is associated with higher olfactory and cognitive 
functioning in postmenopausal women. If HRT were found to 
benefit olfaction and cognition in postmenopausal women, 
improvements in both nutritional and functional status could 
result.

Vascular Gene Expression in Aging Women

    The central hypothesis of the study is that estrogen 
inhibits the initiation and progression of atherogenesis in 
part through direct estrogen receptor-dependent effects on 
vascular gene expression. This study provides insights into the 
progression of the disease as well as potential therapies to 
prevent this age-related disease.

Progestogens vs Phytoestrogens: An Adjunct to ERT

    Postmenopausal estrogen replacement therapy (ERT) reduces 
morbidity and mortality from coronary heart disease (CHD). 
There is a continuing concern, however, that the concurrent use 
of a progestogen to protect the endometrium may reduce the 
cardiovascular benefits of ERT. This research explores whether 
soy phytoestrogens may be an effective alternative approach to 
progestogen therapy.

Hormone Replacement and Cerebral Glucose Metabolism

    There is evidence that estrogen replacement therapy (ERT) 
in postmenopausal women may preserve and improve cognition in 
non-demented women. This study explores whether ERT may produce 
an increase in global cerebral metabolic rate of glucose 
utilization (CMRglc) in humans or whether there are specific 
regional CMRglc increases that may modulate enhanced cognitive 
functioning.

Selective Estrogen Receptor Modulator (SERMs) Workshop

    The overarching objective of the workshop was to identify 
pivotal questions and formulate future projects in SERM 
research that cross disease boundaries and potentially 
incorporate multiple disease endpoints up front.

Older Adults, Health Information and the World Wide Web Conference

    The conference provided information on how to develop 
senior-friendly web sites and offered hands-on opportunities 
for exploring various sites. A variety of new collaborative 
activities were established among the participants.

Phytoestrogens and Healthy Aging: Gaps in Knowledge

    This workshop examined the relationship between phyto 
estrogens and cardiovascular health, cancer, bone disease, and 
menopausal symptoms. The participants suggested areas of 
research to be included on the agenda for future investigation.

Graylyn Conference on Women's Health

    The purpose of the conference was to review and integrate 
the body of knowledge concerning the effects of estrogen on 
both arterial and venous thrombosis and its effects on vascular 
inflammation.

    National Institute of Diabetes and Digestive and Kidney Diseases

    The National Institute of Diabetes and Digestive and Kidney 
Diseases (NIDDK) supports basic and clinical research in 
several major diseases that disproportionately affect older 
Americans. These include type 2 diabetes, end-stage renal 
disease, osteoporosis, and prostate cancer.

Diabetes

    The risk of type 2 diabetes, the most common form of the 
disease, increases dramatically in middle age. For the elderly 
with diabetes, life poses major problems. Of the nearly 16 
million Americans who have type 2 diabetes, over 6 million are 
aged 65 or older. Among Americans over age 65, over 18 percent 
have type 2 diabetes, with the highest prevalence occurring in 
minority populations (African Americans, Hispanic Americans, 
and Native Americans).
    Primary Prevention: The most important risk factors for 
type 2 diabetes are obesity, insulin resistance, physical 
inactivity, impaired glucose tolerance, and a history of 
gestational diabetes or a family history of diabetes. The 
Diabetes Prevention Program (DPP), a clinical trial under way 
in 26 medical centers nationwide, seeks to determine whether 
type 2 diabetes can be prevented with diet and exercise, or 
medication. The study is designed to determine whether lowering 
blood glucose levels in people with impaired glucose tolerance 
can prevent or delay development of type 2 diabetes. Nearly 21 
million Americans are affected by impaired glucose tolerance, a 
precursor to diabetes. These individuals have high blood 
glucose levels, but not high enough to be diagnosed as having 
diabetes. The DPP has met its recruitment goals ahead of 
schedule. Over 3,000 patients have been recruited with nearly 
20 percent of them over 60 years of age.
    Obesity: Another important clinical trial is designed to 
study if interventions to produce sustained weight loss in 
obese individuals with type 2 diabetes will improve health. 
This trial is expected to recruit a patient population which 
reflects the prevalence rates for diabetes in the United 
States, and plans to include individuals over age 70. The NIDDK 
is spearheading this trial with support from the National 
Heart, Lung and Blood Institute, the National Institute of 
Nursing Research, the National Center for Minority Health and 
Health Disparities, the NIH Office of Research on Women's 
Health, and the Centers for Disease Control and Prevention.
    Complications: Diabetes is a major risk factor for 
cardiovascular disease which accounts for 80 percent of 
mortality in people with type 2 diabetes. The NIDDK is co-
sponsoring two major clinical trials with the National Heart, 
Lung and Blood Institute to address issues of optimal 
management of glucose, blood pressure and lipids in people with 
type 2 diabetes. The NIDDK also supported a multicenter 
clinical trial in patients with type 2 diabetes, the United 
Kingdom Prospective Diabetes Study, which demonstrated the 
importance of good blood sugar control in slowing the eye, 
nerve, and kidney damage caused by diabetes. These findings 
further reinforce the results of the nationwide Diabetes 
Control and Complications Trial, which showed similar benefits 
in type 1 diabetes.
    Genetics: Type 2 diabetes is thought to arise from genetic 
factors, combined with environmental factors, such as obesity. 
More than one genetic alteration or mutation is probably 
necessary for the development of type 2 diabetes, which is 
therefore considered a ``complex'' genetic disease. Researchers 
have now found a gene on chromosome 2 calpain 10 which 
predisposes to type 2 diabetes in a population of Mexican 
Americans and individuals studied in Finland where there is a 
high rate of diabetes. In addition, several other groups of 
investigators have identified genes important in the 
development of rare forms of diabetes findings that may shed 
light on type 2 diabetes. The NIDDK has established and 
fostered an ongoing international consortium on the genetics of 
type 2 diabetes, and will continue to capitalize on these 
remarkable advances in genetics, which could provide the means 
to stem or even reverse the increasing incidence of this 
devastating disease.
    Beta Cell Biology: Type 2 diabetes is a consequence of both 
insulin resistance and impairment of the insulin-producing beta 
cells of the pancreas, such that sufficient insulin cannot be 
produced to compensate for the resistance to its action. Among 
the new NIDDK research initiatives important to type 2 diabetes 
in older Americans are the establishment of a Beta Cell Biology 
Consortium, that can be expected to yield new knowledge about 
the molecular events involved in glucose sensing and insulin 
secretion, and a Functional Genomics of the Endocrine Pancreas 
Consortium, that will identify all genes expressed in the beta 
cell at various stages of development.
    Diabetes Mellitus Interagency Coordinating Committee: In 
cooperation with the National Institute on Aging, and the 
Diabetes Mellitus Interagency Coordinating Committee (DMICC), 
the NIDDK is holding a meeting on ``Diabetes and Aging: From 
Basic Biology to Clinical Care.'' The purpose of this meeting 
is to bring together researchers in the genetic, environmental, 
phenotypic, and pathogenic causes of type 2 diabetes during the 
aging process. Also included are researchers looking at 
diabetes health care among the elderly, including disparities 
in diabetes treatment among minority groups during the aging 
process. Federal Agencies which are members of the DMICC will 
participate in this scientific conference and then meet the 
following day to share information on current initiatives and 
report on their efforts in the treatment and clinical 
management of older Americans with type 2 diabetes.

Osteoporosis

    Osteoporosis is characterized by low bone mass and bone 
deterioration, leading to fragile bones and an increased risk 
for fractures of the hip, spine and wrist. According to the 
National Osteoporosis Foundation, more than 28 million 
Americans, 80 percent of them women, have osteoporosis or are 
at increased risk of developing the disease. Osteoporosis has 
been reported in people of all ethnic backgrounds. In addition, 
of the population over age 50, one in two women and one in 
eight men will experience an osteoporosis-related fracture in 
his or her lifetime.
    The NIDDK has a strong program on bone and mineral 
research, focused on the hormones that are major regulators of 
bone mass and on nutritional aspects of osteoporosis, 
particularly calcium and vitamin D intake and metabolism . This 
program encompasses both basic and clinical research. In 
December 1999, the NIDDK, together with other institutes with 
an interest in osteoporosis, issued a research solicitation on 
receptors and signaling in bone health and disease.
    Alterations in hormone levels, such as loss of normal 
estrogen production in post-menopausal women, is a major 
contributor to bone loss with aging. Limited clinical trials 
have determined that hormone replacement can partially mitigate 
or reverse the osteopenia associated with menopause. The use of 
estrogen/progesterone hormone replacement therapy has gained 
wide acceptance in peri- and post-menopausal women, through not 
without undesired side effects. The development and use of 
Selective Estrogen Receptor Modulators (SERMs) has the 
potential to lessen the side effects, while giving some degree 
of protection against post-menopausal bone loss. Still other 
hormonal therapeutic agents, such as parathyroid hormone, have 
recently shown great promise as new approaches to treatment of 
osteoporosis. These clinical studies are a direct outgrowth of 
a longstanding NIDDK-supported basic research program on 
hormonal regulation of bone. Additional studies are needed to 
evaluate the role of these newer therapies in combination with 
established therapies for osteoporosis.
    The NIDDK co-sponsored an NIH Consensus Development 
Conference on Osteoporosis Prevention, Diagnosis and Therapy on 
March 27-29, 2000. The panel's recommendations for future 
research included identifying and intervening in disorders that 
can interfere with peak bone mass in children of ethnic 
diversity; improving diagnosis and treatment of secondary 
causes of osteoporosis; collecting the data necessary to 
establish guidelines for testing for osteoporosis; developing 
quality-of-life measurement tools; conducting randomized trials 
of combination therapies; and developing a paradigm for the 
management of fractures.

End-Stage Renal Disease

    Irreversible kidney failure known as end-stage renal 
disease or ESRD is a serious health problem in older Americans, 
who require either lifelong dialysis or kidney transplantation 
to survive. While ESRD affects persons of all ages, the peak 
incidence is in the sixth decade of life. Over the last decade 
there has been a worrisome growth in the incidence of ESRD, and 
incidence rates have grown more rapidly for individuals over 
age 75. In most instances, ESRD develops as the consequence of 
progressive damage to the kidney that occurs over a decade or 
more. A number of underlying diseases can cause progressive 
renal failure, most importantly diabetes mellitus, which in 
1997 accounted for 42 percent of incident cases of ESRD, and 
hypertension, which was responsible for 26 percent of incident 
cases.
    The NIDDK supports several initiatives to combat ESRD 
through the generation of fundamental insights into kidney 
abnormalities and their progression to kidney failure, and 
through research aimed at improving therapies, as well as 
developing prevention strategies. Some examples of major 
initiatives include:
    Hemodialysis Vascular Access Clinical Trials Consortium: 
Vascular access has been called the ``Achilles heel'' of 
hemodialysis. A very sizable portion of costs of care of 
dialysis patients are attributable to problems with vascular 
access. This newly created clinical consortium will conduct a 
series of multicenter, randomized studies of strategies to 
reduce the failure and complication rate of arteriovenous 
grafts and fistulas in hemodialysis patients over a five-year 
period.
    Prospective Cohort Study of Chronic Renal Insufficiency: In 
FY2000 the NIDDK is initiating a new longitudinal cohort study 
to understand the epidemiology of chronic renal disease. The 
goals of the study are two-fold: To determine the risk factors 
for accelerated decline in renal function, and to determine the 
incidence and identify risk factors for cardiovascular disease. 
Because of the relative and increasing importance of diabetes 
as a cause of ESRD, approximately one-half of the study 
participants in the cohort study will be diabetic.
    The United States Renal Data System (USRDS): Since its 
creation in May 1988, USRDS has pursued the collection, 
analysis, and distribution of information on the incidence, 
prevalence, treatment, morbidity, and mortality of ESRD in the 
United States. The USRDS monitors outcomes for dialysis and 
transplant patients. USRDS data are publicly available on the 
NIDDK World Wide Web site (http://www.niddk.nih.gov).
    Long-Range Plan: In 1999, the NIDDK, in collaboration with 
the Council of American Kidney Societies, released a long-range 
plan for research to improve the treatment and prevention of 
kidney disease and kidney failure. The strategic plan reflects 
the consensus of more than 100 researchers, members of kidney 
societies, and of patients regarding research needs, 
opportunities for advances, and barriers to progress.
    Healthy People 2010: Healthy People 2010 contains the 
first-ever chapter on Chronic Kidney Disease, a major 
contributor to ESRD. It includes scientific background, 
specific objectives, and current and future challenges to 
improving the Nation's kidney health.

Prostate Disease

    The NIDDK supports an active portfolio of basic and 
clinical investigations on benign prostatic hyperplasia and 
prostate cancer, both of which disproportionately affect older 
men.

                      Benign Prostatic Hyperplasia

    Benign prostatic hyperplasia (BPH) is an enlargement of the 
prostate gland that can interfere with urinary function in 
older men. It causes blockage by squeezing the urethra, which 
can make it difficult to urinate. Men with BPH frequently have 
other bladder symptoms including an increase in frequency of 
bladder emptying both during the day and at night. Most men 
over the age of 60 have some BPH, but not all have problems 
with blockage.
    Medical Therapy of Prostate Symptoms (MTOPS): This 
multicenter clinical trial is assessing the effect of two 
different pharmacological agents on the prevention of 
progression of symptomatic BPH, and correlating those clinical 
effects with molecular and genetic actions on prostate biopsy 
tissue from participants in the study.
    Minimally Invasive Surgical Therapies Treatment Consortium 
for Benign Prostatic Hyperplasia: This new initiative, in 
collaboration with the National Cancer Institute and the 
National Institute of Environmental Health Sciences, is 
establishing a group of collaborative Prostate Evaluation and 
Treatment Centers and a Biostatistical Coordinating Center to 
develop and conduct randomized, controlled clinical trials of 
the long-term efficacy and safety of the major ``minimally-
invasive'' approaches for the treatment of symptomatic benign 
prostatic hyperplasia.

                            Prostate Cancer

    In the United States, prostate cancer has become the most 
frequently diagnosed cancer, and the second leading cause of 
cancer mortality in men after lung cancer. Its incidence rate 
has continued to increase rapidly during the past two decades 
especially in men over the age of 50 years.
    Molecular Epidemiology of Prostate Carcinogenesis: This new 
initiative is encouraging molecular epidemiologic studies for 
advancing understanding of prostate cancer development and 
progression. The purpose is to stimulate development and 
application of biological markers of prostate cancer risk and 
tumor aggressiveness and for utilization in chemoprevention 
studies. Of special interest are studies of markers to 
elucidate multiethnic differences in prostate cancer 
susceptibility.
    Role of Hormones and Growth Factors in Prostate Cancer: 
This initiative is encouraging studies to explore the 
underlying mechanism(s) of action of hormones and growth 
factors in the regulation of prostate development, growth, and 
tumor development.
    Biology, Development, and Progression of Malignant Prostate 
Disease: This initiative, in collaboration with the National 
Cancer Institute, the National Institute on Aging, and the 
National Institute of Environmental Health Sciences, is 
encouraging a range of fundamental biological issues considered 
critical for progress in defeating prostate cancer. The purpose 
is to support studies focusing on the biology that underlies 
the development and progression of malignant prostatic disease.

 National Institute of Arthritis and Musculoskeletal and Skin Diseases

    Researchers supported by the National Institute of 
Arthritis and Musculoskeletal and Skin Diseases (NIAMS) use 
powerful research tools to acquire and apply new knowledge to 
studies of some of the most challenging diseases affecting 
older Americans today. Many of these diseases have troubled 
patients and their health care providers for decades, but each 
year significant discoveries have brought researchers closer to 
fully understanding, diagnosing, treating, and ultimately 
preventing these common, disabling, costly and chronic 
diseases, which greatly compromise quality of life. These 
disorders include the many different forms of arthritis and 
numerous diseases of joints, muscles, bones, and skin.

Rheumatoid Arthritis

    Rheumatic diseases such as rheumatoid arthritis and 
osteoarthritis affect people of all races and ages, and are the 
leading cause of disability among adults age 65 and older in 
the United States. It is estimated that by the year 2020, 
nearly 60 million Americans will be affected by arthritis and 
other rheumatic conditions. These diseases may cause pain, 
stiffness, and swelling in joints and other supporting 
structures of the body such as muscles, tendons, ligaments, and 
bones. The NIAMS funds a broad array of research studies across 
the spectrum from basic to clinical to translational, in an 
effort to better understand what causes these conditions and 
how best to treat and prevent them. Such investments include 
support for studies of target organ damage in rheumatoid 
arthritis (RA), an inflammatory disease of the lining of the 
joint, and of new imaging technologies in animal models of RA. 
Other scientists funded by the NIAMS have launched a 
multicenter clinical trial to test the oral administration of a 
small peptide for RA treatment.
    The Institute is also building the research infrastructure 
needed to stimulate additional innovative studies of arthritis 
and other rheumatic conditions. Such efforts include support 
for a consortium that is searching for genes that predispose 
individuals to RA, with the overall scientific goal of 
developing better diagnostic and treatment methods; funding of 
a new research registry on RA in the African American 
population; and support for specialized centers of research in 
both RA and osteoarthritis, which is a degenerative joint 
disease. In the NIAMS intramural research program, we continue 
to support studies designed to understand the genetic and 
cellular bases of arthritis, as well as novel therapeutic 
trials involving targeted biologic agents. Finally, the NIAMS 
is committed to disseminating science-based health information 
on arthritis and related conditions. For that purpose, the 
Institute published a bilingual brochure, in Spanish and 
English, entitled ``Do I Have Arthritis?'' and developed a 
primer for patients on new medications for RA and OA.

Osteoarthritis

    The NIAMS is pursuing a multipronged approach to the 
challenge that osteoarthritis (OA), a degenerative joint 
disease that is the most common form of arthritis, poses as the 
U.S. population ages. This approach includes efforts to create 
a public-private partnership to identify biomarkers and 
surrogate endpoints that can facilitate clinical trials and 
enhance drug development for OA; the initiation of a major 
research contract, in collaboration with the National Center 
for Complementary and Alternative Medicine, to study the 
efficacy of the dietary supplements glucosamine and chondroitin 
sulfate for the treatment of knee OA; and the recent 
publication of a handout on health on OA for affected patients, 
family members, health care providers, and health educators. 
Scientists supported by the Institute have made a number of 
important contributions in the field of OA in recent years, 
including investigations to develop specific chemical compounds 
that prevent the expression of enzymes that cause cartilage 
degradation, and studies to determine the genetic 
predisposition of daughters whose mothers have knee OA in the 
hopes of identifying susceptible individuals as early as 
possible.
    These projects complement other efforts supported by the 
Institute that range from basic studies to examine 
biomechanical signaling mechanisms in cartilage, to tissue 
engineering work that includes the use of animal models to 
develop joint scaffolds and test surgical approaches for 
engineered joints, to novel imaging studies designed to better 
identify joint disorders and assess their progression. We are 
also supporting several pilot projects to test the feasibility 
of new methodologies to understand the causes of, and develop 
novel treatments for, OA. Furthermore, we recently funded a 
number of new grants to identify and evaluate chondroprotective 
agents that prevent cartilage destruction, or facilitate its 
repair. In addition, the NIAMS is building on the insights 
gained at a scientific conference on OA held in the summer of 
1999 by issuing a new solicitation for research on the onset, 
progression, and disability associated with OA, in conjunction 
with other interested Institutes.

Osteoporosis

    Osteoporosis, a disease characterized by low bone mass and 
structural deterioration of bone tissue, is the leading cause 
of bone fractures in postmenopausal women and older people in 
general. The NIAMS leads the Federal research effort on 
osteoporosis and related bone diseases, and supports research 
ranging from very basic studies to clinical and translational 
projects, as well as early intervention and prevention efforts. 
Significant advances in the prevention and treatment of 
osteoporosis are available today as the direct result of 
research focused on determining the causes and consequences of 
bone loss at cellular and tissue levels, assessing risk 
factors, developing strategies to maintain and even enhance 
bone density, and exploring the roles of such factors as 
hormones, calcium, vitamin D, drugs, and exercise on bone mass. 
For example, scientists at a NIAMS-funded specialized center 
for research on osteoporosis recently reported that giving 
lower doses of estrogen and progesterone during hormone 
replacement therapy (HRT), in combination with calcium and 
vitamin D, spares older women significant osteoporotic bone 
mass loss while limiting HRT's more negative side effects.
    In 1999, the Institute funded two new core centers for 
research on musculoskeletal disorders. The first is 
concentrating on studies of skeletal integrity, which 
encompasses biological, chemical, and mechanical influences on 
bone. The second core center focuses on basic bone biology and 
bone diseases. The work at these core centers will boost the 
critical mass of talented scientists working on problems of 
bone growth and disease. In addition, in 2000, the NIAMS issued 
a request for applications for additional specialized centers 
for research in osteoporosis. Such centers are supported by the 
NIAMS to further the translation of basic research findings to 
clinical applications that will help affected patients. 
Furthermore, in the spring of 2000, the Institute sponsored a 
major consensus development conference on osteoporosis at which 
national and international experts presented the latest 
research findings on this disorder, and developed 
recommendations to enhance future diagnosis, prevention, and 
treatment approaches. Finally, the NIAMS and several other NIH 
components support the Osteoporosis and Related Bone 
DiseasesNational Resource Center to promote the dissemination 
of science-based health information to patients, health care 
providers, and the general public.

       National Center for Complementary and Alternative Medicine

    NCCAM is dedicated to exploring complementary and 
alternative healing practices in the context of rigorous 
science; educating and training complementary and alternative 
medicine (CAM) researchers; and disseminating authoritative 
information to the public and professionals. CAM use spans the 
spectrum of conditions and diseases confronting the American 
public as a whole, however, it is especially associated with 
chronic conditions. Consequently, a large component of the 
NCCAM research portfolio, addresses dementia, arthritis, 
cancer, cardiovascular disease, and pain conditions affecting 
the quality of life and longevity of our nation's elderly. Key 
examples from our portfolio are described below.

CAM Use by the Elderly

    Contemporary studies of CAM practices estimate that 42 
percent of all adults in the United States use some form of 
CAM. New findings from an NCCAM-supported survey of senior 
citizens confirm that the extent of their CAM use closely 
mirrors that of the population at large. Results from this 
study of Medicare beneficiaries found that more than 40 percent 
reported using CAM. Of those using CAM, some 80 percent 
maintained that they experienced substantial benefit from it. 
However, the majority did not disclose their use of CAM 
therapies to their physicians. These findings underscore the 
need for conventional physicians to inquire about CAM use by 
their elderly patients.

Dementia

    For centuries, extracts from the leaves of the Ginkgo 
biloba tree have been used as Chinese herbal medicine to treat 
a variety of medical conditions. In Europe and Asia, 
standardized extracts from ginkgo leaves are routinely taken to 
treat a wide range of neurocognitive symptoms, including those 
of Alzheimer's disease. Little is known, however, about the 
safe dosage levels of Ginkgo biloba extract, let alone its 
actual effectiveness in preventing Alzheimer's disease. NCCAM, 
in collaboration with the National Institute on Aging (NIA), 
the National Heart, Lung and Blood Institute (NHLBI), and the 
National Institute of Neurological Disorders and Stroke 
(NINDS), may help resolve these questions through a six-year, 
multi-center effort to study the efficacy of Ginkgo biloba 
extract in preventing dementia, a cognitive decline in memory 
and other intellectual functions, in older individuals. This 
study, the largest of its kind ever conducted on Ginko biloba, 
includes four clinical centers and an enrollment of almost 
3,000 people. Participants who take Ginkgo biloba are being 
compared to a second group of individuals who are taking a 
placebo.

Osteoarthritis

    Osteoarthritis (OA), or degenerative joint disease, is a 
common type of arthritis caused by the deterioration of 
cartilage, the connective tissue that cushions the ends of 
bones and permits their surfaces to slide smoothly across one 
another within the joint. Arthritic diseases are major public 
health problems affecting the quality of life for a large 
segment of the older American population. In 1995, it was 
reported that 32 million Americans were afflicted with this 
disease. Estimated medical costs for people with arthritis 
total $15 billion annually. Accordingly, the first U.S. multi-
center study to investigate the dietary supplements glucosamine 
and chondroitin sulfate for knee OA has been funded by the 
NCCAM in collaboration with the National Institute of Arthritis 
and Musculoskeletal and Skin Diseases (NIAMS). Glucosamine and 
chondroitin sulfate are two natural substances, found in and 
around the cells of cartilage, and commonly used today as 
nutritional supplements. The study is expected to verify their 
clinical safety and effectiveness alone or in combination in 
reducing joint pain and improving mobility. The study involves 
nearly 1,600 OA patients at 13 study centers across the 
country.

Cardiovascular Disease

    Cardiovascular disease, (CVD) accounts for more than 40 
percent of all U.S. deaths and is the leading cause of death in 
African-Americans. NCCAM supports a Speciality Research Center 
for CAM, Minority Aging, and CVD at the Maharishi University of 
Management in Iowa. In collaboration with traditionally black 
universities and medical schools, the Center is testing the 
efficacy of Vedic medicine, an ancient Hindi system of healing, 
for reducing mortality and morbidity associated with CVD in 
high risk, older African-Americans.
    NCCAM has also established a CAM Research Center for 
Cardiovascular Diseases to focus on the investigation of CAM 
modalities to treat and prevent CVD. The Center is employing a 
double-blind, placebo-controlled, randomized trial of a 
standardized extract of the plant Crataegus (Hawthorn) in 
patients who, despite optimal conventional medical therapy, 
continue to experience symptomatic heart failure. The goal is 
to obtain a comprehensive understanding of the potential role 
of Hawthorn in the treatment of heart failure. This study is 
also testing the effectiveness of Reiki treatment for sub-acute 
stroke inpatients. The randomized trial employs three arms: 
Reiki plus standard care, a placebo plus standard care and 
standard care alone. Additionally, the center stresses CAM 
education and promotion of validated CAM treatments for 
cardiovascular well-being.

Cancer

    More than 175,000 women will have been diagnosed with 
breast cancer in the year 2000; nearly 30 percent will 
ultimately die of the disease. Studies show that support group 
participation improves breast cancer survival rates. NCCAM and 
the National Institute of Nursing Research (NINR) are 
supporting the investigation of strategies of self-
transcendence among support group members to improve well-being 
and immune function and to increase understanding of the 
relationship between survival rates and support group 
participation.
    In 2000 NCCAM funded two Specialty Research Centers for 
Cancer dedicated to studying the safety and effectiveness of 
several popular CAM therapies. One of these centers is 
examining the anti-oxidant effects of herbs in cancer cells and 
the safety and efficacy of PC-SPES, a popular mixture of 
Chinese herbal medications, in men with prostate cancer.
    Finally, in conjunction with the National Cancer Institute, 
(NCI) NCCAM is supporting a Phase III clinical trial of shark 
cartilage in over 700 lung cancer patients in the United States 
and Canada.

Menopause

    In collaboration with the NIH Office of Dietary Supplements 
(ODS), NCCAM funds four Centers for Dietary Supplement Research 
with an emphasis on botanicals. The Centers serve to identify 
and characterize botanicals, assess bioavailability and 
activity, explore mechanisms of action, conduct preclinical and 
clinical evaluations, establish training and career 
development, and help select the products to be tested in 
randomized controlled clinical trials. In one of these centers, 
amultidisciplinary team of investigators studies the clinical 
safety and efficacy of botanicals for menopause. Additional 
studies will address identification of active compounds, 
characterizationof metabolism, and pharmocokinetics of active 
species contained in these botanicals.

Prostate Enlargement

    Benign prostatic hyperplasia (BPH), or enlargement of the 
prostate, is the most common benign tumor found in men. 
Anecdotal reports suggested that the botanical product saw 
palmetto is effective in decreasing the swelling associated 
with BPH. To determine the validity of these observations, 
NCCAM, in collaboration with the National Institute of Diabetes 
and Digestive and Kidney Diseases (NIDDK), is supporting a 
large, rigorously designed, placebo-controlled, prospective 
study to evaluate the effect of saw palmetto extract on 
symptoms and quality of life in men with moderate-to-severe 
prostate swelling.

Parkinson's Disease

    The NCCAM's multi-site, double blind study compares the 
effects of the nutritional supplement, melatonin, given at two 
different doses, and placebo on nocturnal sleep. The study 
allows for assessment of any adverse events associated with 
melatonin related to its safety and tolerableness. This 
research may lead to the development of safer, more physiologic 
therapies for treating sleep disturbances in patients with 
Parkinson's Disease.

    National Institute on Deafness and Other Communication Disorders


Genetic Association and Age-Related Causes for Hearing Loss

    Scientists are determining if different mutations in the 
same genes that cause profound hereditary hearing impairment 
also cause age-related hearing loss (presbycusis), a common 
problem for older Americans. It has been presumed for some time 
that presbycusis may be inherited and that genetic factors may 
influence the rate and severity of hearing loss. An NIDCD-
supported study involving a large population of related and 
non-related individuals has demonstrated that a clear genetic 
component exists for age-related hearing loss. The 
investigators were able to demonstrate a genetic component by 
measuring several different hearing thresholds at specific 
frequencies that are most commonly affected in presbycusis. In 
fact, estimates for the amount of a genetic component to age-
related hearing loss were greater than, or comparable to, those 
seen for blood pressure or cholesterol levels. With the ability 
to predict who is at increased risk, better strategies to 
minimize or delay hearing loss within the aging population can 
be developed.
    In another project, NIDCD-supported scientists are 
conducting basic and clinical research on the structural and 
molecular changes in the aging auditory system. Information 
from these studies should form the rationale for designing 
pharmacological and gene-based therapies for treating 
presbycusis and preventing or reducing its prevalence.

Hearing Aid Clinical Trial Yields Important Results

    The prevalence for hearing impairment significantly 
increases with age, and hearing aids are the most common means 
of assistance for persons with hearing loss. The NIDCD and the 
Department of Veterans Affairs conducted a multi-center trial, 
which included elderly volunteers, to compare the effectiveness 
of three commonly used hearing aid circuits. Data from the 
trial 0showed minimal performance differences among the three 
hearing aid circuits. Of greater importance, the trial 
demonstrated that each circuit improved speech recognition 
under both quiet and noisy listening conditions, improved the 
quality of speech for soft and conversational speech levels, 
and reduced the frequency of problems encountered with using 
hearing aids in verbal communication. NIDCD remains committed 
to support research leading to smaller and better hearing aids, 
capitalizing on bioengineering advances in microelectronics.

Vestibular Disorders in the Elderly

    Disorders of balance and the vestibular system affect a 
large proportion of the population, particularly the elderly. 
Disorders of balance and spatial orientation are common 
conditions. Based on an NIDCD analysis of the 1994-1995 
Disability Supplement of the National Health Interview Survey, 
an estimated 6.2 million Americans reported chronic problems of 
dizziness and/or balance. These problems were self-reported in 
approximately nine percent of individuals ages 65 years and 
older. Furthermore, balance-related falls account for a large 
proportion of fractures, including hip fractures, and 
accidental deaths in the elderly. Loss of body stabilizing 
information across the senses will result in problems with 
balance and gait. Scientists supported by the NIDCD are 
studying the mechanisms that control posture and equilibrium in 
stance and gait to better understand disorders of the 
vestibular system and the other body stabilizing systems. The 
scientists are determining how individuals with loss of 
vestibular function substitute sensory information from touch 
and muscle/joint sensations to maintain balance. This research 
will reveal information on how the somatosensory and the 
vestibular systems contribute to movement and stance, with aims 
in developing better rehabilitative strategies for individuals 
with balance disorders.

Molecular Mechanisms Governing Our Sense of Taste

    In humans, the loss of taste sensation can contribute to 
the loss of appetite and poor nutrition, a particularly common 
problem for older Americans. Although scientific advances have 
resulted in a better understanding of the basic mechanism of 
taste, there is still much to be learned about the cellular and 
molecular mechanisms critical for taste perception. The 
molecular pathway resulting in perception of taste is initiated 
when a sweet, bitter, salty, or sour substance binds to 
specific taste receptors found on the outer surface of taste 
cells on the tongue. In a collaboration between investigators 
supported by the National Institute of Dental and Craniofacial 
Research and NIDCD, scientists have discovered a large family 
of genes that encode taste receptors that bind bitter 
substances. The family consists of about eighty genes that code 
for receptor proteins in certain taste cells on the tongue. 
This vast array of receptors explain why structurally diverse 
molecules produce the same perception of bitter taste. These 
ground-breaking studies are crucial towards understanding the 
mechanisms underlying the sense of taste.

Aphasia

    Language deficits in the elderly are most frequently 
associated with aphasia as a result of stroke or head injury or 
with the onset of central nervous system diseases, such as 
Alzheimer's or Parkinson's disease. A language deficit may 
affect employment and social status and can result in isolation 
from family and friends. Aphasia results when the portions of 
the brain that are responsible for language are damaged. This 
disorder usually occurs suddenly and impairs bothexpression and 
understanding of language, as well as reading and writing.
    For many years, it was thought that brain activity 
associated with human language function was restricted to the 
left side of the brain. Studies of individuals with aphasia and 
other types of disorders of language function have revealed 
that other regions in the brain also participate in language 
function. Using functional magnetic resonance imaging (fMRI), 
NIDCD-supported scientists have documented reorganization of 
brain activity after treatment for acquired reading disorders 
following stroke. The neuroimaging performed during a reading 
task before and after treatment indicated a shift in brain 
activation from one area to another, showing that it is 
possible to alter brain activity patterns with therapy for 
acquired language disorders.

           National Heart, Lung, and Blood Institute (NHLBI)

    Many research areas supported by the National Heart, Lung, 
and Blood Institute (NHLBI) re closely related to the health of 
older people. The following paragraphs describe some recent 
NHLBI-supported research results of special relevance to older 
Americans.

Older (and Cheaper) Blood Pressure Drug Holds Its Own

    Although newer, more expensive, antihypertensive drugs do a 
good job of lowering blood pressure and are being prescribed 
widely by physicians, their ability to reduce cardiovascular 
events such as heart attacks has not been demonstrated. A large 
clinical trial that is comparing a diuretic with three types of 
newer drugs, including an alpha-adrenergic blocker, recently 
showed that the diuretic was superior to the alpha-adrenergic 
blocker in terms of its ability to reduce the overall incidence 
of cardiovascular disease events, and particularly the 
incidence of congestive heart failure, in patients over 55 
years of age. This finding provides valuable information for 
physicians seeking to prescribe the best and most cost-
effective drugs for their patients, particularly as the 
incidence of congestive heart failure increases as the 
population ages.
    Antibiotic Inhibits Key Enzyme Responsible for Abdominal 
Aortic Aneurysm.--Scientists recently identified MMP-9 as the 
key enzyme responsible for the development of abdominal aortic 
aneurysm (AAA), a bulging or ballooning of a weak area in the 
main artery, the aorta, as it runs from the heart down through 
the abdomen. More important, the investigators determined that 
the antibiotic doxycycline inhibits MMP-9 production. Aneurysms 
tend to grow and can eventually rupture, causing profuse 
internal bleeding that usually results in death. AAA is 
projected to affect more and more people, since up to 9 percent 
of those over 65 have AAA and since the U.S. population 
continues to age. No drug treatment is currently available to 
prevent small aneurysms from developing into larger, life-
threatening ones. The identification of MMP-9 as the key enzyme 
in AAA development and the recognition that doxycycline 
inhibits it should lead to new strategies for managing AAA. 
Additionally, results suggest that doxycycline has potential 
for preventing aneurysm growth in patients, thereby reducing 
the need for risky and expensive surgery.

Researchers Identify a Potential Therapeutic Compound for Reducing 
        Stroke Damage

    Modern treatment of many strokes includes use of a natural 
compound, tissue-type plasminogen activator (tPA), that helps 
to reestablish blood flow by dissolving clots in the blood 
vessels of the brain. However, tPA can cause serious 
complications if it leaks from the blood vessels into the brain 
cells. Additionally, studies in animal models indicate that the 
brain produces its own tPA in response to traumas such as 
stroke although, paradoxically, the expression of tPA has been 
positively associated with increased brain damage in such 
models. Scientists recently concluded that brain cells can 
reduce damage from tPA by producing an inhibitor called 
neuroserpin. Experiments in rats revealed that injecting 
neuroserpin immediately after a stroke reduces brain cell 
injury and death, indicating that neuroserpin has potential as 
a therapeutic agent to reduce the risks of hemorrhage and brain 
damage associated with tPA treatment.

Combination Therapy to Reduce Risk of Coronary Artery Disease in Women

    Research suggests a new approach for treating healthy 
postmenopausal women who are at increased risk of developing 
coronary artery disease by virtue of elevated cholesterol 
levels. A recent study found that the addition of estrogen 
replacement therapy to treatment with a cholesterol-lowering 
drug has an extra protective effect against heart disease for 
such women. Results showed that combining the two therapies was 
more effective than either treatment alone at lowering the 
level of harmful low-density lipoprotein cholesterol and 
raising the level of the beneficial high-density lipoprotein 
cholesterol. In addition, among women who also received 
estrogen the investigators observed an improved capacity of the 
blood vessel wall to break down blood clots and to resist 
inflammation, two processes important for impeding the 
progression of atherosclerosis. By reducing the risk of 
developing atherosclerosis, this combination therapy could 
reduce the risk of heart attacks and strokes, thereby resulting 
in improved quality of life and monetary savings from fewer 
hospitalizations and less need for surgery.

New Advice for Inhaled Corticosteroids to Help COPD Patients

    A recent study suggests that inhaled corticosteroids have a 
modest benefit in terms of lessened airway reactivity and 
respiratory symptoms in patients with chronic obstructive 
pulmonary disease (COPD), but have no effect on the rate of 
decline of lung function in people with mild to moderate COPD. 
COPD is a result of accelerated decline in lung function and is 
thought to be caused by inflammatory changes in the lung that 
can be initiated by cigarette smoke. Although corticosteroids 
have been widely prescribed for COPD because of their anti-
inflammatory properties, their benefit has been questioned. 
Researchers suggest that inhaled corticosteroids should be used 
only for reducing symptoms rather than as agents to modify the 
long-term course of the disease.

Blood Clot Risk Increases with Old Age

    The potential for developing blood clots, which can lead to 
heart attacks and strokes, increases throughout adulthood, but 
until now little has been known about the mechanisms 
responsible for this normal aging phenomenon. Researchers 
recently identified two elements that are responsible for age-
regulation of the human gene for blood coagulation factor IX. 
Using a mouse model, they determined that one element (called 
AE5'), is responsible for age-stable expression of the gene and 
the second element (designated AE3') controls the age-related 
elevation of expression. These findings provide a new avenue 
for understanding age-related physical disorders and 
determining potential target sites for new therapeutics for 
thrombotic disorders.

Insights into Human Cell Aging

    Researchers have used the ras gene, normally associated 
with many cancers, to study the process of aging in human 
cells. By adding an active form of the gene to human cells 
being grown in laboratory culture, investigators were able to 
induce rapid cellular aging. This occurred because the gene 
dramatically increased the intracellular levels of highly 
reactive forms of oxygen known as free radicals, which can 
function as oxidants and are known to be capable of damaging 
various cellular components. The investigators also determined 
that the chief sources of free radical production were 
mitochondria, which are small structures found scattered 
throughout the cell. Furthermore, these scientists have 
preliminarily identified a class of chemical compounds that 
appear to significantly inhibit the level of mitochondrial 
free-radical production without being toxic to the cells, 
suggesting that an approach using inhibitors of free radicals 
may have potential as one possible strategy for slowing the 
aging process.

               The National Institute of Nursing Research

    The National Institute of Nursing Research (NINR) supports 
studies that address 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 issues to ensure that dying 
patients receive compassionate and life-affirming health care 
that promotes comfort and dignity.
    The National Institute of Nursing Research (NINR) supports 
studies that address health issues of older people, including 
preserving cognition and ability to function; prevention of 
illness and disability; health promotion strategies; management 
of symptoms of chronic diseases, including pain; interventions 
for family caregivers to help them maintain their own health as 
well as that of their relatives; and end-of-life issues to 
ensure that dying patients receive compassionate and life-
affirming health care that promotes comfort and dignity.
    Below are examples of findings during 1999-2000.
           Nursing research has developed a successful 
        arthritis self-management program in Spanish. To test 
        the effectiveness of the program, the investigator 
        analyzed the results of a 6-week course led by lay 
        community members involving 219 participants and 112 
        controls originating from Mexico and Central and South 
        America. The mean age was 62 and a half, and about 85 
        percent were women. Four months after the program, 
        there were notable improvements among those who took 
        the course in range of motion exercise, degree of 
        disability, relief of pain, and self efficacy. A year 
        after the course, participants showed significant 
        improvements in these areas and in self-reported health 
        status and depression. Not only was this hard-to-reach 
        Spanish language population recruited and retained for 
        the course and its evaluation, but they provided 
        important research information and showed continued 
        improvement in their health.
           Research has been conducted in a population 
        of women aged 55 through 75 before coronary artery 
        bypass surgery and one year after. Although they 
        experienced weight loss following surgery, 58 percent 
        of the women continued to be obese, and their dietary 
        intake of fat and cholesterol remained above 
        recommended levels. Blood pressures significantly 
        increased, and 54 percent of patients continued to 
        exhibit hypertension one year after surgery. One-third 
        exceeded recommended levels for triglycerides, 78 
        percent for total cholesterol, and 92 percent for low-
        density lipoproteins. These findings indicate a high 
        risk for future coronary heart disease for these women 
        and a need for healthcare professionals to design 
        prevention strategies for the women's lives after 
        surgery.
           A study of genetic influences for obesity 
        and weight loss has identified variants in PPAR-gamma-2 
        and LPL genes that can serve as potential indicators of 
        obesity and successful weight loss among older, 
        postmenopausal women. These women were placed on a 
        regimen of moderate, regular exercise and a heart-
        healthy diet. Those with the LPL Pvull variant of a 
        gene pair had higher total cholesterol, low-density 
        lipoprotein cholesterol and fasting glucose than women 
        with the normal LPL Pvull gene, thus placing them at 
        increased risk for atherosclerosis. Further, although 
        women with the PPAR gamma-2 variant of a gene pair were 
        highly successful in losing weight, their ability to 
        maintain weight loss was far less successful than women 
        with two normal copies of the gene. They had a nearly 
        two-fold rate of weight regain at 18 months after the 
        intervention was completed. They also had a larger body 
        mass index and a greater increase in insulin 
        sensitivity, which may contribute to their more rapid 
        weight gain. This finding adds important information 
        for development of weight management strategies.
           It is important that caregiver health, as 
        well as that of the patient, be assessed by health care 
        professionals. Research has shown that caregivers who 
        themselves have physical problems are at greater risk 
        for psychological distress. An intervention that better 
        prepares them for their tasks can minimize this 
        distress in the long term and improve the well being of 
        both caregiver and patient. Research comparing a home 
        care intervention using oncology nurse clinical 
        specialists with standard home care found that patients 
        showed 32 percent less distress. Sixteen percent of 
        patients improved function for up to six weeks longer 
        than patients receiving standard care. After the 
        patients died, spouses who were followed for 13 months 
        showed 28 percent less psychological distress. The 
        oncology nursing intervention included providing 
        caregivers with skills training in assessing and 
        monitoring problems, managing symptoms, and taking care 
        of themselves.
           In the absence of specific advance 
        directives, health care providers must rely on 
        decisions made by the patient's family or friends when 
        the patient can no longer communicate adequately. At 
        issue is whether the choices these surrogates make are 
        in tune with what the patient would wish. Researchers 
        looked at how closely these decisions are reflective of 
        the patient's decision by posing three hypothetical 
        clinical scenarios (permanent coma, small chance of 
        survival, severe dementia) to dying patients and their 
        surrogate decisionmakers. Researchers found that 66 
        percent of the time, the surrogates predicted 
        accurately the patients' wishes - under the coma 
        scenario, they made accurate predictions with 84 
        percent accuracy. Among those whose decisions differed 
        from the patient, there was no trend either for or 
        against treatment.

                 National Center for Research Resources

    The National Center for Research Resources (NCRR) creates, 
develops, and provides a comprehensive range of human, animal, 
technological, and other resources to enable biomedical 
research advances in aging research. NCRR serves as a 
``catalyst for discovery'' for NIH-supported investigators by 
supporting resources in four areas: Biomedical Technology, 
Clinical Research, Comparative Medicine, and Research 
Infrastructure.

Growth Patterns in the Developing Brain Using Continuum Mechanical 
        Tensor Maps

    The dynamic nature of growth and degenerative disease 
processes requires the design of experimental protocols to 
detect, track, and quantify structural changes in the brain. 
Researchers at UCLA have created complete four dimensional 
(x,y,z, and time) maps of growth patterns in the developing 
human brain. A new tensor mapping strategy allows much greater 
spatial detail and sensitivity than was previously obtainable. 
A major finding of the research was that different parts of the 
brain grow at markedly different rates during the development 
of a normal child. The researchers also found that the same 
areas of the brain that grow fastest in children degenerates 
fastest during the early stages of Alzheimer's disease. The 
sensitivity of the new experimental protocol may offer 
advantages in tracking the effects of various treatments for 
Alzheimer's disease. This approach can also be extended to 
evaluating the effect that treatments have on other age-related 
diseases affecting the brain such as dementia.

Detection of Neuritic Plaques in Alzheimer's Disease by MR Microscope

    Researchers at Duke University Medical Research Center have 
used Magnetic Resonance Microscopy as a means to identify 
neuritic plaques, the neuropathological hallmark of Alzheimer's 
Disease, in autopsy tissue specimens. Experimental parameters 
were identified to supply sufficient contrast in the magnetic 
resonance microscopy signal to visualize the plaques in vitro 
and correlate them with histological samples. Future and 
ongoing efforts are focused on applying this technology in 
vivo, for example in transgenic rodents overexpressing amyloid 
protein. The ability to detect and follow the early progression 
of amyloid-positive brain lesions will greatly aid and simplify 
the many possibilities to intervene pharmacologically in 
Alzheimer's disease. Ultimately, results gained from such 
studies would benefit humans afflicted with Alzheimer's disease 
and related neurodegenerative disorders associated with aging.

Proton Emission Tomography (PET) Scans in Aged Monkeys

    Aged rhesus monkeys were used in studies at the California 
Regional Primate Research Center to assess safety and survival 
of intracranial grafts. Fibroblastic cells containing a gene 
for the expression of nerve cell growth factor were implanted 
into the cerebrum and were monitored by PET imaging. The 
initial studies suggest that such an approach could be 
successfully used as a potential treatment for Alzheimer's 
disease. This delivery of nerve cell growth factor might 
prevent the death of crucial neurons and ameliorate the effects 
of aging on the central nervous system.

Cognitive studies of aging monkeys

    All of the Regional Primate Research Centers have 
significant populations of aging nonhuman primates, principally 
rhesus macaques, which are being studied to determine the 
behavioral, physiologic and pathologic events which occur 
during aging in a controlled and closely monitored setting. The 
NCRR cooperates with a program of the NIA to study the effects 
of dietary restriction on the aging process which shows that, 
as in rodent studies, caloric restriction is effective in 
retarding the aging process. Investigators at the Oregon, 
Tulane, Wisconsin, Emory and California Regional Primate 
Centers are conducting cognitive research on aging monkeys. 
Studies at the Yerkes Center at Emory are examining the neural 
substrates of cognitive decline in aging rhesus to identify the 
specific cell populations which are important in this decline. 
At the same center, the effects of age and stress are being 
examined in the female rhesus monkey population.

Less Estrogen May Be Just As Effective in Preventing Post-menopausal 
        Osteoporosis

    Osteoporosis, a dangerous thinning of the bones, affects 
millions of Americans, 80 percent of whom are women. Millions 
also suffer from low bone mass, an early warning sign of the 
disease, which can lead to painful, debilitating breaks. 
Osteoporosis is associated with a decrease in estrogen after 
menopause. Replacing estrogen with supplements can slow the 
erosion of bone, as can a number of drugs. Researchers at the 
University of Connecticut General Clinical Research Center 
compared three daily doses of the estrogen estradiol--0.25 mg, 
0.5 mg, 1 mg, the typical treatment dose,--and placebo in women 
age 65 and over. To gauge how well the treatments worked, the 
scientists looked for markers related to bone turnover at 
regular intervals over the three-month study. All doses of 
estrogen helped control bone destruction, but the 0.25 mg dose 
yielded essentially the same response as the 1.0 mg dose. 
However, the women taking the 0.25 mg dose of estrogen reported 
less breast tenderness, and only one woman in the 0.25 mg group 
had bleeding or spotting, compared with eleven in the 0.5 and 1 
mg groups. And, while women taking 1 mg had a marked increase 
in the thickness of the womb tissue, those in the 0.25 mg and 
placebo groups did not. It appears that a lower dose of 
estrogen may prevent osteoporosis as well as the usual, higher 
dose, but with fewer side effects and potentially less risk of 
uterine and breast tumors.

Risk for Alzheimer's Disease in Ethnic Minorities

    The 4 allele of the apolipoprotein E gene (APOE) 
is the chief known genetic risk factor for Alzheimer's disease 
(AD), the most common cause of dementia late in life. At the 
Columbia University General Clinical Research Center in New 
York, an ongoing series of studies is examining the interaction 
of genetic factors and ethnicity on AD risk. A major previous 
finding was that the relative risk of AD associated with one or 
more copies of the 4 allele was significantly 
increased in whites, but not in African Americans or Hispanics. 
A more recent study of familial aggregation of AD confirms that 
genetic factors, but not necessarily the same ones, contribute 
to AD in ethnically diverse communities. The total magnitude of 
the genetic risk component of AD seems to be the same in 
whites, African Americans, and Hispanics. However, in light of 
the weaker contribution of the 4 allele to AD risk in 
African Americans and Hispanics compared with whites, other (as 
yet unknown) genetic risks factors must be present in these 
groups.

Relationship of Parkinson's Disease and Rebound Burst Firing in Rat 
        Subthalamic Neurons

    The subthalamic nucleus (STN) of the basal ganglia is 
important in both normal movement and movement disorders. 
Lesioning or deep-brain stimulation of the STN can alleviate 
resting tremor in Parkinson's disease. Electrophysiologic data 
and therapeutic effect of inactivating the STN strongly 
indicate that this structure is involved in the origin of 
parkinsonian tremor in Parkinson's disease patients. 
Reciprocally connected glutamatergic subthalamic and GABAergic 
globus pallidus neurons have recently been proposed to act as a 
generator of low-frequency oscillatory activity in Parkinson's 
disease. The investigators results suggest that synchronous 
activity of pallidal neuron inputs could underlie rhythmic 
bursting activity of subthalamic neurons which results in 
tremor in Parkinson's disease.

Aging and Central Interleukin-1 Beta Control of Glucose Homeostasis

    Impaired glucose metabolism has long been associated with 
aging. Investigators funded through the Institutional 
Development Award Program (IDeA) have found that injection of 
interleukin-1beta (IL-1b) into the brain causes inhibition of 
insulin secretion and that this inhibition occurs in the 
presence of elevated plasma glucose levels. The investigators 
propose that increased levels of IL-1b within the brain of old 
rats compared to younger rats are responsible for altered 
regulation of insulin secretion. The control of insulin 
secretion by brain levels of IL-1b could be a contributing 
factor in age-related insulin resistance and non-insulin 
dependent diabetes mellitus.

        National Institute of Child Health and Human Development

    The National Institute of Child Health and Human 
Development (NICHD) supports a broad research portfolio that 
has far-reaching implications for human development throughout 
the entire lifespan. Listed below are some examples of the 
Institute's recent initiatives that may be most directly 
related to issues of human aging.

Potential Avenue for Treating Aging or Damaged Brains

    Information gained from neurobiological research is 
challenging old theories about the functioning of the central 
nervous system--specifically, whether old or damaged nerve 
cells can eventually be regenerated or repaired. Once thought 
to be fixed at birth, the number of nerve cells in an 
individual's brain may in fact change to help maintain 
stability later in life, and may be responsive to signals 
outside the cell. NICHD-supported researchers have discovered 
that, instead of decreasing, the number of brain cells is 
actively maintained throughout life. They also found that a 
specific protein, basic fibroblast growth factor, not only 
regulates, but stimulates nerve cell growth. Ultimately, 
treatment with growth factors may help slow the onset of 
neuronal damage, help repair injured brain cells, and stimulate 
replacement of nonfunctional or dead brain cells, offering hope 
to patients with Alzheimer's disease and acute injuries due to 
stroke and trauma.

Older Women's Health

    The transition to menopause encompasses a wide ranging set 
of changes for women. For at least half of their adult lives, 
most women will be affected by decreased levels of the hormone 
estrogen that accompany menopause. Recently, NICHD-supported 
researchers provided important new information about cognitive 
function in postmenopausal women and the possible benefit of 
hormone replacement therapy. They used functional magnetic 
resonance imaging to study the effects of estrogen replacement 
on women's brain activation patterns, finding that estrogen 
actually changed those patterns. These findings indicate that 
the memory systems of mature women are not fixed or immutable 
as previously believed and are responsive to external stimuli.
    In another clinical study funded by NICHD, researchers 
found that nearly two-thirds of women who experienced premature 
ovarian failure (POF) had increased risk for hip fracture due 
to bone loss. Of all bone injuries, hip fractures pose the 
greatest threat, leading to death in some cases and significant 
disability in others. Because estrogen replacement therapy 
alone has been ineffective at stemming bone loss for some of 
these women, researchers are now investigating whether adding 
small amounts of testosterone to the estrogen therapy will 
help.
    Through a Small Business Innovation Research Grant, NICHD 
investigators have developed a new approach to correct urinary 
incontinence. This condition affects nearly twice as many women 
as men; ``stress incontinence,'' in particular, often occurs in 
women due to weakening of the muscles after childbirth or 
menopause. Using recombinant DNA technology, scientists 
developed special polymers that strengthen damaged muscles 
after injection. This discovery holds promise for restoring 
independence and improving quality of life for millions of 
women.

Heart Disease

    One of NICHD's areas of major emphasis involves the 
scientific search for ways to predict adult disease, which in 
turn can often lead to premature aging or death. In one effort, 
scientists examined children's blood levels of the amino acid 
homocysteine to determine if it was associated with their 
parents' history of coronary heart disease. They found that 
significant differences in these levels were associated with 
differences in parents' history of coronary heart disease and 
high blood pressure. Thus, homocysteine levels in childhood 
have become another possible marker for coronary heart disease 
later in life.

Obesity

    Obesity is one of the most widely known risk factors for a 
range of adult diseases. In one study, NICHD researchers found 
that certain ``homeobox'' genes control the origin of fat 
cells. Hoemobox genes are the ``master genes'' that determine 
the pattern in which embryos develop and direct the formation 
of specialized body genes. The researchers identified 10 
different genes that direct early cells to transform themselves 
into fat cells. Further studies may help determine how these 
processes can be altered or blocked.
    On a related front, the prevalence of obesity is increasing 
so rapidly in children of minority populations that an epidemic 
of Type 2 diabetes is appearing in Hispanic and Native American 
adolescents, far earlier than usual. Obesity, Type 2 diabetes, 
and fat metabolism disorders have their origins in the 
interaction of an individual's genes and the intrauterine and 
post-birth environments. In a trans-NIH effort, NICHD will 
support grants to identify variations in coding sequences and 
regulatory regions of genes that may contribute to obesity and 
related chronic diseases.

                      National Library of Medicine


Initiatives To Help Seniors Access Health Information

    The National Library of Medicine joined the National Heart, 
Lung, and Blood Institute, the Office of Research on Women's 
Health, and the Department of Health and Human Service's Health 
Care financing Administration to release findings of a jointly 
sponsored project to ``train trainers'' of senior citizens from 
around the country in how to access health information on the 
Internet. Results of the project indicate that training had a 
positive impact on seniors' confidence in using computers and 
the Internet, in conducting consumer health information 
searches online, and in sharing health care information with 
doctors, families and friends. The report also found that 
seniors can learn to use the Internet and don't want to be left 
behind on the information superhighway. Two-thirds of those who 
search for health information on the Internet talked about it 
with their doctors, and more than half indicated they were more 
satisfied with their treatment as a result of their search. The 
findings suggest that the ``rain the trainer'' approach may be 
used successfully to enable older adults to access credible 
medical information on the Internet. The report, ``Internet 
Train-the-Trainer Program for Older Adults,'' may be requested 
from the Library's Office of Communications and Public Liaison.
    To make the ``Train the Trainer'' program more widely 
available, the National Library of Medicine is supporting the 
development of an online training curriculum which will be 
tested by trainers in senior centers in selected states 
nationwide. This project is administered by the SPRY (Setting 
Priorities for Retirement Years) Foundation in Washington, D.C. 
SPRY is a nonprofit national organization devoted to research 
and education efforts on senior citizens health and retirement 
issues.
    Development Of A Health Website for Older Americans.--The 
National Library of Medicine recognizes that more and more 
older people are using the Internet as a source of health 
information. A survey conducted by Microsoft and the American 
Society on Aging found that 24 percent of seniors age 60 or 
older use computers, and that number is growing daily. Many 
older Americans who log on for health information turn to the 
websites of the National Institutes of Health, where they know 
they can receive free, reliable, comprehensive, and timely 
information. To better serve this population, NLM and the 
National Institute on Aging (NIA) will continue their 
development of a website designed for older Americans during 
2001. A jointly sponsored NLM/NIA pilot to determine the 
usability of this new website is underway in several senior 
centers in Maryland and the District of Columbia. Upon the 
pilot's completion, the website will incorporate recommended 
improvements and add topics of primary interest to senior 
citizens. This new website will serve as an entry point to 
MEDLINEplus for seniors as well as a distance learning site 
specifically geared to older populations and their caregivers. 
Web-based courses will not only contain information seniors 
want and need, they will be designed based on NIA-funded 
research about cognitive function, computer use and 
technological interface among senior populations.

         National Institute of Allergy and Infectious Diseases

    The National Institute of Allergy and Infectious Diseases 
(NIAID) supports and conducts basic and clinical research on 
several diseases and conditions that affect the health of older 
Americans. Several research initiatives are yielding advances 
in the understanding and treatment of these disorders.

Shingles

    Shingles (zoster) is caused by the same virus, varicella-
zoster (VZV) that causes chickenpox (varicella). Primary 
infection with VZV manifests as chickenpox; after a latent 
period, reactivation of the virus leads to shingles. Current 
research is aimed at preventing shingles and shingles-
associated pain in otherwise healthy older Americans.
    Every year, 600,000 to one million Americans are diagnosed 
with shingles. A person has a one-in-five chance of developing 
shingles in his or her lifetime. More than half of shingles 
cases occur in persons 60 years or older, and the incidence and 
severity of shingles and its complications increase with 
increasing age. During the next 30 years, as the number of 
American seniors continues to increase, the need for a shingles 
vaccine will grow.
    The Shingles Prevention Study (SPS) is a national trial of 
an experimental vaccine for the prevention of shingles and its 
complications in people 60 years or older. The SPS is being 
conducted by the Department of Veterans Affairs in scientific 
collaboration with NIAID and Merck & Co., the vaccine's 
developer. The SPS will enroll 37,200 volunteers across the 
United States. The vaccine being studied is a more potent form 
of the same vaccine routinely given to children to prevent 
chickenpox.

Pneumococcal Disease

    Streptococcus pneumoniae, also called pneumococcus, is a 
bacterium that infects the upper respiratory tract and can 
spread to the blood, lungs, middle ear, or nervous system. In 
the United States, S. pneumoniae causes 40,000 deaths, 7 
million middle ear infections (otitis media), 500,000 cases of 
pneumonia, 50,000 blood stream infections (bacteremia), and 
3,000 cases of meningitis annually. Pneumococcal disease kills 
more Americans each year than all other vaccine-preventable 
diseases combined. Adults 65 years old and older are among the 
people disproportionately affected by pneumococcal disease. 
Pneumococcal disease can be difficult to treat because it has 
become more resistant to drug treatment. This makes prevention 
of the disease through vaccination even more important. NIAID 
has conducted and supported research on pneumococcal vaccine 
development for more than 30 years.
    Two Phase I/II trials will be conducted in a high risk 
population to determine what impact a multivalent pneumococcal 
conjugate vaccine has on safety and immunogenicity when 
administered to elderly individuals. Multiple injections of a 
9-valent and an 11-valent pneumococcal conjugate vaccine in 
addition to a propriety adjuvant will be given to study 
participants using several different vaccine schedules. Due to 
the large number of vaccinations, vaccine safety will be 
closely monitored. One trial has begun, and the second trial is 
scheduled to begin within the next couple of months.

Immune Response in the Elderly

    Several of the most common afflictions of the elderly 
involve the immune system, directly or indirectly. 
Historically, the aging of the immune system has not received 
research attention equal to that of other aspects of 
immunology. The effects of aging on the immune system have not 
been widely appreciated by immunologists until fairly recently. 
Several ongoing NIAID research projects should add to the body 
of knowledge about the effects of aging on the immune system.
    A Program Project titled ``Molecular Aspects of Human 
Lymphopoiesis'' is uniting four investigators in studies of the 
development of the immune system. Two of the projects focus on 
the effects of aging on B cell development. The combined 
efforts of these investigators should yield new insights into 
the molecular events in human lymphocyte development and 
abnormalities which lead to immunodeficiencies, autoimmunity, 
and malignancies in the elderly.
    A project titled ``Costimulatory Interactions During the 
Aging Process'' will examine CD4 T cells, which play a pivotal 
role in immunity, primarily by directing responses of other 
lymphoid cells. It is generally accepted that CD4 T cell 
function in aged individuals is diminished, although the 
reasons and mechanisms responsible for this are not clear. This 
study explores several potential explanations for the decrease 
in CD4 T cell function as people age. This research also may 
provide novel findings with regard to T cell-antigen presenting 
cell interactions during the aging process and may highlight 
ways in which hyperesponsiveness can be corrected.

        National Institute of Neurological Disorders and Stroke

    The National Institute of Neurological Disorders and Stroke 
(NINDS) supports research on disorders of the nervous system, 
which includes the brain, spinal cord, and nerves of the body. 
Many nervous system diseases present special problems or are 
markedly prevalent among older people. These include not only 
the classical neurodegenerative diseases of aging, such as 
Parkinson's and Alzheimer's, but also chronic pain, epilepsy, 
trauma, and many other disorders. For this reason, much of the 
research that NINDS supports is relevant to problems of aging.
    In order to more effectively carry out is mission, NINDS 
has embarked on a strategic planning process, engaging the 
efforts of more than 100 of the nation's experts in clinical 
and basic neuroscience. This process produced a five-year 
strategic plan for the Institute, Neuroscience at the New 
Millennium. One immediate outcome of the planning process was 
the reorganization of the Institute's extramural programs into 
seven cross-cutting areas of research emphasis that follow our 
current understanding of the nervous system and disease. One of 
these, Neurodegeneration, reflects the increasing recognition 
that common mechanisms contribute to the many neurodegenerative 
disorders that are caused by the progressive death of neurons, 
such as Alzheimer's and Parkinson's diseases. Another focus 
area, Clinical Trials, will help improve both the number and 
quality of clinical trials that are supported by the Institute. 
Neurodegenerative diseases are an obvious target of many of 
these trials, as are other disorders, such as stroke, that have 
a disproportionate impact on older individuals. Other planning 
activities are underway that complement this initial effort. 
These activities, and selected research highlights of 
particular significance to the field of aging research, are 
described below.

Parkinson's Disease

    To complement its strategic planning activities, which 
emphasize cross-cutting themes, NINDS has also begun planning 
efforts focused on specific disorders. The first of these, 
targeting Parkinson's disease, was initiated in January 2000 
with a major planning conference that included NIH staff, 
researchers, clinicians, and advocacy group representatives. 
Based on the recommendations from this meeting, NINDS, along 
with several other institutes, developed a five-year NIH 
Parkinson's Disease Research Agenda, which was released in 
March 2000. This agenda outlines a number of strategies that 
the NIH will utilize in enhancing research progress in this 
area.
    To help carry out the Parkinson's Agenda, NINDS has 
developed a Parkinson's Disease Implementation Committee that 
includes Institute staff, extramural researchers, and members 
of the advocacy community. This Committee monitors progress and 
suggests new directions for implementation in response to new 
findings. NINDS has taken several actions to make progress on 
the plan as rapidly as possible. In March 2000, the Institute 
convened representatives of the 11 currently funded Morris K. 
Udall Parkinson's Disease Research Centers of Excellence to 
discuss research being conducted at each center and to 
coordinate ongoing and future collaborations. NINDS has awarded 
supplements to Udall centers for critical projects highlighted 
in the agenda such as expediting drug discovery, identifying 
Parkinson's genes, and investigating Parkinson's disease in 
minority populations. Other NINDS actions include a Request for 
Applications (RFA) on parkin, a protein implicated in the 
early-onset forms of Parkinson's, an RFA on the role of 
mitochondria in neurodegeneration, and the funding of several 
projects in response to an RFA on deep brain stimulation. Deep 
brain stimulation is a novel therapy that holds promise for 
providing symptomatic treatment for some Parkinson's patients. 
A follow-up RFA will focus on other aspects of this form of 
therapy. Other program activities in the planning stages 
include an RFA for a large-scale clinical trial on 
neuroprotective agents to slow the progress of Parkinson's. 
Lastly, Parkinson's disease was highlighted in two recent 
meetings sponsored by the Institute, the first a workshop on 
Gene Therapy, and the second a meeting of the Therapeutic 
Opportunities in Parkinson's Disease Working Group, both held 
in late 2000. Both will guide the Institute in further efforts 
in these areas.
    Over the past several years, NINDS-supported researchers 
have made several significant findings, including:
           Demonstration of the potential of stem cell 
        transplantation in animal models of Parkinson's 
        disease, and the development of a technique to 
        stimulate cultured embryonic stem cells in mice to 
        develop into large numbers of dopamine neurons that may 
        someday be useful in cell replacement therapies in 
        Parkinson's patients.
           Generation of a new rodent model of 
        Parkinson's disease using exposure to the pesticide 
        rotenone. The cellular changes that take place in this 
        model of Parkinson's bear such a close similarity to 
        the changes that take place in the human brain as a 
        result of Parkinson's, that this model should prove 
        exceedingly useful in studying both the cellular basis 
        of the disease and in evaluating treatments at the 
        preclinical stage.
           Demonstration that the delivery of specific 
        growth factors in a primate model of Parkinson's 
        disease can be successfully achieved using gene 
        therapy, and that this technique can slow the disease 
        progression in these animals. This was a critical final 
        step before this approach can be initiated in human 
        patients.
           Characterization of the genes that cause 
        Parkinson's in different forms of the disease. These 
        studies suggest that important similarities exist 
        between genetic changes in early-onset and late-onset 
        forms of Parkinson's. Other research has expanded our 
        knowledge about how multiple genetic events, each 
        impacting a different protein family, may be involved 
        in the degeneration of affected neurons.

Alzheimer's Disease

    In efforts coordinated with other institutes at NIH, NINDS 
provides support for a broad range of studies in the area of 
Alzheimer's disease. To foster the transition from preclinical 
findings to human testing as efficiently as possible, the 
Institute, along with the NIMH and NIA, issued two joint 
Program Announcements (PAs) encouraging the submission of 
Alzheimer's Disease Pilot Clinical Trial Planning Grants and 
Clinical Trial grant applications in early 1999. In addition, 
an RFA was released in December 2000, in the area of vaccine 
and immune therapies for Alzheimer's disease. The ultimate 
effect of these program initiatives will not be known for some 
time, but the goal of these activities is to accelerate the 
development of therapies for Alzheimer's disease towards 
clinical testing. NINDS continues to coordinate these, and 
other, research activities in Alzheimer's disease with all 
other institutes working in this field, including NIA and its 
Alzheimer's Disease Center Program.
    Recent research highlights in NINDS-supported Alzheimer's 
disease research include:
           Characterization of the mechanisms by which 
        changes in amyloid beta protein, a cellular hallmark of 
        Alzheimer's disease, lead to neuronal cell damage. A 
        recent study suggests that the conversion of this 
        protein to a fibrillar form may lead to abnormal, and 
        ultimately toxic, interactions with the cell membrane 
        of affected neurons.
           Discovery of a novel mutation in the amyloid 
        precursor protein gene, which may play a role in the 
        development of early-onset Alzheimer's.
           Validation of the theory that the 
        presenilins play an important role in the cleavage and 
        ultimate buildup of amyloid beta protein, confirming 
        that these proteins are an appropriate therapeutic 
        target in Alzheimer's research.
           Demonstration that improved magnetic 
        resonance imaging techniques may be useful in 
        identifying early cognitive changes in individuals at 
        risk for Alzheimer's disease.

Stroke

    Stroke research is a high priority of NINDS because of the 
enormous public health burden and the opportunities science 
presents for progress against stroke. As with Parkinson's and 
Alzheimer's, increasing age is also a risk factor for stroke. 
It has been reported that the chance of having a stroke more 
than doubles for each decade of life after age 55. NINDS is 
engaged in a broad range of activities, from targeted programs 
of public education and prevention, to the design of large-
scale clinical trials of therapeutic agents, and fundamental 
research on how stroke damages brain cells. To enhance these 
efforts, the Institute is now developing a five-year plan for 
stroke research, which will identify topics in need of 
additional study and strategies to improve stroke prevention 
and develop new therapies. The initial organizational phase is 
underway with a planning workshop anticipated by late 2001. 
NINDS will collaborate with other NIH institutes and voluntary 
health organizations in this effort, as it has in many stroke 
related activities in the past.
    In the past two years NINDS-supported researchers have made 
several significant research findings in the area of stroke 
research, including:
           The development of a vaccine that, in animal 
        models of stroke and epilepsy, is capable of reducing 
        damage to the brain caused by these disorders. The 
        vaccine causes the body to produce antibodies to a 
        specific neurotransmitter receptor that has been 
        implicated previously in neuronal cell death.
           The identification of a novel method of 
        introducing genes into the nervous system, across the 
        blood-brain barrier (BBB). The BBB has traditionally 
        acted as an obstacle in the delivery of therapeutic 
        agents to the central nervous system.
           The discovery that individuals experiencing 
        transient ischemic attacks (TIAs) have a much greater 
        risk of experiencing a full-blown stroke shortly after 
        the attack. Intervention with agents such as blood 
        thinners or surgery after a TIA may be useful in 
        preventing subsequent strokes, if patients can be 
        identified and treated rapidly.
    Over the past few years, NINDS has also been involved in a 
number of broad-based stroke education activities, including:
           Creation of a multi-faceted communication 
        effort to raise awareness of the signs of stroke, the 
        need for urgent action, and the possibility of a 
        positive outcome with timely hospital treatment.
           Collaboration with the Brain Attack 
        Coalition (BAC), a group of professional, voluntary, 
        and government groups dedicated to reducing the 
        occurrence, disabilities, and death associated with 
        stroke. Recent accomplishments of this collaboration 
        include the distribution of a stroke symptom list that 
        is now used by all participating BAC organizations, 
        publication of the first clearly defined set of 
        recommendations for hospitals to update their stroke 
        treatment strategies, and creation of a web-based 
        resource for healthcare professionals to provide the 
        latest tools for diagnosis and treatment of stroke.
           Development of a series of public education 
        materials including: airport dioramas jointly sponsored 
        with the National Stroke Association, billboard 
        displays, consumer education brochures, exhibits, and 
        new television and radio public service announcements, 
        all designed to increase awareness of stroke.
           Involvement in a number of community-based 
        stroke awareness activities, both locally and in other 
        regions of the country.

        The National Institute of Environmental Health Sciences

    The National Institute of Environmental Health Sciences 
(NIEHS) explores the environmental factors that contribute to 
human disease, especially the interaction between environment, 
susceptibility, and time over the age span. Understanding of 
these interactions is a key step in promoting seniors' health, 
which manifests the influences of a lifetime of environmental 
exposures. Research on the effects of the environment on aging 
and diseases of aging has been increasing for the past few 
years at the NIEHS. Various NIEHS research activities in the 
area of aging are highlighted below.

Parkinson's Disease

    During 1999-2000 the NIEHS released two requests for 
applications (RFAs) associated to an age-related ailment, 
Parkinson's disease. Parkinson's disease is a neurologic 
disorder marked by a progressive loss of motor function 
resulting from the degeneration of neurons in the area of the 
brain that controls voluntary movement. The average age of the 
onset of this disease is 57. The prevalence of Parkinson's 
disease (PD) is estimated to be approximately 500,000 in the 
general population, with about 50,000 new cases appearing each 
year. Recent evidence has shown that genetics plays less of a 
role and environmental factors play a potentially greater role 
than previously thought in the progression of late-onset PD. 
The purpose of one RFA was to stimulate the career development 
of physician-scientists engaged in research on the factors that 
cause PD. The other RFA was to encourage research aimed at 
revealing the role of the environment in the occurrence of 
Parkinson's disease. The results of these investigations will 
contribute to clarifying the part environmental factors play in 
the development of this disease.

Cancer

    The NIEHS also has a number of intramural researchers who 
are studying aspects of the aging process and certain diseases 
associated with them. An NIEHS investigator is addressing the 
problem of cancer in the elderly. By studying aging at the 
molecular level this scientist hopes to uncover factors that 
influence the development of cancer that create major health 
problems for the aged. More importantly this research may offer 
new insights on how to treat or prevent cancer. Another 
researcher is expanding a technique that will help to better 
study chemical exposures and brain development. This research 
will examine how these chemicals disrupt neurological functions 
and help determine how these exposures affect cognitive 
function later in life. Other intramural researchers are 
studying various components of the aging process to better 
understand how the environment may cause certain diseases or 
cause them to progress faster thereby producing destructive 
health effects later in life. All of these studies should help 
to better understand the aging process and develop better 
intervention and prevention strategies.
    Additionally, NIEHS grantees are working to determine how 
various environmental exposures affect the development of 
assorted diseases in the later stages of life. For example, in 
three separate studies researchers are examining the effects of 
lead, methylmercury, and aluminum exposure and the development 
of chronic diseases such as hypertension and decreased 
cognitive functioning. Determining the consequences of these 
exposures, especially related to cognitive function through the 
aging process, will help understand how to provide therapies 
and intervention strategies to reduce harmful health impacts.

                HEALTH RESOURCES SERVICES ADMINISTRATION


                     Bureau of Primary Health Care

    The Bureau of Primary Health Care (BPHC) helps assure that 
primary health care services are provided to persons living in 
medically underserved areas and to persons with special health 
care needs. It also assists States and communities in arranging 
for the placement of health professionals to provide health 
care in health professional shortage areas. The BPHC provides 
services to older Americans through BPHC-supported Health 
Centers, Migrant Health Centers, Health Care for the Homeless 
Program sites, Public Housing Primary Care Program sites, the 
National Health Service Corps, and the Division of Federal 
Occupational Health.
    In April 2000, the Health Resources and Services 
Administration approved BPHC's establishment of the ``Healthy 
Aging Initiative.'' BPHC named Marion E. Primas, Ph.D., M.S., 
Director of this initiative and she is located in the Division 
of Programs for Special Populations. A number of activities 
have been launched including internal and external 
infrastructure building around the following areas of focus:
          (1) Reimbursement (dual Medicare and Medicaid health 
        coverage)
          (2) Outreach (improved methods to bring older persons 
        into care)
          (3) Quality (appropriate health care specific to 
        client needs)
          (4) Modeling of effective approaches for adaptation 
        in other communities
    Partnerships are being developed with Primary Care 
Association Members and Primary Care Offices throughout the 
Nation. We are collaborating with other Department of Health 
and Human Services programs, (e.g., the Administration on 
Aging, the National Institutes of Health's National Institute 
on Aging and the National Cancer Institute) and the Department 
of Education's Office of Special Education and Rehabilitation 
Services. Collaborating organizations also include the American 
Association of Retired Persons, the Helen Keller National 
Center, the American Foundation for the Blind, the National 
Center and Caucus on Black Aging, Inc., the National Asian 
Pacific Center on Aging, and the National Council of Hispanic 
Aging.

                      Consolidated Health Centers

    On October 11, 1996, the President signed the Health 
Centers Consolidation Act of 1996. This Act consolidates the 
Community Health Centers, Migrant Health Centers, Health Care 
for the Homeless Programs, and Public Housing Primary Care 
Programs under a single statutory umbrella that revised section 
330 of the Public Health Service (PHS) Act. Health Center 
programs are designed to promote the development and operation 
of community based primary health care service systems in 
medically underserved areas for medically underserved 
populations. Legislation governing this program can be found in 
section 330 the PHS Act, as amended (42 U.S.C. 254b). The 
Health Centers Consolidation Act of 1996, under section 
330(a)(1) of the PHS Act, defined the term ``health center'' as 
an entity that serves medically underserved population 
comprised of migratory and seasonal agricultural workers, the 
homeless, and residents of public housing.
    The Consolidated Health Centers Programs entered into 
fiscal year 2000 with 826 grantees and a total of approximately 
$1.0187 billion covering over 3,000 sites, located in medically 
underserved areas throughout the United States and its 
territories. The Consolidated Health Centers Programs entered 
into fiscal year 2001 with an estimated 850 grantees and 
$1.1687 billion covering approximately 3,600 sites.
    Health centers provide access to case-managed, family-
oriented, culturally sensitive preventive and primary health 
care services for people living in rural and urban medically 
underserved areas. The medical services include: preventive 
health and dental services, acute and chronic care services, 
and appropriate hospitalization and specialty referrals. Health 
centers also provide essential ancillary services such as 
laboratory tests, X-ray, environmental health and pharmacy 
services. In addition, many centers provide such enabling 
health and community services as transportation, health 
education, nutrition, counseling, and translation. Case 
management--the coordination of the center's services 
appropriate to the needs of the patient (social, medical, or 
economic)--is emphasized.
    Health centers target medically underserved, disadvantaged 
populations. These populations include: minorities, women of 
child-bearing age, infants, persons with HIV infection, 
substance abusers and/or homeless individuals and their 
families. In fiscal years 1999-2000, the Health Center Program 
served more than 9,500,000 patients annually. Of this total, 7 
percent were age 65 or older.
    The BPHC has implemented clinical performance measures 
related to the primary and preventive care of elderly users. 
The measures include: (1) a functional assessment of activities 
of daily living; (2) an inventory of prescription and 
nonprescription drug use; and, (3) pneumococcal and influenza 
immunization administration.

EXHIBIT A.--Breakdown by program and age cluster of the number of elderly persons who received health care services from BPHC-supported programs for the
                                                                    years 1999-2000.
--------------------------------------------------------------------------------------------------------------------------------------------------------
               Program                                      Age 65+Years                                               Total Users
--------------------------------------------------------------------------------------------------------------------------------------------------------
Community & Migrant Health Center...                                          Females: 395,517                                        Medical: 7,809,390
                                                                                Males: 240,229                                         Dental: 1,235,992
                                                                                Total: 635,746                                          Total: 9,045,382
Homeless Program....................                                            Females: 4,826
                                                                                  Males: 6,534
                                                                                 Total: 11,360                                                   473,057
Public Housing......................                                            Females: 1,137
Primary Care Program................                                                Males: 921
                                                                                  Total: 2,058                                                    42,969
                                     -------------------------------------------------------------------------------------------------------------------
      Total.........................                                                   649,164                                                 9,561,408
--------------------------------------------------------------------------------------------------------------------------------------------------------


   EXHIBIT B.--Breakdown by program and age cluster of the number of elderly persons who received health care
                                   services from BPHC for the year 1999-2000.
----------------------------------------------------------------------------------------------------------------
                                                                                          Subtotal
                    Program                       AGE 65-74    AGE 75-84     AGE 85+      Elderly    Total Users
----------------------------------------------------------------------------------------------------------------
1999/2000 CLUSTER..............................      372,749      198,912       70,948      642,609    9,017,325
----------------------------------------------------------------------------------------------------------------

                   The National Health Services Corps

    The National Health Service Corps (NHSC) places primary 
care physicians, nurse practitioners, physician assistants, 
certified nurse midwives, dental and mental health 
professionals in health professional shortage areas. There are 
now 4,400 clinicians serving communities and populations of 
greatest need (53 percent rural and 47 percent urban). Older 
Americans with special health care needs benefit from the 
proximity of dedicated primary care clinicians that provide 
high quality health care. The NHSC works closely with Bureau-
supported health centers, other primary care delivery systems, 
and the Indian Health Service to provide assistance in 
recruiting and retaining health personnel for the poorest, the 
least healthy, and the most isolated of our fellow Americans, 
including the aging population.

                Division of Federal Occupational Health

    The Division of Federal Occupational Health provides a 
variety of services related to health promotion and disease 
prevention in the elderly to managers and employees of over 
3,000 Federal agencies. Retirement planning, care of aging 
parents, and prevention of osteoporosis are some examples of 
generic issues that are regularly addressed in educational 
seminars and employee assistance programs.

                      Bureau of Health Professions

    The Bureau of Health Professions (BHPr) provides national 
leadership, sets policies, and administers programs to assure a 
health professions workforce that meets the health care needs 
of all Americans. The Bureau's five strategic functions 
include:
    1. Enabling access to health care through improved health 
professions distribution.
    2. Enabling culturally competent health care through 
improved racial and ethnic diversity and cultural competence in 
the health professions workforce.
    3. Ensuring adequate information, analysis and planning to 
strategically enable national health professions workforce 
development.
    4. Enabling ongoing improvement in the quality of health 
professions education through demonstration, education 
research, innovation and dissemination; and of health 
professions practice through innovations in financing and 
regulation.
    5. Providing public information and technical assistance 
relating to health professions.
    Additionally, the Bureau has three areas of emphasis: 
geriatrics, genetics, and diversity. These areas are promoted 
throughout the Bureau's training programs. The geriatric 
emphasis will help ensure that health care workers are trained 
and become knowledgeable about the aging process, diseases and 
common conditions of the elderly, and older people's special 
problems and needs.
    The strategies defined by these functions and areas of 
emphasis are implemented through a variety of collaborative 
public and private efforts and programs supported and operated 
by the Bureau. Programs include: education and training grant 
programs for institutions such as health professions schools 
and health professions education and training centers; loan and 
scholarship programs for individuals, particularly those from 
disadvantaged backgrounds; the Vaccine Injury Compensation 
Program; the National Practitioner Data Bank; the Healthcare 
Integrity and Protection Data Bank; the Ricky Ray Program; and 
the Children's Hospitals Graduate Medical Education Program. In 
addition, BHPr administers several education-service network 
multidisciplinary and inter-disciplinary programs such as the 
Area Health Education Centers (AHECs), the Geriatric Education 
Centers (GECs), and Rural Interdisciplinary Training Programs.
    The multi- and inter-disciplinary programs:
          Train health professional to deliver cost-
        effective, high-quality health care in medically 
        underserved areas;
          Stimulate curricula improvements so that 
        health education reflects the needs of vulnerable 
        populations and changes in health care financing; and
          Improve racial and cultural diversity in the 
        health professions, which results in greater access to 
        health care by minority and lower-income Americans.
    The Bureau also supports the Council on Graduate Medical 
Education, which reports to the Secretary and the Congress on 
matters related to graduate medical education, including the 
supply and distribution of physicians, shortages, or excesses 
in medical and surgical specialties and subspecialties, foreign 
medical graduates, financing medical educational programs, and 
changes in types of programs. It also supports the National 
Advisory Council on Nurse Education and Practice which provides 
advice and recommendations to the Secretary concerning policy 
matters relating to nurse workforce, education, and practice 
improvement.
    The National Vaccine Injury Compensation Program, 
administered by BHPr, became effective October 1, 1988. It was 
created by the National Childhood Vaccine Injury Compensation 
Act of 1986, as a no-fault system through which families of 
individuals who suffer injury or death as a result of adverse 
reactions to certain childhood vaccines can be compensated 
without having to prove negligence on the part of those who 
made or administered the vaccines.
    BHPr maintains a federally sponsored health practitioner 
data bank on all disciplinary action and malpractice claims. 
The National Practitioner Data Bank (NPDB) was created by The 
Health Care Quality Improvement Act of 1986, Title IV of P.L. 
99-660, as amended November 1986. The Act authorized the 
Secretary of Health and Human Services to establish a data bank 
to ensure that unethical or incompetent medical and dental 
practitioners do not compromise health care quality. The NPDB 
is a central repository of information about: malpractice 
payments made on behalf of physicians, dentists, and other 
licensed health care practitioners; licensure disciplinary 
actions taken by State medical boards and State boards of 
dentistry against physicians and dentists; and adverse 
professional review actions taken against physicians, dentists, 
and certain other licensed health care practitioners by 
hospitals and other health care entities, including health 
maintenance organizations, group practices, and professional 
societies. The NPDB began operation on September 1, 1990.
    The Secretary of the U.S. Department of Health and Human 
Services, acting through the Office of Inspector General was 
directed by the Health Insurance Portability and Accountability 
Act of 1996 to create the Healthcare Integrity and Protection 
Data Bank (HIPDB). The HIPDB is a national health care fraud 
and abuse data collection program for the reporting and 
disclosure of certain final adverse actions taken against 
health care providers, suppliers and practitioners. Health 
plans and Federal and State programs and officials (including 
licensing agencies, certification agencies, criminal 
prosecutors, government attorneys participating in civil cases, 
and agencies taking program exclusion actions) are required to 
report to the data bank all final adverse actions (such as 
revocations, suspensions, exclusions, criminal convictions and 
civil judgments) against health care providers, suppliers and 
practitioners. Federal and State agencies and health plans are 
permitted to query the data bank. It began full operation on 
March 2000.
    The Ricky Ray Hempohilia Relief Act of 1998 established in 
the Treasury of the U.S. a trust fund to be known as the 
``Ricky Ray Hemophilia Relief Fund'', to provide compassionate 
payments for individuals with blood-clotting disorder, such as 
hemophilia, who contracted HIV from contaminated antihemophilic 
factor between July 1, 1982 and December 31, 1987. A former 
legal spouse, who was a legal spouse and contracted HIV through 
transmission from their spouse, and an individual who acquired 
infection through perinatal transmission from either of the 
individuals listed above are also eligible for compassionate 
payments under the program. The Act specifies that the Fund 
shall terminate upon the expiration of the 5-year period 
beginning on the date of enactment of the Act.
    The Children's Hospitals Graduate Medical Education Program 
provides a more adequate level of support for health 
professions training in U.S. children's teaching hospitals that 
have a separate Medicare provider number (``free-standing'' 
children's hospitals). These hospitals receive very small 
amounts of from Medicare for graduate medical education (GME) 
and other health professions training, while children's 
hospitals that share Medicare provider numbers with other 
teaching hospitals receive more typical amounts of GME from 
Medicare. As managed care organizations become increasingly 
unwilling to pay for GME, free-standing children's teaching 
hospitals are at a competitive disadvantage, in the absence of 
a similar level of support from Medicare that other hospitals 
receive, and are coming under increasing pressure to reduce 
their level of residency training. Children's hospitals train 
over 25 percent of all U.S. general pediatric residents, the 
majority of pediatric subspecialty residents, and about 4 
percent of all medical residents. The goal of this program is 
to make the level of Federal GME support more consistent with 
other teaching hospitals, including children's hospitals which 
share Medicare provider numbers with other teaching hospitals.

                   Division of Medicine and Dentistry

    The Division of Medicine and Dentistry (DMD) continues to 
support, through its grant and cooperative agreement programs, 
significant educational and training initiatives in geriatrics.
    For FYs 1999 and 2000, predoctoral grantees indicated that 
they were actively involved in the development, implementation, 
and evaluation of their geriatrics curriculum and training. 
There are eleven predoctoral grantees that received funds 
totaling $285,340 for geriatric activities.
    Residency program grants were awarded with a focus on 
geriatrics, emphasizing the interdisciplinary approach, home 
visits, and nursing home visits. There were nine residency 
primary care grantees that received funds totaling $221,463 for 
geriatric activities.
    Faculty development programs instituted training 
activities, enhanced primary care research training, and 
developed strategies for career development in geriatrics. 
These programs also placed an emphasis on the instruction of, 
``Teaching Geriatrics.'' There were twelve faculty development 
grantees that received funds totaling $725,000 for geriatric 
activities.
    The majority of academic administrative units developed a 
research infrastructure in support of primary care research 
with an emphasis on the elderly, palliative care, and geriatric 
education. There are five academic administrative unit grantees 
that received funds, for FY2000, totaling $239,200 for 
geriatric activities.
    One physician assistant training program grantee continued 
participation in the Rural Elderly Assessment Project and 
received funds totaling $30,000 for geriatric activities.
    Podiatric primary care residency programs supported 
training which emphasized geriatric health. Two podiatric 
grantees that emphasized geriatric training received funds 
totaling $167,920.
    Title VII funded training programs in the general and 
pediatric practice of dentistry provide a favorable Special 
Consideration for applicants that propose to prepare 
practitioners to care for underserved populations and high risk 
groups such as the elderly and patients of long term care 
facilities. In addition, applicants may also propose innovative 
projects that encourage curriculum enrichment or unique 
resident experiences in the area of geriatric dentistry. In 
FY1999, twenty-three dental training programs provided care to 
the elderly in nursing homes, clinical settings, and geriatric 
treatment centers. For FY2000, twenty training programs 
utilizing over a hundred and twenty residents provided much 
needed care and treatment for this population in various 
settings throughout the nation.
    The Society of Teachers of Family Medicine (STFM) was 
awarded a four-year contract to develop a faculty resource 
manual to assist medical school faculty with the inclusion of 
geriatrics into the curriculum for medical students over the 
entire four years of medical school. This project will define 
new competencies for medical students that also include 
palliative and end-of-life care. This grantee received 
approximately $25,000, for FY2000, for geriatric activities.
    The Undergraduate Medical Education for the 21st Century 
(UME-21) and Partnerships for Quality Education (PQE): 
Collaborative Faculty Development Program in Managing Patient 
Care with Harvard Pilgrim Health Care, Boston, Massachusetts, 
was initiated in 1999. This 18 month contract was created to 
develop, implement, and evaluate a set of two faculty 
development workshops for physician faculty of UME-21 and PQE 
programs centering on two content areas of managing patient 
care. The purpose is to develop faculty competencies in the 
basics of curriculum development and teaching methodology 
appropriate for medical students in UME-21 and residents in 
PQE. These competencies will be learned within the context of 
two content areas selected from among those common to UME-21 
and PQE; namely, evidence-based and population-based medical 
care; healthy systems finance, economics and delivery; ethics; 
patient-provider communication skills; leadership; quality 
measurement including cost-effectiveness and patient 
satisfaction; systems-based care; medical informatics; and 
wellness and prevention. The focus population for UME-21 and 
PQE range from pediatric to geriatric. The final phase of this 
faculty development program involves dissemination of results 
and instructional materials.

                          Division of Nursing

    In FY1999, the Division of Nursing awarded grants through 
four programs: (four grants) Advanced Nurse Education, (two 
grants) Nurse Practitioner/Nurse Midwifery, (three grants) 
Nursing Special Projects and (four grants) Professional Nurse 
Traineeships. The Professional Nurse Traineeship Program 
provides funds to schools that allocate these funds to 
individual full-time master's and doctoral students preparing 
to be nurse practitioners, nurse-midwives, nurse educators, 
public health nurses, or other clinical nurse specialists. 
Geriatric Nurse Practitioners and Geriatric Clinical Nurse 
Specialists are among those benefitting from the Traineeship 
Program.
    In FY2000, the Division of Nursing legislation changed, 
resulting in the renaming of the four FY1999 grant programs. 
The Advanced Nurse Education Program and the Nurse 
Practitioner/Nurse Midwifery Program were combined and are now 
entitled Advanced Education Nursing. The Professional Nurse 
Traineeship Program was changed to Advanced Education Nursing 
Traineeship Program and expanded traineeship eligibility to 
include part-time students. The Nursing Special Projects Grant 
Program was changed to the Basic Nurse Education and Practice 
Program.
    In FY1999, the Advanced Nurse Education Program supported 
four projects totaling $894,049. In FY2000, the Advanced 
Education Nursing Program supported three projects totaling 
$547,470. All of these projects supported gerontological 
nursing programs leading to a master's or doctoral degree. 
Graduates of these programs are prepared broadly to meet a wide 
range of health needs relative to the elderly in many settings, 
but are particularly prepared to deal with the older individual 
with multiple health care needs. In addition, the program 
prepares nurses who can teach and offer consultation in this 
important field.
    In FY1999, the Nurse Practitioner and Nurse-Midwifery 
Program, supported six master's or post-master's geriatric 
nurse practitioner (GNP) program grants totaling $598,955. In 
FY2000, three master's or postmaster's GNP program grants 
totaling $492,978 were supported. In addition, seven Adult 
Nurse Practitioner (ANP) programs were supported in FY1999 for 
a total of $712,961, and five Family Nurse Practitioner (FNP) 
programs were supported for a total of $735,498. In FY2000, the 
Advanced Education Nurse Program supported five Geriatric Nurse 
Practitioner grants totaling $805,261, and five Adult Nurse 
Practitioner grants totaling $708,825.
    GNPs, ANPs, and FNPs all provide primary care services to 
older adults. As nurses with advanced academic and clinical 
preparation, they are prepared as primary health care providers 
to manage the health problems of the elderly in a variety of 
settings, such as long-term care facilities, ambulatory 
clinics, and homes. They provide nursing care and clinical 
management of common acute and chronic health problems, 
including health promotion and maintenance, disease prevention, 
health assessment, and long-term management of chronic health 
problems. Emphasis is placed on teaching and counseling the 
elderly to actively participate in their own care and to 
maintain optimal health.
    In FY1999, the Nursing Special Projects Grant Program 
supported five Long-Term Care Fellowships for Paraprofessional 
projects in four institutions totaling $1,057,564. These 
fellowships supported approximately 88 individuals employed by 
nursing facilities, including long-term care facilities or home 
health agencies as paraprofessionals and enrolled in approved 
nursing program. The agencies assist the fellows financially to 
obtain further education in nursing.
    In FY1999, the Nursing Special Project Grant Program 
supported three nursing centers providing services specifically 
for elderly populations received support totaling $371,503. In 
FY1999, an additional thirteen nursing centers providing 
services to elders in housing and other community sites 
received support totaling $2,229,950.
    In FY2000, the Basic Nurse Education and Practice Program 
supported six nursing centers providing services to elders in 
clinics in rural and urban underserved areas, receiving support 
totaling $1,312,287. In addition, one nursing center project 
(University of Maryland) provided services specifically to the 
geriatric population, receiving $231,089. All of these centers 
demonstrate methods of improving access to primary health care 
in medically underserved communities.
    The nursing center project at the University of Maryland, 
Baltimore, Maryland, now in the first year of a three year 
grant period, is designed to provide a community-based 
continuum of senior services. The Senior Care Center offers 
three programs: (1) Comprehensive Geriatric Assessment; (2) 
Geriatric focused primary care and (3) Wellness Programs. In 
addition, faculty and students are conducting a community needs 
assessment that will form the basis for the design of 
structured wellness programs that can be implemented at a new 
senior housing facility in Baltimore. This project also 
provides clinical experiences for graduate and undergraduate 
students which will prepare them to provide the specialized 
care needed by older adults.

        Division of Interdisciplinary, Community-Based Programs

    The Division of Interdisciplinary, Community-Based Programs 
was created in FY2000 in response to the Health Professions 
Partnership Act of 1998 (Part D of Title VII of the Public 
Health Service Act). Programs supported by the Division are 
designed to ``carry out innovative demonstration projects for 
strategic workforce supplementation activities as needed to 
meet national goals for interdisciplinary, community-based 
linkages.'' Supported programs include Area Health Education 
Centers, Health Education and Training Centers, Education and 
Training Related to Geriatrics, and Rural Interdisciplinary 
Training Grants.
    The Division (DICP) supports the training of health 
professionals in geriatric care though three principal 
programs--Geriatric Education Centers; Faculty Training in 
Geriatrics for Physicians, Dentists, and Behavioral and Mental 
Health Professionals; and Geriatric Academic Career Awards. 
Authorized by the Public Health Service Act, as amended, 
Sections 753 (a), (b), and (c) respectively, these three 
programs focus on preparing the health care workforce to serve 
an aging population. The AHEC program supports continuing 
education in geriatrics. The Quentin R. Burdick Rural 
Interdisciplinary Training program promotes rural health care 
practice which may include geriatrics.
    Geriatric Education Centers (GECs).--GEC grants help 
accredited health professions schools collaborate with health 
care facilities to train health professions students, faculty 
and practitioners in the diagnosis, treatment, disease and 
disability prevention, and other health problems of the aged. 
Projects must involve at least four health disciplines one of 
which must be medicine. These Centers are educational resources 
providing multidisciplinary and interdisciplinary geriatric 
training for health professions faculty, students, and 
professionals in medicine, dentistry, pharmacy, nursing, 
occupational and physical therapy, podiatric medicine, 
optometry, social work, and related allied and public or 
community health disciplines. They provide comprehensive 
services to the health professions education community within 
designated geographic areas. Grants may support geriatric 
residencies, traineeships or fellowships; development and 
dissemination of curricula; training and retraining of faculty; 
continuing education of health professionals; and clinical 
training in geriatrics in various care settings. Grantees may 
be single institutions or consortia of institutions.
    At the State and National level, the GECs comprise a 
comprehensive educational system, serving as the primary 
coordinating body for the preparation of faculty, health 
professions students, and health care personnel to better serve 
the Nation's elderly. GECs use ambulatory care centers, 
hospitals, long-term care facilities and senior centers to 
provide appropriate educational experiences to health 
professions students and providers, to prepare them to deliver 
humane and dignified care and to be responsive to older 
individuals whose ability to care for themselves has been 
reduced by physical and/or mental disorders. Over 40,000 health 
care professionals received education and training through the 
GECs in FY1999-2000.
    Of the 43 GECs Geriatric Education Centers that make up the 
membership of the National Association of Geriatric Education 
Centers, 34 received BHPr funding in both FY1999 and FY2000. In 
FY1999, there were 27 consortia and 7 single institution 
awards. In FY2000, there were 26 consortia and 8 single 
institution awards. Awards were made to the following 
institutions in FY1999 and FY2000:

                      Geriatric Education Centers


------------------------------------------------------------------------
                                                   FY1999       FY2000
------------------------------------------------------------------------
Consortia:
    University of California, Los Angeles,         $258,323     $319,028
     Univ. of California, Davis, Univ. of
     California, San Francisco, UCLA School of
     Medicine, California State University at
     Fresno...................................
    New York University, Columbia University,       312,422      162,000
     Hunter College...........................
    University of Pittsburgh, Pennsylvania          159,982      263,733
     State University, Temple University......
    University of Miami, Barry University,          252,566       23,673
     Florida A&M, Florida International
     University...............................
    St. Louis University, U. of Missouri,           323,245      160,283
     School of Optometry, Washington U.,
     Occupational Therapy, St. Louis College
     of Pharmacy, Kirksbille College of
     Osteopathic Medicine.....................
    University of Kentucky, East Tennessee          313,236      160,365
     State Univ., U. of Ohio Cincinnati.......
    University of Kansas Medical Center, Aging      161,891      269,991
     Research Institute, University of
     Missouri-Kansas City.....................
    University of Medicine & Dentistry of NJ,       324,807      161,997
     Rutgers University School of Social Work.
    University of Oregon, Portland State            261,847      290,058
     University...............................
    University of Iowa, University of               270,000      324,000
     Osteopathic Medicine and Health Sciences.
    Baylor College of Medicine, University of       322,720      162,000
     Texas, Houston HSC, Univ. Texas, Medical
     Branch, Univ. of North Texas, Univ. of
     Texas-Pan AM, Texas Southern Univ., Univ.
     of Houston, Texas A&M University.........
    George Washington University, Georgetown        321,653            0
     University, Howard University............
    Case Western Reserve University, Ohio           319,440      161,200
     University college of Osteopathic
     Medicine, Bowling Green State University,
     Northeastern Ohio Universities College of
     Medicine.................................
    Marquette University, Univ. of Wisconsin-       162,000      269,821
     Madison, Univ. of Wisconsin-Milwaukee,
     Milwaukee Area Technical College, Medical
     College of Wisconsin, Geriatrics Inst.of
     Sinai Samaritan Medical Center...........
    Michigan State University, Wayne State          269,592      324,000
     University, Michigan Primary Care
     Association, St. Lawrence Hospital.......
University of New Mexico, New Mexico State          248,832      312,292
 University, New Mexico Highlands University,
 National Indian Council on Aging, Indian
 Health Service, Sisters of Charity Health
 Care System..................................
    University of Pennsylvania, Geisinger           235,490      321,191
     Medical Center, Lehigh Valley Hospital,
     Philadelphia College of Pharmacy.........
    University of Rhode Island, Rhode Island        161,997      269,989
     College, Brown University, Rhode Island
     Hospital.................................
    Meharry Medical College, Alabama A&M            269,971      313,616
     University, Tennessee State University...
    University of North Carolina-Chapel Hill,       161,821      204,516
     Program on Aging, Rural Health Group,
     Inc, Area L Area Health Education Center.
    Stanford University, San Jose State             266,219      319,707
     University, On Lok, Senior Health
     Services.................................
    University of Oklahoma....................      211,809      319,887
    University of Texas San Antonio HSC,            162,000      270,000
     University of Texas at El Paso...........
    University of Rochester, Ithaca College,        279,070      149,974
     Cornell University, Nazareth College.....
    University of West Virginia, Rural Health       194,043      161,454
     Education Partnership, West Virginia
     State Community and Technical College,
     West Virginia School of Osteopathic
     Medicine.................................
    University of Minnesota, Arrowhead              324,000      162,000
     Regional Development Commission, Central
     Minnesota Council on Aging, Rochester
     Community and Technical College, Mankato
     State University.........................
    Harvard Medical School, Maine Geriatric/        310,220      160,495
     Gerontology Education....................
Single Institution:
    University of Hawaii......................      215,760      107,934
    University of Puerto Rico.................            0      108,000
    University of Washington..................      161,206      215,997
    University of South Florida...............      216,000      108,000
    University of Nevada......................      158,809      214,013
    University of Arkansas....................      106,258      157,063
    University of Virginia Commonwealth.......      215,040      107,785
    University of Florida.....................       40,711       99,373
    Total GEC Funding.........................   $7,972,980  $7, 485,435
------------------------------------------------------------------------

Faculty Training in Geriatrics for Physicians, Dentists, and Behavioral 
                      Mental Health Professionals

    Faculty Training Projects in Geriatric medicine, dentistry 
and behavioral/mental health grants are awarded to public and 
private nonprofit schools of allopathic or osteopathic 
medicine, teaching hospitals, and graduate medical education 
programs. The grants support fellowships and other training 
efforts that assist health professionals who plan to teach 
geriatrics. Funded projects support two-year fellowships and 
one-year retraining programs.
    Projects emphasize primary care and enable health 
professionals who plan to teach geriatrics to care for elderly 
people at different levels of wellness and functioning and from 
a range of socioeconomic and racial and ethnic backgrounds. 
They offer service rotations such as geriatric consultation, 
acute care, dental care, psychiatry, day and home care, 
rehabilitation, extended care, ambulatory care as well as 
community care for older people with mental retardation. No 
programs were funded in FY1999. In FY2000, a total of $1.6 
million was awarded to five newprograms.

     Faculty Training in Geriatrics for Physicians, Dentists, and 
                 Behavioral/mental Health Professionals


------------------------------------------------------------------------
                                                                FY2000
------------------------------------------------------------------------
University of California Los Angeles.......................     $336,040
Boston University/Boston Medical Center....................      430,010
New Jersey University of Medicine and Dentistry............      261,052
University of North Texas Health Science Center............      251,892
University of Texas Health Sciences Center at San Antonio..      371,006
    Total..................................................  $1, 650,000
------------------------------------------------------------------------

                Geriatric Academic Career Awards (gacas)

    The Bureau of Health Professions made awards for the first 
time under the newly established Geriatric Academic Career 
Award (GACA) Program in September 1999. Intended to support the 
development of newly trained geriatric physicians into first 
rate teachers of geriatrics, GACAs provide five years of 
support for academic career development. The awards require and 
allow the recipients to devote the bulk of their academic 
careers to teaching geriatrics to a wide range of health care 
professionals. The career development plans of the first cohort 
of awardees show a strong commitment to the development of best 
practices in the care of older patients. They have chosen a 
wide range of topics to devote their time to developing, 
including direct service projects such as mobile geriatric 
assessment clinics for older people living in rural areas, 
home-based geriatric assessment, and geriatric rehabilitation, 
all aimed at restructuring and facilitating delivery of care to 
the elderly; interdisciplinary care for the chronically ill and 
the development of chronic disease state ``glide paths;'' 
effective clinical teaching of palliative care for the elderly; 
geropharmacy and nutrition; acute care of the elderly; 
culturally competent care of the elderly; infection control 
interventions in long-term care; development of resource 
materials on organ system normative aging; hospice care; 
special issues in the delivery of rural health care by family 
practitioners; and the design and implementation of community-
based programs which allow the frail elderly remain in their 
homes. The program contributes not only to the training of 
physicians but to many other health professionals who have 
responsibility for the care of the elderly. As specified in the 
statutory language, awards were made directly to individuals 
who were required to obtain the commitment of their employing 
institution for a period of five years.

                    Geriatric Academic Career Awards


------------------------------------------------------------------------
                                                   FY1999       FY2000
------------------------------------------------------------------------
Total Awarded.................................     $818,400     $795,645
------------------------------------------------------------------------

                    Rural Interdisciplinary Training

    The Quentin R. Burdick Rural Health Interdisciplinary 
Program promotes rural health care practice by providing 
support for the interdisciplinary training of health 
professions students. The program requires two or more 
applicant organizations to apply together in order to foster 
collaborative efforts to promote and retain health 
professionals in rural areas. Specific programs demonstrate 
innovation in interdisciplinary training and curriculum 
development, and forge linkages among academic health training 
institutions and rural health care agencies and practice 
facilities, State health departments, and health professionals 
who practice in rural areas. Though not limited to training in 
geriatrics, some projects focus prominently on geriatric care. 
In FY1999, one project focused primarily on geriatric care, and 
in FY2000, two projects focused on geriatrics.

------------------------------------------------------------------------
                                         FY 1999            FY 2000
------------------------------------------------------------------------
Total.............................           $147,165           $373,377
------------------------------------------------------------------------

     Area Health Education Centers (ahec) ce Programs in Geriatrics

    The Area Health Education Centers (AHEC) is an active 
provider of continuing education (CE) for primary health care 
providers with nearly every Federally funded AHEC program 
within 40 States providing a wide array of topics. CE Programs 
in Geriatrics is one of the most frequently requested and 
offered topics. During FY99, a summary of the AHEC CE offerings 
in geriatrics were as follows: a total of 478 programs was 
offered, 118 were offered via distance education methodologies, 
12,445 CE participants attended these geriatric programs, and 
1157 were distance participants in the CE programs.

                  Geriatric Education Futures Project

    In 1994-1995, the Bureau of Health Professions sponsored a 
major assessment of the state of workforce development in 
geriatrics. The effort resulted in the production of A National 
Agenda for Geriatric Education with specific recommendations 
for action in eleven broad areas. In Fiscal Year 2000, the 
Bureau is beginning a follow-up to the National Agenda. Through 
various efforts, the Bureau will track where health professions 
training is in relation to the earlier recommendations and 
where workforce development activities need to go in light of 
progress-to-date and recent changes in health care delivery 
systems.

                              Publications

    A National Agenda for Geriatric Education: Forum Report, 
Volume 2. Rockville, MD: Interdisciplinary, Geriatrics and 
Allied Health Branch, Division of Associated, Dental and Public 
Health Professions, Bureau of Health Professions, Health 
Resources and Services Administration, Public Health Service, 
U.S. Department of Health & Human Services. 1996
    A National Agenda for Geriatric Education: White Papers, 
Volume 1. Rockville, MD: Interdisciplinary, Geriatrics and 
Allied Health Branch, Division of Associated, Dental and Public 
Health Professions, Bureau of Health Professions, Health 
Resources and Services Administration, Public Health Service, 
U.S. Department of Health & Human Services. 1995
    Geriatric Education Centers: A Resource Directory, 
Rockville, MD: Interdisciplinary, Geriatrics and Allied Health 
Branch, Division of Associated, Dental and Public Health 
Professions, Bureau of Health Professions, Health Resources and 
Services Administration, Public Health Service, U.S. Department 
of Health & Human Services. 1998

                     Office of Rural Health Policy

    The Office of Rural Health Policy (ORHP) was established in 
1987 at the urging of the Senate Special Committee on Aging in 
order to address severe shortages of health services in rural 
areas, where one quarter of the Nation's elderly live. Aging-
related issues are of particular importance to the Office, 
since rural counties have, on average, a higher percentage of 
individuals over 65 years of age than urban counties; and these 
residents are often poorer, sicker, and more isolated than 
their urban counterparts.
    To strengthen support for health services in rural areas, 
the office plays a collaborative role throughout the Department 
and with the States and the private sector. For example, it 
informs interest groups, such as the National Council on Aging 
and the American Association of Retired Persons about its 
activities and about the needs of the rural elderly. Within the 
Department, the Office advises the Secretary and the Assistant 
Secretary on Aging on the affects that Medicare and Medicaid 
programs have on rural health care, on the shortage of health 
care providers, the viability of rural hospitals, and the 
availability of primary care and also emergency medical 
services to elderly and other rural residents.
    The Office supports local and States initiatives to build 
rural health care services through almost $39 million in grants 
to rural communities, themselves, and a $3 million program of 
matching grants to the States to support States offices of 
rural health, which can recruit rural providers and assist 
their rural communities in developing more local health 
services.
    The ORHP also promotes informed policy making by 
administering a $3.0 million program of grants for policy-
relevant studies at established rural research centers 
throughout the country. These centers provide data capability 
on a wide range of rural health concerns, including areas 
relevant to the elderly. For example, one study currently 
underway looks at quality differences between rural and urban 
nursing homes to examine the consequences of a lower skill-mix 
of staff in rural areas. Another is estimating the 
Medicare+Choice threshold payment rate which will attract and 
retain Medicare managed care plans in rural areas. Also under 
study is an examination of the impact on rural elderly of 
different approaches for restructuring Medicare.
    The Office also administers a $25 million grant program to 
States to help them implement the Medicare Rural Hospital 
Flexibility Program. Under this program, rural hospitals that 
convert to a smaller Rural Critical Access Hospital can receive 
cost-based payments from the Medicare. The grants help States 
and rural communities plan and implement the conversion of 
rural hospitals and promote the development of new local 
networks of care.
    In collaboration with other Federal agencies such as the 
Health Care Financing Administration, the Department of 
Agriculture, the Department of Transportation, and the National 
Institute on Aging, ORHP sponsors workshops and seeks public 
advice on a range of rural health needs. These issues may 
included such issues as emergency medical services, managed 
care options for Medicaid and Medicare clients, physician 
recruitment, and rural economic development.
    To provide health care professionals, researchers, 
community officials, and the public with an efficient source of 
information and referral, the office sponsors the Rural 
Information Center Health Service, or RICHS. This service is 
operated in cooperation with the USDA and its National 
Agricultural Library. It is available toll-free at 1-800-633-
7701. Internet information is available at: http://
www.nal.usda.gov/ric/richs.
    The Office also channels public advice on rural issues to 
the Department by staffing the Secretary's National Advisory 
Committee on Rural Health, a citizen's advisory panel chartered 
in 1987 to address health care crises in rural America.

                    OFFICE OF THE INSPECTOR GENERAL


                              Introduction

    The Office of Inspector General (OIG) was established by 
the Inspector General Act of 1978. The OIG's mission is to 
identify ways to improve effectiveness and promote economy and 
efficiency in HHS programs and operations, and protect them 
against fraud, waste, and abuse. This is accomplished by 
conducting independent and objective audits, evaluations, and 
investigations which provide timely, useful, and reliable 
information and advice to Department officials, the 
Administration, the Congress, and the public. In carrying out 
its mission, the OIG partners with the Department and its 
operating divisions, the Department of Justice (DOJ), other 
Federal and State agencies, and the Congress to bring about 
systemic improvements in HHS programs and operations, and 
successful prosecutions and recovery of funds from those who 
defraud the Government. The OIG is comprised of the following 
components:
    The Office of Audit Services (OAS) conducts and oversees 
audits of HHS programs, operations, grantees, and contractors; 
identifies systemic weaknesses that give rise to opportunities 
for fraud, and abuse; and makes recommendations to prevent 
their recurrence. The OAS also provides overall leadership and 
direction in carrying out the responsibilities mandated under 
the Chief Financial Officers Act of 1990 and the Government 
Management Reform Act of 1994 relating to financial statement 
audits.
    The Office of Evaluation and Inspections (OEI) seeks to 
improve the effectiveness and efficiency of departmental 
programs by conducting program inspections that provide timely, 
useful, and reliable information and advice to decision makers. 
These inspections are program and management evaluations that 
focus on specific issues of concern to theDepartment, the 
Congress, and the public. The results of these inspections 
generate accurate and up-to-date information on how well HHS 
programs are operating and offer specific recommendations to 
improve their overall efficiency and effectiveness.
    The OIG's Office of Investigations (OI) conducts 
investigations of fraud and misconduct to safeguard the 
Department's programs and protect the beneficiaries of those 
programs from individuals and activities that would deprive 
them of rights and benefits. Working with Federal and State law 
enforcement agencies, OIG investigators seek criminal, civil, 
and exclusion actions against those who commit fraud or who 
thwart the effective administration of HHS programs.
    The Office of Counsel to the Inspector General (OCIG) 
coordinates the OIG's role in the resolution of health care 
fraud and abuse cases, including the litigation and imposition 
of administrative sanctions, such as program exclusions, civil 
monetary penalties, and assessments; the global settlement of 
cases arising under the Civil False Claims Act; and the 
development of corporate agreements for providers that have 
settled their False Claims Act liability with the Federal 
Government. It also develops and promotes industry awareness of 
models for corporate integrity and compliance programs and 
monitors ongoing integrity agreements. The OCIG also provides 
all administrative litigation services required by OIG, such as 
patient dumping cases and all administrative exclusion cases. 
In addition, OCIG issues special fraud alerts and advisory 
opinions regarding the application of OIG's sanction statutes 
and is responsible for developing new, and modifying existing, 
safe harbor regulations under the anti-kickback statute. 
Finally, OCIG counsels OIG components on personnel and 
operations issues, subpoenas, audit and investigative issues, 
and other legal authorities.
    The Office of Management and Policy (OMP) provides support 
services to the OIG, including congressional relations; public 
affairs; strategic planning and budgeting; financial and 
information resources management; and preparation of the OIG's 
semiannual and other reports.

                            Accomplishments

    During Fiscal Years 1999 and 2000, the OIG reported more 
than $890 million in fines and restitutions deposited into the 
Medicare Trust Fund. More than 6,320 individuals and entities 
were excluded from doing business with Medicare, Medicaid, and 
other Federal and State health care programs. The OIG's 1999 
and 2000 accomplishments included 815 convictions of 
individuals or entities that engaged in crimes against 
departmental programs.
    The OIG reported savings of $28.2 billion for Fiscal Years 
1999 and 2000. This is comprised of $26.1 billion in 
implemented legislative or regulatory recommendations and 
actions to put funds to better use; $393 million in audit 
disallowances, and $1.6 billion in investigative receivables. 
The savings that result from OIG recommendations that are 
implemented into law or regulation represent the dollars that 
will not be spent.

                              Health Care

    In recent years, Medicare has been a major focus of OIG 
work. Approximately 75 percent of OIG resources in the past two 
years were dedicated to Medicare audits, evaluations, and 
enforcement activities. OIG work continues to show that 
Medicare is not always a prudent purchaser of health care goods 
and services and is inherently vulnerable to making improper 
payments. In discharging its responsibilities, the OIG responds 
both reactively and proactively to counteract these problems 
and is pleased to report that measurable progress is being 
made. For example, through a statistically valid sample of 
FY1999 Medicare fee-for-service payments, OIG estimated that 
the overall dollar value of claims paid in error had decreased 
42 percent since FY1996.
    A key element of HHS/OIG's prevention efforts has been the 
development of compliance program guidance to encourage and 
assist the private health care industry to fight fraud and 
abuse. The guidance, developed in conjunction with the provider 
community, identifies steps that health providers may 
voluntarily take to improve adherence to Medicare and Medicaid 
rules. In 1999 and 2000, the OIG developed and released final 
compliance program guidance for third party medical billing 
companies, hospices, durable medical equipment (including 
prosthetics and orthotics, and suppliers), Medicare+Choice 
organizations offering coordinated care plans, nursing 
facilities, and individual and small group physician practices.
    Some of the significant OIG work involving the elderly, 
during this reporting period, includes the following:
    Quality of Care in Nursing Homes.--The OIG has focused on 
the quality of care in nursing homes in a number of inspection 
reports. Topics include: deficiency trends, survey and 
certification system capacity, public access to deficiency 
information, ombudsman program complaints and overall capacity, 
medical necessity and quality of care of physical and 
occupational therapy in nursing homes, nursing home 
vaccination, effect of the prospective payment system on access 
to skilled nursing facilities, and the effect of financial 
screening and distinct part rules on access to nursing 
facilities.
    Home Health Care.--Under the interim payment system, in 
effect prior to the start of the prospective payment system on 
October 1, 2000, home health agencies had an incentive to stay 
below the new payment limits by reducing the number of visits 
per patient and limiting the number of potentially high-cost 
patients. Because of this, concerns were raised as to whether 
this system so adversely affected home health agencies that 
they were unable to care for all Medicare patients needing home 
health services. In a number of studies, we found that these 
concerns are not well supported. Hospital discharge planners 
reported that almost all Medicare beneficiaries can be placed 
into home health care. In addition, an OIG follow-up to an 
earlier review revealed that improper Medicare payments for 
home health services had been significantly reduced, down from 
40 to 19 percent.
    Withdrawal of Managed Care Organizations From Medicare.--In 
the last several years, a number of managed care organizations 
(MCO) left the Medicare program or reduced their service areas. 
We recently examined the impact of these withdrawals on 
beneficiaries, including the adequacy of notification, the 
availability of other health care options, and the extent of 
costs to beneficiaries associated with these changes. We found 
that the 1999 MCO withdrawals affected fewer beneficiaries than 
did the 1998 withdrawals (about 300,000 in 1999 versus about 
400,000 in 1998); however, a greater percentage of 
beneficiaries were left without an MCO option in 1999. As a 
related issue, OIG's body of work during this period finds that 
MCOs receive more than an adequate amount of funds to deliver 
the Medicare package of covered services, i.e., those services 
received by 85 percent of Medicare beneficiaries (those in the 
Medicare fee-for-service program).
    Managed Care Marketing Materials.--We examined how well 
informed Medicare beneficiaries were of the choices available 
to them under the managed care option. In one study we found 
that the Health Care Financing Administration (HCFA) did not 
completely meet its goals to expedite the marketing material 
review process; reduce resubmissions of material; ensure 
uniform review across the Nation; and, most importantly, 
provide beneficiaries with accurate and consumer-friendly 
marketing materials to help them make informed health care 
choices. Some of the marketing materials that we examined were 
difficult to understand. We also looked at the influence of 
``extra'' benefits offered by managed care plans on 
beneficiaries' decisions to join Medicare+Choice MCOs.
    Medicare Payments for Mental Health Services.--We examined 
Medicare payments for mental health services across a variety 
of settings. One such setting is community mental health 
centers, where payments for partial hospitalization services 
increased almost five-fold between 1993 and 1997. Although 
partial hospitalization consists of an intensive program of 
outpatient services for acutely ill beneficiaries in order to 
prevent inpatient hospitalization, both OIG and HCFA reviews 
found that Medicare was paying for services to beneficiaries 
with no history of mental illness and for beneficiaries who 
suffered from conditions that would preclude their benefitting 
from the program. Our five-State review found that over 90 
percent ($229 million of $252 million) of such payments in this 
setting were unallowable or highly questionable. In a similar 
review, we examined Medicare charges in 10 States for 
outpatient psychiatric services provided at acute care 
hospitals. Here our statistical sample estimated that 58 
percent ($224 million of $382 million) of such services in 
these States were unallowable or unsupported.

          ITEM 7--DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

                              ----------                              


        U.S. HOUSING FOR THE ELDERLY--FISCAL YEAR 1997 AND 1998

    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 afford their housing costs, maintain their 
independence, remain as part of the community, and live their 
lives with dignity and grace.
    The Department is committee to meeting the needs of our 
elderly citizens. This report provides a brief overview of the 
programs and activities undertaken by the Department to assist 
the elderly with their housing needs during FY1999 and 2000.

                          I. Office of 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 63,023 units approved under the Section 
202 program and 17,494 units approved under the Section 811 
program. Of those amounts 7,142 Section 202 units and 1,801 
Section 811 were approved in Fiscal Year 1999. In FY2000, there 
were 6,518 additional units approved under Section 202 for 
$493,274,200 and 1,483 more units approved under Section 811 
for $109,588,400.

     b. 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 substantial 
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 with children, projects insured under Section 221 may 
be designed for occupancy wholly or partially for the elderly, 
and the mobility impaired of any age. In FY1999, a total of 
31,880 additional units in 198 projects were approved under 
Section 221(d)(3) and (4) for $2.1 billion. In FY2000, 28,707 
units in 155 projects were approved for $1.7 billion.

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

    The Section 232 program authorized the Department to offer 
financing for 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 FY1999, HUD insured 
155 projects worth $896 million consisting of 76 nursing homes, 
53 assisted living facilities, and 26 board and care homes. In 
FY2000, HUD insured 159 projects at $979 million (100 nursing 
homes, 49 assisted living facilities, and 10 board and care 
homes.)

                     d. section 8--new construction

    The Section 8 program sponsored the new construction of 
housing for families and for the elderly by attaching subsidies 
to the units being developed. That way the landlord would 
guarantee the ability to make payments and operate the 
developments. The new construction program was active from 1974 
until it was repealed by Congress in 1983. No new units have 
been approved since 1983 but units approved prior to that may 
still receive a subsidy. The maximum term of the housing 
assistance payments vary from 20 to 40 years, depending on how 
the project was financed. There are 1.4 million private, 
project-based Section 8 units, about 50 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 
used to subsidize new development.

              e. service coordinators in assisted housing

    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. The 
service coordinator is responsible for ensuring that the 
elderly individuals and persons with disabilities living in 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 as long as possible and avoid 
premature and unnecessary institutionalization.
    In FY1999, HUD awarded $5,000,000 in service coordinator 
grants to 51 projects, 33 of which were Section 202 projects; 
the remainder were Section 8, 221(d)(3) or 236.
    In FY2000, HUD funded 259 projects for $28,579,665 in new 
grants, 170 of which were 202s, 42 were Section 8, and 47 were 
Section 221(d)(3) or Section 236.
    In FY1999 and 2000, HUD also provided one-year extension 
funds to expiring Service Coordinator contracts. These 
extensions enable the Service Coordinator programs to continue 
operating without breaks. In FY1999, HUD made extensions to 150 
contracts at a cost of $4,069,376. In FY2000, the Department 
extended 329 contracts with $9,168,441 in funding.
    Funding for service coordinators in public housing is 
discussed below.

               f. 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 Development Service.
    In FY1999, HUD extended 80 existing grantees for an 
additional year at a cost of $9,774,859. In FY2000, HUD 
extended 63 existing grantees for an additional year at a cost 
of $6,156,306. There were no funds appropriated for new grants 
in FY1999 or FY2000.

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

    The Flexible Subsidy Program (FLEX) is comprised of two 
components: (1) the Operating Assistance Program (OAP), which 
is designed to provide temporary funding to replenish project 
reserves, cover operating costs, and pay for limited physical 
improvements. The Operating Assistance (OA) is provided in the 
form of a non-amortizing ``contingent'' loan; of major capital 
improvements when funding such improvements cannot be done with 
project reserves. CILP assistance is provided in the form of an 
amortizing loan. Both programs are designed to restore or 
maintain the physical and financial soundness of eligible 
projects at the lowest possible cost to the Federal government. 
Because of the limited funding, however, Flexible Subsidy funds 
are strictly reserved for the emergency needs of 202 projects. 
Such projects must have been in occupancy for at least 15 years 
and have emergency health and safety needs. In FY1999, 
$13,716,999 was disbursed to over 20 projects. In FY2000, 
Flexible Subsidy funding was awarded to 30 projects, totaling 
$17,195,115.
    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. Funding has not been available 
for this program for several years.

                       h. 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.

             i. 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 improve the basic livability or 
utility of the property. There are no age or income 
requirements to qualify for a Title I loan. HUD funded 30,689 
loans in FY1999 and 18,387 loans in FY2000.

              j. 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. HUD 
funded 350 loans in FY1999 and 313 in FY2000.

          k. 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. HUD funded 7,921 
loans in FY1999 and 6,641 loans in FY2000.

     l. 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 aged 62 years or older, married or 
single. Nonprofit as well as profit-motivated sponsors are 
eligible under this program. The program is largely inactive 
and produced no units in FY1999 or FY2000.

                II. Office of 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 15 percent of Section 8 certificate and voucher 
recipients are being used by the elderly. As of January 2001, 
this represented 213,000 occupied units.

                b. elderly/disabled service coordinators

    Section 673 of the Housing and Community Development Act of 
1992 authorized the Department to fund service coordinators in 
public housing developments to ensure that the elderly and non-
elderly disabled residents have access to the services they 
need to live independently. From FY 1994 to 1998, the 
Department awarded 227 grants totaling approximately $62.8 
million for public housing authorities to hire service 
coordinators for their elderly and non-elderly disabled 
residents to provide general case management and referral 
services, connect residents with the appropriate services 
providers, and educate residents on service availability. 
Service coordinator grants that were previously awarded are 
being renewed annually to maintain the level of services for 
elderly residents and residents with disabilities. In FY1999 
approximately $13 million in renewal grants were awarded. 
Because funds are still available from FY1999, service 
providers who had not applied for funds were asked to submit 
applications. HUD staff are currently reviewing these 
applications and may award additional funds. In FY2000 
approximately $12 million in grants were awarded.

                     c. tenant opportunity program

    Section 20 of the U.S. Housing Act of 1937, as amended, 
authorized the Tenant Opportunities Program (TOP). The program 
enables resident entities to establish priorities and training 
programs for their specific public housing communities that are 
designed to encourage economic development, stability, and 
independence. The program began in 1988 and to date has awarded 
about 986 grants totaling approximately $80 million. Public 
housing developments with elderly residents are eligible to 
participate and perhaps 7 percent are primarily elderly 
grantees.
    As part of the implementation of Section 538 of the Public 
Housing Reform Act, the TOP program was consolidated into the 
Resident Opportunities and Self Sufficiency (ROSS) program. 
Section 538 authorizes a program to link services for public 
housing residents to promote self sufficiency and economic 
empowerment. Many of the activities previously eligible under 
TOP are eligible under ROSS.

                 d. public housing development program

    The Public Housing Development Program was authorized by 
Sections 5 and 23 of the U.S. Housing Act of 1937 to provide 
adequate shelter in a decent environment for families that 
cannot afford such housing in the private market.
    In 1999, 4 additional units of public housing for the 
elderly were reserved, 25 started construction, and 261 became 
available for occupancy. In 2000, 36 units were reserved, 36 
started construction, and 775 because available for occupancy. 
As of February 2001, there were approximately 404,860 elderly 
low income persons residing in public housing:

             III. Office 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 
CDBG program beneficiaries by age. The Department estimates, 
that grantees spent about 1 percent of their CDBG program funds 
(about $35 million in 1999 and $34 million in 2000) for public 
services that were specifically targeted to 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.

 B. CDBG STATE-ADMINISTERED AND HUD-ADMINISTERED SMALL CITIES PROGRAMS

    The CDBG State-administered program (and its predecessor, 
the HUD-administered Small Cities program, which still operates 
in Hawaii) is HUD's principal vehicle for assisting communities 
with populations under 50,000 that are not central cities of 
metropolitan areas. States provide grants to small cities, 
counties and other units of local government, which use the 
CDBG funds to undertake a broad range of activities. (HUD makes 
grants directly to counties in Hawaii.) 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. The extent of benefit to the elderly in the State 
CDBG program may be similar to that in the Entitlement CDBG 
program, since many small communities and rural areas have high 
concentrations of elderly persons.

             C. HOME INVESTMENT PARTNERSHIPS (HOME) PROGRAM

    The HOME Program continues to serve as a major resource for 
elderly housing assistance, particularly for the rehabilitation 
of deteriorating properties of low-income elderly homeowners, 
allowing them to remain in their own homes and keep those homes 
in standard condition. The figures below represent the number 
of HOME-assisted units that participating jurisdictions 
reported were completed and occupied by elderly residents 
during calendar years 1999 and 2000 and the percentage of units 
in that category that this figure represents.

----------------------------------------------------------------------------------------------------------------
                                                                              Total Units
          Tenure type             Calendar 1999-2999  Elderly Cumulative       Completed      Percentage Elderly
----------------------------------------------------------------------------------------------------------------
Homeowner Rehabilitation.......  10,391.............  36,054............  86,974............  42.9%
Rental Units...................  11,589.............  20,193............  125,173...........  16%
New Homebuyers.................  1,624..............  3,911.............  145,234...........  3%
                                --------------------------------------------------------------------------------
      Total elderly units......  23,604.............  60,158............  357,381...........  17%
----------------------------------------------------------------------------------------------------------------

    To date, HOME has assisted 60,158 low-income elderly 
households. This constitutes an investment of over 
$1,027,000,000 in HOME funds, which have leveraged another 
$1,406,000,000 in private investment and other non-HOME funds 
(which includes Federal, State and local funds) to provide 
housing for the elderly (estimates based on a weighted average 
of $17,072/per unit HOME subsidy for production, and 
conservative estimate of $1.37 per $1.00 of HOME as leverage).
    For data collection purposes, the HOME Program defines 
elderly as 62 or older. Therefore the above numbers do not 
reflect projects which are designed for seniors between 55 and 
62.

                  D. EMERGENCY SHELTER GRANTS PROGRAM

    The Emergency Shelter Grants (ESG) 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.
    According to a recent Federal study entitled HOMELESSNESS: 
Programs and the People They Serve, about 2 percent of homeless 
persons are 65 years or older. While about 1 percent of the ESG 
funds go to seniors-only facilities for the homeless, this 
population often receives emergency housing and services at 
other shelter facilities that are not reported in the ESG 
program. Shelters normally serve all homeless adults of any 
age, unless they have a particular family or single person 
focus.

                     E. SUPPORTIVE HOUSING PROGRAM

    The Supportive Housing Program (SHP) funds may be used to 
provide: (1) transitional housing designed to enable homeless 
persons and families to move to permanent housing within a 24 
month period, which may include up to 6 months of follow-up 
services after residents move to permanent housing; (2) 
permanent housing provided in conjunction with appropriate 
supportive services designed to maximize the ability of persons 
with disabilities to live as independently as possible within 
permanent housing; (3) innovative supportive housing; or (4) 
supportive services for homeless persons not provided in 
conjunction with supportive housing.

            IV. Office of Fair Housing and Equal Opportunity


                        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.'' 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 and operated for occupancy by at least one 
person 55 years of age or older per unit, provided various 
other criteria are met.

              B. THE HOUSING FOR OLDER PERSONS ACT OF 1995

    The Housing for Older Persons Act (HOPA) of 1995 amends the 
``55 and older'' housing exemption to the Fair Housing Act's 
prohibition against discrimination based on familial status. 
HOPA eliminates the requirement that housing ``55 and older'' 
have significant facilities and services and establishes a good 
faith reliance defense from monetary damages for individual 
real estate professionals on a legitimate belief that the 
housing was entitled to an exemption. In order to qualify for 
the ``55 and older 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) publish and adhere to policies and procedures which 
demonstrate an intent by the owner or manager to provide 
housing for persons 55 and older; and (3) comply with the rules 
issued by the Secretary for verification of occupancy through 
reliable surveys and affidavits.
    The Department published the HOPA final rule on April 2, 
1999 with an effective date of May 3, 1999.

                       C. AGE DISCRIMINATION ACT

    The Age of Discrimination Act of 1975 prohibits programs or 
activities receiving Federal financial assistance from directly 
or through contractual, licensing, or other arrangements, using 
age distinctions or taking any other actions which have the 
effect, on the basis of age, of: excluding individuals from, 
denying them the benefits of, or subjecting them to 
discrimination under a program or activity receiving Federal 
financial assistance; or denying or limiting individuals their 
opportunity to participate in any program or activity receiving 
Federal financial assistance. The Department's regulations 
implementing the Age Discrimination Act became effective on 
April 10, 1987, and are codified at 24 CFR Part 146.
    During FY1999, the Department received 16 complaints 
alleging age discrimination, all of which were referred to the 
Federal Mediation and Conciliation Services (FMCS). One of 
these complaints were successfully mediated and agreements was 
reached. Of the remaining cases, 3 were unsuccessfully 
mediated, 1 is pending mediation, and in 11 cases mediation was 
canceled due to the failure to attend the mediation meeting. 
These 15 cases may be administratively closed out at a later 
date.

                         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, disabled families 
only, or elderly and disabled families, if the plans met 
certain statutory requirements outlined in Section 7 of the 
United States Housing Act. The Housing Opportunities Program 
Extension Act of 1996 simplified and streamlined those 
requirements, but continued to require HUD to review and 
approve or disapprove designated housing plans.
    For FY2000, 26 housing authorities received approval to 
designate 4,450 units for elderly families.

              V. Office of Policy Development and Research


                       A. AMERICAN HOUSING SURVEY

    The American Housing Survey for the United States, Current 
Housing Report Series Number H150 for the year 1999 contains 
special tabulations on the housing situations of elderly 
households in the United States. 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) also contain data on the elderly. In addition, 
Current Housing Report Series Number H170 contains data on the 
elderly for the 47 largest metropolitan areas that are 
individually surveyed over four-to six-year cycles.
    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 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 Congregate Housing Services Program (CHSP) provides a 
combination of housing and support services to frail elderly 
and non-elderly disabled persons living in federally subsidized 
apartment developments. CHSP services include service 
coordination and non medical supportive services, such as 
housekeeping, congregate meals, personal care, and 
transportation.
    The main purpose of CHSP is to promote and encourage 
maximum resident independence within a home environment, and to 
improve housing management's ability to assess eligible 
residents' service needs and provide or ensure the delivery of 
needed services to them. HUD pays up to 40 percent of the costs 
of CHSP; the grantees pay 50 percent or more, and the remaining 
10 percent is paid by fees from participating residents. CHSP 
services are subsidized through grants to public housing 
authorities, Section 202 and other developments that serve 
frail elderly and disabled residents (project based model).
    Data for the evaluation was collected over a two-year 
period. The final report, which was Congressionally mandated, 
was transmitted to Congress in September 2000.

                                Findings

    The number of residents served in different developments 
ranges from fewer than 10 to more than 100, with a median in 
1996 of 24 participants. Services are targeted to residents who 
have functional limitations that meet eligibility requirements, 
and are income-eligible for subsidized housing. CHSP 
participants are typically elderly (average age 81 years) white 
women who live alone. In their age and race/gender composition, 
the group served by CHSP is similar to other frail elderly 
populations receiving supportive services. Although they live 
alone, they are not socially isolated: 84 percent have at least 
one family member living nearby, and more than half (58 
percent) see family at least once a week. Also, most have 
contact with friends (63 percent see friends at least once a 
week).
    Most participants (75 percent) report 3 more activities of 
daily living (ADL) limitations and half have 6 or more ADLs. 
Areas in which more than half of CHSP participants report ADL 
limitations include: doing housework (81 percent); shopping (72 
percent); getting in or out of a tub or shower (59 percent); 
preparing meals (56 percent); and getting in or out of a bed or 
chair (54 percent). Comparison shows that CHSP participants are 
more impaired than the overall population of U.S. elderly.
    Half of CHSP participants studied were still in the program 
24 months after the baseline survey; about 14 percent had died; 
and about 9 percent had left the program because they were no 
longer eligible; were dissatisfied, or obtained services from 
another source. Among residents who remained in CHSP over the 
24 month study period, about half (48 percent) showed the same 
ADL level over the period and 29 percent experienced decline.
    Annual per-participant costs of CHSP services and 
associated housing were estimated and compared with costs for 
assisted living and nursing homes. These show that the costs 
per participant for housing plus CHSP services ($8,900 to 
$11,000 per year) are substantially lower than the costs for 
assisted living ($15,000 to $20,000) or a nursing home 
($41,000). This supports the view that CHSP provides a cost 
effective means of providing housing and supportive services 
for the frail elderly.
    Several conclusions from the evaluation are specially 
relevant: (1) CHSP has been successful in delivering supportive 
services to frail, low-income elderly residents of subsidized 
housing; (2) HUD funds have been important for grantees in 
leveraging funds from other sources; (3) the CHSP data show 
that housing and supportive services can be delivered in 
subsidized housing at costs below those for assisted living and 
nursing home care; and (4) the kinds and levels of service can 
be changed as individual residents needs change over time.

   C. EVALUATION OF THE HOPE FOR ELDERLY INDEPENDENCE DEMONSTRATION 
                            PROGRAM--HOPE IV

    The final report on the evaluation of the HOPE for Elderly 
Independence Program was released in February 1999.
    HOPE IV combines HUD Section 8 rental assistance with case 
management and supportive services to low-income elderly 
persons (62 and older) with limitations in three or more 
personal care and home management activities, such as bathing, 
dressing, and housekeeping. The purpose of HOPE IV, 
administered by local Public Housing Agencies (PHAs), is to 
expand access to Section 8 rental assistance by frail elderly 
tenant populations and help participants avoid nursing home 
placement or other restrictive settings when home and 
community-based options are appropriate. In addition to rental 
assistance, as vouchers for private-market housing, HUD pays 40 
percent of the supportive services costs, the grantees pay 50 
percent, and participants, except for those with very low 
incomes, pay 10 percent.
    The vast majority of HOPE IV participants are widowed, 
white females, consistent with the profile of frail elderly 
Americans overall. In addition, approximately half of the 
participants are age 75 and over, have less than a high-school 
education, and receive incomes under $8,000 per year. Over half 
of the participants, however, are between 62 and 74 years old, 
but with few exceptions and in spite of their relatively young 
age, these persons have similar levels of frailty as their 
counterparts above age 75.
    Most HOPE IV participants have several factors that are 
highly correlated with frailty and risk of institutionalization 
in national studies--low-income, low level of education, 
minority status, and living alone. HOPE IV participants are 
much frailer than non-instutionalized elderly persons in the 
general population, and they are considerably less frail than 
elderly persons in community-based programs (nursing home 
eligible) or persons receiving nursing home care. During the 
two-year period between the baseline and follow-up survey, the 
percentage of participants and comparison group (control group) 
members reporting an ADL limitation increased for all 
activities of daily living. However, the comparison group 
reported fewer increases than the participants.
    Many HOPE IV participants are not isolated, participate in 
activities outside the home, and enjoy their social contact. 
However, the patterns of both in-person and telephone contact 
showed that most participants have either a great deal of 
contact or little contact at all, with surprisingly few cases 
in between.
    Participants in the HOPE IV program received a 
significantly higher level of supportive services than the 
comparison (or control) group, and this disparity in access to 
care remained over time. For example, at follow-up (2 years 
after baseline), nearly one-third (32 percent) of the 
comparison group reported receiving no services at all despite 
high levels of frailty, versus seven percent of the 
participants. In addition, receipt of services has a 
significant correlation with range of positive outcomes, across 
multiple domains of functioning. For example, service 
recipients scored significantly higher in four major mental 
health dimensions, social functioning, vitality, and other 
measure of social well-being. However, there wee no 
statistically significant differences between the participants 
and the comparison group members in the rates of nursing home 
placement, mortality, or remaining in Section 8. This finding 
is consistent with the results of prior studies that show the 
impacts of similar programs address quality of life and care, 
rather than changing such overt outcomes as death, 
institutionalization, or otherwise having to leave one's home 
due to frailty.
    Over the two-year period of the study, 40 percent of the 
participants left the HOPE IV program, including Section 8. 
This consisted of 15 percent who died, 9 percent who went into 
a nursing home or other similar setting, 9 percent who moved to 
another location, and 7 percent who left HOPE IV and Section 8 
for other or unspecified reasons. Sixty percent of the 
participants remained in assisted housing, including 7 percent 
who left HOPE IV but retained their Section 8 rental 
assistance. Over the same two-year period, 38 percent of the 
frail elderly comparison group left Section 8, including 13 
percent who died, 8 percent who went into a nursing or related 
care home, 9 percent who moved to another location, and 8 
percent who left for other or unspecified reasons.
    An overwhelming 85 percent of participants at baseline, and 
an even higher 91 percent at follow-up (2 years later), 
reported they were very satisfied with HOPE IV; 11 percent and 
6 percent, respectively, said they were somewhat satisfied. 
Only one respondent indicated active dissatisfication with the 
program at either point in time, while a very few were 
uncertain or did not say.

Comparison of HOPE IV and CHSP

    This report compares the effectiveness of providing 
assistance under the Congregate Housing Services program (CHSP) 
and the HOPE for Elderly Independence Demonstration (HOPE IV) 
program as requested in the 1990 Cranston-Gonzales National 
Affordable Housing Act (Public Law 101-625. HOPE IV and CHSP 
combined HUD housing assistance with case management and 
supportive services for low-income elderly persons (62 and 
older) with limitations in personal care and home management 
activities, such as bathing, dressing, and housekeeping. The 
report was released in June 2000.
    The purpose of HOPE IV and CHSP was to expand existing 
housing assistance programs to an elderly population often 
deprived of access to them due to frailty and to help these 
participants avoid nursing home placement or other restrictive 
settings when home and community-based options were 
appropriate. In addition to the housing assistance, HUD paid 40 
percent of the supportive services costs, the grantees paid 50 
percent, and participants, except for those with very low 
incomes, paid 10 percent of total program costs.

                   ITEM 8--DEPARTMENT OF THE INTERIOR

                              ----------                              


             AGING REPORT FOR CALENDAR YEARS 1999 AND 2000

               Departmental Office for Equal Opportunity

    The Departmental Office for Equal Opportunity (OEO) is 
responsible for enforcing a variety of Federal anti-
discrimination laws that guarantee equal employment opportunity 
and nondiscrimination in all aspects of the Department of the 
Interior's (DOI) operations. OEO serves as the focal point for 
ensuring nondiscrimination on the basis of age in all aspects 
of DOI's operations including its employment practices, 
federally conducted education programs, and in all programs and 
activities receiving Federal financial assistance. In calendar 
years 1999 and 2000, OEO promoted and oversaw an array of 
proactive diversity initiatives to ensure nondiscrimination in 
DOI's employment practices, i.e., diversity training for bureau 
and office managers, diversity presentations, and listening 
sessions on diversity workforce issues. Each of these diversity 
initiatives covered age discrimination matters and quality of 
life issues that generally affect older DOI job applicants and 
employees. DOI continues to provide equal employment 
opportunity (EEO) counseling services through collateral duty 
personnel who have been specifically trained to address age 
discrimination issues that may affect DOI job applicants and 
employees. DOI has a ``Zero Tolerance Policy'' in place that is 
aimed at prohibiting discriminatory employment policies and 
practices based on age. DOI's age discrimination policy is 
prominently proclaimed to the public and its employees through 
a variety of approaches.
    In 1999, DOI processed a total of 117 civil rights 
complaints of which two were age discrimination complaints. In 
2000, out of a total of 132 civil rights complaints received by 
DOI, as in 1999 only two complaints alleged discrimination on 
the basis of age. These complaints were filed against State and 
local government agencies who received Federal financial 
assistance from DOI. Generally, the complaints did not relate 
to discriminatory age based policies, rather these complaints 
alleged instances of maltreatment and inaccessible programs 
encountered by older people with disabilities. In calendar year 
1999, experts from the U. S. Department of Health and Human 
Services, the lead Federal agency for providing government wide 
guidance in enforcement of the Age Discrimination Act of 1975, 
provided comprehensive civil rights training to key DOI equal 
opportunity personnel on the requirements of the Act. (The Age 
Discrimination Act of 1975 prohibits discrimination on the 
basis of age in federally assisted programs.) This training was 
provided to all DOI bureaus and offices that administer Federal 
financial assistance programs. During the period, policy 
guidance and procedural information were developed on how to 
conduct age discrimination complaint investigations filed 
against recipients of Federal financial assistance. Technical 
assistance was routinely provided by OEO to bureaus having 
responsibility for addressing age discrimination complaints. 
Comprehensive guidance was issued on DOI's civil rights public 
notification requirements which are intended to inform the 
public of DOI's nondiscrimination policy and the procedures for 
filing age discrimination complaints. Additionally, compliance 
reviews of DOI's federally assisted programs were conducted 
that covered age discrimination issues. These reviews were 
conducted to ascertain, in part, whether or not DOI's 
recipients of Federal financial assistance were in compliance 
with the requirements of the Act. DOI's bureaus and offices 
have established continuous civil rights compliance and 
enforcement programs that provide for conducting civil rights 
compliance reviews, complaints processing, training, and the 
provision of technical assistance in DOI's most service-
delivery oriented Federal assistance programs. All of these 
particular processes cover the requirements of the Act. DOI 
continues to have a complaints processing system in place that 
facilitates prompt investigations of age discrimination 
complaints against DOI recipients of Federal financial 
assistance. DOI's complaint processing procedures incorporate 
routine determinations as to whether a complaint is within 
DOI's jurisdiction and covered by the Act. Complaints received 
by DOI that contain sufficient information which identify the 
recipient, the location of the program or activity, the policy 
or issue in question, and the approximate date the alleged 
discrimination occurred are routinely referred to the Federal 
Mediation and Conciliation Service as required by Departmental 
regulation.
    During the period, DOI also initiated work life assessments 
to ascertain the needs and wants of its employees with the 
older worker in mind. These assessments were accomplished in 
terms of improving conditions in DOI's workplace for all 
workers. These work life assessments resulted in the re-opening 
of DOI's health center and a refurbished fitness center which 
substantially benefits DOI's aging employees. Older workers can 
now take advantage of family support rooms that have been 
established in DOI facilities. In addition, DOI's aging 
employees, on an as needed basis, can avail themselves of DOI 
sponsored wellness programs including free physical 
examinations, flexi-time work schedules, telecommuting, 
retirement planning programs, and alternative work schedules.

                        Bureau of Indian Affairs

    The Bureau of Indian Affairs (BIA) administers initiatives 
and programs to benefit aging American Indians and Alaskan 
Natives. More specifically, BIA provides and finances adults 
with custodial and protective care services. These services 
have been provided in homes, group homes and nursing care 
facilities for elderly persons who lack financial, physical and 
mental capability to care for themselves. Other aging citizens 
have received protective and counseling services without 
custodial care payments. BIA coordinates intensive nursing care 
services for aging residents through referrals to other 
Federal, state or local agencies. The Division of Social 
Services recently established standards that focuses on 
upgrades for homemakers and custodial care services. On January 
22, 2001, BIA published in the Federal Register, guidance that 
addresses the handling of financial matters for adults with 
disabilities including the elderly. The BIA administers a 
Housing Improvement Program that provides for repairs and home 
improvements, and the construction of new homes on Indian 
reservations or in Indian communities. The Housing Improvement 
Program is a Federal financial assistance program designed to 
improve housing standards for Native Americans who are 
ineligible for such aid under conventional housing assistance 
programs. Program participants are selected from weighted 
criteria that favor low income individuals, people with 
disabilities, and the elderly. Furthermore, Tribal governments 
are authorized to use ``638 Contracts'' as a means to meet the 
housing needs of elderly Native Americans. In addition, the BIA 
continues to enforce the Age Discrimination in Employment Act. 
The Act prohibits discrimination in employment on the basis of 
age in the BIA's employment practices.

          Office of Surface Mining Reclamation and Enforcement

    The Office of Surface Mining Reclamation and Enforcement 
(OSM) is committed to ensuring that all persons are provided 
equal opportunity in all employment matters. For calendar years 
1999 and 2000, an equal employment opportunity policy statement 
from the Director was in effect. This policy governs OSM's 
employment practices. The policy states that ``(in the OSM) 
discrimination based on age (40 and older) will not be 
tolerated.'' Older workers are represented in most of OSM's 
occupational workforce series. In fact, over half (69.6%) of 
OSM's workforce will have reached retirement eligibility within 
the next 5-10 years.
    OSM continuously keeps abreast of what is important to its 
workers and their quality of work place issues. In 1999 and 
2000, OSM sponsored a series of seminars on retirement, breast 
cancer, prostate cancer, the Thrift Savings Plan, and social 
security These seminars were chosen because of their direct or 
indirect impact on OSM's aging workforce. Moreover, service 
awards for 25, 30, and 35 years of service were awarded to many 
OSM employees during calendar years 1999 and 2000. For further 
information regarding OSM's policies and practices, please 
contact Diane Wood on (202) 208-2997.

                       Bureau of Land Management

    The Bureau of Land Management (BLM) offered retirement 
training to its employees. The training was provided to BLM 
employees who were at retirement age. The training was attended 
mostly by employees age 50 and over.
    The BLM has established a family room in its Washington 
Office. This room is used by employees who have elderly parents 
requiring close attention especially in cases where there is no 
one at home to care for them. The room is equipped with a 
computer and other office amenities to allow employees to 
perform their duties while taking care of their parents.
    BLM employs thousands of senior citizens in volunteer jobs 
in the States of Alaska, Arizona, California, Colorado, Idaho, 
Montana, the Dakotas, Idaho, Nevada, New Mexico, Oregon, Utah, 
and Wyoming. These volunteers perform tasks as diverse as 
clearing public lands, collecting data on raptor populations, 
maintaining fish habitat, serving as campground hosts, 
monitoring and protecting caves and other related resources, 
conducting archeological inventories, nurturing plant species 
growing on public lands from Eastern Florida to Western Oregon, 
and teaching kids and adults about natural resources.
    Volunteers are recognized during the Earth Day 
celebrations. A group of the best volunteers is recognized by 
the Secretary of the Interior every year in Washington, DC. In 
1999, 17,300 persons participated in the BLM volunteers 
program. We do not have the report for 2000 as of this date. A 
high percentage of these volunteers are older citizens.
    The BLM Nevada State Office has an established Elder Care 
Program for BLM families caring for older parents. Senior 
Resource Guides are distributed to BLM Nevada State employees 
to assist them in providing care and support for their aging 
parents. The guide contains information regarding 
transportation, counseling services, and support groups, i.e., 
grandparents raising grandchildren, protective services for 
elderly persons, centers for independent living, ``meals-on-
wheels,'' nursing homes, companion care, educational programs, 
employment opportunities and volunteer programs for senior 
citizens. The Nevada State Office participates regularly in the 
Children's Cabinet, a public service program that affords 
volunteer and employment opportunities to Older Americans. The 
program also offers advice to BLM employees who are in need of 
day care services for their elderly parents. Free meeting 
facilities are provided for employee support group meetings. 
Telephone numbers for elder care services located outside of 
the State of Nevada are routinely provided to BLM employees who 
need assistance in finding reputable elder care services for 
their parents or grandparents.
    The BLM participates in the Senior Community Service 
Employment Program (SCSEP). SCSEP is a program that affords 
part-time employment and basic entry level job training 
opportunities to persons 55 years of age and older who meet 
established Federal low income guidelines. An enrollee's duties 
in the program others similar to those performed by others 
already employed by the BLM. A SCSEP person is not considered a 
Federal employee within the context of the laws administered by 
the Office of Personnel Management. Hence, they do not have 
Federal employee status, except for the purpose of the Tort 
Claims Act and Federal Employees Compensation Act. The 
objective of the program is to help older Americans to get into 
or return to private sector jobs. The pay for a SCSEP employee 
is the Federal minimum wage or if they live in a state where 
the minimum wage is higher they get paid the higher wage. BLM's 
SCSEP employees receive one hour of excused leave for every 20 
hours they work. They are paid for Federal holidays that occur 
during their scheduled tour-of-duty. SCSEP employees do not 
receive Federal health benefits. However, they are covered by 
the Federal Workman's Compensation Act for injuries that occur 
while working on the job.

                         Bureau of Reclamation

    The Bureau of Reclamation's mission is to manage, develop, 
and protect water and related resources in an environmentally 
and economically sound manner, in the interest of the American 
public. The Bureau of Reclamation offers extensive career 
opportunities for diverse individuals with a wide variety of 
education and work backgrounds. In order to ensure diversity, 
the Bureau of Reclamation instituted a Workforce Diversity 
Implementation Plan in 1999. This was in response to the 
Department of the Interior's Strategic Plan for Improving 
Diversity. The plan outlines five separate and distinct goals, 
all of which impact the aged population. The five goals are 
cited in the following section of this report.
    Recruit a workforce that reflects the diversity of the 
nation.--As an equal opportunity employer, the Bureau of 
Reclamation continues to recruit individuals from all age 
groups. However, examples of specific opportunities for aged 
applicants is re-employed annuitants 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. For example, one office hired 
an annuitant for an employee relations specialist position. 
Other offices have volunteer and work trainee programs 
specifically designed for seniors. In Farmington, New Mexico, 
the county provides names of volunteer seniors to perform 
receptionist and clerical duties at the Reclamation 
Construction Office. In addition, the Pacific Northwest Region 
utilizes senior volunteers as ``Park Hosts'' every summer. They 
also utilize volunteer referrals from organizations such as the 
local Easter Seals for a variety of worker trainee positions, 
from thinning forests to office automation.
    Retain a workforce that reflects the diversity of the 
nation.--In 1995, the Bureau of Reclamation established a Work 
and Family Team (WAFT) to implement the Presidential directive 
on Family-Friendly Federal Work Arrangements. Initiatives taken 
on behalf of older Americans and their families include:
          Human Resource Centers located in seven 
        geographically dispersed regions which are designed to 
        be ``one stop shopping centers.'' Aside from job 
        information, they also provide resources and seminars 
        on work and family issues, such as child and elder 
        care, as well as health maintenance. The WAFT regularly 
        updates its web page, which covers a wide range of 
        topics and allows employees to send questions about 
        work and family policies, such as the Family and 
        Medical Leave Act. A WAFT Handbook is also available to 
        employees in all offices.
           The Bureau of Reclamation conducts many 
        activities throughout the year which affect senior 
        citizens. The Bureau of Reclamation's Human Resources 
        Offices maintain contact and provide services to many 
        retirees who need advice or have questions concerning 
        their retirement and health benefits. The Bureau of 
        Reclamation also makes available to its retirees and 
        their spouses annual health insurance fairs that are 
        attended by reputable health insurance carriers. 
        Several regional offices of the Bureau of Reclamation 
        continue to mail out a highly regarded monthly 
        newsletter to all retirees as a way of keeping in 
        touch. Additionally, pre-retirement seminars are held 
        for all interested employees who are within five years 
        of retirement eligibility.
    Ensure accountability at the Secretarial and bureau levels 
for improving diversity.--Bureau of Reclamation offices are 
required to provide quarterly updates of their activities and 
progress in attaining and maintaining a diverse workforce.
    Educate managers, supervisors and employees regarding 
diversity.--Training is provided on a continuous basis to all 
employees of the Bureau of Reclamation regarding the value of 
maintaining a diverse workforce. In addition, observances that 
focus on the contributions of contemporary and historic 
individuals, particularly women, minorities, and people with 
disabilities are featured periodically throughout the year. 
Other relevant seminars cover such topics as U. S. Census Data, 
which highlight demographic shifts and raise awareness of the 
nation's aging population.
    There will be zero tolerance for discrimination, harassment 
or hostile work environments.--This goal assures that all 
operations are conducted without discrimination including, but 
not limited to, age discrimination. Moreover, the Bureau of 
Reclamation has responsibilities in assuring equal access to 
employees and the public through its federally conducted and 
federally assisted programs. The Bureau of Reclamation is 
committed to serving the diverse populations of this country by 
improving work and public environments, consistent with its 
mission of managing water resources. Tasked with meeting legal 
responsibilities, the Bureau of Reclamation has developed a 
corporate approach to providing accessible opportunities for 
people with disabilities. The Bureau of Reclamation believes 
that these equal opportunity policies and practices will 
continue to have a positive impact on our nation's seniors.

                         National Park Service

    The National Park Service (NPS) continues to ensure that a 
broad range of services is provided to the visiting public 
including senior citizens. The NPS hosts the Senior Community 
Employment Program. This activity is implemented in cooperation 
with a number of parks with the National Park system and the U. 
S. Forest Service, U. S. Department of Agriculture. The program 
seeks to provide supplemental income to seniors in general and 
in rural communities.
    The Summer Seasonal Employment Program hires and employs a 
number of retirees to perform duties in those parks where the 
visitation rates have increased and the workload of the 
permanent workforce requires hiring of seasonal employees.
    The Golden Age Passport, for individuals 62 or older, is a 
lifetime entrance pass to the majority of the 384 park sites in 
the National Park system with entrance fees. The passport 
permits the holder and accompanying passengers to be admitted 
to these sites.
    The NPS Accessibility Office provides park and recreation 
services to special populations including senior citizens and 
individuals with disabilities. The office develops and 
implements comprehensive approaches for ensuring that the park 
sites are accessible. The office also provides training and 
technical assistance to these sites.
    Volunteers are vital in meeting the NPS's mission. In turn, 
having a meaningful experience while helping to preserve and 
protect America's national treasures is vital to NPS's 
volunteers. The National Park Service Volunteers-In-Parks 
program provides opportunities that are mutually beneficial to 
volunteers and parks.
    In an effort to expand these opportunities and tap what has 
been a somewhat untapped resource in the past, the NPS 
developed the idea of a Volunteer Senior Ranger Corps. The 
original idea, conceptualized two years ago, was to create a 
cadre of seniors with specialized skills who would work with 
parks on specific projects projects that might not get the 
level of attention required without the help of volunteers.
    Within the last year, the National Park Foundation was 
presented with an opportunity to receive grant money from the 
United Parcel Service (UPS) Foundation. The UPS Foundation's 
Volunteer Impact Initiative was a perfect way to implement the 
Volunteer Senior Ranger Corps. The grantor's requirement for 
this initiative involved a strong youth component. The National 
Park Foundation, the NPS, and the Environmental Alliance for 
Senior Involvement partnered together in creating a proposal 
which incorporated a strong intergenerational component where 
seniors would work with youths on park projects as well as 
sharing experiences and building stewardship.
    The UPS Foundation is very excited about the NPS being a 
part of their Volunteer Impact Initiative. As one of four 
grantees, the National Park Foundation and its partners are in 
the process of implementing the Volunteer Senior Ranger Corps.

                        U. S. Geological Survey

                                  1999

    The U. S. Geological Survey (USGS) provides opportunities 
to individuals of all ages in all areas of the USGS's 
operations. The USGS ensures that the skills of older 
individuals are utilized through special programs and 
employment opportunities.
    In 1999, USGS employed a total of 9,889 individuals in 
permanent and temporary jobs. During this period, 6,750 (68.3%) 
USGS employees were age 40 and over. Of USGS employees age 40 
and over, there were 475 (7%) employees who were 60 years of 
age and older, and two employees over 80 years old.
    The majority of USGS's mission related occupations, which 
include occupations such as hydrologists, geologists, 
cartographers, and biologists, are in the professional 
category. Of the 6,750 USGS employees age 40 and over, there 
were 3,612 (53.5%) in professional positions, 277 (7.7%) of 
whom were age 60 or over, and two employees over 80. Other 
demographic information regarding USGS employees age 40 and 
over are as follows:
           1,046 (15.5%) were in ``Administrative'' 
        positions with 49 (4.7%) of them age 60 and over;
           1,645 (24.4%) were in ``Technical'' 
        positions with 112 (6.8%) of them age 60 and over;
           309 (4.6%) were in ``Clerical'' positions 
        with 31 (10%) of them age 60 and over;
           18 (0.3%) were in ``Other'' positions with 
        none of them age 60 and over; and
           120 (1.8%) were in ``Wage Grade'' positions 
        with eight (6.7%) 60 and over.
    There were two employees over the age of 80, one geologist 
and one wildlife biologist, both of whom worked full time.
    In 1999, USGS selected participants for the following 
career development activities:
           Women's Executive Leadership Program: six 
        participants, four were age 40 and over; and
           Federal Executive Institute: 18 
        participants, 17 were over the age of 40. There were 6 
        complaints filed based on age during this period.

                                  2000

    In 2000, USGS employed a total of 10,050 individuals in 
permanent and temporary jobs. There were 6,859 (68.2%) USGS 
employees who were age 40 and over. Of USGS employees age 40 
and over, there were 506 (7.4%) employees who were 60 years of 
age and older, and there were three employees over the age of 
80,
    The majority of USGS' mission related occupations, which 
include positions such as hydrologists, geologists, 
cartographers, and biologists, are in the professional 
category. Of the 6,850 USGS employees age 40 and over, there 
were 3,673 (53.6%) in professional positions, 294 (8%) of whom 
were age 60 and over, and two employees over the age of 80. 
Other demographic information regarding USGS employees who were 
age 40 and over are as follows:
           1,080 (15.7%) were in ``Administrative'' 
        positions with 56 (5.2%) of them age 60 and over;
           1,661 (24.2%) were in ``Technical'' 
        positions with 119 (7.2%) of them age 60 and over;
           307 (4.5%) were in ``Clerical'' positions 
        with 29 (9.4%) of them age 60 and over;
           23 (0.3%) were in ``Other'' positions with 
        none of them age 60 and over; and
           115 (1.7%) were in ``Wage Grade'' positions 
        with eight (7%) age 60 and over.
    There were three employees over 80 years of age, a 
geologist, a wildlife biologist, and a clerk typist. All three 
were full time employees.
    In FY2000, USGS selected participants for the following 
career development courses:
           Women's Executive Leadership Program: four 
        participants. Out of that total, three were over the 
        age of 40;
           Team Leadership Program: six participants. 
        Out of that total, four were over the age of 40; and
           Federal Executive Institute: 20 
        participants. Out of that total, 18 were over the age 
        of 40 and one over the age of 60.
    There was a two-part Elder Care Workshop that was sponsored 
by the USGS Employee Assistance Program (EAP) covering the 
options to be considered when creating a plan to serve aging 
family members in the best way possible. Information was 
provided about Medicare and other health maintenance 
organization plans and the legal issues related to health care 
needs of elderly individuals.
    As a follow-up to the workshop, an Elder Care Support Group 
was established which has continued to the present. There were 
also workshops during Fiscal Year 1999 and Fiscal Year 2000 
providing information on health issues related to aging 
including Alzheimer's disease, heart health, osteoporosis, and 
stroke. Health screening for health issues related to aging 
have been offered through the National Center Health Unit 
including stroke, heart disease, and osteoporosis screening.
    There were eight complaints filed based on age during this 
time. The following chart illustrates the numbers of 
individuals who retired from USGS, some of whom have continued 
to provide outstanding services to USGS and the public 
nationwide in a variety of capacities.

                      Total Number of USGS Retirees
------------------------------------------------------------------------
                       Categories                          1999    2000
------------------------------------------------------------------------
Retirees................................................     278     403
Docents.................................................       6       6
Scientists Emeritus.....................................       1       7
------------------------------------------------------------------------

    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 from the Scientists Emeritus.

                      Minerals Management Service

    The Minerals Management Service (MMS) continues to work to 
support programs for older Americans. MMS's workforce 
statistics are as follows:
           Eighty-two percent of MMS's workforce is 
        comprised of employees age 40 and over (1,450 of 
        1,767);
           Older employees are well represented in a 
        variety of occupations within MMS, including 
        accountants, auditors, computer specialists, engineers, 
        and physical scientists;
           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;
           Employees are given flexibility to 
        accommodate family needs through Family and Medical 
        Leave Act initiatives;
           Eligible MMS employees attend retirement 
        planning workshops; and
           Managers and supervisors continue to receive 
        equal employment opportunity training, which includes 
        age discrimination and how to avoid it.
    The MMS continues to perform its mission related functions 
with diligence and with appreciation of the importance of MMS's 
mission. A major mission responsibility affecting large numbers 
of citizens is the approval of mineral royalty payments to 
various landholders, including numerous older Americans who 
often greatly depend on these payments to meet their basic 
humans needs and rely on the ability of the MMS to effectively 
discharge its finance responsibilities.
    The MMS offshore mission has the ultimate objective of 
increasing domestic minerals (oil and gas) production through 
offshore resources, thereby decreasing our nation's 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.

                    U. S. Fish and Wildlife Service

    The U. S. Fish and Wildlife Service (FWS) provides 
opportunities for all employees regardless of their age and 
ensures that older individuals are utilized through special 
programs, volunteer programs, and employment opportunities. The 
following are the FWS reports on aging for 1999 and 2000.

                                  1999

    The FWS currently employs a total of 7,666 individuals. 
There are 5,433 (71%) of FWS employees over the age of 40, 
which is an increase of 319 employees from the previous year. 
Of the FWS employees over the age of 40, there are 306 (4%) 
over the age of 60, an increase of 4 employees from the 
previous year.
    The majority of the FWS's mission related occupations, 
which include biologists, are in professional positions. 
Demographic information regarding FWS employees over the age of 
40 is as follows:
           2,407 (31%) were in Professional position; 
        80 (1%) were over the age of 60;
           1,073 (14%) were in Administrative 
        positions; 47 (0.6%) were over the age of 60;
           841 (11%) were in Technical positions; 63 
        ().6%) were over the age of 60;
           381 (%5) were in Clerical positions; 36 
        (0.5%) were over the age of 60;
           30 (0.4%) were in Other positions; one was 
        over the age of 60;
           690 (9%) were in Wage Grade position; 79 
        (1.0%) were over the age of 60.
    In 1999, there were 30 employment related discrimination 
complaints filed alleging discrimination on the basis of age 
(40 and above). Among the federally assisted program related 
complaints filed during this period, none contained an 
allegation of discrimination on the basis of age (40 and 
above).
    A total of 6,686 Golden Age Passports were issued 
throughout the FWS in 1999. The Golden Age Passport Program 
provides free or lower entrance fees to most national parks, 
monuments, historic sites, recreation areas and national 
wildlife refuges for any individual over the age of 62.
    The FWS recognizes the numerous contributions of older 
individuals through various awards programs. There were 4,947 
FWS employees over the age of 40 who were recognized for their 
exceptional contributions through the FWS's Special Act or 
Service Awards. Additionally, six FWS employees over the age of 
40 received Senior Executive Service performance awards.

                                  2000

    The FWS employed a total of 7,922 individuals. There were 
5,629 (71%) of FWS employees over the age of 40, which was an 
increase of 207 employees from the previous year. Of the FWS 
employees over the age of 40, 324 (4%) were over the age of 60; 
a increase of 18 employees from the previous year.
           2,527 (32%) were in Professional position; 
        80 (1%) were over the age of 60;
           1,109 (14%) were in Administrative 
        positions; 53 (0.6%) were over the age of 60;
           902 (11%) were in Technical positions; 76 
        (1%) were over the age of 60;
           362 (%5) were in Clerical positions; 35 
        (0.4%) were over the age of 60;
           27 (0.3%) were in Other positions; none were 
        over the age of 60;
           702 (9%) were in Wage Grade position; 80 
        (1%) were over the age of 60.
    The following chart illustrates the total number of FWS 
employees over the age of 40 who were employed in mission 
related occupations in calendar years 1999 and 2000.

FWS Employees Over the Age of 40 Employed in Mission Related Occupations
                     in Calendar Years 1999 and 2000
------------------------------------------------------------------------
                                         CY 1999            CY 2000
                                   -------------------------------------
                                                Over               Over
                                     Over 40     60     Over 40     60
------------------------------------------------------------------------
Professional......................      2,407      80      2,527      80
Administrative....................      1,073      47      1,109      53
Technical.........................        841      63        902      76
Clerical..........................        381      36        362      35
Other.............................         30       1         27       0
Blue Collar (Wage Grade)..........        690      79        702      80
Total.............................      5,422     306      5,629     324
    Total FWS Workforce...........       7666  ......  .........    7922
------------------------------------------------------------------------

    In 2000, there was one employment discrimination complaint 
filed alleging discrimination on the basis of age (940 and 
above). Additionally, the FWS has two federally assisted 
program related complaints filed during the year alleging 
discrimination on the basis of age.
    A total of 7,513 Golden Age Passports were issued 
throughout the FWS in 2000. The Golden Age Passport Program 
provides free entrance or lower entrance fees to most national 
parks, monuments, historic sites, recreation areas and national 
wildlife refuges for any individual over the age of 62. The FWS 
recognizes the numerous contributions of older individuals 
through various awards programs. There 1,437 cash and other 
incentive awards given to employees over the age of 40 to 
recognize their exceptional contributions to the FWS. 
Additionally, three FWS employees over the age of 40 received 
Senior Executive Service performance awards.

                     ITEM 9--DEPARTMENT OF JUSTICE

                              ----------                              


            INITIATIVES RELATED TO OLDER AMERICANS 1999-2000

                              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 protection against criminals and 
subversion, in ensuring healthy competition of business in our 
free enterprise system, in safeguarding the consumer and 
government programs, and in 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.
    The evolving role of the Department of Justice in 
protecting older Americans began with efforts to fight street 
crime, health care fraud that depletes programs intended to 
benefit older people, consumer fraud targeting elders, and 
civil rights violations. More recently, through its Nursing 
Home Initiative and Elder Justice efforts, the Department also 
increasingly has focused on elder abuse and neglect prevention 
and prosecution, spanning the continuum of care from home, to 
community-based, to nursing home settings.
    Historically, elder abuse and neglect cases have been the 
province of Federal regulatory and state and local law 
enforcement efforts. At the same time, the Department 
increasingly has recognized the role for stepped up Federal 
leadership and law enforcement, and works closely with the 
Department of Health and Human Services and with its state and 
local colleagues on these matters.
    In 1999-2000, the Department sponsored the following 
initiatives relating to older Americans:

             Protecting Older Americans from Consumer Fraud

    During the past decade, older Americans have increasingly 
become the targets of a wide range of fraudulent schemes. 
Telemarketing ``boiler room'' operations, for example, have 
often targeted seniors with fraudulent offerings ranging from 
``guaranteed'' foreign lotteries to prize-promotion schemes to 
fraudulent charities that purport to help persons in need, such 
as anti-drug programs and relief for victims of natural 
disasters. In some cases, fraudulent telemarketers even operate 
``recovery rooms,'' pretending to be law enforcement agents, 
lawyers, or court personnel who can help victims recover a 
portion of their past losses. The effects of these schemes have 
often been magnified by the fact that telemarketing operations 
buy so-called ``mooch lists'' (i.e., lists of people victimized 
by previous schemes) and then recontact those victims to offer 
new fraudulent opportunities. As a result, telemarketing fraud 
victims have often suffered substantial financial losses in 
some instances, even their life savings and their homes as well 
as tremendous personal humiliation and embarrassment. Other 
fraudulent schemes, such as home-repair and advance-fee 
schemes, have also targeted seniors for substantial losses.
    To combat the criminals who conduct such ruthless schemes, 
the Department developed a three-part approach that 
incorporates a number of new and innovative measures.
    Undercover Investigations and Prosecutions.--In cooperation 
with other Federal law enforcement agencies, the Federal Bureau 
of Investigation conducts undercover operations directed at 
telemarketing fraud. For example, Federal agents and 
investigators take over the telephone numbers of people who 
have been repeatedly victimized by telemarketing schemes or 
established undercover identities as victims. Agents tape 
record fraudulent and deceptive solicitations to provide 
evidence for search warrants, criminal indictments, and 
information relating to Federal criminal violations. To date, 
these efforts have resulted in the indictment of thousands of 
fraudulent telemarketers and have crippled fraudulent 
telemarketing operations. In some cities where telemarketing 
``boiler rooms'' had been widespread, such as Las Vegas, 
Chattanooga, and San Diego, telemarketing fraud was virtually 
eliminated as a result of targeted Federal and state law 
enforcement efforts.
    International Cooperation and Coordination.--Even as law 
enforcement has made major inroads against U.S.-based 
telemarketing operations, more and more major telemarketing 
schemes directed at seniors have been operating 
internationally, typically calling from venues in Canada to 
U.S. residents. To combat this problem of cross-border 
telemarketing fraud, in 1997 the United States and Canada 
established a binational working group on telemarketing fraud 
that produced a major report and recommendations for the two 
nations on measures needed to combat cross-border telemarketing 
fraud more effectively. These recommendations included 
identifying telemarketing fraud as a serious crime, 
establishing regional task forces to provide cross-border 
cooperation on telemarketing fraud, and coordination of 
national strategies against telemarketing fraud. During the 
past several years, both countries have implemented 
substantially all of these recommendations; the United States, 
for example, has adopted enhancements to the U.S. Sentencing 
Guidelines that authorize higher sentences in all telemarketing 
cases, and in cases where a substantial part of the scheme is 
conducted from outside the United States. In addition, U.S. law 
enforcement authorities have been working closely with Canadian 
law enforcement in Montreal, Toronto, and Vancouver on 
telemarketing fraud investigations and prosecutions.
    Public Education and Prevention.--The Department has taken 
several significant steps to improve its outreach and 
prevention efforts to combat fraud directed at seniors. One 
initiative involves ``Elder Fraud Prevention Teams'' (EFPT), in 
which United States Attorneys' Offices and other law 
enforcement agencies partner with the AARP to educate older 
Americans about consumer fraud scams that target them. In 
Arizona, for example, the EFPT collaborated with the AARP and 
the Arizona Cardinals football team to produce a series of 
public service advertisements on telemarketing fraud, and to 
conduct a ``reverse boiler room'' an event in which law 
enforcement, AARP, and Cardinals' representatives telephoned 
people on fraudulent telemarketers' call lists to warn them 
about telemarketing fraud that reached thousands of people in 
Arizona and other states. The pilot project is currently 
operating in 5 cities, and the Department is now exploring the 
expansion of the EFPT concept to additional jurisdictions.
    The Department also has created a series of English- and 
Spanish-language Webpages on telemarketing fraud to inform the 
public about the problem and to assist in reporting possible 
telemarketing fraud. In addition, the Department provided 
significant advice and assistance to the AARP in the AARP's 
development of a massive public-service advertisement campaign 
to inform older Americans about the dangers of telemarketing 
fraud and how to protect themselves from it.
    Telemarketing Fraud Prevention and Public Awareness 
Program.--The Department's Office of Justice Programs (OJP) 
also continued activities under its Telemarketing Fraud 
Prevention and Public Awareness Program in 1999 and 2000. The 
program, which began in 1997, is supported by a Congressional 
earmark for ``programs to assist law enforcement in preventing 
and stopping marketing scams against senior citizens.'' The 
goal of the program is to support Federal, state, and local 
efforts among law enforcement, crime prevention, victim 
assistance, consumer protection, adult protective services, and 
programs that serve older people in implementing public 
education and training efforts.
    Under this program, OJP's Bureau of Justice Assistance 
created a Telemarketing Fraud Training Task Force to develop 
and provide training for state and local investigators and 
prosecutors and to develop public awareness materials. The task 
force is a consortium comprised of the National Association of 
Attorneys General (NAAG), the American Prosecutors Research 
Institute (APRI), the National White Collar Crime Center 
(NWCCC), and AARP. As part of the program, BJA also provided 
grants to five demonstration sites to undertake a collaborative 
multijurisdictional approach to prosecuting and preventing 
telemarketing fraud and other scams targeting the elderly.
    Additionally, under the Telemarketing Program, OJP's Office 
for Victims of Crime continued funding for three projects that 
are addressing these crimes:
           The Oregon Senior and Disabled Services 
        Division developed a training curriculum and provides 
        training on fraud against older people for bank 
        personnel throughout Oregon. The training curriculum 
        has been used by jurisdictions throughout the country. 
        The project also created services for senior fraud 
        victims.
           The National Sheriffs' Association (NSA) 
        established ``Operation Fraudstop,'' a national, 
        coordinated public education and awareness and training 
        effort among NSA and a range of agencies and 
        corporations, including AARP, NDAA, NAAG, Triad, state 
        sheriffs' associations, and Radio Shack.
           The National Hispanic Council on Aging 
        funded a public education campaign to combat 
        telemarketing fraud in the Latino community.

      Protecting Government Programs that Benefit Older Americans

    In addition to combating consumer fraud directed at 
individual older Americans, the Department pursues health care 
fraud that depletes government programs designed to benefit 
older Americans. As a result of these efforts, the Department 
has collected billions in funds defrauded from Federal health 
care programs, recouping more than $1.7 billion between October 
1998 and December 31, 2000 alone. In 1999 the Department, 
together with AARP and the Department of Health and Human 
Services (HHS), launched a public awareness campaign called 
``Who Pays? You Pay,'' which encouraged older people to join in 
the fight against health care fraud by asking questions and 
checking their bills. The Department also made a grant to the 
National Association of Attorneys General to strengthen health 
care fraud efforts at the state level.
    In fiscal year 2000, DOJ brought to successful conclusion 
the investigation and prosecution of numerous costly health 
care fraud schemes. Among them are the following:
           The Department recently announced an $840 
        million criminal and civil settlement with HCA-The 
        Hospital Company, the largest for-profit hospital chain 
        in the United States. The settlement, for $95 million 
        in criminal fines and $745 million in civil recovery, 
        is the largest health care fraud settlement ever 
        reached by the Federal Government and reflects the 
        coordination of resources and collaboration DOJ has 
        brought to bear in investigating health care fraud. 
        This was the largest investigation of a health care 
        provider ever undertaken. It involved a multi-agency 
        investigation by attorneys, investigators, auditors, 
        and other agency personnel over the course of several 
        years. The Department is continuing to follow up on a 
        number of issues unresolved by the civil settlement 
        implicating HCA's cost report practices (i.e. the 
        method by which the company charges Medicare, Medicaid, 
        and other programs for the costs of operating its 
        hospitals), as well as its alleged unlawful practices 
        in paying remuneration to physicians in exchange for 
        referrals of patients to HCA facilities.
           In fiscal year 2000, before the HCA 
        settlement, the Federal Government won or negotiated 
        more than $1.2 billion in judgments, settlements, and 
        administrative impositions in health care fraud cases 
        and proceedings. As a result of these activities, as 
        well as prior year judgments, settlements, and 
        administrative impositions, the Federal Government in 
        2000 collected $716 million. More than $539 million of 
        the funds collected and disbursed in 2000 was returned 
        to the Medicare Trust Fund. An additional $27 million 
        was recovered as the Federal share of Medicaid 
        restitution.
           Fresenius, Inc., the world's largest 
        provider of kidney dialysis products and services, 
        agreed to pay the United States government $486 million 
        to resolve a sweeping investigation of health care 
        fraud. This investigation revealed that Fresenius 
        submitted false claims seeking payment for nutritional 
        therapy provided to patients during their dialysis 
        treatments, for services that were provided to patients 
        as part of clinical trials, for hundreds of thousands 
        of fraudulent blood testing claims, for kickbacks, and 
        for improper reporting of credit balances. The criminal 
        fine and the civil settlement were, at the time, the 
        largest ever recovered by the United States in a health 
        care fraud investigation.
           The government entered a global settlement 
        agreement with Beverly, Inc., the Nation's largest 
        operator of nursing homes, to resolve allegations that 
        it fabricated records to make it appear that nurses 
        were devoting more time to Medicare patients than they 
        actually were. Although the company received an 
        estimated $400 million in overpayments from Medicare, 
        the settlement required the company to pay $170 million 
        in civil settlement, a figure negotiated based on the 
        chain's limited ability to pay.
           Anthem Blue Cross and Blue Shield of 
        Connecticut, a former Medicare fiscal intermediary (a 
        contractor that processes Medicare claims for the 
        government), agreed to pay $74 million to resolve 
        claims that it falsified interim payments on settled 
        hospital cost reports in order to meet HCFA's 
        Contractor Performance Evaluation standards. In so 
        doing, the contractor caused improper Medicare payments 
        or reduced offsets to a number of hospitals, 
        overpayments that exceeded $30 million.
           A $53 million settlement with GAMBRO 
        Healthcare resolved allegations of false billings for 
        laboratory services primarily provided to dialysis 
        clinics treating patients with end-stage renal disease 
        (ESRD). The government's investigation revealed that 
        the laboratories billed Medicare, Medicaid, and TRICARE 
        for medically unnecessary lab tests; double billed for 
        lab tests included in ESRD composite rate payments; and 
        violated the 50 percent rule, which specifies that if 
        50 percent or more of the laboratory tests performed as 
        a profile of tests are included in the composite rate, 
        then the entire profile is considered to be included in 
        the composite rate.
           Community Health Systems (CHS) paid $31 
        million to resolve allegations it improperly assigned 
        diagnostic codes for the purpose of increasing 
        reimbursement amounts. Seven states received a portion 
        of the settlement for losses to their Medicaid 
        programs.
           More than 70 entities that provided or 
        assisted in providing radiation oncology services to 
        cancer patients, as well as their billing companies, 
        agreed to pay almost $10 million to settle allegations 
        of false claims to federally funded health care 
        programs. These radiation oncology service providers 
        often billed Medicare for services that were not 
        provided, billed twice for the same service, or sought 
        a higher rate of reimbursement than that to which they 
        were entitled. The settlement also resolved claims that 
        the defendants fraudulently transferred assets to avoid 
        repaying the United States.
           In the first settlement with a Medicare 
        managed-care company, Humana, Inc. paid $14.5 million 
        to settle allegations that the company provided 
        inaccurate payment information from 1990 through 1998. 
        Humana incorrectly listed beneficiaries as eligible for 
        both Medicare and Medicaid, thus securing the higher 
        reimbursement afforded such dually eligible 
        beneficiaries.
           During fiscal year 2000, the United States 
        recovered $2.6 million from clients of the Oklahoma-
        based Emergency Physician Billing Services (EPBS) to 
        settle claims of overpayments based on false claims 
        submitted by EPBS. These settlements follow on the 
        heels of a September 1999 settlement with EPBS and its 
        physician founder for $15 million for fraudulent 
        billing to Medicare, Medicaid, TRICARE, and the Federal 
        Employees Health Benefits Program (FEHBP). The 
        government's investigation revealed that EPBS submitted 
        false Medicare, Medicaid, TRICARE, and FEHBP claims on 
        behalf of their physician-clients for patients seen by 
        the physicians. EPBS then typically ``upcoded'' claims 
        and billed for services more extensive than those 
        actually provided. Including settlements in prior 
        years, recoveries from EPBS clients top $13 million. 
        The Department continues to pursue other clients of the 
        company.
           The Department uncovered a sophisticated 
        scheme by a prominent Texas doctor, his attorney 
        brother, their mutual certified public accountant, a 
        physician's assistant, a physical therapist, office 
        managers, and staff, as well as clients. The scheme 
        defrauded local, state, and Federal Government health 
        programs, as well as private insurers, of over $46 
        million from 1986 to 1998. The conspiracy involved a 
        large cross-referral scheme of auto-accident, personal 
        injury, and workers compensation patients/clients 
        between the brothers.

  Preventing Elder Abuse and Neglect: Elder Justice and Nursing Home 
                           Initiative Efforts

    In October 1998, the Department launched an initiative to 
crack down on abuse, neglect, and fraud in nursing homes and 
other residential care facilities. The Nursing Home Initiative 
focuses on issues cutting across many of the Department's 
components. In 2000, the Initiative expanded to address Elder 
Justice issues generally, not limited to nursing home matters. 
The primary objective of these efforts was to enhance 
enforcement, training, coordination, and awareness; create the 
infrastructure for broad-based collaboration at the national 
policy level, as well as at the state and grass roots levels; 
and to bridge the historical gap between those on the front 
lines, who see the problems first hand, and those charged with 
enforcing the law. These efforts have focused on the following 
areas:
    1. Stepped Up Enforcement.--The Department has worked to 
step up investigations and prosecutions at the Federal, state, 
and local levels through the training and coordination efforts 
described below. Federal cases to redress elder abuse and 
neglect primarily involve nursing homes and other Medicare and 
Medicaid recipients. In those cases, the Department works 
closely with the Department of Health and Human Services to 
balance the law enforcement and public health goals and seek 
remedies that protect residents, punish wrongdoers, recoup 
Federal funds, and improve care. Examples of cases in this area 
include:
           The Department is bringing more civil False 
        Claims Act and false statement prosecutions for failure 
        of basic care leading to profound malnutrition, 
        pressure ulcers, and other harm. The Civil Division is 
        pursuing such cases against national nursing home 
        chains. To date, the United States Attorney for the 
        Eastern District of Pennsylvania has resolved six such 
        cases, and several other jurisdictions have resolved or 
        are pursuing these cases. In addition, nursing home 
        officials in Arkansas recently were convicted and 
        sentenced for making false statements regarding the 
        cause of death of a resident.
           In a public corruption matter in Oklahoma, 
        the deputy commissioner for health and a nursing home 
        owner were convicted in October 2000 of soliciting and 
        offering to pay a bribe, respectively. The 
        investigation is ongoing.
           Five of the country's seven largest nursing 
        home chains Vencor, Sun, Mariner, Integrated Health 
        Services (IHS), and Genesis (cumulatively owning about 
        2000 facilities) as well as several mid-sized chains, 
        are attempting to reorganize under the Federal 
        bankruptcy code. The Department's Civil Division is 
        handling these massive cases to find resolutions that 
        protect residents and the Federal programs designed to 
        benefit them. To that end, Vencor recently entered into 
        a far-reaching Corporate Integrity Agreement (CIA) with 
        the Department of Health and Human Services, Office of 
        Inspector General (HHS/OIG) that is similar to the 
        consent orders in the Eastern District of Pennsylvania 
        nursing home cases.
           Because these cases often raise difficult 
        legal, investigative, and medical issues, the 
        Department prepared a proposal for a Resource Group 
        that would be available to assist Department attorneys 
        with such matters. The group would consist of a small 
        number of Department attorneys and medical experts with 
        relevant expertise. Decision-making and litigation 
        responsibility for the cases would remain with the 
        respective U.S. Attorneys Offices handling the cases.
    2. Training, Publications, and Information Sharing.--The 
Department of Justice also has sponsored conferences and 
symposia and publishes and disseminates reports and other 
documents to promote knowledge about the problem of elder 
victimization and what works and needs to be done in 
preventing, investigating, and prosecuting abuse and neglect of 
older Americans. These include the following:
           Nursing Home Fraud, Abuse and Neglect 
        Prevention Conferences and State Working Group 
        Meeting.--Between July 1999 and June 2000, the 
        Department held four regional conferences and one State 
        Working Group meeting to provide training and promote 
        multidisciplinary coordination among the many players 
        with responsibility for nursing homes and their 
        residents. During the regional conferences, State 
        Working Groups were formed to continue the work at the 
        state and local levels. In all, more than 1,000 
        Federal, state, and local law enforcement, regulatory, 
        survey, health care, advocacy, and social service 
        professionals were trained in how to identify, respond 
        to, coordinate, and prosecute cases of abuse, neglect, 
        and fraud.
           National Symposium on Elder Victimization.--
        In October 2000, DOJ sponsored a national symposium 
        entitled ``Our Aging Population: Promoting Empowerment, 
        Preventing Victimization, and Implementing Coordinated 
        Interventions'' in partnership  with  the  Department  
        of Health  and Human Services. The  symposium  focused  
        on promising  approaches  to preventing and responding 
        to the victimization of our aging population. It 
        showcased Federal, state, and local multidisciplinary 
        programs designed to: promote empowerment of older 
        people to live safe and healthy lives; prevent them 
        from becoming victims of abuse, fraud, exploitation, 
        and neglect; and improve the response of law 
        enforcement and social service agencies to 
        victimization. The programs highlighted collaborations 
        among health, human service, and social service 
        agencies, advocates, medical professionals, law 
        enforcement, and other public safety professionals to 
        prevent and respond to victimization. Multidisciplinary 
        teams from each state and several Indian tribes, 
        representing  public  safety,  social service,  and  
        health care professionals, were  invited to  
        participate  in the symposium. A report of the 
        proceedings was released in January 2001 and is 
        available online at http://www.ojp.usdoj.gov/docs/ncj--
        186256.pdf .
           Medical Forensic Issues in Elder Abuse and 
        Neglect.--There is widespread consensus that detection, 
        diagnosis, research, training, availability of experts, 
        and multidisciplinary cooperation are significantly 
        less advanced in the area of elder abuse and neglect 
        than in other areas, such as child abuse and domestic 
        violence. This has an impact, among other things, on 
        the ability to pursue such cases because elder abuse 
        and neglect often go undetected and the medical 
        community is rarely trained to diagnose or report it. 
        Even when it is identified, there are very few experts 
        who can investigate or prepare or provide medical 
        forensic testimony in these cases. To address these and 
        other issues, the Department hosted a medical forensic 
        roundtable discussion in October 2000. Health care, law 
        enforcement, and social service experts addressed 
        impediments to fighting elder abuse and neglect in 
        institutional, community, and home settings. Those 
        impediments include the dearth of expertise among first 
        responders and health care providers in detecting and 
        diagnosing elder abuse and neglect, the paucity of 
        research and training in the area, the infrequency with 
        which medical forensic evidence is available to law 
        enforcement, and the need for improved collaboration 
        among all disciplines with a role in this area. The 
        experts also presented their conclusions and 
        recommendations to the Attorney General, who joined 
        their discussion. A report of the event is available 
        online at http://www.ojp.usdoj.gov/nij/elderjust/
        index.html. Also available at that Web site are brief 
        papers authored by the experts and a transcript of the 
        proceedings.
           Focus Group on Abuse and Neglect in Nursing 
        Homes.--In 1999 the Office for Victims of Crime (OVC) 
        sponsored a focus group entitled ``Preventing Abuse, 
        Neglect and Fraud in Nursing Homes'' to explore the 
        needs of victims in residential settings. The focus 
        group included representatives of aging organizations, 
        elder advocacy organizations, offices of state 
        attorneys general, ombudsman programs, victim advocacy 
        organizations, the National District Attorneys 
        Association, the National Association of Attorneys 
        General, the National Association of Medicaid Fraud 
        Control Units, the National Association of Adult 
        Protective Services, the Centers for Disease Control, 
        the American Bar Association Commission on Legal 
        Problems of the Elderly, and DOJ. The discussion 
        highlighted several general categories of need: (1) 
        more effective measures by providers to assure quality 
        of care; (2) improved law enforcement and 
        administrative/regulatory enforcement; (3) programs to 
        increase family and community involvement in nursing 
        homes; (4) improved laws and regulations; and (5) 
        improved detection of abuse and neglect by those with 
        contact with residents. The recommendations have been 
        incorporated into the Department's Nursing Home 
        Initiative and a focus group report is expected to be 
        issued in early 2001.
           Promising Practices Monograph.--OVC is in 
        the final stages of producing a publication that 
        profiles several innovative approaches to reaching 
        older individuals who are abused, neglected, and 
        financially exploited. The monograph is designed for 
        use by victim service providers, allied professionals, 
        and agencies and organizations that serve older people.
           Clearinghouse on Domestic Violence.--Under 
        the Violence Against Women Act Technical Assistance 
        Program, OJP's Violence Against Women Office funded the 
        Wisconsin Coalition Against Domestic Violence in 1999 
        and 2000 to establish a national clearinghouse on 
        domestic violence in later life. The purpose of the 
        clearinghouse is to provide technical assistance and 
        training to service providers and criminal justice 
        personnel and to enhance services to older battered 
        women.
           Statistical Data/Publications.--In January 
        2000, OJP's Bureau of Justice Statistics released 
        ``Crimes against Persons Age 65 or Older, 1992-97'' 
        using data from its National Crime Victimization Survey 
        (NCVS). The statistics include: comparisons of 
        victimization of senior citizens with that of other age 
        groups; patterns of victimization that are different 
        among the elderly than other groups in the population; 
        and some statistics on violence committed against 
        senior citizens by relatives and other people who are 
        well-known to the victim.
    3. Coordination, Outreach, and Public Awareness.--As part 
of the Nursing Home Initiative, the Department established 
multidisciplinary, interagency State Working Groups (SWGs) at 
the state and local levels to bolster enforcement, prevention, 
training and coordination on an ongoing basis. These SWGs 
provide a forum for key players to share information and skills 
and to identify problem facilities, best practices, and ways to 
improve the quality of care given the unique situations in the 
various states. In June 2000, the Department held a meeting of 
SWG representatives and relevant national organizations to 
address the challenges and successes of those groups. A report 
of that meeting will be released in 2001.
           Federal coordination also has been enhanced 
        by productive monthly Nursing Home Steering Committee 
        meetings attended by DOJ and HHS representatives. In 
        addition, nursing home issues are frequent topics at 
        DOJ/HHS Health Care Fraud Senior Staff and Executive 
        Level Health Care Fraud Policy Group meetings, as well 
        as before the Health Care Fraud and Abuse Task Force, 
        which brought together Federal state and local law 
        enforcement entities.
           To promote public awareness, Attorney 
        General Janet Reno presented three keynote speeches in 
        2000 addressing elder issues at the Department's State 
        Working Group meeting on June, the AARP Foundation's 
        Aging and the Law conference in October, and the 
        National Citizens' Coalition for Nursing Home Reform 
        (NCCNHR) Annual Meeting in October. The Attorney 
        General was presented with awards for the Department's 
        efforts at the two latter events. The Attorney General 
        also presented remarks to and participated in the 
        Department's symposium on promising practices to 
        address elder victimization and roundtable on medical 
        forensic issues in elder abuse and neglect discussed 
        below. In addition, other Department personnel have 
        spoken publicly on a regular basis to promote efforts 
        to reduce elder abuse and neglect of all types.
           In an attempt to raise the profile of elder 
        abuse and neglect issues in the medical and public 
        health communities, Attorney General Reno and Secretary 
        Shalala together sent letters to deans of medical, 
        public health, and 100 nursing schools asking them to 
        consider devoting research monies and teaching time to 
        the issues of elder abuse and neglect. In addition, the 
        letter encouraged them to partner with local law 
        enforcement agencies in elder abuse and neglect matters 
        and to inform DOJ of their activities.
    4. Legislation.--There are gaps in Federal law that limit 
the ability of Federal law enforcement to pursue cases of abuse 
and neglect, whether in nursing homes or other settings. For 
example, the Department has no primary jurisdiction to bring a 
case for inadequate care, per se, against a privately owned 
nursing home. Failure of care cases currently are pursued under 
financial fraud and/or falsification of records theories. In 
addition, HHS may impose sanctions only against individual 
facilities; its authority does not extend to chains or 
management companies. Therefore, the Department drafted and the 
Administration sent to Congress a bill that would address gaps 
in current law by creating criminal, civil, and injunctive 
remedies for patterns of abuse or other illegal conduct causing 
harm to residents.
    5. Data.--Through the Nursing Home Steering Committee, the 
Departments of Justice and Health and Human Services are 
working to analyze the myriad nursing home data sources to 
determine how they might be used most effectively and to assist 
SWGs to identify problem facilities. The Department of Justice 
worked with HHS to draft a certification for the Minimum Data 
Set (MDS) forms, which include key information used to 
determine reimbursement rates and resident care.
    6. Criminal Background Checks.--The Department has renewed 
efforts to work with industry to boost compliance efforts, 
among other things, by encouraging increased use of Federal 
criminal background checks. In October 1998, Congress enacted 
Public Law 105-277, which provides that ``[a] nursing facility 
or home health care agency may submit a request to the Attorney 
General to conduct a search and exchange of [Federal Bureau of 
Investigation (FBI) criminal history] records . . . regarding 
an applicant for employment if the employment position is 
involved in direct patient care.'' By early 2000, that statute 
had been used only a handful of times. The Department has been 
working with the FBI to educate providers and the relevant 
state entities about the existence of and procedures for 
obtaining background information under this statute. A report 
to Congress on the use of this statute will be filed in early 
2001.

              Protecting the Civil Rights of Older People

    Through its Civil Rights Division, DOJ enforces Federal 
statutes prohibiting discrimination on the basis of race, sex, 
disability, religion, and national origin. In the civil rights 
arena, the Department pursues several types of cases. Where 
predatory lenders target older persons usually elderly minority 
women for loans with higher prices and more onerous conditions 
than for other borrowers, DOJ has brought cases under the Equal 
Credit Opportunity Act, which prohibits discrimination on the 
basis of age. The Department also pursues cases under other 
civil rights statutes, such as the Americans with Disabilities 
Act for seniors with disabilities, under the Fair Housing Act, 
where nursing homes or other facilities employ discriminatory 
admission practices, and under the Civil Rights of 
Institutionalized Persons Act (CRIPA), where public nursing 
homes or other facilities provide substandard care.

              Protecting Older People Against Street Crime

    During this period OJP's Bureau of Justice Assistance 
funded Triad, a national program to reduce victimization of 
older citizens, which is cosponsored by the National Sheriffs' 
Association, the International Association of Chiefs of Police, 
and AARP. Triad combines the efforts and resources of law 
enforcement, older individuals and organizations that represent 
them, and victim assistance providers. Activities include 
educating communities about elder abuse; strengthening the 
criminal justice system's process of prevention, detection, and 
assistance for elderly crime victims; implementing reassurance 
programs for homebound and isolated elders; and providing 
technical assistance for new and existing Triads. There are now 
more than 730 Triad programs in 46 states, Canada, and England.
    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 homepage 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. For information about other 
Department initiatives, see the main Web site at www.usdoj.gov. 
In particular, the ``Elder Justice'' Web page at www.usdoj.gov/
elderjustice.htm contains information about the Department's 
activity on these issues. For information about the activities 
of the Civil, Criminal or Civil Rights Divisions or the United 
States Attorneys Offices, see the Web sites for those 
components.

                      ITEM 10--DEPARTMENT OF LABOR

                              ----------                              

    Our Nation is experiencing a dramatic growth in the 
population of Americans aged 55 and older, and our citizens can 
look forward to living longer, healthier, and more productive 
lives. Unfortunately, it is often the case that individuals 
aged 55 and older encounter serious difficulty finding new 
employment when they lose a job or seek to change careers. In 
the global economy of the 21st century, job growth will make it 
imperative for us to fully utilize our experienced older 
workers. They have much to offer American business, and, at a 
time of notable skills shortages, older workers are a crucial 
resource that America cannot afford to squander.
    The welfare and security of our Nation's older citizens is 
a matter of substantial concern to the Department of Labor. We 
are pleased to provide this summary of the programs the 
Department administers which can provide helpful assistance to 
older Americans. 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 BenefitsAdministration; 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 the Family and Medical Leave 
Act, administered by the Employment Standards Administration; 
and various initiatives and collaborations relating to older 
persons, work and family, and retirement income sponsored or 
administered by the Women's Bureau, including the National 
Resource and Information Center, a Clearinghouse which provides 
information and resources to workers and employers interested 
in developing or implementing family-friendly policies such as 
elder 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 1998 (July 1, 1998-June 30, 1999) and 1999 (July 
1, 1999-June 30, 2000) 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

    Through grants from the Department of Labor to states and 
National organizations, SCSEP, which is 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, are offered annual physical 
examinations, job training, and in many cases, referral to 
private sector jobs.
    About 80 percent of the participants are age 60 or older, 
and about 60 percent are age 65 or older. Almost three-fourths 
are female; about 40 percent have not completed high school. 
All participants are economically disadvantaged.
    On November 13, 2000, President Clinton signed into law the 
Older Americans Act Amendments of 2000, Public Law 106-501. 
This legislation reauthorizes and enhances the SCSEP by 
increasing emphasis on assisting participants in obtaining 
unsubsidized employment; establishing an enhanced performance 
accountability system to assess the performance of grantees; 
reinforcing connections between the SCSEP and the workforce 
investment system established under the Workforce Investment 
Act; and providing for broad participation in the development 
of a plan in each State to ensure an equitable distribution of 
projects and the coordination of services to seniors.
    Table I below shows SCSEP enrollment and participant 
characteristics for the program year July 1, 1998, to June 30, 
1999, in Column 1 and July 1, 1999, to June 30, 2000, in Column 
2.

  TABLE 1.--SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP):CURRENT
 ENROLLMENT AND PARTICIPANT CHARACTERISTICS--PROGRAMYEARS JULY 1, 1998,
   TO JUNE 30, 1999, (PY98) AND JULY 1, 1999, TO JUNE 30, 2000 (PY99)
------------------------------------------------------------------------
                                                        Program Years
                                                   ---------------------
                                                       1998       1999
------------------------------------------------------------------------
Enrollment:
    Authorized positions established..............     61,207     61,211
    Unsubsidized employment rate (Percent)........       32.5       36.1
Characteristics (Percent):
    Sex:
        Male......................................       26.3       27.1
        Female....................................       73.7       72.9
    Educational status:
        8th grade and less........................       16.7       16.1
        9th grade through 11th grade..............       18.5       18.4
        High School graduate or equivalent........       41.0       40.9
        1-3 years of college......................       16.5       17.0
        4 years of college or more................        7.3        7.6
    Veterans......................................       12.4       11.5
    Ethnic Groups: \1\
        White.....................................       58.8       55.8
        Black.....................................       26.0       27.6
        Hispanic..................................        9.8       10.1
        American Indian/Alaskan Native............        1.9        1.7
        Asian/Pacific Island......................        3.5        4.9
    Economically disadvantaged....................      100.0      100.0
    Poverty level or less.........................       86.3       84.4
    Age groups: \1\
        55-59.....................................       16.3       15.6
        60-64.....................................       22.2       21.8
        65-69.....................................       24.2       24.2
        70-74.....................................       20.1       20.2
        75 and over...............................       17.2       18.2
------------------------------------------------------------------------
\1\ Figures may not add to 100 percent due to rounding.
Source: U.S. Department of Labor, Employment and Training
  Administration.

                 Job Training Partnership Act Programs

    The Job Training Partnership Act (JTPA), in effect through 
June 30, 2000, provided job training and related assistance to 
economically disadvantaged individuals, dislocated workers, and 
others who face significant employment barriers. The ultimate 
goal of JTPA was to move program participants into permanent, 
self-sustaining employment. Under JTPA, Governors had the 
approval authority over locally developed plans and were 
responsible for monitoring local program compliance with the 
Act. JTPA functioned through a public/private partnership which 
planned, designed and delivered training and other services. 
Private Industry Councils (PICs), in partnership with local 
governments in each Service Delivery Area (SDA), were 
responsible for providing guidance for, and oversight of, job 
training activities in the area.
    JTPA amendments affecting older workers became effective 
July 1, 1993. These amendments targeted program services to 
those with serious skill deficiencies; and individualized and 
intensified the quality of services provided. Five percent of 
the funds appropriated for the adult program (Title II-A) had 
to be used by States in partnership with SDAs for older 
workers. The amendments also required Governors to ensure that 
services under the adult program were provided to older workers 
on an equitable basis.
    In the fall of 1998, President Clinton signed into law the 
Workforce Investment Act (WIA), Public Law 105-220, which 
replaced JTPA. This bipartisan legislation streamlined the job 
training system for the 21st century. The WIA empowered 
individuals by giving adults and dislocated workers more 
control and choice over their training or retraining and 
providing universal access to core labor market services; 
streamlined job training services by mandating the 
consolidation of a dispersed network of individual programs 
into a simple system through a nationwide network of One-Step 
Career Centers; enhanced accountability through tough 
performance standards for States, localities, and training 
providers; and increased flexibility so that States could 
innovate and experiment with new ways to better train America's 
workers.
    While there are fewer federal set aside provisions than had 
previously existed under JTPA, the WIA does provide states with 
discretionary funds that can be used for statewide workforce 
investment strategies, representing an opportunity for 
developing and expanding services to older workers. States may 
reserve up to 15 percent of each of their separate adult, youth 
and dislocated worker WIA allotments to ``carry out statewide 
employment and training activities.'' The state set aside funds 
may provide an opportunity for developing and funding special 
services for older workers.

                           Basic JTPA Grants

    Title II-A of JTPA authorized a wide range of training 
activities to prepare economically disadvantaged adults for 
employment. Training and training-related services available to 
eligible older individuals through the basic Title II-A grant 
program included 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 left the Title II-A program during the 
period July 1, 1998, through June 30, 1999, and during the 
period July 1, 1999, through June 30, 2000. (The data do not 
include the 5 percent set-aside for older individuals, which is 
discussed separately.)

      TABLE 2.--JTPA DATA JULY 1, 1998--JUNE 30, 1999 [Title II-A]
------------------------------------------------------------------------
                                             Number served
                  Item                  ----------------------  Percent
                                            PY98       PY99
------------------------------------------------------------------------
Total Adult Terminees..................    151,580   138,862*        100
55 years and over......................      3,032     3,034*          2
------------------------------------------------------------------------
*Preliminary data from six early WIA implementation states remain to be
  reported and are omitted from the Program Year 1999 figures.
  Comparisons with Program Year 1998 are inappropriate.
Source: U.S. Department of Labor, Employment and Training
  Administration.

                         Section 204 Set-Aside

    The JTPA amendments which took effect in 1993 required 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. Generally, only economically 
disadvantaged individuals who are 55 years of age or older are 
eligible for services under this State set-aside.
    Governors had wide discretion regarding use of the JTPA 5 
percent set-aside. Two basic patterns evolved. One was adding 
set-aside resources to Title II-A to ensure that a specific 
portion of older persons participated in the basic Title II-A 
program. The other was using the resources to establish 
specific projects targeted to older individuals which operated 
independently of the basic job training program for 
disadvantaged adults. Likewise, States wererequired to provide 
``equitable services to older individuals throughout the State, 
taking into consideration the incidence of such workers in the 
population.'' Some States distributed all or part of the 5 
percent set-aside by formula to local SDAs; other States 
retained the resources forState administration or model 
programs.
    Governors were expected to coordinate services as much as 
possible with those provided under Title V of the Older 
Americans Act--the Senior Community Service Employment Program. 
There were 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 have been individuals who were not 
economically disadvantaged, but who had a serious barrier to 
employment. Under such title, older Americans were taken into 
consideration for assistance. Second, when a JTPA grantee and 
Title V sponsor established jointprojects, individuals eligible 
under Title V of the Older Americans Act ``were deemed to 
satisfy the requirements'' of JTPA.
    These joint (JTPA-SCSEP) projects may have included co-
enrollment of Title V participants in Title II-A activities. 
Joint programs had to have a written agreement, which must have 
been financial or nonfinancial in nature, and may have included 
a broad range of activities. A recent joint WIA-SCSEP provision 
allows SCSEP participants to be deemed by workforce investment 
boards established under title I of WIA, as eligible for 
receiving services that are available to adults.
    For Program Year 1998 (July 1, 1998, through June 30, 
1999), 11,643 participants were enrolled in the State set-aside 
program for economically disadvantaged individuals 55 years of 
age and older. For Program Year 1999 (July 1, 1999, through 
June 30, 2000), it is estimated that 11,600 estimated 
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 authorized a State and locally-
administered dislocated worker program that provided retraining 
and readjustment assistance to workers who had been, or had 
received notice that they were about to be, laid off due to a 
permanent closing of a plant or facility; laid off workers who 
were unlikely to be able to return to their previous industry 
or occupation; and the long-term unemployed with little 
prospect for local employment or re-employment. Those older 
dislocated workers eligible for the program were allowed to 
receive such services as job search assistance, retraining, 
pre-layoff assistance and relocation assistance. During the 
period July 1, 1998, through June 30, 1999, approximately 
24,722 individuals 55 years of age and over exited the program 
(10 percent of the program terminations). During the period 
July 1, 1999, through June 30, 2000, approximately 20,252 \1\ 
individuals 55 years of age and over left the program (8 
percent of the program terminations).
---------------------------------------------------------------------------
    \1\ At the time of the drafting of this summary, preliminary data 
from eight early WIA implementation States remained to be reported; 
thu, the figures do not reflect complete totals.
---------------------------------------------------------------------------

              The Federal-State Employment Service System

    Employment services funded under the Wagner-Peyser Act and 
related statutes and provided through locally-designed One-Stop 
systems offer employment assistance to all job seekers, 
including special populations such as older workers, veterans, 
recipients of public assistance and disabled individuals. 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 were revised effective July 1, 1992, to capture 
additional information on applicant characteristics, including 
data on the age of all Employment Service (ES) applicants and 
those placed in employment. During the period July 1, 1998 
through June 30, 1999 over 1,230,000 ES applicants were age 55 
and older. Over 85,000 of them were placed in jobs during this 
period. Preliminary data for the period July 1, 1999 through 
June 30, 2000 show nearly 1,200,000 ES applicants age 55 and 
older, approximately 86,000 of whom were placed in jobs 
(reports from several employment service agencies had not been 
received at the time this summary was prepared).
    In addition to those ES applicants who were placed, the 
Department also collects data on the numbers of persons who 
obtained employment within 90 days of receiving a reportable 
employment service. This total is not broken down by age 
cohort. However, many of the 1.55 million and 1.86 million 
(preliminary data) who were reported in the ``obtained 
employment'' category during the last two program years were 
age 55 and older.

         Internet Information Products and America's Career Kit

    The Employment and Training Administration and a number of 
other government and academic partners have collaborated to 
provide a number of Internet web-based information products and 
services for older workers. From specially-targeted material on 
the Department's website to the various tools in America's 
Career Kit, the agency ensures that this expanding segment of 
the population can take advantage of opportunities to re-enter 
the workforce, acquire new skills for a short-term job pursuit, 
or engage in learning enrichment activities in the retirement 
years. The partners in America's Job Bank (www.ajb.org), 
America's Career InfoNet (www.acinet.org) and America's 
Learning Exchange (www.alx.org) are continually focused on the 
requirement to create easily-accessible and beneficial content 
for our seniors. ETA also closely participates with other 
governmental agencies in ensuring that other public sector web-
sites (such as Access America for Seniors and the First.gov 
special portal site for seniors) provide useful links to our 
various employment, training, and learning databases and 
services.

              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 and the Internal Revenue Code, designed to ensure that 
employees actually receive promised benefits. Employee benefit 
plans generally 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 to the government 
and disclosure to participants (Title I, Part 1) and fiduciary 
responsibility (Title I, Part 4). Pension plans must comply 
with additional ERISA and Internal Revenue Code 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, also called ``group health plans,'' 
must comply with ERISA continuation of coverage requirements 
and medical child support orders (Title I, Part 6). These plans 
must also comply with several consumer rights provisions (Title 
1, Part 7), which include protections for individuals who lose 
their health insurance coverage or have it terminated, women 
who have just given birth, individuals with mental illness, and 
women who have certain types of cancer.
    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.
    PWBA has also been assigned additional regulatory, 
interpretative, enforcement, and disclosure responsibilities 
under the recently enacted provisions of Part 7 of ERISA. These 
provisions include requirements added by the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA), the 
Newborns' and Mothers' Health Protection Act of 1996, the 
Mental Health Parity Act of 1996, and the Women's Health and 
Cancer Rights Act of 1998. These laws set Federal requirements 
concerning health care coverage provided through health plans 
and added similar provisions to the Public Health Services Act 
and the Internal Revenue Code. As a result, the Departments of 
Labor, Health and Human Services, and the Treasury have shared 
jurisdiction with regard to these health care provisions.
    Under the Savings Are Vital to Everyone's Retirement Act 
(SAVER), which was passed in November 1997, PWBA is responsible 
for establishing a program to educate the public about the 
importance of retirement savings--to initiate a broad-based 
public education program and to coordinate periodic national 
retirement savings summits in conjunction with the White House 
and Congress.

                  Legislative & Regulatory Initiatives

    During fiscal years 1999 and 2000, PWBA examined issues 
that arise in connection with conversions of traditional 
pension plans to cash balance plans. PWBA worked with other 
Agencies to formulate legislation that would require more 
extensive disclosure when plans are converted. The 
Administration also supported legislation that would ban 
periods during which some workers (typically older workers) 
would not earn benefits as a result of conversions.
    PWBA also worked to protect retirement assets in 
bankruptcy. In this regard, PWBA drafted provisions for 
proposed legislation that would clarify that retirement assets 
are not included in a bankruptcy estate. The Assistant 
Secretary for PWBA testified in hearings before Congress and 
opposed legislation that would enable creditors to seize funds 
that have been set aside for retirement in tax-qualified plans.
    PWBA also pushed for legislation to improve patient 
protections, create external review mechanisms and provide 
meaningful remedies for patients who have been harmed when 
their managed care plans wrongfully delay or deny needed care. 
The Assistant Secretary for PWBA testified in hearings before 
Congress in this regard, and also participated in roundtables, 
forums, and discussed the issue with the news media.
    The Agency completed work on its health benefits claims 
regulation and released it in November, 2000. This regulation 
was in development for more than two years, and makes 
significant changes to the health benefit claims procedures 
that have been on the books since 1977. The new regulation will 
speed up the time ERISA-governed health benefit plans may take 
to render decisions regarding whether a specific treatment is 
covered, requiring 72 hour turnaround times for ``urgent'' care 
decisions and 15 days for pre-service claims (i.e., services 
that have not yet been delivered). For claims filed after 
services have been delivered, the regulation requires a plan to 
make a decision within 30 days. It will also speed up the 
appeals process for denied claims and require plans to use 
medical experts in appeals requiring medical judgement. PWBA 
has also recently released new regulations that require both 
pension and group health plans to clarify the information they 
provide to participants, and to ensure that Multiple Employer 
Welfare Arrangements (MEWAs) are in compliance with HIPAA.

                                Research

    In fiscal years 1999 & 2000, PWBA continued its program of 
funding studies directed toward improving the understanding of 
the employment-based pension and health benefit systems. These 
studies took advantage of the newly available data on 
households of older workers who will be approaching retirement 
over the next few years. For example, two studies focused on 
cashing out pension benefits at job changes or retirement, one 
analyzing the decision to cash out benefits and the other 
evaluating the effects of tax legislation over the last 15 
years. Additional studies examined women's retiree health and 
pension benefits and the implications for older women's work 
patterns. PWBA also published its annual compendium of private 
pension statistics, the most recent titled ``Private Pension 
Plan Bulletin: Abstract of 1996 Form 5500 Annual Reports.''

              Outreach, Education & Participant Assistance

    Since 1995, PWBA has conducted a national campaign to 
educate workers and their families about retirement issues. 
With the passage of the SAVER Act in FY1998, PWBA is now 
mandated to continue and expand its retirement savings 
education activities as well as to coordinate periodic national 
summits on the issues. The next national summit will take place 
in the fall of FY2001.
    During FY1999 and FY2000, PWBA developed and distributed a 
new series of print public service ads about retirement savings 
that reached millions of readers. An updated slogan was adopted 
for the Campaign ``Saving Matters!'' In collaboration with the 
Certified Financial Planner Board of Standards, a new 
publication was developed and released, ``Saving Fitness: A 
Guide to Your Money and Your Financial Future''. The 
publication was featured in Parade Magazine and Dear Abby. Also 
in partnership with the Federal Consumer Information Center and 
the IRS, two million randomly selected taxpayers received an ad 
promoting retirementsavings enclosed with their tax refund 
check. As a follow-up to the successful 1998 brochure for 
employees, a guide for employers was published to assist them 
in assessing 401(k) fees. Simultaneously, the American Bankers 
Association, the Investment Company Institute and theAmerican 
Council of Life Insurance released a plan disclosure form to 
help employers evaluate 401(k) fees. A news segment on women 
and retirement savings issues was produced for CNBC's Today's 
Health, which reached 55 million households. Also a news 
segment was produced for Parenting in the 90s and Beyond to 
encourage parents to teach their kids to save. This program 
aired in syndication for the complete year.
    In July 2000 at the Department of Labor, the Secretary 
hosted an event to celebrate the 5th Anniversary of the 
Retirement Savings Education Campaign. Several new initiatives 
were announced to include: a new partnership with the Consumer 
Federation of America to reach low-income workers through the 
America Saves program; a new Website developed in partnership 
with the Small Business Administration and the U.S. Chamber of 
Commerce, designed to educate small employers about pension 
plan options; an educational video also geared for small 
business owners; a new educational seminar for women, entitled 
the ``Every womans' Money Conference'' sponsored in part by the 
Department of Labor; and the award of the first annual Oseola 
McCarty Super Saver Award.
    During FY1999, the Secretary of Labor launched a companion 
educational campaign designed to educate individuals about 
their health benefits and related issues. The mission of the 
new Campaign is for the Department, in conjunction with over 70 
public and private partner organizations, to lead an effort to 
educate consumers about their rights and issues of quality 
under their employer provided health plans, and to inform 
employers, particularly small employers, of the value of 
providing quality health benefits to employees. Several new 
brochures have been developed and are being distributed by the 
Department through its toll free hotline as well as by the 
partner organizations. Those brochures include, ``The Top Ten 
Ways to Make Your Health Benefits Work for You'', ``Life 
Changes Require Health Choices, know Your Options'', ``Work 
Changes Require Health Choices, Protect Your Rights'', ``What 
Your Should Know About Your Retiree Health Benefits'', 
``Questions & Answers: Recent Changes in Health Laws'', ``COBRA 
Benefits'', and ``Pension and Health Coverage: Questions and 
Answers for Dislocated Workers''. Fact Sheets and Public 
Service Announcements were also released on the``Health 
Insurance Portability and Accountability Act''.
    PWBA publishes other literature and audio-visual materials 
which, in some depth, explain provisions of ERISA, procedures 
for plans to ensure compliance with the Act and the rights and 
protections afforded participants and beneficiaries under the 
law. Further, PWBA has established an 800 number to facilitate 
distribution of materials and publications, has developed a 
comprehensive Website with access to all its publications and 
educational materials, and has implemented an intense outreach 
program to disseminate information utilizing various media.
    PWBA maintains an ongoing participant assistance program 
throughout the 15 field and national offices to respond to 
pension and health plan participants, including older workers 
and retirees seeking assistance in collecting benefits and 
obtaining information about ERISA. This assistance is provided 
by PWBA's Benefits Advisors, who also are responsible for 
conducting grassroots outreach on the local and regional level 
to inform participants about the Agency's services and to 
disseminate educational materials to various targeted 
populations. By FY2000, 105 positions within PWBA were 
dedicated as Benefits Advisors. These Benefits Advisors respond 
to inquiries from the public regarding their pension or health 
benefits by mail, email, telephone or in person. In FY2000, 
PWBA's Benefits Advisors handled over 158,000 inquiriesand 
obtained over $67 million in benefit recoveries on behalf of 
participants whose claims for benefits had been previously 
denied.
    In addition, for the first time in FY2000, each of the 
field offices developed an annual strategic plan for conducting 
outreach in their geographic area. As a result, the Benefits 
Advisors, using materials developed through the educational 
campaigns, conducted numerous regional outreach seminars and 
workshops for dislocated workers to assist them in 
understanding their rights to transitional health benefits and 
their ability to roll over pension benefits to another plan. 
They participated in workshops geared to educate women about 
retirement savings issues and conducted workshops for small 
business owners about various pension plan options.

                  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.

                       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

    During Calendar Years 1999 and 2000 the Women's Bureau took 
a variety of actions that affected older Americans. They 
included serving as a member of an interagency planning 
committee and cosponsoring conferences that dealt with issues 
of interest to older Americans, their caregivers, or younger 
workers planning for their lifelong economic security. The 
following are examples of these actions:

                  International Year of Older Persons

    The Women's Bureau was a member of the Federal Committee 
for the International Year of Older Persons, chaired by the 
U.S. Administration on Aging (AoA), which planned an 
invitational symposium for Federal leaders, held on June 2, 
1999, in Bethesda, Maryland. In 2000, the Committee was renamed 
the Federal Ad Hoc Committee on Aging Issues. The Committee 
held a meeting on December 6, 2000, to discuss possible 
recommendations for revisions to the International Plan of 
Action on Aging developed at the first World Assembly on Aging 
held in Vienna, Austria, in 1982. (The Second World Assembly on 
Aging, convened bythe United Nations, will be held in Madrid, 
Spain, April 8-12, 2002.) A representative of the Women's 
Bureau, as well as representatives from the Employment and 
Training Administration and the Pension and Welfare Benefits 
Administration attended the meeting.

                            Work and Family

    The Women's Bureau has been holding monthly virtual 
conference calls to educate employers on the range of work-life 
programs available to them to improve the recruitment, 
retention, and productivity of their employees, and to assist 
their employees in balancing work and family responsibilities. 
This program started as a Northwest regional program but now 
involves all Women's Bureau regional offices. Employers, 
unions, work-family advocates, and interested individuals are 
invited to participate, and are encouraged to share their own 
information and resources with other employers across the 
Nation. The Women's Bureau ``Work and Family Exchange'' 
utilizes a combination of conference call and electronic mail 
discussion.
    In Fiscal Years 1999 and 2000, the Women's Bureau worked to 
promote programs to help workers balance work and family. In 
FY1999, among other activities, the Women's Bureau collaborated 
with the San Diego Work-Life Coalition, the San Diego City and 
County Commissions on the Status of Women, and the Redlands 
Childcare professionals to create a work-life partnership in 
Southern California. Also in Fiscal Year 1999, the Women's 
Bureau had an exhibit table at the Southern University Women's 
Symposium ``Balanced Lives: Constructing a Vision'' in Dallas, 
Texas. The symposium was attended by approximately 400 people, 
and the Women's Bureau distributed over 1,200 publications on 
many topics, including the Family and Medical Leave Act and 
elder care.
    Efforts in Fiscal Year 2000 included the Business-to-
Business Work Life Exchange Forum in Chicago, Illinois, 
cosponsored by the Women's Bureau and the Governor's Commission 
on the Status of Women in Illinois. The forum fostered 
information-sharing among 150 Illinois employers who have or 
who are considering work/life options. Many employers indicated 
in their evaluations of the forum that they would utilize the 
information received to implement or explore options for work 
life programs for their employees.
    Also in Fiscal Year 2000, the Women's Bureau, along with 
the New Jersey Chamber of Commerce, whose members include 
Johnson & Johnson, Merrill Lynch, and the Public Service Energy 
Group, the Middlesex Chamber of Commerce, and many other New 
Jersey businesses, co-sponsored the first ever Work Family Fair 
in the Convention Center in Edison, New Jersey. The purpose of 
the Fair was to provide small and mid-sized employers with 
work-life options and resources available to them. 
Approximately 1500 individuals passed through the Work Family 
Fair and obtained self-selected tailored information and 
resources from a variety of work-life exhibitors. Forty percent 
of the participants stated that they would do more research on 
work/family options and 10 percent indicated that they would 
implement a work/family program at the workplace.

                           Retirement Income

    In Fiscal Years 1999 and 2000, the Women's Bureau planned 
or participated in a number of conferences and seminars 
concerning retirement security for women. For instance, in 
FY1999 the Women's Bureau took part in planning for the Atlanta 
meeting ``Americans Discuss Social Security,'' a video 
broadcast which featured First Lady Hillary Rodham Clinton and 
drew 236 persons. The broadcast, which was interactive, allowed 
the participants to express their concerns and to explore 
issues relating to Social Security reform.
    The Women's Bureau also cosponsored the Milwaukee meeting 
of ``Americans Discuss Social Security.'' The 200 Milwaukee 
participants, most of whom were women, learned about the 
importance of Social Security as a safety net, especially for 
older women, and about various proposals on Social Security 
reform. They were able to voice their individual opinions 
through electronic polling devices and share their views on 
Social Security reform with each other.
    On April 17, 1999, in Chicago, the Women's Bureau, the 
International Foundation of Employee Benefit Plans, and the 
University of Illinois at Chicago co-sponsored a ``Summit on 
Financial Security: A Blueprint for Today's Woman.'' The summit 
provided education to women, employers, unions, and the general 
public on the unique financial challenges facing women that can 
lead to poverty in their later years. Seventy-five 
participants, mostly women, learned to evaluate their needs and 
take positive steps toward a financially secure retirement, to 
establish a budget with savings and investment goals, to better 
understand the laws and government programs that affect their 
security, to assess the investment options available, and to 
evaluate their current and future pension and health care 
protection.
    The Women's Bureau joined the White House Office for 
Women's Initiatives, the Office of Federal Contract Compliance 
Programs, the Pension and Welfare Benefits Administration, and 
key women's organizations to develop a model conference called 
``Your Future Paycheck: What Smart Women Don't Know about Pay 
Equity, Social Security, Health Care, Pensions, Saving, and 
Investing.'' The conference, which was held on September 16, 
1999, in Purchase, New York, was designed as a ``train the 
trainer'' retreat for some 200 leaders of major New York City 
and Westchester County women's organizations. Co-sponsors 
included the U.S. Treasury, the Women's Institute for a Secure 
Retirement, American Women in Economic Development, the New 
York Women's Agenda, and the Westchester County Office for 
Women.
    In Fiscal Year 2000, the Women's Bureau, along with the 
Westchester County Office for Women, the New York Women's 
Agenda, American Women in Economic Development, the Women's 
Institute for a Secure Retirement, and the Heinz Foundation, 
co-sponsored the second part of the conference ``Your Future 
Paycheck,'' at Bell Atlantic Headquarters. Approximately 80 
local leaders of women's organizations in the New York 
Metropolitan Area were given intensive training on pensions, 
savings, debt, and investing by key experts in the field. They, 
in turn, took the information and materials back to 
approximately 5000 of their members regionally.
    On April 7, 2000, in San Juan, Puerto Rico, the Women's 
Bureau co-sponsored an all day conference on ``Financial Self-
sufficiency for Women.'' Topics covered included women's 
equality in wages, Social Security, Pensions, and Savings. The 
other co-sponsors were the Puerto Rican Department of Labor, 
the Women's Committee of the Puerto Rican Senate, the Puerto 
Rican Commission on the Status of Women, the University of 
Sacred Heart, the Puerto Rican Development Bank, the Office of 
Federal Contract Compliance Programs, and the Pension and 
Welfare Benefits Administration. Two hundred and fifty women 
participated and received training, expert opinions, and 
materials in Spanish on the importance of knowing about their 
financial future.
    Other Women's Bureau events in FY2000 included: (1) 
organizing a presentation on Social Security, pensions, and 
savings that was delivered by a panel of experts on August 3, 
2000, in Washington, DC; (2) participating in the Louisiana 
``Women and Social Security'' statewide video conference and 
65th Anniversary Celebration on August 9, 2000, in Baton Rouge, 
Louisiana; and (3) co-sponsoring a three-hour seminar for women 
business owners entitled ``Pension Options for You and Your 
Employees'' in Hartford, CT on September 25, 2000.

                National Resource and Information Center

    The National Resource and Information Center (NRIC), was 
established in 1999 to provide the nation's working women with 
the most direct means of access to information on issues of 
concern to them, their families, and their employers. Among 
other things, the NRIC offers a Work and Family Clearinghouse, 
Fair Pay Clearinghouse, ``Don't Work in the Dark!'' Public 
Education materials, an array of other publications, and 
conference and convention information. NRIC is accessible 
through two toll-free phone numbers (1-800-827-5335 and 1-800-
347-3741) as well as via the Internet, and offers updated 
information on Women's Bureau programs and publications as well 
as contacts for additional and supporting resources. Each year, 
NRIC serves approximately 25,000 nationwide.

                     Work and Family Clearinghouse

    The Work and Family Clearinghouse is a computerized 
database and resource center responsive to women's employment 
issues that impact work and family, such as child care and 
elder care. Among its popular resources are the Working Women 
Count Honor Roll Report and the Working Women Count Executive 
Summary, which provide information on companies with policies 
and programs that make work better for working women; a 
business mentoring initiative on child care, which matches 
companies with successful programs that assist employees with 
balancing the demands of work and family with those looking to 
implement similar programs; and numerous supporting 
publications and resources.

         ``Don't Work in the Dark!'' Public Education Campaign

    The ``Don't Work in the Dark!'' public education campaign 
began in January 1994 as a means of alerting America's working 
women about their rights in the workplace. With a widely-
identified base of brochures, women can access reader-friendly 
information on laws regarding issues such as sexual harassment, 
the Family and Medical Leave Act, age discrimination, wage 
discrimination, and disability discrimination. Supporting 
information includes publications from the Women's Bureau and 
related agencies on the aforementioned topics. Available 
employment rights brochures include:
           Don't Work in the Dark-Disability 
        Discrimination
           Don't Work in the Dark-Sexual Harassment
           Don't Work in the Dark-Family and Medical 
        Leave Act
           Don't Work in the Dark-Age Discrimination
           Don't Work in the Dark-Wage Discrimination

        ``Facts for Caregivers and Their Employers'' Fact Sheet

    Published in May 1998, and utilized in 1999-2000, this fact 
sheet gives an introduction which discusses statistics on the 
aging population, women workers, and elder care.
    The second section discusses the types of elder care 
assistance available: geriatric care managers; homemakers and 
home health aides; companions/friendly visitors; telephone 
reassurance systems; respite care; daily money managers; home-
delivered meals; chore and repair; legal assistance or 
resources; family and medical leave; and assistance with 
financing care.
    The third section discusses ways employers/labor 
organizations can help employees with elder care: needs 
surveys; elder care resource and referral; seminars; support 
groups; employee assistance programs; caregiver fairs; 
counseling; long-term care insurance; visiting nurse services; 
adult day care, including intergenerational day care; emergency 
care; elder care pager programs; flexible spending or dependent 
care accounts; flexible schedules and leaves of absence; case 
management; and transportation.

                      ITEM 11--DEPARTMENT OF STATE

                              ----------                              

    The Department is pleased to report that we continued to 
expand services for aging Americans and their caregivers during 
1999 and 2000. 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 
continued to grow.
    In 1999 the Department of State established an Eldercare 
Coordinator position in the Office of Employee Relations to 
develop and promote a series of initiatives to significantly 
improve the level of support the Department offers to employees 
with caregiving responsibilities for parents and other elderly 
relatives. The Coordinator formed a working group to conduct a 
policy review that considered caregiving issues identified by 
the Foreign Service union, by the Associates of the American 
Foreign Service, Worldwide (AAFSW) at an AAFSW-organized 
Eldercare Forum held at the Department, and by the Director 
General of the Foreign Service and Director of Personnel of the 
Department.
    The Eldercare Working Group studied the unique needs of 
both Civil Service and Foreign Service employees as well as 
current rules, regulations and practices with a major impact on 
caregivers. It devised an Eldercare Mission Statement to guide 
the development of Department eldercare support policy and 
recommended the establishment of a dependent care resource and 
referral service, a reinvigorated information program at 
Washington headquarters, and several major regulatory changes 
that could help caregiving employees who serve at overseas 
posts.
    The Eldercare Mission Statement, which was accepted by 
unions that represent Department Civil Service and Foreign 
Service employees, serves as a guide to developing a 
coordinated eldercare support program. The Statement says, 
``The Department recognizes that growing numbers of employees 
will have caregiving responsibilities for parents and other 
elderly relatives. To enable employees to make better decisions 
for the well being of their families, the Department will 
endeavor to provide information on available supports and 
services that affect the elderly. For employees serving abroad, 
it will also seek ways consistent with budget constraints to 
make available certain allowances and other benefits that 
assist in defraying additional eldercare costs due to service 
overseas. In Washington, the Department will provide a 
professionally-led eldercare support group, current and useful 
information on resources, and referral to community support 
services in the metropolitan area.''
    In 2000 the Office of Employee Relations launched LifeCare, 
a dependent care resource and referral service; created a new 
travel benefit for Foreign Service employees when a parent 
faces a health crisis that may threaten continuing 
independence; and continued as a coordinating and advisory body 
for the eldercare support programs and services offered by 
other offices in the Department.
    The Employee Consultation Service, the Department's 
employee assistance program, continued to offer counseling and 
referral and facilitated an ongoing Eldercare Support Group 
with weekly meetings for employees in the Washington area. The 
Family Liaison Office surveyed employees overseas to determine 
the number of elderly parents accompanying Foreign Service 
members on assignment abroad and publishes information papers 
on caring for an aging parent. It also advocated within the 
Department on behalf of Foreign Service employees and family 
members with caregiving issues arising out of high 
international mobility. The Office of Allowances expanded rules 
governing the Separate Maintenance Allowance to permit an 
employee to obtain additional financial support from the 
Department if a parent who has lived in the employee's 
household for a year prior to overseas assignment cannot 
accompany the family to the next post abroad.
    The Office of Employee Relations organized a bimonthly 
lunchtime seminar series called ``Caring for Your Aging 
Parents'' which provided information on legal issues of aging, 
long-distance-caregiving, housing options for the elderly, 
coping with Alzheimer's Disease, respite care, and more, as 
well as promoted the use of LifeCare, the dependent care 
referral service. This office presented an annual Eldercare 
Fair at headquarters of the Department which brought 
organizations and local businesses offering support to seniors 
ranging from Medicare to AARP to private geriatric care 
managers into direct contact with employees. The Office of 
Medical Services hosted an annual Health Fair in Washington and 
additional lunchtime seminars that focussed on active, healthy 
aging.
    During this period, the Office of Employee Relations' 
Employee Programs Division took steps to enhance flexible work 
schedules and arrangements which can help caregiving employees. 
The Department's first telecommuting policy was published in 
1999. A ``Leave and Alternative Work Schedules'' handbook which 
explains family-friendly changes in sick leave policy as well 
as alternative work schedules available to Department employees 
was published in 1999. Home leave policy was revised in 2000 to 
allow Foreign Service employees to use 5 weeks (vice 3) of home 
leave in the U.S. following a tour overseas, thus permitting 
employees to spend more time with parents and other family 
members left behind during assignment abroad.
    Finally, staff from the Office of Employee Relations have 
been active participants in OPM's Interagency Family-Friendly 
Workplace Working Group which aims to share information about 
best practices in this area throughout the federal government.

                 ITEM 12--DEPARTMENT OF TRANSPORTATION

                              ----------                              


   SUMMARY OF ACTIVITIES TO IMPROVE TRANSPORTATION SERVICES FOR THE 
                                ELDERLY

                              Introduction

    The following is a summary of significant actions taken by 
the U.S. Department of Transportation during calendar years 
1999 and 2000 to improve transportation for elderly persons.\1\
---------------------------------------------------------------------------
    \1\ ``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 transit administration (fta)

    Under 49 USC 5310, the FTA provides assistance to private 
nonprofit organizations and certain public bodies for the 
provision of transportation services for the elderly and 
persons with disabilities. In FY1999, $67 million was used to 
help 1,332 local providers purchase 1,755 vehicles and for 
contracted services. In FY2000, $140 million was used to help 
approximately 1,400 local providers purchase more than 1,800 
vehicles and for contracted service for the provision of 
transportation services for the elderly and individuals with 
disabilities. The large increase in funds obligated between 
FY1999 and FY2000 is due mostly to two transfers of flexible 
funds (a category of funds that may be used for highway or 
transit projects), totaling $62.6 million, into the Section 
5310 program by Los Angeles County Metropolitan Transit 
Authority for the provision of paratransit services required by 
the Americans with Disabilities Act for operators of fixed-
route service. Most of the agencies funded under the elderly 
and persons with disabilities 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 servicing 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 persons with 
disabilities. 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 (Formula Grants for Other Than Urban 
Areas), the FTA obligated $208 million in FY1999 and $229 
million in FY2000. 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 are 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 (Urbanized Area Formula Grants), the FTA 
obligated $2 billion in FY1999 and $4 billion in FY2000. 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.
    Section 3038 of the Transportation Equity Act for the 21st 
Century authorized a program to fund the incremental capital 
and training costs of complying with DOT's over-the-road bus 
accessibility final rule. In FY1999, the first year of the 
program, $2 million was obligated to 11 providers of intercity 
fixed-route service. These funds were used to make 87 vehicles 
wheelchair accessible and for training. In FY2000, $3.7 million 
was provided to 47 providers of intercity fixed-route service 
and others, including charter and tour operators. These funds 
were used to make 168 vehicles wheelchair accessible and for 
training. Approximately 25 percent of the over-the-road bus 
industry's ridership is elderly, and a large proportion of 
persons who use wheelchairs are elderly. Providers of over-the-
road bus services are encouraged to use accessibility training 
resources developed by the National Easter Seal Society's 
Project Action, an FTA-funded program to promote cooperation 
between the disability community and transportation industry.

                 federal railroad administration (fra)

    The National Railroad Passenger Corporation (Amtrak) 
continued throughout calendar years 1999 and 2000 to provide 
discounted fares, accessible accommodations, and special 
services, including assistance in arranging travel for older 
citizens and passengers with disabilities. These passengers 
continue to represent a substantial part of Amtrak's 
ridership--in 2000 alone ridership among seniors age 62 or 
older increased by almost 8 percent to approximately 1.8 
million travelers.
    Discounted Fares.--Amtrak has a systemwide policy of 
providing elderly persons and persons with disabilities a 15 
percent discount on ticket purchases. During this period, 
Amtrak also offered a 15 percent discount to adult companions 
traveling with a passenger with a mobility impairment. This 15 
percent discount cannot be combined with any other discount. 
Amtrak also offered passengers with mobility impairments a 30 
percent discount on the standard fare for accessible bedrooms.
    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 
as well as accessible coach seating and bathrooms. 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, including the recently unveiled Acela Express high-speed 
rail cars, provide enhanced accessibility for passengers, with 
mobility and other types of disabilities. Amtrak allows only 
passengers with mobility impairments to reserve an accessible 
bedroom up until 14 days prior to the date of a train's 
departure from the city of origin.
    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, written menus, 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.
    Assistance in Making Travel Arrangements.--Amtrak has 
available publications describing its services and facilities 
for the benefit of passengers with disabilities. A pamphlet 
entitled ``Access Amtrak: A Guide to Amtrak Services for 
Travelers with Disabilities'' is available upon request. 
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 successful responded 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.

                                Research

                    department-wide aging initiative

    National Agenda for the Transportation Needs of an Aging 
Society.--As a follow-up to its January 1997 study, and to 
prepare the nation's transportation system for the near 
doubling of older Americans expected between now and 2030, the 
Department has initiated development of a National Agenda, 
laying out the actions needed to manage safe transportation for 
older adults in the first decades of the new century. The U.S. 
Department of Transportation Office of the Secretary, National 
Highway Traffic Safety Administration (NHTSA), Federal Highway 
Administration (FHWA), and Federal Transit Administration are 
participating in this effort. The agenda is based on a national 
dialog on the transportation needs of an aging population, 
begun by the Department in 1999. This dialog has included 
regional forums, workshops, professional society meetings, 
international conferences, and the work of a companion study 
done by the Transportation Research Board (see below). Its 
purpose has been to get the broadest possible viewpoint from 
those practicing in the field--transportation professions, 
medical and social service providers, public officials, and the 
agencies and interest groups who deal with the elderly on a 
day-to-day basis. Concurrent with the regional forums a series 
of focus group discussions were held with other people and 
their lay care givers (usually adult children) to obtain their 
perspectives on elderly driving, the difficulties associated 
with driving cessation and the use of other transportation 
options. Several telephone surveys of older adults were also 
conducted.
    The result of this effort is a report entitled Safe 
Mobility for a Maturing Society: A National Agenda. It points 
out that there is no simple solution, nor is responsibility 
vested in one single organization. It lays out what needs to be 
done to manage safe transportation for our older adults, with a 
comprehensive set of recommendations and the potential roles 
that different authorities, agencies, the private sector, and 
the public can have in implementing them. It includes an array 
of possible innovations and measures for maintaining 
transportation safety and quality of life for older adults: 
improved roads, safer cars, better driver screening and 
retraining, more access to non-driving alternatives, and 
dissemination of better information to the public. It will be a 
source of guidance on the actions that hold the most promise by 
transportation planning, law enforcement, social service, and 
medical agencies at all levels, as well as the private sector, 
and by older adults themselves and their advocates. The report 
should be available in early 2002.
    Transportation Research Board (TRN) Report.--The TRB, with 
the support of the Department, is working to update a 1988 
report on needed research covering transportation for older 
adults. The update examines what has been done since 1988, what 
the requirements are for new work, and what the new research 
priorities should be for meeting the needs of an increasing 
elderly populace over the next 25 years. This report, 
Transportation for an Aging Society--a Decade of Experience 
will be published by TRB in 2001.

                 federal aviation administration (faa)

    The Office of Aviation Medicine's Civil Aeromedical 
Institute (CAMI) has contributed to the following research 
related to the needs and concerns of the aging population in 
aviation transportation.
    Cognitive Function Test.--The CogScreen test was developed 
to measure the underlying perceptual, cognitive, and 
information processing abilities associated with flying. It is 
being validated against a group of older military aviators, 
including repatriated military aviators and a control group. 
This validation extends the age groups of the original 
CogScreen validation by including more aviators in older age 
groups. Analyses are completed; results have been presented at 
a scientific meeting, and an Office of Aerospace Medicine (OAM) 
technical report is being written. Overall, results indicate a 
pattern of lowered CogScreen scores with advancing age.
    Flight Deck-Related Human Factors Research.--Previous 
observations in simulator studies suggest that older segments 
of the General Aviation pilot population are having difficulty 
hearing specific auditory warnings in the cockpit. A study to 
assess age-related changes in pilots' auditory thresholds was 
completed using stratified age sampling. Comparisons of 
threshold for pilots and non-pilots revealed the expected high-
frequency decrements attributable to aging and general 
environmental exposure. Significant differences were found 
between non-pilots and pilots, with greater threshold shifts, 
between 2 and 6 kHz, among pilots. Results were presented at a 
scientific meeting and a draft report is currently under 
review.
    Age-60 Rule.--A series of four studies on the Age 60 rule 
were completed by CAMI in response to a Congressional request. 
The first study provided an overview and update of the relevant 
scientific literature. The second study re-analyzed accident 
and incident data published by the Chicago Tribune in July 
1999. That re-analysis found, as did the Tribune, no 
significant differences in accident/incident rates for pilots 
age 40-49 and 50-59. The third study analyzed the accident rate 
for professional pilots holding an air transport pilot (ATP) 
and Class I medical certificate by age, for accidents occurring 
under Part 121. While there was an overall statistically 
significant ``U''-shaped relationship between pilot age and 
accident rate, the difference between accident rates between 
pilots aged 55-59 and 60-63 was not statistically significant. 
The fourth study analyzed the accident rate for professional 
pilots holding an ATP or Commercial Pilot and Class I or Class 
II medical certificate by age, for accidents occurring under 
Part 121 and Part 135. There was an overall statistically 
significant ``U''-shaped relationship between pilot age and 
accident rate. In addition, the accident rate for pilots aged 
60-63 was statistically greater than the rate for pilots age 
55-59. However, the difference may be attributable to the fact 
that all accidents involving pilots age 60 to 63 occurred under 
Part 135, which are generally acknowledged as having a higher 
base rate. The reports were provided by the FAA to the 
Department of Transportation in September 2000, and a formal 
OAM technical report is in preparation. Additional analyses are 
planned in FY2002, based on suggestions and recommendations 
from the researchers in this area.
    On August 14, 2001, the U.S. Court of Appeals for the 7th 
Circuit, in Yetman vs. Garvey, affirmed an FAA decision to deny 
exemptions to its age 60 rule sought by a total of 69 pilots. 
The court upheld the exemption denials in light of FAA's 
paramount safety concerns.
    Air Traffic Control.--The model developed in a previous 
report that focused on a systematic projection of the aging of 
the current air traffic control workforce and retirement 
eligibility was revised. The revised model was developed to 
reflect more closely the actual retirement trends and expanded 
to airways facilities.
    As part of the validation of a new computerized selection 
instrument for air traffic controllers, a study was conducted 
to determine the relationship between age and performance on 
both the selection tests and on the criterion measures of 
controller performance. The two criterion measures used in the 
study were ratings (peer and supervisor) and the score on a 
newly developed computer-based performance measure. Results 
revealed a curvilinear relationship between age and both test 
scores and criterion measures, with performance declining for 
controllers over the age of 42. Results were presented at 
scientific meetings and published as two OAM technical reports 
in 1999.

                 federal highway administration (fhwa)

    Beginning in 1989, a High Priority Area for research was 
established to develop a clear understanding of older driver 
needs and capabilities 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.
    Research findings from this program were incorporated into 
an Older Driver Highway Design Handbook (FHWA-RD-97-135) that 
became available in January 1998. The handbook serves as an 
important resource for traffic engineers in assuring that 
highways meet the needs and capabilities of older drivers and 
pedestrians. The handbook has been widely distributed and 
extremely well received. A condensed version, titled Older 
Driver Highway Design Handbook: Recommendations and Guidelines 
(FHWA-RD-99-045), became available in December of 1998.
    Currently, an update to the Handbook is in the final stages 
of development. Besides including the most recent research 
findings, this document will address a broader ranger of 
highway design areas and will contain format and content 
changes to improve its usefulness. The new editions: Highway 
Design Handbook for Older Drivers and Pedestrians (FHWA-RD-01-
103) and Guidelines and Recommendations to Accommodate Older 
Driver Highway Design Handbook: Recommendations and Guidelines 
(FHWA-RD-99-045), became available in December of 1998.
    Currently, an update to the Handbook is in the final stages 
of development. Besides including the most recent research 
findings, this document will address a broader range of highway 
design areas and will contain format and content changes to 
improve its usefulness. The new editions: Highway Design 
Handbook for Older Drivers and Pedestrians (FHWA-RD-01-051) are 
due to be printed and delivered this fall. Both documents will 
be produced in electronic as well as traditional paper media.
    It should be noted that all human centered research, 
including Intelligent Transportation Systems initiatives, 
conducted by FHWA includes an older driver component to ensure 
the system's utility for all potential users.
    The FHWA is continuing work to fulfill a mandate issued by 
Congress that requires public agencies to maintain signs and 
pavement markings to minimum levels of retroreflectivity (i.e., 
brightness). In the process of establishing these minimum 
guidelines, research has been conducted to determine the 
brightness of signs and pavement markings necessary for older 
drivers to drive safely and comfortably at night. A recent 
study using older drivers as subjects, has determined an 
optimum brightness for overhead guide signs. FHWA is also 
investigating the effectiveness of new automobile headlight 
systems, which have the potential to drastically improve the 
visibility of signs, pavement markings, and pedestrians at 
night. Older drivers have been included in the field 
experiments of the ultraviolet infrared, and other new headlamp 
technologies, and results indicate that there are several 
options that can enhance night visibility for older drivers. 
Efforts are continuing on this project to evaluate driver 
visibility with these headlight systems under adverse weather 
conditions at the Virginia Smart Road (a high priority project 
in Blacksburg, Virginia, funded by the Transportation Equity 
Act for the 21st Century). The FHWA is also using the 
sophisticated fixed lighting test system at the Virginia Smart 
Road to test varying light types, levels, and placement to 
identify optimum lighting design for older drivers. Ninety 
older drivers have participated in field experiments, which 
measured their ability to see objects on the road under varying 
levels of street lighting and glare from on-coming vehicles. 
This effort is expected to validate new lighting design 
standards.
    The results of these studies and other research will be 
incorporated into the Manual on Uniform Traffic Control 
Devices, the Highway Lighting Handbook, and other documents 
used in highway design.

                  federal transit administration (fta)

    The National Easter Seal Society's Project Action (funded 
by FTA) hosted three consumer education workshops in 2000 for 
seniors with disabilities. Participants had an opportunity to 
learn about the transportation provisions of the Americans with 
Disabilities Act (ADA) and to gain first hand experience in 
using fixed route services in their communities. Over the past 
few years Project Action has worked with a number of aging 
organizations in addressing accessible public transportation. 
Among the more than 100 products available free of change from 
its clearinghouse are three publications that specifically 
focus on seniors and public transportation.
    Through the Transit Cooperative Research Program, FTA is 
sponsoring the research project begun in FY1999, ``Improving 
Public Transit Options for Older Persons.'' This project will 
examine the population of interest in detail and will: identify 
barriers to mobility and methods to overcome them; detail best 
practices from transportation programs designed to improve 
transportation opportunities for older persons; and identify 
further innovations. An interim report was issued on December 
8, 2000.
    The Independent Transportation Network (ITN) in Portland, 
Maine, provides convenient and affordable transportation for 
seniors who have chosen to reduce or totally eliminate driving 
their own cars. Service is provided by a fleet of standard size 
sedans driven by paid drivers and a large number of volunteer 
drivers using their own cars. Innovative payment plans 
eliminate the need for cash transactions and member accounts 
make it easy for other family members to help pay for a 
senior's transportation needs. This project is primarily funded 
by FTA with additional funding assistance from the 
Transportation Research Board (TRB), AARP, NHTSA, as well as 
foundation awards and corporate and community support.

            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. Emerging 
vehicle technologies could help reduce older driver crashes and 
enhance their mobility. For example, voice turn-by-turn in-
vehicle navigation systems may allow drivers to concentrate on 
watching for dangerous traffic conflicts instead of being 
distracted while searching for road signs. Similarly, 
collision-warning systems would alert drivers to potential 
crash situations. In this area, NHTSA continues development of 
crash warning systems for rear-end crashes, lane changes 
crashes, road departure crashes, and intersection crashes. 
Other developments in driver interfaces could provide 
technology-based innovations that would help older, 
functionally less able people continue to drive by offering all 
drivers much wider adaptability to unique personal needs, say 
through programmable ``glass dash'' options where older drivers 
could improve contrast and font size programming rather than 
settling for current fixed-configuration designs, and could 
even control the nature of the information that is passed to 
them from the vehicle. NHTSA's research focus is thus to 
determine how the design and function of vehicle systems could/
should be adapted to better meet the needs of older drivers, 
including the unique capabilities and needs of older drivers.
    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 more 
than one in five (22.4 percent) pedestrian fatalities. In 
response to this problem, NHTSA and FHWA are continuing work 
aimed at preventing crashes involving pedestrians. One example 
is a pilot project that was initiated by NHTSA in Miami/Dade 
County, Florida. That project involves a demonstration program 
of targeted behavioral safety information combined with 
enforcement activities and traffic engineering applications in 
selected zones of the county that have been shown to have a 
high incidence of pedestrian crashes. In 2000, awareness for 
senior citizens; the medical community that serves them; 
community organizations that provide outreach to them; and 
transportation providers that service them. Another project 
begun in 2000, with the State of Texas, will evaluate the 
conversion of their safety materials for more than 25 percent 
of the population is of Hispanic origin, and it is important to 
address the safety needs of this growing group. This will also 
help NHTSA in refining materials for older pedestrians--
Spanish-speaking or otherwise.
    Older Driver Safety.--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. There are, however, individuals who are at increased 
risk for crashes. NHTSA is hard at work trying to identify 
those drivers through its research program. The research study 
Intersection Negotiation Problems of Older Drivers revealed 
that cognitively impaired drivers referred to the DMV for 
further testing are more likely than other older drivers to 
exercise poor judgment in making left turns. Evaluating Drivers 
Licensed with Medical Conditions in Utah, 1992-1996 used 
NHTSA's Crash Outcome Data Evaluation System (CODES) to link 
crash data with licensing information. Drivers who had certain 
reportable conditions, such as memory problems and 
musculoskeletal abnormalities had an increased risk for crash 
involvement.
    In addition to conducting research in this are, NHTSA 
participated in the November 1999 Transportation Research Board 
(TRB) conference on Transportation in an Aging Society: A 
Decade of Experience. Participants at this conference 
identified research gaps in the knowledge base regarding older 
road users. In July 2000, NHTSA initiated a contract to develop 
research problem statements for studies from that conference 
that fall under NHTSA's mission.
    Driver Assessment Activities.--Those older 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 problems 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 tests of 
``speed of attention'' and ``visual perception'' may have such 
potential, particularly at detecting the cognitively impaired. 
An ongoing study in the State of Maryland promises to reveal 
which of these test is most predictive of crash involvement. 
Similar research is being conducted at Ohio State University, 
looking specifically at their medical assessments of older 
drivers and how the assessments relate to driving performance. 
In addition, a project with the State of Florida aims to better 
identify and counsel cognitively impaired drivers. NHTSA is 
also investigating the degree to which rehabilitation is an 
option in drivers with certain medical conditions. The goal is 
to keep people driving for as long as it is safe for them to do 
so.
    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. Because older women are 
more likely to stop driving than older men, a Literature Review 
on the Status of Research on the Transportation and Mobility 
Needs of Older Women was conducted. Because mobility is so 
closely tied to economics, living arrangements, and health and 
life expectancy, this review revealed that older women are at a 
disadvantage with regard to mobility.

          research and special programs administration (rspa)

    RSPA manages the Department's University Transportation 
Centers Program as revised and expanded in the Transportation 
Equity Act for the Twenty-First Century (TEA-21).
    Each center focuses its research on a specific theme or 
interest area. Several of these themes are linked in whole or 
in part with improving mobility for elderly citizens:
          University of Arkansas: Rural Transportation
          University of California--Berkeley: Improving 
        Accessibility for All
          Marshall University: Economic Growth and Productivity 
        in Rural Appalachia Through Transportation
          Montana State University: (Western Transportation 
        institute): Rural Travel and Transportation
          Morgan State University: Transportation--A Key to 
        Human and Economic Development
          University of Nebraska--Lincoln: Improved Design and 
        Operation of Transportation Facilities and Services in 
        Mid-America
          North Carolina A&T State University: Urban Transit
          University of Southern California and California 
        State/Long Beach: Solutions to Transportation Issues in 
        Major Metropolitan Areas
          University of South Florida: Urban Transit
          North Dakota State University: Rural and Non-
        Metropolitan Transportation
    In addition, the Director of the University Transportation 
Center at the Massachusetts Institute of Technology presented a 
paper at the October 2000 White House Forum on Technologies for 
Successful Aging. The Department of Veterans Affairs hosted the 
Forum, with support from the Department of Health and Human 
Services, the Department of Education, the National Institutes 
of Health, and the Office of Science and Technology Policy.

                       Information Dissemination

                 federal highway administration (fhwa)

    A one-day workshop was developed to familiarize traffic 
engineers and highway designers with the Older Driver Highway 
Design Handbook. The workshop covers the needs and capabilities 
of older road users, reviews the recommendations of the 
Handbook in detail, and presents case studies as learning 
exercises. It was designed for federal, state, and local 
highway designers, traffic engineers, and transportation 
professional. To date, over 50 workshops have been held in over 
30 states, training approximately 1500 traffic engineers. FHWA 
personnel from across the country have attended ``train the 
trainer'' sessions, thereby allowing FHWA to better meet the 
numerous requests fro workshops. The workshop is being revised 
to reflect the new edition of the Handbook that will be 
available in Fall 2001.
    In 1999,  the FHWA  established  the Pedestrian  and  
Bicycle Information Center (PBIC) to provide technical 
assistance to localities on accommodating pedestrians, 
including older pedestrians. The PBIC is operated  by the  
Highway  Safety  Research Center  of the University of North 
Carolina, and offers a website (www.walkinginfo.org), an 800 
number (877-925-5245), fact sheets and expert assistance. The 
PBIC enhances the effectiveness of the USDOT by providing 
additional technical expertise to individuals with questions 
about pedestrian and bicycle facilities and programs.
    As an implementing agency for the Americans for 
Disabilities Act (ADA), FHWA published a guideline Designing 
Sidewalks and Trails for Access--A Review of Existing 
Guidelines and Practices--Part 1. A Best Practices Guidebook 
will be released in September 2001. This document explains the 
needs of pedestrians with disabilities, including the needs of 
older pedestrians, and provides guidance on how to design 
universally accessible pedestrian facilities. FHWA also 
initiated a project in 2000 focusing on Intelligent 
Transportation Systems-based pedestrian countermeasures, 
including some technologies (infra-red detection that will 
benefit older pedestrians. Older pedestrian issues are included 
in all ongoing FHWA outreach activities, including the 
Intersection Hazard Index for Pedestrians and Bicyclists, and 
the University Pedestrian/Bicyclists Graduate Course, as well 
as other active work with State DOT's and other transportation 
agencies.

                 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 or ordering from the Amtrak website at 
www.amtrak.com. Amtrak also works directly with a number of 
organizations each year on moving groups of passengers needing 
assistance and traveling together.

         national highway traffic safety administration (nhtsa)

    A broad array of public information materials and resources 
were first introduced in 1999 and 2000. Through partnerships 
with outside organizations and within DOT, NHTSA has been able 
to expand its outreach efforts and reach new audiences. 
Adapting Motor Vehicles for People with Disabilities is a step-
by-step guide for making vehicle adaptations to enhance the 
mobility of the disabled passenger and driver. It is estimated 
that half of the disabled population is over age 50, and that 
each individual will experience at least one form of disability 
in their lifetime.
    NHTSA has contributed to FHWA's Pedestrian and Bicycle 
Information Center (PBIC), most notably to the segment on 
pedestrians over 50 on www.walkinginfo.org. In particular, 
there was a partnership with FHWA to develop the Pedestrian and 
Bicycle Crash Analysis Tool, which became available in 2000, 
and is distributed through PBIC. The tool helps users analyze 
crash data to select appropriate countermeasures to prevent 
such crashes from recurring. Countermeasures might include 
traffic calming or targeted education.
    Driving Safely While Aging Gracefully contains information 
on common age-related changes as they relate to driving, paired 
with actions an older person can take to minimize the effects 
of those changes. This booklet is the result of a partnership 
with AARP and USAA Educational Foundation.

          research and special programs administration (rspa)

    RSPA continues to disseminate technical reports describing 
the mobility needs of senior citizens, and alternative ways to 
meet them. Documents are available in hard copy from the 
Department at no charge, and may be ordered on the INTERNET at 
the Technology Sharing Program home page: http://
www.tsp.dot.gov.
    RSPA provided staff support to the National Science and 
Technology Council's (NSTC's) Committee on Technology, 
including its subcommittee on Transportation R&D. In April 1999 
the NSTC National Transportation Science and Technology 
Strategy was released, which included recommendations for 
several government/academic/private sector strategic 
partnership initiatives to promote technology application and 
implementation. One of these initiatives deals specifically 
with ``Accessibility for Aging and Transportation Disadvantaged 
Populations.'' A goal of this initiative is to create model 
alternative transportation systems that serve the needs of the 
elderly and transportation-disadvantaged people while taking 
full advantage of existing services, resources, and development 
patterns. More detailed implementation activities were defined 
in the NSTC Transportation Technology Plan, which was being 
released in May 2000. The DOT Transportation Research, 
Development and Technology Plan also emphasizes this topic as 
an area for implementation partnerships.
    To facilitate communication and information-sharing on 
technology issues and support the NSTC, RSPA has brought a 
science and  technology  INTERNET  home  page  on line.  The 
element deal with the accessibility partnership is located at 
http://scitech.dot.gov/partech/accage/accessaging.html. It 
includes background information on the need, links to selected 
on-line manuals and technical reports, and announcements of 
upcoming conferences and events.
    The University Transportation Centers Program integrates 
its products in a directory of University Research Results on 
its INTERNET Home Page at http://utc.dot.gov. The directory 
includes the title of each report and a contact who can provide 
further information on the research and the availability of 
documentation from it. In addition, program staff is exploring 
making key UTC products available on-line as volumes in the 
National Transportation Library at (http://www.bts.gov/NTL).

                    ITEM 13--DEPARTMENT OF TREASURY

                              ----------                              


    U.S. TREASURY ACTIVITIES IN 1999-2000 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 the Managing Trustee of 
the two Social Security Trust Funds (Old-Age and Survivors 
Insurance and Disability Insurance). The Trustees issue an 
annual report on the short- and long-run financial status of 
these Trust Funds. In the March 2000 report, covering calendar 
year 1999, the Trustees project that full benefits can be paid 
for about the next 37 years, three years longer than in the 
1999 report. The 75-year actuarial deficit of the Social 
Security program in the 2000 report is estimated to be 1.89 
percent of taxable payroll, an improvement from 2.07 percent in 
the 1999 report. The improvement in the status of the trust 
funds in 2000 comes from strong recent economic growth, a 
higher long-run wage growth assumption, and changes in 
assumptions and methods. The OASDI Trustees' Report is 
available at www.ssa.gov/OACT/TR/index.html.
    There was an automatic 2.4 percent benefit increase in 
December 1999, and an additional 3.5 percent in December 2000. 
The taxable wage base was increased to $72,600 in 1999 and 
$76,200 in 2000, and is $80,400 in 2001.
    On April 7, 2000, President Clinton signed the ``Senior 
Citizens Freedom to Work Act of 2000,'' which repealed the 
Retirement Earnings Test for Social Security recipients above 
the Normal Retirement Age, age 65 in 2001.

                          medicare trust funds

    The Secretary of the Treasury is the Managing Trustee of 
the Federal Hospital Insurance (HI) and Federal Supplementary 
Medical Insurance (SMI) Trust Funds. In their (corrected) March 
2000 report, covering calendar year 1999, the Trustees project 
that the HI trust fund will be exhausted in 2025, compared to 
2015 in the 1999 report. In the 2000 report the 75-year HI 
actuarial deficit is projected to be 1.21 percent of taxable 
payroll, compared to 1.46 percent in the 1999 report. This 
improvement is due to lower benefit expenditures and higher 
economic growth than projected. The SMI trust fund is projected 
to remain adequately funded into the indefinite future because 
its funding, by law, comes almost entirely from general 
revenues and premium payments. The Medicare Trustees' Reports 
are available at www.hcfa.gov/pubforms/tr.

                               income tax

    Each year, the width of the income tax brackets and the 
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 $2,700 in 1998 to $2,750 in 1999 and to $2,800 
in 2000.
    Taxpayers age 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 standard deduction of $1,050 in 1998 and 1999, and 
$1,100 in 2000. Each married taxpayer age 65 or over was 
entitled to an extra standard deduction of $850 in each of the 
three years. Thus, in all three years, married couples where 
both members were at least age 65 were entitled to an extra 
standard deduction of $1,700. Including the extra standard 
deduction amounts and the basic standard deduction amounts, 
taxpayers age 65 and over were entitled to the following 
standard deductions for tax years 1998 through 2000:

------------------------------------------------------------------------
             Filing Status                  1998       1999       2000
------------------------------------------------------------------------
Single.................................     $5,300     $5,350     $5,500
Unmarried Head of Household............      7,300      7,400      7,550
Married Filing Jointly:
    One spouse age 65 or older.........      7,950      8,050      8,200
    Both spouses age 65 or older.......      8,800      8,900      9,050
------------------------------------------------------------------------

    The tax credit for the elderly (and permanently disabled) 
was retained throughout the period.
    Two provisions of the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA) are particularly relevant to 
the aged. HIPAA 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. Also, 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. 
(The Taxpayer Relief Act of 1998 accelerated the increases, and 
ultimately raised to 100 percent, the deductibility of health 
insurance premiums for a self-employed individual and the 
individual's spouse and dependents if neither the individual 
nor spouse are eligible for health insurance coverage as 
employees. The changes are phased in beginning in tax year 2000 
.)
            Medical Savings Account
    The Balanced Budget Act if 1997 permits Medicare-eligible 
individuals to choose either the traditional Medicare program 
or Medicare Plus Choice, which may include a medical savings 
account (MSA). The option became available in 2000. Under the 
Medicare Plus Choice MSA, limited contributions will be made to 
the individual's MSA, and those contributions and the earnings 
on balances in the MSA account will not be subject to tax. 
Withdrawals which are used to pay for qualified medical 
expenses will not be subject to tax. Withdrawals which are used 
to pay for qualified medical expenses will not be subject to 
tax. Withdrawals used for other purposes will be included in 
income subject to tax and, subject to certain rules, will also 
be subject to additional tax.

                          gift and estate tax

    A gift tax is imposed on lifetime transfers by gift, and an 
estate tax is imposed on transfers at death. A unified credit 
applying to both the gift and estate taxes permits a certain 
amount to be transferred before gift or estate taxes are 
imposed. The Tax Reform Act of 1997 increased the unified 
credit, providing an effective exemption of $625,000 for 1998, 
$650,000 for 1999, and $675,000 for 2000 and 2001. Further 
increases are scheduled until the effective exemption reaches 
$1 million in 2006. (The unlimited exemption for transfers to 
spouses was retained.) Estates may elect special estate tax 
treatment for certain qualified family-owned business 
interests; the elected deduction for family-owned business 
interests together with the general effective exemption may not 
exceed $1.3 million.

                        internal revenue service

            Publications
    The 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. The following 
publications, revised on an annual basis, are directed to older 
Americans. Each year, IRS reviews the publication to ensure 
that they are updated to reflect changes in tax law as well as 
to simplify the explanation in them.
    Publication 524, ``Credit for the Elderly or 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 age 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. The Guide serves as 
a primary source of tax information for older Americans.
    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 and Equivalent Railroad 
Retirement Benefits,'' assists taxpayers in determining the 
taxability, if any, of benefits received from Social Security 
and Tier I Railroad Retirement.
    Publication 590, ``Individual Retirement Arrangements 
(IRAs),'' includes information about deductions and tax 
treatment of distributions for various retirement accounts.
    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 and post offices stock the most frequently requested 
forms, schedules, instructions, and publications for taxpayers 
to pickup. Also, many libraries stock a reference set of IRS 
publications and a set of reproducible tax forms and also may 
have access to the Internet to download tax materials.
    Most forms and some publications are on CD-ROM and are on 
sale to the general public through the National Technical 
Information Service on the Internet at www.irs.gov./cdorders, 
or by calling toll free 1-877-CDFORMS (1-877-233-6767). Forms, 
instructions, and tax information are available by fax by 
calling (703) 368-9694 using a telephone connected to a fax 
machine.
    Taxpayers may obtain most forms, instructions, 
publications, and other products via the IRS Internet web site 
24 hours a day, 7 days a week, at www.irs.gov.
    The IRS has continued the availability of large-print 
versions of the Form 1040 and print versions of the Form 1040 
and Form 1040A packages earmarked for older Americans. These 
packages (designated as Publication 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).
            Volunteer and Outreach Programs
Volunteer Income Tax Assistance Program
    The Volunteer Income Tax Assistance (VITA) program offers 
FREE tax help to people who cannot afford paid professional 
assistance. Volunteers answer questions and 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. Many sites provide free electronic filing of tax 
returns. Volunteers generally include college students, law 
students, members of professional organizations; members of 
retirement, religious, military, and community groups; and IRS 
employees.
    During 2000, over 48,200 volunteers donated more than 
945,600 hours assisting over 2 million individuals. There were 
over 1.1 million returns prepared at over 8,200 VITA sites 
across the nation.
Tax Counseling for the Elderly (TCE) Program
    Congress first authorized the TCE Program 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. The IRS, in partnership with the AARP, supports 
the TCE program by providing training for volunteers, as well 
as the use of computers and printers for electronic filing. In 
2000, there were over 9,100 TCE sites in retirement homes, 
neighborhood and senior citizens centers, and shopping malls. 
Volunteers also traveled to the private residences of the 
homebound. There were over 29,700 TCE volunteers providing more 
than 1.6 million hours of income tax assistance to over 1.6 
million taxpayers in 2000. The TCE volunteers prepared over 
458,000 federal income tax returns.
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 
tax-related topics. Conducted at various community locations, 
the seminars are tailored for groups and individuals with 
common tax interests, such as groups of older Americans.
    In 2000, over 2,900 volunteers provided tax information to 
over 1.4 million taxpayers in over 7,000 sessions through this 
program.
Small Business Tax Education Program (STEP)
    The STEP provides information about business taxes and the 
tax-related responsibilities of operating a small business. 
During 2000, small business owners and other self-employed 
persons had an opportunity to learn 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 retired individuals participate in this program.
Banks, Post Offices and Library (BPOL) Program
    During 2000, the BPOL program provided approximately 36,900 
locations with free tax preparation materials such as tax forms 
and publications to assist in preparing 1999 Federal Income Tax 
Returns. In some areas, the IRS recruited volunteers who worked 
at libraries answering tax questions and directing taxpayers to 
the appropriate tax forms.

                      financial management service

    In Fiscal Year 2000, the Financial Management Service (FMS) 
issues more than 892 million payments, including Social 
Security, Supplemental Security Income, and Veterans benefits. 
Working under the mandate of the Debt Collection Improvement 
Act, signed by President Clinton on April 26, 1996, Federal 
Departments and agencies are on the fast track to convert 
Federal payments to electronic funds transfer (EFT). The law 
required most payments to be made electronically by January 2, 
1999, but also gave the Secretary of the Treasury broad 
authority to grant waivers. EFT significantly improves the 
certainty of 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 are 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 thirty times more likely to 
have a problem with a paper check than with an EFT transaction, 
and in FY2000 Treasury received more than 1.4 million inquiries 
from recipients regarding checks not received. 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, if misrouted, the payments are 
typically routed to the correct bank account within 24 hours.
    During the past four years, Treasury has overseen 
government-wide implementation of the Debt Collection 
Improvement Act of 1996, working with Federal agencies to 
identify and resolve the major issues confronting stakeholders. 
Federal agencies have made significant progress to convert 
payments made electronically, has increased from 53 percent in 
Fiscal Year 1996 to 70 percent in Fiscal Year 2000. More than 
77 percent of Social Security payments were made 
electronically, an increase or more than 16 percentage points 
since Fiscal Year 1996. Other Federal benefit agencies show 
similar increases in EFT payments. Approximately 14.6 million 
benefit checks are still issued on a monthly basis.
    Federal payment recipients who elect to receive their 
payments via Direct Deposit enjoy the benefits of this simple, 
safe, and secure payment mechanism. Recipients who have not 
signed up for Direct Deposit do have choices, as described in 
31 CFR 208. Federal check recipients receiving salary, wage, 
benefit, or retirement payments can choose to: (1) receive 
payment via Direct Deposit through a financial institution, (2) 
open a low-cost Electronic Transfer Account (ETASM) 
at a participating Federally insured financial institution, or, 
(3) continue to receive a paper check, if receiving payment by 
Direct Deposit would cause the recipient a hardship.
    In 1999 Treasury developed ETA SM, a basic, low-
cost account which is available to individuals who receive 
Federal benefit, wage, salary, or retirement payments. Over 600 
Federally insured financial institutions at over 9500 branch 
locations nationwide, offer the ETA SM on a 
voluntary basis, subject to published standards and terms set 
forth in an agreement between Treasury and the financial 
institution. These low-cost accounts are designed to meet the 
statutory mandate that recipients have access to an account at 
a reasonable cost and with consumer protections, comparable to 
other accounts at the same financial institution. Anyone who 
receives a Federal benefit, wage, salary, or retirement payment 
is eligible to open an ETA SM, even if they have 
been unable to qualify for a checking or savings account in the 
past. The ETA SM cost $3.00 a month or less, and 
requires no minimum balance to open or maintain the account, 
except as required by law.
    FMS and Treasury have been conducting a massive public 
education campaign on both a national and regional basis. 
Seeking the involvement of national, regional, and local 
consumer and community-based organizations, financial trade 
associations, and Federal regulatory agencies to distribute 
materials and conduct ``in touch'' programs with Federal 
recipients to educate them about their choices under the law. 
The campaign has produced Public Service Announcements for 
television and radio; print ads; and posters, brochures, and 
other educational materials.
    FMS continues to support the implementation of a nationwide 
program to make Electronic Benefits Transfer (EBT) a viable 
electronic payment option. EBT is an electronic benefit 
delivery mechanism that enables recipients to use plastic cards 
to access their benefits at automated teller machines and 
point-of-sale terminals. Forty-one states have some type of EBT 
program which provides electronic access to their benefits; 
thirty-six of these states and the District of Columbia are 
full-fledged, statewide programs, and others are either in the 
pilot phases, expanding statewide, or in the process of being 
awarded to providers. In 1996, FMS partnered with the Southern 
Alliance of States SAS, to deliver Federal and State benefits 
through EBT to recipients in an eight-state area. In the SAS, 
recipients of Federal and State benefits can access their 
benefits using the same EBT card. All 50 States are required by 
statute to operate statewide EBT systems for food stamps by 
October 2002.
    Information on EFT '99 is available on the FMS Web site 
(www.treas.gov/eft), describing FMS products and services. 
Information available includes recent FMS activities related to 
EFT '99, publication, statistics, and contact information. The 
EFT web site includes topics on General Information, 
Regulations and Policy, Agency Assistance, News and Media, 
Education and Marketing, Vendor Information, and the ETA 
SM.
The Check Forgery Insurance Fund
    The Check Forgery Insurance Fund (CFIF) legislation was 
enacted into law on April 26, 1996 as part of the Debt 
Collection Improvement Act of 1996. The CFIC is a revolving 
fund established to settle payee claims of non-receipt where 
the original Treasury check has been fraudulently negotiated. 
FMS uses the Fund to promptly issue replacement checks to 
innocent payees.
    Check forgery is a concern of FMS and individuals who 
receive paper check payments, and FMS continues to address this 
concern. On March 26, 1998, FMS enhanced various Treasury 
Systems, utilizing the CFIC, to comply with the legislation and 
modify both internal and external operational and system 
procedures required to process check forgery claims in a more 
timely manner. Reinstitution of the CFIF relieves the burden 
for recipients of forged checks, especially the elderly.
    Although EFT payment has substantial benefits, some 
recipients of Federal payments prefer paper checks. Many 
elderly continue to receive payments by check; however, this 
increases the probability of forgery. Many of those harmed by 
forgery are elderly, low-income, unbanked, and dependent on the 
monthly payment for their basic subsistence. The CFIF allows 
for immediate relief to the elderly and other payees after FMS 
has substantiated the claim of forgery.
    CFIF relieves Federal Program Agencies (FPAs) of the 
responsibility for issuing replacement checks out of their 
appropriations on forgery claims. Typically, the FPAs would not 
issue a replacement check on a forgery claim until after FMS 
had recovered the forged amount from the financial institution 
(FI) and credited the agency with the check amount. The FI has 
60 days to respond to FMS' request for refund. The CFIF 
provides for expeditious processing of these cases and does not 
make issuance of the replacement check contingent on recovery 
of the forged amount.
Debt Collection Improvement Act
    The Debt Collection Improvement Act of 1996 and the 
Taxpayer Relief Act of 1997 authorize the collection of 
delinquent debt through administrative offset and levy of 
Federal payments, including Social Security benefits. Over the 
last several years, FMS has coordinated with the Internal 
Revenue Service and the Social Security Administration to 
collect $372 million annually in delinquent debt potentially 
available through levy and offset of benefit payments. FMS and 
SSA recently have agreed to begin phased-in implementation of 
benefit payment offset in March 2001 and continuous tax levy in 
October 2001. Implementation will begin with the offset of 
Cycle EFT payments. The offset of Cycle Check payments and 
Third of the Month EFT and Check payments will be phased in 
following the Cycle EFT payments implementation. Supplemental 
Security Income payments are exempt from offset, as required by 
law. Old-Age Survivors and Disability Insurance benefit 
payments are offset internally by SSA.
    In a preliminary FMS test in February 1998, a comparison of 
SSA benefits payees and the FMS Debtor Database found 35,670 
matches, implying more than 400,000 annual benefit offset 
payments. Annual government collections from these offsets are 
estimated at $36 million to $61 million. The amount of the 
offset of the Social Security benefit payment will be the 
lesser of (1) the amount of the debt, or (2) an amount equal to 
15 percent of the monthly benefit payment, or (3) the amount, 
if any, by which the monthly benefit payment exceeds $750. 
Fifteen percent is the maximum amount that will be offset from 
an individual's benefit payment.
    FMS will provide the debtor with a notice of the intent to 
offset and an opportunity to review the basis for the debt 
twice in writing, at both 60 days and 30 days prior to the 
anticipated offset. The warning letters will include the name 
of the agency that originated the debt and the name of a 
contact within that agency to answer questions regarding the 
delinquent debt. FMS will also send the debtor an offset notice 
that includes the amount and date of the offset, as well as the 
information in the previous notices, to coincide with the 
timing of the pre-scheduled payment. The offset remains legal 
even if the debtor does not receive the notices.
    In the case of payment levies to collect delinquent tax 
debt, IRS will send each tax debtor a notice that includes the 
tax bill, a statement of the intent to levy, an explanation of 
an individual's appeal rights, and an IRS telephone number for 
inquiries and assistance. The notice, which will be sent by 
certified mail to the taxpayer's last know address, will also 
inform the debtor that if repayment arrangements are made 
within 30 days, the levy will not occur. Also, IRS will send 
tax debtors who receive Social Security benefit payments an 
additional notice of intent to levy. At the time of the levy, 
FMS will send a notice to the debtor explaining the reason for 
the reduced payment and giving a contact at IRS who will answer 
questions regarding the tax debt. At any time during this 
process, either prior to or after the levy process begins, a 
debtor may make repayment arrangements with IRS, which will 
then release the levy.

                       BUREAU OF THE PUBLIC DEBT

    Public Debt continues to improve its programs to better 
serve all investors, including older Americans. The Bureau is 
particularly committed to providing its retail marketable 
securities and savings bonds customers and expanding number of 
services over the Internet or through automated telephone 
services. These services, in many cases, allow Public Debt 
customers to conduct investment activities from their homes, a 
benefit for many older investors.
            Marketable securities
    Treasury securities are popular with older Americans; they 
are safe, secure investments and provide interest income. 
Through TreasuryDirect, an electronic securities system 
provided by Public Debt, investors can purchase Treasury bills, 
notes and bonds and hold them in an account directly with the 
U.S. Treasury. Sixty-seven percent of TreasuryDirect investors 
are 65 or older.

Toll-Free Access to Account Services

    In 2000, Public Debt completed the consolidation of 37 
TreasuryDirect offices into three. The three consolidated 
offices include modern customer contact centers offering a 
full-range of services to customers. By using one toll-free 
telephone number (1-800-722-2678), TreasuryDirect investors can 
access electronic account services, order forms, listen to 
auction information, or reach a customer service 
representative. The offices also process a wide variety of 
transaction requests received through the mail. Voice menus 
were recorded with older investors in mind and contact center 
employees received special training on how to meet the needs of 
older investors.

Electronic Services Expanded

    Public Debt continues to expand TreasuryDirect electronic 
services so investors can conduct their business from home. 
Today more than half of TreasuryDirect customers use either our 
Internet or automated telephone services. Pay Direct allows 
existing customers to pay for their securities by authorizing 
Treasury to debit their bank account on the day the security is 
issued. Reinvest Direct allows customers to reinvest maturing 
securities by phone or Internet 24 hours a day, 365 days a 
year.
    Sell Direct allows customers to authorize Public Debt to 
sell their securities rather than first having to transfer them 
to a bank or brokerage firm. Buy Direct gives current 
TreasuryDirect customers an easy way to purchase securities 
through the Internet or automatically by telephone. Recently 
investors were given new options of checking or changing 
addresses and phone numbers via the Internet. And now forms can 
be completed online, making it convenient for investors to 
complete a transaction.

SmartExchange from Definitive to Book-Entry

    Public Debt continues to encourage investors holding 
registered and bearer security certificates to convert them to 
book-entry. Book-entry provides safer and more reliable 
electronic payments and eliminates the need for investors to 
safeguard physical certificates.

New Survey to be Conducted

    As part of an ongoing effort to stay in touch with our 
customers. Public Debt will conduct a new TreasuryDirect survey 
in 2001 to gather consumer information. This will help Public 
Debt identify ways to better serve customers by understanding 
their needs and preferences. It will also provide a profile 
update of investors, now predominantly 65 or older.
            Savings Securities
    U.S. Savings  Bonds  have been  sold since  1935 and  today 
55 million investors hold them. Many older Americans purchase 
bonds for themselves, as well as for gifts. Through its web 
site (www.publicdebt.treas.gov), Public Debt continues to make 
it easier for investors to buy bonds; calculate their value; 
download forms to complete for lost, stolen or destroyed bonds; 
and access a wide variety of bond information.

Savings Bonds Direct

    Savings Bonds Direct, introduced in November 1999, allows 
investors to buy savings bonds over the Internet directly from 
Treasury. Bonds can be purchased by credit card 24 hours a day, 
7 days a week from the convenience of an investor's home. Based 
on customer feedback, a large number of bonds sold online are 
gifts purchased by older Americans for their grandchildren.

Home Banking

    Today more than 460 banks and credit unions sell savings 
bonds from their home banking web sites 350 more financial 
institutions than in 1999. Now more older investors can 
purchase savings bonds from home using the same ``electronic 
connection'' that they use for other banking business. This 
benefits customers who have trouble getting out of the house. 
Public Debt continues to work with banks, credit unions, and 
software companies to expand the availability of this 
convenient electronic service.

Online Savings Bond Calculator

    Public Debt's web site has added a calculator allowing 
customers to price their bonds online. The calculator prices 
bonds and provides additional information such as current 
interest rate, next accrual date, and final maturity date. The 
calculator also reminds investors to cash in their matured 
bonds. Customers can also calculate year-to-date interest 
earned on their bonds for tax purposed. Past redemption values, 
back to 1996, are also accessible to assist in tax and estate 
valuations. The online calculator accommodates most operating 
systems and a variety of web browsers, including WEB TV. 
Customers can price their bonds and save the page to reload at 
a later date to update their bond values.

Inflation-Indexed Savings Bonds

    In September 1998, Public Debt introduced the Series I, 
inflation-indexed savings bond. I Bonds offer small investors a 
vehicle that preserves the purchasing power of their savings 
with a fixed real rate of return over and above inflation. This 
purchasing power protection is attractive for many investors, 
including those on fixed incomes.

EasySaver

    Public Debt has conducted a concentrated marketing effort 
over the past year to let investors, especially retirees, know 
about the EasySaver Plan for purchasing savings bonds. Now 
investors, particularly the retired and those without access to 
payroll savings plans, can buy bonds automatically for 
themselves and their families. All the customer needs to do is 
complete an order form authorizing Treasury to charge their 
bank account for the price of the bond and choose the date(s) 
to charge their account for savings bond purchases. Bonds are 
then delivered by mail.

Matured Unredeemed Banks

    Public Debt has been working to increase investor awareness 
of savings bonds that are no longer earning interest. Up-to-
date information about these bonds is on the Public Debt web 
site and millions of inserts have been sent out with tax 
refunds and bond mailings. In addition to a public service 
advertising campaign released in May 2000, numerous articles 
have appeared in newsletters, newspapers, magazines, and on web 
sites. The Savings Bond Wizard and Savings Bond Calculator, 
available on the Public Debt web site, identify matured bonds. 
Public Debt tries to locate owners of matured bonds to let them 
know their bonds are no longer earning interest. Since most of 
these bonds are at least 30-40 years old, many owners are 
senior citizens.

Forms Available Online

    Savings bond customers can order most forms directly from 
Public Debt's web site, eliminating the need to call or write 
to request them. Addditional downloadable forms were added in 
2000 to bypass the request process. Customers can download some 
of our more popular forms, print them, and then complete and 
mail them. Several forms can now be filled-in online, 
eliminating the need to manually write in the necessary 
information.
            Cross-Cutting Initiatives
    The following initiatives cut across programs and affect 
the way Public Debt does business.

New Retail Customer Service System

    In 2000 Public Debt launched a long-term effort to develop 
a single system to support retail customers. This system will 
allow holders of Treasury securities, from savings bonds to 
direct-access marketables, to more conveniently access a wide 
range of information and services through a single consolidated 
Internet interface. It will be a collection of processes 
composed of new components and legacy applications that will be 
knit together with a variety of information technologies and 
through a series of progressive releases. Over time, back-end 
systems will be reengineered to support new Treasury securities 
offerings. The single retail system will greatly extend the 
Bureau's commitment to high-quality customer service to all 
investors, including older Americans, who will be able to do 
all their investment business with the Bureau from one web 
site.

Outreach

    Through direct participation in a variety of public events, 
including Securities and Exchange Commission Investor Town 
Meetings, AARP conventions, and other investor education 
forums, Public Debt provides information, answers questions, 
and solicits feedback from current and potential investors.

Web Site Meets Accessibility Standards

    In April 1999, Public Debt certified that all of the pages 
on its web site met accessibility standards established by the 
Center for Applied Special Technology (CAST). The purpose of 
these accessibility standards--called ``Bobby'' standards--is 
to ensure that persons with disabilities, such as blindness and 
deafness, can use the worldwide web. For instance, because 
Public Debt complies with Bobby, a blind person can come to the 
Bureau's web site and listen to a word-for-word reading of the 
site's pages; this reading includes a verbal description of all 
graphics. These features, in addition to assisting those with 
disabilities, also benefit many older Americans who, for 
example, may have hearing loss.

Public Debt Web Sites to Visit

    www.publicdebt.treas.gov to learn about Treasury 
securities, Treasury auctions, what the current public debt is 
and much more. www.treasurydirect.gov to read about 
TreasuryDirect, which allows investors to buy, hold, reinvest, 
and sell marketable Treasury securities. www.savingsbonds.gov 
to find out the various ways to buy savings bonds and their 
attractive investment features. www.easysaver.gov to learn 
about EasySaver, an easy way to buy savings bonds on a 
recurring schedule.

                             SECRET SERVICE

            Advanced Fee Fraud Schemes
    Advanced fee fraud schemes are very creative and innovative 
cons in which victims are enticed into believing that they have 
been ``singled out'' to share in a multi-million dollar 
windfall profit. The most prevalent type involves an 
unsolicited letter, fax, or e-mail to a business or individual 
from a Nigerian criminal claiming to be a senior official from 
the Nigerian government. These communications request the 
recipient's assistance in transferring tens of millions of 
dollars out of Nigeria, in exchange for a commission of ten to 
thirty percent.
    Such fraudulent schemes result in reported financial losses 
of tens of millions of dollars annually. The true losses are 
much higher because many victims fail to report their losses 
dues to embarrassment or fear. The elderly population is 
especially susceptible. The Secret Service has received 
numerous reports from elderly individuals who have lost their 
life savings to such fraudulent schemes. In conjunction with 
the Departments of State and Commerce, the Secret Service has 
contacted organizations that are associated with the principal 
targets of this scam, namely small businesses and the elderly. 
The Better Business Bureau, the American Bankers Association, 
and AARP have assisted the Secret Service in publishing 
materials designed to educate the public about these schemes, 
with the goal of preventing further victimization.
    The Secret Service public education effort also includes a 
public awareness advisory that is posted on the Secret Service 
homepage (www.ustreas.gov/usss). This advisory provides 
detailed explanations of the more common advance fee fraud 
schemes, gives advice to those who have received solicitations, 
and lists contact information for the Secret Service Financial 
Crimes Division. The site also allows users to send an e-mail 
directly to the Secret Service Nigerian Crime Coordinator.
    Although the Internet is a very effective tool for 
disseminating information, the Secret Service recognizes it 
does not yet reach all segments of the population. Therefore, 
the Secret Service also uses the more traditional mediums of 
print and television journalism. From July 1, 1999 through June 
30, 2000, a number of media reports features Secret Service 
Financial Crimes Division representatives in an effort to 
encourage the general public to protect themselves from 
financial crimes, including advance fee fraud. These media 
reports included thirteen articles in ten major newspapers and 
newsmagazines, and ten television interviews which aired on 
national news for ABC, CBS, NBC, CNN, as well as local 
affiliates. The Secret Service is committed to the fight 
against advance fee fraud, and will continue with these public 
education initiatives.
            Identity Theft
    In today's economy, Social Security numbers, in conjunction 
with other personal identifiers, are used to grant credit and 
open bank and investment accounts. Government agencies request 
Social Security numbers on applications for licenses, permits, 
and benefits, and most health care providers require them for 
the maintenance of medical records. Because of this increased 
availability of personal information, even relatively 
unsophisticated criminals can perpetrate the crime of identity 
theft with minimal effort.
    As a result, identify theft affects more people each year. 
It is the responsibility of government regulators, law 
enforcement agencies, financial institutions, and other private 
sector entities to work together and reduce the risk that this 
information falls into the wrong hands. These groups must also 
work together to identify, investigate, and prosecute 
individuals who perpetrate identity theft schemes. The Secret 
Service has taken a lead role in this area, working with 
Congress to modify existing laws applicable to identity theft 
to increase the rights of victims and strengthen sentencing 
provisions. The Secret Service has also coordinated two 
national conferences addressing issues related to the 
investigation, prosecution, and prevention of identity theft.
    The Secret Service also actively participates in public 
education and awareness campaigns to instruct consumers on 
avoiding identity theft. The Secret Service has also worked 
closely with the Federal Trade Commission and the Department of 
Justice to develop educational materials designed to reach all 
consumers, including the elderly, and give them the information 
needed to protect them from being victimized.

                              U.S. CUSTOMS

    The Customs Service offers special treatment for the 
elderly, 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 another Customs port of 
entry. The supervisor can 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, facilitate the movement of the 
elderly and handicapped.
    The Customs Service also has a number of programs 
supporting Customs employees. For example, the Employee 
Assistance Program encourages elderly employees 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 fitness, CPR/first aid, 
stress management, conflict resolution, defense tactics, 
allergy and asthma inoculations, nutrition, and health 
screening. In addition, special seminars and video broadcasts 
are offered throughout Customs on elder care. Topics include 
long-term health care, legal issues, caregiver issues, and 
nursing homes, and are available for the elderly as well as 
younger employees who may have older relatives and friends. The 
Customs Service also offers retirement seminars several times 
each year to all employees who are eligible to retire within 
the next 5 years. These seminars cover retirement benefits, 
legal matters and financial planning.

                           UNITED STATES MINT

    The United States Mint continues to consider the needs and 
concerns of older Americans in its programs, activities, and 
operations.
            Golden Sacagawea Dollar
    Launched as the first coin of the new millennium, the 
Golden Sacagawea Dollar coin features a smooth, raised edge 
that is distinctive to the touch for the visually impaired.
            Mint Tours and Exhibits
    The staff of the public tours and exhibits areas of both 
the Philadelphia and Denver Mints recognize the special needs 
of older persons and persons with disabilities. The Mints 
provide special service such as wheelchairs, benches placed 
strategically along the tour route, and additional individual 
assistance as requested.
            Employee Training
    Mint staff participate in various workshops that provide 
knowledge and skills needed to assist, effectively interact 
with, and be sensitive and responsive to the diverse needs of 
the aged and persons with disabilities.
            Employee Assistance
    The Mint offers its employees a number of on-going services 
that address issues related to aging. The Mint provides 
employees with direct counseling, information, and referral 
services related to aging issues and caregiving for the 
elderly.

                    BUREAU OF ENGRAVING AND PRINTING

            Currency
    The National Academy of Sciences conducted a study on ways 
to assist the blind and visually impaired with currency 
transactions. Based upon the recommendations of that study, the 
Bureau of Engraving and Printing (BEP) redesigned the $10 and 
$5 Federal Reserve notes with several features to assist the 
elderly and visually impaired. The Federal Reserve introduced 
these notes into circulation on May 24, 2000.
    In addition to several counterfeit deterrent features, the 
notes contain a large high-contrast numeral on the back, lower 
right corner. The large high-contrast numeral is designed to 
assist the more than 23 million Americans, mostly elderly, with 
varying degrees of vision impairment.
    Based upon discussions with the American Council for the 
Blind, the BEP has also incorporated a machine-readable feature 
into the new $10 and $5 bills. This feature is intended to 
facilitate the development of convenient scanners for the blind 
and people with low vision. With the exception of the $1 bill, 
which has not been redesigned, the BEP has incorporated the 
machine-readable feature into all denominations of U.S currency 
($100, $50, $20, $10 and $5).

               OFFICE OF THE COMPTROLLER OF THE CURRENCY

    During 1999 and 2000 the Office of the Comptroller of the 
Currency (OCC) continued to enforce fair lending laws relating 
to age discrimination. OCC has also continued to emphasize 
evaluating the performance of national banks with respect to 
the Community Reinvestment Act (CRA). Created in 1998, a new 
OCC division has specifically focused on consumer compliance, 
the CRA, and fair lending. This division became fully 
operational in 1999, and now provides a direct link between 
policy makers and compliance examiners in the field, supporting 
the OCC's consistent enforcement of compliance laws.
    OCC examiners are alert to the potential for discrimination 
on the basis of age (as well as the other bases covered by ECOA 
and Reg. B) when conducting fair lending examinations. In 1999, 
the OCC found evidence of age discrimination during one fair 
lending exam and referred the case to the Department of Justice 
(DOJ) for action. DOJ ultimately returned the case to the OCC 
for administrative action. The OCC made no referrals based on 
age discrimination to DOJ in 2000. The addition of the case 
identified in 199 brings the total number of OCC cases 
involving age discrimination to ten since 1993.
    During 1999 and 2000, Comptroller John D. Hawke, Jr. met 
twenty times with representatives from national and community 
organizations, including representatives of organizations 
focused on issues affecting senior citizens. These outreach 
sessions were to share information about OCCpolicy and national 
bank examination practices with bank customer organizations, 
and to learn first-hand about the concerns these organizations 
had with the activities of national banks, as well as the OCC's 
supervision of the national banking system. Topics typically 
discussed included fair lending, community development, EFT 
'99, predatory loans, payday lending, and access to financial 
services for the ``unbanked,'' including elderly individuals, 
who do not have a relationship with a depository financial 
institution.
    The OCC's Customer Assistance Group (CAG) is responsible 
for reviewing and processing complaints made about national 
banks, including those complaints submitted by older Americans. 
During 1999, the CAG received 123,000 telephone contacts 
resulting in 79,00 new cases. In its continuing efforts to 
improve accessibility and quality, the CAG has developed an 
Internet site (www.occ.treas.gov/customer/htm) that can provide 
consumers information about the OCC and how to file a complaint 
about a national bank. The CAG maintains a toll-free national 
consumer hot-line (800-613-6743) that is staffed with trained 
professionals to assist consumers with questions about banking 
laws and issues related to complaints.

                      OFFICE OF THRIFT SUPERVISION

            Community Affairs Program
    During 1999 and 2000, OTS continued its Community Affairs 
Program. The primary mission of this program is to provide 
outreach and support to the thrift industry's efforts to meet 
its CRA obligations and to provide safe and sound loans, 
investments, and financial services for low- and moderate-
income individuals and communities, and other areas of greatest 
need. As such, OTS Community Affairs staff serve as a liaison 
between the thrift industry, consumer and community groups, 
government agencies and others on housing and community 
development issues and opportunities; and identify 
opportunities for thrifts to partner with others in helping to 
meet financial services needs in their communities. OTS 
Community Affairs staff interact with many groups representing 
low- and moderate-income individuals, including older persons.
    Community Affairs staff, along with senior management, 
participated in various forums with thrifts, community 
organizations and others across the country, including groups 
with particular emphasis on older persons. At these forums 
Community Affairs shared information on affordable housing, 
including affordable housing for seniors, financial services; 
and economic development needs, including the needs of aging 
population. Community Affairs also shared information on 
thrifts' authorities and abilities, and on opportunities for 
collaborative partnerships, to help meet these needs.
    Community Affairs staff serve on an Interagency Predatory 
Lending Task Force and Consumer Education/Outreach 
subcommittee. Many low- and moderate-income elderly homeowners 
are vulnerable to and victims of predatory lending practices. 
The subcommittee is developing an informational brochure for 
consumers on how to avoid becoming victims of predatory loans. 
This brochure will be available on-line for consumer and 
community groups to download for local distribution.

Other Community Affairs Initiative

    Community Affairs staff have been involved with a number of 
initiatives aimed at educating regulated financial institutions 
and their community partners about predatory lending, and ways 
that these entities can help consumers, including elderly 
homeowners, avoid predatory lenders.
    OTS's Community Liaison newsletter spotlights achievements 
in affordable housing and community development, many of which 
have benefited older Americans. The newsletter is distributed 
to all thrifts and to several hundred community and consumer 
organizations. In 1999 and 2000, the newsletter included 
articles on the attributes of Electronic Transfer Accounts 
(ETAs), affecting many older Americans who receive federal 
benefit or retirement payments, and an article on financial 
exploitation of elderly adults and ways that financial 
institutions can help prevent financial abuse of the elderly.
    OTS West Region staff has been involved in a number of 
forums to help educate financial institutions about financial 
abuse of the elderly and ways to help prevent such abuse.
    In 2001, OTS Community Affairs Program will partner with 
the Federal Reserve Bank of San Francisco and a community-based 
organization to create an educational video addressing the 
problem of financial abuse of elderly and dependent adults. 
Rollout of the video will be coupled with at least one local 
training session. This video should be available nationwide.
    OTS will host a thrift industry leadership conference for 
thrift CEOs and directors in April 2001. The conference will 
focus on strategic planning for the future and developing new 
market opportunities. One of the sessions will focus on 
maturing baby boomers, and ways that banks can better serve the 
housing credit and financial services needs of this group.
            Other Initiatives
    In July and August 1999, OTS Midwest Region senior 
management participated in seven forums in Houston, TX, 
sponsored by Representative Ken Bentsen, to educate the elderly 
about financial schemes and how to avoid fraud and abuse. Other 
participants included in the SEC, OCC, and representatives of 
state and local governments.
    OTS's Office of the Ombudsman has taken an active role in 
directing seniors to other resources that can provide 
assistance with a variety of consumer concerns. Some of the 
issues the Ombudsman deals with frequently are problems with 
Social Security benefits, income tax preparation and 
assistance, information about cashing Treasury obligations, 
Thrift Savings Plan Accounts, and accounts held at financial 
institutions. OTS also works with the state government 
Ombudsmen to refer consumers with concerns about assisted 
living and long-term care programs. The telephone number for 
the OTS Ombudsman is (202) 906-5685; more information is 
available at www.ots.treas.gov/ombudsman.html.
    For many years, OTS has maintained an active program for 
addressing complaints that consumers may have against the 
thrifts that OTS regulates. OTS provides a free nationwide 
consumer hotline (1-800-842-6929), a TDD line (1-800-917-2849), 
and an e-mail address ([email protected]). 
Professional staff is available to help people evaluate whether 
OTS regulations address their concerns. If the complaint falls 
outside of OTS's regulatory jurisdiction, OTS refers the 
consumer to other resources. Senior citizens are frequent users 
of this service.
    OTS also maintains a Customer Service Plan for consumer 
complaints and urges the institutions it regulates to give high 
priority to consumer relations. Of approximately 10,530 
complaints filed with OTS in 1999 and 2000, 17 complaints 
alleged credit discrimination based on age. OTS investigates 
each complaint in accordance with its expanded procedures for 
discrimination complaints, interviewing the complainant and 
reviewing the complainant's loan file. Thirteen of the 
complaints were reviewed and concluded without a finding of 
discrimination; four complaints are pending.

                       OFFICE OF PERSONNEL POLICY

    As part of its comprehensive family-friendly Employee 
Assistance Program, the Treasury Office of Personnel Policy 
supports and promotes an eldercare program. Eldercare programs 
provide information on resources available to Treasury 
employees who care for elderly parents, spouses, or other 
family members. To help relieve what can be a burden for 
employees, the program helps Treasury employees identify needed 
eldercare services (ranging from `daycare' for olders persons 
to specialized medical attention). This support demonstrates 
Treasury's commitment as a progressive and family-friendly 
employer. The Employee Assistance Program also reduces 
absenteeism and anxiety which employees may experience from 
caring for an elderly family member, thus enhancing their 
productivity and benefiting the Treasury Department.

                  ITEM 14--COMMISSION ON CIVIL RIGHTS

                              ----------                              

    During calendar years 1999 and 2000 the Commission 
continued to process complaints received from individuals 
alleging denials of thier civil rights. Specifically, in 1999, 
15 complaints alleging discrimination on the basis of age were 
received by the Commission and referred to the appropriate 
agency for resolution. In 2000, the Commission referred 22 
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 age 
65 and older are treated in U.S. hospital emergency rooms for 
injuries associated with products they live with and use every 
day. The death rate for older people is almost seven times that 
of the younger population for unintentional injuries involving 
consumer products. Consumer products used in and around the 
home are associated with almost 40 deaths per 100,000 persons 
65 and older, and over six deaths per 100,000 persons under 65.
Fires and burns in the home
    Burns from fires in the home are a significant source of 
injury to older Americans. In fact, adults age 65 and over are 
twice as likely to die in fires as all ages combined. CPSC has 
taken many actions to reduce the potential for fire-related 
injury and has set the reduction of deaths from fire-related 
causes as one of its five strategic goals for the period 1995-
2005.
    CPSC is coordinating a research project to assess current 
fire alarm technologies and identify potential improvements for 
future alarms. CPSC recommends that consumers install and 
maintain smoke alarms on every level of multi-story homes 
outside sleeping areas and inside bedrooms.
    Kitchen fires also cause injury and death to older 
consumers. To prevent cooking fires, CPSC is evaluating the 
feasibility of technologies to detect a pre-fire condition and 
shut the burner off before a fire occurs. CPSC urges consumers 
to protect themselves by keeping pot handles turned inward, and 
keeping cooking surfaces and surrounding areas free from 
clutter and grease build-up. Also, CPSC advises consumers to 
avoid wearing loose clothing with flowing sleeves while 
cooking.
    Older consumers are at greater risk of dying from fires 
involving upholstered furniture, mattresses, and bedding than 
the general population. CPSC is currently acting to address 
upholstered furniture and mattress and bedding flammability. 
CPSC has begun a rulemaking proceeding to establish 
flammability requirements for upholstered furniture. These 
requirements would address small open-flame ignition from 
sources such as lighters, matches, and candles.
    CPSC is also considering a petition to develop mandatory 
requirements to address open-flame ignition of mattresses and 
bedding. A CPSC safety standard addressing cigarette ignition 
of mattresses has led to a decline in deaths from this ignition 
source. Open-flame ignition is not addressed by the standard, 
and deaths from open-flame ignition remain high. Therefore, 
CPSC is considering taking additional steps to address open-
flame ignition.
    CPSC provides safety advice to consumers on steps they can 
take to prevent fire-related injury. First, CPSC cautions 
consumers who smoke never to smoke in bed, while drowsy, or 
while under the influence of medication or alcohol. Further, it 
advises consumers to use large, deep ashtrays for smoking 
debris and to let the contents cool before disposing of them. 
To help prevent burns while wearing nightwear, CPSC advises 
older consumers to look for nightwear that will resist flames, 
such as a heavy-weight fabric or tightly-woven fabrics like 
polyester, modacrylics, or woolen fabrics.
    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.
    CPSC provides safety information on its web site and 
distributes safety publications containing information on these 
and other hazards. The following are two of CPSC's popular 
publications for older consumers:
          Safety for Older Consumers--Home Safety Checklist, a 
        room-by-room checklist, identifying hazards and 
        recommending ways to avoid injury. In 1999-2000, CPSC 
        distributed 160,000 copies in English and Spanish.
          Fire Safety Checklist for Older Consumers, a booklet 
        developed in partnership with AARP (at that time the 
        American Association for Retired Persons) and the 
        National Association of State Fire Marshals. In 1999-
        2000, CPSC distributed over 60,000 copies in English 
        and Spanish.
Electrical wiring in older homes
    In 1994-95, CPSC conducted a study of electrical wiring 
fires in older homes, a subject of particular importance to 
senior citizens. 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. CPSC has 
distributed about 5,000 copies of the video to electrical 
safety inspectors, code officials, and others nationwide.
    CPSC launched the wiring safety campaign to help prevent 
the estimated 40,000 home electrical wiring fires each year. 
These fires claim 250 lives annually. CPSC is working with fire 
departments, electrical safety experts, and building code 
officials to encourage electrical reinspections and upgrades to 
home electrical wiring.
    The publication, CPSC Guide to Home Wiring Hazards, is 
available on CPSC's web site www.cpsc.gov and in hard copy. In 
1999-2000, CPSC distributed approximately 20,000 copies.
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. In fact, about 20 percent of 
prescription medicines ingested by children under age five 
belong to grandparents or other relatives. 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 900 
children under age five since 1974 (about 40 or more children 
saved annually). Net societal savings from this action are 
estimated at more than $160 million annually, due to prevented 
deaths. These savings are more than three times CPSC's 2000 
budget of $49 million.
    CPSC adopted a new regulation in 1995 to ensure that child-
resistant packaging is more ``adult-friendly.'' Many older 
consumers found it difficult to open CR packaging and did 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 changed 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 was effective for packaging marketed 
after January 1998. The change has encouraged 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.
    CPSC Chairman Ann Brown awarded commendations to two 
companies for safety innovations in child-resistant packaging 
that were especially useful for older consumers. Procter & 
Gamble received an award for taking the lead in 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.
Recalls of unsafe products
    One of CPSC's most important responsibilities is to recall 
unsafe products from the marketplace to prevent injuries and 
deaths. Each year CPSC recalls millions of unsafe products, 
many of them products that older consumers use in their daily 
lives. In 1999 and 2000, CPSC conducted recalls of several 
products commonly used by older consumers, including candles, 
ceiling light fixtures, in-wall heaters, tool battery packs, 
vacuum cleaners, power blowers, gas grills, and furnaces. 
Consumers should check to be sure they do not have these 
recalled products in their homes. Grandparents should also 
check to be sure they do not have recalled toys, children's 
products, or hazardous used cribs in their homes.
    CPSC is able to remove potentially hazardous products from 
store shelves quickly, but it is much more difficult to get 
them out of people's homes. Each spring CPSC conducts a 
``recall round-up'' to remind consumers to check their attics, 
basements, and storage areas for previously recalled products. 
Before making any purchases on web auction sites, at yard 
sales, or in thrift stores, consumers should check to be sure 
the products have not been recalled. Information on all 
products recalled by CPSC is available on its web site 
www.cpsc.gov.
Sports Safety for Seniors
    A recent CPSC study shows a 54 percent increase in the 
number of sports-related injuries suffered by persons 65 years 
of age and older between 1990 and 1996--from 34,400 to 53,000. 
The report shows that most of these increases in injuries to 
older persons are in connection with more active sports, such 
as bicycling, weight training, and skiing. In 1998, the CPSC 
and the American Academy of Orthopaedic (AAOS) Surgeons teamed 
up to help reverse this trend.
    In Keep Active and Safe at Any Age, a brochure developed 
jointly, CPSC and AAOS give older Americans important tips for 
remaining safe while enjoying the many benefits of exercise. 
Exercise is beneficial for most people of all ages, and 
Americans are remaining more physicallyactive into their 70s, 
80s, and 90s. Studies cited by the AAOS show that exercise can 
result in a longer, healthier life, while building stronger 
bones and reducing joint and muscle pain. Exercise improves 
mobility and balance, and reduces the risk of falls and serious 
injuries like hip fractures. However, many injuries can occur 
while people exercise.
    The CPSC/AAOS brochure strongly recommends the use of 
proper safety gear when exercising or participating in sports. 
Safety gear is the best way to reduce or eliminate injuries 
while exercising. For example, bicycling injuries to older 
Americans increased 75 percent from 1990 to 1996. Most 
bicycling injuries result from falls. Head injuries accounted 
for 21 percent of the injuries. Virtually none of the fall 
victims was wearing a bike helmet. The brochure recommends that 
bikers always wear a helmet. Injuries associated with exercise 
activity (aerobics, weight training, etc.) increased 173 
percent between 1990 and 1996. The most common types of 
injuries were falls and strains. The brochure recommends that 
persons using exercise equipment should read instructions 
carefully and, if needed, ask someone qualified to help.
    In April 2000, CPSC and AAOS turned their spotlight on 
sports-related injuries to ``baby boomers''--those ages 35-54, 
an age group that includes younger seniors. CPSC released a 
report showing that sports-related injuries to this age group 
increased about 33 percent from 1991 to 1998. Seven sports 
showed significant increasing trends in the number of emergency 
room-treated injuries to persons in this age group in 1998: 
bicycling, golf, soccer, basketball, exercise and running, 
weightlifting, and in-line skating. CPSC estimated there were a 
total of more than one million injuries to baby boomers in 
1998. CPSC and AAOS released a brochure entitled Boomeritis, 
which encouraged persons in this age group to exercise for 
health, but to use safety gear to prevent sports-related 
injuries.
    In 1999 and 2000, CPSC distributed almost 25,000 copies of 
Keep Active and Safe at Any Age. Copies of the brochure and 
both CPSC reports can be accessed at the CPSC web site at 
www.cpsc.gov. Boomeritis may be obtained from the American 
Academy of Orthopaedic Surgeons by calling 1-800-824-BONES 
(2663).
Grandchild Safety
    The role of grandparents ranges from occasional babysitting 
to primary caregiving. A recent U.S. Census Bureau study states 
that 1.3 million children are being raised by their 
grandparents, and 3.9 million children under 18 live in 
grandparent-headed households. In the years since grandparents 
were raising their own children, many safety issues have arisen 
or drastically changed.
    As more and more grandparents became caregivers for 
American children, it became clear there was a need to reach 
them with critical child development and safety information. In 
1997, CPSC Chairman Ann Brown and noted pediatrician T. Berry 
Brazelton, M.D., head of Pampers Parenting Institute, unveiled 
the booklet, A Grandparents' Guide for Family Nurturing & 
Safety. This easy-to-read booklet contains important child care 
and nurturing information for grandparents. It also features a 
safety checklist with potentially life-saving tips for 
childproofing homes and protecting grandchildren, from newborns 
to five-year-olds. This booklet is available on the CPSC web 
site at www.cpsc.gov in the publications section.
International Year of Older Persons 1999
    The United Nations (UN) General Assembly recognized 
``humanity's demographic coming of age'' by adopting 1999 as 
the International Year of Older Persons (IYOP). The UN 
encouraged countries, organizations and governments at all 
levels to observe the IYOP. In 1998, CPSC joined the federal 
committee to prepare for the International Year of Older 
Persons, which consisted of 12 cabinet agencies and 15 other 
federal agencies, commissions, and councils, working to support 
government preparations for the aging of society.
    The CPSC participated in both the media and conference 
subcommittees. CPSC developed a media sheet that summarized 
agency programs and activities supporting IYOP. At the official 
launch event on October 19, 1998, this media sheet was included 
in the federal committee's IYOP press kit. The media sheet, 
CPSC publications and technical reports were used in a number 
of CPSC exhibits/displays and other CPSC-supported programs 
around the country during the IYOP to help increase public 
awareness of the CPSC safety programs CPSC for older consumers. 
The CPSC also contributed to planning the federal committee's 
conference on June 1 and 2, 1999 and participated in panels on 
grandparent and home safety.
Safety Information of Interest to Older Consumers
    The following materials have been developed by CPSC and are 
available to the public on CPSC's web site www.cpsc.gov or by 
contacting CPSC as described below.
Home Safety:
    Safety for Older Consumers--Home Safety Checklist--This 
CPSC booklet gives tips on home safety in a room-by-room 
checklist format. Although geared for older consumers, it 
contains important information for people of all ages.
    Fire Safety Checklist for Older Consumers--Adults age 65 
and over are twice as likely to die in fires as all ages 
combined. CPSC, in partnership with AARP and the National 
Association of State Fire Marshals, offers this booklet of tips 
to help protect older Americans and their families from fires.
    CPSC Guide to Home Wiring Hazards--CPSC estimates that 
annually there are over 40,000 fires (with about 250 deaths) 
involving home electrical wiring systems. Many of these fires 
occur in homes of older consumers. CPSC offers this guide to 
help consumers find and correct electrical dangers in their 
homes before fires or electrical shock occurs.
Grandchild Safety:
    A Grandparents' Guide for Family Nurturing & Safety--The 
role of grandparents may range from occasional babysitting to 
primary caregiving. In this helpful booklet, CPSC Chairman Ann 
Brown and noted pediatrician T. Berry Brazelton, M.D., head of 
the Pampers Parenting Institute, offer advice to grandparents 
and a grandchild safety checklist (available on CPSC web site 
only).
Poison Prevention:
    Grandparents! Prevent Your Grandchildren from Being 
Poisoned safety alert. This one-page safety alert reminds 
grandparents to keep medicines away from grandchildren to 
prevent poisonings (available on CPSC web site only).
Sports Safety for Seniors:
    Sports-Related Injuries to Persons 65 Years of Age and 
Older and Keep Active and Safe at Any Age--A recent CPSC study 
shows a 54 percent increase in the number of sports-related 
injuries suffered by older Americans between 1990 and 1996--
from 34,400 to 53,000. In a companion brochure, CPSC and the 
American Academy of Orthopaedic Surgeons give older Americans 
important tips on remaining safe while enjoying the many 
benefits of exercise.
    Baby Boomer Sports Injuries--A CPSC report released in 
April 2000 showed that sports-related injuries to ``baby 
boomers'' aged 35-54 increased 33 percent from 1991 to 1998.
To order materials or contact CPSC:
    To order single, free copies of publications, send a 
postcard with the name of the desired publication to: 
Publication Request, OIPA, U.S. Consumer Product Safety 
Commission, Washington, DC 20207. Many publications are 
available on CPSC's web site www.cpsc.gov (search for ``Older 
Consumers''). These publications are in the public domain. They 
may be reproduced in part or in whole by an individual or 
organization without permission from CPSC.
    To obtain safety information or report dangerous products 
or product-related injuries in English or Spanish, check CPSC's 
web site or call CPSC's toll-free hotline at (800) 638-2772 or 
CPSC's teletypewriter  at (800) 638-8270  for  the  hearing  
and  speech impaired. Consumers can also report product hazards 
to [email protected].

               ITEM 16--CORPORATION FOR NATIONAL SERVICE

                              ----------                              

    The Corporation for National Service was established in 
1993 to engage Americans of all ages and backgrounds in 
community-based service. It supports a range of national and 
community service programs, providing opportunities for 
individuals to serve full or part-time, with or without 
stipends, as individuals or as part of a team. The Corporation 
works with Governor-appointed state commissions, nonprofits, 
faith-based groups, schools, and other civic organizations to 
provide opportunities for Americans of all ages to serve their 
communities.
    The Corporation's mission is to provide opportunities for 
Americans of all ages and backgrounds to engage in service that 
addresses the nation's educational, public safety, 
environmental, and other human needs to achieve direct and 
demonstrable results and to encourage all Americans to engage 
in such service. In doing so, the Corporation will foster civic 
responsibility, strengthen the ties that bind us together as a 
people, and provide educational opportunity for those who make 
a substantial commitment to service.
    The Corporation's three major service initiatives are the 
National Senior Service Corps, AmeriCorps, and Service-
Learning.

                 NATIONAL SENIOR SERVICE CORPS OVERVIEW

    THe National Senior Service Corps (Senior Corps) is a 
network of more than half a million seniors who are making a 
difference as Foster Grandparents, Senior Companions, and 
Retired and Senior Volunteer Program (RSVP) volunteers. These 
programs tap the experience, skills, talents, interests, and 
creativity of seniors age 55 and over. With more than thirty 
years of experience, the Senior Corps was a pioneer in 
developing volunteer opportunities for older adults. The Senior 
Corps continues to serve as a leader in testing and refining 
new models of senior service that will meet the needs of 
communities, as well as the interests and priorities of the 
older adults of today and tomorrow.
    The Senior Corps' three programs provide a wealth of 
volunteer opportunities to seniors while meeting an array of 
community needs.
           the Foster Grandparent Program (FGP), 
        established in 1965, links income eligible seniors ages 
        60 and older to children and youth with special and 
        exceptional needs.
           The Retired and Senior Volunteer Program 
        (RSVP), established in 1971, places senior volunteers 
        age 55 and older to perform a myriad of services, 
        including organizing neighborhood block watches, 
        identifying sources of groundwater contamination, 
        teaching computer classes, tutoring and mentoring 
        children and youth, and participating in natural 
        disaster recovery.
           The Senior Companion Program (SCP), 
        established in 1974, creates opportunities for income 
        eligible seniors age 60 and older to serve adults in 
        need of extra support to continue living independently 
        and with enhanced quality of life.
        Additionally, through its Senior Demonstration 
        Programs, Senior Corps tests and pilots innovations in 
        senior service, using the demonstration authority to 
        try elements and program models beyond the scope of its 
        three main programs. These demonstration activities 
        serve as ``incubators'' for innovation and new ideas, 
        with the intent of incorporating promising and 
        successful lessons into the three existing programs.
    In 1999, more than half a million Senior Corps volunteers 
contributed their time, skills, wisdom and experience to 
addressing unmet community needs, while emphasizing the impact 
on both the individuals and the communities served.

                          Table 1:--National Snapshot of the Senior Corps Programs \1\
----------------------------------------------------------------------------------------------------------------
                                                    Number of Local       Number of         Volunteer Hours of
                     Program                            Projects          Volunteers      Service to Communities
----------------------------------------------------------------------------------------------------------------
FGP..............................................                333             28,700               29 million
RSVP.............................................                764            485,000               78 million
SCP..............................................                207             14,700             12.5 million
                                                  --------------------------------------------------------------
      Totals.....................................              1,304            528,400           119.5 million
----------------------------------------------------------------------------------------------------------------
\1\ Source: 1999 Annual Project Profile of Volunteer Activities (PPVA), Corporation for National Service,
  National Senior Service Corps.


                                Table 2:--Senior Corps Programs in the Community
----------------------------------------------------------------------------------------------------------------
                                                                                          Number of Local Public
                                                    Number of Local    Number of Census   and Nonprofit Agencies
                     Program                            Projects       Districts Served     With Senior Corps
                                                                                                Volunteers
----------------------------------------------------------------------------------------------------------------
FGP..............................................                333                762                   10,300
RSVP.............................................                764              1,447                   67,500
SCP..............................................                207                567                    3,150
                                                  --------------------------------------------------------------
      Totals.....................................              1,304              2,776                   80,950
----------------------------------------------------------------------------------------------------------------

FUNDING FOR THE NATIONAL SENIOR SERVICE CORPS: A COST-EFFECTIVE FEDERAL 
                    INVESTMENT IN LOCAL COMMUNITIES

    The total Federal funding for National Senior Service Corps 
programs in fiscal year 2000 was $182,819,000, apportioned 
among each of the three programs as follows:

Table 3:--National Senior Service Corps fiscal year 2000 Federal Funding
                                   \2\
------------------------------------------------------------------------
                                                     fiscal year 2000
              Senior Corps Program                       Funding
------------------------------------------------------------------------
Foster Grandparent Program.....................            $95.8 million
Retired and Senior Volunteer Program (RSVP)....            $46.6 million
Senior Companion Program.......................            $39.7 million
      Total....................................          $182.1 million
------------------------------------------------------------------------
\2\ Source for fiscal data: FY2000 federal appropriation, Corporation
  for National Service, National Senior Service Corps.

    Senior Corps projects are locally sponsored and 
administered. Within the broad framework of its legislation, 
service activities grow out of agreements among the 
participants, funded projects, and the communities served. As a 
result, these activities reflect a mix of needs unique to each 
community.
    The community-driven focus is, in large part, a reason for 
the local non-Federal support enjoyed by Senior Corps programs.

                       Table 4:--Senior Corps Programs and Non-Federal Local Contributions
----------------------------------------------------------------------------------------------------------------
                                                                                            Non-Federal Local
                     Senior Corps Program                          Federal Investment          Contribution
----------------------------------------------------------------------------------------------------------------
Foster Grandparent Program....................................            $95.8 million              $37 million
Retired and Senior Volunteer Program (RSVP)...................            $46.6 million              $46 million
Senior Companion Program......................................            $39.7 million              $26 million
                                                               -------------------------------------------------
      Total...................................................           $182.1 million             $109 million
----------------------------------------------------------------------------------------------------------------

    Senior Corps programs allow local agencies to provide 
greater levels of service within their relatively small 
operating budgets and demands placed on them as community 
service providers. The monetary value of the volunteer services 
provided by Senior Corps volunteers exceeds one billion 
dollars.\3\
---------------------------------------------------------------------------
    \3\ Based on the 1999 Biannual Report, Giving and Volunteering in 
the United States, Independent Sector, which assigned a comparable 
value of $14.00 per hour to volunteer service.
---------------------------------------------------------------------------

                VOLUNTEER OPPORTUNITIES FOR OLDER ADULTS

    Twice as many older adults live in the United States today 
as 30 years ago and the number of persons over age 55 will 
double again by 2025. Three factors make older persons the 
nation's best increasing natural resource:
           Health--More than 80 percent of Americans 
        age 65 and over report no difficulties with activities 
        of daily living. Less than 5 percent are 
        institutionalized.
           Time--Americans are now spending a third of 
        their lives in retirement, freeing an average of more 
        than 20 hours a week to engage in additional 
        activities.
           Interest--According to the Independent 
        Sector, a Washington, D.C.-based organization that 
        studies American volunteerism, when persons 55 and 
        older are asked to volunteer, over 70 percent do.
    Service by seniors is changing the definition of 
satisfaction and success in post-retirement, and is 
increasingly regarded as an essential ingredient in productive 
aging. For example, in a 2.5 year follow-up of the MacArthur 
Successful Aging study, participation in volunteer activities 
was predictive of improved functioning in older adults, with 32 
percent lower risk of poor physical function in those so 
involved, independent of the effective of being physically 
active. There is preliminary evidence from the same study that 
the amount of time one is involved in formal volunteering 
activities is important in conferring health benefits, with 
greater time involvement predictive of the level of physical 
functioning 2 years later. Finally, there is evidence that 
organized and structured roles and behavior are among the best 
predictors of survival (Fried, Freedman, et. al, 1997). It 
follows, therefore, that public investment in volunteer service 
by seniors is not only prudent, but that it has multiple 
benefits.

                    FOSTER GRANDPARENT PROGRAM (FGP)

    In fiscal year 1999 nearly 29,700 Foster Grandparents gave 
care and attention to more than 230,000 children and youth with 
special and exceptional needs.

                            Program Overview

    The Foster Grandparent Program began in August 1965 as a 
national demonstration effort. Since its inception, the Foster 
Grandparent Program has provided young and old the chance to 
grow together. Today, nearly 30,000 older Americans serve as 
Foster Grandparents. They give care and attention every day to 
175,000 children and youth with special and exceptional needs, 
and served an annual total of more than 230,000 children. In 
improving the lives of children they serve, Foster Grandparents 
also profoundly enrich their own lives.
    Foster Grandparents volunteer in schools, hospitals, drug 
treatment centers, correctional institutions, and Head Start 
and day care centers. They offer emotional support to children 
who have been abused and neglected, mentor troubled teenagers 
and young mothers, care for premature infants and children with 
physical disabilities or severe illnesses, including AIDS. This 
special care helps young people grow, gain confidence, and 
become more productive citizens. In the process, Foster 
Grandparents strengthen communities by providing personalized 
services to special needs children that community budgets 
cannot afford and by building strong bridges across 
generations.
    Foster Grandparents must be at least 60 years of age and 
meet certain income eligibility requirements. They serve 20 
hours per week and receive pre-service orientation, training 
throughout their service, and a modest stipend to offset the 
cost of volunteering. They receive reimbursement for 
transportation, some meals during service, an annual physical, 
and accident and liability insurance while on duty.

            NATIONAL PROFILE OF FOSTER GRANDPARENT VOLUNTEERS
------------------------------------------------------------------------
                      Characteristics                        Percent (%)
------------------------------------------------------------------------
Distribution by Gender:
    Female.................................................   90 percent
    Male...................................................   10 percent
Distribution by Age:
    60-64 years............................................   15 percent
    65-74 years............................................   49 percent
    75-84 years............................................   30 percent
    85 and over............................................    5 percent
Distribution by Ethnicity:
    White..................................................   56 percent
    African American.......................................   38 percent
    Hispanic/Latino........................................    9 percent
    Asian/Pacific Islander.................................    1 percent
    American Indian/Alaskan Native.........................    3 percent
Population Served
    Urban..................................................   60 percent
    Rural..................................................   40 percent
------------------------------------------------------------------------

                  Foster Grandparent Project Examples

    Foster Grandparent Shirley Lewis of New Orleans, Louisiana 
worked for more than 25 years as a nurse's aide. As a Foster 
Grandparent, she serves at a group home for teenage girls in 
crisis. One of her first assignments was 16-year-old Cindy. 
Cindy was withdrawn, depressed, sullen, the child of drug-
dependent parents, and her only passion was a love for animals. 
Cindy was also a poor student, failing academically. With the 
patient tutoring and encouragement of her Foster Grandparent, 
Cindy was able to obtain her GED. ``Grandma Shirley'' 
encouraged her through the next few years, as she found work at 
the zoo, caring for animals. Two years later, Cindy attends 
Delgado College, working toward a degree as a veterinary 
technician. She remembers ``Grandma Shirley'' with love and 
fondness, as the ``real grandmother'' who loved her, believed 
in her, pushed her when she needed it, and took the time to 
understand and listen. It made all the difference.

                                  Iowa

              FGP of Rock Valley Rotary Club, Rock Valley

    A significant focus at River Valley School is preparing 
students to become active participants in society when they 
leave school. For many students, that means learning how to 
become a ``working'' member of society. The students are taught 
prevocational skills from how to stay on task, to how to 
complete a task correctly, to how to complete a take timely, 
etc. Foster Grandparents are assigned to assist these students 
with their prevocational tasks. Initially, many of River 
Valley's students need one-to-one supervision and training in 
order to complete the task assigned to them with a goal of 
being able to complete the vocational task independently. The 
22 Foster Grandparent served a total of 61 children in 1999.
    The goal of this program is to give the students real 
vocational experience so they will be prepared to enter the 
work force or be able to participate in a sheltered workshop 
environment.
    The types of prevocational skills in which students and 
Foster Grandparents are involved include:
           School laundry--gathering, sorting, washing, 
        etc.
           Juice--making, distributing, etc.
           Rug making--marking material, cutting 
        material, sewing material, looming, etc.
           Shredding recycled paper--gathering, 
        separating papers, folding papers, and operating the 
        shredding and clipping machines.
           School trash--collecting and disposing
           Recycling--gathering and disposing

                                 Maine

               PROP Foster Grandparent Program, Portland

    Eight Foster Grandparents served a total of 175 children in 
literacy-focused placements in 1999. During the school year, 
PROP FGP project conducted an evaluation of teachers 
supervising in-school FGP volunteer tutors. The goal was to 
assess the impact the FGP program was having on the children 
with whom Foster Grandparents were working and to determine how 
effective the Foster Grandparents were as in-school tutors.
    The findings confirmed that Foster Grandparents are an 
integral member of the school community providing support to 
children with special needs. A summary of the findings were:
           Overall, teachers reported that they 
        observed ``significant improvement'' in the assigned 
        children.
           When asked to score how much Foster 
        Grandparents contributed to this observed improvement, 
        teachers said that the volunteers contributed in a 
        meaningful manner.
           Foster Grandparents received high scores in 
        improving children's self-esteem, increasing enjoyment 
        from reading, and increasing self-confidence.

                                 Nevada

                 Elvirita Lewis Forum FGP, Reno/Sparks

    The Elvirita Lewis Forum (ELF) teamed up with the Foster 
Grandparent Program to have Foster Grandparents work with the 
children of families going through Family Drug Court. At 
present there are 9 volunteers working with 40 children who are 
placed in foster care while their parents serve out time for 
drug related convictions. The volunteers work with the children 
to help them maintain relationships with their parents, and 
help keep the child actively engaged during the parent(s) 
absence. Volunteers organize picnics and outings for the 
children, and when parents are allowed supervised visits with 
their children, volunteers help organize activities that both 
the children and parents can enjoy.
    In addition to working with the children, volunteers will 
work with the convicted parents, providing them with emotional 
support, advice on parenting, and at times educational 
training, such as helping them study and pass the GED test so 
they can be better educated.

                                 Oregon

                    Rogue Valley Manor FGP, Medford

    In the summer of 1999, the highest risk, economically 
depressed area of Medford was served by an innovative program 
this summer called ``Kids Unlimited''. The summer day camp 
delivered 8 weeks of activities, grouped into weekly themes 
called Grandma's Corner, Earth First Club, Reading Clubs, 
Mulit-Cultural Camps, The Creative Corner and Weird Science 
Club. Foster Grandparent, Joy Burns did such an outstanding 
job, she was nominated for and received the coveted Jackson 
County Community Service Award in recognition of her service to 
youth. Four Foster Grandparents, including Beneva McKinley, 
Gayle Varang and Nerribee Warner provided vital community 
service and made a difference in the lives of 150 at risk 
youth.

                              Pennsylvania

    Many of Pennsylvania's Foster Grandparents served as tutors 
and mentors in schools, working with students in small groups 
and one-to-one on such activities as literacy and learning 
skills. Ninety-four volunteers gave special attention to 948 
students, many of whom improved their reading levels and 
abilities as a direct result. Projects reporting significant 
impact include:

    FGP of Luzerne and Wyoming Counties, AAA of Luzerne and Wyoming 
                         Counties, Wilkes-Barre

    In the Hazleton Area School District, teachers reported 
that 95 percent of the students served by Foster Grandparents 
had received a passing grade in reading and math, while 100 
percent demonstrated improvement in their self-esteem and work 
habits. In the Wilkes-Barre Area School District, teachers 
reported that 22 percent of the students assisted had improved 
their grade in reading by at least one letter grade, while 82 
percent of the students received at least a passing grade in 
reading, an improvement of 20 percent. Meanwhile, 98 percent of 
the students demonstrated improvement in their self-esteem, and 
90 percent improved their work habits.

    FGP of Montgomery County, Family Services of Montgomery County, 
                               Norristown

    Sixty-nine percent of the students served improved their 
reading levels, 68 percent improved their verbal communication 
skills, 59 percent improved their math skills, 54 percent 
improved their written communication skills, and 59 percent 
demonstrated improved self esteem.

                               Wisconsin

Statewide FGP and the Central Wisconsin Center for the Developmentally 
                                Disabled

    The Central Wisconsin Center for the Developmentally 
Disabled is one of three facilities operated by the Wisconsin 
Department of Health and Family Services for Wisconsin 
residents with developmental disabilities. Currently 33 Foster 
Grandparents are working with 108 young residents to help them 
develop independent living skills so that they can work and/or 
live in a community setting. Foster Grandparents also accompany 
residents on community outings, take them to special functions 
and help staff during recreational activities. With the support 
of Foster Grandparents, three Central Wisconsin Center 
residents attained the necessary independent living skills to 
transition to a home in the community. After moving into the 
community, Foster Grandparents will often maintain their 
relationship with a resident through letters, phone calls and 
home visits.

                     SENIOR COMPANION PROGRAM (SCP)

    In fiscal year 1999 14,700 Senior Companion volunteers 
served 61,900 adults in need of additional support.

                            Program Overview

    The Senior Companion Program awarded funds to its first 
projects in August 1974. This program recruits low-income 
persons age 60 and over to provide assistance and friendship to 
frail adults, mostly the elderly who are homebound and living 
alone. The services Senior Companions provide help others to 
live independently in their own homes instead of moving to 
expensive institutional care. Senior Companions also provide 
respite care for short periods of time to relieve live-in 
caretakers.
    By assisting clients with simple chores, providing 
transportation to medical appointments, and offering needed 
contact to the outside world, Senior Companions often provide 
the supportive services that the frail need to continue to live 
independently. Because Senior Companions spend significant 
amounts of time with their clients, they are often a critical 
part of the client's care team. Senior Companions alert doctors 
and family members of potential health problems, allowing them 
to provide immediate care to the client.
    Senior Companions serve three to four clients in an average 
week, predominately in the clients' own homes. Community 
organizations that address health needs of the elderly such as 
home health care agencies, hospitals, or centers on aging serve 
as volunteer stations. These organizations identify individuals 
who need assistance and then work with Senior Companion 
projects to match them with available Senior Companions.
    Like Foster Grandparents, Senior Companions serve 20 hours 
per week. They also receive pre-service orientation, training 
throughout their service, and a modest stipend to offset the 
cost of volunteering. They are provided transportation, some 
meals during service, an annual physical, and accident and 
liability insurance while on duty.
    Compared with the average cost of nursing home care, which 
exceeds $38,000 annually, the annual cost for Senior Companion 
services is $3,850. This is a very cost-effective way to 
provide supportive services to an average of five frail adults 
per Senior Companion, who might otherwise be at risk for 
premature institutionalization.

             NATIONAL PROFILE OF SENIOR COMPANION VOLUNTEERS
------------------------------------------------------------------------
                      Characteristics                        Percent (%)
------------------------------------------------------------------------
Distribution by Gender:
    Female.................................................   85 percent
    Male...................................................   15 percent
Distribution by Age:
    60-64 years............................................   16 percent
    65-74 years............................................   51 percent
    75-84 years............................................   28 percent
    85 and over............................................    5 percent
Distribution by Ethnicity:
    White..................................................           60
    African American.......................................          333
    Hispanic/Latino........................................   11 percent
    Asian/Pacific Islander.................................    4 percent
    American Indian/Alaskan Native.........................    2 percent
Population Served
    Urban..................................................   63 percent
    Rural..................................................   37 percent
------------------------------------------------------------------------

                   Senior Companion Project Examples

    Mr. Ware is a diabetic amputee with failing vision, no 
family in the area, and who was increasingly depressed and 
withdrawn. His life was almost entirely isolated until Senior 
Companion ``Nate'' came along. Other than going to the doctor, 
Mr. Ware had not left his house in 8 months. Nate suggested a 
ride, and the two of them ended up driving through the area, 
taking the first steps in what would become a strong bond 
between two aging men: one who needed help and one who needed 
to be needed.
    Nate visits Mr. Ware fives days a week. Mr. Ware now gets 
out of wheelchair, does his own shopping, and goes to the 
barbershop with Nate. The two men are good friends, and Nate is 
like family. Mr. Ware's physical appearance and mental attitude 
changed vastly, much more like the proud man he once was.
    --Senior Citizens Services SCP, Georgia

                                Arkansas

  West Central Arkansas SCP, Hot Springs; Central Arkansas SCP, North 
              Little Rock Garland County SCP, Rock Garland

    These three Senior Companion projects mobilize 236 
volunteers who provide in-home care for 472 clients, helping 
delay or prevent institutionalization. They provide personal 
care, light housekeeping, meal preparation, transportation to 
medical appointments, shopping and banking, and provide respite 
and hospice care. Respite care is especially important for 
primary caregivers who are in a highly stressful situation. 
Nineteen Senior Companions were given special training in 
providing personal and respite care for both the client and the 
caregiver. In addition, four Leaders provide 340 home visits, 
and each client family received 3 telephone reassurance calls 
each week. Pre-and post-stress tests were given the primary 
caregiver and virtually100 percent showed lower stress levels 
thanks to the assistance of Senior Companions.

                                 Idaho

   Panhandle Health District Senior Companion Program, Coeur d'Alene

    Many elderly who require respite care are in jeopardy of 
institutionalization without help from the Senior Companion 
Program. Under this program, 80 Senior Companions provide 
respite care, companionship, and assistance with daily living 
activities such as meal preparation and light chores, to 240 
clients and caregivers. Companions also help clients maintain 
healthy eating and exercise plans, provide transportation, and 
locate resources for both clients and caregivers. As a result 
of Senior Companion volunteers, caregivers receive relief from 
the 24-hour care of a loved one, helping them maintain more 
balance in their own lives.

                                Kentucky

 Blue Grass Community Action Agency Senior Companion Program, Frankfort

    Prior to the start of its 1998 grant year, the Blue Grass 
CAA SCP project surveyed new clients for nutritional health to 
gauge their risk for involuntary weight gain/loss, poor eating 
habitats, reduced social contact, diabetes, high blood 
pressure, and other possible negative factors . After 12 hours 
of in-service training by local nutrition and health 
professionals, 15 Senior Companions administered a nutrition 
screening tool to 25 of their in-home clients who were most at 
nutritional risk based on the above mentioned factors. During a 
5-month period, each client received support from their Senior 
Companion, who taught them how to prepare and eat balanced 
meals, shop for healthy foods and exercise regularly. At the 
end of the 5 month period, the Senior Companions again 
administered the nutritional risk assessment tool to each 
client. Results included one-third of those who were at high 
risk for poor nutritional heath moved into the moderate risk 
category; and 16 percent moved into the good or low risk 
category.

                                Nebraska

  Lincoln Senior Companion Program Eastern Nebraska Senior Companion 
                             Program, Omaha

    Both Senior Companion Programs in Nebraska provide respite 
care a time away for caregivers. During one 3-month period in 
1999, the Lincoln program alone provided 24 Senior Companions 
to relieve 42 caregivers an average total of 147.5 hours a 
week. Most of the caregivers feel that without this support 
they would be unable to care for their family member at home. 
Since the cost of paid unskilled respite care is out of reach 
for many families, the Senior Companions literally stand 
between the client remaining at home and going to the nursing 
home.

              RETIRED AND SENIOR VOLUNTEER PROGRAM (RSVP)

    In fiscal year 1999, a total of 39,847 RSVP volunteers 
provided assistance and services to 264,495 children as 
follows:
           21,354 RSVP volunteers served as literacy 
        tutors to 119,821 children;
           7,917 RSVP volunteers served as mentors to 
        55,859 children;
           4,554 RSVP volunteers assisted 57,742 
        children through before and after school activities;
           2,853 RSVP volunteers worked with 19,220 
        children in child care programs;
           3,129 RSVP volunteers provided outreach to 
        ethnic groups with limited English proficiency; and
           Reached 43,840 parents through services to 
        their children.

                            Program Overview

    The Retired and Senior Volunteer Program (RSVP) was 
launched in 1971. RSVP matches the personal interests and 
skills of seniors age 55 and older with opportunities to help 
solve the problems in their communities and meet the needs of 
their fellow citizens. RSVP volunteers choose how and where 
they want to serve--from a few to over 40 hours a week in a 
wide range of community organizations such as hospitals, youth 
recreation centers, schools, and local police stations.
    RSVP volunteers provide hundreds of community services. 
They tutor at-risk youth, computerize information systems for 
community health organizations, get children immunized, teach 
parenting skills to teen parents, provide respite care for 
caregivers of Alzheimer's victims, establish neighborhood watch 
groups, plan community gardens, and a myriad of other community 
services. Through such efforts, RSVP is meeting community needs 
that strained local budgets cannot afford to address.
    In 1999, over 485,000 RSVP volunteers served through 764 
projects sponsored by local public and private nonprofit 
agencies. RSVP volunteers contributed approximately 85 million 
hours of service to their communities annually in approximately 
1,400 counties nationwide.

                   NATIONAL PROFILE OF RSVP VOLUNTEERS
------------------------------------------------------------------------
                      Characteristics                        Percent (%)
------------------------------------------------------------------------
Distribution by Gender:
    Female.................................................   75 percent
    Male...................................................   25 percent
Distribution by Age:
    55-59..................................................    4 percent
    60-64 years............................................   11 percent
    65-74 years............................................   38 percent
    75-84 years............................................   36 percent
85 and over................................................   10 percent
Distribution by Ethnicity:
    1White.................................................   89 percent
    African American.......................................    8 percent
    Hispanic/Latino........................................    4 percent
    Asian/Pacific Islander.................................    1 percent
    American Indian/Alaskan Native.........................    1 percent
Population Served
    Urban..................................................   54 percent
    Rural..................................................   46 percent
------------------------------------------------------------------------

                         RSVP Project Examples

    ``More than 40 RSVP volunteers spend time each week in our 
elementary schools helping children to improve their reading 
and comprehension skills. The volunteers meet with the children 
one-on-one. This project is credited with boosting student 
self-esteem, as well as improving overall reading success. It 
provides opportunities for positive interaction between older 
adults and children. The services provided by the RSVP 
volunteers are a valuable resource to the children in Unified 
School District #428.''
    With a teaching and nursing career, Sandy Smith has many 
commitments. She is a registered nurse and an instructor at 
Northwest Technical College in East Grand Forks. However, last 
winter, she heard about child literacy efforts and became an 
RSVP volunteer tutor. Ms. Smith admits that she is a ``non-
traditional'' RSVP recruit. She is not retired and 
significantly younger in age. According to Ms. Smith, RSVP 
helped to meet her volunteer goals of getting involved with a 
dedicated community project to help connect her to meaningful 
programs. ``RSVP is easy to work with,'' she notes. ``RSVP is 
also a great way to match interests with volunteers, in 
unlimited opportunities. My interest is reading and tutoring. 
Someone else may have a background in law enforcement, 
insurance, tax planning, or home economics. RSVP is a wonderful 
way to pursue those interests.

                                Indiana

                   RSVP of Daviess County, Washington

    Daviess County ranks 87th of 92 Indiana counties in family 
income, with 54 percent of households living on less than 
$25,000 annually. Many families are unable to afford 
immunizations for their pre-school children. The local health 
department now offers free immunizations and asked RSVP 
volunteers for assistance at the immunization clinics. Six RSVP 
volunteers register the children, check immunization records 
and act as receptionists, calling the children in order of 
registration. Last year, 3,600 children were immunized, many of 
them from local Amish and Hispanic communities that previously 
had low rates of immunization.

                               Louisiana

                   Calcasieu Parish Police Jury RSVP

    Louisiana's ``Shots for Tots'' Program set a goal of having 
90 percent of 2-year olds immunized by the year 2000. In April, 
five RSVP volunteers joined forces with local nurses to 
coordinate monthly clinics in various locations throughout the 
community in order to me more accessible to the public. RSVP 
volunteers ``meet and greet'' clients and record information on 
client immunization histories. To date, RSVP volunteers have 
assisted with nine clinics, providing immunizations to 145 
young children.

                                Montana

                   RSVP of Flathead County, Kalispell

    The RSVP of Flathead County, in collaboration with the 
Agency on Aging, local food banks, and disabled community 
organizations, put together a Senior Surplus Commodity Program. 
This initiative was in response to discovery that only 3 
percent of those using area food banks were seniors and that 
problems of transportation, access, and unwillingness to use 
the food banks even in times of need were major issues. 
Handicap accessibility is an issue at food banks as well. RSVP 
volunteers deliver commodities monthly to the homes of seniors 
and the disabled. The first month of operation saw 144 
deliveries and by the third month the RSVP volunteers were 
reaching 260 people in need.

                                 Oregon

                    Rogue Valley Manor FGP, Medford

    In the summer of 1999, the highest risk, economically 
depressed area of Medford was served by an innovative program 
this summer called ``Kids Unlimited''. The summer day camp 
delivered 8 weeks of activities, grouped into weekly themes 
called Grandma's Corner, Earth First Club, Reading Clubs, 
Mulit-Cultural Camps, The Creative Corner and Weird Science 
Club. Foster Grandparent, Joy Burns did such an outstanding 
job, she was nominated for and received the coveted Jackson 
County Community Service Award in recognition of her service to 
youth. Four Foster Grandparents, including Beneva McKinley, 
Gayle Varang and Nerribee Warner provided vital community 
service and made a difference in the lives of 150 at risk 
youth.

                                Vermont

                     Rutland/Addison, RSVP, Rutland

    Rutland/Addison RSVP, sponsored by Rutland Area Community 
Services, Inc. Rutland READs program. A collaboration between 
RSVP Volunteers, Volunteer Center Volunteers, A*VISTA and FGP, 
the program brings volunteer readers into K-grade 2 classrooms 
in Rutland County to read once a week for 6 weeks. Many 
volunteers continue to support the classes by acting as mentors 
to them for the duration of the school year. Other volunteer 
readers will be working with after school activities and in-
school enrollment programs. Volunteer readers go through 
specific training that provides reviews of books that are 
appropriate to be read to the age K-2. Rutland Reads program 
will bug a paperback book for each participating classroom, 
which have been donated by the Rutland Herald and the Rutland 
Rotary Club. This past year, 24 RSVP volunteers were involved 
with Rutland Reads and 457 students participated in group 
readings and thirty five students were individually tutored. A 
new program also began this year that brought older students to 
the schools to read to children during breakfast time for 
eligible students. One hundred and thirty students participated 
in this program.

                                Wyoming

                    Southeast Wyoming RSVP, Cheyenne

    The Cheyenne Community Solar Greenhouse was created due to 
the arid conditions of southeast Wyoming and the need for 
vegetation throughout the city. The staff of the Botanic 
Garden, where the greenhouse is located, provides education in 
horticulture and landscaping techniques for Cheyenne residents, 
including RSVP volunteers who serve at the Botanic Garden. The 
21 RSVP volunteers spent an average of 330 hours per month 
planting, cultivating and harvesting seedlings and vegetables. 
The efforts of the volunteers saved the city $9,230 in initial 
plant costs the city was able to use to meet other needs. The 
garden work saved food banks an average of $35 per person 
served, or a total of $3,850. This saving was then applied to 
meeting housing and medical needs. Three local food banks 
estimate they received 315 pounds of produce with community 
people gleaning what was left over.

                ITEM 17--ENVIRONMENTAL PROTECTION AGENCY

                              ----------                              

    No submission from the Environmental Protection Agency

    
    

               ITEM 19--FEDERAL COMMUNICATIONS COMMISSION

                              ----------                              


     Summary of 1999 and 2000 Activities Affecting Older Americans

    This report summarizes the significant activities in 1999-
2000 of the Federal Communications Commission (``FCC'' or ``the 
Commission'') affecting older Americans.
    The Commission continued to take actions to implement 
statutory requirements or Commission policies on behalf of the 
general public and all telecommunications consumers. These 
include the millions of Americans with some kind of hearing, 
vision, speech or other disability, many of whom are older 
Americans. Since many older and aging Americans may experience 
some loss in one or more sensory function, such as in hearing, 
speech or vision, they may benefit greatly from the various 
disability-specific, consumer protection actions undertaken by 
the Commission in 1999-2000.
Consumer Information Bureau (CIB)
    CIB is a new bureau created in 1999 to enhance the public's 
understanding of the Commission's programs. The new bureau 
represents a consolidation of functions that had been scattered 
across several other Commission units, including the 
Commission's Gettysburg National Call Center, the Public 
Service and Reference Operations Divisions of the former Office 
of Public Affairs, the informal complaint functions in the 
Wireless Telecommunications and Common Carrier Bureaus, and the 
various offices which previously handled public information 
requests throughout the Commission. The Commission created CIB 
based on the conviction that consumers, including senior 
citizens, can only benefit from increased competition and the 
resulting proliferation of new services and devices if they 
have information that is adequate to enable them to make 
informed choices on which a free market system depends.
    Outreach and Consumer Education.--CIB provided extensive 
outreach and consumer education in 1999-2000 on Commission 
programs and policies in a variety of ways. CIB hosted several 
major forums providing a unique opportunity for consumers, 
including older Americans, and industry to share best practices 
on a number of issues, including those concerning telephone 
billing and customer service. For example, in June 2000, CIB 
held a national forum on telephone company customer service. 
The forum was designed to provide feedback to telephone 
companies' top management on the effectiveness of their 
customer service centers, and to receive a commitment from 
these carriers to improve their customer service. Panelists at 
the forum included representatives from the senior citizen, 
Hispanic and disability communities, all of whom shared their 
customer service experiences and challenged local, long 
distance, and wireless telecommunications service providers to 
initiate efforts to better serve consumers.
    In addition, CIB in 1999-2000 made special efforts to 
convey the Commission's message beyond the ``beltway'' by 
addressing consumer, industry, and governmental audiences at 
over 40 conferences across the nation. One of these conferences 
was the national conference of the American Association of 
Retired Persons held in Florida. CIB took special care to make 
senior citizens aware of these fora and conferences by 
distributing written materials and contacting senior citizen 
organizations directly.
    Revised Fact Sheets.--CIB also undertook a project to 
consolidate and revise all of the Commission's nearly 200 
``Fact Sheets'' about various issues, practices and policies to 
make them more reader friendly. It also provided easy access to 
these documents through its Consumer Centers and on the 
Commission's website. CIB also broke new ground in initiating 
the translation of its documents into multiple languages to 
reach consumers, including seniors, from various cultures. In 
addition to its own initiatives, CIB provides technical and 
writing support to other FCC bureaus and offices in their 
efforts to expand consumer education about FCC regulatory 
programs.
    CIB is continuing to explore new ways to reach out to and 
meet the needs of all Americans. These include mechanisms that 
will help senior citizens realize the benefits of an 
increasingly competitive telecommunications marketplace.
Creation of Disabilities Rights Office (DRO)
    In 1999, the FCC created as part of the Consumer 
Information Bureau the Disabilities Rights Office (``DRO''). 
The DRO consolidates disability-related activities and policy 
matters previously spread among the various Bureaus and Offices 
of the FCC.
    The DRO works to protect consumers with disabilities, 
provides technical assistance to consumers and entities on 
their rights and responsibilities with regard to disability 
accessibility provisions in telecommunications law, and 
provides comprehensive policy analyses to ensure access to 
persons with disabilities.
    In the 1999-2000 period, the DRO provided service to 
consumers in all 50 states and the District of Columbia, Puerto 
Rico and the Virgin Islands. It also provided technical 
assistance to consumers in Australia, Canada, Denmark, Italy, 
the Netherlands, Nigeria, South Africa, Sweden, and the United 
Kingdom. In 2000, the first year the DRO maintained statistics, 
it processed nearly 1,200 inquiries and complaints on 
disability-related telecommunications matters.
    Disability Initiative: An Accessible FCC.--A key prong of 
the FCC's disability initiative is to ensure access to FCC 
documents and processes by people with disabilities and other 
functional limitations, such as individuals who are aging. 
Section 504 of the Rehabilitation Act of 1973 prohibits 
discrimination on the basis of disability in federally assisted 
programs and activities. It was amended in 1978 to extend its 
coverage to programs and activities conducted by federal 
executive agencies. The DRO led FCC compliance with Section 504 
which also benefits many older Americans seeking access to FCC 
services.
    Compliance with Section 504 in providing accessible 
information for consumers and employees requires that the 
Commission convert printed materials into accessible, 
alternative formats, and provide sign language interpretation 
of spoken or audio information.
    Accessible Documents.--During 2000, the Commission 
processed approximately 200 requests for accessible documents 
or sign language accessibility. These documents were provided 
in Braille format or put on audiocassette for either an 
employee of the agency or an interested customer of the FCC 
with a disability or sensory limitation. Older Americans made 
many of these requests. The kinds of documents made accessible 
included legal documents, such as releases of FCC reports and 
statutory rules and regulations, general FCC documents, such as 
public notices, announcements or statements, as well as 
specific consumer-oriented information documents, such as fact 
sheets and consumer guides.
    Other material made accessible included publicly available 
FCC documents such as employee orientation and training 
materials, the FCC phonebook, and correspondence to and from 
the Commission. Access was provided in alternate formats such 
as Braille, large print, audiocassette, electronic disk format 
and sign language interpretation. For example, the FCC 
reformatted the Commission's Part 97 Rules for Amateur Radio 
Services into Braille, ASCII text and large print for many 
individuals with vision disabilities. Sign language 
interpretation is more usually carried out by the Office of the 
Managing Director; however, DRO provides a specialized 
interpreter for ex parte meetings, and for small conferences 
and meetings where sign language interpretation requires 
extensive knowledge of the technical background of the subject 
under discussion.
    ``One-Stop Shop'' Access.--In 1999, the DRO aggregated 
disability-specific telecommunications information on a 
dedicated and accessible FCC web site at http://www.fcc.gov/
cib/dro that includes agency rules, recent actions, and 
consumer information. This web site is usable by people with 
vision disabilities who use adapted equipment and is designed 
to be consumer-friendly for any person, including older 
Americans. Examples of items on the DRO web site include DRO's 
release, in May 2000, of ``A Consumer's Guide to Relay 
Services'' and, in September 2000, of ``Consumer Tips on Filing 
a Section 255 Complaint.'' These materials translate legal 
documents into plain English and are more usable by individuals 
experiencing loss of hearing, speech and vision, common among 
older Americans.
    Additionally, to ensure broader access and to open up FCC 
processes to consumers with physical limitations, the DRO 
established an electronic listserve, DRO INFO, for the 
disability community and interested others. This provides free 
updates on any disability-related item at the FCC via routine 
electronic mailings. Similarly, the creation of a single E-mail 
address (access @fcc.gov) as a point of entry for inquiries 
also assists in providing a ``one-stop shop'' for access to FCC 
activities and events for people with disabilities and with 
other functional limitations resulting from aging.
    Rulemakings.--Rulemakings were a critical prong of the 
FCC's disability initiative in 1999-2000. Rules providing for 
disability access benefit individuals with hearing, speech, 
vision and other disabilities, and benefit many individuals 
with functional limitations as a result of aging. The 1999-2000 
rulemakings in which the DRO participated addressed 
requirements for consumers with hearing, vision, speech and 
other disabilities across communications modes such as 
telephony and television. Described below are the FCC's new 
rules and other actions adopted in 1999-2000 for: (1) 
telecommunications manufacturers and service providers for 
disability access, pursuant to Section 255 of the 
Communications Act, as amended by the Telecommunications Act of 
1996; (2) expansion of closed captioning into digital 
television; (3) video description of video programming; (4) 
emergency access for E911-TTY digital wireless connections; (5) 
emergency access to video programming; (6) telecommunications 
relay services that include new services such as Spanish Relay, 
Speech To Speech and Video Relay Services; and (7) new 711 
nationwide access. Other items described below include (8) 
carrier of choice; (9) hearing aid compatibility rules;`and 
(10) reports and a Notice of Inquiry on advanced 
telecommunications services that will facilitate access to 
electronic communications for older Americans.
    Rulemaking efforts involved FCC staff from multiple bureaus 
such as the Common Carrier Bureau and its Network Services 
Division, the Cable Services Bureau, the Wireless 
Telecommunications Bureau and staff from the Office of 
Engineering and Technology. Additionally, FCC rulemakings 
involve consultation with members from industry, the disability 
community and other communities, such as from organizations and 
individuals representing the needs of older Americans. Rules 
issued by the agency in this two-year period, 1999-2000, 
establish the United States as a world leader in ensuring 
access to telecommunications for people with disabilities, 
sensory limitations, and other problems of older Americans in 
the 2lst century.
    1. Section 255.--In August 1999, after an extended, 
proposed rulemaking period, the agency released final rules to 
implement Section 255 of the Communications Act of 1934, as 
amended by the Telecommunications Act of 1996. Section 255 
requires all manufacturers of telecommunications equipment and 
providers of telecommunications services to ensure that, if 
``readily achievable,'' telecommunications equipment and 
services must be designed, developed and fabricated to be 
accessible to, and usable by, individuals with disabilities. If 
it is not readily achievable to do this, telecommunications 
equipment manufacturers and service providers must make their 
equipment and services compatible with the equipment commonly 
used by individuals with disabilities. The rule included a 
Notice of Inquiry (NOI) to aid understanding of the access 
issues presented by communications services and equipment not 
covered by the rules adopted in the Order. The inquiry seeks 
input on aspects of communications technology that may present 
new accessibility issues, such as telephony that uses computer-
based equipment that replicates telecommunications 
functionality and any other innovations in telecommunications 
that may present accessibility challenges for people with 
sensory or physical limitations.
    As part of its implementation of Section 255, the FCC 
launched a new web page on the DRO web site, www.fcc.gov/cib/
dro, listing the disability contact persons at 
telecommunications manufacturing and services provider 
companies covered by the Section 255 rules. This listing makes 
for easy access to the industry by individuals with functional 
limitations who have inquiries and complaints about products 
and services. Additionally, to ensure greater understanding of 
the statutory provisions for access, the Commission held an in-
house enforcement training session in May 2000 for all FCC 
employees and has conducted training with its staff of Consumer 
Advocacy Mediation Specialists (consumer center 
representatives) on disability access and Section 255.
    The Report and Order on Section 255 ensures that most 
agency rulemakings and activities are reviewed for disability 
accessibility implications. For example, a June 2000 Public 
Forum on telephone customer service included as a panel topic 
the disability usability obligations under Section 255.
    2. Closed Captioning of Digital Television.--In July 1999, 
the Commission proposed standards for closed captioning on 
digital television so that people who use captioning due to 
their sensory limitations will be able to choose the color, 
font, size, and language of their captions. After comment and 
review, the Commission on July 21, 2000, issued Closed 
Captioning Requirements for Digital Television Receivers in a 
Report and Order on Video Programming Accessibility. In this 
action, the Commission amended its rules to require closed 
captioning display capability in digital television receivers. 
This will ensure that closed captioning services will continue 
to be available to consumers as the transition from analog to 
digital video progresses in the television industry.
    3. Video Description.--In September 1999, the Commission 
released a Notice of Proposed Rulemaking on Video Description. 
Video description refers to the narrated description of key 
visual elements in a television program, inserted at natural 
pauses in the dialogue of the program. It is designed to make a 
program more accessible to people with visual disabilities. 
``Closed'' video description is provided on the Second Audio 
Program (SAP) channel, which is a standard feature of stereo TV 
sets. Viewers can activate the channel at will in order to 
control whether they hear the main audio program without video 
description, or the SAP with video description.
    Video description is a service that benefits older 
Americans in particular. Estimates of the number of Americans 
with visual disabilities are as high as twelve million. Older 
Americans are disproportionately represented among this group. 
This is becausedeclining vision often accompanies the aging 
process. As more and more Americans live longer, and 
consequently the population ages, video description should also 
benefit increasingly older Americans.
    Public television stations have provided ``closed'' video 
description on the SAP channel for over a decade, but 
commercial television stations have not. In order to begin to 
bring the benefits of video description to the commercial video 
programming marketplace, the Commission adopted rules in July 
2000 to require the largest television broadcast stations and 
multichannel video programming distributors (MVPDs), such as 
cable television system operators and direct broadcast 
satellite operators, to provide a limited amount of video 
description. The FCC adopted these rules concurrent with the 
10th anniversary of the Americans with Disabilities 
Act(``ADA''). In response to petitions for reconsideration, the 
Commission clarified and refined these rules in January 2001.
    The video description rules require television broadcast 
stations affiliated with the four largest networks (i.e., ABC, 
CBS, Fox, and NBC) and licensed to communities in the 25 most 
populous television markets (i.e., Nielsen Media Research's 
``Designated Market Areas'') to provide 50 hours per calendar 
quarter of programming with video description. The rules also 
require MVPDs with 50,000 or more subscribers to provide the 
same amount of programming with video description on each of 
the five highest-rated national nonbroadcast networks they 
carry that also reach 50 percent or more of MVPD households. 
The affected television broadcast stations and MVPDs must 
provide the programming with video description during prime 
time or during children's programming. The new rules also 
require all television broadcast stations and MVPDs that have 
the technical capability to ``pass through'' video description 
they receive from their programming suppliers to, in fact, do 
so. The first calendar quarter these rules become effective is 
April-June 2002.
    The new rules also require all television broadcast 
stations and MVPDs that provide emergency information to make 
that information accessible to people with visual disabilities. 
The rules require that television broadcast stations and MVPDs 
that provide emergency information during a regularly scheduled 
newscast, or during a special news bulletin that interrupts 
regularly scheduled programming, make the critical details of 
that information accessible to people with visual disabilities. 
In addition, the rules require that television broadcast 
stations and MVPDs that provide emergency information as part 
of a crawl or scroll accompany that information with an aural 
tone to alert people with visual disabilities that they are 
providing such information.
    4. Emergency Access: E911 Digital Wireless.--To ensure 
compatibility with enhanced 911 emergency calling, on December 
11, 2000, the Commission adopted an Order to ensure that 
persons with hearing and speech disabilities using text 
telephone (TTY) devices will be able to make 911 emergency 
calls over digital wireless systems. Although the Commission 
had required covered carriers operating digital wireless 
systems to pass through TTY E911 calls in October 1997, 
carriers had been unable to comply because the Baudot-encoded 
audio tones produced by TTY devices were unable to pass through 
digital systems. (Such tones were successful in passing through 
many analog wireless networks.)
    In May 2000, the Commission issued a Public Notice setting 
an implementation deadline by which TTY access to digital 
wireless systems for 911 calls will be required. Based on 
technological advances related to TTY/digital compatibility, 
the Commission has now established June 30, 2002, as the 
deadline by which digital wireless service providers must be 
capable of transmitting 911 calls made using TTY devices. This 
Order includes a rule to monitor the development and 
implementation of this capability by carrier networks.
    5. Access to Emergency Video Programming.--In April 2000, 
the FCC increased accessibility of televised video programming 
to viewers with hearing disabilities. It did so by requiring 
programmers to make local emergency information accessible to 
persons with hearing disabilities when this information is 
provided through a regularly scheduled newscast, or during an 
unscheduled newscast that interrupts regularly scheduled 
programming. Emergency information is information about a 
current emergency and must include the critical details on 
issues affecting life, health, safety, or property, and how to 
respond to the emergency. This access can be provided through 
closed captioning, or by using another method of visual 
presentation, such as a text scroll or crawl. Examples of 
emergencies include events such as toxic gas spills, floods, 
civil unrest, hurricanes, school bus changes resulting from 
these events and similar emergency situations. In determining 
which particular details about the emergency need to be made 
accessible, programmers may rely on their own good faith 
judgments.
    6. Telecommunications Relay Services (TRS).--The FCC also 
undertook several actions in 1999-2000 to improve 
telecommunications relay services (TRS), a critical component 
of telephone service to the community of persons who are deaf, 
hard-of-hearing or with speech disabilities, many of whom are 
older Americans. Title IV of the ADA, codified at section 225 
of the Communications Act of 1934, requires the Commission to 
ensure that TRS is available, to the extent possible and in the 
most efficient manner, to individuals with hearing and speech 
disabilities in the United States. TRS is a telephone 
transmission service that provides the ability for an 
individual with a hearing or speech disability to engage in 
communication by wire or radio in a manner functionally 
equivalent to the experience of someone without such a 
disability.
    The FCC first adopted rules and policies to implement 
section 225 in 1991. These rules required common carriers to 
provide TRS in the areas they served beginning July 26, 1993. 
On March 6, 2000, the Commission released a Report and Order 
expanding the scope of relay services and creating new mandates 
for improved relay service quality.
    The March 2000 Order requires improved quality standards, 
provides for Speech-To-Speech (STS) relay, and a funding 
mechanism for video relay services (VRS). The March 2000 Order 
also included a Further Notice of Proposed Rulemaking to ensure 
that TRS keeps up with the Information Age. It asked for 
comments on: (1) the establishment of a national outreach and 
education campaign to increase awareness of relay services; (2) 
whether outreach efforts should be supported by the interstate 
TRS fund through establishment of guidelines for funding a 
coordinated national outreach and education campaign to be 
developed by the fund administrator; and (3) the extent to 
which new technologies should be mandated for TRS, including 
the extent to which providers should have access to SS7 
technology to better handle emergency calls, be compatible with 
Caller ID and more efficiently bill for and deliver relay 
services.
    The FCC also held a TRS Fair to demonstrate relay services 
equipment concurrent with the public meeting that adopted the 
revised relay services rules. To address some of the issues 
raised in the TRS NPRM, the DRO held an additional public forum 
on TRS in March 2000 to share information on new technology 
trends involved in relay services and outreach to underserved 
populations, including older Americans. Later, in June 2000, 
the FCC adopted an Order on Reconsideration on 
Telecommunications Relay Service and Speech-to-Speech Relay 
that clarified the effective dates for STS and VRS and the 
annual submission of complaint log summaries by states, in 
addition to other technical clarifications. On February 23, 
2001, the FCC released another Order further amending the 
implementation dates for the new TRS rules.
    7. TRS--711 Access.--In 1999, the agency held a public 
forum on how to implement 7-1-1 access for relay services 
nationwide during its review of a proceeding on the allocation 
of N11 numbers. 7-1-1 dialing permits 3-digit access to relay 
services, advantageous to relay services users with manual 
dexterity limitations, such as older Americans with arthritis 
or other fine motor disorders. In July 2000, after a period of 
comment on the technical feasibility of using this type of 
dialing, the Commission issued a Report and Order on 
Implementation of Nationwide 711 Access to TRS. This new 
dialing arrangement will supplement existing systems in most 
states that require 7- or 10-digit numbers in order to initiate 
relay calls. 711 nationwide access, affecting wireline, 
wireless and payphones, is required on or before October 1, 
2001. It is expected to make relay services usage easier for 
persons with and without disabilities and should go a long way 
to ensuring that older Americans take advantage of this 
telephony service.
    8. TRS--Carrier of Choice.--Other public notices and 
actions in the 1999-2000 period addressed TRS concerns. For 
instance, in August 1999, the FCC, through a widely 
disseminated Public Notice, reminded telecommunications 
carriers of their obligation to provide choice to TRS users. 
This Public Notice reminded carriers that users of relay 
services have the same right to select a long distance 
telephone services carrier as other telephone users.
    9. Hearing Aid Compatibility and Volume Control.--To serve 
consumers with hearing and speech disabilities, the Commission 
released a public notice in April 1999 reminding wireline 
telephone manufacturers of their obligation to have all 
telephones hearing aid compatible. A telephone is hearing aid 
compatible if it provides internal means (i.e., without the use 
of external devices) to enable individuals who use hearing aids 
to use the telephone (the technical standard is codified at 47 
C.F.R. Sec. 68.316). This is usually accomplished by inserting 
a telecoil in telephones that detects, or is compatible with, a 
similar telecoil in the hearing aid, and thus allows the 
hearing aid to ``couple'' with the telephone through an 
electromagnetic field.
    In October 2000, the Wireless Telecommunications Bureau 
issued a public notice seeking comment on the re-opening of a 
petition that requested a rulemaking on hearing-aid compatible 
phones. Petitioners asked that the exemption for personal 
communication services (certain wireless) devices from the 
Hearing Aid Compatibility Act of 1988 (HAC Act) be revoked. 
Significant numbers of older Americans and others with hearing 
loss have told DRO that the lack of hearing aid compatibility 
with, and interference from, digital wireless telephones is 
still an ongoing problem. As more and more wireless networks 
become digital, the needs of hearing aid and cochlear implant 
users will need to be addressed.
    10. Advanced Telecommunications.--In January 1999, the FCC 
adopted a Report and Order and Notice of Inquiry on the 
Deployment of Advanced Telecommunications Capability to All 
Americans in a Timely Fashion, and Possible Steps to Accelerate 
Deployment. This notice specifically sought comment on the 
disability access needs of persons with disabilities. Later, in 
February 2000, the FCC issued a Notice of Inquiry on the FCC's 
second report on advanced telecommunications capability. In 
particular, this sought data to determine the rate of 
deployment especially in rural and inner city areas and to 
persons with disabilities, which includes aging populations.
    Advisory Councils and White Papers.-- The FCC made other 
policy efforts in 1999-2000 to ensure that issues and concerns 
of people with disabilities, including those disabilities that 
result from aging, were addressed. For example, the DRO 
spearheaded efforts to create a Consumer/Disability Federal 
Advisory Committee, designed to gather feedback on 
telecommunications issues affecting consumers, including older 
consumers. A Public Notice announcing creation of the advisory 
committee was released in November 2000, and the Committee's 
first meeting was scheduled to occur in March 2001. Older 
Americans are represented through various consumer groups on 
this committee.
    Similarly, other policy activities were undertaken to 
continue to raise the profile of the telecommunications needs 
of persons with functional limitations in speech, hearing and 
vision. Examples include sending letters in May 2000 to Federal 
agency heads reminding them of the obligation to caption public 
service announcements that are funded in whole or in part by 
Federal agencies.
    Another FCC policy action was to seek comment on expanding 
the Telecommunications Advisory Council of the National 
Exchange Carriers Administration, the organization that manages 
the interstate funds for carriers' contributions to relay 
services, to include a member who would represent consumers 
with speech disabilities. This resulted in the appointment of a 
person with severe speech disabilities to this advisory body.
Cable Services Bureau(CSB)
    The FCC bureau which regulates the cable television 
industry, the Cable Services Bureau, focused on three issues in 
1999-2000 that affect older Americans:
    Senior Citizen Discounts.--Senior citizen discounts benefit 
older Americans who often have limited incomes. By enacting 
Section 623(e)(1) as part of the system of rate regulation 
pursuant to the 1992 Cable Act, Congress intended to encourage 
cable operators to offer, and to continue to offer through 
existing franchise agreements, reasonable discounts to senior 
citizens or other economically disadvantaged groups. In 
response to a Petition for Declaratory Ruling, the Commission 
upheld a previously issued informal letter ruling stating that 
it would not interfere with senior citizen discounts previously 
allowed for in local franchise agreements.
    Video Accessibility.--Older Americans with hearing and 
visual 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.'' 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 report on the availability of closed captioning 
to persons with hearing disabilities and to assess the 
appropriate method for phasing video description into the 
marketplace to benefit persons with visual disabilities. The 
Commission submitted a Report to Congress addressing these 
issues on July 29, 1996. In that Report to Congress, the 
Commission indicated that there was a lack of experience with 
video description because it is a newer service than closed 
captioning. Since the record on video description before the 
Commission at the time of the 1996 Report was insufficient to 
assess appropriate methods and schedules for phasing in video 
description, the Commission provided Congress with additional 
information and comment in the context of the 1997 Annual 
Report to Congress on the Status of Competition in Markets for 
the Delivery of Video Programming. This issue continued to be 
monitored by the CSB during 1999-2000.
    The 1996 Act also directed the Commission to prescribe 
rules and implementation schedules for the closed captioning of 
video programming regardless of the entity that provides the 
programming to consumers or the category of programming. In 
August 1997, the Commission established rules to ensure that 
video programming is made accessible through closed captioning. 
In September 1998, in response to petitions for 
reconsideration, the Commission modified and clarified the 
closed captioning rules to better comply with the statutory 
mandate to provide accessibility to persons with hearing 
disabilities.
    The rules establish timetables that gradually increase the 
amount of closed captioning provided on programs. For 
programming first published or exhibited on or after January 1, 
1998, the effective date of the rules, the Commission 
established benchmarks to be met every two years until 100 
percent of such programming is required to be captioned as of 
January 1, 2006. Beginning on January 1, 2000, the benchmarks 
generally require 450 hours of captioned new programming on 
each channel during each calendar quarter. For programming 
first published or exhibited prior to January 1, 1998 (``pre-
rule programming''), mandatory captioning is phased-in over a 
10-year period. As of January 1, 2008, the end of this 
transition period, 75 percent of the pre-rule programming on 
each channel must include closed captioning, with at least 30 
percent of such programming required to be captioned as of 
January 1, 2003. The rules also require video programming 
distributors (e.g., television station operators or cable 
operators) to generally pass through to consumers any captions 
they receive with the programming they distribute. Video 
programming distributors also must continue to provide 
captioned programming at substantially the same level as the 
average level of captioning that they provided during the first 
six months of 1997, even if that amount of captioning exceeds 
the requirements under the transition schedules.
Common Carrier Bureau (CCB)
    Some of the most important policy actions of the FCC in 
1999-2000 affecting older Americans were initiated by the 
Commission's Common Carrier Bureau (CCB). This FCC bureau 
regulates wireline communications in the telecommunications 
industry.
    ``Slamming .''--``Slamming'' is the practice of switching a 
person's telephone company without that person's permission. 
Older Americans are especially vulnerable to such anti-consumer 
activity. In 1998, the Commission adopted new rules to ensure 
that carriers do not use misleading or confusing forms that 
consumers sign to change their long distance service and to 
ensure that consumers do not pay any charges to a slamming 
company.
    In 2000, the Commission modified the slamming liability 
rules to take the profit out of slamming and also gave state 
commissions the opportunity to become the primary forums for 
resolving slamming complaints filed by their citizens. As of 
January 2001, 34 states had opted to administer the revised 
slamming rules, which took effect on November 28, 2000. The 
Commission also made several other improvements in its rules 
and procedures that protect consumers against slamming, such as 
the rules governing preferred carrier freezes, i.e., rules 
which allow a customer to ``freeze'' the choice of long 
distance carrier so that it can only be changed with the 
direct, written permission of the customer.
    Truth in Billing and ``Cramming.''--``Cramming'' is the 
inclusion of unauthorized or unexplained charges on a person's 
phone bill. To further protect consumers against cramming and 
other billing-related fraudulent practices, the FCC adopted 
rules in the 1999-2000 reporting period that require telephone 
bills to be more clear and better organized, and to highlight 
charges from new service providers. These rules give customers, 
including older Americans, the tools they need to make sure 
they have not been improperly charged.
    Consumer Information.--The Common Carrier Bureau continued 
during 1999-2000 to produce customer information to help all 
consumers better understand and make choices regarding their 
telephone service. The Bureau made available information on 
such matters as how to select a carrier, how to get the best 
rates, and which companies have the worst complaint records.
    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. During 1999-2000, the Bureau 
continued to implement these principles of universal service 
through its work to assure access to advanced 
telecommunications services for health care providers, 
including hospitals, health clinics, and libraries, all of 
which serve many older Americans.
    Lifeline/Link Up Services.--The Commission during this time 
period also continued to implement the FCC's ``Lifeline'' and 
``Link Up'' programs. The federal Lifeline program provides 
between $3.50 and $7.00 a month to reduce low-income consumers' 
monthly telephone bills. The amount of federal support varies 
depending on decisions made by state public service 
commissions. All eligible low-income consumers receive at least 
a $3.50 reduction per month on their telephone bills from the 
federal universal service program. The reduction applies to a 
single telephone line at a qualifying consumer's residence.
    The Link Up program offers eligible low-income consumers a 
reduction in the local telephone company's charges for starting 
telephone service (the reduction is one-half of the telephone 
company's charge, or $30, whichever is less); and a deferred 
payment plan for the remaining charges.
    Additional Lifeline and Link Up support is also available 
for service to Indian lands as part of the Commission's 
initiative in this time period to enhance telecommunications 
services on native American, Indian lands.
Mass Media Bureau (MMB)
    See above for discussion of video description, the major 
matter during 1999-2000 affecting the elderly on which the Mass 
Media Bureau focused. (The MMB regulates the radio and 
television industries.)
Office of Engineering and Technology(OET)
    The Commission's chief office for engineering and technical 
policy advice is the Office of Engineering and Technology or 
``OET.'' During 1999-2000, OET focused on the following issues 
of interest to and impact on older Americans:
    Medical Telemetry.--In June 2000, the FCC allocated 
spectrum to ensure the protection of medical telemetry devices 
from radio frequency interference caused by other services. 
Medical telemetry devices are typically used in health care 
institutions to monitor the vital signs of critically ill 
patents, a disproportionate number of whom are elderly. OET 
works closely with the Federal Drug Administration (FDA), the 
medical community and equipment manufacturers to ensure the 
continued technical viability of these valuable medical 
monitoring services.
    Closed Captioning.--In July 2000, the FCC adopted rules to 
provide for closed captioning of digital television 
programming, to ensure continued access to closed captioning 
during the transition from analog to digital television 
transmission. (See also above for further discussion.)
    TRS and 711.--Telecommunications Relay Service permits a 
speech- or hearing-impaired user of a TTY to communicate with 
speaking and hearing persons. (711 is the national free number 
for TRS.) Many elderly persons can and do use TRS. Through 
OET's familiarity with industry practices, the FCC was able to 
institute a procedure for gathering simple industry 
documentation which enables it to monitor progress of the 
implementation of the 711 feature for wireless-initiated calls 
and make the industry accountable for its handling of problems 
that may arise during implementation. OET's technical expertise 
also guided the Commission in issuing accurate and precise 
rules, so that service providers and manufacturers provide the 
desired services for TTY users when they follow the letter of 
the law. The FCC's new rules in this area assure that 
performance measurements are appropriate, for example, by 
measuring ``wait time'' from the placing of a call rather than 
from the time a call is answered (an answer could be 
considerably delayed), and by insisting that counts are made 
not just of calls blocked, but also of those dropped or 
indefinitely held. (See also above for further discussion.)
Office of Managing Director(OMD)
    The FCC's chief management office, the Office of Managing 
Director (``OMD''), reports that in 1999-2000. as part of the 
Commission's ongoing efforts to recruit its staff from many 
diverse sources, the FCC sought out older Americans by, for 
example, sending vacancy announcements to organizations whose 
membership consists of older Americans.
Wireless Telecommunications Bureau(WTB)
    The Commission's wireless telecommunications policies are 
developed by the Wireless Telecommunications Bureau (``WTB''). 
In 1999-2000, the WTB helped older Americans by encouraging 
more competitors and decreasing wireless prices, thereby making 
wireless service more affordable to the elderly. The WTB in 
this time period focused on:
    Wireless Enhanced 911.--In 1999 and 2000, the Commission 
continued its efforts to promote public safety by adjusting the 
rules requiring wireless carriers and manufacturers to 
implement technologies needed to bring emergency assistance to 
wireless callers throughout the United States. The Commission 
modified its wireless 911 rules to allow covered wireless 
carriers to use handset-based technology to provide public 
safety authorities with information about the location of the 
911 caller. By allowing carriers to choose among different E911 
location methods, the Commission expects to foster competition 
among various technologies, ultimately resulting in the 
deployment of the best and most efficient technologies. In 
2000, the Commission also adopted a deadline of June 30, 2002, 
by which digital wireless systems must be capable of 
transmitting 911 calls placed by individuals with speech and 
hearing disabilities using text telephone (TTY) devices. 
Although the Commission required all covered wireless carriers 
to be capable of transmitting these calls as part of its 
original E911 rules, operators of digital systems have been 
unable to comply with this requirement because they have not 
been able to accurately pass the Baudot-encoded audio tones 
produced by TTY devices. In light of the industry's progress in 
developing solutions to the TTY-digital incompatibility, 
setting a deadline for compliance will ensure that TTY users on 
digital systems will receive the benefits of E911 at the 
earliest possible time. (See also above for further 
discussion.)
    Spectrum for Public Safety.--The WTB authored a number of 
items in 1999-2000 to promote the use of radio by public safety 
entities. The primary item during this period were new rules 
for the 700 MHz public safety band, as directed by the Balanced 
Budget Act of 1997. The Commission's Federal public safety 
advisory committee, the National Coordinating Committee for 
Public Safety, completed recommendations for technical and 
operational standards for use of this spectrum. Specifically, 
these standards will allow interoperable radio communications 
between all public safety systems used by local, state, and 
Federal public safety organizations during emergencies. The 
Commission also designated a portion of the spectrum for use by 
States to build statewide systems in this new 700 MHz spectrum.
    Amateur Radio.--The Commission amended its amateur service 
rules to reduce the number of telegraphy examination elements 
in the amateur radio license structure from three elements to 
one. These rule changes became effective April 15, 2000. These 
changes have allowed many amateur radio service licensees, 
including many older Americans, to qualify for additional 
operating privileges without requesting credit for higher speed 
telegraphy examination elements on the basis of physical 
limitations, particularly hearing loss due to aging processes. 
These changes also eliminated the need and expense for an 
applicant to go to his or her doctor and request a Physician's 
Certification of Disability if the applicant desired to receive 
credit for the higher speed examination elements. The rule 
changes eliminating the higher speed telegraphy Morse code 
examinations greatly assisted older individuals to take full 
advantage of the benefits the amateur service has to offer.
    Wireless Medical Telemetry Service.--The Wireless Medical 
Telemetry Service (WMTS) was established by the Commission on 
June 12, 2000, to enhance the reliability of equipment that is 
vital to the effective care of patients with acute and chronic 
health problems. Medical telemetry equipment is used in health 
care facilities to transmit patient measurement data, such as 
pulse and respiration rates, to a nearby receiver. By 
permitting such remote monitoring of patients' vital signs, 
medical telemetry equipment provides significant benefits to 
patients in terms of mobility and comfort. In addition, because 
wireless medical telemetry equipment allows remote monitoring 
of several patients simultaneously, it might be a significant 
tool in reducing health care costs. (See also above for further 
discussion.)
    Application Licensing.--The Universal Licensing System 
(ULS) fundamentally changes the way the Commission receives and 
processes wireless applications. ULS enables all wireless 
applicants and licensees to file all licensing-related 
applications and other filings electronically, thus increasing 
the speed and efficiency of the application process. The 
enhanced information collection capabilities of ULS also 
enables the Commission staff to easily monitor spectrum use and 
competitive conditions in the wireless marketplace and will 
promote effective implementation of spectrum management 
policies. Finally, ULS enhances the availability of licensing 
information to the public, which has access to all wireless 
licensing data on-line, including maps showing licensing areas 
and service providers.
    To further improve application processing and access to 
licensing information the ULS is continually being enhanced. 
Recent enhancements to the ULS include a complete redesign of 
the ULS homepage. This redesign has made it easier for 
applicants and researchers to locate information using the ULS 
website. In redesigning the homepage, the Commission improved 
access for individuals with disabilities. The new homepage is 
compatible with various screen readers. Additionally, in 
January 2001, we began real time processing for applications 
filed by Amateur Radio Licensees. Previously, these 
applications were processed once nightly; now they are 
processed every 30 minutes.
    Future planned enhancements to ULS include redesigning the 
public access interface to the ULS Antenna Structure 
Registration (ASR) database. This will provide easier search 
capabilities to anyone using the Commission ASR data. This new 
interface will also include an on-line interactive training 
module, which will provide general overview of ASR and 
assistance regarding individual data elements. These changes 
and enhancements improve service to all ULS users, including 
older Americans.
Additional Information
    Anyone who wants more information on any of these 
activities, especially on how they impact older Americans, can 
contact the FCC through its National Call Center at 1-888-CALL-
FCC (225-5322), or the Commission's web site on the Internet at 
www.fcc.gov. For more information about this report, please 
contact Steve Klitzman, Associate Director, Office of 
Legislative and Intergovernmental Affairs (OLIA), 202-418-1900, 
fax: 202-418-2806; or at [email protected] .



                   ITEM 21--GENERAL ACCOUNTING OFFICE

                              ----------                              


   CALENDAR YEARS 1999 AND 2000 REPORTS AND CORRESPONDENCE ON ISSUES 
                       AFFECTING OLDER AMERICANS

    During calendar years 1999 and 2000, GAO issued 120 reports 
on issues affecting older Americans. Of these, 72 were on 
health issues, 33 were on income security issues, 10 were on 
veterans and Department of Defense (DOD) issues and 5 were on 
multiple issues.

                             Health Issues

Adverse Drug Events: The Magnitude of Health Risk Is Uncertain Because 
        of Limited Incidence Data. (GAO/HEHS-00-21, Jan. 18, 2000).
    About 2.7 billion prescriptions were filled in the United 
States in 1998. Although prescription drugs have great clinical 
benefits, serious adverse drug events can lead to 
hospitalization, disability, and even death. Adverse drug 
events are caused by harmful drug reactions or by medication 
errors committed by health care professionals and patients. Two 
factors that can increase the risk of a patient suffering from 
an adverse drug event are illness severity and intensity of 
treatment, including taking several drugs simultaneously. 
Although it is clear that a wide range of commonly used drugs 
cause adverse drug events with potentially serious consequences 
for patients, relatively little is known about their frequency. 
Data routinely collected on adverse drug events during clinical 
trials or after drugs are marketed are intended to identify the 
adverse drug events that are associated with particular drugs 
and do not focus on their frequency. Information on the overall 
incidence of adverse drug events from all drugs has been 
limited to a few research studies that typically examined the 
experience of patients in one of two specific institutions--
generally hospitals or sometimes nursing homes--leaving the 
overall incidence of adverse drug events in outpatient care 
largely unexplored. Greater understanding of certain factors 
that affect the likelihood of adverse drug events has led 
researchers and patient safety advocates to suggest a range of 
measures to decrease their number and severity. These proposals 
range from better communication between doctors and patients 
about the risks and benefits of medications to accelerating 
research on the safety of marketed drugs. Suggestions for 
reducing medication errors include developing computerized 
prescribing and dispensing systems to detect possible errors, 
increasing the role of pharmacists as advisers to physicians 
and as monitors of drug therapy, and improving health care 
providers' pharmaceutical education.
Assisted Living: Quality-of-Care and Consumer Protection Issues in Four 
        States. (GAO/HEHS-99-27, April 26, 1999).
    Assisted living facilities provide a growing number of 
elderly Americans with an alternative to nursing homes. To make 
informed choices from among various facilities, consumers need 
clear and completeinformation on services, costs, and policies. 
A GAO review of assisted living facilities in four states--
California, Florida, Ohio, and Oregon--found that the 
facilities did not always give consumers enoughinformation to 
determine whether a particular facility could meet their needs, 
for how long, and under what circumstances. Marketing 
materials, contracts, and other written materials provided by 
facilities are often incomplete and sometimes vague or 
misleading. Only about half of the facilities GAO surveyed 
reported that they provide prospective residents with such key 
written information as the amount of assistance residents can 
expect to receive with medications, the circumstances under 
which the cost of services might change, or when residents 
might be required to leave if their health deteriorates. 
Consumers also need assurance that facilities provide high-
quality care and protect consumers' interests. All four states 
license assisted living facilities, conduct periodic 
inspections, and investigate complaints. Yet GAO found that 
more than one-fourth of the facilities it reviewed had been 
cited by state licensing, ombudsman, or other agencies for five 
or more quality-of-care or consumer protection deficiencies or 
violations during 1996 and 1997. Eleven percent of the 
facilities had been cited for 10 or more deficiencies or 
violations during the same period. Frequently 
identifiedproblems included facilities (1) providing poor care 
to residents, such as inadequate medical attention following an 
accident; (2) having insufficient, unqualified, and untrained 
staff; (3) not providingresidents with appropriate medications 
and not storing medications properly; and (4) not following 
admission and discharge policies required by state regulation.
Blood Supply: Availability of Blood to Meet the Nation's Requirements. 
        (GAO/HEHS-99-187R, Sept. 20, 1999)
    Pursuant to a congressional request, GAO provided 
information on the availability of blood to meet the nation's 
requirements, focusing on: (1) recent trends in blood donation 
and the demand for blood transfusions; (2) the expected effect 
of a ban on blood from donors who have traveled to the United 
Kingdom; and (3) the potential effect of policy changes to 
allow units of blood collected from individuals with 
hemochromatosis to be distributed.
    GAO noted that: (1) GAO found that, while there is cause 
for concern about shortages of certain blood types or in 
certain regions, the blood supply as a whole is not in crisis; 
(2) GAO believes that the National Blood Data Resource Center 
(NBDRC) study overstates the decline in the blood supply; (3) 
most of the decline found by NBDRC was in donations targeted 
for specific individuals, not in the community supply of blood 
available to anyone in need; (4) further, the projection relies 
on data from only 2 years, the most recent of which is now 2 
years old; (5) the United Kingdom donor exclusion policy has 
been estimated to reduce the blood supply by approximately 2.2 
percent; (6) blood banks fear that the actual loss due to this 
exclusion will be greater, but it is not possible to assess the 
accuracy of these estimates; (7) while the estimates of the 
potential increase in the blood supply from donations by 
individuals with hemochromatosis vary widely, most of these 
increases could not occur until regulations are changed; and 
(8) therefore, such donations will not affect the available 
blood supply for some time.
Comments on HCFA Medicare Integrity Program Operating Plans. (B-282777. 
        Sept. 2, 1999).
    GAO commented on the Health Care Financing Administration's 
(HCFA) plans for operating the Medicare Integrity Program 
(MIP), focusing on whether: (1) the law authorizing the MIP 
permits HCFA to assign responsibility for local Medicare 
coverage policy to the payment safeguard contractors (PSC) who 
will run the MIP under contract to HCFA; and (2) HCFA's 
proposed MIP regulations would provide an adequate legal basis 
for HCFA to conduct local policy-making through PSCs. GAO noted 
that HCFA reasonably interpreted the law to mean that its PSCs 
could set local Medicare coverage policy. GAO also noted that 
the proposed MIP regulations provide an adequate basis for 
HCFA's action.
HCFA: Three Largest Medicare Overpayment Settlements Were Improper. 
        (GAO/OSI-00-4, Feb. 25, 2000).
    The Health Care Financing Administration (HCFA) provided 
GAO with copies of 96 agreements in which HCFA negotiated 
settlements for Medicare overpayments exceeding $100,000. In 93 
of the 96 matters, which were negotiated between 1991 and 1999, 
GAO found nothing improper. In settling the three largest 
overpayments, however, HCFA acted inappropriately. These three 
largest matters represented 66 percent of all Medicare 
overpayment settlements since 1991 for which HCFA provided 
records. In the settlements, HCFA agreed to accept $120 million 
for debts exceeding $332 million (or about 36 cents on the 
dollar). GAO found that (1) former HCFA Administrator Bruce 
Vladek's participation in the largest settlement raised 
conflict-of-interest concerns, (2) HCFA chose not to obtain the 
Department of Justice's approval of the settlements and ignored 
its own regulations and internal guidance requiring them to do 
so, (3) HCFA appears to have disregarded permissible settlement 
criteria established by regulations, (4) the settlement 
agreements contained questionableprovisions, and (5) HCFA 
executed settlements without the benefit of legal counsel.
Health Care: Fraud Schemes Committed by Career Criminals and Organized 
        Criminal Groups and Impact on Consumers and Legitimate Health 
        Care Providers. (GAO/OSI-00-1R, Oct. 5, 1999).
    Pursuant to a congressional request, GAO provided 
information on the proliferation of Medicare, Medicaid, and 
private health insurance fraud on the part of criminals and 
organized criminal groups, focusing on: (1) the makeup and 
prior activities of such groups; (2) how organized criminal 
groups created medical entities or used legitimate medical 
entities or individuals to defraud Medicare, Medicaid, and 
private insurers; (3) schemes used by such groups to commit 
health care fraud; and (4) the impact that illegal activity by 
such groups has on consumers and legitimate health care 
providers.
    GAO noted that: (1) while the full extent of the problem 
remains unknown, GAO determined that career criminal and 
organized criminal groups are involved in Medicare, Medicaid, 
and private insurance health care fraud or alleged fraud 
throughout the country; (2) in the cases GAO reviewed, criminal 
groups varied in size from 2 or 3 participants to more than 20 
participants and generally had one leader; (3) many group 
members had prior criminal histories for criminal activity 
unrelated to health care fraud, indicating that they moved from 
one field of criminal activity to another; (4) the primary 
subjects in these cases had little or no known medical or 
health care education, training, or experience; (5) at least 
two groups learned or were suspected of having learned how to 
commit health care fraud from others already engaged in such 
fraud; (6) in some of the cases GAO reviewed, criminal-group 
members had relatives or associates in foreign countries who 
helped them transfertheir ill-gotten health care proceeds; (7) 
these groups created as many as 160 sham medical entities--such 
as medical clinics, physician groups, diagnostic laboratories, 
and durable medical equipment companies, often using fictitious 
names or the names of others on paperwork--or used the names of 
uninvolved legitimate providers to bill for services and 
equipment not provided or not medically necessary; (8) for the 
most part, these entities existed only on paper; (9) once the 
structure was inplace, subjects used a variety of schemes to 
submit claims to Medicare, Medicaid, or private insurance 
companies; (10) one scheme used is sometimes referred to as 
``patient brokering'' or ``rent-a-patient;'' (11) under this 
scheme, the subjects used recruiters to organize and recruit 
beneficiaries (patients) who visited clinics owned or operated 
by such subjects for unnecessary diagnostic testing or medical 
services; (12) recruiters received a fee for each beneficiary 
brought in; (13) the above-described activities affect 
consumers, beneficiaries, health care providers, and law 
enforcement officials; (14) consumers pay increased health care 
costs in the form of taxes, because taxpayer 
contributionssupport Medicare and Medicaid; (15) in the case of 
private insurance, insured individuals pay increased premiums; 
and (16) because of the multiplicity of schemes and the ease 
with which subjects move their operations from location to 
location, law enforcement officials find it difficult to keep 
up with this growing and widespread form of fraud and are often 
unable to seize or recoup fraudulent proceeds that are quickly 
moved out of their reach.
Influenza Pandemic: Plan Needed for Federal and State Response. (GAO-
        01-4, Oct. 27, 2000).
    Although vaccines are considered the first line of defense 
to prevent or reduce influenza-related illness and death, GAO 
found that they may be unavailable, in short supply, or 
ineffective for some portions of the population during the 
first wave of an influenza pandemic. Antiviral drugs and other 
secondary interventions, such as pneumonia vaccines are also 
expected to be in short supply if a pandemic occurs. Federal 
and state influenza pandemic plans are in various stages of 
completion and do not completely or consistently address key 
issues surrounding the purchase, distribution, and 
administration of vaccines and antiviral drugs. Inconsistencies 
in state and federal policies could contribute to public 
confusion and weaken the effectiveness of the public health 
response.
Internet Pharmacies: Adding Disclosure Requirements Would Aid State and 
        Federal Oversight. (GAO-01-69, Oct. 19, 2000).
    The unique qualities of the Internet pose new challenges 
for enforcing state pharmacy and medical practice laws because 
they allow pharmacies and physicians to reach consumers across 
state and international borders and remain anonymous. Public 
officials are concerned about unlicensed Internet pharmacies, 
particularly those that are affiliated with physicians that 
prescribe on the basis of an online questionnaire and those 
that dispense drugs without a prescription. Dispensing 
prescription drugs without adequate physician supervision 
increases the risk of consumers' suffering adverse events, 
including side effects from inappropriately prescribed 
medications and misbranded or contaminated drugs. State efforts 
to stop Internet pharmacies have encountered difficulty in 
identifying responsible parties and enforcing laws across state 
boundaries. Federal efforts to stem the flow of prescription 
drugs from foreign-based Internet pharmacies have also faced 
difficulties. Enactment of federal legislation requiring 
Internet pharmacies to disclose minimum information would aid 
consumers and state and federal regulators.
Formula Grants: Effects of Adjusted Population Counts on Federal 
        Funding to States. (GAO/HEHS-99-69, Feb. 26, 1999).
    Twenty-two of the 25 large grant programs rely partly on 
decennial census data to apportion federal funding among state 
and local governments. In fiscal year 1998, $167 billion was 
obligated for them. By comparing statistical sampling results 
to the actual 1990 census count, the Census Bureau estimated 
that it had undercounted the U.S.population by 4 million 
persons. GAO recalculated current funding amounts for 15 of the 
22 programs, assuming the same proportional net undercount. 
These 15 represented $147 billion, or 79 percent, of 
population-based programs. Using the adjusted population counts 
would have reallocated $449 million among the 50 states and the 
District of Columbia. California, Arizona, New Mexico, and 
Texas the four states bordering Mexico--accounted for more than 
one-third of the adjusted populations and would have received 
nearly 75 percent of the total reallocated, or $336 million. 
California accounted for about 20 percent and would have 
received $223 million. Pennsylvania would have received the 
largest dollar reduction ($110 million); Rhode Island the 
largest percentage reduction (1.8 percent). Medicaid accounted 
for 90 percent of all reallocated funds. Funding would have 
generally shifted from northeastern and midwestern states to 
southern and western states. The Bureau proposes to use 
statistical sampling techniques to estimate the population for 
the 2000 census. Although the Supreme Court has ruled that the 
Census Act prohibits using sampling techniques for 
reapportioning seats in the House of Representatives, the 
ruling did not address the use of adjusted counts for 
apportioning federal grant funding.
Low-Income Medicare Beneficiaries: Further Outreach and Administrative 
        Simplification Could Increase Enrollment. (GAO/HEHS-99-61, 
        April 9, 1999).
    In 1995, premiums, deductibles, and coinsurance cost single 
persons at the federal poverty level 10 percent of income, and 
married couples, 15 percent. State Medicaid programs helped 
them bear their costs through the congressionally enacted 
Qualified Medicare Beneficiary (QMB) program, the Specified 
Low-Income Medicare Beneficiary (SLMB) program, and the 
Qualifying Individuals program. In 1996, about 43 percent of 
the potentially eligible Medicare beneficiaries were not 
enrolled in either QMB or SLMB. Enrollment in these programs is 
relatively low for Medicare beneficiaries who are white, 
widowed or married, or have Medicare coverage because of age 
rather than disability. Many potential recipients do not enroll 
because they do not know the programs exist, fear that the 
state will try to recover payments made to them from a 
surviving spouse or children, or are unwilling to accept what 
they think of as welfare. Moreover, the application process 
will be burdensome and complex, and the states' cost-sharing 
obligations limit their incentives to notify and enroll 
eligible individuals. Efforts to increase enrollment include a 
Social Security Administration demonstration project, state 
outreach and enrollment efforts through their State Children's 
Health Insurance Programs, and efforts by the Health Care 
Financing Administration under the Government Performance and 
Results Act.
Major Management Challenges and Program Risks: Department of Health and 
        Human Services. (GAO/OCG-99-7, Jan. 1, 1999).
    This publication is part of GAO's performance and 
accountability series which provides a comprehensive assessment 
of government management, particularly the management 
challenges and program risks confronting federal agencies. 
Using a ``performance-based management'' approach, this 
landmark set of reports focuses on the results of government 
programs--how they affect the American taxpayer--rather than on 
the processes of government. This approach integrates thinking 
about organization, product and service delivery, use of 
technology, and human capital practices into every decision 
about the results that the government hopes to achieve. The 
series includes an overview volume discussing government wide 
management issues and 20 individual reports on the challenges 
facing specific cabinet departments and independent agencies. 
The reports take advantage of the wealth of new information 
made possible by management reform legislation, including 
audited financial statements for major federal agencies, 
mandated by the Chief Financial Officers Act, and strategic and 
performance plans required by the Government Performance and 
Results Act. In a companion volume to this series, GAO also 
updates its high-risk list of government operations andprograms 
that are particularly vulnerable to waste, fraud, abuse, and 
mismanagement.
    This volume deals with the major management challenges at 
the Department of Health and Human Services. Among the 
challenges are
           the solvency of Medicare's Hospital 
        Insurance Trust Fund, which funds Medicare Part A;
           the need for reliable and comprehensive data 
        and data systems to manage programs and assess results; 
        and
           the integrity of the Medicare program.
Medicare: Access to Home Oxygen Largely Unchanged; Closer HCFA 
        Monitoring Needed. (GAO/HEHS-99-56, April 5, 1999).
    Before the Balanced Budget Act of 1997, Medicare's payment 
rates for home oxygen exceeded those of the Department of 
Veterans Affairs by almost 38 percent. The act reduced 
Medicare's rates by 25 percent effective January 1, 1998, and 
GAO evaluated changes in Medicare's patients' access to home 
oxygen since the payment reduction. Preliminary indications are 
that access remained substantially unchanged. The number of 
Medicare beneficiaries using home oxygen equipment increased, 
and the proportion of those using the more costly stationary 
liquid oxygen systems decreased. Even Medicare beneficiaries 
who were expensive or difficult to serve were able to get the 
appropriate systems for their needs, and suppliers accepted the 
Medicare allowance as full payment for more than 99 percent of 
claims. Most suppliers increased operating efficiencies to 
mitigate the effect of the payment reduction. However, subtle 
access issues may not be readily apparent, and problems could 
emerge as more and better information becomes available. Beyond 
contracting with a peer review organization for an evaluation 
of access to and the quality of home oxygen equipment, the 
Health Care Financing Administration (HCFA) has not established 
an ongoing method to monitorthe use of this benefit and gather 
the information essential to assessing the payment system. It 
has also not developed service standards for home oxygen 
suppliers, as required by the act, to allow them to decide 
themselves what services they will provide.
Medicare: Contractors Screen Employees but Extent of Screening Varies. 
        (GAO/HEHS-00-135R, June 30, 2000).
    Pursuant to a congressional request, GAO provided 
information on the use of employee screening measures by 
Medicare claims administration and program safeguard 
contractors, focusing on the: (1) requirements the Health Care 
Financing Administration (HCFA) has placed on Medicare 
contractors to conduct employee background checks; (2) steps 
Medicare contractors are taking to ensure that employees are 
trustworthy in handling Medicare funds and sensitive 
information; and (3) costs to Medicare contractors of 
conducting background checks or using other employee screening 
measures.
    GAO noted that: (1) HCFA expects its contractors to 
exercise sound business judgment when they make hiring 
decisions; (2) as a result, HCFA does not specifically require 
its Medicare claims administration and program safeguard 
contractors to conduct background checks or undertake other 
employee screening measures; (3) however, HCFA does advise its 
claims administration contractors to adopt personnel selection 
safeguards, specifically employment verification and applicant 
certifications; (4) HCFA also requires its claims 
administration contractors to obtain fidelity bonds for certain 
employees; (5) in addition, both Medicare claims administration 
and program safeguardcontractors are required to collect and 
submit to HCFA conflict of interest information; (6) the 
Medicare claims administration and program safeguard 
contractors GAO surveyed screen their employees as common 
business practice without specific requirements from HCFA to do 
so; (7) nearly all the contractors in GAO's sample said that 
they perform typical screening measures, such as employment and 
education verification, reference checking, and credential 
validation; (8) most of the claims administration contractors 
GAO spoke to also reported that they perform more extensive 
screening measures, such as criminal background checks and drug 
tests; (9) in contrast, the two program safeguard contractors 
GAO surveyed indicated that they do not conduct criminal 
background checks or require drug testing unless such 
requirements are included in their contracts; (10) both claims 
administration and program safeguard contractors reported that 
they rarely use less traditional screening measures, such as 
credit checks and government debarment and exclusion database 
reviews; (11) the costs associated with employee screening vary 
by the complexity and urgency associated with each screening 
measure; (12) however, the Medicare contractors GAO surveyed 
could not calculate the total cost of their employee screening 
measures; and (13) the factthat employee screening efforts are 
conducted and continue to be recognized as a common business 
practice within the Medicare contractor community suggests that 
such measures are considered worthwhile.
Medicare: Early Evidence of Compliance Program Effectiveness Is 
        Inconclusive. (GAO/HEHS-99-59, April 15, 1999).
    In general, a compliance program consists of a Medicare 
provider organization's internal policies, processes, and 
procedures that help it prevent and detect violations of 
Medicare law. According to recent surveys, most hospitals 
either had or planned to soon implement a compliance program, 
but no readily available data exist on program prevalence. 
Direct program costs appear to account for less than one 
percent of total patient revenues; indirect costs may be 
larger. Lacking compliance budgets, hospitals cannot always 
distinguish between compliance program and normal operations 
costs. Comprehensive baseline data with which to measure 
programs' effectiveness are lacking. The costs associated with 
gathering baseline data on the amount of improper payments made 
to providers--or comparison data for providers without 
compliance programs--have precluded the use of this 
effectiveness measure. Although hospital officials reported 
that program benefits outweigh costs, Medicare contractors 
reported receiving refunds of provider overpayments with more 
frequency, and formal provider self-disclosures have increased 
in recent years. This preliminary evidence, however, does not 
demonstrate that compliance programs have reduced improper 
Medicare payments. According to hospitals, the major intangible 
indicator of effectiveness is an increased corporate awareness 
of compliance as shown by frequent calls to compliance staff or 
hotlines for guidance. Some hospitals plan to measure improved 
employee knowledge of compliance issues, risk areas, and 
procedures in conjunction with compliance training.
Medicare: HCFA Could Do More to Identify and Collect Overpayments. 
        (GAO/HEHS/AIMD-00-304, Sept. 7, 2000).
    Pursuant to a congressional request, GAO provided 
information on efforts to recover Medicare's overpayments, 
focusing on: (1) how the Health Care Financing Administration 
(HCFA) and its contractors identify potential overpayments, and 
whether techniques used by recovery auditors would improve 
overpayment identification; (2) how well HCFA and its 
contractors collect overpayments once they are identified, and 
whether the services of recovery auditors would improve HCFA 
collection efforts; and (3) what challenges HCFA would face if 
it were required to hire recovery auditors to augment its 
overpayment identification and collection activities. GAO noted 
that: (1) despite HCFA's efforts to pay claims correctly in its 
$167 billion fee-for-service Medicare program, several billions 
of dollars in Medicare overpayments occur each year; (2) it is 
therefore critical that HCFA undertake effective postpayment 
activities to identify overpayments expeditiously; (3) HCFA's 
claims administration contractors use several postpayment 
techniques to identify overpayments; (4) these include medical 
review to ensure reports for providers that are paid on the 
basis of their costs, and reviews to determine if another 
entity besides Medicare has primary payment responsibility; (5) 
the contractors identify and collect billions of dollars 
through these activities, but how well each contractor performs 
them is not clear because HCFA lacks the information it needs 
to measure the effectiveness of contractors' overpayment 
identification activities;(6) while recovery auditors may also 
save money for clients, such as state Medicaid agencies, by 
identifying overpayments, the identification techniques they 
use are generally similar to those already used by HCFA and its 
contractors; (7) this does not mean that HCFA could not benefit 
from a stronger focus on specific postpayment activities; (8) 
however, doing so may require additional program safeguard 
funding so as not to shift funds away from HCFA's other 
efforts, such as prepayment review to prevent overpayments; (9) 
Congress has given HCFA assured funding for program safeguard 
activities; (10) however, the funding level is about one-third 
less than it was in 1989 and, although it will increase until 
2003, it will only keep pace with expected growth in Medicare 
expenditures; (11) for fiscal year 1999, based on HCFA 
estimates, the Medicare Integrity Program saved the Medicare 
program more than $17 for each dollar spent about 55 percent 
from prepayment activities and the rest from postpayment 
activities; (12) because these activities can bringa positive 
return, GAO suggests that Congress consider increasing HCFA's 
funding to bolster its postpayment review program; (13) HCFA 
plans to expand its pilot projects from some to all of its 
claims administration contractors; and (14) however, it has 
established minimum thresholds forreferrals for collection that 
are higher than the Department of the Treasury and debt 
collection center will accept because HCFA says that it does 
not have the resources needed to pursue collection on the large 
volume of debt below its thresholds.
Medicare: HCFA's Approval and Oversight of Private Accreditation 
        Organizations. (GAO/HEHS-99-197R, Sept. 30, 1999).
    Pursuant to a congressional request, GAO provided 
information on the Health Care Financing Administration's 
(HCFA) approval and oversight of private Medicare accreditation 
organizations, focusing on: (1) HCFA's criteria for approving 
accreditation organizations; (2) HCFA's ongoing oversight of 
accreditation organizations that have been granted deemed 
status; and (3) recent evaluations of accreditation 
organizations' performance.
    GAO noted that: (1) HCFA is required to consider several 
factors when evaluating a private accreditation organization 
for deemed status; (2) HCFA must assess an organization's 
standards to ensure that the providers they accredit will meet 
or exceed Medicare requirements; (3) HCFA is required to 
evaluate an accreditation organization's ability to monitor and 
enforce provider compliance with its standards; (4) HCFA 
monitors the performance of accreditation organizations and 
ensures continued equivalence of its standards to those of 
Medicare by requiring accreditation organizations to provide 
survey findings and to submit proposed changes to its standards 
for HCFA's review; (5) HCFA requires each accreditation 
organization to document its policies and procedures regarding 
employee professional or financial affiliation with facilities 
being accredited; (6) HCFA has not, however, developed specific 
criteria to prohibit conflicts of interest between these 
organizations and the providers they accredit, even though 
accreditation organizations are typically governed by a board 
of directors that includes industry representatives; (7) a 
recent evaluation of accreditation organization performance by 
the Department of Health and Human Services' Office of 
Inspector General found that the Joint Commission on 
Accreditation of Healthcare Organizations' (JCAHO) collegial 
approach to hospital accreditation relies heavily on education 
and performance improvement,with less emphasis on regulatory 
approaches, which include unannounced surveys, responding to 
complaints, and collecting standard performance measures; (8) 
in another report HCFA recommended against relying on JCAHO for 
deeming of nursing homes, citing concerns that JCAHO 
requirementsfor nursing home accreditation were not sufficient 
to ensure that medicare conditions and requirements would be 
met and questioning whether JCAHO surveyors would identify 
serious care deficiencies in nursing homes.
Medicare: HCFA to Strengthen Medicare Provider Enrollment 
        Significantly, but Implementation Behind Schedule. (GAO-01-
        114R, Nov. 2, 2000).
    One of the first defenses against improper Medicare 
billings is the screening of applications from providers 
seeking to participate in the program. The Health Care 
Financing Administration (HCFA) operates and manages the 
Medicare program and, with help from insurance companies, 
reviews provider applications to determine whether providers 
meet Medicare requirements and if there is a reason to suspect 
that providers' future Medicare billings would be improper. GAO 
found that HCFA's current provider enrollment process does not 
completely ensure that dishonest and unqualified providers are 
prevented from obtaining Medicare billing privileges. GAO 
suggests consolidating provider enrollment tasks with fewer 
contractors to strengthen HCFA's ability to oversee these 
contractors and enhance the efficiency of the enrollment 
process. HCFA is implementing several changes to its provider 
enrollment processes that may make it more difficult for 
dishonest providers to enroll in Medicare; however, delays in 
implementing these initiatives will also postpone their 
benefits.
Medicare: Improper Third-Party Billing of Medicare by Behavioral 
        Medical Systems, Inc. (GAO/OSI-00-5R, Mar. 30, 2000).
    Pursuant to a congressional request, GAO reviewed the 
operations of Behavioral Medical Systems, Inc.
    GAO noted that: (1) while BMS represented itself to the 
Medicare Program as a provider, in fact it functioned as a 
broker and a third-party biller; (2) GAO found a consistent 
pattern by which BMS caused improper Medicare claims to be 
submitted for services not provided by six psychiatrists; (3) 
of the Medicare claims filed by BMS during a 20-month period, 
87 percent were for provider services that reportedly were not 
rendered; (4) these Medicare claims totaled $1.3 million, of 
which BMS received over $362,000; (5) GAO referred the matter 
to the Office of the Inspector General, Department of Health 
and Human Services, for its consideration; and (6) in 
functioning as a broker and a third-party biller, BMS violated 
42 U.S.C. 1395u(b)(6), which establishes the general principle 
that Medicare program payments should be made directly to the 
beneficiary or, under an assignment, to the physician who 
provides the medical service.
Medicare Financial Management: Clerical Errors in the Medicare Hospital 
        Insurance and Supplementary Medical Insurance Trust Funds. 
        (GAO-01-39R, Oct. 31, 2000).
    In its fiscal year 1999 accountability report to Congress, 
the Health Care Financing Administration (HCFA) reported 
clerical errors in the accounting for the Medicare trust funds, 
which caused the Hospital Insurance (HI) Trust Fund to be over 
invested by about $14 billion and the Supplementary Medical 
Insurance (SMI) Trust Fund to be under invested by about $18 
billion. Because of these errors, the HI Trust Fund earned 
excess interest and the SMI Trust Fund lost interest. GAO found 
that these errors occurred over a six month period and were not 
detected because of internal control weaknesses. Inadequate 
training and supervision and ineffective reconciliations were 
key factors that allowed the errors to go undetected. HCFA, in 
coordination with Treasury, took corrective action once the 
errors were discovered.
Medicare: Health Care Fraud and Abuse Control Program Financial Reports 
        for Fiscal Years 1998 and 1999. (GAO/AIMD-00-257R, July 31, 
        2000).
    Pursuant to a legislative requirement, GAO reviewed the 
Health Care Fraud and Abuse Control (HCFAC) Program financial 
reports for fiscal years (FY) 1998 and 1999 as required by the 
Health Insurance Portability and Accountability Act (HIPAA) of 
1996.
    GAO noted that: (1) the Department of Health and Human 
Services (HHS) and the Department of Justice (DOJ) joint HCFAC 
reports for fiscal years 1998 and 1999 reported that $107.4 
million and $114.4 million, respectively, were deposited into 
the trust fund pursuant to HIPAA; (2) the sources of these 
deposits, as shown in the joint reports, were primarily 
penalties and damages ($103 million in FY1998 and $73.6 million 
in FY1999) resulting from health care fraud audits, 
evaluations, investigations, and litigation; (3) the joint 
reports also stated that $119.6 million in FY1998 and $137.2 
million in FY1999 were appropriated from the trust fund for the 
HCFAC program; (4) of those amounts, HHS and DOJ allocated 
$85.7 million in FY1998 and $98.2 million in FY1999 to the HHS/
Office of Inspector General (OIG) to continue its Medicare and 
Medicaid fraud enforcement activities; (5) the remaining $33.9 
million in FY1998 funds and $39 million in FY1999 funds were 
allocated to: (a) DOJ, which received $28.5 million in FY1998 
and $30.7 million in FY1999 primarily to continue its 
litigative efforts and to provide health care fraud training; 
and (b) other HHS organizations, which received $5.5 million in 
FY1998 and $8.2 million in FY1999 for a variety of activities, 
including the development of a new adverse action databank; (6) 
based on GAO's review of selected deposit, allocation, and 
expenditure transactions, GAO found that these transactions 
were related to HIPAA deposits, allocations, and expenditures 
as reported by HHS and DOJ in their joint reports; (7) GAO 
found no material weakness in HHS' and DOJ's processes for 
accumulating HCFAC deposit, allocation, and expenditure 
information; (8) GAO could not identify expenditures from the 
trust fund for HCFAC activities not related to Medicare because 
neither the HHS/OIG nor DOJ separately account for or monitor 
those expenditures; (9) GAO also could not determine the 
magnitude of savings to the trust fund, or other savings, 
resulting from the HCFAC trust fund expenditures during fiscal 
years 1998 and 1999; (10) however, the HHS/OIG reported $10.8 
billion and $11.8 billion for fiscal years 1998 and 1999, 
respectively, in cost savings of health care funds as a result 
of its recommendations or other initiatives; (11) the 
Healthcare Integrity and Protection Data Bank (HIPDB) opened 
for reporting on November 22, 1999, and for querying on March 
6, 2000; and (12) however, implementation of HIPDB was 
postponed primarily as a result of the delayed issuanceof final 
governing regulations.
Medicare: Identifying Third-Party Billing Companies Submitting Claims. 
        (GAO/HEHS-99-127R, June 2, 1999).
    Pursuant to a congressional request, GAO described how the 
Health Care Financing Administration (HCFA) and its contractors 
monitor third-party billing companies' involvement in the 
submission of claims to Medicare. GAO noted that: (1) providers 
are ultimately responsible for the claims that they submit or 
that are submitted on their behalf; (2) despite this, HCFA has 
an interest in tracking claims submitted by third-party billers 
as one way of targeting its program safeguard resources and 
determining the source of inappropriate or fraudulent claims; 
(3) GAO found that HCFA cannot identify when third-party 
billers were involved in the more than 700 million electronic 
claims in fiscal year 1998, because its systems identify only 
one of the many possible entities involved in preparing a 
claim; (4) further, paper claims--146 million in 1998--do not 
have any identifying information that would indicate whether 
third-party billers submitted them; (5) GAO also found 
weaknesses in HCFA's efforts to obtain information about third-
party billers; (6) HCFA issued a new enrollment form for 
providers first enrolling in Medicare after May 1996; (7) this 
form obtains the identity of third-party billers that the 
enrolling providers use; (8) however, since 96 percent of 
Medicare's providers enrolled in Medicare before 1996, HCFA has 
no information on billing arrangements for most providers; (9) 
HCFA is proceeding with plans to develop a national system to 
capture this information on the enrollment form, even though 
the system would initially contain data for only a fraction of 
all Medicare providers; and (10) although HCFA's plans for 
implementing this system are not final, HCFA officials told GAO 
they plan to complete it after addressing computer systems work 
needed to prepare for year 2000.
Medicare: Improprieties by Contractors Compromised Medicare Program 
        Integrity. (GAO/OSI-99-7, July 14, 1999).
    Criminal and/or civil actions have been taken against at 
least six Medicare contractors since 1993. Three of the 
contractors or their employees--BCBS of Illinois, Blue Shield 
of California, and Pennsylvania Blue Shield--pled guilty to 
criminal charges and agreed to pay fines and penalties. 
Investigations of three other contractors--BCBS of 
Massachusetts, BCBS of Michigan, and BCBS of Florida--resulted 
in civil settlements only. More than $261 million was assessed 
against these six contractors. Contractors improperly screened, 
processed, and paid claims, resulting in additional costs to 
Medicare; improperly destroyed or deleted claims; failed to 
recoup overpayments to Medicare providers within the prescribed 
time and to collect required interest payments; falsified 
documentation and reports to the Health Care Financing 
Administration (HCFA) about their performance; and altered or 
hid files that involved claims that had been incorrectly 
processed or paid and altered contractor audits of Medicare 
providers before HCFA's reviews. The persons GAO spoke with 
said that these deceptions and improprieties became a way of 
doing business and went undetected for long periods because 
HCFA reviews of Medicare contractors relied on information 
supplied by the contractors. HCFA also gave contractors 
advanced notice of the files it intended to review, giving 
contractors ample time to ``correct,'' delete, or hide claim-
related documents or redo provider audits and related 
workpapers before HCFA's review. This system also resulted in 
contractors deviating from their normal operating procedures 
during HCFA evaluations in order to deceive HCFA about their 
accuracy and efficiency in claims processing and customer 
service. As a result, criminal and other improper activities 
were discovered only after whistleblowers filed complaints 
under the False Claims Act.
Medicare: Improvements Needed to Enhance Protection of Confidential 
        Health Information. (GAO/HEHS-99-140, July 20, 1999).
    The Health Care Financing Administration (HCFA) collects 
and maintains personally identifiable health information on its 
39 million Medicare beneficiaries for paying claims, 
determining eligibility, reviewing care, and performing 
research that helps improve Medicare. Under the Privacy Act of 
1974, HCFA may disclose this information to other agencies, but 
confidentiality is compromised by HCFA's and its contractors' 
management of electronic information and its inability to 
prevent unauthorized disclosures or uses and to correct them in 
a timely way. HCFA also cannot readily provide beneficiaries 
with an accounting of the disclosures it makes and does not 
always clearly inform them of its purpose in disclosing 
information as required by the Privacy Act. It does not 
adequately provide oversight agencies such as the Office of 
Management and Budget with complete information on its Privacy 
Act activities. Also, HCFA's policy of allowing the states to 
withhold sensitive health information could adversely affect 
its ability to set rates, monitor quality, and conduct or 
support health-related research. GAO recommends ways HCFA can 
improve its protection of confidential information.
Medicare: Lessons Learned From HCFA's Implementation of Changes to 
        Benefits. (GAO/HEHS-00-31, Jan. 25, 2000).
    Medicare has undergone many changes as Congress has 
expanded and modernized the program. The Health Care Financing 
Administration's (HCFA) implementation of these changes has 
sometimes created program vulnerabilities. As a result, 
dishonest or unknowing providers have submitted claims for 
inappropriate service, unknowledgeable contractors have 
processed these claims, and HCFA has sometimes paid more than 
it should have. The Balanced Budget Act of 1997 set in motion 
additional changes that were intended to modernize the Medicare 
program, expand benefits, and extend the life of the Medicare 
trust fund. HCFA faces the challenge of implementing the act's 
provisions in a way that ensures beneficiaries' access to 
covered services without compromising the program's fiscal 
integrity. This report compares (1) HCFA's implementation of 
the expansion of the partial hospitalization benefit and (2) 
HCFA's implementation of the more recent changes under the act 
to determine whether HCFA is acting upon lessons learned from 
the partial hospitalization program.
Medicare: Methodology to Identify and Measure Improper Payments in the 
        Medicare Program Does Not Include All Fraud. (GAO/AIMD-00-69R, 
        Feb. 4, 2000).
    Pursuant to a congressional request, GAO provided 
information on the methodology used to estimate the $12.6 
billion in Medicare improper payments, as reported by the 
Department of Health and Human Services' (HHS) Office of 
Inspector General (OIG) for fiscal year (FY) 1998, focusing on 
whether the methodology included tests to detect improper 
payments resulting from fraudulent and abusive schemes in the 
Medicare program.
    GAO noted that: (1) the HHS OIG developed an overall 
methodology to estimate the level of improper payments within 
the Medicare Fee-for-Service program; (2) the OIG developed and 
tested the methodology during its audit of the FY1996 financial 
statements of the Health Care Financing Administration (HCFA); 
(3) previously, no overall methodology existed to estimate 
Medicare improper payments; (4) the methodology was a 
significant step toward quantifying Medicare improper payments; 
(5) its primary purpose was to provide users of HCFA's 
financial statements with an estimate of Medicare fee-for-
service claims that were paid in error; (6) it was not designed 
to identify or measure the full extent of levels of fraud and 
abuse in the Medicare program; (7) the HHS OIG testified that 
the estimate of improper payments did not take into 
consideration numerous kinds of outright fraud such as ``phony 
records'' or kickback schemes; (8) the methodology assumes that 
all medical records received for review represent actual 
services provided; (9) in response to the increased focus 
resulting from HHS OIG's efforts in this area, HCFA is 
developing plans to enhance its efforts to identify or measure 
Medicare improper payments; and (10) GAO is reviewing these 
plans and will report to Congress separately on them.
Medicare: More Beneficiaries Use Hospice but for Fewer Days of Care. 
        (GAO/HEHS-00-182, Sept. 18, 2000).
    Pursuant to a congressional request, GAO provided 
information on the Medicare hospice benefit, focusing on: (1) 
the patterns and trends in hospice use by Medicare 
beneficiaries; (2) factors that affect the use of the hospice 
benefit; and (3) the availability of hospice providers to serve 
the needs of Medicare beneficiaries.
    GAO noted that: (1) the number of Medicare beneficiaries 
choosing hospice services has increased substantially; (2) in 
1998, nearly 360,000 Medicare beneficiaries enrolled in a 
hospice program, more than twice the number who elected hospice 
in 1992; (3) of Medicare beneficiaries who died in 1998, about 
one in five used the hospice benefit, but use varies 
considerably across the states; (4) although cancer patients 
account for more than half of Medicare hospice patients, growth 
in use has been particularly strong among individuals with 
other common diagnoses such as heart disease, lung disease, 
stroke, and Alzheimer's disease; (5) although more 
beneficiaries are choosing hospice, many are doing so closer to 
the time of death; (6) the average period of hospice use 
declined from 74 days in 1992 to 59 days in 1998; (7) half of 
Medicare hospice users now receive care for 19 or fewer days, 
and care for 1 week or less is common; (8) many factors 
influence the use of the Medicare hospice benefit; (9) 
decisions about whether and when to use hospice depend on 
physician preferences and practices, patient choice and 
circumstances, and public and professional awareness of the 
benefit; (10) along with these factors, increases in federal 
scrutiny of compliance with program eligibility requirements 
may have contributed to a decline in the average number of days 
of hospice care that beneficiaries use; (11) the growth in the 
number of Medicare hospice providers in both urban and rural 
areas and in almost every state suggests that hospice services 
are more widely available to program beneficiaries than in the 
past; (12) between 1992 and 1999, the number of hospices 
participating in Medicare increased 82 percent, with large 
providers and those in the for-profit sector accounting for a 
greater proportion of the services delivered; (13) at the same 
time, hospice industry officials report cost pressures from 
declining patient enrollment periods and increased use of more 
expensive forms of palliative care; (14) because reliable data 
on provider costs are not available, however, the effect of 
these reported cost pressures on the overall financial 
condition of hospice providers is uncertain; and (15) as 
required by the Balanced Budget Act of 1997, the Health Care 
Financing Administration began collecting information in 1999 
from hospice providers about their costs to allow a 
reevaluation of the Medicare hospice payment rate.
Medicare: Outpatient Rehabilitation Therapy Caps Are Important Controls 
        But Should Be Adjusted for Patient Need. (GAO/HEHS-00-15R, Oct. 
        8, 1999).
    Pursuant to a congressional request, GAO provided 
information on the: (1) rationale for imposing per-beneficiary 
limits on Medicare's coverage of rehabilitation therapy 
services; and (2) effect of the therapy caps on Medicare 
beneficiaries' access to needed care.
    GAO noted that: (1) the per-beneficiary caps on coverage of 
outpatient rehabilitation therapy services are part of a larger 
effort by Congress to curb Medicare spending for post-acute 
care services; (2) in particular, Medicare spending for 
outpatient rehabilitation therapy services, between 1990 and 
1996, grew at nearly double the rate of Medicare spending 
overall; (3) at the same time, inadequate program controls 
failed to ensure that this spending growth was warranted; (4) 
under the fee schedule and coverage caps imposed by the 
Balanced Budget Act of 1997 (BBA), Medicare can moderate the 
price and utilization of these services; (5) the beneficiary 
caps are unlikely to affect the vast majority of Medicare's 
outpatient therapy users; (6) only a small share of 
beneficiaries uses outpatient therapy extensively; (7) 
furthermore, most of the users with greater needs will likely 
have access to hospital outpatient departments, which are not 
subject to the $1,500 caps; (8) in addition, owing to Health 
Care Financing Administration's (HCFA) partial approach to 
enforcing the caps while year 2000 adjustments are made to 
Medicare's automated systems, noninstitutionalized 
beneficiaries can avoid having the caps curtail service 
coverage by switching providers; (9) however, the caps may 
restrict coverage for some nursing facility residents; (10) 
studies are under way or planned to better assess the effect of 
the caps and evaluate alternative utilization controls; (11) 
BBA required HCFA to recommend a need-based payment system by 
2001, which could help target payments to beneficiaries who 
genuinely require more services than are covered under the 
current dollar limits; and (12) such a system would raise the 
dollar limits for therapy users with extensive needs and lower 
them for users with modest needs.
Medicare: Post-Hearing Questions Related to Financial and Information 
        Technology Management. (GAO-01-275R, Dec. 21, 2000).
    GAO responded to congressional questions related to 
financial and information technology management of the Medicare 
Program. Among the topics discussed were claims processing, 
management of statistical data, and computer viruses. For 
example, in reference to claims processing, GAO noted that, as 
of December 2000, Medicare carriers and fiscal intermediaries 
use six standard claims processing systems to process Medicare 
part A and B claims. Each contractor relies on one of these 
standard systems to process its claims, and adds its own front-
end and back-end processing systems. These claims processing 
systems date back as far as 1982. In reference to the 
management of statistical data, GAO noted that the Health Care 
Financing Administration's (HCFA) common working file provides 
individual beneficiary claims data to HCFA's National Claims 
History File, which is used as the source of statistical 
information on Medicare and medical data. HCFA officials were 
not aware of any system outside HCFA where this type of data 
could be obtained. Finally, regarding computer viruses, a HCFA 
information technology security official informed GAO that the 
``ILOVEYOU'' virus did not contaminate its systems. The 
official said the virus had no adverse effects on any of the 
workstations, because the electronic mail application used at 
HCFA was not capable of executing the Visual Basic Script file, 
which is how the ``ILOVEYOU'' virus was executed. The official 
also said that the Melissa virus was detected and there were no 
incidents.
Medicare Physician Payments: Need to Refine Practice Expense Values 
        During Transition and Long Term. (GAO/HEHS-99-30, Feb. 24, 
        1999).
    In 1992, Medicare began using a fee schedule to pay doctors 
for more than 7,000 procedures, from routine office visits to 
brain surgery. The intent of the new payment system was to base 
physicians' payments on the relative resources used to provide 
a procedure rather than on the physicians' charges. To develop 
the fee schedule, each medical procedure is ranked on a scale 
according to the amounts of three categories of resources used 
to perform the procedure -- physician work, practice expenses, 
and malpractice expenses. A fee schedule amount for each 
procedure is computed by multiplying the sum of the procedure's 
three rankings, known as relative value units, by a conversion 
factor that translates the units into dollars. This report 
discusses the Health Care Financing Administration's (HCFA) 
ongoing efforts to develop resource-based practice expense 
relative value units. GAO's review focuses on (1) whether the 
new methodology is an acceptable approach for revising 
Medicare's fee schedule; (2) questions raised about the data, 
assumptions, and adjustments underlying the new methodology 
that need to be addressed during the three-year phase-in 
period; and (3) the need for future updates to the practice 
expense relative value units to reflect changes in health care 
delivery and for ongoing assessments of the fee schedule's 
effect on Medicare beneficiaries' access to physicians' care.
Medicare: Program Safeguard Activities Expand, but Results Difficult to 
        Measure. (GAO/HEHS-99-165, Aug. 4, 1999).
    Health Care Financing Administration (HCFA) contractors 
perform five main types of program safeguard activity under the 
Medicare Integrity Program, which was established in 1996 to 
protect Medicare from fraud, waste, and abuse. The program has 
dedicated, assured funding and HCFA's contractors are better 
able than before to plan and implement their safeguard strategy 
and efforts. HCFA is emphasizing prepayment claims reviews to 
promote correct claims payment and avoid the difficulty of 
seeking repayment from providers when claims are paid in error. 
HCFA has also recently hired program safeguard contractors 
which will initially supplement, rather than take over, the 
safeguard activities of its claims processing contractors. HCFA 
has taken or plans to take corrective action to improve 
important areas identified by audit reports under the Chief 
Financial Officers Act. It is also taking seriously its 
responsibilities to improve program safeguard operations in 
response to recommendations from GAO and from the HHS Office of 
the Inspector General. HCFA will be better able to measure the 
program's effects with more time and better data.
Medicare: Reporting on the Health Care Fraud and Abuse Control Program 
        for Fiscal Years 1998 and 1999. (GAO/AIMD-00-51R, Dec. 13, 
        1999).
    Pursuant to a legislative requirement, GAO reviewed the 
Health Care Fraud and Abuse Control (HCFAC) program, focusing 
on: (1) the amounts deposited to the Federal Hospital Insurance 
Trust Fund pursuant to the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA) and the sources of such 
amounts; (2) the amounts appropriated from the trust fund for 
HCFAC program and the justification for the expenditures of 
such amounts; (3) expenditures from the trust fund for HCFAC 
activities not related to Medicare; (4) any savings to the 
trust fund, as well as other savings, resulting from 
expenditures from the trust fund for the HCFAC program; and (5) 
other aspects of the operation of the trust fund.
    GAO noted that: (1) the Departments of Health and Human 
Services (HHS) and Justice (DOJ) together administer the HCFAC 
program and are required to issue a report to Congress on 
January 1 of each year concerning HCFAC program activities for 
the preceding fiscal year (FY); (2) they are required to report 
on: (a) amounts appropriated to the Federal Hospital Insurance 
Trust Fund pursuant to HIPAA and the source of those amounts; 
and (b) amounts appropriated from the trust fund for the HCFAC 
program and the justification for the expenditure of such 
amounts; (3) HHS and DOJ have issued two joint reports, 
covering fiscal years 1997 and 1998; (4) the next joint report, 
covering the FY1999 HCFAC program, is due on January 1, 2000; 
(5) the joint report covering FY1999 HCFAC program activity, 
which is not required to be issued until January 1, 2000, will 
contain information GAO needs to perform its review; (6) after 
receiving the joint report covering FY1999, GAO will need time 
to determine what, if any, additional information is needed as 
well as to obtain and review that information; and (7) 
therefore, GAO will be unable to meet its reporting deadline of 
January 1, 2000, and in all likelihood, its 2002 and 2004 
commitments as well.
Medicare and Managed Care Plans: Payments and Costs for Selected 
        Hospitals. (GAO/HEHS-00-177R, Sept. 1, 2000).
    Pursuant to a congressional request, GAO reviewed Medicare 
and managed care plan hospital costs and payments, focusing on: 
(1) the relationship between Medicare and managed care plan 
payments and costs; (2) managed care plan payments and the 
relative importance of managed care business; and (3) Medicare 
and managed care plan payments and costs by hospital teaching 
status.
    GAO noted that: (1) for the average hospital responding to 
GAO's survey, payments from both managed care plans and 
Medicare covered their respective costs for all types of cases, 
although there was considerable variation across hospitals in 
the relationship between payments and costs; (2) average 
managed care plan payments per case for inpatient services were 
lower than average Medicare payments for the types of cases GAO 
examined; (3) however, average managed care plan costs per case 
were also lower than Medicare's; (4) the relationship between 
managed care plan payments and costs appeared to be associated 
with the level of managed care enrollment in the responding 
hospital's market area and the hospital's relative share of 
inpatient revenues from this payer; (5) responding hospitals in 
areas with low managed care plan enrollment or responding 
hospitals with more managed care plan business were more likely 
to have higher plan payments, relative to their costs, than 
other responding hospitals; (6) the average hospital with a 
large teachingprogram reported losses from its managed care 
business, but Medicare payments were well above its costs; and 
(7) managed care plan payments were more generous than 
Medicare's to the average responding hospital with a smaller 
teaching program, although Medicare payments still on average 
covered its costs.
Medicare and Medicaid: Implementing State Demonstrations for Dual 
        Eligibles Has Proven Challenging. (GAO/HEHS-00-94, Aug. 18, 
        2000).
    Pursuant to a congressional request, GAO reviewed states' 
initiatives to enroll dual eligibles (beneficiaries who qualify 
for both Medicare and Medicaid benefits) into one managed care 
plan, focusing on: (1) the status and key features of state 
initiatives to integrate care for dual-eligible beneficiaries; 
and (2) factors that have contributed to the length of the 
waiver negotiation process and implementation time frames.
    GAO noted that: (1) Minnesota and Wisconsin are enrolling a 
small number of dual eligibles in limited geographic areas into 
integrated care programs, and two additional states plan to 
implement programs by 2001; (2) officials in these four states 
view their initial efforts as stepping stones and plan to make 
their programs more widely available; (3) since the 1995 
approval of an integrated care program in Minnesota, the states 
of Wisconsin and New York also have received federal approval 
to integrate Medicaid and Medicare services for dual eligibles, 
and the Health Care Financing Administration and Massachusetts 
are working toward approval of that states' program; (4) states 
are emphasizing service delivery in beneficiaries' homes and 
targeting different segments of the dual-eligible population 
compared with the Program for All-Inclusive Care for the 
Elderly, which enrolls only frail individuals; (5) all health 
plans in states with approved programs are nonprofit, including 
the three participating health maintenance organizations in 
Minnesota; (6) important factors associated with states' 
decisions about pursuing integrated care programs for dual 
eligibles are the complexity of planning and implementing a 
demonstration and the extended time frames needed to do so; (7) 
states have criticized the length of the process required to 
gain federal approval for their initiatives; (8) in states with 
approved programs, the federal waiver review process ranged 
from over 1 year to over 3 years; (9) though some delays were 
associated with the Health Care Financing Administration's 
(HCFA) 1997 reorganization and the heavy new demands on the 
agency as a result of 1997 legislation, HCFA has taken action 
to try to speed up the review process; (10) difficulty in 
reaching agreement on an appropriate Medicare payment 
methodology for integrated care programs was an important 
factor that delayed the approval of state waiver applications; 
(11) the challenge has been to agree on payment rates that 
adequately compensate health plans for differences in frailty 
among dual eligibles while meeting the Office of Management and 
Budget's requirement that Medicare demonstrations notincrease 
federal Medicare expenditures from what they would have been 
without the demonstration; (12) Medicare's move toward a new 
diagnosis-based risk-adjustment methodology raises concerns for 
state demonstrations because research has shown that the 
methodology tends to underestimate the costs of frail 
beneficiaries; and (13) this situation underscores the 
importance of learning from these four state demonstrations so 
that their experience may inform similar initiatives that other 
states may be considering.
Medicare+Choice: Impact of 1997 Balanced Budget Act Payment Reforms on 
        Beneficiaries and Plans. (GAO/HEHS-99-137, June 9, 1999).
    The net effect of payment revisions under the Balanced 
Budget Act of 1997 has been to reduce, but not fully eliminate, 
excess payments to health plans. Some provisions, such as the 
reduced annual updates, have been implemented while others, 
such as the health-based risk adjustment system, are still to 
be phased in. Sweeping amendments to the act are not yet 
warranted for three reasons. First, the net effect of reforms 
on plans has been modest. Cuts in rate increases, for example, 
have held down per capita payment growth by only a little more 
than one percent. Second, at least some plans can provide the 
traditional Medicare package of benefits, offer some additional 
benefits, and make a profit even if they are paid less than 
they are today. For example, plans serving the Los Angeles area 
can provide the traditional Medicare package of benefits for 
about 79 percent of what they are currently paid. Third, the 
withdrawals GAO observed this year were not a reaction to the 
act's rate reductions alone. Market forces appear to have 
played a larger role. The acts health plan payment reforms will 
reduce aggregate excess payments and, as a result, some 
Medicare+Choice plans may reduce their supplemental benefits 
and rethink their participation in Medicare. The continuing 
challenge for Congress is to strike the appropriate balance 
between containing Medicare spending and fostering growth in 
Medicare+Choice.
Medicare+Choice: New Standards Could Improve Accuracy and Usefulness of 
        Plan Literature. (GAO/HEHS-99-92, April 12, 1999).
    GAO found that 16 managed care organizations participating 
in the Medicare+Choice program--Medicare's alternative to fee-
for-service--gave beneficiaries materials containing inaccurate 
or incomplete benefit information. For example, materials from 
five organizations said that annual screening mammograms 
required a physician's referral, even though Medicare 
explicitly prohibits this. One organization provided an 
outpatient prescription drug benefit that was substantially 
less generous than that agreed to in its Medicare contract. GAO 
found no errors about ambulance services but written materials 
often omitted important information about that benefit. Some 
organizations provided complete information on benefits and 
restrictions only after a beneficiary had enrolled. Each 
organization used its own format and terms to describe its 
plan's benefit package, making it difficult for beneficiaries 
to compare available options. Weaknesses in the processes the 
Health Care Financing Administration (HCFA) uses to review 
organizations' member literature led some reviewers to rely on 
the organization to help verify its accuracy, created 
opportunities for inconsistent review practices, and led HCFA 
to fail to ensure that errors reviewers identified were 
corrected. Beneficiaries would be helped by (1) full 
implementation of HCFA's new contract form describing the 
plans' benefit coverage; (2) new standards for terminology, 
formats, and distribution of key member literature; (3)standard 
forms for routine administrative functions; (4) standard 
marketing procedures to review material; and (5) requiring 
organizations to provide beneficiaries with a single standard 
brochure like that distributed to members of the Federal 
Employees Health Benefits Program.
Medicare+Choice: Oversight Lapses in HCFA's Review of Humana's 1998 
        Florida Contract. (GAO-01-176R, Nov. 27, 2000).
    Humana, Inc., a large Medicare Choice Plan, provided a 
prescription drug benefit with a coverage limit that was below 
the amount listed in its 1998 Florida Medicare Choice contract. 
Ernst and Young, the contractor hired by the Health Care 
Financing Administration (HCFA) to review Humana's contract 
submission, did not detect the discrepancies because it failed 
to follow HCFA's review procedures. HCFA has revised its 
processes and procedures for monitoring the accuracy of the 
information in Medicare Choice plans' contracts. The Humana 
case shows that the agency did not follow procedures that could 
have revealed the contract discrepancies that caused some 
beneficiaries to receive less coverage for brand name 
prescription drugs than the amount specified in their plan's 
basic package. Unless HCFA adheres to its revised monitoring 
procedures, beneficiaries will have few guarantees that they 
will receive the prescription drug benefits for which the 
government contracted and paid.
Medicare+Choice: Payments Exceed Cost of Fee-for-Service Benefits, 
        Adding Billions to Spending. (GAO/HEHS-00-161, Aug. 23, 2000).
    Medicare+Choice has not yielded savings for Medicare 
because its plans attract a disproportionate selection of 
healthier and less-expensive beneficiaries relative to 
traditional fee-for-service (FFS) Medicare--a phenomenon known 
as favorable selection. The program spent about $3.2 billion, 
or 13.2 percent, more on health plan enrollees than if 
enrollees had received services through traditional FFS 
Medicare. Although the Health Care Financing Administration 
(HCFA) introduced a new methodology to adjust payments for 
beneficiary health status, it may ultimately remove less than 
half of the excess payments caused by favorable selection. 
Spending forecast errors built into plan payment rates and 
provisions in the Balanced Budget Act caused an additional $2 
billion, or eight percent, in excess payments to plans. 
Although all of the 210 plans in the study received excess 
payments, the percentage of estimated excess payments varied 
substantially among plans. The largest estimated excess payment 
totaled $334 million, or 40 percent more than Medicare would 
have paid in an FFS plan. Nine plans received payments below 
their enrollees' expected FFS costs. When excess payments due 
to forecast error are included, only two of the 210 plans were 
paid less--$1.7 million and $175,000--than its enrollees' 
expected FFS costs.
Medicare+Choice: Plan Withdrawals Indicate Difficulty of Providing 
        Choice While Achieving Savings. (GAO/HEHS-00-183, Sept. 7, 
        2000).
    Pursuant to a congressional request, GAO reviewed health 
care plans' withdrawal from the Medicare+Choice program, 
focusing on the: (1) geographic distribution and the 
distribution among plans of enrollees affected by the recent 
plan withdrawals; (2) factors associated with plans that 
terminated or reduced their participation in the program; and 
(3) likely role of payment rates in affecting plans' decisions.
    GAO noted that: (1) of 309 plans serving Medicare 
beneficiaries at the end of 1999, 99 plans terminated their 
contracts or reduced the number of counties they served for the 
2000 contract year, and 118 have announced they will terminate 
their contracts or reduce service areas for the 2001 contract 
year; (2) these withdrawals affected about 328,000 enrollees in 
2000 and will affect almost 1 million enrollees in 2001; (3) 
the number of enrollees affected accounts for about 5 percent 
of Medicare+Choice enrollees in 2000 and about 15 percent in 
2001; (4) a disproportionate number of affected enrollees live 
outside of major urban areas; (5) a portion of the affected 
enrollees, approximately 79,000 in 2000 and 159,000 in 2001, 
will have no other Medicare managed care option available in 
their area and must either switch to a non-managed care option, 
if one is available in their area, or return to traditional 
fee-for-service (FFS) Medicare; (6) while a new private FFS 
plan has begun to offer services in many of the affected areas 
as an alternative to the traditional public FFS Health Care 
Financing Administration (HCFA) manages, does not offer a 
prescription drug benefit; (7) in January 2000, Medicare+Choice 
plans tended to withdraw from more difficult to serve rural 
counties or large urban areas that they had entered more 
recently or where they failed to attract sufficient enrollment; 
(8) in 2001, the trend is essentially the same for the service 
area reductions butsomewhat different for the contract 
terminations, which involve some older, more established plans; 
(9) the pattern of Medicare+Choice withdrawals shares common 
elements with plan participation in the similarly choice-based 
health insurance program for federal employees; (10) industry 
representatives contend that the Balanced Budget Act's (BBA) 
payment rate changes were too severe and that low Medicare 
payment rates are largely responsible for the plan withdrawals; 
(11) however, since the BBA was enacted, Medicare+Choice 
payment rates have risen faster than per capita FFS spending; 
(12) in addition, many plans have attracted beneficiaries who 
have lower-than-average expected health care costs, while 
Medicare+Choice payments are largely based on the expected cost 
of beneficiaries with average health care needs; and (13) the 
extent to which Medicare+Choice payment rate increases would 
affect plans' participation decisions is unclear.
Medicare+Choice: Reforms Have Reduced, but Likely Not Eliminated, 
        Excess Plan Payments. (GAO/HEHS-99-144, June 18, 1999).
    The Medicare+Choice program was created in 1997 to expand 
beneficiaries' health plan options, both by encouraging the 
wider availability of health maintenance organizations and by 
permitting othertypes of health plans, such as preferred 
provider organizations, to participate in Medicare. At the same 
time, the methodology used to determine plan payments was 
changed, in part because of concerns that (1) many health plans 
were overcompensated for the beneficiaries they served and (2) 
Medicare's managed care program had not, as originally 
expected, saved the program money. The new methodology is 
designed to both slow the growth of aggregate payments and more 
closely align per capita payments with the expected health care 
costs of plan members. Some health plan and industry 
representatives believe that these payment changes were too 
severe and will reduce beneficiaries' access to plans and 
additional benefits, such as outpatient prescription drug 
coverage, that are unavailable under fee-for-service plans. 
This report (1) reviews the extent to which health plans now 
provide additional benefits and whether they could continue to 
provide additional benefits if payments were reduced, (2) 
summarizes the evidence about managed care's effect on Medicare 
spending, and (3) assesses whether the provisions of the 
Balanced Budget Act will eliminate excess plan payments.
Medicare Contractors: Despite Its Efforts, HCFA Cannot Ensure Their 
        Effectiveness or Integrity. (GAO/HEHS-99-115, July 14, 1999).
    The Health Care Financing Administration's (HCFA) 
intermediary and carrier contractors improperly paid an 
estimated $12 billion in 1998 for Medicare fee-for-service 
claims from hospitals, physicians, and others. Yet HCFA does 
only limited reviews of these contractors' activities, 
generally accepting financial and workload information as 
presented, without systematically validating it and without 
verifying contractors' self-certifications that internal 
controls are working effectively. HCFA should (1) establish 
measurable contractor performance standards, particularly in 
the program safeguard area; (2) set program wide priorities for 
assessing all contractors on core performance standards; and 
(3) develop a standardized report format that will facilitate 
comparisons of contractors' performance and the use of trend 
data for longitudinal assessments of individual contractor 
performance. HCFAalso needs an organizational structure that 
will ensure that regions are evaluated on, and held accountable 
for, the quality of their oversight of contractors. It needs to 
regularly share best practices and ensure that regional 
oversight staff adopt them. HCFA contracts out claims 
administration to a shrinking pool of companies whose private 
interests are increasingly competing with their Medicare 
responsibilities. It is seeking legislative remedies, but it 
will need time, additional information, and experience to 
properly implement them. HCFA could benefit from a strategic 
plan for routinely conducting competitive procurements and 
managing claims administration contractors.
Medicare Contractors: Further Improvement Needed in Headquarters and 
        Regional Office Oversight. (GAO/HEHS-00-46, Mar. 23, 2000).
    HCFA is taking a number of steps to strengthen contractor 
oversight by its central office and10 regional offices, but 
most of these actions are still in the planning or early 
implementation stages. Even if these efforts are successful, 
HCFA's central and regional offices are still likely to face 
difficulties in working together effectively to oversee 
Medicare contractors. Until very recently, HCFA regional 
overseers were not directly accountable to the central office 
group responsible for contractor oversight activities.
    Other weaknesses in its oversight management have not yet 
been addressed. Specifically, HCFA (1) lacks adequate 
management information on regional office resources used or 
needed for evaluating contractors; (2) since 1995, has provided 
late annual instructions (or none at all) on what oversight 
must be conducted by regional office reviewers; and(3) does not 
effectively employ available management tools--such as routine 
feedback to regional offices--to ensure that adequate 
contractor oversight is performed. To enhance management of 
contractor oversight and improve accountability and 
communications, we made several recommendations in this report.
Medicare Financial Management: Further Improvements Needed to Establish 
        Adequate Financial Control and Accountability. (GAO/AIMD-00-66, 
        March 15, 2000).
    Although the Health Care Financing Administration (HCFA) is 
supposed to ensure that the billions of dollars spent on 
Medicare each year are managed in a fiscally responsible way, 
it has yet to establish adequate accountability and control 
over the program's financial operations. HCFA's financial 
management activities--from evaluation and follow-ups on audit 
findings to contractor monitoring and financial reporting--fall 
short in addressing weaknesses repeatedly cited in audits and 
other reviews. Unless these weaknesses are resolved, the 
government is at risk of substantial losses. Financial 
statement audits have long criticized claims contractors for 
internal control and financial reporting weaknesses, including 
failure to safeguard checks received from providers for 
overpayments and incorrectly recording billions of dollars owed 
to Medicare for such overpayments. However, HCFA's procedures 
for following up on audit findings and evaluating corrective 
actions remain insufficient. Poor monitoring of contractors' 
financial activities is another problem. Audit reports have 
also cited HCFA for inefficiencies in its internal financial 
reporting practices, including a lack of documented policies 
and procedures. These deficiencies call into question the 
reliability of the data that Congress and HCFA use to track 
Medicare program costs and make decisions about future funding. 
HCFA officials have launched several initiatives to strengthen 
the agency's control andaccountability, such as hiring outside 
consultants to evaluate the contractors' internal controls. 
However, the agency still lacks a comprehensive strategy to 
ensure successful implementation of these initiatives, direct 
financial management activities, and sustain improvements in 
the long term. Without such a strategy, billions of dollars 
will remain vulnerable to fraud and abuse and HCFA's financial 
management problems will likely persist.
Medicare Fraud and Abuse: Early Status of DOJ's Compliance With False 
        Claims Act Guidance. (GAO/HEHS-99-42R, Feb. 1, 1999).
    Pursuant to a legislative requirement, GAO provided 
information on: (1) the Department of Justice's (DOJ) 
implementation of its False Claims Act guidance; and (2) DOJ's 
U.S. Attorneys' Offices' involvement in DOJ's national health 
care initiatives.
    GAO noted that: (1) DOJ has begun taking steps to implement 
its False Claims Act guidance and has designated four national 
antifraud projects as national initiatives; (2) however, it is 
too early for GAO to reach a conclusion regarding DOJ's 
compliance with the guidance, in part, because its working 
groups are in various stages of preparing documentation to 
guide participating U.S. Attorneys' Offices; (3) in addition, 
while GAO surveyed all U.S. Attorneys' Offices concerning their 
involvement in national initiatives, GAO still needs to visit 
selected offices to evaluate their compliance with the 
guidance; (4) GAO's survey indicated that while most offices 
have matters pending related to at least one of these national 
initiatives, such matters represent a small part of their 
overall civil caseload; (5) the survey also indicated that 
since the guidance was issued, almost seven times as many 
national initiative matters were closed as were opened; and (6) 
about one-half of these closed matters involved settlements, 
while the remainder did not involve any adverse actions against 
providers.
Medicare Fraud and Abuse: DOJ Has Made Progress in Implementing False 
        Claims Act Guidance. (GAO/HEHS-00-73, Mar. 31, 2000).
    Health care fraud in the United States costs taxpayers 
billions of dollars each year. A key weapon against health care 
fraud is the False Claims Act, which allows the Justice 
Department to bring civil enforcement actions and seeks 
significant damages and penalties against providers who 
knowingly submit fraudulent bills to Medicare, Medicaid, and 
other federal health programs. The government collected more 
than $490 million from health care fraud settlements, 
judgements, and administrative actions in 1999. The Justice 
Department's use of the act, however, has been controversial. 
The hospital industry has alleged that a Justice Department 
investigation of hospitals nationwide has been unfair and 
overzealous. The Justice Department responded by issuing 
guidance to its staff on the appropriate use of the act in 
civil health care matters. In a July 1999 report, GAO found 
that the Justice Department's process for assessing compliance 
at U.S. Attorney's Offices appeared superficial and that 
implementation of the guidance varied among the U.S. Attorney's 
Offices. GAO recommended that the Justice Department improve 
its oversight. This report discusses what has been done in 
response to GAO's earlier recommendations. This report also 
focuses on the mostcontroversial of the four national 
initiatives--Laboratory Unbundling.
Medicare Fraud and Abuse: DOJ's Implementation of False Claims Act 
        Guidance in National Initiatives Varies. (GAO/HEHS-99-170, Aug. 
        6, 1999).
    The Department of Justice (DOJ) uses four ``national 
initiatives'' to enforce the False Claims Act rather than 
seeking repayment for Medicare overpayments made because of 
error, fraud, medically unnecessary services, and other 
problems. After hospitals alleged that DOJ had targeted them 
unfairly and applied the act and the initiatives overzealously, 
and Congress expressed concern, DOJ issued guidance for the 
appropriate use of these enforcement tools. GAO found that 
DOJ's process for assessing the U.S. Attorneys' Offices' 
compliance with the guidance is superficial. DOJ's assessments 
involve little more than reviewers asking supervisors what they 
have done to ensure compliance. DOJ's plans for strengthening 
the process will not provide more substantive information. GAO 
also found varied implementation of the guidance among the U.S. 
Attorneys' Offices: Some actions were inconsistent with the 
guidance and some offices may not have promptly incorporated it 
into their investigations. GAO could not conduct a complete and 
independent review because DOJ officials restricted access to 
some types of information. Nevertheless, it appears that two of 
the four initiatives are being developed in accordance with the 
guidance. GAO's survey of state hospital associations found 
that half of those that had expressed concern before the 
guidance was issued now believe that ithad fully addressed 
their concerns. GAO recommends that DOJ take additional steps 
to improve its oversight of national health care initiatives.
Medicare Home Health: Effect on Spending of Limiting Payment for Non-
        Patient-Care Costs. (GAO/HEHS-00-19R, Oct. 19, 1999).
    Pursuant to a congressional request, GAO modeled the impact 
of constraining, through various limits, home health agency 
(HHA) costs that are not directly related to patient care, 
focusing on the: (1) variation in total and non-patient-care 
costs across agencies; and (2) effect on Medicare payments if 
constraints were imposed on payments for non-patient-care 
costs.
    GAO noted that: (1) per-visit costs varied widely both by 
visit type and across free-standing agencies; (2) home health 
aide visits were the least expensive, and medical social 
service visits were the most expensive; (3) across agencies, 
costs per visit for the most expensive agencies were 4 to 10 
times those of the least expensive agencies, depending on the 
type of visit; (4) non-patient-care costs constituted a 
substantial portion of the cost for each home health visit, 
averaging around 44 percent for each visit type; (5) moreover, 
the portion of visit costs that were not directly related to 
patient care was higher for more expensive visits; (6) in 
addition, for the sample of free-standing HHAs GAO analyzed, 
Medicare payments would have been approximately 4 to 13 percent 
less if payments for non-patient-care costs had been held to 
various limits based on the cost experience of a subset of 
HHAs; (7) for example, if Medicare payments for non-patient-
care costs had been limited to the median costs of free-
standing HHAs (the 50th percentile), total payments would have 
been reduced by 3.9 percent; (8) if payments for non-patient-
care costs had been limited to the cost level of the least 
expensive 20 percent of HHAs (20th percentile), total spending 
would have been 12.6 percent lower; (9) the per-visit cost 
limits already indirectly constrain Medicare payments for non-
patient care costs, although not as much as a limit applied 
directly to non-patient-care costs would; and (10) it is not 
known how the savings estimates would have differed if all 
HHAs, including the generally higher-cost hospital-based ones, 
had been included in the analysis.
Medicare Home Health Agencies: Closures Continue, With Little Evidence 
        Beneficiary Access Is Impaired. (GAO/HEHS-99-120, May 26, 
        1999).
    Until 1998, home health care was one of Medicare's fastest 
growing benefits. In response to concerns about rising costs, 
fraud and abuse, and inadequate oversight, an interim payment 
system has been introduced that limits Medicare payments for 
home health care. Industry representatives claim that the cost 
limits are too stringent, causing some home health agencies to 
close. GAO found that prior to the widely publicized closures 
of agencies, both the number of agencies and the use of home 
health services had grown considerably. Although 14 percent of 
agencies closed between October 1997 and January 1999, 
beneficiaries are still served by more than 9,000 agencies--
about the same number that were in business in 1996. Forty 
percent of the closures were concentrated in three states with 
considerable growth in the number of agencies and utilization 
rates (visits per user as well as users per thousand fee-for-
service beneficiaries) well above the national average. In 
addition, most closures occurred in urban areas that still have 
a large number of agencies offering services. The pattern of 
agency closures suggests a response to the interim payment 
system. Attention has focused on the number of Medicare-
certified home health agencies available to provide care, but 
GAO believes that the more important question is whether 
beneficiaries continue to have access to Medicare-covered home 
health services. Overall home health utilization in the first 
quarter of 1998 had declined since 1996, but it was about the 
same as a comparable period in 1994--the year that serves at 
the base for interim payment system limits. Moreover, the 
sizeable variation in utilization between counties with high 
and low use has narrowed. These changes are consistent with 
interim payment system incentives to control utilization. GAO 
interviews in 34 primarily rural counties with substantial 
closures indicate that beneficiaries continue to have access to 
services.
Medicare Home Health Agencies: Overpayments Are Hard to Identify and 
        Even Harder to Collect. (GAO/HEHS/AIMD-00-132, April 28, 2000).
    The Health Care Financing Administration (HCFA) has been 
slow to identify amounts that closed home health agencies (HHA) 
owe Medicare, and it collects little of the overpayments due 
from them after they close. HCFA is in the process of 
implementing the home health prospective payment system 
mandated by the Balanced Budget Act of 1997, which will involve 
predetermined payments for home health services. This system 
should reduce the potential for overpayments to HHAs because 
payment amounts would not be adjusted retrospectively to 
reflect allowable agency costs. GAO's estimate of the 
overpayments due from 15 closed HHAs in Texas that had the 
largest recorded overpayments among closed HAA's in that state 
differs significantly from an estimate HCFA reported. Using the 
same definitions of overpayment, GAO estimated that these 
agencies could owe $68 million, one-third of HCFA's initial 
$209 million estimate. HCFA's inability to accurately record 
and track overpayments has been a consistent weakness, 
documented in its financial statement audits from fiscal year 
1996 through fiscal year 1999. The fiscal year 1998 audit, for 
example, found that HCFA lacked an integrated financial 
management system to track overpayments and their collection 
and that its procedures to help ensure that overpayments were 
valid and supported were inadequate. HCFA's contractors record 
and track overpayment activity for HHAs and other providers 
using fragmented and overlapping computer systems but do not 
always reconcile the data from these various systems.For 
example, contractor staff incorrectly keyed data from one of 
the contractor's systems into a HCFA system, erroneously 
reporting $77 million in overpayments for one Texas HHA in 
1998. HCFA implemented several interim measures in 1999 to 
improve the reliability of its overpayment information and is 
planning additional improvements, but they could take years to 
implement.
Medicare Home Health Agencies: Role of Surety Bonds in Increasing 
        Scrutiny and Reducing Overpayments. (GAO/HEHS-99-23, Jan. 29, 
        1999).
    In 1997, Congress required home health agencies (HHA) to 
begin posting $50,000 surety bonds that would allow the Health 
Care Financing Administration (HCFA) to recover delinquent 
overpayments made for any reason--not just in cases of fraud 
and abuse. However, net unrecovered overpayments were less than 
one percent of Medicare's home health care expenditures in 
1996. HCFA requires larger HHAs to obtain bonds equal to 15 
percent of their Medicare revenues and that they obtain 
separate bonds for Medicare and for Medicaid, which imposes a 
greater burden on them without a demonstrated commensurately 
greater benefit. GAO believes that requiring one $50,000 surety 
bond for both Medicare and Medicaid could effectively screen 
new HHAs to determine whether they are reasonably organized, 
follow sound business practices, and have financial stability. 
It would balance the benefit to Medicare of increased HHA 
scrutiny and recovery of overpayments with the burden on 
participating agencies to supply bond fees and collateral.
Medicare Home Health Care: Prospective Payment System Could Reverse 
        Recent Declines in Spending. (GAO/HEHS-00-176, Sept. 8, 2000).
    Pursuant to a congressional request, GAO provided 
information on Medicare home health care's recent declines in 
spending, focusing on: (1) the declines in service use 
underlying the changes in spending; (2) the extent of the 
changes in use across beneficiaries, home health agencies 
(HHA), and locations; and (3) identify any implications these 
new patterns of home health use have for the impact of the 
prospective payment system (PPS).
    GAO noted that: (1) the 48-percent reduction in Medicare 
home health care spending following the Balanced Budget Act 
(BBA) of 1997 was due to sharp declines in both the numbers of 
users and services used; (2) the number of Medicare 
beneficiaries receiving home health services fell by 22 
percent; (3) during the same period, the average number of home 
health visits received by each user went down 44 percent; (4) 
changes in home health care varied across agencies and types of 
users as well; (5) in nearly all instances, declines were 
greatest for the types of agencies that had provided and the 
patients who had used the most services in 1996; (6) there was 
a similar pattern in the drop in usage across states; (7) 
declines in rural areas were larger than in urban areas; (8) 
states that had the highest levels of service use in 1996 had 
larger declines than states where beneficiaries historically 
received fewer services; (9) the recent changes in home health 
utilization occurred at least in part in response to changes in 
Medicare's payment policies mandated by the BBA; (10) because 
the new PPS payment rates are based on the historically high 
utilization in 1998, even after adjusting for projected 
declines in utilization, they likely will be generous compared 
with current use patterns; (11) for this reason, home health 
agency responses to the PPS could result in overpayments 
relative to services provide while simultaneously raising 
Medicare spending; (12) under the PPS, Medicare will make a 
single payment for each 60-day episode of home health care; 
(13) the PPS will give agencies an incentive to increase the 
episodes of care they provide; and (14) this, in turn, could 
cause total Medicare home health spending to rise.
Medicare Home Health Care: Prospective Payment System Will Need 
        Refinement as Data Become Available. (GAO/HEHS-00-9, Apr. 7, 
        2000).
    Pursuant to a congressional mandate, GAO provided 
information on the design of a Medicare prospective payment 
system (PPS) for home health care, focusing on: (1) the 
objectives, findings, and costs of the Health Care Financing 
Administration's (HCFA) research projects related to the design 
of a home health PPS, and (2) how these projects contributed to 
the proposed design of the PPS and which design decisions were 
based on incomplete information.
    GAO noted that: (1) HCFA sponsored research and 
demonstration projects totaling almost $27 million; (2) yet key 
features of a PPS were not evaluated, thus limiting the ability 
to evaluate the effects of certain payment policies on home 
health care service delivery and spending; (3) the research 
provided evidence that home health agencies (HHAs) would reduce 
their costs of providing visits when paid under a tightly 
controlled PPS that limited their profits and losses; (4) the 
research did not develop a system to adjust payments to reflect 
differences in resource use across groups of patients, but that 
ongoing research would continue to develop and refine this key 
component of a PPS; (5) quality measurement and monitoring are 
not well developed that will limit the ability to evaluate the 
effects of payment changes; (6) information gaps, coupled with 
the lack of standards for whatconstitute appropriate care mean 
that the PPS could cause unintended consequences for some 
beneficiaries, some HHAs, and Medicare spending; (7) the 
proposed unit of payment may be too long for many beneficiaries 
and could result in unnecessary expenditures; (8) a national 
average payment level will result in sharp revenue increases 
for some HHAs and large declines for others; (9) how patients 
are classified and how much the agencies are paid depend on 
therapy service provision that is directly controlled by HHAs, 
and (10) without adequate design features Medicare could 
overpay for unneeded services or under pay for required care, 
resulting in beneficiaries facing access problems or receiving 
poor quality of care.
Medicare Hospital Payment: PPS Includes Several Policies Intended to 
        Help Rural Hospitals. (GAO/HEHS-00-174R, Sept. 15, 2000).
    Pursuant to a congressional request, GAO provided 
information on the scope and efficacy of Medicare's existing 
rural hospital inpatient payment policies, focusing on the 
major special payment provisions available to rural hospitals 
under the prospective payment system (PPS) and the inpatient 
financial performance of these hospitals under PPS.
    GAO noted that: (1) Medicare has implemented a variety of 
inpatient payment policies that have the effect of increasing 
payments under PPS to certain rural hospitals; (2) two-thirds 
of rural hospitals obtain some sort of special status to modify 
their Medicare PPS payments; (3) rural hospitals with special 
designations generally have fared better than other rural 
hospitals, although as a group they have still experienced 
consistently poorer financial performance under Medicare's PPS 
than have urban hospitals; and (4) there is considerable 
variation in performance behind this average, and many rural 
hospitals operate at a loss in providing Medicare inpatient 
services.
Medicare Improper Payments: While Enhancements Hold Promise for 
        Measuring Potential Fraud and Abuse, Challenges Remain. (GAO/
        AIMD/OSI-00-281, Sept. 15, 2000).
    Pursuant to a congressional request, GAO provided 
information on the structural problems that exist in the 
Medicare claims processing system, focusing on: (1) what Health 
Care Financing Administration (HCFA) proposals have been 
designed or initiated to measure Medicare improper payments; 
and (2) the status of these proposals and initiatives and how 
well they enhance HCFA's ability to comprehensively measure 
improper Medicare payments and the frequency of kickbacks, 
false claims, and other inappropriate provider practices.
    GAO noted that: (1) since 1990, GAO has designated Medicare 
as a high-risk program, recognizing that the size of the 
program, its rapid growth, and its administrative structure 
continue to present vulnerabilities that challenge HCFA's 
ability to safeguard against improper payments, including those 
attributable to fraud and abuse; (2) due to the broad nature of 
health care fraud and abuse, a variety of detection methods and 
techniques--such as contacting beneficiaries and providers and 
performing medical records reviews, data analyses, and third 
party verification procedures--are being utilized to uncover 
suspected health care fraud and abuse; (3) efforts to measure 
the extent of improper payments, and ultimately to stem the 
flow of Medicare losses, depend upon the use of an effective 
combination of these techniques; (4) the Office of Inspector 
General's study to measure the extent of Medicare fee-for-
service improper payments was a major undertaking and, as GAO 
reported, the development and implementation of the methodology 
it used as the basis for its estimates represent significant 
steps toward quantifying the magnitude of this problem; (5) it 
is important to note, however, that this methodology was not 
intended to and would not detect all potentially fraudulent 
schemes perpetrated against the Medicare program; (6) HCFA has 
initiated three projects designed to enhance its ability to 
measure the extent of Medicare fee-for-service improper 
payments; (7) two of these projects are designed to improve the 
precision of future improper payment estimates and help develop 
corrective actions to reduce losses--however, like the current 
methodology, they are not specifically designed to identify and 
measure the extent of improper payments attributable to 
potential fraud and abuse; (8) the third project, while still 
in the concept phase, will test the viability of using a 
variety of investigative techniques to develop a potential 
fraud and abuse rate; (9) determining the most appropriate 
combination of improper payment identification techniques to 
incorporate into measurement efforts requires careful 
evaluation; and (10) some techniques may be challenging to 
implement, such as contacting beneficiaries due to difficulties 
in locating them.
Medicare Managed Care: Greater Oversight Needed to Protect Beneficiary 
        Rights. (GAO/HEHS-99-68, April 12, 1999).
    Medicare requires managed care plans to notify a 
beneficiary in writing of the reasons for denying to provide or 
pay for a service and to state the beneficiary's appeal rights. 
The beneficiary can appeal a denial, in writing, first to the 
plan, then to the Center for Health Dispute Resolution, then to 
an administrative law judge, and finally to a U.S. District 
Court. Beneficiaries are entitled to expedited decisions on 
their appeals if the standard time for making decisions could 
endanger their health or life. Between January 1996 and May 
1998, health maintenance organizations reported an average of 
nine appeals per 1,000 Medicare members (this number may be 
rising) and reversals of 75 percent of the original denials. 
However, the number of appeals may understate beneficiaries' 
dissatisfaction with the plans' initial decisions: (1) some 
beneficiaries switch out of their plans rather than appeal and 
(2) some receive notices that fail to state reasons for a 
denial or to explain their appeal rights or they receive no 
notices at all. Furthermore, plans sometimes give beneficiaries 
little advance notice when they decide to discontinue paying 
for services. The Health Care Financing Administration (HCFA) 
does not determine whether beneficiaries who were denied 
services but did not appeal were informed of theirappeal 
rights. HCFA does not monitor the provider groups to whom 
issuing denial notices and deciding whether to expedite initial 
decisions are delegated. HCFA also has not issued specific 
criteria for expedited cases. HCFA is implementing or planning 
initiatives to better protect beneficiaries' rights.
Medicare Managed Care Plans: Many Factors Contribute to Recent 
        Withdrawals; Plan Interest Continues. (GAO/HEHS-99-91, April 
        27, 1999)
    The Balanced Budget Act of 1997 created the Medicare+Choice 
program to expand beneficiaries' managed care options, both by 
encouraging the wider availability of health maintenance 
organizations (HMO) and by allowing other types of health plans 
to participate in Medicare. The act also contained provisions 
to slow the growth in Medicare spending. Last fall, shortly 
before the start of the program, nearly 100 Medicare managed 
care plans announced that they would not renew their Medicare 
contracts or that they would reduce the geographic areas they 
served. Beneficiaries affected by these withdrawals either had 
to switch plans or return to traditional fee-for-service 
Medicare; a small number of beneficiaries were left with no 
alternative but fee-for-service. GAO found that although an 
unusually large number of managed care plans left Medicare 
recently, a number of new plans have applied to enter the 
program or expanded the areas in which they offer services. 
Plan withdrawals cannot be traced to a single cause; rather, 
various factors appear to be behind a plan's decisions to 
participate. Payment level is one factor that influences where 
plans offer services, but withdrawalswere not limited to 
counties with low payments. When a plan reduced its service 
area, however, GAO found that counties with low payment rates 
were more likely to experience a withdrawal than counties with 
higher payment rates. Also, a portion of the withdrawals may 
have been the result of plans' deciding that they were unable 
to compete effectively in certain areas. Plan representatives 
also cited the administrative burden associated with 
Medicare+Choice as a significant factor. A broad comparison of 
plan benefit packages from 1997 and 1999 indicates modest 
reductions in the inclusion of certain benefits. In 1999, a 
slightly higher percentage of beneficiaries can join a plan 
offering prescription drug coverage, while a slightly smaller 
percentage of beneficiaries have access to a plan offering 
dental care, hearing exams, and foot care. Beneficiaries living 
in the lowest-payment areas saw greater decreases in access 
than the average beneficiaries. Also, those living in the 
lowest payment areas saw a decrease in access to plans offering 
prescription drug benefits, while beneficiaries in higher 
payment areas saw an increase in access to plans offering those 
benefits.
Medicare Quality of Care: Oversight of Kidney Dialysis Facilities Needs 
        Improvement. (GAO/HEHS-00-114, June 23, 2000).
    The oversight of end-stage renal disease (ESRD) facilities 
needs improvement. Increasing the number of federally funded 
inspections of ESRD facilities should help improve oversight, 
as would putting some teeth into the enforcement process. One 
way to give facilities more incentives to stay in compliance 
with Medicare reimbursement policies would be to have available 
the kinds of monetary penalties that can be used when nursing 
homes are found to have severe or repeated serious 
deficiencies. For example, the Health Care Financing 
Administration (HCFA) can fine nursing homes, and the fines are 
not forgiven when the facility corrects its problems. Another 
way to strengthen oversight would be for state agencies and 
ESRD's networks to share information on complaints and known 
quality-of-care problems at specific facilities. This would 
help target inspection resources where they are most needed. 
HCFA's efforts to use available outcome data for targeting its 
survey efforts might also eventually help in this regard, but 
more testing and evaluation are needed to help ensure that the 
data used are sufficient to predict noncompliance with 
Medicare's quality standards.
Medigap: Premiums for Standardized Plans that Cover Prescription Drugs. 
        (GAO/HEHS-00-70R, Mar. 1, 2000).
    Pursuant to a congressional request, GAO provided 
information on premiums for four of the ten Medicare 
supplemental insurance (Medigap) policies, including the three 
that provide outpatient prescription drug coverage, focusing on 
describing: (1) a description of the benefits under the four 
standard plans; and (2) the average premiums charged for the 
four plans.
    Specifically: (1) GAO obtained Medigap premiums for four 
standard plans--F, H, I, and J--from insurance commissions in 
38 states; (2) plans H and I provide drug coverage with a $250 
deductible, 50 percent coinsurance, and an annual limit of 
$1,250; (3) plan J has the same drug benefit deductible and 
coinsurance and an annual limit of $3,000; (4) premiums for 
plan F, the most frequently purchased plan, are presented as a 
comparison because it does not cover prescription drugs; (5) 
the insurance companies report their premiums to state 
insurance commissions; (6) some companies list different 
premiums that are specific to a certain type of policy; (7) a 
company may have different premiums for policies that use 
different age-rating methodologies; (8) premiums may also 
differ by characteristics of the policyholder, such as gender 
or smoking status; (9) other companies may report a single 
sample premium for each age; (10) states may also have 
regulations that affect the standard premiums, such as not 
allowing premiums to vary based on age; (11) the average 
premiums should not be interpreted as the average prices that 
Medicare beneficiaries are paying for Medigap policies in a 
given state; and (12) although companies may offer policies at 
the published premiums, the number of Medicare beneficiaries 
who are actually paying the premiums was not available from the 
states, so GAO was not able to calculate the average premiums 
weighted by the number of policyholders.
National Practitioner Data Bank: Major Improvements Are Needed to 
        Enhance Data Bank's Reliability. (GAO-01-130, Nov. 17, 2000).
    The National Practitioner Data Bank is presently the 
nation's only central source of medical malpractice payment 
information. The data bank also maintains information on 
licensure actions imposed by states as well as certain clinical 
privilege restrictions imposed by hospitals and other health 
care providers. However, it is unclear whether all relevant 
data are being properly reported. GAO's review suggests that 
information in that data bank may not be as accurate, complete, 
or as timely as it should be. Inaccuracies in the way reported 
information was coded could confuse or mislead querying 
organizations about the severity of actions taken against 
practitioners. Also, duplicate reports overstate the amount of 
information that the databank has on a particular practitioner. 
The Health Resources and Services Administration (HRSA) has not 
established criteria for the information that states and other 
entities must report when notifying the data bank of the 
disciplinary actions taken. Moreover, HRSA lacks procedures for 
ensuring that reporters adhere to the criteria established for 
medical malpractice reports, including inappropriate references 
to patients' names. Furthermore, the practitioner notification 
and dispute resolution processes have not ensured that 
inaccurate and erroneously reported information is removed from 
the data bank and not released to entities seeking information 
on specific practitioners. Finally, without an examination of 
its financial operations, HRSA has little assurance that its 
data bank user fees are appropriate. An analysis of its cash 
balances and cash flows--user fee collections and 
disbursements--would be the best way for HRSA to determine the 
appropriateness of fees.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would 
        Better Ensure Quality. (GAO/HEHS-00-6, Nov. 4, 1999)
    Pursuant to a congressional request, GAO provided 
information on the Health Care Financing Administration's 
(HCFA) oversight programs of state agencies' nursing home 
survey process, focusing on the: (1) effectiveness of HCFA's 
approaches to assessing state agency performance; (2) extent to 
which HCFA's regional offices vary in their application of 
these approaches; and (3) the corrective actions available to 
HCFA when it identifies poor state agency performance.
    GAO noted that: (1) since last year, HCFA has undertaken a 
series of initiatives intended to address quality problems 
facing the nation's nursing home residents, including 
redesigning its program for overseeing state agencies that 
survey nursing homes to ensure quality care; (2) the objective 
of HCFA's oversight program is to evaluate the adequacy of each 
state agency's performance in ensuring quality care in nursing 
homes, but the mechanisms it has created to do so are limited 
in their scope and effectiveness; (3) HCFA's oversight 
mechanisms are not applied consistently across each of its 10 
regional offices; (4) HCFA does not have sufficient, 
consistent, and reliable data to evaluate the effectiveness of 
state agency performance or the success of its recent 
initiatives to improve nursing home care; (5) given the wide 
range in the frequencies with which states identify serious 
deficiencies, HCFA cannot be certain whether some states are 
failing to identify serious deficiencies that harm nursing home 
residents; (6) HCFA does not have an adequate array of 
effective sanctions to encourage a state agency to correct 
serious or widespread problems with its survey process; (7) 
HCFA's primary mechanism to monitor state survey performance 
stems from its statutory requirement to survey annually at 
least 5 percent of the nation's 17,000 nursing homes that 
states have certified as eligible for Medicare or Medicaid 
funds; (8) but HCFA's approach to these federal monitoring 
surveys does not produce sufficient information to assess the 
adequacy of state agency performance; (9) to fulfill its 5 
percent monitoring mandate, HCFA makes negligible use of its 
most effective technique--an independent survey done by HCFA 
surveyors following completion of a state's survey--for 
assessing state agencies' abilities to identify serious 
deficiencies in nursing homes; (10) a second HCFA oversight 
mechanism also has significant shortcomings; (11) about 3 years 
ago, HCFA implemented the State Agency Quality Improvement 
Program (SAQIP), a program under which the state agency does a 
self-assessment to inform HCFA, at least once a year, whether 
the state is in compliance with seven standard requirements; 
and (12) SAQIP is limited as an oversight program, however, 
because HCFA: (a) does not independently validate the 
information that the states provide, so it is uncertain whether 
all serious problems are identified or whether identified 
problems are being corrected; and (b) has no policy regarding 
consequences for states that do not comply.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That 
        Regulatory Actions Were Unreasonable. (GAO/HEHS-99-154R, Aug. 
        13, 1999).
    Pursuant to a congressional request, GAO analyzed materials 
from the American Health Care Association (AHCA) to determine 
whether any cases reflected the actions of an overly aggressive 
regulatory process.
    GAO noted that: (1) in each of the eight cases for which 
there was sufficient information for an objective assessment, 
GAO believes appropriate regulatory action was taken; (2) in 
these cases, either the surveyor's actions were justified or 
the Health Care Financing Administration (HCFA) or the state 
withdrew the initial actions after the nursing homes presented 
additional information; (3) in the remaining two cases, GAO was 
unable to obtain sufficient information to make a 
determination; (4) specifically, of the seven cases AHCA 
believes represent inappropriate citations, GAO found that in 
three of these cases a citation was justified; (5) in another 
two cases, the states withdrew the citations when the nursing 
homes supplied additional information not available to the 
surveyors, and for the final two, GAO was unable to obtain 
enough information to make a judgment; (6) in all three cases 
inwhich the homes were recommended for termination by a state 
agency, GAO believes the states and HFCA ultimately acted 
correctly in accordance with regulatory requirements; (7) 
furthermore, in only one of these cases did HFCA actually 
terminate the home from Medicare and Medicaid; (8) in the 
remaining two, HCFA rescinded the termination actions: in one 
case because deficiencies were corrected and in the other 
because of procedural errors by the state; (9) in GAO's 
analysis of the cases that AHCA selected as ``symptomatic of a 
regulatory system run amok,'' GAO did not find evidence of 
inappropriate regulatory actions; (10) furthermore, in a 
recently released report in which GAO examined a random sample 
of 107 nursing home surveys containing 201 actual harm 
citations affecting one or a few residents, GAO found that 98 
percent of the surveys documented that one or more residents 
had experienced actual harm; (11) moreover, two-thirds of these 
107 nursing homes also were cited for actual harm or higher-
level deficiencies in a prior or subsequent survey; (12) most 
of these repeat violators were cited for the same deficiency, 
and an additional 34 percent were cited for closely related 
deficiencies; and (13) GAO also found that most of the examples 
AHCA provided had deficiencies, in addition to those cited by 
AHCA, that caused harm to residents.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of 
        Federal Quality Standards. (GAO/HEHS-99-46, March 18, 1999).
    Despite reforms to ensure that nursing homes comply with 
federal quality standards, one-fourth of all homes nationwide 
continue to be cited for deficiencies that either caused actual 
harm to residents or carried the potential for serious injury 
or death. Although the reforms equipped federal and state 
regulators with many alternatives and tools to help sustain 
compliance with Medicare and Medicaid standards, the way in 
which the states and the Health Care Financing Administration 
(HCFA) have applied them appears to have resulted in little 
headway. Repeated noncompliance carries few consequences. 
HCFA's recent actions, such as broadening the definition of a 
poorly performing facility, are a step in the right direction. 
However, four key problems remain. First, if the backlog of 
civil monetary penalties is not reduced, much of their 
deterrent effect will be lost. Second, weaknesses remain in the 
deterrent effect of termination, including the lack of a tie to 
poorly performing facility status for reinstated homes and the 
limited reasonable assurance period for monitoring terminated 
homes before reinstating them. Third, the states are not 
required to refer for sanction all homes with deficiencies that 
contribute to resident deaths. Fourth, the changes do not 
address HCFA's need to improve its management information 
system. HCFA's ability to improve its oversight of nursing 
homes will depend heavily on whether it has the information to 
identify and monitor the homes that pose the greatest risk of 
harm.
Nursing Homes: Complaint Investigation Processes Often Inadequate to 
        Protect Residents. (GAO/HEHS-99-80, March 22, 1999).
    Federal and state practices for investigating complaints 
about nursing home care are often not as effective as they 
should be. GAO found many problems in the 14 states it 
reviewed, including procedures or practices that may limit the 
filing of complaints, understatement of the seriousness of 
complaints, and failure to investigate serious complaints 
promptly. Complaints alleging that nursing home residents were 
being harmed have gone uninvestigated for weeks or months. 
During that time, residents may have remained vulnerable to 
abuse, neglect (which can lead to serious problems like 
malnutrition and dehydration), preventable accidents, and 
medication errors. Although the federal government finances 
more than 70 percent of total expenditures for complaint 
investigations nationwide, the Health Care Financing 
Administration (HCFA) plays a minimal role in providing states 
with direction and oversight regarding these investigations. 
HCFA has left it largely to the states to decide which 
complaints put residents in immediate jeopardy and should be 
investigated immediately. More generally, HCFA's oversight of 
state agencies that certify federally qualified nursing homes 
has not focused on complaint investigations. GAO recommends (1) 
stronger federal requirements for states to promptly 
investigate serious complaints alleging situations that may 
harm residents but are not classified as posing an immediate 
threat, (2) more federal monitoring of states'efforts to 
respond to complaints, and (3) better tracking of the 
substantial findings of complaint investigations.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes 
        Has Merit. (GAO/HEHS-99-157, June 30, 1999).
    GAO has previously reported that one in four of the 
nation's nursing homes has deficiencies so serious that they 
have harmed residents or placed them at serious risk of death 
or injury. (See GAO/HEHS-99-46, Mar. 1999.) Forty percent of 
the homes with serious deficiencies were cited for repeat 
deficiencies. The Health Care Financing Administration (HCFA), 
which oversees the quality of nursing home care, has announced 
plans to beef up enforcement at homes found to have repeatedly 
harmed residents. This includes expanding the definition of 
homes classified as poor performers. HCFA's proposal to include 
homes with repeated isolated actual harm deficiencies would 
significantly increase the number of homes that would be 
subject to immediate sanctions without a grace period to 
correct the problems. If this revised definition had been in 
effect as of April 1999, GAO estimates that the number of 
nursing homes meeting HCFA's poor-performer criteria would have 
risen from about one percent to nearly 15 percent of facilities 
nationwide. Two-thirds of the poor-performing nursing homes GAO 
surveyed had repeated violations. As a result, they would have 
been subject to immediate sanction under HCFA's revised poor 
performer definition. The current definition allows them an 
opportunity to correct the problems without sanctions. 40 
percent of the repeat violators were cited for the same 
deficiency, and another one-third were cited for closely 
related problems. These findings suggest that HCFA's enhanced 
enforcement of homes found to repeat these serious care 
problems has merit.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 
        the Quality Initiatives. (GAO/HEHS-00-197, Sept. 28, 2000).
    Pursuant to a congressional request, GAO provided 
information on federal and state initiatives to improve the 
quality of nursing homes, focusing on: (1) progress in 
improving the detection of quality problems and changes in 
measured nursing home quality; (2) the status of efforts to 
strengthen states' complaint investigation processes and 
federal enforcement policies; and (3) additional steps taken at 
the federal level to improve oversight of states' quality 
assurance activities.
    GAO noted that: (1) overall, the introduction of the recent 
federal quality initiatives has generated a range of nursing 
home oversight activities that need continued federal and state 
attention to reach their full potential; (2) the states are in 
a period of transition with regard to the implementation of the 
quality initiatives, in part because the Health Care Financing 
Administration (HCFA) is phasing them in and in part because 
states did not begin their efforts from a common starting 
point; (3) efforts at the federal level toward improving the 
oversight of states' quality assurance activities have 
commenced but are unfinished or need refinement; (4) federal 
initiatives were introduced to strengthen the rigor with which 
states conduct required annual nursing home surveys; (5) the 
states GAO visited have begun to use the new methods introduced 
by the initiatives to spot serious deficiencies when conducting 
surveys, but HCFA is still developing important additional 
steps; (6) GAO's results showed a marginal increase nationwide 
in the proportion of homes with documented actual harm and 
immediate jeopardy deficiencies, although there was 
considerable variation across states; (7) the states GAO 
contacted also have made strides in improving their 
investigations of andfollow-up to complaints, but not enough 
time has elapsed to consider these efforts complete; (8) for 
some states, the provision of federal funding to support the 
nursing home initiatives came too late in the state budget 
cycle for agencies to capitalize on the additional funds for 
fiscal year 1999; (9) it is too early to assess the effect of 
the additional funding intended to reduce the large number of 
pending appeals by nursing homes because the new HHS staff were 
only hired within the past year and other changes in 
enforcement policy are expected to increase the volume of 
nursing home appeals; (10) to improve nursing home oversight at 
the federal level, HCFA has made recent organizational changes 
to address past consistency and coordination problems between 
its central office and 10 regional offices; (11) it also 
intends to intensify its use of management information data 
systems and reports to verify and assess states' oversight 
activities and view more closely the performance of the homes 
themselves; and (12) GAO's review showed that an examination of 
previously available information could have identified 
shortcomings in a state's survey activities even before they 
came to light as the result of a criminal investigation.
Physician Shortage Areas: Medicare Incentive Payment Not an Effective 
        Approach to Improve Access. (GAO/HEHS-99-36, Feb. 26, 1999).
    The Medicare Incentive Payment program pays doctors a 10-
percent bonus for Medicare services they provide in areas 
identified as having a shortage of primary care physicians. GAO 
found that the program is not an effective way to improve the 
ability of Medicare beneficiaries to obtain health care. Since 
the program began, Congress has taken additional action to 
address this concern. This action generally increased 
reimbursement rates for primary care services and reduced the 
geographic variation in physician reimbursement rates. In 
addition, survey data from the Health Care Financing 
Administration show that Medicare beneficiaries who have access 
problems, including those who may live in underserved areas, 
generally cite reasons other than the unavailability of a 
physician--such as the cost of services not paid by Medicare--
for their access problems. Moreover, the program does not 
appear to play a significant role in attracting and retaining 
physicians in shortage areas. The relatively small bonus 
payments most doctors receive--a median payment of $341 for the 
year in 1996--are unlikely to have a significant impact on 
physician recruitment and retention. The Department of Health 
and Human Services has not developed goals or related 
performance measures for the program to clarify what the 
program is expected to accomplish. As it stands, the program 
provides no assurance that the more than $90 million spent each 
year is improving access to care in underserved areas. HCFA's 
oversight of the program also has shortcomings that allow 
physicians and other providers to receive and keep bonus 
payments they claimed in error.
Prescription Drug Benefits: Implications for Beneficiaries of Medicare 
        HMO Use of Formularies. (GAO/HEHS-99-166, July 20, 1999).
    More than 90 percent of the 6 million beneficiaries 
enrolled in Medicare+Choice have outpatient drug coverage. 
However, before they enroll in Medicare health maintenance 
organizations (HMO), beneficiaries may not be aware of how the 
HMOs manage the cost of providing drugs through formularies, or 
lists of drugs that they prefer that their physicians 
prescribe. Comparing HMO plans is difficult for beneficiaries 
because the plans vary widely in the drugs they cover in their 
formularies, how they manage them, the copayments they require, 
their annual coverage limits, and the methods they use to 
notify beneficiaries of formulary changes and to consider 
exceptions from formulary changes. Beneficiaries in some plans 
may not learn about formulary changes until they are at the 
pharmacy counter. Some plans also make it difficult for 
physicians to obtain an exception to allow patients to remain 
on their existing medication at no additional cost if it is 
dropped from the formulary.
Prescription Drugs: Drug Company Programs Help Some People Who Lack 
        Coverage. (GAO-01-137, Nov. 16, 2000).
    As Congress considers Medicare beneficiaries' access to 
prescription drug coverage, there is increased interest in the 
range of options available to help vulnerable populations 
obtain access to needed medications. Patient assistance 
programs, offered voluntarily by drug companies, are generally 
designed to provide prescription drugs to low-income persons 
who lack drug coverage. These programs typically rely on health 
care providers' involvement with some or all stages of applying 
for and receiving drugs from the programs. Drug companies 
characterize their programs as a last-resort source of 
prescription drugs, and most programs are not designed to 
provide long-term prescription drug coverage. To comply with 
the programs' eligibility criteria, which are intended to 
target patients who need assistance, application procedures 
require information about the patient's financial and insurance 
status. The provider's role in the application process is 
significant, involving obtaining applications, completing all 
or part of the forms, and receiving and dispensing drugs.
Prescription Drugs: Expanding Access to Federal Prices Could Cause 
        Other Price Changes. (GAO/HEHS-00-118, Aug. 7, 2000).
    Pursuant to a congressional request, GAO provided 
information on the expansion of Medicare beneficiaries' access 
to prescription drugs, focusing on the: (1) federal drug price 
discounts available to federal and nonfederal purchasers and 
the size of those discounts; and (2) potential effects that 
extending such discounts to nonfederal purchasers may have on 
outpatient drug prices paid by federal and nonfederal 
purchasers.
    GAO noted that: (1) federal departments and agencies, state 
Medicaid programs, and numerous nonfederal public health 
entities have access to prescription drugs at substantially 
lower prices than many other purchasers; (2) federal entities 
can purchase drugs from the federal supply schedule at prices 
that are the same or lower than those drug manufacturers charge 
their most-favored private purchasers; (3) federal law also 
specifies that state Medicaid programs and certain nonfederal 
purchasers can receive substantial discounts on prescription 
drug prices; (4) under the Omnibus Budget Reconciliation Act of 
1990, drug manufacturers must provide rebates to state Medicaid 
programs for their outpatient drugs in exchange for Medicaid 
coverage; (5) the Public Health Service Act also provides some 
nonfederal purchasers, such as community health centers and 
certain public hospitals, access to drug prices based on 
Medicaid rebates; (6) mandating that federal prices for 
outpatient prescription drugs be extended to a large group of 
purchasers, such as Medicare beneficiaries, could lower the 
prices they pay but raise prices for others; (7) such price 
changes could occur because drug manufacturers would be 
required to charge beneficiaries and federal purchasers the 
same prices; (8) to protect their revenues, manufacturers could 
raise prices for federal purchasers; (9) furthermore, because 
federal prices are generally based on prices paid by nonfederal 
purchasers, manufacturers would have to raise prices to these 
purchasers in order to raise the federal prices; (10) in 
particular, large private purchasers that tend to pay lower 
prices, such as health maintenance organizations and other 
insurers, could see their prices rise; (11) while it is not 
possible to predict the extent or timing of any changes in 
manufacturer pricing strategies if Medicare beneficiaries 
gained access to the same prices available to federal 
purchasers, the experience following implementation of a 
Medicaid rebate suggests that manufacturers would adjust prices 
quickly; and (12) the magnitude of these potential effects 
would vary by drug and would depend on a number of factors, 
including the relationship between the specific federal price 
extended to Medicare beneficiaries and the price paid by 
nonfederal purchasers, as well as the number of Medicare 
beneficiaries with access to the federal price.
Rural Ambulances: Medicare Fee Schedule Payments Could Be Better 
        Targeted. (GAO/HEHS-00-115, July 17, 2000).
    Because many rural ambulance providers serve a large 
geographic area with a low population density, they face a set 
of unique challenges. Unless they rely on volunteers, they tend 
to have high per-trip costs because of the lower volume of 
transports as compared to urban and suburban providers. The 
proposed Medicare fee schedule will alter the way rural 
ambulance providers are paid. Much of the variation in payment 
rates among similar rural providers will be eliminated. In 
addition, providers that transport beneficiaries in rural areas 
will receive enhanced payments intended to help to sustain 
essential service in sparsely populated areas. However, this 
adjustment does not sufficiently distinguish the providers 
serving beneficiaries in isolated areas. Therefore, we 
recommended that HCFA refine the payment adjuster to better 
target the necessary fixed costs of essential providers in 
isolated areas.
    We also found in a review of 1998 claims data that payment 
denials have varied widely among the contractors that process 
claims for freestanding ambulance providers. Different 
practices among these contractors, including increased 
attention to potential fraud, differences in local policies, 
and failure to apply the coverage criteria appropriately, may 
have contributed to the variation in claims denials. 
Additionally, the absence of a national coding system that 
readily identifies the beneficiary's medical condition at the 
time of transport has impaired providers' ability to convey 
information to carriers in a way that facilitates review of 
claims.
Skilled Nursing Facilities: Medicare Payment Changes Require Provider 
        Adjustments But Maintain Access. (GAO/HEHS-00-23, Dec. 14, 
        1999).
    Pursuant to a congressional request, GAO provided 
information on skilled nursing facilities, focusing on: (1) the 
initial effect of the skilled nursing facility (SNF) 
prospective payment system (PPS) on Medicare beneficiaries' 
access to care; (2) the initial effect of the SNF PPS on 
providers; and (3) the role the SNF PPS has played in the poor 
financial performance of large nursing home chains.
    GAO found that: Medicare beneficiaries' ability to obtain 
needed care does not appear to have decreased since the 
implementation of the SNF PPS, although some patients may stay 
longer in the hospital before being admitted to a nursing home 
or may receive care from other post-acute-care providers. The 
PPS does appear, however, to have affected the willingness or 
ability of some nursing homes to accept certain types of 
Medicare patients. Hospital discharge planners reported that 
facilities are reluctant to admit patients requiring certain 
high-cost services, indicating that the payments for some types 
of SNF patients may be too low. Hospital discharge planners 
also reported that Medicare patients needing short-term 
rehabilitation are preferred by nursing homes, raising concerns 
that payments for these patients may be too high. Although the 
new payment system changes in financial incentives, GAO 
believes it is likely that aggregate SNF payments to providers 
are adequate, given that inflated costs were used to establish 
the per diem payment rates. However, the case-mix 
classification system used to adjust payments to reflect the 
needs of patients may not appropriately allocate payments 
across patients and providers. Payments, therefore, may be too 
lowfor certain types of patients and too high for others. 
Nevertheless, the generally low proportion of patient-days 
covered by Medicare at most nursing homes will dampen the 
initial effects of PPS on providers, and the transition to the 
full PPS rates will give them time to adjust. Some facilities 
will have to make bigger changes in their treatment patterns, 
particularly facilities with a large proportion of patient-days 
covered by Medicare, those with inefficient practices, and 
those that historically furnished excessive services to 
patients to maximize revenues. Other facilities may be more 
selective in their admission policies until refinements in the 
classification system fully account for differences across 
patients. GAO also found that the SNF PPS is only one of the 
many factors contributing to the poor financial performance of 
Sun Healthcare Group, Inc., and Vencor, Inc., two corporations 
that operate a large number of nursing homes. The large total 
losses reported by the corporations stem from high capital 
related costs that have shrunk SNF margins; reduced demand for 
ancillary services, related to several provisions of the 
Balanced Budget Act of 1997; and substantial nonrecurring 
expenses and write offs, reflecting reductions in future 
anticipated earnings.
Skilled Nursing Facilities: Medicare Payments Need to Better Account 
        for Nontherapy Ancillary Cost Variation. (GAO/HEHS-99-185, 
        Sept. 30, 1999).
    The Balanced Budget Act of 1997 replaced Medicare's cost-
based payment method for skilled nursing facility (SNF) care 
with a prospective payment system (PPS). Concern has arisen 
over whether rates under the new system are adequate, and 
legislation has been proposed to raise them. GAO found that 
total Medicare payments for all SNFs are likely to be adequate, 
if not generous, to cover the costs of nontherapy ancillary 
services. However, the PPS may not appropriately account for 
the variation in nontherapy ancillary costs and thus may not 
correctly raise or lower payments across patient groups to 
reflect expected differences in need. Therefore, Medicare 
payments for certain patient groups may be too high or too low, 
relative to the average. Assessing the adequacy of total 
Medicare payments to any SNF would require considering total 
Medicare costs and payments over the entire year. Aware of 
concern about the issue, the Health Care Financing 
Administration has commissioned relevant research. Meanwhile, 
GAO suggests that the extent of any maldistribution of SNF 
payments be assessed. If problems are found, the payment 
weights should be recalculated to better target payments to 
patients with high expected nontherapy ancillary needs.
State Pharmacy Programs: Assistance Designed to Target Coverage and 
        Stretch Budgets. (GAO/HEHS-00-162, Sept. 6, 2000).
    Pursuant to a congressional request, GAO examined state-
administered pharmaceutical assistance programs and described 
(1) the characteristics of state programs designed to provide 
prescription drug access to eligible populations, and (2) the 
administrative and policy issues that states have encountered 
in operating drug assistance programs.
    GAO noted that: (1) in 1999, 14 states were operating 
independent, state-funded and administered programs that 
provided more than 760,000 elderly and other low-income persons 
with access to prescription drugs; (2) most programs are funded 
with the state's general revenues, but some receive earmarked 
funds; (3) all state pharmacy programs provide benefits for 
low-income elderly state residents, but specific eligibility 
rules differ; (4) the programs vary in the number of people 
enrolled and their size relative to the number of Medicare 
beneficiaries in the state; (5) states attempt to provide 
access to drugs and manage program costs through coverage 
restrictions such as dollar caps on benefits, deductibles, 
copayments, and limits on the types of drugs covered; (6) among 
state programs, copayments and coinsurance are more common than 
benefit caps and deductibles, but the amount of cost sharing 
varies widely across programs; (7) all state programs obtain 
rebates from drugmanufacturers to offset part of their 
expenditures--most state programs receive manufacturers' 
rebates that are calculated on terms similar to rebates under 
the Medicaid program; (8) to provide a pharmacy assistance 
benefit to a low-income and largely elderly population, while 
remaining within the program budget, states have taken a 
variety of approaches to administering their programs; (9) 
these include developing adequate systems to administer 
benefits and coordinating payment with and recovering payment 
from other insurers; (10) states have also attempted to 
encourage enrollment by mitigating the perceived stigma 
attached to assistance programs, which could inhibit 
enrollment, and by providing information to eligible persons so 
that they are aware of the program and know how to apply; (11) 
three program administrators said that drug assistance programs 
were intentionally administered apart from Medicaid programs to 
avoid the perceived stigma attached to Medicaid; (12) however, 
several states administer aspects of their programs through and 
employ the policies of the agency administering Medicaid; (13) 
administering programs using Medicaid systems allows states to 
avoid duplicating program functions, such as eligibility 
determination and claims processing and adjudication; and (14) 
nevertheless, some states have encountered administrative 
challenges in developing adequate eligibility determination and 
claims processing systems and in recovering payments from 
insurers when program enrollees have other drug coverage.

                         Income Security Issues

Additional Information Related to Analysis of the Administration's 
        Proposal to Ensure Solvency of the United Mine Workers of 
        America Combined Benefit Fund. (GAO/AIMD-00-308R, Aug 31,2000).
    Pursuant to a congressional request, GAO provided 
information on the United Mine Workers of America Combined 
Benefit Fund.
    GAO noted that: (1) both the net average cost per 
beneficiary of providing benefits under the fund and per 
beneficiary premium increased each fiscal year for the past 5 
years; (2) the percentage increase in the average net cost per 
beneficiary of providing benefits under the fund for the past 5 
fiscal years fluctuated from 1 to 14 percent, while the 
percentage increase in the medical component of the Consumer 
Price Index (CPI) for those years was relatively stable, 
fluctuating from 3 to 4 percent; (3) according to Fund 
officials, while the increase in the medical component of the 
CPI is driven primarily by price increases, the increase in the 
fund's average net cost of providing benefits per beneficiary 
is driven by the increased use of medical care in addition to 
price increases; (4) income during fiscal years 1996 through 
2000 was derived from three primary sources: (a) coal company 
premiums; (b) the Health Care Financing Administration; and (c) 
transfers of interest from the Abandoned Mine Land Reclamation 
trust fund; and (5) these three sources provided over 85 
percent of the fund's total income for each of the past 5 
years.
Analysis of the Administration's Proposal to Ensure Solvency of the 
        United Mine Workers of America Combined Benefit Fund. (GAO/
        AIMD-00-267R, Aug. 15, 2000).
    Pursuant to a congressional request, GAO reviewed the 
administration's proposal to ensure solvency of the United Mine 
Workers of America (UMWA) Combined Benefit Fund, focusing on 
the impact of the proposal to: (1) extend the Abandoned Mine 
Land (AML) Reclamation fees; (2) reverse the effects of 
National Coal v. Chater; (3) reverse the effects of Dixie Fuel 
Company v. Social Security Administration; and (4) appropriate 
federal funds.
    GAO noted that: (1) if the administration's proposal is not 
adopted, the federal government potentially would have to 
provide $513 million over the next 8 years to ensure the Fund's 
solvency through 2008, assuming that the Dixie Fuel decision is 
not implemented; (2) however, if the Dixie Fuel decision is 
implemented, the Fund may have to refund an estimated net $57 
million in premiums to coal companies and would have to find 
funding for 10,000 additional unassigned beneficiaries; (3) 
although an estimate of the cost has not yet been developed, 
nationwide implementation of the Dixie Fuel decision would 
increase the Fund's projected deficit; (4) according to GAO's 
review of available financial data, while the administration's 
proposal improves the projected financial position of the Fund, 
reducing the fiscal year 2008 anticipated cumulative deficit, 
not including borrowing costs, from $513 million to $83 
million, it does not ensure the solvency of the Fund; and (5) 
additional funds will be needed to ensure the solvency of the 
Fund.
Cash Balance Plans: Implications for Retirement Income. (HEHS-00-207. 
        Sept. 29, 2000).
    Pursuant to a congressional request, GAO provided 
information on cash balance plans for retirement income, 
focusing on the: (1) prevalence and features of cash balance 
plans; (2) factors employers considered in making a decision 
about whether or not to use a cash balance formula; (3) effects 
of using cash balance formulas on the adequacy of individual 
workers' retirement income; and (4) effects of current 
disclosure practices on plan participants' ability to address 
issues regarding the adequacy of their retirement funds.
    GAO noted that: (1) its survey of 1999 Fortune 1000 firms 
indicated that about 19 percent of these firms sponsor cash 
balance plans covering an estimated 2.1 million active 
participants, more than half of these plans have been 
established within the last 5 years; (2) firms in many sectors 
of the economy sponsor these plans, but greater concentrations 
are found in the financial services, health care, and 
manufacturing industries; (3) of the firms GAO surveyed that 
sponsor such plans, about 90 percent previously covered their 
workers under a traditional defined benefit plan; (4) as with 
traditional defined benefit plans, there is significant 
variation in the design and operation of cash balance plans; 
(5) cash balance plans have had such visibility in recent years 
that most firms GAO surveyed had at least considered adopting 
such a plan; (6) these firms reported that their decisions to 
adopt or not to adopt a cash balance plan were based on many 
factors, including corporate philosophy, the need to remain 
competitive, and the potential impact on workers; (7) cash 
balance plans offer both opportunities and challenges to 
workers seeking to ensure adequate retirement income; (8) cash 
balance plans generally are structured such that workers accrue 
benefits earlier in their careers than they would under most 
traditional defined benefit plans; (9) this feature, combined 
with the lump sum payouts also common to such plans, provides 
opportunity for more mobile workers to secure andretain higher 
benefits, even when they change jobs, than they would under 
most traditional defined benefit plans; (10) older workers may 
be disadvantaged if their employer converts from a traditional 
defined benefit plan to a cash balance plan or if they leave a 
firm with a traditional plan for one with a cash balance plan; 
(11) to mitigate the impact of conversion, many Fortune 1000 
employers provide transition provisions for workers previously 
covered under their traditional defined benefit plans; (12) 
because the decisions of individual participants play a more 
significant role in maximizing retirement income under such 
balance plans than under traditional defined benefit plans, 
cash balance plan participants have a particular need for clear 
and timely information about their plans; (13) most plans 
provided insufficient information to allow a participant to 
make informed career-and retirement--related decisions; and 
(14) GAO found a wide variation in the quantity and quality of 
information that firms provided to participants in cash balance 
plans.
Determining the Taxable Portion of Federal Pension Distributions. (GAO/
        GGD-99-73R, May 3, 1999).
    Pursuant to a congressional request, GAO provided 
information on: (1) what reasons, if any, exist for the Office 
of Personnel Management (OPM) to report the taxable portion of 
annuity benefits for newly retired federal employees on the 
Form CSA 1099R (Statement of Annuity Paid); and (2) the 
feasibility of OPM's doing so.
    GAO noted that there are three reasons for OPM to report on 
Form CSA 1099R the taxable portion of the annuity for newly 
retired federal employees; (1) the task of calculating this 
portion can be burdensome from the retirees' perspective; (2) 
the complexity of the requirement could result in retirees' 
miscalculating the taxable portion of their annuity for income 
tax purposes; and (3) reporting the taxable portion of the 
annuity on Form CSA 1099R would allow the Internal Revenue 
Service (IRS) to use it for computer matching purposes. 
Computer matching of information and tax returns is one way 
that IRS verifies a taxpayer's income to determine the proper 
tax owed.
    According to OPM officials, it would be feasible for OPM to 
report the taxable portion on Form CSA 1099R for federal 
employees with annuities starting after November 18, 1996, when 
the Simplified Method became the only method allowed. Before 
that date, retirees could use either the Simplified Method or 
the General Rule method, and OPM would not know which method 
the retiree preferred. OPM has the necessary data, which are 
computerized, to make the Simplified Method calculation. The 
officials GAO spoke with said that a calculation formula could 
easily be programmed to determine the tax-free amount and 
subtract it from the retiree's gross annuity amount. They also 
said the costs of doing so would not be large. OPM expects to 
report taxable amounts on tax year 2000 Forms CSA 1099R in 
January 2001 for employees who retired after November 18, 1996. 
The officials said that OPM has taken other actions to help 
retirees calculate the taxable amount.
Federal Pensions: Judicial Survivors' Annuities System Costs. (GGD-00-
        125, May 25, 2000).
    The Judicial Survivors' Annuities System (JSAS) is one of 
several survivor benefit plans applicable to specific groups of 
federal workers. JSAS provides annuities to the surviving 
spouse and dependent children of deceased federal judges and 
other judicial officials. GAO is required to review JSAS' costs 
every three years and determine whether the participants' 
contributions covered one-half of the costs. If the 
contributions are less than one-half of these costs, GAO is to 
determine what adjustments would be needed to achieve the 50-
percent figure. GAO found that participating judges did not pay 
one-half of the JSAS normal cost during fiscal years 1996 
through 1998 and that the judges' contribution would need to 
increase 0.3 percentage points to cover one-half of the future 
costs. However, increasing required contributions could affect 
judges' rate of participation and increasing participation was 
one of the major reasons for prior changes made to JSAS. GAO 
issued its first report on this subject in 1997. (See GAO/GGD-
97-87.)
Federal Retirement: Key Elements Are Included in Agencies' Education 
        Programs. (GAO/GGD-99-27, March 29, 1999).
    Federal workers covered by either of the government's two 
main retirement programs could retire with dramatically 
different benefits depending on whether and how they plan for 
retirement throughout their careers. Agencies' retirement 
education programs play an important role in helping federal 
employees make well-informed decisions about retirement 
planning. However, little is known about how agencies fulfill 
this role. This report discusses the views of the Office of 
Personnel Management (OPM) and retirement experts on the 
recommended elements of retirement education programs and 
describes OPM's and agencies' retirement education roles, 
responsibilities, and practices in the context of these 
elements.
Financial and Legal Issues Facing the United Mine Workers of America 
        Combined Benefit Fund. (GAO/AIMD-00-280R, Aug. 15, 2000).
    Pursuant to a congressional request, GAO reviewed the 
United Mine Workers of America (UMWA) Combined Benefit Fund, 
focusing on: (1) the status of the Fund's financial position 
and its financing mechanism; (2) the impact of major court 
decisions on the assignment of beneficiaries; and (3) 
significant litigation and its related costs.
    GAO noted that: (1) the Fund has been experiencing 
financial difficulties due to rising costs and a financing 
mechanism that has been negatively affected by recent court 
decisions; (2) according to the Fund's September 30, 1999, 
audited financial statements, the Fund had a cumulative deficit 
of $12.2 million; (3) the Fund's actuary estimates that the 
cumulative operating deficit will increase to approximately 
$513 million by 2008; (4) in addition, the actuarial projection 
includes borrowing costs of $101 million during the same time 
frame, which results in a total deficit of $614 million; (5) 
the Fund is involved in extensive litigation arising from the 
Coal Act and normal business operations; (6)Fund officials 
classified their significant litigation into seven major 
categories: (a) constitutional cases; (b) Dixie Fuel court 
cases; (c) companies challenging assessments; (d) premium rate 
cases; (e)bankruptcy cases; (f) successorship cases; and (g) 
Evergreen cases; (7) Eastern Enterprises v. Apfel (1998) and 
Dixie Fuel Company v. Social Security Administration (1999) are 
two of the significant cases that have affected or may affect 
the assignment of beneficiaries; (8) Eastern resulted in 
approximately 8,000 beneficiary reassignments; (9) Dixie Fuel, 
which has not yet been implemented,could potentially result in 
the reassignment of 10,000 beneficiaries; and (10) the Fund has 
incurred legal costs of over $11 million for all significant 
cases since its inception.
Food Assistance: Options for Improving Nutrition for Older Americans. 
        GAO/RCED-00-238, Aug. 17, 2000).
    Pursuant to a congressional request, GAO: (1) determined 
why some older persons do not use federal food relief programs; 
and (2) identified strategies that could be used to increase 
participation in these programs.
    GAO noted that: (1) older persons do not participate in 
federal food assistance programs for many reasons; (2) some of 
these reasons cut across programs; (3) for example, older 
persons are often reluctant to accept food assistance because 
they believe such acceptance would compromise their 
independence; (4) additionally, some older persons associate 
accepting food assistance with welfare, which many older 
persons view negatively; (5) furthermore, funding constraints 
limit participation in several of the programs; (6) older 
persons' lack of awareness of the availability of programs and 
problems with access to transportation hinder participation in 
several of the programs; (7) other problems, however, are more 
program-specific; (8) state food stamp directors told GAO some 
eligible older persons believe the burden of applying for food 
stamps outweighs the expected low benefits; (9) unlike the 
other programs, the Child and Adult Care Food Program is 
limited in the benefits it provides to senior citizens because 
a limited number of facilities participate in the program; (10) 
program officials, providers, and advocacy groups have 
identified a number of actions that might increase older 
persons' participation in nutrition assistance programs; (11) 
in some instances, the options suggested would likely require a 
large infusion of resources; (12) for example, nearly all of 
the state food stamp directors endorsed increasing the minimum 
benefit level from $10 to $25 per month; (13) GAO estimates 
that the annual cost of this increase in Food Stamp Program 
benefits would be about $102 million for older persons who 
participate and could increase participation resulting in 
additional annual costs of about $26 million; (14) similarly, 
Elderly Nutrition Program providers and officials administering 
the Commodity Supplemental Food Program suggested that 
additional funding is needed to expand both programs to serve 
more people; (15) at this time, neither the Food and Nutrition 
Service nor the Administration on Aging has estimated the 
additional cost that might result if more people were attracted 
to these programs; (16) other suggestions are not likely to be 
as costly; and (17) for example, state food stamp directors 
endorsed proposals to simplify the application process, such as 
automatically making older persons eligible for food stamps 
when they are approved for other means-tested programs, such as 
Medicaid.
Food Stamp Program: Data on Assistance for the Elderly. (GAO/RCED-00-
        223R, June 28, 2000).
    Pursuant to a congressional request, GAO provided 
information on the Food Stamp Program and its state activities 
to increase older Americans' participation and the number of 
elderly food stamp participants in each state.
    GAO reported on: (1) states' activities to encourage 
elderly participation in the Food Stamp Program; (2) states' 
actions, during the last 3 years, to implement suggestions by 
the Food and Nutrition Service to increase elderly persons' 
access to the program; (3) the number and percentage of older 
Americans' households in each state receiving food stamps in 
fiscal year 1998, the most recent year for which complete data 
are available; and (4) the average benefits received by elderly 
households in each state.
Food Stamp Program: Information on the Costs of Special Diets. (GAO/
        RCED-00-144R, May 8, 2000).
    Pursuant to a congressional request, GAO provided 
information on the costs of food stamp recipients' special 
diets, focusing on the: (1) number of food stamp recipients 
whose special dietary costs exceed the maximum food stamp 
benefit; and (2) costs of recipients' special diets compared 
with the maximum food stamp benefit.
    GAO noted that: (1) the federal government does not have 
the information to determine the number of food stamp 
recipients whose special diets exceed the maximum food stamp 
benefit; (2) while two federal government surveys provide some 
information about the number of food stamp recipients with 
special diets, no information is collected about the costs of 
these diets or the degree to which the special dietary needs of 
food stamp recipients are unmet due to their limited financial 
resources; (3) the costs of recipients' special diets can vary, 
according to Department of Agriculture (USDA) officials; (4) 
they explained that the costs of some of these diets can fall 
within the maximum food stamp benefit, or they can exceed it; 
(5) but they do not know how frequently special dietary costs 
exceed the maximum or to what extent the maximum is exceeded; 
(6) USDA officials were, however, able to identify situations 
in which the maximum benefits could fail to meet special 
dietary needs; (7) for example, they cited diets that require 
cans of oral nutritional supplements, which can each cost about 
half of the maximum daily benefit of $3.51; (8) GAO's 
comparison of the weekly costs of one special diet for 
hypertension showed that its costs were 41 percent more than 
the food stamp benefit; and (9) hypertension was the primary 
reason that food stamp recipients reported changing their diets 
in a prior 12-month period.
Food Stamp Program: Relatively Few Improper Benefits Provided to 
        Individuals in Long-Term Care Facilities. (GAO/RCED-99-151, 
        June 4, 1999).
    In the seven states it reviewed, GAO identified about 4,500 
people living in long-term care facilities who were potentially 
improperly included as members of households receiving food 
stamps. These households could have received an estimated 
$500,000 in food stamp overpayments during 1997. These 
potential overpayments represented a very small percentage of 
the $8.5 billion in benefits distributed in the seven states 
that year. In view of the relatively small number of potential 
food stamp overpayments involving residents of long-term care 
facilities, GAO concludes that computer matching may not be 
practical for all of the seven states included in its review.
Major Management Challenges and Program Risks: Social Security 
        Administration. (GAO/OCG-99-20, Jan. 1, 1999).
    This publication is part of GAO's performance and 
accountability series, which provides a comprehensive 
assessment of government management, particularly the 
management challenges and program risks confronting federal 
agencies. Using a ``performance-based management'' approach, 
this landmark set of reports focuses on the results of 
government programs--how they affect the American taxpayer--
rather than on the processes of government. This approach 
integrates thinking about organization, product and service 
delivery, use of technology, and human capital practices into 
every decision about the results that the government hopes to 
achieve. The series includes an overview volume discussing 
governmentwide management issues and 20 individual reports on 
the challenges facing specific cabinet departments and 
independent agencies. The reports take advantage of the wealth 
of new information made possible by management reform 
legislation, including audited financial statements for major 
federal agencies, mandated by the Chief Financial Officers Act, 
and strategic and performance plans required by the Government 
Performance and Results Act. In a companion volume to this 
series, GAO also updates its high-risk list of government 
operations andprograms that are particularly vulnerable to 
waste, fraud, abuse, and mismanagement.
    This volume reports the major management challenges at the 
Social Security Administration. Among the challenges are:
           the long-term solvency of the Social 
        Security system (the most critical overarching issue 
        facing SSA);
           the implementation of new computer 
        equipment, which is intended to play a major role in 
        SSA's redesigned work processes and in better serving 
        of a larger beneficiary population;
           redesign of its disability programs to 
        reduce long waiting times for case adjudication; and
           address long-standing problems associated 
        with the Supplemental Security Income program regarding 
        increasing program overpayments, inability to collect 
        program debt, and vulnerability to fraud and abuse.
Observations on the Social Security Administration's Fiscal Year 1999 
        Performance Report and Fiscal Year 2001 Performance Plan. (GAO/
        HEHS-00-126R, June 30, 2000).
    Pursuant to a congressional request, GAO reviewed the 
Social Security Administration's (SSA) fiscal year (FY) 1999 
performance report and FY2001 performance plan required by the 
Government Performance and Results Act of 1993.
    GAO noted that: (1) SSA considers customer service one of 
its key priorities, and according to its FY1999 performance 
report, SSA met many of its goals related to providing 
accurate, timely, and useful service to the public; (2) SSA met 
key goals related to overall customer satisfaction and the 
timely processing of retirement claims; (3) however, SSA's 
progress lagged in some areas, such as waiting times for 
persons with appointments and the accuracy of the handling of 
calls to its toll-free number; (4) in its FY2001 plan, as with 
its FY2000 plan, SSA has demonstrated its desire to use an even 
broader range of measures for customer satisfaction through its 
new Market Measurement Program; (5) the FY1999 report clearly 
indicates that making accurate and timely disability 
determinations remains one of SSA's most challenging service 
areas; (6) in those cases where performance data were 
available, SSA did not meet any of the key goals it set for 
itself; (7) unmet goals included average processing times and 
other timeliness measures of disability decisions at both the 
initial application and appellate levels; (8) SSA's FY2001 
performance plan reflects some improvements in how SSA assesses 
its progress; (9) the FY1999 report also reflects that minimal 
progress has been made in reducing long-term disability 
benefits as a result of returning beneficiaries to work; (10) 
however, the FY2001 plan includes improvements; (11) SSA's 
progress toward providing decisionmakers timely information 
necessary to address program policy issues in FY1999 was also 
unclear; (12) while SSA listed a number of research activities 
it conducted during the fiscal year, it was difficult to 
determine how timely or useful they were; (13) the FY2001 
performance plan, however, reflects significant improvements; 
(14) the FY1999 report indicates that SSA met all key goals 
related to reducing fraud, waste, and error in the Supplemental 
Security Income (SSI) program; (15) the FY2001 plan reflects a 
continued commitment of effort and resources and contains 
additional measures for assessing error; (16) of the 9 
management challenges known to SSA at the time it developed its 
FY2001 performance plan, SSA has established goals and measures 
for five, including long-term program solvency, SSI program 
integrity, redesigning the disability claims process and 
focusing on return to work, program complexity, and service to 
the public; and (17) however, room for improvement both in 
measuring and achieving progress exist for each of these 
challenges.
Pension Plans: Characteristics of Persons in the Labor Force Without 
        Pension Coverage. (HEHS-00-131, Aug. 22, 2000).
    About 53 percent of the employed labor force lacked a 
pension plan in 1998, a decrease of 5 percentage points from a 
decade earlier. The economic expansion since 1991 may have 
encouraged companies to offer pensions as part of their 
compensation packages and may have increased interest in 
pension coverage by persons in the labor force. About 39 
percent of the employed labor force lacked a pension plan 
because their firms did not sponsor a plan, while 14 percent 
were ineligible or chose not to participate in their firm's 
plan. About 85 percent of those who do not have a pension plan 
had relatively low income, were employed part-time or part of 
the year, worked for a relatively small firm, or were 
relatively young. About 48 percent of retirees lacked pension 
income or annuities in 1998. These retirees were more likely to 
be single, female, less educated, and nonwhite. About 21 
percent of retired persons without pension income had incomes 
below the federal poverty threshold, compared with three 
percent with pension income.
Private Pensions: Implications of Conversions to Cash Balance Plans. 
        Letter Report. (HEHS-00-185, Sept. 29, 2000).
    Pursuant to a congressional request, GAO provided 
information on private pensions, focusing on: (1) the 
prevalence and major features of cash balance plans, and 
reasons why firms adopt them; (2) how the use of cash balance 
plans affect the pension benefits for workers of different ages 
and tenure, particularly after conversion; and (3) what 
information employers converting to cash balance plans 
typically provide to plan participants and how disclosure might 
be improved.
    GAO noted that: (1) GAO's survey of 1999 Fortune 1000 firms 
indicates that the number of firms sponsoring cash balance 
plans has increased within the last few years, with few firms 
sponsoring such plans prior to the early 1990s, but increasing 
to about 19 percent of all Fortune 1000 firms this year; (2) 
these plans cover an estimated 2.1 million workers; (3) firms 
in many sectors of the economy sponsor these plans but greater 
concentrations are found in the financial services, health 
care, and manufacturing industries; (4) about 90 percent of the 
firms GAO surveyed that sponsor such plans previously covered 
their workers under a traditional defined benefit plan; (5) 
most of the conversions occurred within the past 5 years; (6) 
key reasons firms gave for converting include lowering total 
pension costs, adding a lump sum feature to increase the 
portability of pension benefits, thereby improving the firm's 
ability to recruit more mobile workers, and facilitating 
communication of the value of plan benefits; (7) as with 
traditional pension plans, cash balance plan designs vary 
significantly; (8) conversions to cash balance plans can be 
advantageous to certain groups of workers, for example, to 
those who switch jobs frequently, but can lower pension 
benefits for others; (9) cash balance plans provide a larger 
share of a participant's accumulated benefit earlier in a 
career,compared with a traditional defined benefit plan that is 
based on final average pay; (10) as a result, conversions can 
increase the value of some workers' benefits, especially 
younger or short-tenured workers who leave firms before 
retirement; (11) unlike traditional defined benefit plans, cash 
balance plans can result in a declining rate of normal 
retirement benefit accrual over time; (12) this declining 
accrual rate can result in older workers receiving lower 
benefits at retirement from a cash balance plan than they would 
have from a traditional final average pay plan if it had not 
been converted; (13) current disclosure requirements provide 
minimum standards for the information plan sponsors must give 
participants about plan changes; (14) GAO found wide variation 
in the type and amounts of information workers receive; (15) 
the communications provided to employees vary from general 
statements about plan changes to specific examples of how a 
conversion to a cash plan might affectworkers of different ages 
and tenure; and (16) often, sponsors did not ensure that 
participants received sufficient information about plan changes 
that can reduce future benefit accruals.
Pension Plans: IRS Programs for Resolving Deviations From Tax-Exemption 
        Requirements. (GAO/GGD-00-169, Aug.14, 2000).
    Pursuant to a congressional request, GAO reviewed the 
Internal Revenue Service's (IRS) programs for resolving 
pension-plan deviations from tax-exemption requirements, 
focusing on: (1) the frequency and types of pension plan 
qualification failures that were detected and corrected through 
IRS audits; (2) the frequency and types of pension plan 
qualification failures that were identified by pension plan 
sponsors and reported to IRS for approval of the correction; 
(3) the sanctions established under IRS' audit program with the 
compliance fees that could have been imposed if the same 
qualification failures had been self-reported by the pension 
plans to IRS; and (4) whether any cost-effective means, other 
than pension plan audits, have been identified that would 
detect unreported qualification failures.
    GAO noted that: (1) of all IRS fiscal year (FY) 1999 
qualification failure case closings, GAO's review showed that 
of 1,802 affected pension plans: (a) 42 percent experienced 
plan document failures (i.e., the documents governing plan 
operations did not comply with tax law requirements); (b) 66 
percent experienced at least one operational failure (i.e., the 
plan did not operate in accord with plan documents); (c) less 
than 2 percent experienced demographic failures (i.e., the 
plans had failed certain tests for ensuring that pension 
benefits were provided in a nondiscriminatory manner); (d) 9 
percent had both operational and document failures; and (e) in 
general, all types and sizes of plans were represented among 
those with qualification failures; (2) of a random sample of 
FY1999 closed audit cases, on average, pension plan sponsors 
were assessed monetary sanctions that GAO estimated were 10 
times greater than the compliance fees that could have been 
assessed if the plan sponsors had reported the qualification 
failures to IRS for supervised correction; (3) however, there 
were substantial differences in this ratio, depending on the 
type of reporting program available to the plans and the manner 
in which IRS applied its guidelines for assessing audit 
sanctions; (4) IRS officials said that, because of concerns 
expressed by pension groups, they had initiatives under way to 
ensure consistency among amounts assessed within compliance 
programs and coordination acrosscompliance programs; (5) the 
pension experts GAO talked with at IRS and outside of the 
government generally viewed audits as an integral part of the 
government's efforts to promote voluntary compliance and 
preserve pension benefits for the U.S. workforce; and (6) while 
they did not identify any cost-effective alternatives to 
replace IRS audits, both IRS and the pension experts thought 
that enhancements could be made to existing IRS programs.
Private Pensions: ``Top-Heavy'' Rules for Owner-Dominated Plans. (GAO/
        HEHS-00-141, Aug. 31, 2000).
    Pursuant to a congressional request, GAO reviewed top-heavy 
rules in relation to other pension laws and regulations 
intended to ensure that workers benefit equitably from their 
pension plans, focusing on: (1) key differences between top-
heavy rules and the general rules for nondiscrimination and 
vesting in contributions and benefits; (2) the most recent data 
available for GAO analysis on the characteristics of new plans 
that report being top-heavy; and (3) what is known about the 
overall effects of top-heavy rules on numbers of plans and 
participants and on employer costs.
    GAO noted that: (1) top-heavy rules for measuring how 
benefits are apportioned, together with required minimum 
benefits and vesting, ensure that workers get certain minimum 
benefits that they would otherwise not receive under the 
general nondiscrimination and vesting rules; (2) top-heavy 
rules are designed to address situations prevalent in owner-
dominated firms; (3) the rules identify pension plans in which 
the majority of benefits accrue to owners and officers, and 
they require higher minimum benefits and faster vesting for 
workers in such plans; (4) top-heavy rules utilize a single 
measure of the value of participants' accumulated contributions 
or benefits; (5) in contrast, nondiscrimination rules permit 
employers to choose among many optional measures for valuing 
the amount of benefits, a number of which may rely on 
projections that overstate the value of pension benefits 
workers actually receive; (6) use of certain nondiscrimination 
rules can leave workers who are outside the top employee group 
with annual employer contributions or benefits accruals that 
are well below those that are required if the top-heavy rules 
are applied; (7) new plans reporting top-heavy status tend to 
be small, defined contribution plans in the service sector of 
the economy; (8) approximately 84 percent of all top-heavy 
plans established in 1996, most recent year for which data were 
available, had fewer than 10 participants; (9) the vast 
majority of all new plans, and of new top-heavy plans, were 
defined contribution plans; (10) whereas plans of service firms 
comprised 52 percent of all new plans, service firm plans 
constituted 70 percent of new top-heavy plans in 1996; (11) 
within the service sector, two-thirds of plans started by 
physicians, dentists, and legal service firms were top-heavy, a 
rate far higher than for other parts of the service sector; 
(12) little is known about the overall effects of top-heavy 
rules on plan formation; (13) formidable data and 
methodological challenges make it difficult to isolate the 
incremental effect of top-heavy rules form the many other 
economic and regulatory factors that influence employers' 
behavior regarding pension plan formation; (14) GAO found no 
research that has quantified the overall effects of top-heavy 
rules on the number of pension plans and participants; and (15) 
in evaluating top-heavy rules' impact, the federal government 
must weigh the extent to which top-heavy rules discourage 
coverage against the higher participant benefits they provide.
Social Security: Actuarial Projections of the Trust Funds. (GAO/AIMD-
        00-53R, Jan. 14, 2000).
    Pursuant to a congressional request, GAO reviewed the 
Pricewaterhouse Coopers (PwC) report on the actuarial 
projections for the trust funds of the Old Age, Survivors, and 
Disability Insurance programs, focusing on whether the Social 
Security Administration's (SSA) Board of Trustees': (1) 1999 
long-range intermediate actuarial projections--their best 
estimates--as presented in the Trustees' 1999 report are based 
on generally accepted actuarial methods and techniques and 
include economic and demographic assumptions that contain no 
material defects because of errors or omissions and are 
individually reasonable; and (2) sensitivity tests include all 
assumptions that could have a significant effect on the 
projections and are reasonable.
    GAO noted that: (1) PwC found that the actuarial methods 
and techniques used in preparing the long-range intermediate 
projections of the Social Security trust funds were sound; (2) 
it also found that the assumptions used in preparing the 
projections in the Trustees' report were individually 
reasonable at the time of the projections; (3) 7 months after 
the Trustees' 1999 report, on October 28, 1999, the Department 
of Commerce's Bureau of Economic Analysis released revised 
estimates of gross domestic product and other economic 
indicators for the period from 1959 through the second quarter 
of 1999; (4) PwC noted that these revisions may affect some 
economic assumptions and as a result, some assumptions may no 
longer be reasonable for future reports; (5) according to SSA 
officials, SSA actuaries have already begun reviewing the 
impact of these revisions for the Trustees' 2000 projections; 
(6) with regard to one of the demographic assumptions--
mortality--the recent TechnicalPanel report concluded that the 
long-range cost of the Social Security system as currently 
designed is likely to be higher than previously projected; (7) 
the panel based its conclusions largely on indicationsthat life 
expectancy will increase faster in the next century than 
currently assumed by the Trustees; (8) in contrast, PwC 
concluded that in the aggregate, the mortality assumptions used 
by the Trustees were reasonable; and (9) in addition, the 
sensitivity tests shown in the Trustees' report were 
reasonable.
Social Security: Capital Markets and Educational Issues Associated with 
        Individual Accounts. (GAO/GGD-99-115, June 28, 1999).
    The aging of the U.S. population poses a financing 
challenge for the Social Security program. Some have suggested 
including individual investment accounts as an element of 
Social Security reform. To help Congress better understand the 
potential implications of individual accounts, this report 
describes how such accounts could affect the (1) private 
capital and annuities markets as well as national savings, (2) 
potential returns and risks to individuals, and (3) disclosure 
and educational efforts needed to inform the American people 
about such a program.
Social Security: Issues in Comparing Rates of Return With Market 
        Investments. (GAO/HEHS-99-110, Aug. 5, 1999)
    Some proposals to restructure Social Security include 
individual retirement savings accounts that would either 
supplement or partially replace the current program's benefits. 
Proponents say that such accounts would substantially improve 
rates of return that individuals could receive on their 
retirement contributions. Others say that the rate of return 
concept should not be applied to Social Security because it is 
a social insurance rather than an investment program.
    Implicit rates of return on Social Security contributions 
vary significantly by birth year, reflecting the program's 
income transfers to the first generations of retirees from 
subsequent generations. They also vary by earnings level, 
number of dependents and survivors, and life expectancy, 
reflecting other income transfers. Rates of return on private 
market assets vary substantially, depending on the risk of 
asset price volatility and the risk of firms' defaulting on 
obligations. Individuals' choice of assets in a portfolio and 
timing of investment decisions ultimately help determine their 
returns and risks.
    A simple comparison between rates of return for the current 
Social Security program and private market investments would be 
misleading because it would not reflect all the costs 
associated with a new system of individual accounts. Rates of 
return under the new system would depend on how unfunded 
liabilities are paid and on costs for managing and annuitizing 
the new accounts. Also, future market investment returns could 
differ from historic averages, and risks differ between Social 
Security and market investment. Comparisons should be made 
instead between comprehensive return estimates for specific 
reform proposals that include both individual accounts and the 
Social Security components of the resulting system. However, 
this is only one criterion for comparing proposals; other 
criteria include the adequacy and predictability of benefits, 
the extent of solvency improvement, and the effect on the 
federal budget and national saving.
Social Security Administration: Compliance with Presidential Directive 
        to Reduce Management-to-Staff Ratio. (GAO/HEHS-99-43R, Jan. 22, 
        1999).
    Pursuant to a congressional request, GAO reviewed the 
Social Security Administration's (SSA) efforts to implement a 
National Performance Review (NPR) recommendation to reduce its 
management-to-staff ratio, focusing on the: (1) progress SSA 
has made to date in achieving the directive to reduce its 
management-to-staff ratio, particularly for staff graded GS-12 
and above; and (2) steps SSA has taken to reduce the number of 
supervisory positions.
    GAO noted that: (1) SSA is making progress in its efforts 
to achieve a supervisor-to-staff ratio of 1-to-15 by the close 
of fiscal year (FY) 1999; (2) by the end of FY1998, the agency 
had reduced its supervisor-to-staff ratio to 1-to-12.4 from 
about 1-to-7 in FY1994; (3) SSA achieved these reductions, 
consistent with the Office of Personnel Management guidance, by 
use of a number of special initiatives available to federal 
departments and agencies; (4) according to SSA officials, these 
initiatives included early retirements, employee buyouts, and 
reassignment of supervisory staff to newly created 
nonsupervisory positions; (5) since FY1993, SSA has created a 
total of 1,900 new nonsupervisory positions--550 team leader 
positions in headquarters and an additional 1,350 management 
support specialists and area systems coordinator positions in 
field offices; and (6) all of the 550 headquarters positions 
and 1,222 of the 1,350 regional office positions have been 
filled.
Social Security Administration: Longstanding Problems in SSA's Letters 
        to the Public Need to Be Fixed. (GAO/HEHS-00-179, Sept. 26, 
        2000).
    Pursuant to a congressional request, GAO assessed the 
equality of the Social Security Administration's (SSA) letters 
to the public, focusing on the: (1) problems that make SSA's 
letters difficult to understand; and (2) status of SSA's 
actions to fix the problems.
    GAO noted that: (1) the majority of letters in each of the 
four categories GAO reviewed did not clearly communicate at 
least one of the following key points: (a) SSA's decision (that 
is, the action SSA was taking on a claim that prompted the 
agency to send the letter); (b) the basis for SSA's decision; 
(c) the financial effect of SSA's decision on the person 
addressed in the letter; or (d) the recourse the person could 
take in response to SSA's decision; (2) the lack of clarity was 
caused by one or more problems, such as illogically sequenced 
information, incomplete or missing explanations, contradictory 
information, and confusing numerical information; (3) an 
unclear explanation of the basis for SSA's decision was the 
most widespread problem among the four categories of letters; 
(4) for example, it was difficult to understand the basis for 
SSA's decision in Supplemental Security Income (SSI) award 
letters because the letters did not explain the relationship 
between program rules and the amount of the SSI benefit; (5) a 
subgroup of SSI award letters--those sent to about 13 to 15 
percent of SSI awardees who are eligible for previous but not a 
future month's benefits--were unclearin communication all four 
key points; (6) SSA acknowledges that these letters contain the 
problems GAO identified; however, for many of the problems, the 
agency has not taken any corrective action; (7) many of the 
problems GAO identified are not amenable to quick fixes but, 
rather, will require a comprehensive revision of the language 
used in the letters and rewriting the agency's software 
applications that generate them; (8) the agency has repeatedly 
rescheduled plans to make comprehensive changes for its Social 
Security benefit adjustment letters because of competing 
demands of computer systems resources; the agency allocated 
resources to other priorities, such as making computer system 
changes that resulted from legislation; (9) however, the agency 
announced plans to make significant changes to this category of 
letter, but few details are yet available; (10) major 
improvements to SSI letters were also delayed, but in this case 
SSA was waiting for resolution of a nationwide court case 
involving these letters; (11) in September 1999, a federal 
court ordered SSA to develop and implement a plan to improve 
its SSI letters, prompting SSA to begin a major, multiyear 
initiative to improve its SSI award and benefit adjustment 
letters; (12) this initiative is still in the early phase; and 
(13) SSA has not placed a high priority on improving its 
letters to the public.
Social Security Administration: Subcommittee Questions Concerning 
        Current and Future Service Delivery Challenges. (GAO/AIMD/HEHS-
        00-165R, May 11, 2000).
    Pursuant to a congressional request, GAO provided 
information on the Social Security Administration's (SSA) 
efforts to prepare its workforce to meet future service 
delivery challenges. This information was requested subsequent 
to our February 2000 testimony, SSA Customer Service: Broad 
Service Delivery Plan Needed to Address Future Challenges (GAO/
T-HEHS/AIMD-00-75, February 10, 2000).
Social Security Reform: Administrative Costs for Individual Accounts 
        Depend on System Design. (GAO/HEHS-99-131, June 18, 1999).
    Proposals to protect the Social Security program's future 
solvency and sustainability include creating a system of 
individual accounts for accumulating retirement savings. 
Available studies of the costs to run a system of individual 
accounts do not capture all the likely costs. For example, the 
costs of government oversight, enforcement activities, and 
public education are generally not included. Designers of a 
system of individual accounts must make critical decisions 
about who would assume the new administrative and recordkeeping 
responsibilities, how much choice individuals would have in 
selecting and changing their investment options, and how 
retired workers would receive their benefits. Administrative 
costs would vary, depending on these decisions and the types 
and level of customer service offered. They could be higher for 
more decentralized systems and for those offering broader 
investment choices, more customer service options, or both. In 
GAO's analysis, a man who had average annual earnings every 
year for 45 years would accumulate $125,430 (in 1998 dollars) 
in his account under a 0.1-percent annual administrative cost, 
as opposed to $75,995 under a two-percentadministrative cost. 
If individuals bought an annuity, ensuring a steady stream of 
income throughout retirement, the average administrative cost 
in the current market would be five percent of the amount being 
converted into the annuity.
Social Security Reform: Evaluation of the Gramm Proposal. (GAO/AIMD/
        HEHS-00-71R, Feb. 1, 2000).
    This report applies GAO's criteria for assessing Social 
Security reform proposals to the plan outlined by Senator Phil 
Gramm. GAO's report is based on an analytical framework that 
the agency provided to Congress last March. That framework 
consists of the following three criteria: the extent to which 
the proposal achieves sustainable solvency and how it would 
affect the U.S. economy and the federal budget; the balance 
struck between the twin goals of income adequacy (level and 
certainty of benefits) and individual equity (rates of return 
on individual contributions); and how readily such changes 
could be implemented, administered, and explained to the 
public.
Social Security Reform: Evaluation of the Nick Smith Proposal. (GAO/
        AIMD/HEHS-00-102R, Feb. 29, 2000).
    This report applies GAO's criteria for assessing Social 
Security reform proposals to the plan outlined by Congressman 
Nick Smith. GAO's report is based on an analytical framework 
that the agency provided to Congress last March. That framework 
consists of the following three criteria: the extent to which 
the proposal achieves sustainable solvency and how it would 
affect the U.S. economy and the federal budget; the balance 
struck between the twin goals of income adequacy (level and 
certainty of benefits) and individual equity (rates of return 
on individual contributions); and how readily such changes 
could be implemented, administered, and explained to the 
public.
Social Security Reform: Experience of the Alternate Plans in Texas. 
        (GAO/HEHS-99-31, Feb. 26, 1999).
    Under an option available to state and local governments 
until 1983, three Texas counties withdrew from Social Security 
in 1981 and replaced it with a system of individual accounts 
that provided retirement, survivor, and disability benefits to 
their employees. Social Security faces a long-term funding 
shortfall, and some have suggested that the experience of these 
three counties underscores the advantages of individual 
accounts as an element of Social Security financing reform. GAO 
found that although Social Security and the alternate plans of 
the three Texas counties offer retirement, disability, and 
survivor benefits, there are fundamental differences in the 
purpose and the structure of the two approaches. Social 
Security is a social insurance program designed to provide a 
basic level of retirement income to help retired workers, the 
disabled, and their dependents and survivors avoid poverty. 
Social Security benefits are tilted to provide relatively 
higher benefits to low-wage earners and the benefits are fully 
indexed to protect against inflation. Social Security, a pay-
as-you go system, is projected to produce a negative cash flow 
in 2013 and become insolvent by 2032. In contrast, the 
alternate plans are advance-funded; that is, the contributions 
made by workers and their employers, which total 13.915 percent 
of workers' pay, and the earnings from those invested 
contributions are used to fund retirement benefits. At 
retirement, a worker can withdraw the money in the account as a 
lump sum or choose from several monthly payment options, 
including the purchase of a lifetime annuity. GAO's simulations 
of how workers for the three Texas counties and their 
dependents might fare under the two systems revealed that 
outcomes generally depend on individual circumstances and 
conditions. For example, the alternate plans provide larger 
benefits for high-wage workers than Social Security would, but 
in some cases, such as when spousal benefits are involved, 
Social Security benefits could also eventually exceed those of 
the alternate plans. GAO notes that the alternate plans' 
performance is not necessarily indicative of how well 
individual accounts might perform within Social Security. For 
example, the alternate plans have followed a very conservative 
investment strategy that precludes investing in common stocks.
Social Security Reform: Implementation Issues for Individual Accounts. 
        (GAO/HEHS-99-122, June 18, 1999).
    Social Security is one of the nation's most important and 
visible programs. Although individual accounts offer the 
possibility of an improved rate of return on individual 
contributions, a flawed or failed system of individual accounts 
could have devastating effects on individuals' retirement 
security and undermine public confidence in government. GAO 
believes that the following three critical questions need to be 
addressed in designing and implementing a system of individual 
accounts: Who would assume new administrative and record-
keeping responsibilities? How much choice would individuals 
have in selecting and controlling their investment options? How 
much flexibility would workers have when they retire and begin 
to draw on their accounts? This report discusses the 
fundamental choices associated with each question and several 
options that could be considered.
Social Security Reform: Implications of Private Annuities for 
        Individual Accounts. (GAO/HEHS-99-160, July 30, 1999).
    The private annuities market would likely be able to 
provide annuities for individual accounts in a reformed Social 
Security system, but their structuring would significantly 
affect retirees' income. Requiring workers to buy annuities 
with their individual account balances would help preserve 
their retirement income but would also expose them to risks and 
costs in retirement that they do not currently face. Some 
options that would mitigate the effects of various costs on 
annuity payments would require limiting retirees' payout 
choices. In a reformed Social Security system in which 
individuals were required to buy annuities, they would need to 
fully understand the factors affecting their annuity income and 
its protection. The federal government would need to play some 
role in ensuring that insurance markets worked efficiently or 
in providing annuities if the private market failed to do so. 
To protect annuitants and ensure their equal treatment, the 
government might have to establish uniform guaranty protections 
for them and standardized solvency requirements for insurance 
companies. Policymakers would need to balance the states' 
longstanding authority to regulate insurance markets with the 
desire for uniform protections for the annuitants.
Social Security Reform: Implications of Raising the Retirement Age. 
        (GAO/HEHS-99-112, Aug. 27, 1999).
    Raising the normal or earliest eligibility age or both 
could have substantial net positive effects on the financial 
integrity of the Old-Age and Survivors Insurance and Disability 
Insurance Trust Funds. These measures would reduce the 
retirement benefits paid out and increase the payroll taxes 
collected. Raising the retirement age would boost the number of 
older workers in the labor force, as more workers would be 
employed for longer periods of time. Increasing the number of 
older workers in the labor force, however, could also create 
the potential for additional unemployment. An understanding of 
the cumulative effects of any reform proposal is essential to 
preventing a disproportionate burden from falling on vulnerable 
groups, such as minorities, who are most likely to be in blue-
collar jobs and to experience unemployment.
Social Security Reform: Information on the Archer-Shaw Proposal. (GAO/
        AIMD/HEHS-00-56, Jan. 19, 2000).
    This report applies GAO's criteria for assessing Social 
Security reform proposals to the plan outlined by Congressmen 
Archer and Shaw. GAO's report is based on an analytical 
framework that the agency provided to Congress last March. That 
framework consists of the following three criteria: the extent 
to which the proposal achieves sustainable solvency and how it 
would affect the U.S. economy and the federal budget; the 
balance struck between the twin goals of income adequacy (level 
and certainty of benefits) and individual equity (rates of 
return on individual contributions); and how readily such 
changes could be implemented, administered, and explained to 
the public.
State Pension Plans: Similarities and Differences Between Federal and 
        State Designs. (GAO/GGD-99-45, March 19, 1999).
    This report discusses the design components of retirement 
programs that states offer to their general employees and 
compares them to the design components of the two principal 
federal retirement programs for federal workers--the Federal 
Employees' Retirement System and the Civil Service Retirement 
System. GAO also describes the changes that the states have 
considered and made to their retirement programs.
Tax Administration: Billions in Self-Employment Taxes Are Owed. (GAO/
        GGD-99-18, Feb. 19, 1999).
    A GAO analysis of the Internal Revenue Service's (IRS) 
accounts receivable data as of September 1997 found that more 
than 1.9 million self-employed taxpayers were delinquent in 
paying $6.9 billion in self-employment taxes on 3.6 million 
returns. These taxpayers generally have low incomes and 
multiple delinquencies. More than 144,000 taxpayers with 
delinquent self-employment taxes of $487 million were receiving 
about $105 million in monthly Social Security benefits. The 
income on which the self-employment taxes had not been paid 
resulted in an estimated $2.5 million in monthly benefits that 
would not have been paid if those earnings had not been 
included in the benefit computation. Self-employed taxpayers 
can get Social Security benefits on the basis of earnings for 
which they did not pay taxes because the law requires the 
Social Security Administration (SSA) to grant earnings credits, 
which are used to determine benefit eligibility and amounts, 
and pay benefits without regard to whether the Social Security 
taxes have been paid. However, not all self-employed taxpayers 
can receive credit for their earnings. Under the law, when 
taxpayers do not file their tax returns within 3 years, 3 
months, and 15 days after the end of the year in which the 
income was earned, they are not to receive Social Security 
credit. Of the 3.6 million returns with delinquent self-
employment tax, SSA did not post earnings to its records for 
nearly 474,000 returns. For an estimated 81.9 percent of the 
returns with unposted earnings, taxpayers filed the returns 
after the statutory time limit. Many of the taxpayers may have 
been unaware of the statutory time limit because neither SSA's 
nor IRS' widely available publications discuss it. GAO notes 
several ways to enhance the collection of taxes from self-
employed persons.

                        Veterans and DOD Issues

Defense Health Care: Improvements Needed to Reduce Vulnerability to 
        Fraud and Abuse. (GAO/HEHS-99-142, July 30, 1999.)
    It is impossible to quantify precisely the amount lost to 
fraud in the military health care system, but the Defense 
Department (DOD) and the health care industry generally agree 
that fraud and abuse could account for as much as 20 percent of 
all health care costs. Because DOD spent 5.7 billion on managed 
care contracts between 1996 and 1998, DOD could have lost more 
than $1 billion to fraud and abuse during this time. Fraud and 
abuse can also undermine the quality of care provided and can 
harm patients' health. For example, patients might receive 
incorrect diagnoses and inadequate treatment when a provider 
bills DOD for fabricated test results. DOD and its contractors 
have had limited success in identifying fraud and abuse in 
TRICARE--DOD's managed health care system. To its credit, DOD 
recognizes that it needs to reduce its vulnerability to fraud 
and abuse and has identified several revisions it could make to 
its antifraud policies and requirements. However, it has been 
slow to implement these policy changes, which would require 
contractors to establish a more aggressive fraud and abuse 
identification program.
DOD Retiree Health Benefits Liability: Evaluation of DOD's Sensitivity 
        Analysis. (GAO-01-164R, Oct. 31, 2000).
    GAO has been working with the Department of Defense (DOD) 
to develop and report a reliable estimate for the post 
employment health care benefits due to military retirees, their 
dependents, and survivors. To help accomplish this, the DOD 
Office of Actuary prepared a sensitivity analysis that 
identified the health care liability's key data elements and 
assumptions and determined what amount of change in each 
element was required to raise or lower the resulting liability 
by a set amount. Because of the technical nature of actuarial 
projections, GAO hired a contractor to evaluate the 
completeness and accuracy of the DOD sensitivity analysis and 
also review the methodology that DOD used to calculate the 
retiree health care benefits liability. This report provides a 
non-technical summary of the contractor's findings and includes 
GAO's recommendation that DOD implement the improvements 
discussed in the contractor's reports. In general, the 
contractor found that the sensitivity analysis did a good job 
of identifying the factors that affect the liability and of 
evaluating their relative impact on the liability calculation. 
However, the contractor did identify several issues that should 
be addressed in order to make the analysis more complete and a 
few areas where an additional breakout of information is needed 
in order to adequately analyze its impact on the calculation. 
Finally, the contractor found that DOD's methodology was 
generally reasonable but it was not fully documented and one of 
the five calculations that were tested by the contractor was 
erroneous.
Financial Management: Review of VA's Actuarial Model for Veterans' 
        Compensation Benefits. (GAO/AIMD-99-46, Jan. 29, 1999)
    In a report on the government's consolidated financial 
statements for fiscal year 1997, GAO noted that the Department 
of Veterans Affairs' (VA) estimated liability for veterans' 
compensation benefits was materially understated primarily 
because it did not include estimates for anticipated changes in 
disability ratings and for incurred claims not yet reported. 
(See GAO/AIMD-98-127, Mar. 1998.) Because of these limitations, 
VA's methodology for computing the liability did not comply 
with Statement of Federal Financial Accounting Standards 
(SFFAS) No. 5, which prescribes accounting standards for the 
federal government's liabilities. VA revised its model to 
comply with SFFAS No. 5 before issuing its own audited 
financial statements for the Department in April 1998. Using 
the revised model, VA's estimated liability as of September 30, 
1997, in its April 1998 report was $466 billion--an increase of 
$270 billion over that reported in the government's 
consolidated financial statements for fiscal year 1997. This 
report discusses the improvements that VA has made to the model 
and makes recommendations for additional improvements that 
should enhance the reliability ofestimates produced by the 
model.
Information Technology: VA Actions Needed to Implement CriticalReforms. 
        (GAO/AIMD-00-226, Aug. 16, 2000).
    To improve information technology (IT) investment decision-
making at the Department of Veterans Affairs (VA), GAO 
recommends that the agency (1) establish and monitor deadlines 
for completing formal in-process reviews at key milestones in a 
project's life cycle, (2) provide decisionmakers with 
information on lessons learned from IT post-implementation 
reviews, and (3) develop and implement guidance to better 
manage IT projects. To fully addresses these provisions, VA 
needs to fill the position of assistant secretary for 
information and technology as quickly as possible, reassess its 
decision to delegate business process reengineering to the 
individual administrations, and direct the department's Chief 
Information Officer or designee to lead the effort to work with 
VA business owners to develop a logical architecture as a step 
toward an integrated IT architecture.
Major Management Challenges and Program Risks: Department of Veterans 
        Affairs. (GAO/OCG-99-7, Jan. 1999).
    This publication is part of GAO's performance and 
accountability series which provides a comprehensive assessment 
of government management, particularly the management 
challenges and program risks confronting federal agencies. 
Using a ``performance-based management'' approach, this 
landmark set of reports focuses on the results of government 
programs--how they affect the American taxpayer--rather than on 
the processes of government. This approach integrates thinking 
about organization, product and service delivery, use of 
technology, and human capital practices into every decision 
about the results that the government hopes to achieve. The 
series includes an overview volume discussing governmentwide 
management issues and 20 individual reports on the challenges 
facing specific cabinet departments and independent agencies. 
The reports take advantage of the wealth of new information 
made possible by management reform legislation, including 
audited financial statements for major federal agencies, 
mandated by the Chief Financial Officers Act, and strategic and 
performance plans required by the Government Performance and 
Results Act. In a companion volume to this series, GAO also 
updates its high-risk list of government operations and 
programs that are particularly vulnerable to waste, fraud, 
abuse, and mismanagement.
    This report addresses the major management challenges at 
the Department of Veterans Affairs. Among the challenges are:
           Obsolete infrastructure in VA's health care 
        system;
           Poor monitoring of the effects of health-
        care delivery changes on patient outcomes;
           Inadequate data to ensure that veterans have 
        access to needed health-care services;
           Ineffective management of non-health-care 
        benefits; and
           Ineffective management of VA's management 
        information system.
Observations on the Department of Veterans Affairs' Fiscal Year 1999 
        Performance Report and Fiscal Year 2001 Performance Plan. (GAO/
        HEHS-00-124R, June 30, 2000).
    Pursuant to a congressional request, GAO reviewed the 
Department of Veterans Affairs' (VA) fiscal year (FY) 1999 
performance report and FY2001 performance plans required by the 
Government Performance and Results Act.
    GAO noted that: (1) VA's FY1999 performance showed progress 
in providing quality health care at a reasonable cost; (2) 
although VA did not meet all of its FY1999 performance goals, 
it met one of its most important goals--to reduce the average 
health care cost per patient by 13 percent since FY1997--actual 
performance reported was a 16-percent reduction; (3) VA failed 
to meet its FY1999 performance goals related to the timely and 
accurate processing of veterans' benefit claims; (4) thesegoals 
covered the accuracy and timeliness of VA decisions on claims 
for compensation and pension benefits, and the timeliness of 
resolution of veterans' appeals of claims decisions; (5) VA set 
a FY1999 goal to complete decisions on compensation and pension 
claims in an average of 99 days--actual performance was 166 
days; (6) another goal was to resolve initial decisions 
appealed to VA's Board of Veterans Appeals within an average of 
590 days--actual performance was 745 days; (7) the revised 
FY2001 goal for claims processing timeliness is 142 days, the 
goal for appeals resolution timeliness is 650 days; (8) in 
FY1999, VA achieved both performance goals related to helping 
disabled veterans acquire and maintain suitable employment; (9) 
in particular, 53 percent of veterans who exited the vocational 
rehabilitation program obtained and maintained suitable 
employment--technically exceeding the performance goal of 45 
percent; (10) while this rehabilitation rate generally shows 
VA'sprogress in moving the vocational rehabilitation program's 
focus toward helping veterans find employment, it does not 
fully measure program results because it: (a) focuses on 
veterans who left the program, rather than on all veterans 
eligible for the program; and (b) does not consider how long it 
took veterans to complete the program; (11) VA does not have 
any performance goals and measures directly related to reducing 
the availability and use of illegal drugs; (12) however, VA 
slightly exceeded its one performance goal indirectly related 
to this outcome; (13) in FY1999, 56 percent of the patients 
with primary addictive disorders showed improvement in their 
addiction severity index (ASI) composite scores at 6 months 
after their initial assessment; and (14) in its FY2001 
performance plan, VA changed its goal to assess the percentage 
of patients who receive a 6-month follow-up ASI assessment.
VA Health Care: Improvements Needed in Capital Asset Planning and 
        Budgeting. (GAO/HEHS-99-145, Aug. 13, 1999).
    GAO recommends that the Department of Veterans Affairs (VA) 
implement more effective health care capital asset planning and 
strengthen its budgeting processes to avoid spending billions 
of dollars operating hundreds of unneeded buildings over the 
next five or more years. VA should focus on Office of 
Management and Budget guidelines that suggest that agencies use 
market-based assessments to determine target population needs, 
evaluate the capacity of existing assets, identify excesses and 
deficiencies, estimate assets' life-cycle costs, and compare 
these with alternatives for meeting the population's needs. VA 
has 40 markets with two to nine VA locations that have 
utilization significantly below inpatient capacity and that 
compete with other VA locations to serve rapidly declining 
veteran populations. VA could restructure these assets and 
enhance veterans' benefits. VA has 66 other markets with a 
single VA location, many in areas with rapidly declining 
inpatient workloads and veteran populations, where assets could 
be restructured and benefitsenhanced. VA's centralized budget 
development process, which reviews and approves capital 
investments of $4 million or more under its major construction 
appropriation relies on inconsistent or incomplete information 
for decision-making. The 22 regional offices that make less 
expensive investment decisions in VA's decentralized assessment 
process generally do so without systematically assessing ways 
to redesign or simplify work processes or explore lower-cost 
alternatives. Such decisions account for more than 85 percent 
of VA's total health care investment dollars requested for 
fiscal year 2000. Over the past 3 years, VA has significantly 
reduced the number of high-cost investment proposals involving 
alterations or improvements by dividing them into less 
expensive ones, which require less information about benefits, 
risks, and alternatives. This has resulted in VA's 
decentralized process having approved investments that VA's 
centralized process considered, orwould consider, to be a low 
priority or unsound.
VA Health Care: VA's Management of Drugs on Its National Formulary. 
        (GAO/HEHS-00-34, Dec.14, 1999).
    Pursuant to a congressional request, GAO reviewed how the 
Department of Veterans Affairs (VA) manages its national 
formulary and how drugs other than those on the formulary are 
made available to veterans. GAO noted that: (1) VA's national 
formulary is administered by the Pharmacy Benefits Management 
Strategic Healthcare Group (PBM), a strategy modeled after one 
commonly used in private health care systems; (2) PBM adds 
drugs to, and deletes drugs from, the national formulary on the 
basis of a review of current literature related to drugs' 
safety and efficacy and the contributions they can make in 
treating veterans; (3) PBM also performs drug class reviews 
that determine which drugs are therapeutically 
interchangeable--essentially equivalent in terms of efficacy, 
safety, and outcomes; (4) this determination allows VA to 
obtain better prices for one or more of these drugs by using 
competitively bid contracts; (5) PBM safeguards against 
inappropriate use by requiring that clinical guidelines be 
followed when some drugs are used, limiting prescribing 
privileges in certain cases to specially trained physicians; 
and in other cases, requiring consultation with a specialist 
before a drug can be prescribed; (6) drugs not on the national 
formulary may be available to veterans through independent 
formularies maintained by Veterans Integrated Service Networks 
(VISN) and some medical centers; (7) these formularies are 
designed to provide local facilities flexibility by giving 
physicians access to additional drugs that meet the special 
needs of their patients; (8) if prescribers believe that a 
patient needs a drug that is not on the national, VISN, medical 
center formulary, they may request a nonformulary drug waiver, 
which would allow the prescriber to provide the nonformulary 
drug; (9) new drugs may be added to VISN and medical center 
formularies immediatelyupon Food and Drug Administration 
approval; (10) however, VA policy states that new drugs 
generally may not be added to the national formulary until they 
have been on the U.S. market for at least 1 year because VA 
believes veterans may be exposed to potential side effects that 
are not identified during the drug review and approval process; 
and (11) this potentially allows veterans treated in some 
facilities to benefit from new drugs before veterans in other 
locations, but it may also expose them to any side effects that 
are identified within the first year of a drug's general use.
VA Information Systems: Computer Security Weaknesses Persist at the 
        Veterans Health Administration. (GAO/AIMD-00-232, Sept. 8, 
        2000).
    In conjunction with the Department of Veterans Affairs (VA) 
required annual financial audit, GAO reviewed information 
system general controls over financial and sensitive veteran 
medical information maintained by the Veterans Health 
Administration (VHA), focusing on: (1) specific computer 
security weaknesses GAO identified at the New Mexico and North 
Texas health care systems in conjunction with the audit of the 
Department of Veterans Affairs (VA) fiscal year (FY) 1997 
financial statements; and (2) departmentwide computer security 
initiatives that GAO reported in October 1999.
    GAO noted that: (1) in September 1998, GAO reported that 
computer security weaknesses placed critical VA operations, 
including health care delivery, at risk of misuse and 
disruption; (2) since then, VA's New Mexico and North Texas 
health care systems have corrected most of the specific 
computer security weaknesses that were identified in 1998; (3) 
however, serious computer security problems persist throughout 
VHA and the department because: (a) VA has not yet fully 
implemented an integrated security management program; and (b) 
VHA had not devoted adequate resources to effectively manage 
computer security at its medical facilities; (4) consequently, 
financial transaction data and personal information on veteran 
medical records continue to face increased risk of inadvertent 
or deliberate misuse, fraudulent use, improper disclosure, or 
destruction, possibly occurring without detection; (5) GAO 
identified additional computer security problems at the New 
Mexico and North Texas health care systems and also found 
similar serious weaknesses at the VAMaryland Health Care 
System; (6) these medical facilities had not adequately 
controlled access granted to authorized users, prevented 
employees from performing incompatible duties, secured access 
to networks, restricted physical access to computer resources, 
or ensured the continuation of computer processing operations 
in case of unexpected interruption; (7) the access and service 
continuity weaknesses GAO found are similar to problems 
consistently identified since 1998 at VHA medical facilities by 
VA's Office of Inspector General (OIG), internal VHA reviews, 
and consultant studies; (8) VA's OIG has reported 
departmentwide information system security as a material 
internal control weakness since the FY1997 consolidated 
financial statement reporting period; (9) VArecognized the 
significance of these problems and began reporting information 
system security as a material weakness in its Federal Managers' 
Financial Integrity Act of 1982 report for 1998; (10) onereason 
for VA's continuing information system control problems is that 
the department had not implemented a comprehensive, integrated 
security management program; (11) initiating a process to 
review and build on security practices developed by other VA 
organizations could expedite VAefforts to develop 
departmentwide guidance in these areas; and (12) until VA 
develops and implements a comprehensive, coordinated security 
management program and ensures that adequate resources are 
devoted to this program, it will have limited assurance that 
financial information and sensitive veteran medical records are 
adequately protected from misuse, unauthorized disclosure, and/
or destruction.
Veterans' Benefits Claims: Further Improvements Needed in Claims-
        Processing Accuracy. (GAO/HEHS-99-35, March 1, 1999).
    The Department of Veterans Affairs (VA) pays monthly 
compensation benefits to veterans with injuries or diseases 
incurred or aggravated while on active military duty and 
monthly pension benefits to wartime veterans who have low 
incomes and are permanently and totally disabled for reasons 
not connected to their service. The Veterans Benefit 
Administration's (VBA) new accuracy measurement system, 
deployed at the beginning of fiscal year 1999, indicates that 
VBA needs to give more attention to ensuring that the regional 
offices that process compensation and pension claims make 
correct decisions the first time so that veterans need not make 
unnecessary appeals or be unnecessarily delayed in receiving 
benefits. Compared with VBA's previous system, the new one 
focuses more on regional office decisions that are likely to 
contain processing errors, uses a stricter method for computing 
accuracy rates, provides more data on the performance of VBA's 
organizational levels, collects more data on processing errors, 
and stores more accurate review results in a centralized 
database for review and analysis. However, VBA should (1) 
further strengthen its ability to identify error-prone cases by 
collecting more detailed data on the human body systems, 
specific impairments, and deficiencies in medical evidence and 
examinations involved in disability claims, (2) implement a 
system for reviewing claims-processing accuracy that meets 
standards on separation of duties and organizational 
independence, and (3) keep Congress informed on its progress in 
establishing stricter employee accountability and developing 
more effective training for claims adjusters.

                            Multiple Issues

Federal Budget: The President's Midsession Review. (GAO/OCG-99-29, July 
        27, 1999).
    This statement, which was originally prepared for a hearing 
before the Senate Budget Committee, discusses the President's 
Midsession Review and the implications of the President's 
proposals for fiscal policy and the federal budget. After years 
of budgetary belt tightening and difficult policy decisions, 
the goal of budget balance has finally been achieved. Congress 
and the President now face a series of choices that will have a 
major impact on the nation's economic future. Despite the 
euphoria surrounding the projected surpluses, the reality is 
that the country has run up a large debt from years of deficit 
spending. Using a significant portion of the surplus to pay 
down the debt would ultimately lower interest costs and spur 
economic growth. The miracle of compounding means that interest 
payments saved today will yield huge dividends tomorrow. Few, 
however, expect the entire projected surplus to go to debt 
reduction, and choices will have to be made about shoring up 
entitlement programs, boosting defense spending, and providing 
tax cuts. At the same time, looming demographic trends demand 
that the surplus be put to good use. The fact remains that our 
society is aging. Less than 10 years from now, the baby boomers 
will begin drawing retirement benefits. GAO projects that even 
if the country were to save the entire surplus and adhere to 
the budget caps, the combined spending pressures of Social 
Security, Medicare, and Medicaid would eventually reignite the 
vicious circle of escalating deficits, debt, and interest 
costs. Debt reduction must be accompanied by entitlement 
reform. In his midsession budget review, the President proposes 
to reduce publicly held debt more than he did in his February 
budget. He also wants to increase spending in several areas. 
But the big items in the budget continue to be Social Security 
and Medicare. Until these two programs are fundamentally 
reformed, their long-term solvency and sustainability will 
remain in doubt. The surplus presents both an opportunity and 
an obligation: to reduce the debt burden, to provide a strong 
foundation for future economic growth, and to ensure that 
government's future commitments are both adequate and 
affordable.
Federal Mandatory Spending on the Elderly. (GAO/AIMD-00-166R, May 11, 
        2000).
    Pursuant to a congressional request, GAO provided 
information on federal mandatory spending on the elderly.
    GAO noted that: (1) GAO estimates that federal mandatory 
spending on the elderly for the applicable programs as a share 
of gross domestic product (GDP) will grow from 6 percent in 
2000 to 6.5 percent in 2010; (2) in the following decade, as 
the baby boom generation begins to retire, this spending will 
accelerate, reaching 8.4 percent of GDP in 2020; (3) this 
represents a growth of about 30 percent in federal mandatory 
spending on the elderly as a share of GDP between 2010 and 
2020; (4) not surprisingly, Social Security and Medicare 
comprise the largest share of federal spending on the elderly; 
(5) Medicaid's spending on the elderly as a share of GDP is 
projected to grow the fastest, doubling over the next 20 years; 
(6) on the other hand, GAO's estimates show that federal 
spending on civilian and military retirees is projected to 
remain relatively constant as a share of the economy; (7) 
future claims of the elderly on the economy are likely to be 
larger than indicated by GAO's estimates; (8) for example, 
GAO's estimates do not include federal tax expenditures 
targeted to the elderly, such as the extra standard deduction 
for those elderly taxpayers who do not itemize deductions, 
Veterans Administration expenditures for the elderly, other 
federal programs targeted to or used by the elderly (including 
those for housing and food assistance), or spending by state 
and local governments; and (9) GAO's estimates also do not 
include private spending on the elderly, such as for pensions, 
prescription drugs, or long-term care including out-of-pocket 
costs and hours of work foregone by those caring for elderly 
parents.
Medicare Subvention Demonstration: DOD Data Limitations May Require 
        Adjustments and Raise Broader Concerns. (GAO/HEHS-99-39, May 
        28, 1999).
    The Balanced Budget Act of 1997 authorized a three-year 
test--called Medicare subvention--that allows Medicare-eligible 
military retirees, their dependents, and survivors to enroll in 
a new Department of Defense (DOD) health maintenance 
organization (HMO). The goal is to offer accessible, quality 
care while keeping costs down for DOD and Medicare. Care for 
these beneficiaries at military treatment facilities is now 
provided on a space-available basis that lacks the continuity 
often important to many older retirees. Under the Medicare 
subvention demonstration, Medicare will pay DOD for health care 
provided to retirees at six sites. DOD will provide enrollees 
with the full range of Medicare-covered services as well as 
some additional ones. In principle, beneficiaries, DOD, and 
Medicare could all gain under subvention. Because of data 
inaccuracies in DOD's medical cost accounting systems, portions 
of DOD's baseline costs may be understated, and this, if not 
adjusted, could lead to Medicare overpayments. Data problems 
also make the demonstration project more difficult to manage at 
both the national and local levels. DOD officials have 
developed a management improvement plan to begin addressing 
data weaknesses and HCFA plans to hire a contractor to review 
DOD's data.
Medicare Subvention Demonstration: Enrollment in DOD Pilot Reflects 
        Retiree Experiences and Local Markets. (GAO/HEHS-00-35, Jan. 
        31, 2000).
    Many military retirees would like to use their Medicare 
benefits at military medical facilities, but federal law does 
not allow Medicare to pay the Defense Department (DOD). Many 
retirees can get health care at military facilities only when 
space is available and cannot rely on them for comprehensive, 
continuous care. DOD is willing to provide such care to these 
retirees if the law is changed so that Medicare could reimburse 
DOD. In light of these concerns, recent legislation authorized 
a three-year, six-site demonstration project, called Medicare 
subvention, which allows Medicare-eligible military retirees to 
enroll in a new, DOD-run health maintenance organization (HMO). 
Medicare can pay DOD for the health care provided to retirees 
enrolled in the demonstration project, subject to certain 
conditions. The demonstration's goal is to implement an 
alternative for delivering accessible and quality care to these 
``dual-eligible'' retirees without increasing the cost to 
Medicare or DOD. This report examines enrollment in DOD's pilot 
HMOs for seniors. GAO discusses (1) how successful the 
demonstration has been in enrolling eligible beneficiaries, (2) 
what influenced retirees to join DOD's pilot HMOs, and (3) what 
factors accounted for differences in enrollment rates across 
demonstration sites.
VA Health Care: Supply of Nursing Home Beds Is Sufficient to 2005 in 
        the Detroit, Michigan, Area. (GAO/HEHS-00-164R, Aug. 21, 2000).
    Pursuant to a congressional request, GAO reviewed the 
Department of Veterans Affairs' (VA) needs assessment of 
nursing home care in Detroit, Michigan.
    GAO noted that: (1) VA's conclusion in its assessment--that 
the supply of beds available to VA in 2005 will be sufficient 
to meet VA's needs--is likely to be correct; (2) even allowing 
for underestimates by VA regarding demand for nursing home care 
and overestimates of the supply of nursing home beds, the 
supply of beds available is likely to be sufficient to meet 
demand; (3) to determine whether the number of nursing home 
beds would be adequate, VA used 1996 national nursing home use 
rates and current population projections to estimate the total 
demand for nursing home beds in 2005; (4) it then used current 
Detroit-area data from the Health Care Financing Administration 
on nursing home bed availability to project the likely number 
of beds that would beavailable in 2005; and (5) VA concluded 
that the supply would be sufficient to meet projected demand.

  CALENDAR YEARS 1999 AND 2000 TESTIMONIES ON ISSUES AFFECTING OLDER 
                               AMERICANS

    GAO testified 68 times before Congressional committees 
during calendar years 1999 and 2000 on issues relating to older 
Americans. Of these testimonies, 49 were on health issues, 10 
on income security issues, 7 on veterans and DOD issues and 2 
were on multiple issues.

                             Health Issues

Adverse Drug Events: Substantial Problem but Magnitude Uncertain. (GAO/
        T-HEHS-00-53. Feb. 1, 2000)
    This testimony summarized our January report, Adverse Drug 
Events: The Magnitude of Health Risk Is Uncertain Because of 
Limited Incidence Data. (GAO/HEHS-00-21, Jan. 18, 2000).
Adverse Events: Surveillance Systems for Adverse Events and Medical 
        Errors. (GAO/T-HEHS-00-61, Feb. 9, 2000).
    Adverse events are injuries to patients caused by medical 
treatment. Medical errors are mistakes in medical care that may 
or may not harm a patient. Identifying adverse events and 
evaluating their causes are important parts to any strategy to 
reduce harm to patients. Several recent GAO reports have 
considered surveillance systems for medical products, 
particularly drugs and medical devices. (See GAO/HEHS-00-21, 
Jan. 2000, and GAO/HEHS-97-21, Jan. 1997.) GAO testified that 
although adverse events are recognized as a serious problem, 
the full magnitude of their threat to the American public is 
unknown. At the same time, gathering valid and useful 
information on adverse events is extremely difficult. For 
example, systems that rely on health care providers to take the 
initiative to make a report suffer from serious limitations. 
Moreover, many of the injuries that patients suffer as a result 
of medical treatment do not stem from errors but reflect the 
inherent risks of treatments that are administered correctly. 
It can be difficult to identify these adverse reactions and 
distinguish them from medical errors or from the course of a 
patient's underlying illness.
Assisted Living: Quality-of-Care and Consumer Protection Issues. (GAO/
        T-HEHS-99-111, April 26, 1999).
    This testimony summarized our April 1999 report entitled 
Assisted Living: Quality-of-Care and Consumer Protection Issues 
in Four States. (GAO/HEHS-99-27, April 26, 1999).
Blood Supply: Availability of Blood. (GAO/T-HEHS-99-195, Sept. 23, 
        1999).
    The National Blood Data Resource Center projects that the 
demand for blood will outstrip its supply by next year. GAO 
believes that the Center has overstated the decline in supply. 
Most of the decline the Center found was in donations targeted 
for specific individuals, not in the community supply available 
to everyone else in need. Also, blood banks fear that supply 
losses will exceed estimates of losses arising from the Food 
and Drug Administration's recommended exclusion of blood 
donated by individuals who spent six or more months in the 
United Kingdom between 1980 and 1996. The exclusion is based on 
concern over the transmissibility of a new variant of so-called 
``mad cow'' disease among humans. The Department of Health and 
Human Services has proposed removingbarriers to donations from 
individuals with hemochromatosis, a treatable iron-overload 
disease, to make up for some of the loss from U.K. donors, but 
consequent increases in blood supply would have to wait for 
changes in current regulations. GAO concludes that the blood 
supply is not in crisis but that there is cause for concern 
about the possibility of some regional shortages and shortages 
of some types of blood.
Federal Health Care: Comments on H.R. 4401, the Health Care 
        Infrastructure Investment Act of 2000. (GAO/T-AIMD-00-240, July 
        11, 2000).
    Pursuant to a congressional request, GAO discussed the 
Health Care Infrastructure Investment Act of 2000 (H.R. 4401), 
which calls for the development of an immediate claim, 
administration, payment resolution and data collection system, 
focussing on the: (1) effects of the system on the claims 
processes of both the Medicare Part B program and the Federal 
Employees Health Benefit program (FEHBP); and (2) the role and 
composition of a proposed Health Care Infrastructure 
Commission. H.R. 4401 would establish a Health Care 
Infrastructure Commission within the Department of Health and 
Human Services (HHS) to design, construct, and implement an 
immediate claim, administration, payment resolution, and data 
collection system that would initially be used by the Medicare 
part B program. However, most Medicare claims could be paid 
more quickly using current processes by simply eliminating the 
mandatory delay in paying claims. One drawback to eliminating 
this delay is that the Supplementary Medical Insurance Trust 
Fund, which funds part B, would lose some of the interest it 
earns on its balance. A drop in interest earnings could require 
additional appropriations or an increase in beneficiaries' 
premiums. Because a real-time claims processing system could 
open theprocess to a possible risk of improper payments, 
appropriate internal controls are needed. Current program 
safeguards, such as the edit process, must not be compromised. 
Because a real-time claims processing system is vulnerable to 
code manipulation, problem providers should be excluded from 
participating, and adequate documentation controls must ensure 
that the electronic trail is not lost or tampered with. The 
project's return on investment, links to a strategic plan, and 
evidence of compliance with the organization's overall systems 
architecture must also be considered as well as the possibility 
of computer viruses and computer attacks. Developing a single 
real-time claims processing system for both Medicare part B and 
the Federal Employees Health Benefits program would be 
challenging because the programs are so different. Further, If 
a real-time processing system is to be developed, consideration 
should be given to including key Health Care Financing 
Administration (HCFA) and carrier officials with health care 
claims processing, program integrity and financial management 
expertise on the Infrastructure Commission, as well as OPM and 
providers, since the system would affect HCFA, OPM, and the 
providers.
HCFA Management: Agency Faces Multiple Challenges in Managing Its 
        Transition to the 21st Century. (GAO/T-HEHS-99-58, Feb. 11, 
        1999).
    The Health Care Financing Administration (HCFA) pays for 
health care coverage for nearly a quarter of the population. 
Two programs that HCFA administers--Medicare and Medicaid--cost 
taxpayers about $370 billion in fiscal year 1998. Over the 
years, GAO has reported on problems in HCFA's management that 
have weakened the fiscal integrity of HCFA programs, leading to 
increased monetary loss from fraud, abuse, and erroneous 
payments. GAO has included Medicare on its list of government 
programs that are especially vulnerable to waste, fraud, abuse, 
and mismanagement. (See GAO/OCG-99-7, Jan. 1999.) Medicare's 
long-term financial condition is now one of the nation's most 
pressing problems. Recent legislation gave HCFA substantial new 
authorities and responsibilities for reforming Medicare in 
order to extend the solvency of Medicare's Hospital Insurance 
Trust Fund beyond 2008. The legislation also established the 
Bipartisan Commission on the Future of Medicare to develop more 
long-term solutions for further ensuring Medicare' integrity 
and solvency. This testimony updates GAO's assessment of HCFA's 
progress in implementing these new authorities and 
administering its programs. Specifically, GAO reviews HCFA's 
progress in (1) addressing its most immediate priorities and 
(2) strengthening its internal management to effectively 
discharge its major implementation and oversight 
responsibilities.
Health Care Access: Programs for Underserved Populations Could Be 
        Improved. (GAO/T-HEHS-00-81, Mar. 23, 2000).
    The Community and Migrant Health Center program and the 
National Health Service Corps, administered by the federal 
Health Resources and Services Administration (HRSA), are 
designed, respectively, to increase the availability of primary 
and preventive health care services for low-income people 
living in medically underserved areas and to offer scholarships 
and educational loan repayments for health care professionals, 
who, in turn, agree to work in these centers and other sites in 
communities where there is a shortage of providers. GAO found 
that HRSA could increase the centers' effectiveness by 
establishing a systematic best practices program so centers can 
learn from each other and by improving the completeness and 
accuracy of the data it uses to monitor them. Also, the Health 
Care Financing Administration could help ensure the centers' 
ability to continue serving Medicaid beneficiaries and 
uninsured persons by monitoring state Medicaid programs' 
compliance with federal requirements for reimbursing the 
centers. The National Health Service Corps program would be 
improved by shifting some resources from the scholarship 
program to the loan repayment program. Furthermore, a better 
system is needed for identifying and measuring where health 
careprofessional placements are needed.
Health Care Financing Administration: Three Largest Medicare 
        Overpayment Settlements Were Improper. (GAO/T-OSI-00-7, Mar. 
        28, 2000).
    This testimony summarizes the February 2000 GAO report, 
HCFA: Three Largest Medicare Overpayment Settlements Were 
Improper. (GAO/OSI-00-4, Feb. 25, 2000).
Health Care Fraud: Schemes to Defraud Medicare, Medicaid, and Private 
        Health Care Insurers. (GAO/T-OSI-00-15, July 25, 2000).
    Across the country, career criminals and organized crime 
have become involved in health care fraud. Both the House and 
Senate have introduced bills designed to combat waste, fraud, 
and abuse in Medicare programs. Under the proposed legislation, 
the purchase, sale, or distribution of two or more Medicare or 
Medicaid beneficiary identification numbers will be a felony. 
In the rent-a-patient scheme, organizations pay for--or 
``rent''--persons to go to clinics for unnecessary diagnostic 
tests and examinations. Medicare, Medicaid, and other insurers 
are billed for these services and for other services and 
equipment that is never provided. In a variation of this 
scheme, perpetrators buy individual health care insurance 
identification numbers for cash. In the pill mill scheme, 
separate health care individuals--usually including a 
pharmacy--collude to generate a flood of fraudulent claims that 
Medicaid pays. The patient sells the prescription medications 
to pill buyers on the street who then sell the drugs back to 
the pharmacy. The drop box scheme uses a private mailbox 
facility as the fraudulent health care entity's address, with 
the entity's suite number actually being its mailbox number at 
the private mailbox facility. The perpetrator then retrieves 
the checks and deposits them into a commercial bank account. 
The third-party billing scheme revolves around a third-party 
biller who prepares and remits claims to Medicare or Medicaid 
on behalf of health care providers. The billermay or may not be 
in on the scheme. Enacting the proposed legislation will give 
the Department of Human Services' Office of Inspector General 
additional enforcement tools with which to pursue health care 
swindlers.
Long-Term Care Insurance: Better Information Critical to Prospective 
        Purchasers. (GAO/T-HEHS-00-196, Sept. 13, 2000).
    Pursuant to a congressional request, GAO discussed the 
challenges the baby boom generation and society face in 
planning for and financing its future long-term care needs, and 
the role that private long-term care insurance may play in 
meeting those challenges, focusing on: (1) the increased demand 
the baby boom generation will likely create for long-term care; 
(2) an overview of current spending for long-term care of the 
elderly, including recent changes in Medicaid and Medicare 
financing of long-term care; and (3) the potential role of 
private long-term care insurance in helping finance this care, 
including who buys this insurance, its affordability, and the 
critical need for consumer information and protections.
    GAO noted that: (1) estimates of the magnitude of the baby 
boomers' future long-term care needs vary, with estimates of 
the number of disabled elderly when the baby boom generation 
becomes elderly ranging from 2 to 4 times the current number; 
(2) estimates of cost are even more imprecise due to the 
uncertain effect of several important factors, including how 
many will be needing care, the types of care they will need, 
and the availability of public and private sources to pay for 
that care; (3) spending for long-term care for the elderly is 
an estimated $123 billion this year; (4) Medicaid and Medicare 
will pay for nearly 60 percent of these services, contributing 
$43 billion and $29 billion respectively; (5) Medicaid funds go 
primarily to nursing homes and other institutional settings of 
long-term care, but home and community-based services represent 
a growing share of Medicaid spending and recipients; (6) 
Medicare primarily covers acute care services, and thus plays a 
lesser role in financing nursing home care but has grown to 
play a significant role in covering long-term care through its 
home health benefit; (7) recent federal legislative changes in 
response to rapid andinexplicable growth in spending for long-
term care services in Medicare have already resulted in a 
reduction in home health spending, but it remains uncertain how 
much Medicare will be spending for long-term care services in 
the future; (8) several recent congressional initiatives, 
including establishing a program to make group long-term care 
insurance available to federal employees and proposals to 
provide tax subsidies to individuals purchasing long-term care 
insurance, aim to expand the role of private long-term care 
insurance; (9) less than 10 percent of the elderly and an even 
lower percentage of near-elderly individuals have purchased 
long-term care insurance, although these numbers are 
increasing; (10) questions remain about the affordability of 
policies and the value of the coverage relative to the premiums 
charged; (11) if long-term care insurance is to have a more 
significant role in addressing the baby boom generation's 
upcoming chronic health care needs, the policies offered must 
be viewed by consumers as good, affordable products that are 
easily understandable; and (12) the National Association of 
Insurance Commissioners has recently strengthened its model 
regulation for long-term care insurance, including recommending 
that states enact laws requiring additional disclosure to 
consumers about the potential for future policy rate increases 
and better ensuring that long-term care insurers accurately 
price their policy premiums.
Managed Care: State Approaches on Selected Patient Protections. (GAO/T-
        HEHS-99-85, March 11, 1999)
    Health insurance statutes and regulations in 15 states, 
which collectively account for about two-thirds of all 
Americans enrolled in health maintenance organizations, address 
consumers' concerns about access to health care and information 
disclosure with differing approaches, scope, and form. For 
example, California and Minnesota address some aspects of seven 
types of patient protection: coverage of emergency services, 
access to obstetricians and gynecologists, access to 
pediatricians, access to other specialists, continuity of care 
for enrollees whose providers leave their plans, drug formulary 
provisions, and open patient-provider communication. Colorado 
addresses three of these protections, Massachusetts only one. 
The most prevalent protections address open patient-provider 
communication, emergency care coverage, and access to other 
specialties. Continuity-of-care provisions differ; about half 
of the states specify pregnancy as a condition subject to this 
coverage. An effective approach to ensuring quality and 
efficient health care for managed care enrollees would balance 
the regulatory assurance of minimum standards with quality-
based competition among providers.
Medicare: Beneficiaries' Prescription Drug Coverage. (GAO/T-HEHS-99-
        198, Sept. 28, 1999).
    In deliberating Medicare and the rising availability, cost, 
and use of prescription drugs, Congress faces a policy dilemma: 
The lack of a prescription drug benefit may impede 
beneficiaries' access to treatment advances while adding that 
benefit could be costly to the program. One possible resolution 
would be to model the benefit after Medicaid's drug rebate 
program; price discounts could be substantial, but 
beneficiaries would have no incentive to make cost-conscious 
decisions about drug use. Another possible resolution would be 
to do what the private sector does in negotiating price 
discounts from manufacturers in exchange for shifting market 
share. However, Medicare's using pharmacy benefit managers to 
process claims, negotiate with manufacturers, establish 
preferred drug lists, and develop beneficiary incentives for 
controlling spending would be difficult because of the 
program's size, need for transparency, and imperative for 
equity.
Medicare: Better Information Can Help Ensure That Refinements to BBA 
        Reforms Lead to Appropriate Payments. (GAO/T-HEHS-00-14, Oct. 
        1, 1999).
    Payment reforms under the Balanced Budget Act of 1997 that 
sought to curb unnecessary Medicare spending are beginning to 
have their intended effect, but pressure is building to return 
to more generous payment policies. Adjustments based on 
thorough quantitative assessments may be necessary. For home 
health care, the prospective payment system, a more appropriate 
tool for the long term than the earlier interim payment system, 
will likely require adjustment after it is implemented and more 
information on home health costs, utilization, and users 
becomes available. The Health Care Financing Administration is 
trying to solve problems with access to skilled nursing care 
facilities under the new system. A need-based payment system, 
rather than the per-beneficiary cap on payments for outpatient 
physical, speech, and language therapy, might help target 
beneficiaries better. Medicare+Choice payments may need to be 
modified by establishing an appropriate base rate and a risk 
adjustment method that pays more for serving beneficiaries with 
serious health problems and less for serving those who are 
relatively healthy.
Medicare: Concerns About HCFA's Efforts to Prevent Fraud by Third-Party 
        Billers. (GAO/T-HEHS-00-93, Apr. 6, 2000).
    To help ensure the integrity of Medicare, the Health Care 
Financing Administration (HCFA) and its contractors need to 
develop reliable and sophisticated approaches to identify 
potentially fraudulent billing practices. It is especially 
important that they be able to match up third-party billers 
with the providers they represent so contractors can identify 
potentially questionable billing patterns and subject these 
claims to more scrutiny. Although HCFA has various efforts 
under way to better identify providers' questionable claims and 
their associated third-party billers, there continue to be gaps 
in its safeguards. HCFA needs to complete its provider 
recertification program as soon as possible so that it will 
have comprehensive information on all Medicare providers and 
their billers. GAO is also concerned about inherent problems 
with data reliability.
Medicare: Considerations for Adding a Prescription Drug Benefit. (GAO/
        T-HEHS-99-153, June 23, 1999).
    Proposals to add a Medicare prescription drug benefit have 
come during a period of rapid growth in national spending for 
pharmaceuticals and transformations in the prescription drug 
market. What remains unchanged since 1965, however, is the 
absence of coverage for outpatient prescription drugs by 
traditional Medicare. One third of the Medicare population 
lacks the supplemental drug coverage provided to most 
beneficiaries through employer-sponsored plans, managed care 
organizations, Medicaid, or Medigap insurance. Moreover, high 
drug use among Medicare beneficiaries translates into a 
potentially daunting financial burden. The implications of 
adding prescription drug coverage to Medicare depend on the 
choice made about details, such as its scope and financing. Its 
design and implementation will also shape the impact of this 
benefit on beneficiaries, Medicare spending, and 
thepharmaceutical market. Recent experience suggests at least 
two approaches for implementing a drug benefit. One would 
involve the Medicare program obtaining price discounts from 
manufacturers. Such an arrangement could be modeled after 
Medicaid's drug rebate program. The second approach would draw 
from private sector experience in negotiating price discounts 
from manufacturers in exchange for shifting market share.
Medicare: Few Beneficiaries Use Colorectal Cancer Screening and 
        Diagnostic Services. (GAO/T-HEHS-00-68, Mar. 6, 2000).
    Use of colorectal cancer screening and diagnostic services 
by Medicare beneficiaries is very low relative to recommended 
use rates and has remained almost unchanged over the past 5 
years. Although guidelines recommend annual fecal occult blood 
testing for all people aged 50 and older, only 9 percent of 
fee-for-service beneficiaries received that test each year. Use 
rates for flexible sigmoidoscopy are significantly lower and 
have remained constant at about 2 percent of beneficiaries. 
Women's use of some colorectal cancer screening and diagnostic 
services was slightly higher than men's, and white 
beneficiaries received the services at somewhat higher rates 
than African Americans, Asians, and Hispanics. Although use 
data are not available for Medicare beneficiaries in HMOs, 
research suggests that enrollees in managed care plans are at 
least as likely to have colorectal cancer screening as those in 
fee-for-service Medicare. Key among the reasons for low use of 
screening and diagnostic services are poor patient awareness of 
recommendations and coverage for screening, physician 
reluctance to perform the procedures because of the time and 
complexity involved, and the lack of monitoring systems to 
encourage their use. Efforts are underway to enhance public 
awarenessof the risks of colorectal cancer and the benefits of 
screening.
Medicare: HCFA Faces Challenges to Control Improper Payments. (GAO/T-
        HEHS-00-74, Mar. 9, 2000).
    Major information gaps exist in the Medicare program in 
both traditional Medicare and Medicare+Choice that impede 
HCFA's ability to minimize program losses attributable to 
improper payments. In traditional Medicare, HCFA does not have 
a clear picture of the individual or relative performance of 
Medicare's claims administration contractors, which are 
responsible for safeguarding the program's fee-for-service 
payments that totaled $171 billion in fiscal year 1999. HCFA 
also lacks sufficient information on newly designed payment 
systems to determine whether providers have delivered excessive 
services or stinted on patient care to inappropriately maximize 
payments. For Medicare+Choice, HCFA similarly lacks the data 
needed to monitor the appropriateness of payments made to 
health plans and the services Medicare enrollees receive. Owing 
to a failed attempt in the 1990s to modernize Medicare's 
multiple information systems, HCFA's current systems remain 
seriously outmoded. Without effective systems, the agency is 
not well-positioned collect and analyze data regarding 
beneficiaries' use of services information that is essential to 
managing the program effectively and safeguarding program 
payments.
Medicare: HCFA Needs to Better Protect Beneficiaries' Confidential 
        Health Information. (GAO/T-HEHS-99-172, July 20, 1999).
    This testimony summarizes the July 1999 report, Medicare: 
Improvements Needed to Enhance Protection of Confidential 
Health Information. (GAO/HEHS-99-140, July 20, 1999).
Medicare: HCFA Oversight Allows Contractor Improprieties to Continue 
        Undetected. (GAO/T-HEHS/OSI-99-174, Sept. 9, 1999).
    The Health Care Financing Administration (HCFA) paid its 
Medicare fee-for-service claims administration contractors $1.6 
billion in fiscal year 1998 to serve as the program's first 
line of defense against inappropriate and fraudulent claims. 
Since 1993, eight contractors have been convicted of criminal 
offenses, have been fined, or have entered into civil 
settlements. Several of their employees engaged in 
improprieties and covered up poor performance to allow 
contractors to keep their Medicare business. Improper 
activities included improperly screening, processing, and 
paying claims; destroying claims; and failing to properly 
collect money providers owed Medicare. Contractors also 
falsified their performance results and tried to deceive HCFA 
and circumvent its performance reviews. HCFA often failed to 
detect improper activities because it gave contractors too much 
advance notice of its oversight visits and record reviews. 
Weaknesses in HCFA's current oversight might allow the same 
types of activities to continue undetected. GAO believes that 
HCFA plans to act on recommendations GAO made in July 1999 
regarding its contractor management policy and plans, 
assessment, evaluation, and oversight. Although this will help 
improve its management and oversight of the contractors, it 
will not make Medicare less vulnerable to their abuses.
Medicare: HCFA Should Exercise Greater Oversight of Claims 
        Administration Contractors. (GAO/T-HEHS/OSI-99-167, July 14, 
        1999).
    Weak oversight of Medicare fee-for-service claims 
administration contractors has left the Health Care Financing 
Administration (HCFA) with few guarantees that contractors are 
doing their jobs, including paying providers appropriately. 
Since 1993, at least six contractors have settled civil and 
criminal charges arising from allegations that they were not 
checking claims to ensure proper payment, were allowing 
Medicare to pay claims that other insurers should have paid, or 
were committing other improprieties. For years, HCFA left 
decisions about oversight priorities entirely in the hands of 
regional reviewers, did not evaluate regional oversight to 
achieve consistency, and set few performance standards to hold 
contractors accountable. GAO recommends that Congress amend the 
Social Security Act to allow the Secretary of Health and Human 
Services explicit authority to more freely contract with 
appropriate types of companies for claims administration. Also, 
HCFA should berequired to report to the Congress with an 
independent evaluation on the impact of any new authorities on 
the Medicare program.
Medicare: Improper Third-Party Billing of Medicare by Behavioral 
        Medical Systems, Inc. (GAO/T-OSI-00-9, Apr. 6, 2000).
    This testimony summarized our March report, Medicare: 
Improper Third-Party Billing of Medicare by Behavioral Medical 
Systems, Inc. (GAO/OSI-00-5R, Mar. 30, 2000).
Medicare: More Beneficiaries Use Hospice; Many Factors Contribute to 
        Shorter Periods of Use. (GAO/T-HEHS-00-201, Sept. 18, 2000).
    Pursuant to a congressional request, GAO discussed issues 
related to the use of Medicare's hospice benefit, focusing on: 
(1) the patterns and trends in hospice use by Medicare 
beneficiaries; (2) factors that affect the use of the hospice 
benefit; and (3) the availability of hospice providers.
    GAO noted that: (1) the number of Medicare beneficiaries 
choosing hospice services has grown substantially during the 
past decade--nearly 360,000 beneficiaries enrolled in 1998, 
more than twice the number that elected hospice in 1992; (2) 
cancer patients account for more than half of Medicare hospice 
users, but the most dramatic growth in use is among persons 
with other terminal conditions, such as heart disease, lung 
disease, stroke, or Alzheimer's disease; (3) although more 
beneficiaries are choosing hospice, many are doing so closer to 
the time of death; (4) half of Medicare hospice users are 
enrolled for 19 or fewer days, and service periods of 1 week or 
less are common; (5) many factors influence decisions about 
whether and when to begin hospice services, including physician 
practices, patient preferences and circumstances, and general 
awareness of the benefit among professionals and the public; 
(6) along with these factors, federal oversight of compliance 
with Medicare eligibility requirements may also have affected 
hospice use; (7) growth in the number of Medicare hospice 
providers in both urban and rural areas and in almost every 
state suggests that hospice services are more widely available 
to program beneficiaries than in the past; (8) at the same 
time, hospice officials report increased cost pressures from 
shorter patient enrollment periods and the use of more 
expensive forms of palliative care; (9) because data on 
provider costs are not available, however, the effect of these 
factors on the overall financial condition of hospice providers 
is uncertain; and (10) the Health Care Financing Administration 
is beginning to gather information from hospice providers about 
their costs, which should allow the adequacy Medicare hospice 
payment rates to be evaluated in the relatively near future.
Medicare: Program Reform and Modernization Are Needed But Entail 
        Considerable Challenges. Testimony, 02/08/2000, (GAO/T-HEHS/
        AIMD-00-77, Feb. 8, 2000).
    The Comptroller General's statement discusses the competing 
concerns at the heart of the Medicare reform debate and 
provides a conceptual framework for evaluating the possible 
combinations of reform options. To qualify as meaningful 
reform, a proposal should make a significant down payment 
toward ensuring Medicare's long-range financial integrity and 
sustainability--the most critical issues facing the program. 
Fundamental reforms are vital to reducing the program's growth, 
which threatens to absorb ever-increasing shares of the 
nation's budgetary and fiscal resources. At the same time, 
Medicare is outmoded from a programmatic perspective. To 
address to need for an updated benefit package and adequate 
tools to moderate program spending, proposals have been 
advanced that would expand benefits while introducing changes 
to make beneficiaries more cost-conscious and incentives to 
make health care providers efficient. Ideally, the unfunded 
promises associated with today's program should be addressed 
before or concurrent with proposals to add new ones, such as 
prescription drug coverage. To so otherwise might be 
politically attractive but not fiscally prudent. If benefits 
are added, policymakers need to consider targeting strategies 
to fully offset their costs. Because of the size of Medicare's 
unfunded liability, it is realistic to expect that reforms 
intended to bring down future costs will have to proceed 
incrementally. As reform options come under greater scrutiny, 
the importance of design details should not be overlooked. 
GAO's work on efforts to implement recent reforms suggests that 
those details will determine whether reform options will be 
both effective and acceptable.
Medicare: Refinements Should Continue to Improve Appropriateness of 
        Provider Payments. (GAO/T-HEHS-00-160, July 19, 2000).
    The Comptroller General has repeatedly cautioned that, even 
without expanding program benefits, projected Medicare spending 
threatens to absorb ever-increasing shares of the nation's 
budgetary and economic resources. In the absence of meaningful 
reform, demographic and cost trends will drive Medicare 
spending to levels that will prove unsustainable. Under the 
Balanced Budget Act of 1997 (BBA) and the Balanced Budget 
Refinement act of 1999, providers have had to adjust their 
operations because of tightened payment policies. The 
adjustments have been particularly disruptive for providers 
that took advantage of Medicare's previous payment policies to 
finance inefficient and unnecessary care delivery. Industry 
representatives are advocating the partial restoration of 
payment cuts since the BBA's implementation developments have 
occurred in the areas of home health services, skilled nursing 
facilities (SNF), and the Medicare+Choice program. Use of home 
health services has dropped substantially, well below what 
would have been required to remain within the BBA-imposed 
payment limits. The new Medicare payment system, scheduled for 
implementation in October, should generally provide agencies a 
comfortable cushion to deliver necessary services. Some 
corporate SNF chains have declared bankruptcy. The new Medicare 
payment system will adequately cover the cost of beneficiary 
services but not support extensive capital expansions or 
ancillary service business that the chains relied on to boost 
revenues. Many plans are withdrawing from Medicare because of 
the changes to the Medicare program and plans' business 
decisions. Ongoing GAO work shows thatpayments to plans for 
Medicare enrollees continue to exceed the expected fee-for-
service costs. This finding is significant: Medicare managed 
care, although originally expected to achieve program savings, 
continues instead to add to program cost.
Medicare: 21st Century Challenges Prompt Fresh Thinking About Program's 
        Administrative Structure. (GAO/T-HEHS-00-108, May 4, 2000).
    Key problems that undermine the ability of the Health Care 
Financing Administration (HCFA) to manage Medicare effectively 
can be solved. Currently, no one senior official in HCFA is 
responsible for managing only Medicare; instead, HCFA's 
Administrator also oversees Medicaid and other state-centered 
programs' worthy competitors for agency management attention. 
Frequent changes in agency leadership make it difficult to 
develop and implement a consistent long-term vision. And 
constraints on HCFA's ability to acquire appropriate resources 
and expertise limit its ability to modernize Medicare's 
operations and carry out the program's growing 
responsibilities. Elements of recent Medicare reform proposals, 
together with alternatives from other federal agencies, 
suggestways of addressing the focus, leadership, and capacity 
issues. Options could include creating an entity that would 
administer Medicare without any non-Medicare responsibilities; 
establishing a tenure for the program's administrator that, at 
minimum, would overlap presidential terms; and granting the 
entity administering Medicare greater operational flexibility.
Medicare and Budget Surpluses: GAO's Perspective on the President's 
        Proposal and the Need for Reform. (GAO/T-AIMD/HEHS-99-113, 
        March 10, 1999).
    The President proposes to use about two-thirds of the 
projected budget surpluses over the next 15 years to reduce 
publicly held debt. At the same time, he also proposes to 
transfer a like amount to the Social Security and Medicare 
trust funds in the form of nonmarketable Treasury securities, 
which is projected to extend the life of Medicare's Hospital 
Insurance (HI) trust fund from 2008 to 2020. His proposal would 
trade debt held by the public for debt held by the Social 
Security and Medicare trust funds. These new Treasury 
securities would constitute a new unearned claim on general 
funds for the HI program--a marked break with the payroll tax-
based financing structure of the program. This change could 
undermine the remaining fiscal discipline associated with the 
self-financing trust fund concept and could induce a false 
complacency about the financial health of the HI program. 
Without change, however, Medicare is projected to more than 
double its share of the economy by 2050, and Social Security, 
health, and interest will take nearly all the revenues the 
federal government takes in. Real and substantive Medicare 
reform, not simple financing shifts among funds within the 
budget, is essential. Acting now would allow changes to 
benefits and health care delivery systems to be phased in 
gradually so that stakeholders and participants would have time 
to adjust their saving or retirement goals.
Medicare Financial Management: Further Improvements Needed to Establish 
        Adequate Financial Control and Accountability. (GAO/T-AIMD-00-
        118, March 15, 2000).
    This testimony summarizes the March 2000 GAO report, 
Medicare Financial Management: Further Improvements Needed to 
Establish Adequate Financial Control and Accountability. (GAO/
AIMD-00-66, March 15, 2000).
Medicare Improper Payments: Challenges for Measuring Potential Fraud 
        and Abuse Remain Despite Planned Enhancements. (GAO/T-AIMD/OSI-
        00-251, July 12, 2000).
    This testimony is related to our September report, Medicare 
Improper Payments: While Enhancements Hold Promise for 
Measuring Potential Fraud and Abuse, Challenges Remain. (GAO/
AIMD/OSI-00-281, September 15, 2000)
Medicare Quality of Care: Oversight of Kidney Dialysis Facilities Needs 
        Improvement. (GAO/T-HEHS-00-136, June 26, 2000).
    This testimony is related to our June report, Medicare 
Quality of Care: Oversight of Kidney Dialysis Facilities Needs 
Improvement. (GAO/HEHS-00-114, June 23, 2000).
Medicare+Choice: HCFA Actions Could Improve Plan Benefit and Appeal 
        Information. (GAO/T-HEHS-99-108, April 13, 1999).
    This testimony summarizes the April 1999 report, 
Medicare+Choice: New Standards Could Improve Accuracy and 
Usefulness of Plan Literature (GAO/HEHS-99-92, April 12, 1999).
Medicare Managed Care: Better Risk Adjustment Expected to Reduce Excess 
        Payments Overall While Making Them Fairer to Individual Plans. 
        (GAO/T-HEHS-99-72, Feb. 25, 1999).
    Medicare provides managed care plans with a fixed monthly 
payment, called a capitation payment, for each beneficiary they 
enroll. However, the enrollment of beneficiaries in managed 
care plans has yet to save the government money, mainly for two 
reasons. First, Medicare's capitation rates are excessive 
because payments are based on health care spending for the 
average non-enrolled beneficiary, while the plans' enrollees 
tend to be healthier than average. Second, instead of 
diminishing as more beneficiaries enrolled in managed care, 
excess payments per enrollee continued to grow. To solve these 
problems, the Balanced Budget Act of 1997 changed the rate 
setting formula used by the Health Care Financing 
Administration (HCFA), which runs Medicare. It required that 
most of the rate-setting provisions be in place in 1998 and 
required that HCFA replace Medicare's current risk-adjuster--
the mechanism that modifies a plan's average capitation rate to 
better reflect an enrollee's expected medical costs--with a new 
one to be implemented in 2000. The risk adjusterhas been widely 
criticized as a major factor in the health maintenance 
organization overpayment problem. This testimony discusses (1) 
the important of improving the current risk adjustment method, 
(2) the implications of rate-setting changes implemented in 
1998, and (3) the advantages and drawbacks of HCA's proposed 
new interim risk adjuster.
Medicare: Options for Reform. (GAO/T-HEHS-99-130, May 26, 1999).
    Budgetary pressures and public concern have forged a 
consensus that major reforms are needed if Medicare is to be 
sustainable in the future. Medicare reform proposals have 
generally focused on two areas: expanding Medicare's benefit 
package and containing costs. Two commonly discussed benefit 
expansions are the inclusion of a prescription drug benefit and 
coverage for extraordinary out-of-pocket costs, known as 
catastrophic coverage. Financing reforms include modernizing 
the fee-for-service program and the Medicare+Choice program and 
adopting premium support for Medicare fashioned after the 
Federal Employees Health Benefits Program. In reforming 
Medicare, attention should be paid to lessons learned from 
recent experience in implementing reforms mandated by the 
Balanced Budget Act of 1997, particularly regarding new payment 
mechanisms, provider behavior in evolving markets, and 
Medicare+Choice information initiatives.
Medicare: Progress to Date in Implementing Certain Major Balanced 
        Budget Act Reforms. (GAO/T-HEHS-99-87, March 17, 1999).
    The Balanced Budget Act of 1997 created the Medicare+Choice 
program to give Medicare beneficiaries a broader range of 
health plans, such as those of preferred provider and provider-
sponsored organizations. It also continued the movement away 
from Medicare's paying skilled nursing facilities, home health 
agencies, hospital outpatient departments, and rehabilitation 
facilities for services on the basis of their incurred costs 
toward using prospective rates that set their payment levels in 
advance. This testimony discusses the implementation of (1) the 
Medicare+Choice program, particularly the payment method and 
consumer information efforts, and (2) prospective payment 
systems for skilled nursing facilities and home health agencies 
in Medicare's traditional fee-for-service program.
Medicare Post-Acute Care: Better Information Needed Before Modifying 
        BBA Reforms. (GAO/T-HEHS-99-192, Sept. 15, 1999).
    The Balanced Budget Act of 1997 seeks to make Medicare a 
more efficient and prudent purchaser of post-acute care 
services. The act's payment reforms are changing home health 
care, skilled nursing facility, and rehabilitation therapy 
service delivery practices. There is still not enough 
information to distinguish desirable from undesirable 
consequences, so that calls to amend or repeal the Act are 
premature. But imperfections in the design of the payment 
system require attention. The prospective payment system is an 
appropriate long-term tool for access to Medicare's home health 
benefits but will require adjustment when more information on 
cost, use, and users becomes available. The Health Care 
Financing Administration is working on a solution to the 
problem that prospective payment system rates may underpay for 
high-cost skilled nursing facility care, leading to 
beneficiaries' staying longer in acute care hospitals. A system 
for basing outpatient rehabilitation therapy payments on need, 
rather than on dollar caps, might help better target the 
beneficiaries who genuinely require services.
Medicare Reform: Ensuring Fiscal Sustainability While Modernizing the 
        Program Will be Challenging. (GAO/T-HEHS/AIMD-99-294, Sept. 22, 
        1999).
    The affordability of Medicare reform proposals should be 
considered in relation to the long-term sustainability of 
Medicare expenditures, the fairness to providers and 
beneficiaries, the adequacy of resources for allowing 
appropriate access and cost-effective and clinically meaningful 
innovations for addressing beneficiaries' needs, the 
feasibility for implementation and monitoring, and the 
transparency about costs and policy tradeoffs. Current 
proposals would modernize Medicare's financing and organization 
by changing fee-for-service or Medicare+Choice options or 
offering premium support, such as that of the Federal Employees 
Health Benefits Program. Benefit options being considered 
include covering outpatient prescription drugs and limiting 
beneficiaries' cost liability. Congress should consider fiscal 
incentives to control costs and a targeting strategy when 
deliberating these options. Reform will be done best with lead 
time to phase in changes and with prudent decisions about how 
to use current and projected budget surpluses.
Medicare Reform: Issues Associated With General Revenue Financing. 
        (GAO/T-AIMD-00-126, March 27, 2000).
    Recent GAO testimony before Congress has raised concerns 
about the expanded use of general revenues to pay for the 
Medicare program and has urged comprehensive reforms to help 
ensure the program's long-term sustainability. (See GAO/T-HEHS/
AIMD-00-77, Feb. 2000, GAO/T-HEHS/AIMD-00-103, Feb. 2000, and 
GAO/T-AIMD/HEHS-99-236, July 1999.) Leading Medicare reform 
proposals that include comprehensive reforms, such as those of 
the President and Breaux-Frist, would use general funds as part 
of their financing mechanisms. General fund infusions may well 
be a necessary part of program reform, but caution is warranted 
in considering the commitment of additional general revenues. 
The testimony discusses the specifics of Medicare's financial 
health and issues raised by growing reliance on general revenue 
financing.
Medicare Reform: Leading Proposals Lay Groundwork, While Design 
        Decisions Lie Ahead. (GAO/T-HEHS/AIMD-00-103, Feb. 24, 2000).
    The Comptroller General's statement focuses on two leading 
Medicare reform proposals: the President's Plan to Modernize 
and Strengthen Medicare for the 21st Century and S.1895, 
commonly known as the Breaux-Frist proposal. Both proposals 
recognize the need for more comprehensive reform--a position 
consistent with GAO's belief that the unfunded promises 
associated with today's program should be addressed before 
adding new benefits, such as prescription drug coverage. Such 
additions must be considered in the context of broader efforts 
to correct Medicare's current fiscal imbalance and sustain the 
long-term viability of this popular program. Also, any reform 
package should include a mechanism to monitor aggregate program 
costs over time and establish funding thresholds that would 
trigger a call for fiscal action. In the case of both 
proposals, the details will need to be worked out. And those 
details will determine whether the reforms will be effective 
and acceptable.
Medicare Reform: Observations on the President's July 1999 Proposal. 
        (GAO/T-AIMD/HEHS-99-236, July 22, 1999).
    The President's Medicare reform proposal is an important 
first step in the debate over how the country will deal with 
the explosive costs of medical care for older Americans in the 
coming decades. The President has included a first step toward 
Medicare reform as part of a broader plan that would use a 
significant share of the surplus to pay down the debt, 
ultimately lowering interest rate costs and spurring economic 
growth. The President would use 13 percent of the projected 
budget surpluses during the next 15 years to help shore up the 
Medicare Hospital Insurance Trust Fund and to offset the cost 
of the proposed prescription drug benefit. Although the surplus 
transfer in the form of additional Treasury securities would 
extend the Fund's solvency, this move would represent a 
significant departure from the long-standing use of payroll 
taxes to finance the Fund. GAO is concerned that without 
underlying program reform, the transfers would simply extend 
the Fund's solvency on paper but do nothing to make Medicare 
more sustainable--that is, they would not reduce the program's 
projected share of gross domestic product or the federal 
budget. More importantly, the proposed transfer, by extending 
the solvency of the Hospital Insurance program through 2027, 
well into the baby boomers' retirement years, could end up 
masking the Fund's underlying condition and remove any sense of 
urgency among policymakers to address the program's underlying 
fiscal imbalance. The President wants to make two major program 
changes to Medicare. First, he would have Medicare's health 
plans compete on the basis of price. However, the 
administration has yet to provide specifics on the design and 
implementation of this proposal. Second, the President would 
add a prescription drug benefit. GAO is concerned about (1) the 
cost of the benefit and who would be targeted, (2) the fact 
that some costs now borne by employers and retirees could 
become the responsibility of taxpayers, (3) uneven impact 
across states, and (4) obstacles to the governmentrealizing 
savings from the use of pharmacy benefit managers.
Nursing Homes: Aggregate Medicare Payments Are Adequate Despite 
        Bankruptcies. (GAO/T-HEHS-00-192, Sept. 5, 2000).
    Pursuant to a congressional request, GAO discussed the 
causes of the bankruptcies of large corporations owning nursing 
homes and the implications for nursing home residents, focusing 
on: (1) the adequacy of Medicare's payment rates for skilled 
nursing services furnished in nursing homes; (2) the 
relationship between the changes wrought by the Balanced Budget 
Act and recent nursing home bankruptcies; and (3) what exists 
to protect patients.
    GAO noted that: (1) aggregate Medicare payments for covered 
nursing home services likely cover the cost of care needed by 
beneficiaries, although some refinements to the payment system 
are needed; (2) Medicare policy changes have required many 
nursing homes to adjust their operations; (3) the adjustments 
have been particularly disruptive for homes that took advantage 
of Medicare's previous payment policies to finance inefficient 
and unnecessary care delivery and for those companies that 
invested heavily in the provision of ancillary services (such 
as rehabilitation therapies) to nursing homes; (4) the problems 
experienced by some providers of nursing home and ancillary 
services are therefore the result of business decisions made 
during a period when Medicare exercised too little control over 
its payments; (5) filing for bankruptcy protection under 
Chapter 11 of the U.S. Bankruptcy Code allows these providers 
time to restructure their debts and streamline their operations 
while continuing to care for their nursing home residents; and 
(6) should any of these providers not emerge from bankruptcy, 
however, the nursing homes will be sold or the residents may 
have to find alternative care arrangements.
Nursing Homes: Complaint Investigation Processes in Maryland. (GAO/T-
        HEHS-99-146, June 15, 1999).
    In a March report, GAO cited nursing home problems in 14 
states, including Maryland. These deficiencies ranged from 
procedures that may limit the filing of complaints to failures 
to investigate serious complaints promptly. Compared with other 
states, Maryland devoted fewer resources to investigating 
complaints, recorded substantially fewer complaints than 
Michigan or Washington, generally classified similar complaints 
as needing less prompt investigation, did not meet the assigned 
time periods for investigating many complaints, and had a large 
backlog of uninvestigated cases and poor tracking of the status 
of investigations. Consequently, serious complaints alleging 
that nursing home residents are being harmed can remain 
uninvestigated for weeks or months in Maryland. Such delays can 
prolong situations in which residents may be subject to abuse 
or neglect resulting in serious care problems like malnutrition 
and dehydration, preventable accidents, and medication errors. 
In response to GAO's findings, the Health Care Financing 
Administration has told states to investigate any complaint 
alleging actual harm to a resident within 10 workdays. The 
Maryland General Assembly recently approved funding to 
significantly increase the number of nursing home surveyors. 
However, the seriousness and systemic nature of the weaknesses 
GAO identified require sustained commitment and strengthened 
oversight to help ensure adequate care to nursing home 
residents.
Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will 
        Require Continued Commitment. (GAO/T-HEHS-99-155, June 30, 
        1999).
    The federal government will pay an estimated $39 billion 
for nursing home care in 1999. Working with the states, the 
federal government also plays a key role in ensuring quality 
care at these facilities. GAO has issued three reports that 
focus on problems in California nursing homes as well as the 
enforcement and complaint investigation processes nationwide. 
(See GAO/HEHS-98-202, July 1998, GAO/HEHS-99-46, Mar. 1999, and 
GAO/HEHS-99-80, Mar. 1999.) GAO found that one-fourth of 
nursing homes nationwide had serious deficiencies that actually 
harmed residents or placed them at risk of death or injury; 40 
percent of these homes had repeated deficiencies. Complaints 
alleging serious care problems often went uninvestigated for 
weeks or months. Even when serious deficiencies were found, 
state and federal enforcement policies were ineffective in 
ensuring that deficiencies were corrected and stayed that way. 
HCFA agreed with GAO's recommendations and has developed about 
30 initiatives to strengthen federal standards, oversight, and 
enforcement for nursing homes. This testimony discusses (1) the 
overall scope of HCA's initiatives, (2) the early experiences 
of initiatives for which HCFA has already issued revised 
guidance to the states, (3) the implications of a proposed 
expansion of the category of nursing homes that would face more 
intensive review and immediate sanctions for deficiencies, and 
(3) the initiatives that will require a long-term commitment 
for HCFA to implement.
Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies 
        to Better Ensure Quality Care. (GAO/T-HEHS-00-27. November 4, 
        1999).
    Pursuant to a congressional request, GAO discussed its 
study of the Health Care Financing Administration's (HFCA) 
implementation of two of its nursing home initiatives.
    GAO noted that: (1) HCFA's mechanisms for assessing state 
agency survey performance are limited in their scope and 
effectiveness and are not being applied consistently across 
each of HCFA's 10 regional offices; (2) as a result, HCFA does 
not have sufficient, consistent, and reliable data to evaluate 
state agencies or to measure the success of its other nursing 
home initiatives; (3) given the wide range in the frequencies 
with which states identify serious deficiencies, HCFA cannot be 
certain whether states with lower rates of deficiencies have 
better quality homes or are failing to identify deficiencies 
that harm nursing home residents; (4) this uncertainty results, 
in part, because HCFA makes negligible use of independent 
inspections, known as comparative surveys, that could surface 
information about whether states appropriately cite 
deficiencies; (5) generally, only one to three comparative 
surveys per state were conducted in the more than 17,000 
nursing homes over the last year; (6) nevertheless, two-thirds 
of these surveys found deficiencies that were more serious than 
those found by state surveyors during their reviews conducted 
typically 1 or 2 months earlier; (7) about 90 percent of the 
inspections HCFA conducts nationwide are, instead, 
observational surveys; (8) these surveys, in which HCFA 
surveyors accompany state survey teams, are useful in helping 
HCFA to provide training to state surveyors, but are limited as 
a method for evaluating state agencies'performance; (9) beyond 
these surveys, HCFA also relies on a quality improvement 
program that is largely based on states' self-reported 
performance measures, which do not accurately or completely 
reflect problems in state's performance; (10) these limitations 
in HCFA's oversight methods are compounded by inconsistencies 
in how the methods are applied by its regions; (11) for 
example, the regions vary in how they select nursing home 
surveys to review and how they choose samples ofresidents to 
review; (12) regions also commit differing amounts of time to 
conduct observational surveys, ranging on average from 27 to 71 
hours, which raises questions about whether the level of effort 
some regions dedicate to observational surveys is sufficient to 
thoroughly review state surveyors' performance; and (13) 
furthermore, if HCFA finds a state agency's performance to be 
inadequate, HCFA has not developed a sufficient array of 
alternatives to encourage state agencies to improve their 
performance.
Nursing Homes: Stronger Complaint and Enforcement Practices Needed to 
        Better Ensure Adequate Care. (GAO/T-HEHS-99-89, March 22, 
        1999).
    This testimony summarizes the March 1999 GAO report, 
Nursing Homes: Complaint Investigation Processes Often 
Inadequate to Protect Residents. (GAO/HEHS-99-80, March 22, 
1999).
Nursing Homes: Success of Quality Initiatives Requires Sustained 
        Federal and State Commitment. (GAO/T-HEHS-00-209, Sept. 28, 
        2000).
    Pursuant to a congressional request, GAO discussed the 
quality of care in nursing homes, focusing on: (1) progress in 
improving the detection of quality problems during annual 
surveys; (2) how the prevalence of identified problems has 
changed; (3) the status of efforts to strengthen states' 
complaint investigation processes and federal enforcement 
policies; and (4) additional activities occurring at the 
federal level to improve oversight of states' quality assurance 
activities.
    GAO noted that: (1) overall, the series of federal quality 
initiatives begun 2 years ago has produced a range of nursing 
home oversight activities that need continued federal and state 
commitment to reach their full potential; (2) certain of the 
federal initiatives seek to strengthen the rigor with which 
states conduct their required annual surveys of nursing homes; 
(3) others focus on the timeliness and reporting of complaint 
investigations and the use of management information to guide 
federal and state oversight efforts; (4) the states are in a 
period of transition with regard to the implementation of these 
initiatives, partly because the Health Care Financing 
Administration (HCFA) is phasing them in and partly because 
states did not begin their efforts from a common starting 
point; (5) HCFA's efforts toward improving the oversight of 
states' quality assurance activities have begun but are 
unfinished or need refinement; (6) the results from states' 
recent standard surveys provide a picture of federal and state 
efforts in progress; (7) on average, a slightly higher 
proportion of homes were cited nationwide for actual harm and 
immediate jeopardy deficiencies on their most recent survey 
than were cited during the previous survey cycle; (8) while it 
was expected that more deficiencies would be identified owing 
to the increased rigor in nursing home inspections, the survey 
results could also suggest that nursing homes may not have made 
sufficient strides to measurably improve residents' quality of 
care; (9) the results also show a wide variation across states 
in the proportion of homes with identified serious care 
deficiencies; (10) while these proportions are expected to vary 
somewhat from one state to another, the wide range may reflect 
the extent to which the inspection of homes is inconsistent 
across states; and (11) in GAO's view, the full potential of 
the nursing home initiatives to improve quality will more 
likely be realized if greater uniformity in the oversight 
process can be achieved.
Prescription Drug Benefits: Applying Private Sector Management Methods 
        to Medicare. (GAO/T-HEHS-00-84, Mar. 22, 2000).
    In earlier congressional testimony, GAO has addressed 
considerations for adding a prescription drug benefit to 
Medicare. If a prescription drug benefit were added to the 
Medicare program, the federal government would face cost 
pressures similar to those experienced by private insurers, 
managed care plans, and employers. The private sector has 
attempted to manage the high and rising costs of prescription 
drugs by adopting cost and utilization control techniques. The 
challenge in adding prescription drug coverage to the Medicare 
program will be in designing and implementing drug coverage to 
minimize the financial implications for Medicare while 
maximizing the positive effect of such coverage on Medicare 
beneficiaries.
Prescription Drug Benefits: Impact of Medicare HMOs' Use of Formularies 
        on Beneficiaries. (GAO/T-HEHS-99-171, July 20, 1999).
    This testimony summarized our July 1999 report, 
Prescription Drug Benefits: Implications of Medicare HMOs' Use 
of Formularies on Beneficiaries. (GAO/HEHS-99-166,July 20, 
1999).
Prescription Drugs: Adapting Private Sector Management Methods for a 
        Medicare Benefit. (GAO/T-HEHS-00-112, May 11, 2000).
    Private insurers, managed care plans, and employers have 
tried to manage the high and rising costs of prescription drugs 
by adopting cost and utilization control techniques. In many 
cases, insurers and managed care plans contract with a pharmacy 
benefit management company (PBM) to develop and implement these 
strategies. If a prescription drug benefit were added to the 
Medicare program, the federal government would face similar 
cost pressures and would need to employ methods to control 
spending. The experience gained in the private sector can 
provide useful insights into options for managing a possible 
Medicare benefit. However, the unique responsibilities and 
characteristics of the Medicare program raise a number of 
issues and introduce questions about applying private sector 
tools to the traditional Medicare fee-for-service program and 
the appropriate roles of the Health Care Financing 
Administration (HCFA) and other entities, such as PBMs, in 
managing a drug benefit. In adapting, these cost and 
utilization management techniques, it is important to keep in 
mind that: (1) the size of the Medicare program and the need 
for transparency in its actions may reduce the effectiveness of 
some cost control techniques; (2) using private-sector entities 
to implement a drugbenefit introduces concerns related to 
beneficiary equity and concentrating market power; (3) private-
sector management tools require a capacity to process and 
scrutinize a large number of claims more quickly than is 
typical of the traditional Medicare program; and (4) strategies 
involving coverage restrictions impose an obligation to provide 
beneficiaries with adequate information about the benefit.
Prescription Drugs: Increasing Medicare Beneficiary Access and Related 
        Implications. (GAO/T-HEHS/AIMD-00-99, Feb. 15, 2000). 20 pp.
Prescription Drugs: Increasing Medicare Beneficiary Access and Related 
        Implications. (GAO/T-HEHS/AIMD-00-100, Feb. 16, 2000).
    [These similar testimonies were given to different 
committees.]
    Concerns are growing about gaps in the Medicare program, 
most notably the lack of outpatient prescription drug coverage, 
which may leave the most vulnerable program beneficiaries with 
high out-of-pocket costs that they can ill afford. Nearly one-
third of Medicare beneficiaries lacked prescription drug 
coverage in 1996. At the same time, however, the long-term cost 
pressures confronting the Medicare program are considerable. A 
consensus appears to be emerging that substantive financing and 
programmatic reforms are needed to put Medicare on a sound 
footing in the future. These reforms are vital to reducing the 
program's growth, which threatens to consume ever-larger shares 
of the nation's budgetary and economic resources. Continuing 
economic prosperity and projected federal surpluses provide an 
opportunity to address the structural imbalances in Medicare, 
Social Security, and other entitlement programs. Congress faces 
the difficult decision of how best to guarantee the Medicare 
program's sustainability while being mindful of the plight of 
many seniors who cannot afford the latest pharmaceutical 
breakthroughs. Congress and the President may ultimately decide 
to include some form of prescription drug coverage as part of 
Medicare reform. Care must be taken, however, to ensure that 
any expansion of the program is accompanied by other 
programmatic reforms that will sustain Medicare's long-term 
financial integrity. This testimony discusses (1) the factors 
contributingto the growth in prescription drug spending and 
efforts to control that growth and (2) the design and 
implementation issues associated with proposals to improve 
seniors' access to affordable prescriptiondrugs.

                         Income Security Issues

Social Security Administration: SSA's Letters to the Public Remain 
        Difficult to Understand. (GAO/T-HEHS-00-205, Sept. 26, 2000).
    This testimony is liked to our September report, Social 
Security Administration: Longstanding Problems in SSA's Letters 
to the Public Need to Be Fixed. (GAO/HEHS-00-179, Sept 26, 
2000).
Social Security: Criteria for Evaluating Social Security Reform 
        Proposals. (GAO/T-HEHS-99-94, March 25, 1999).
    Social Security forms the foundation for the nation's 
retirement income system and, in doing so, provides benefits 
that are critical to the well-being of millions of Americans. A 
wide array of proposals have been put forth to restore the 
program's solvency. This testimony provides an analytical 
framework for evaluating these proposals. The Comptroller 
General discusses the (1) purpose of the Social Security 
system, (2) basic criteria for assessing reform proposals, and 
(3) importance of establishing the proper benchmarks against 
which reforms must be measured. The Comptroller General does 
not advocate for or against specific reform proposals or 
elements. Rather, his remarks are intended to help clarify the 
debate over various proposals as Congress continues to 
deliberate this important issue. In choosing among proposals, 
policymakers need to consider three basic criteria: to what 
extent a proposal achieves sustainable solvency and how it 
would affect the economy and the federal budget; the balance 
struck between the twin goals of individual equity (rates of 
return on individual contributions) and income adequacy (level 
and certainty of benefits); and how readily these changes could 
be implemented, administered, and explained to the public. 
Although the many reform proposals offer a wide range of 
options, all of them would restore long-term solvency through 
some combination of benefit cuts, revenue increases, or higher 
returns from invested contributions. Making Social Security a 
sustainable program involves difficult choices. At the same 
time, the strong U.S. economy offers an historic opportunity to 
deal with this problem. GAO believes that it is possible to 
craft a comprehensive package of reforms that will protect the 
benefits of current retirees while striking the right balance 
of equity and adequacy for future beneficiaries. Regardless of 
which reformproposal is adopted, better public education and 
information will be needed so that Americans can adjust their 
retirement planning accordingly.
Social Security: Individual Accounts as an Element of Long-Term 
        Financing Reform. (GAO/T-HEHS-99-86, March 16, 1999).
    Some proposals to ensure the solvency of Social Security 
would add individual accounts, similar to defined contribution 
plans, to the current defined benefit plan. By themselves, 
however, such individual accounts cannot guarantee the system's 
solvency. The current system is designed to achieve both 
individual equity (some relationship between contributions made 
and benefits received) and retirement income adequacy 
(proportionately larger benefits to lower earners and 
households with dependents). These two goals are combined in a 
single defined benefit formula that bases retirement benefits 
on a worker's lifetime record of earnings, not on the payroll 
tax the worker contributed. Individual accounts would directly 
link a portion of the worker's contributions to benefits. This 
defined contribution structure would enable workers to earn a 
higher rate of return on their contributions but with some 
measure of risk. However, individual accounts would do nothing 
to help Social Security unless incremental investment income 
either supplement Social Security revenues or offset current 
promised benefits. Decisions about the appropriate balance 
between the defined benefit and defined contribution portions 
will need to consider whether to make individual accounts 
mandatory or voluntary, who would manage the necessary 
information and money flow, how much flexibility individuals 
would have over investment options and access to their 
accounts, and the mechanisms for paying out retirement 
benefits.
Social Security: The President's Proposal. (GAO/T-HEHS/AIMD-00-43, Nov. 
        9, 1999).
    Pursuant to a congressional request, GAO discussed the 
President's proposal for Social Security financing, focusing 
on: (1) the extent to which the proposal achieves sustainable 
solvency and how the proposal would affect the economy and the 
federal budget; (2) whether the proposal balances individual 
equity and income adequacy; and (3) how readily changes could 
be implemented, administered, and explained to the public. GAO 
noted that: (1) according to Administration officials, the 
President's proposal would constitute a significant down 
payment on Social Security reform while contributing to 
achieving the Administration's goal of eliminating publicly 
held debt by 2015; (2) while the President's proposal for 
Social Security financing differs in some respects from his 
earlier proposals, the bottom line of the proposal with respect 
to sustainable solvency is unchanged; (3) the proposal: (a) 
reduces debt held by the public from current levels, which 
reduces net interest costs, and raises national saving, thereby 
contributing to future economic growth; (b) provides general 
revenues to the Old Age and Survivors Insurance and Disability 
Insurance trust funds, thereby representing a fundamental 
change in Social Security financing; (c) has no effect on the 
projected cash flow imbalance in the Social Security program's 
taxes and benefits, which begins in 2014; and (d) represents a 
financing, rather than a Social Security reform proposal; (4) 
GAO's analysis shows that the President's Social Security 
transfer proposal has the same effect on the economy and the 
federal budget as a policy of No Action that would simply 
continue spending and revenue along its path while making no 
change in Social Security or Medicare benefits; (5) the 
President's Social Security transfer proposal does not address 
sustainable solvency; (6) because the President proposes no 
changes to the structure of the current Social Security system, 
his proposal does not affect income adequacy; (7) specifically, 
the President's proposal maintains current-law benefits for 
current and future retirees, including low-income workers and 
others most reliant on Social Security, and makes no changes to 
disabled, dependent or survivor benefits; (8) the proposal also 
makes no changes from the current Social Security structure in 
the way workers are covered, and it preserves the progressivity 
of the system; (9) in addition, it retains the compulsory 
nature of the current payroll tax; (10) because the President's 
transfer proposal does not alter the Social Security program in 
any way, there are no implementation costs, and the program's 
current administrative costs will remain less than 1 percent of 
benefit outlays; and (11) without programmatic change, there 
are no changes that must be explained to the public and no risk 
of an ``expectations gap'' with respect to benefits.
SSA Customer Service: Broad Service Delivery Plan Needed to Address 
        Future Challenges. (GAO/T-HEHS/AIMD-00-75, Feb. 10, 2000).
    The Social Security Administration (SSA) will be challenged 
to maintain a high level of service to the public in the next 
decade and beyond. Demand for services is expected to grow 
significantly. At the same time, the expectations and needs of 
SSA's customers are changing. Some want faster, more convenient 
service, while others, such as non-English speakers and the 
many beneficiaries with mental impairments, may require 
additional help from SSA staff. SSA's ability to respond to 
these challenges will be difficult because the number of SSA 
employees who retire is expected to peak at the same time that 
large increases will occur in applications for benefits. 
Although GAO has recommended since 1993 that SSA prepare a 
service delivery plan, the agency is only now beginning to 
develop a broad vision for customer service for 2010. In the 
meantime, SSA is counting on efficiencies from technology to 
help it cope with its rising workload. SSA has had mixed 
success with its information technology initiatives, however, 
and the benefits from its technology investments have largely 
been unclear. On the other hand, SSA's efforts to prepare for 
the rising number of retirements among its among its own 
workforce and changing customer needs and expectations have 
shown more promise, although many initiatives are still in the 
early stages and much work remains. SSA needs to fully assess 
the skills that its workforce will need to serve its customers 
in the future. SSA also needs to ensure continuity in 
leadership through ongoing succession planning efforts. 
Finally, without a vision for future service followed by a more 
detailed service delivery plan, SSA cannot be sure that its 
investments in technology and human capital--that is, its 
workforce--are consistent with and fully support its future 
approach to delivering services.
Social Security and Minorities: Current Benefits and Implications of 
        Reform. (GAO/T-HEHS-99-60, Feb. 10, 1999).
    Although Social Security's benefit and contribution 
provisions are neutral with respect to race, ethnicity, and 
gender, GAO found that because of socioeconomic 
characteristics, minorities have benefited from the Social 
Security program. Because minorities are more likely than 
whites to have lower lifetime earnings, they are advantaged by 
Social Security's progressive benefit formula that provides 
larger relative benefits for lower-paid workers. Moreover, 
blacks in particular are more likely to receive other important 
Social Security benefits, such as disability, that protect 
against lost earnings. Some reforms that would reduce benefits 
to restore solvency could have a disproportionate effect on 
low-wage earners, including blacks and Hispanics, depending on 
how they are structured. Restructuring Social Security to 
include individual accounts would also likely have varying 
effects on different racial and ethnic groups. However, GAO 
found that education and family income are better predictors of 
individuals' investment behavior than race. Persons with less 
education and lower incomes tend to invest more conservatively 
than those with more education and higher income. Because 
blacks and Hispanics are more likely to have less education and 
lower incomes, they would likely earn smaller returns on their 
accounts, although they would bear less risk. These results 
suggest that if individual accounts were adopted as part of 
comprehensive Social Security reform, investor information and 
education would be needed to help low-income individuals with 
their investment decisions.
Social Security Reform: Implications for Women. (GAO/T-HEHS-99-52. Feb. 
        3, 1999).
    Women have benefited greatly from the Social Security 
program. Many women who work are advantaged by the progressive 
benefit formula that provides larger relative benefits to those 
with lower lifetime earnings. Women who did not work or had low 
lifetime earnings and who were married benefit from the 
program's spousal and survivor benefit provisions. However, 
women typically receive lower monthly benefits than men because 
benefits are based on earnings and the number of years worked. 
Any across-the-board benefit cuts to restore solvency might 
fall disproportionately on women as a group because they rely 
more heavily on Social Security income than men do. Other 
reform approaches can have positive or negative effects on 
women depending on how the reforms are designed. Restructuring 
Social Security to include individual accounts also will likely 
have different effects on men and women. Because women earn 
less than men, contributions of a fixed percentage of earnings 
would put less into women's individual retirement accounts. 
Available evidence indicates that women also tend to invest 
more conservatively than men do, and thus would likely earn 
smaller returns on their accounts. In addition, how such 
accounts are structured will be extremely important to women. 
For example, whether individuals will be required to buy 
annuities with the proceeds of their accounts at retirement and 
how the annuities are priced could affect women quite 
differently from men. How benefits might be distributed to 
divorcees and how accountsare transferred to survivors could 
critically affect the retirement income of some elderly women. 
Understanding the potential consequences of the various reform 
proposals can help ensure that Social Security continues to 
protect vulnerable groups, such as elderly unmarried women.
Social Security: What the President's Proposal Does and Does Not Do. 
        (GAO/T-AIMD/HEHS-99-76, Feb. 9, 1999).
Social Security and Surpluses: GAO's Perspective on the President's 
        Proposals. (GAO/T-AIMD/HEHS-99-95, Feb. 23, 1999).
Social Security and Surpluses: GAO's Perspective on the President's 
        Proposals. (GAO/T-AIMD/HEHS-99-96, Feb. 23, 1999).
    [These similar testimonies were given to three Senate and 
House committees.] The President's recent proposal for 
addressing Social Security and the use of the budget surplus is 
complex, which makes it all the more important to focus on what 
it does--and what it does not do--for the nation's long-term 
future. In summary, the President's proposal does reduce debt 
held by the public from current levels, thereby also reducing 
net interest costs, raising national saving, and contributing 
to future economic growth. The President's proposal also 
changes Social Security financing in two fundamental ways: it 
promises general funds in the future by, in effect, trading 
publicly held debt for debt held by the Social Security Trust 
Fund and it invests some of the trust fund in equities with the 
goal of capturing higher returns over the long term. However, 
the President's proposal does not have any effect on the 
projected cash flow imbalance in the Social Security program's 
taxes and benefits, which begins in 2013. In GAO's view, the 
President's proposal does not represent a Social Security 
reform plan and does not come close to saving Social Security.

                        Veterans'and DOD Issues

Defense Health Care: Need for Top-to-Bottom Redesign of Pharmacy 
        Programs. (GAO/T-HEHS-99-75, March 10, 1999).
    The Defense Department (DOD) and its managed care support 
contractors provide prescription drug benefits to about 8.1 
million active-duty personnel, their families, and retirees. 
GAO found that the significant problems that DOD is 
experiencing delivering its pharmacy benefits result largely 
from the way in which DOD manages its three pharmacy programs. 
Rather than viewing the programs as integral parts of a single 
pharmacy system, DOD manages the programs as separate entities, 
not taking into account, for example, the merits of 
establishing a uniform DOD formulary and integrated databases 
or the effects that initiatives, such as implementing a 
separate mail-service pharmacy program, will have on other 
programs. Unless DOD begins to manage the various components of 
the pharmacy programs as a single system, the problems GAO 
identified will continue and potentially worsen.
DOD and VA Health Care: Jointly Buying and Mailing Out Pharmaceuticals 
        Could Save Millions of Dollars. (GAO/T-HEHS-00-121, May 25, 
        2000).
    The Department of Veterans Affairs (VA) and Department of 
Defense (DOD) are the largest direct federal drug purchasers, 
although their combined purchases are less than two percent of 
total domestic drug sales. They enjoy varying, but significant, 
discounts on their drug purchases, the largest when they 
contract jointly to purchase the same drugs for their systems 
and through their separate national contracts with drug makers. 
However, their joint and separate contracting have been 
limited. Only about 19 percent of VA and DOD combined drug 
purchases are made through such contracts; most are made at 
smaller discounts. If they could jointly contract for most of 
the 30 drug classes that now make up about two-thirds of their 
combined drug purchases, they could save hundreds of millions 
of dollars annually. Obstacles to overcome include DOD's need 
to develop a national drug formulary and the departments' need 
to mitigate their institutional competitiveness and pursue such 
joint actions as drug contracting.
Military Retirement: Proposed Changes Warrant Careful Analysis. (GAO/T-
        NSIAD-99-94, Feb. 25, 1999).
    Overall, GAO sees no clear indication that the proposed 
change to the military's retirement system, which would cost an 
estimated $13 billion in higher costs and unfunded liabilities, 
will address the retention issue. Although the recently 
reported downturn in retention rates is of concern, the nature 
of the retention problem is unclear. Is the problem widespread 
or is it concentrated in certain military occupations or year 
groups? Is it a transitory problem attributable to such factors 
as reduced accessions during the drawdown and the strong 
economy, or is it the beginning of a long-term problem? 
Understanding the nature of the retention problem is critical 
in crafting solutions. According to the Defense Department, the 
1986 Military Retirement Reform Act has become a symbol of 
eroding benefits to military members. Although surveys of 
military personnel show increasing dissatisfaction with the 
retirement system, it is not clear what that really means. For 
example, somesurveys do not differentiate between retirement 
pay and other retirement benefits. The link between retirement 
pay and retention is also unclear. According to an analysis 
done by the Congressional Budget Office, retention rates under 
the act have not been markedly different than rates under the 
earlier system. Even if the retirement system is found to be 
linked to retention, it may not be the most cost-effective way 
to address existing retention problems. In addition, DOD's 
proposed pay and retirement changes do not address other 
military retirement issues and their impact on the structure of 
the force.
VA Information Technology: Progress Continues Although Vulnerabilities 
        Remain. (GAO/T-AIMD-00-321, Sept. 21, 2000).
    This testimony focuses on the status of the Department of 
Veterans Affairs' (VA) efforts in seven areas of its 
information technology (IT) program: improving its process for 
selecting, controlling and evaluating IT investments; filling 
the chief information officer position; developing a strategy 
for reengineering its business processes; completing a 
departmentwide integrated systems architecture; tracking its IT 
expenditures; implementing the Veterans Health Administration 
(VHA) Decision Support System and the Veterans Benefits 
Administration's (VBA) compensation and pension replacement 
project; and improving the department's computer security. 
Progress has been made in some of these areas, such as IT 
investment decision-making and selecting a chief information 
officer. In other areas, plans have changed--the Department no 
longer plans to develop an overall strategy for reengineering 
its business processes to function as One VA, nor has it 
defined the integrated IT architecture needed to efficiently 
acquire and use information systems across VA. No uniform 
mechanism is in place throughout VA that tracks IT spending; 
instead, VA's different offices use various mechanisms for 
tracking IT expenditures. VHA's Decision Support System and 
VBA's compensation and pension replacement project continue to 
face challenges. Although VA has begun to address computer 
security weaknesses, it will have few guarantees that financial 
information and sensitive medical records are adequately 
protected until it develops and implements a comprehensive, 
coordinated security management program.
VA Patient Safety: Initiatives Promising but Continued Progress 
        Requires Culture Change. (GAO/T-HEHS-00-167, July 27, 2000).
    The Department of Veterans Affairs (VA) has undertaken 
several initiatives to better detect and prevent adverse 
events, including falls, medication errors, missing patients, 
and suicides. For example, VA has established systems that 
include bar code technology to prevent blood product and 
medication administration errors. VA is completing its 
implementation of a revised mandatory adverse event reporting 
and prevention process; the success of this initiative depends 
on VA establishing a culture in which employees feel safe to 
openly report actual adverse events as well as close calls. VA 
needs to prepare a detailed implementation plan that identifies 
how and when VA's various patient safety initiatives will be 
implemented, how they are aligned to support improved patient 
safety, and what contribution each initiative can be expected 
to make toward the goal of improved patient safety.
Veterans' Affairs: Observations on Selected Features of the Proposed 
        Veterans' Millennium Health Care Act. (GAO/T-HEHS-99-125, May 
        19, 1999).
    The proposed Veterans' Millennium Health Care Act should 
help the Department of Veterans Affairs (VA) provide care for 
veterans in more appropriate settings, reduce per-patient 
costs, increase thenumber of its patients, and reduce its 
reliance on appropriations. The bill's facility realignment and 
cost-sharing provisions would help VA reduce budget pressures 
and generate the resources needed to serve more veterans and 
enhance their benefits. Its long-term care provisions appear to 
be designed to reduce variability in veterans' access to care, 
addressing GAO's concern about the potential adverse effect of 
VA's transformation on the equity of veterans' access to care. 
On facility services realignment, the bill requires (1) VA to 
develop enhanced-service plans to address veterans' health care 
needs, (2) VA's stakeholders to participate in plan 
development, and (3) VA to use efficiency savings locally. On 
long-term care, the bill (1) requires the development of a 
national program of services, (2) increases the percentage of 
VA's budget for noninstitutional services, and (3) mandates 
coverage for services for certain higher-priority veterans. The 
bill's cost-sharing provisions address prescription drugs, 
outpatient services, long-term care, and certain high-cost 
supplies.
Veterans Benefits Administration: Problems and Challenges 
        FacingDisability Claims Processing. (GAO/T-HEHS/AIMD-00-146, 
        May 18, 2000).
    Claims processing in the disability compensation program is 
done by the Veterans Benefits Administration (VBA). Congress, 
the Department of Veterans Affairs, and veterans' service 
organizations have been concerned about the program for years. 
The concerns have focused on the backlogs of claims, long waits 
for disability decisions, and the poor quality of these 
decisions, all of which have undermined the quality of service 
provided to veterans. VBA's problems with large backlogs and 
long waits for decisions have not improved, despite years of 
studying these problems. Moreover, VBA's new quality 
measurement system shows that nearly one-third of its decisions 
are incorrect or have technical or procedural errors. Many 
performance problems stem from the process's complexity, which 
is growing as the number of service-connected disabilities per 
veteran increases and judicial review requires more procedures 
and documentation. Although VBA has begun several efforts to 
streamline its claims-processing performance, it is unclear how 
much improvement will result. Also, VBA may need to collect and 
analyze additional case-specific data to better understand its 
claims-processing problems and better target its corrective 
actions. Furthermore, because some issues affecting VBA's 
performance are a function of program design, more fundamental 
changes may have to be considered to realize significant 
improvements.

                            Multiple Issues

Medicare Subvention: Challenges and Opportunities Facing a Possible VA 
        Demonstration. (GAO/T-HEHS/GGD-99-159, July 1, 1999).
    Medicare subvention in the Department of Veterans Affairs 
(VA) would have the goal of providing an alternative for 
delivering accessible and quality care to certain veterans 
eligible for Medicare without increasing the cost to Medicare 
or VA. Subvention would allow VA to supplement its funds with 
Medicare payments. In principle, by paying VA a discounted 
rate, the Medicare program might save money, so long as it does 
not pay for services that VA would have previously covered. A 
three-year Department of Defense (DOD) subvention demonstration 
program involves about 30,000 retirees and limits Medicare 
payments to DOD to $65 million a year. However, a nationwide 
DOD subvention program could potentially involve Medicare 
payments of several hundred million dollars or more. The 
potential size of a nationwide VA program may be even greater, 
with nearly all the nine million veterans aged 65 and older 
covered by Medicare. Proposed legislation before the House and 
the Senate would authorize VA subvention demonstrations. Under 
either bill, VA would (1) be challenged to attract veterans who 
currently enjoy a generous VA benefits package, (2) need to 
strengthen its billing systems, and (3) need to ensure that 
access to services is not reduced. VA will need sufficient time 
to implement a demonstration, and it must carefully design and 
implement its payment methods to protect Medicare trust funds 
and to promote cost consciousness and efficiencies at the 
demonstration sites. Finally, sound data systems are essential 
for managing and evaluating a subvention demonstration.
Medicare Subvention Demonstration: DOD Experience and Lessons for 
        Possible VA Demonstration. (GAO/T-HEHS/GGD-99-119, May 4, 
        1999).
    Medicare-eligible military retirees to get Medicare-covered 
care from the Defense Department (DOD). Proposals have also 
been made to allow veterans to use their Medicare benefits at 
Department of Veterans Affairs (VA) facilities. Under 
subvention, Medicare pays DOD and would pay VA less than the 
rate paid to private Medicare providers and managed care plans. 
Although it got off to a slow start, DOD initiated its 
subvention demonstration and is serving medicare-eligible 
beneficiaries at six sites. Remaining operational issues 
include the development of viable payment rules and development 
of data to manage the demonstration. GAO's complete evaluation 
will not be available until after the demonstration ends. 
Meanwhile, DOD's early experience suggests that, if medicare 
subvention is permitted for VA, it would need to consider, in 
collaboration with the Health Care Financing Administration, 
how to determine its baseline costs and payment rules and the 
need for good data for implementing, managing, and controlling 
costs. VA would need to make its regular enrollment of veterans 
who wish to use VA health care services interface smoothly with 
subvention enrollment and would need to be concerned about 
crowding out other, currently higher-priority veterans. VA 
would succeed better if it had enough time to plan and 
establish its demonstration and to reconsider the value and 
feasibility of implementing fee-for-service and managed care 
subvention models simultaneously.

                          Related GAO Products

Published by GAO:
Aging Issues: Related GAO Reports and Activities in Fiscal Year 1995. 
        (GAO/HEHS-96-82, Mar. 6, 1996).
Aging Issues: Related GAO Reports and Activities in Fiscal Year 1996. 
        (GAO/HEHS-97-41, Dec. 31, 1996).
Aging Issues: Related GAO Reports and Activities in Calendar Years 1995 
        and 1996. (GAO/HEHS-98-101, March 27,1998).
Published by the committee:
Aging Issues: Related GAO Reports and Activities in Calendar Years 1997 
        and 1998. (GAO/HEHS-99-73R, Feb. 26, 1999).
Aging Issues: Related GAO Reports and Activities in Calendar Years 1998 
        and 1999. (GAO/HEHS-99-97R, Apr. 26, 2000).

                  ITEM 22--LEGAL SERVICES CORPORATION

                              ----------                              


                          Service to the Aging

    In 1974, Congress created the Legal Services Corporation 
(LSC) to provide civil legal aid access to low-income 
Americans. LSC receives an annual appropriation from Congress. 
In 1999, LSC funded 237 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, ethnic groups, and ages. The problems 
that bring people to local legal services offices arise out 
everyday of 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. 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 1999, LSC-funded programs served 136,854 Americans ages 
60 and over. Older Americans represented 13 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 obtain 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 YEARS 1999-
                                  2000

                              Introduction

    As part of its overall mission, the Endowment encourages 
greater access to and participation in the arts as a way of 
contributing to the quality of life for all citizens. Most 
important, the energy, wisdom and creative potential that older 
adults bring to the arts are an important part of our cultural 
heritage. The National Council on the Arts has long been 
committed to making the arts available to underserved 
populations, including older adults, as stated in its 1973 
resolution:
    ``No Citizen, regardless of physical and mental condition 
and abilities, age or living environment, should be deprived of 
the beauty and insights into the human experience that only the 
arts can impart.''
    Everyone should have the opportunity to learn through the 
arts from childhood into their oldest years. However, access to 
cultural activities is often denied to older and disabled 
people because of architectural, programmatic, financial, 
logistic and attitudinal barriers. Surveys, including the 
Endowment's Survey of Public Participation in the Arts, 
indicate that participation in arts activity declines with age, 
and that disabled and older people are under represented in 
arts audiences. An individual's ability to participate in the 
arts with dignity and independence has a direct effect on arts 
programming and facility design.

                        Office for AccessAbility

    This Office serves as the advocacy and technical assistance 
arm of the Arts Endowment for people who are older, disabled, 
or living in institutions. The Endowment's AccessAbility 
Coordinator works in a myriad of ways to assist grantees and 
applicants in making arts programs available to these important 
segments of our citizenry. A broad range of cooperative efforts 
have been developed with Endowment disciplines, grantees, arts 
service groups, private groups representing older and disabled 
populations and with other Federal agencies--to assist in 
achieving the Endowment's goal of increased access to the arts 
for all Americans. For example, the Coordinator worked with the 
Consortium of New York Geriatric Education Centers and the 
Gerontological Society of America (GSA) to chair a symposium on 
``Innovative Research and Programs on Creativity and Aging'' at 
GSA's November 18-20, 2000 conference in Washington, DC. The 
discussion highlighted three best practices that demonstrate 
the universality and importance of the arts in the lives of 
older adults, assessment of community's resources for arts and 
aging programs, and creating linkages between arts and aging 
activities nationwide.
    The focus of these efforts is inclusion, opening up 
existing programs and outreach to citizens who would not 
otherwise have opportunities to be involved in the best arts.
    The report that follows outlines many of our leadership and 
technical assistance efforts that involve older adults.

                           Regional Symposia

    The Office provides technical assistance to applicants and 
grantees on the most effective and efficient ways to make the 
arts more available to underserved populations. This work 
includes workshops, seminars and how-to publications. While the 
doors of a theater or museum are theoretically open to 
everyone, many are denied such opportunities because the 
appropriate accommodations, such as assistive listening systems 
for people who are hard-of-hearing, audio description for 
individuals with vision loss or an elevator for those with 
limited mobility.
    During this reporting period, the Endowment supported two 
regional symposia that were convened by the New England 
Foundation for the Arts and the Western States Arts Federation. 
The New England symposium, ``Clearing the Path: Art and 
Accessibility,'' took place on March 1-3, 1999 in Boston, MA 
with 260 participants from its six-state region. It included 
acknowledged leaders in the arts, aging and accessibility 
communities presenting sessions on best practices and policies; 
technologies such as audio description; universal design; 
effective ways to achieve community involvement; staff training 
and resources for change.
    The Western States Arts Federation convened ``From Insight 
to Innovation: Art and Accessibility in the West'' for its 
twelve state region on December 14-16, 2000 in Oakland, CA. The 
275 participants (arts administrators, artists and 
representatives from aging and disability organizations) who 
attended workshops that focused on design, performing and 
visual arts, media and outreach to people living in 
institutions. The program featured several performances by 
older artists, including Stagebridge's senior actor's troupe. 
Stagebridge is an exemplary arts and literacy program in 
Oakland that reached 2,000 older adults and 12,000 at-risk 
youth this year.
    These highly successful efforts have a catalytic effect 
where many state arts agencies have: replicated the symposia in 
regional meetings throughout their states; organized access 
evaluation teams to assist arts groups planning and 
implementing accessible programs; and set up grants programs to 
assist grantees with accessibility.

                          Careers in the Arts

    During this reporting period, substantial work was 
completed to begin implementing recommendations from our 
interagency, leadership initiative, ``Careers in the Arts.'' 
This effort began in 1998 when the Arts Endowment initiated and 
developed interagency agreements with the U.S. Department of 
Education, Department of Health and Human Services, the Kennedy 
Center for the Performing Arts and the Social Security 
Administration--to look at ways the agencies may advance 
careers in the arts for people with disabilities. Subsequently, 
the agencies worked in partnership to convene the first-ever 
``National Forum on Careers in the Arts for People with 
Disabilities'' in June 1998. Forum participants identified 
obstacles faced by people with disabilities pursuing careers in 
the arts and developed strategies to overcome such barriers.
    On June 13, 1999, the Endowment renewed its partnership 
with its Federal partners, and convened three 1-day summits at 
the Kennedy Center in Nov-Dec 1999 to plan specific activities 
for implementing the recommendations. They include sponsoring 
internships with cultural groups and convening state-level 
careers in the arts' forums.
    With regard to financial disincentives, there are a number 
of older or disabled artists who receive some form of 
government benefits, and have lost these essential resources 
for months or even years when they received some support, such 
as an apprenticeship, a Heritage Award or selling a quilt. In 
response to these concerns, the Social Security Administration 
(SSA) supported a December 7, 1999 policy education meeting to 
address government financial disincentives that affect artists 
who receive sporadic income from their art or monetary awards. 
Convened in the Senate Dirkson Building, artists and government 
officials talked openly with each other about these issues. SSA 
staff discussed proposed legislation that would provide people 
leaving the system for work, the option of continuing 
government health benefits, including Medicaid. The legislation 
was signed into law by President Clinton on Dec. 18, 1999.
    The reports from the Forum, Summits and SSA meetings are 
posted on the Kennedy Center's website at http://
artsedge.kennedy-center.org forum

                            Universal Design

    Since 1990, the Arts Endowment has conducted a leadership 
initiative on universal design, the design process that 
eliminates ``special labels'' to create excellent design that 
make products and spaces functional for people from childhood 
into their oldest years.
Universal Design Exemplars
    The Endowment supported the Center for Universal Design at 
North Carolina State University in Raleigh to conduct a 
national search to identify, document and produce on CD-Rom the 
second set of excellent examples of universal design that will 
be disseminated to designers, educators, city planners and 
others. The new exemplars include architecture, exhibit design, 
industrial design, interior design and landscape architecture; 
and they are displayed on the Center's website at 
www.design.ncsu.edu/cud/ude
June 7-8,1999 Endowment Meeting on Universal Design
    The Endowment's AccessAbility Office convened a meeting of 
thirteen universal design experts from design professions, 
academia, consumer groups, and government to: assess the 
current state of universal design; and to identify future 
opportunities for encouraging and assisting the practice of 
universal design. A starting point was the seminal Endowment 
meeting held a decade ago to outline a blueprint for action to 
advance universal design practice.
    Chairman Ivey addressed the group, and asked for their 
suggestions on how the Endowment may best serve the field in 
this area, which stimulated much discussion. The group agreed 
that universal design has gained a significant foothold in 
professional organizations and among cultural institutions. At 
several universities, centers and curricula that incorporate 
universal design have made substantial contributions to the 
field. Major publications, international conferences and 
exhibitions have helped to raise public awareness. The American 
Association of Retired Persons (AARP) has seized upon it as a 
leading issue to support healthy aging-in-place.
    In spite of the accomplishments, universal design faces 
challenges in the areas of public and professional 
misperceptions about what universal design is, and that it 
extends to every aspect of society and seeks to imbue all 
design with values of full inclusion regardless of a person's 
age or abilities. Participants advised that strategies be 
developed to broaden the appeal of universal design, to take it 
out of the disability community into the broad mainstream of 
society. Public relations efforts in the press, radio and 
television could assist this goal. Design competitions could 
reveal exemplars to take to consumers, showing how objects and 
environments that feature universal design principles add both 
to the quality of life and to the business's bottom line. At 
the same time that the broader society discovers the value of 
universal deign, educators and practitioners need constant 
reminders of the movement's activities and philosophy. The 
meeting report containing a wealth of recommendations is posted 
on the Endowment's website at www.arts.gov.
    In addition, we developed a universal design working group 
composed of the Administration on Aging, the AARP, the 
Association of Collegiate Schools of Architecture, the 
Industrial Design Society, U.S. Dept. of Housing and Urban 
Development, Adaptive Environments, Inc., and the American 
Institute of Architects to look at ways that we may work 
together to implement some of the recommendations, including a 
student competition on universal design.
Access to Design Professions
    This 1999 leadership project builds on our Careers in the 
Arts and Universal Design leadership initiatives. We found that 
there are few designers with disabilities in any design 
professions. Traditional recruitment methods do not target 
students with disabilities, and rehabilitation counselors do 
not direct or support disabled students into design 
professions. This three-part project will result in an action 
plan that begins to address this complex problem. It includes 
conducting research on barriers in education, career planning 
and work experience. Phase two will convene educators, 
vocational professionals, and designers with and without 
disabilities to draft and finalize the action plan. Although 
next steps will be determined by the plan, action steps will 
include pilot projects and a functioning network of design 
practitioners with disabilities.

                           Arts in Healthcare

    The Arts Endowment has continued to play an important role 
in infusing the arts into healthcare, including hospitals, 
hospices, and drug treatment centers. This agency and its state 
and regional partners fund outreach activities of many groups 
that take their art into healthcare settings (i.e., Los Reyes 
de Albuquerque Foundation in New Mexico and the Grace Roots and 
Community Efforts in Vermont).
    The AccessAbility Coordinator serves on a 23-member 
interagency committee on Healthcare Environments that initiated 
and convened two conferences during this reporting period. The 
first was an invitational meeting on the ``Effect of Working 
Conditions on Quality of Care'' that took place on October 12-
13, 1999 in Washington, DC. Over 150 participants, including 
healthcare professionals, researchers and staff from Federal 
agencies, looked at the problems associated with working 
conditions and ways to solve them. Chairman Bill Ivey keynoted 
the conference, highlighting the important role that the arts 
can play in the healthcare experience.
    Further, the committee developed and presented a national 
conference, ``Enhancing Working Conditions and Patient Safety: 
Best Practices'' that convened on October 17-18, 2000 in 
Pittsburgh, PA. The Endowment organized and supported a 
stimulating session on ``The Arts in Healthcare,'' that 
addressed the built environment, visual arts in the design 
process, and arts programs that celebrate community.
Society for Arts in Healthcare
    The former Cultural Services Director at Duke, Janice 
Palmer, helped found the International Society for Arts in 
Healthcare in 1990 that is located in Washington, DC. Composed 
of healthcare institutions, healthcare professionals, artists 
and arts administrators, this service group promotes the 
incorporation of the arts as an integral component of 
healthcare through conferences and technical assistance. The 
Society received a 1999 Endowment leadership grant to train 
arts administrators and artists, who are working in healthcare, 
as consultants . Subsequently, they will provide onsite 
consultation to interested healthcare institutions across the 
country on establishing comprehensive, professional arts 
programming within their institutions. The University of MA's 
Arts Extension Service trained twelve consultants in June and 
the Society is presently working with medical institutions to 
set up the consultations.

                   Lifelong Learning and Older Adults

    The desire and ability to create have no bearing on a 
person's age or physical characteristics. Lifelong learning in 
the arts continues to me a major goal of the Arts Endowment.
National Database Arts and Older Americans
    The Endowment's AccessAbility Office worked with Elders 
Share the Arts in Brooklyn, NY to update a national data base 
on arts programs involving older adults. It includes over 600 
project descriptions, with resources to assist groups in 
developing similar programs, networks and partnerships. It is 
organized state-by-state, with funding and contact information, 
and will be available on Elders' website in June 2001.
International Year of the Older Person
    The AccessAbility Coordinator served on a planning 
committee for a symposium that was organized by the 
Administration on Aging and held in conjunction with the United 
Nations' International Year of the Older Person, ``Coming of 
Age: Federal Agencies and the Longevity Revolution.'' Convened 
on June 2, 1999 at the National Institute of Health in 
Bethesda, MD, it brought together 300 Federal policymakers to 
look at ways that government agencies may work collaboratively 
to meet the needs of America's aging population. Two of sixteen 
policy panels for the meeting focused on the arts, ``Universal 
Design and Independent Living,'' and ``Promoting Active Aging 
through Life-Long Learning and the Arts.'' Both presentations 
were well received and stimulated extensive discussion.

                         Arts Endowment Funding

    The National Endowment for the Arts continues to support 
arts activities that benefit people of all ages. Many of these 
projects specifically address older adults as listed in the 
following examples by arts discipline.

                             FY 1999 Grants

                                 Dance

    Jacob's Pillow Dance Festival, Inc. in Lee, Massachusetts 
was awarded a grant to support a consortium project entitled 
``What is Dance?: A Model for Dance Literacy.'' The consortium 
of Jacob's Pillow Dance Festival (Lee, MA), The Flynn Theatre 
of the Performing Arts (Burlington, VT), Bates Dance Festival 
(Lewiston, ME), and the Hopkins Center at Dartmouth College 
(Hanover, MA) presented What is Dance?: A Model for Dance 
Literacy, a program that assists adults of all ages in 
understanding and appreciating dance as an art form.
    Very Special Arts Montana Inc. of Missoula, Montana 
received a grant to support a consortium project to provide 
dance programs for children and adults with and without 
disabilities and concerts for community audiences. Very Special 
Arts Montana, Young Audiences of Western Montana, and The 
Montana Transport Company provided school programs and master 
classes in dance and presented a community performance in 
modern dance.

                       Folk and Traditional Arts

                         folk arts fellowships

    Eleven National Heritage Fellowships were awarded to 
artists who are over the age of sixty-two, in recognition of 
their outstanding contributions to the arts. They include:
        Alfredo Campos of Federal Way, Washington is the 
        unsurpassed senior horsehair hitcher of the late 20th 
        century. Raised on a ranch in Arizona, Mr. Campos was 
        fascinated by the beautiful horsegear made from pieces 
        of braided rawhide in the Mexican vaquero tradition. 
        Prized horsehair hitching was difficult to find in the 
        years before Alfredo Campos was ``discovered,'' but the 
        impeccable workmanship and colorful beauty of his 
        quirts, headstalls, bosals, and reins were a key to a 
        renaissance in the art form.
        Elliott Mannette, of Morgantown, West Virginia, is the 
        most widely recognized innovator, teacher, and 
        representative of the steel drum tradition. At the end 
        of World War II, Mr. Mannette became the leader of one 
        of Trinidad's greatest and longest-lasting bands, 
        Invaders. Also at this time, oil drum lids became the 
        standard source material for steel drums, and Mr. 
        Mannette, a machinist by trade, applied his skills to 
        improve the pan, helping to propel it to broad 
        popularity. Over the next several decades he brought an 
        even more sophisticated approach to pan tuning, and in 
        1967 he settled in the United States, where he has 
        taught and become the main source of steel band 
        instruments through his company The Mannette Touch.
        Eudokia Sorochaniuk of Pennsauken, New Jersey learned 
        the arts of nyzanka embroidery and weaving as a young 
        girl in Ukraine. Leaving her home with her family 
        following World War II, she eventually settled in the 
        United States. Working days at a garment factory, she 
        wove traditional patterns on a loom at home at night. 
        Over the fifty years that she has been in New Jersey, 
        she has reproduced albums full of nyz patterns, each 
        containing one or more of the intricate designs. Ms. 
        Sorochaniuk's commitment to tradition involves 
        preserving not just the patterns but the practice of 
        the art forms. She has taught and participated in 
        numerous folk arts programs in the United States and 
        Ukraine.

                            folk arts grants

    Apache Tribe of Oklahoma in Anadarko, Oklahoma received a 
grant to support workshops in the creating and decorating of 
material culture items associated with the Apache Tribe of 
Oklahoma, to be taught by tribal elders. Of importance to 
community members as a whole is that the patterns, forms, 
color, and styles of beading, twining of fringe, and the 
collecting of and use of paint be preserved and passed on to 
future generations.
    Los Reyes de Albuquerque of Albuquerque, New Mexico was 
awarded a grant to support and perpetuate the traditional 
Nuevomexicano music, songs and culture of northern New Mexico 
and southern Colorado through presentations at child day-care 
centers and urban, rural, and Pueblo senior centers. Each 
presentation consisted of brief talks with songs and dances in 
a relaxed, friendly setting where the audience is encouraged to 
sing along, dance or simply enjoy the music.
    Senior Arts Project in Albuquerque, New Mexico received a 
grant to support activities that enabled older adults to gain 
an in-depth understanding of New Mexico's Spanish Colonial 
cultural heritage. Senior Arts presented Antonia Apodaca and 
Cipriano Vigil, older folk musicians who specialize in the 
Spanish Colonial music and dance of Northern New Mexico.

                         Leadership Initiatives

    Accessible Arts, Inc. of Kansas City, Missouri was awarded 
a grant to support the creation of a community cultural plan. 
Partners worked together to expand arts/education data bases to 
include artists with disabilities of all ages throughout the 
state and identify schools that need training for work with 
children with disabilities.
    Society for the Arts in Healthcare in Washington, DC 
received a Leadership Initiatives grant to support a national 
technical assistance project that trains arts administrators 
and artists as consultants to educate and assist healthcare 
institutions across the country in establishing comprehensive, 
professional arts programming within their institutions.
    VSA arts of Washington, DC received a leadership initiative 
grant to support stipends for 50 artist presenters at the 
ArtCareers Expo, where people with disabilities of all ages 
explored careers in the arts. ArtCareers Expo was held in Los 
Angeles, CA, in conjunction with the International VSA Festival 
in June 1999.

                               Literature

    One literature fellowship went to a writer over the age of 
sixty-two:
    George Economou of Norman, Oklahoma is Professor of English 
at the University of Oklahoma. He has published six books of 
poetry, several books on medieval literature, and numerous 
translations from ancient and modern Greek as well as from a 
number of medieval languages. His poems, translations, and 
criticism have appeared in many leading literary and scholarly 
journals, and he has held fellowships for his writing from the 
New York State Council for the Arts and the Rockefeller 
Foundation. He has received two NEA Creative Writing 
Fellowships in Poetry, in 1988 and 1999.

                               Media Arts

    Washington, DC International Film Festival received funding 
to support the 1999 Washington, DC International Film Festival. 
Held annually in the spring, this event includes free films for 
children, older adults, and underserved communities.

                           Multi Disciplinary

    Elders Share the Arts in Brooklyn, New York received 
funding for the development of new earned income through the 
establishment of Creative Aging Institutes, which offer 
training to develop arts programs for older adults. The project 
includes support for marketing the ESTA training program in San 
Francisco, CA; Chicago, IL; Boston, MA; and Atlanta, GA.

                                 Museum

    The Mint Museum of Art, Inc. in Charlotte, North Carolina 
received a grant to support the exhibition ``Harvey Littleton: 
Reflections, 1946-1994,'' and an accompanying catalogue and 
education programs. The project will examine Littleton's long 
career as a glass artist and his influence as a teacher and 
advocate for the American studio crafts movement.

                                 Music

                   american jazz masters fellowships

    Three American Jazz Masters fellowships were awarded to 
older artists in recognition of their contributions to the 
field of Jazz.
        Dr. David Baker, of Bloomington, Indiana, was one of 
        the first trombonists to incorporate avant-garde 
        effects on the horn. Levels (1973), a concerto for solo 
        double bass, jazz band, wind, and strings was nominated 
        for a Pulitzer Prize, and his compositions have been 
        recorded by many other musicians. David Baker has 
        written extensively on jazz and produced several 
        innovative textbooks and analyses of jazz works. He is 
        well known in his capacity as the Chairman of the Jazz 
        Department in the School of Music at Indiana 
        University, and continues to make a mark on the 
        preservation of jazz in this country by his leadership 
        as Conductor and Artistic Director of the Smithsonian 
        Jazz Masterworks Orchestra.
        Dr. Donald Byrd, of Teaneck, NJ, is a trumpet virtuoso 
        who has been one of the most creative and influential 
        figures in jazz for four decades, gaining an 
        outstanding reputation as a composer, arranger, and 
        bandleader. In the mid-1950's, his career skyrocketed 
        in the areas of bebop and hardbop with Art Blakey's 
        Jazz Messengers. In the early 1970's, the jazz fusion 
        movement established Dr. Byrd as a ``pioneer of a new 
        sound.'' Dr. Byrd has been a seminal figure at the 
        forefront of jazz education, helping to create such 
        jazz programs as those now available at Rutgers, 
        Howard, and North Carolina Central Universities.
        Marian McPartland of Port Washington, NY is the host of 
        the National Public Radio's ``Marian McPartland's Piano 
        Jazz,'' winner of the prestigious Peabody Award. 
        Developed into one of jazz's premiere showcases, Ms. 
        McPartland plays duets with a stunningly diverse array 
        of known and lesser-known musicians (and legends such 
        as Dizzy Gillespie and Benny Carter) and engages them 
        in often intimate interviews some of the best shows are 
        issued on Jazz Alliance CDs. Ms. McPartland is also a 
        gifted composer and writer. Ms. McPartland is a 
        recipient of the Lifetime Achievement Award presented 
        by Downbeat magazine and also the Duke Ellington 
        Fellowship Medal.

                              music grants

    Amherst Saxophone Society, Inc. of Williamsville, New York 
was awarded a grant to support a residency in western New York. 
The residency included a concert series, free outdoor concerts, 
residency activities at the University of Buffalo, a virtual 
residency of distance learning through the Center for Applied 
Research in Technology at Buffalo State College, and a 
videotape series to reach less-accessible audiences.
    DaCapo Chamber Players, Inc. of New York, New York received 
funding to support artists' fees and production costs for four 
concerts and mini-residencies in several states. These concerts 
and mini-residencies of two separate programs brought American 
chamber music to rural audiences and to students of all ages 
and backgrounds, helping expand artistic horizons.
    Houston Symphony Society of Houston, Texas was awarded 
funding to support a community outreach project by the Houston 
Symphony. During 1999-2000, the Symphony conducted outreach 
activities to underserved Houston and Harris County 
communities, including schools, hospitals, and long-term care 
facilities.
    New Sounds Music, Inc. of Brooklyn, New York received a 
grant to support residency activities by the Prism Saxophone 
Quartet and composer Jennifer Higdon at three institutions in 
Philadelphia: The Kardon Institute of the Arts for People with 
Disabilities, Settlement Music School, and the Free Library of 
Philadelphia. The project encompassed the second year of the 
residency in Philadelphia, March 1999 to February 2000.

                                 Opera

    New Cleveland Opera Company of Cleveland, Ohio received 
funding to support education and outreach programs for students 
kindergarten age to senior adult in underserved urban and rural 
communities. The project emphasized participatory activities 
for elementary, middle, and high school students in addition to 
cross-generational and community partnerships for adults.

                                Theater

    Center Stage Associates, Inc. in Baltimore, Maryland was 
awarded a grant to support the expenses associated with the 
production of a play in which deaf and hearing actors were 
utilized. Rehearsals for the production of Brendan Behan's 
play, The Hostage, explored language and systems of 
communication that could be implemented onstage.
    Deaf West Theatre of North Hollywood, California was the 
recipient of a grant to support the production of Carmen 
Zapata's translation of ``The House of Bernarda Alba'' by 
Federico Garcia Lorca. Presented at Actors Alley at the El 
Portal (North Hollywood) and adapted for a 1-hour, youth-
oriented version for school groups, the play was a 
collaboration between deaf and hearing individuals, co-written 
by a deaf playwright and a Latino writer.
    National Theatre of the Deaf, Inc. of Hartford, Connecticut 
received funding to support the expenses associated with the 
development, video documentation, and showcase performance of a 
new work. It was original piece by playwright Romulus Linney 
and based upon the work of Willard R. Trask. Entitled The 
Unwritten Song, it was further developed through a series of 
workshops and showcase performances during which a documentary 
of the play and its development process was produced and 
broadcast in cooperation with Connecticut Public Television.
    Non-Traditional Casting Project, Inc. of New York, New York 
received funding to support costs for Artist Files/Artist Files 
Online. The two services expand opportunities for, and access 
to, artists of color, artists of all ages, and artists with 
disabilities in the American non-profit professional theater.
    Stagebridge of Oakland, California received a grant to 
support expenses associated with Storybridge, an 
intergenerational literacy project. The project brings older 
storytellers into elementary schools and offers presentations 
of a literacy-based play entitled Grandparents Tales.

                              Visual Arts

    Grass Roots Art and Community Effort of Hardwick, Vermont 
received funding to support a weekly community arts workshop 
for developmentally disabled adults and children in a rural and 
economically depressed region of Vermont. The project built on 
GRACE's successful workshop model in the nearby community of 
Greensboro.
    Little City Foundation of Palatine, Illinois received 
funding to support ``Creativity on Wheels,'' a series of 
traveling art classes that serve adults and children with 
developmental disabilities. Artist/teachers, equipped with 
mobile art materials, traveled to non-profit and community 
organizations in the greater Chicago area to conduct art 
classes from fall of 1999 to the summer of 2000.
    Real Art Ways, Inc. of Hartford, Connecticut was awarded 
funding to support ``Access/Real/Art,'' an educational program 
to complement the contemporary exhibitions scheduled at Real 
Art Ways. The project targeted school-age children and older 
adults and includes the establishment of a pilot program to 
train community members as docents.

                             FY 2000 Grants

                                 Dance

    Colorado Dance Festival, Inc. in Boulder, Colorado was 
awarded funding to support Tap 2001, a project examining the 
legacy and future of the art of tap. This project brings 
together several generations of leading tap artists to examine 
essential aesthetic, philosophical, and practical issues for 
the field in the new millennium.
    Professional Flair, Inc. of Cleveland, Ohio received a 
grant to support the development of a model school for the 
performing arts and continuation of lecture-demonstrations. 
Classes at the school introduce dance technique and provide 
advanced technique training to people of all ages who use 
wheelchairs for mobility as well as to students with other 
types of disabilities and participants who are not disabled.
    Rhythm In Shoes, Inc. of Dayton, Ohio received funding to 
support the creation of a new work. Artistic Directors Sharon 
Leahy and Rick Good are collaborating with local performing 
artists, company members, and senior adults from southwestern 
Ohio to create the final piece of an evening length work titled 
Nova Town.

                                 Design

    Business and Professional People for the Public Interest of 
Chicago, Illinois was awarded a grant to support a national, 
two-stage design competition for a new ``universal design'' 
elementary school that fully integrates disabled and non-
disabled students. Leadership for Quality Education and the 
Small Schools Coalition will also participate in the project. 
Universal design accommodates people from childhood into their 
oldest years.
    LINC Housing Corporation of Long Beach, CA received funding 
to support a limited competition for the design of an 
innovative, intergenerational residential and educational 
village. The villages acts as a demonstration project for the 
integration of affordable housing and existing educational 
programs.

                       Folk and Traditional Arts

                       national heritage fellows

    Nine of the thirteen National Heritage Fellows in 2000 are 
older adults. They include:
        Nettie Jackson, a Klickitat basketmaker from White 
        Swan, Washington. She is recognized as one of the most 
        skilled and creative Native American basketmakers of 
        the Klickitat people, and admired as an extraordinary 
        artist, cultural conservator, mentor and role model. 
        Her work is displayed in museums throughout the 
        Northwest.
        Frankie Manning, of Corona, New York. Mr. Manning is 
        the quintessential master of the Lindy Hop dance style, 
        having introduced new and dazzling dance elements that 
        included synchronized ensembles, horizontal postures, 
        ``freeze'' steps and the ``aerial,'' catapulting a 
        partner in a forward somersault. He appeared with the 
        swing bands of Count Basie, Benny Goodman and Louis 
        Armstrong, and won a Tony Award for his choreography in 
        the Broadway show Black and Blue.
        Don Walser, a western singer and guitarist from Austin, 
        Texas. Termed ``the Pavarotti of the Plains,'' Mr. 
        Walser possesses one of the powerful tenor voices in 
        the field of country music. A yodeler and singer of 
        amazing facility, he preserves a style reminiscent of 
        earlier cowboy singers while adding his own fresh and 
        engaging approach. After forty-five years with the 
        National Guard, Mr. Walser has turned to music full 
        time.

                            folk arts grants

    Los Reyes de Albuquerque Foundation in Albuquerque, New 
Mexico received funding to support and perpetuate nuevomexicano 
folk traditions and to present specially arranged performances 
of the Fiesta de los Novios. Nuevomexicano presentations are 
held at urban, rural and Pueblo senior centers, and child day-
care centers; the Fiesta de los Novios presentations at 
Albuquerque Community Center After School Programs are designed 
to educate inner city youth ages 6-14.
    Montana Asian-American Center of Missoula, Montana received 
a grant to support the passing on of the artistic repertoire, 
techniques, and traditions of paj ntaub applique and embroidery 
to Hmong and non-Asian youth in Missoula, Montana; including an 
exhibition. Two master embroiderers and Hmong elders mentor 20 
students through a year-long course in Hmong cross-stitch, 
tuck-and-fold, crewel, and reverse applique.
    Senior Arts Project in Albuquerque, New Mexico was awarded 
a grant to support the Senior Arts Celebration of Native 
Artists. A series of performances and workshops are taking take 
place in Albuquerque's public senior facilities featuring 
Native American art and culture.
    University of Missouri at Columbia in Columbia, Missouri 
received funding to support a consortium project, the Missouri 
Traditional Arts Apprenticeship Program. The apprenticeship 
program is designed to encourage the state's most skilled, 
active, and communicative tradition bearers to pass their 
knowledge on the next generation.

                         Leadership Initiatives

    Arts Iowa City in Iowa City, Iowa received a grant to 
support the design and development of promotional materials to 
identify the city arts and culture district. Located in the 
refurbished downtown, the city's cultural district is being 
identified through a signature sculpture commissioned for the 
space, banners, maps and other printed materials that promote 
and inform the public of Iowa City's cultural assets. Partners 
include: Johnson County/Iowa City Senior Center, the Downtown 
Association, Iowa City Area Chamber of Commerce, Iowa City/ 
Coralville Visitors and Convention Bureau, University Relations 
Office of the University of Iowa, Iowa City Jazz Festival, Iowa 
Arts Festival, Englert Civic Theatre Association, Iowa City 
Public Library, city of Iowa City Planning Department, Inner 
Ear Theatre, Riverside Theater, and the Public Art Program 
advisory committee.
    Delta State University in Cleveland, Ohio received funding 
to support a series of arts education professional development 
workshops for arts educators at the Bologna Performing Arts 
Center. With instructors drawn from both local arts 
organizations and from the Kennedy Center for the Arts 
``Partners in Education'' program, the primary intent of the 
workshops is to provide tools for public school teachers to 
more effectively incorporate the arts into existing school 
curricula. Parnters include: Bolivar Regional Medical Center, 
Region I Mental Health Department, Delta Area Association for 
the Improvement of Schools, Benoit School District, North 
Bolivar School District, Washington County School District, 
Mississippi Alliance for Arts Education, Crossties Arts 
Council, Greenville Arts Council, the AmeriCorps Program at 
Delta State University's Center for Community Development, 
DSU's Department of Education, Junior Auxiliary of Cleveland, 
and King's Daughters Hospital Social Services Department.
    Elders Share the Arts of Brooklyn, New York was awarded 
funding to support a Creative Links project. The partnership 
brings together Union Settlement Association to support the 
intergenerational after-school program Living History, which 
pairs teens in East Harlem with older adults who are unable to 
attend programs and live at home. The students in this project 
work with two professional artists to transform the elders' 
oral history into exhibited artworks. Twenty-one students, ages 
14 to 16, and 12 to 20 elders will work together to create an 
exhibition at Union Settlement s Community Gallery.
    El Puente de Williamsburg, Inc. in Brooklyn, New York was 
awarded a grant to support a Creative Links project that 
involves a partnership with the Los Sures Senior Citizen Center 
for Recipe for Cultural Wellness. This program brings together 
approximately 30 low-income youth, ages 12 to 21, and 20 older 
adults in the Latino community to create a mural, theatrical 
presentation, and documentary video around the theme of food 
and cultural wellness, utilizing the tradition of oral history 
and the rituals of cooking.
    Greater Akron Musical Association, Inc. in Akron, Ohio 
received funding to support a Creative Links project. Musicians 
from the Akron Symphony and Omo Iroko Dance Society provide 
lessons in Trinidadian steel drum and African drum playing for 
middle school students participating in a health program for 
youth of the Children's Hospital Center of Akron. The youth 
then teach drum playing to older adults at the Akron 
Metropolitan Housing Authority s Saferstein Towers.
    Maine Indian Basketmakers Alliance in Old Town, Maine 
received a grant to support a Creative Links project. The 
partnership brings together the Passamaquoddy Tribe to organize 
and lead traditional basketry workshops in four reservation 
communities in Maine. The program seeks to encourage younger 
generations of tribal members to learn traditional ash and 
sweetgrass basketry to preserve this endangered traditional 
Native American art form.
    VSA arts of Michigan in Detroit, Michigan received a grant 
to support a Creative Links project. The partnership brings 
together The Arc Detroit, Great Lakes CIL, Detroit Institute of 
Art, Wayne State University, Michigan Rehabilitation Services, 
Detroit Public Schools and the Center for Creative Studies to 
provide after-school vocational training and creative 
opportunities in visual arts, conducted by professional artists 
of all ages with disabilities for 30 teens with disabilities.

                               Literature

                         literature fellowships

    Three literature fellowships were awarded to individual 
writers over the age of sixty-two.
        Rosa Shand of Spartanburg, South Carolina, currently 
        Professor of English at Converse College, has published 
        short fiction in literary journals such as The Virginia 
        Quarterly Review, The Massachusetts Review, and The 
        Indiana Review. Her first novel, The Gravity of 
        Sunlight, was released by Soho Press in the summer of 
        2000. The recipient of artist residencies at Yaddo and 
        the MacDowell Colony, she was awarded an Arts Endowment 
        Creative Writing Fellowship in Fiction in 2000.
        Margaret E. W. Jones of Lexington, Kentucky holds the 
        Chair of the Department of Spanish at the University of 
        Kentucky. She is a widely published translator of 
        Spanish fiction and essay, and author of numerous 
        scholarly books and articles on contemporary Spanish 
        literature and feminism. She was awarded a 2000 
        Fellowship in Translation from the NEA to support the 
        translation of a book-length essay by Carmen Martin-
        Gaite.
        Donald A. Yates of St. Helena, California is retired 
        Professor Emeritus of Spanish American Literature at 
        Michigan State University. His translations include: 
        Labyrinths: Selected Writings of Jorge Luis Borges, the 
        first collection of Borges' work to appear in English; 
        and novels by Argentinian authors Manuel Payrou, Marco 
        Denevi, and Adolfo Bioy Casares. He was awarded a 2000 
        Fellowship in Translation from the Arts Endowment to 
        support the translation of the complete works of 
        Argentinian novelist Edgar Brau.

                           literature grants

    Curbstone Press, Inc. of Willimantic, Connecticut received 
funding to support the Windham Area Poetry Project, a program 
of readings and writing workshops serving immigrant 
communities, senior care homes, juvenile homes, prisons, social 
service organizations and public schools in northeastern, rural 
Connecticut.

                           Local Arts Agency

    Burklyn Arts Council in Lyndonville, Vermont was awarded a 
grant to support ticket subsidies for school children and older 
adults to attend area performances and exhibitions. The arts 
events are sponsored by Catamount Arts, a major presenter of 
regional artistry, with scheduled performances by folk 
musicians Peter Ostroushko and Dean McGraw, actress Billie Jean 
Young in a one woman show, jazz artist David Liebman, and the 
Perlman-Nikkanen-Bailey Trio, a chamber music ensemble.

                                 Media

    Hot Springs Documentary Film in Hot Springs, Arkansas 
received a grant to support educational activities during the 
2000 Hot Springs Documentary Film Festival. These include 
symposia, forums, discussion groups, and special programs for 
children and older adults.
    L.A. Theatre Works in Los Angeles, California was awarded a 
grant to support the distribution of up to five audio plays to 
hundreds of underserved libraries, including facilities that 
serve blind and visually impaired people. In addition, L.A. 
Theatre Works is providing the organizations with print 
materials (large print and recorded versions for visually 
impaired people) to augment the collection.
    Washington, DC International Film Festival received a grant 
to support the Washington, DC International Film Festival. Held 
annually in the spring, this event includes free films for 
children, older adults, and underserved communities.

                           Multidisciplinary

    ARTREACH Inc. in Philadelphia, Pennsylvania received 
funding to support the development and distribution of a 
``Cultural Access Guide for the Disabled.'' This resource guide 
includes comprehensive information about access to buildings, 
programs, and services offered to people with disabilities by a 
number of cultural venues in a tri-state region of 
Pennsylvania, Delaware, and southern New Jersey.
    Elders Share the Arts in Brooklyn, New York received a 
grant to support their consortium project, the Center for 
Creative Aging. The project supports program maintenance and 
expansion in up to five cities Boston, Miami, New York, 
Philadelphia, and San Francisco.
    Little City Foundation of Palatine, Illinois received 
funding to support Have Art, Will Travel, a series of traveling 
arts classes that serve children and adults of all ages with 
developmental disabilities where they live and work. Artist 
teachers equipped with movable art materials offer classes in 
visual, performing, and media arts.
    VSA Arts of Massachusetts in Boston, Massachusetts received 
funding to support the National Cultural Access Initiative. 
This initiative works with each state to provide local 
infrastructure for people of all ages with disabilities and the 
cultural organizations of their communities.

                                 Music

                   american jazz masters fellowships

    Three American Jazz Masters fellowships were awarded to 
older artists in recognition of their contributions to the 
field of Jazz.
        John Lewis of New York City, as pianist, composer/
        arranger, and music director of the Modern Jazz Quartet 
        (formed in 1952), became the architect of a unique 
        sound in the history of jazz, and was instrumental in 
        greatly expanding the audiences for jazz. In the 1950's 
        and 60's he assisted in the establishment of the Jazz 
        and Classical Music Society and Orchestra USA. The 
        latter ensemble performed and recorded ``third-stream'' 
        compositions the merging of traditional jazz and 
        European Classical forms of composed music. He has held 
        teaching positions at City College of New York and at 
        Harvard University. Leonard Feather wrote in the 
        Encyclopedia of Jazz, ``John Lewis is regarded as one 
        of the most brilliant minds ever applied to Jazz.''
        Jackie McLean of Hartford, Connecticut was raised in 
        Harlem's Sugar Hill district, and began playing alto 
        saxophone at age 15. He developed his talents to become 
        one of the true masters of his instrument and the 
        ``free'' jazz sound evolving from bebop. In 1970 he and 
        his wife Dollie established the Artists Collective, 
        Inc., a cultural center that uses arts education for 
        social improvement for the inner-city youth. Mr. McLean 
        also teaches at the Hartt College of Music at the 
        University of Hartford, where he developed the jazz 
        degree program and is chairman of the African American 
        Music Department.
        Randy Weston of Brooklyn, New York remains one of the 
        world's foremost pianists and composers today, a true 
        innovator and visionary. A disciple of Duke Ellington 
        and his music, Mr. Weston's formative years were shaped 
        by his mentorship with Thelonious Monk. Visiting parts 
        of Africa in the early 60's and finally settling in 
        Rabat, Morocco in 1968, his artistry became infused 
        with the continent's music and its rhythms. Many of his 
        works have become indelible jazz standards. In addition 
        to being a master jazz artist, Mr. Weston is a pioneer 
        in recognizing important cultural connections and he 
        continues to demonstrate ways to erode barriers that 
        separate nations.

                              music grants

    Cedar Rapids Symphony Orchestra in Cedar Rapids, Iowa 
received a grant to support the education program, ``Creating 
the Future: a Plan for the New Millennium.'' In 2000-01, the 
program's many components include an enrichment program for 
third graders; music education in an older adults housing 
complex; after-school music lessons for students in grades 
three through five; a video broadcast of interactive, 
educational programs to Iowa schools; an early childhood 
education program for families with special needs and ``at 
risk'' children; and music education enhancements in four area 
colleges.
    Composers Conference and Chamber Music Center, Inc. in 
Wayland, Massachusetts was awarded funding to support a 
composer's project enabling young composers to study with 
senior composers and musicians, and for concert presentations 
and recordings of their work by new music experts at Wellesley 
College. Ten young composers, selected by a professional jury 
from an applicant pool of about 100, participated in this 
project, part of the 56th Annual Composers Conference from July 
23 to August 6, 2000.
    Concord Community Music School (CCMS) in Concord, New 
Hampshire received a grant to support the ``Music in the 
Community Initiative,'' providing rural and underserved 
communities with music education opportunities. Statewide in 
scope, the initiative is taking place through partnerships with 
schools, senior centers, human service agencies, pre-schools 
serving at-risk families, and mental health centers during 
2000-01.
    Houston Symphony Society in Houston, Texas received a grant 
to support ``Music Matters: Community Connections,'' an 
outreach project for underserved communities. During 2000-01, 
the Houston Symphony's musicians is performing at various 
sites, including nursing homes, community centers, hospitals, 
and schools.
    Music & Arts Center for the Handicapped, Inc. in 
Bridgeport, Connecticut was awarded funding to support access 
to music education for visually impaired people of all ages. 
During 2000-01, the Music & Arts Center for the Handicapped is 
providing training to music teachers in Braille music and in 
the use of computer music technology, including workshops held 
during various national education conferences.
    Rhode Island Philharmonic in Providence, RI was awarded a 
grant to support ``Music After Hours,'' a consortium project 
with the Music School. During 2001, the Rhode Island 
Philharmonic and the Music School will provide after-school 
music education programs to children in grades three to five, 
particularly youths at risk, and senior adults.

                            Musical Theater

    Children's Theatre of Cincinnati in Cincinnati, Ohio 
received funding to support sign language interpretation and 
pre-production expenses of a commissioned work entitled ``The 
Beethoven Symphony.'' The Children's Theatre of Cincinnati will 
develop and co-produce the new work with the National Theatre 
of the Deaf of Chester, CT, composed by adults of all ages.

                                 opera

    New Cleveland Opera Company in Cleveland, Ohio received 
funding to support the company's education program encompassing 
in-school residencies, student/artist opera productions, and 
student/senior service center partnerships. The program also 
includes a year-long Music! Words! Opera! project for 
elementary and middle-school students, and Great Works-teacher 
and artist-led activities that prepare students in grades 6 
through 12 to attend the Cleveland Opera matinee performances.
    Opera Association of Central Ohio in Columbus, Ohio 
received a grant to support the company's educational programs, 
with emphasis on longer-term residencies and the integration of 
opera programming into the classroom curriculum. The touring 
component of Opera/Columbus's education department is 
conducting as many as 200 educational events in churches, 
classrooms, community centers, and senior living-facilities 
during 2000-01.

                                Theater

    Indiana Repertory Theatre, Inc. in Indianapolis, Indiana 
received funding to support the development of a co-
commissioned play in consortium with the People's Light & 
Theatre Company of Malvern, PA. The play, by James Still, 
explores the 20th century through the eyes of three 
generations.
    New York Deaf Theatre, Ltd. of New York City was awarded a 
grant to support the development and production of a play 
written by deaf playwright Harrison Lewis. The production is 
titled ``Remembrance of an Alumni Room.'' Playwrights Project 
of San Diego, California received funding to support the 
expansion of Lifestages, a program that creates theatre from 
the life experiences of older people. Older adults in 
convalescent hospitals or residences are paired with 
professional actor/writers to create and perform 
autobiographical vignettes from their lives.
    Stagebridge of Oakland, California received funding to 
support expenses associated with an intergenerational literacy 
project. Storybridge brings young and old together through 
theater and storytelling to teach language, reading, 
interpersonal, and artistic skills.
    Theater By The Blind Corporation in New York, New York 
received a grant to support their continuing education of blind 
and visually impaired actors through a series of reading 
projects. Theatre By The Blind has established a text/script 
reading service for blind and visually impaired actors that 
culminates in public staged readings of scripts.

                              Visual Arts

    Grass Roots Art and Community Effort of Hardwick, Vermont 
received funding to support community art workshops for 
residents in rural and economically distressed areas of 
Vermont. Designed to reach a diverse spectrum of the community 
including older adults and developmentally disabled adults and 
children, the project builds on a 16-year history of workshop 
opportunities.
    St. Mark's Church in-the-Bowery in New York City was 
awarded a grant to support workshops and exhibitions in 
photography, video, and Web site design for youths and seniors 
residing on New York's Lower East Side. The project is part of 
``The Diary Project,'' an international exchange program 
between schools in the United States, Kenya, and South Africa.

             ITEM 24--NATIONAL ENDOWMENT FOR THE HUMANITIES

                              ----------                              


Report on Activities Affecting Older Americans in Fiscal Years 1999 and 
                                  2000

                           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 purposes 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 lifelong learning opportunities for everyone, of whatever 
age.
    Guaranteeing the availability of these 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 almost 13 percent, will rise to 20 percent by 
2030. 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; 67 percent of Americans 65 or older 
have at least a high school diploma, and nearly 15 percent have 
completed four years of college. The Census Bureau projects 
that, by 2030, 83 percent of retirement-aged Americans will be 
high school graduates and 24 percent will have a bachelor's 
degree.
    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.

                              oral history

    In November 1999, just in time for the Thanksgiving 
holiday, the Endowment and the White House Millennium Council 
launched My History is America's History, a nationwide family 
history initiative. Through a widely distributed guidebook and 
an interactive website (myhistory.org), the project details 
fifteen things anyone can do to preserve America's stories. 
There are easy-to-follow instructions for conducting oral 
history interviews with elderly relatives; preserving and 
researching family photographs, letters, and other treasures; 
constructing a family tree; exploring hometown history; and 
connecting family stories with the larger narrative of American 
history. Visitors to the website are encouraged to post 
favorite family stories that have been told and retold across 
generations. Stories so far posted include ``My Grandfather's 
World War II Story,'' ``Myrtle May Campbell and the Choctaws,'' 
and ``Roosevelt Cookies.''
    During the past two fiscal years, the Endowment has 
supported many oral history projects that are helping to save 
America's stories, even as they strengthen intergenerational 
and community ties. For example, the Jewish Women's Archive in 
Brookline, Massachusetts received two grants totaling $50,797 
to plan Weaving Women's Words, an effort that will create a 
web-based archive of oral histories that record the lives of 
American Jewish women as they have been lived in Seattle, 
Baltimore, and Omaha during the 20th century. Two small grants 
were awarded to preserve and catalogue oral history collections 
at the Centro Alameda in San Antonio, Texas, and at Fort 
Berthold Community College, a tribal institution in North 
Dakota. Three projects in Alaska received grants of $10,000 to 
support the collaborative efforts of scholars and Aleut, Minto 
Athabascan and Tlingit elders to document Native American 
traditions. Grants of $10,000 were awarded to the Wing Luke 
Asian Museum of Seattle to plan the public interpretation of 
Chinese-American artifacts and oral histories and to the 
University of Guam to plan oral history interviews and public 
presentation on Guamanian history. The state humanities 
councils in Texas and Ohio each received a grant of $20,000 for 
state-wide oral history projects. And, the Community College 
Humanities Association is using an NEH grant of $280,367 to 
support Faces of America: Photographs and Memory. At a series 
of forums in 30 communities nationwide, scholars and members 
the public will discuss family photographs contributed by the 
participants, relating each to the broader contexts of local 
and national history.

                            library programs

    During fiscal years 1999 and 2000, 3,200 NEH-supported 
reading and discussion programs took place in 800 libraries and 
other community-based institutions nationwide, attracting 
approximately 6 million participants. Intellectually and 
socially engaging activities such as these are open to the 
general public, but the scholars and other specialists who 
direct them report especially strong participation by older 
Americans.
    Most NEH-supported reading and discussion programs are 
geared to intergenerational audiences. 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 
may have few other sources of cultural enrichment. In FY1999, 
National Video Resources, Inc. received $282,000 to produce two 
series of film discussion programs at 45 sites throughout the 
United States. Entitled From Rosie to Roosevelt: A Film History 
of Americans in World War II and Post War Years, Cold War 
Fears, the six-week programs were conducted at each location by 
a scholar who led the participants in discussions of selected 
documentary films and readings including specially commissioned 
essays by John Morton Blum, Sterling Professor of History at 
Yale University, and Leon Litwack, Morrison Professor of 
History at the University of California, Berkeley. In FY2000, 
the American Library Association received $245,000 for a 
project on American regional literature that--in tandem with a 
series of library-based reading and discussion programs--will 
feature thirteen, one-hour call-in programs on public radio. 
Libraries in eight Midwestern states make available extra 
copies of books by such regional authors as Carl Sandburg, 
Sherwood Anderson, Richard Wright, Jane Smiley, and Toni 
Morrison. Listeners over a broad geographic area will hear a 
panel of scholars discuss these and other books, and then will 
have an opportunity to call in questions and reactions via a 
toll-free 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 burgeoning 
phenomenon 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, 28 percent 
of adults aged 65 to 74 visited an art museum at least once 
during a 12-month period (1997). Attendance by adults aged 75 
and older was nearly as great (20 percent percent). Impressive 
as these figures are, they do not take account of the 
additional numbers of older Americans who visited historical 
and other kinds of museums.
    At any time during FY 1999 and FY 2000, approximately 120 
different, NEH-funded museum exhibitions could be seen at 
locations in each of the fifty states and the District of 
Columbia. 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.
    Your Place in Time: 20th Century America, supported with an 
NEH grant of $151,029 to the Henry Ford Museum & Greenfield 
Village, was expressly created by for intergenerational 
audiences. At the museum's Dearborn, Michigan, site and at 
shopping malls and other public places where a traveling panel 
version of the exhibition was shown, visitors were invited to 
explore five venues: ``The Progressive Generation,'' ``The War 
Generation,'' ``Baby Boomers,'' ``Generation X,'' and ``The 
Next Generation.'' Each venue employed artifacts and 
interactive displays to convey the impact of technology on the 
lives of a generation that came of age during the 20th century. 
The Lower East Side Tenement Museum in New York City received 
$197,553 to recreate a 19th-century sweatshop on its original 
site and interpret the lives of the owners and the immigrant 
laborers who worked there. Through an authentically recreated 
environment and the stories of real individuals, the exhibition 
will vividly bring to life the history of immigration and the 
garment industry in New York.
    NEH exhibitions are not limited to urban areas. It funds 
exhibitions accessible to those living in rural communities as 
well. 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 grant from NEH, the exhibition has been 
touring small rural museums and historical societies since 
1996.

                        television documentaries

    Public television reaches virtually every community and 
home in the United States. During 1999 and 2000, millions 
across the country watched such NEH-funded documentaries as 
MacArthur and Eleanor Roosevelt, both of which were broadcast 
on ``The American Experience.'' For seniors who have limited 
mobility or who simply prefer to stay home, rewarding and 
engaging viewing choices such as these provide opportunities 
for them not only to engage in learning, but to share in a 
history in which they themselves lived and remember.

                            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 1997, according to the NEA-commissioned survey 
Arts Participation in America, 37 percent of American 65 to 74 
visited an historical park at least once, and 25 percent of 
those between 75 and older did so.
    Two examples of grants awarded during fiscal years 1999 and 
2000 suggest the range of NEH-supported projects underway, in 
communities large and small, to reclaim our historic places. 
Historic Hudson Valley of Tarrytown, New York, received 
$300,008 to implement new interpretive tours of Philipsburg 
Manor, the site of a working 18th century farm and mill. The 
redesigned tours will incorporate new research about the lives 
of African-American slaves who operated the mill circa 1750, 
shedding light on the little understood story of slavery in the 
North during the pre-Revolutionary period. The Dubuque County 
Historical Society received $100,530 to implement a new 
interpretive plan at the Mississippi River Museum in Dubuque, 
Iowa. The new exhibition will include a reconstruction of the 
Dubuque Boat and Boiler Works, which once stood on the museum's 
river-front site.

                            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 happily 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. Among the senior scholars whose work NEH research 
grants supported during fiscal years 1999 and 2000 were Ehsan 
Yarshater of Columbia University, editor of the Encyclopaedia 
Iranica, an internationally renowned resource on the history 
and culture of a vast area that encompasses much of the Middle 
East, Central Asia, and the Indian subcontinent; and 
independent scholar Frederick Burkhardt, who under the auspices 
of the American Council of Learned Societies is compiling an 
edition of the correspondence of Charles Darwin.

                           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--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 the 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--PENSION BENEFIT GUARANTY CORPORATION

                              ----------                              


               Message from the Executive Director (1999)

    We recently marked the 25th anniversary of the Employee 
Retirement Income Security Act of 1974 and the Pension Benefit 
Guaranty Corporation. In looking forward to the next 25 years, 
we should not forget the lessons of the first 25 years. Defined 
benefit plans have been and must continue to be an important 
part of the retirement income security for working Americans. 
PBGC has played and will continue to play a crucial role in 
protecting benefits. And, while PBGC is in a strong financial 
condition today, we must always remain vigilant.
    I am proud of the role that the Pension Benefit Guaranty 
Corporation has played in protecting the retirement income of 
American workers and retirees. PBGC has paid benefits without 
interruption to hundreds of thousands of individuals whose 
pension plans terminated without adequate assets. The PBGC 
guarantee makes a real difference in people's lives. I attend 
virtually every meeting that PBGC conducts for participants in 
terminated plans, and I have seen the look of relief on 
thousands of faces when we tell them their benefits are 
protected.
    Today, PBGC is responsible for the pensions of more than a 
half million people in almost 2,800 PBGC-trusteed plans, and 
they are our priority. These individuals, and the sponsors of 
the 40,000 ongoing defined benefit plans, are PBGC's customers.
    PBGC must be a premier customer service organization for 
our customers. We have taken a new look from a customer service 
viewpoint at everything we do--from our computer systems to our 
regulations to how we respond to phone calls. We have made many 
changes as a direct result of customers' comments and 
suggestions. The ``Listening to Our Customers'' section of this 
Report describes many of the changes we have made.
    I am committed to satisfying our customers' changing needs 
and expectations. PBGC maintains a continuing dialogue with our 
customers, through focus groups, surveys, and meetings, to 
assess how well we are doing and to identify where we must make 
further improvements. We want our customers to be delighted 
with the level of service we provide. We will be satisfied with 
no less.
                                          David M. Strauss,
                                                 Executive Director

                       Listening to our Customers

    Today, we live in an era of rising customer expectations. 
Excellent customer service is no longer discretionary. 
Businesses must not only provide quality products, they must 
also provide excellent customer service.
    Based on the best practices of private-sector businesses, 
the federal government has adopted a set of customer service 
principles:
           Identify your customers;
           Ask your customers what they want;
           Set standards so people know what to expect; 
        and
           Measure and publicize the results.

                     pbgc's customer service pledge

    Our customers deserve our best effort as well as our 
respect and courtesy.
    On the first call from you, our customer, we will say:
           what we can do immediately and what will 
        take longer,
           when it will be done, and
           who will handle your request.
    We will call you if anything changes from what we first 
said, give you a status report, and explain what will happen 
next.
    We will have staff available from 8:00 a.m. - 5:00 p.m. 
Eastern time to answer your calls. If you leave a message, we 
will return the call within one work day.
    We will acknowledge your letter within one week of receipt.
    PBGC has put these principles into practice. The agency has 
opened a continuing dialogue with its customers--participants 
in PBGC-trusteed plans, and sponsors of PBGC-insured plans and 
the pension professionals who assist them. Over the last few 
years, PBGC has conducted numerous focus groups with, and 
annual surveys of, both participants and practitioners. Through 
these focus groups and surveys, PBGC asks its customers about 
the quality of the agency's service and how that service can be 
improved.
    Under its ongoing Reach for Excellence and Customer 
Happiness (REACH) initiative, PBGC used interdepartmental teams 
of employees to translate the focus group and survey findings 
into service improvements. As a result of participant 
suggestions, PBGC made system enhancements in the Customer 
Service Center to allow PBGC's customer service representatives 
to take routine changes over the telephone and update 
participant records more efficiently. The agency also 
simplified the benefit application requirements to make it 
easier for participants in PBGC-trusteed plans to apply for 
benefits.
    PBGC continued to provide easy-to-find information for its 
customers on its website at www.pbgc.gov. The on-line Pension 
Search Directory, www.search.pbgc.gov, simplifies the search 
for missing plan participants. During the year, PBGC issued a 
new publication, ``Finding A Lost Pension,'' to help people 
expand the search for missing pensions from former employers.
    In addition, PBGC improved the nature and frequency of its 
communications with participants. The agency rewrote 
publications and most of its standard letters in plain 
language. A team of PBGC employees developed a new package of 
materials that will improve initial communications with 
participants in newly trusteed plans. PBGC also redesigned the 
newsletter for participants who have not yet begun receiving 
benefit payments and began sending the newsletter semiannually 
instead of annually to keep participants better informed about 
the pension insurance program and their benefits. In addition, 
the agency began developing systems that will make it possible 
to provide participants with benefit estimates upon request. To 
capture the agency's attitude toward customer service, PBGC 
employees came up with a new slogan, ``Working together to 
guarantee your future,'' that encourages a relationship between 
the agency's staff and participants.
    PBGC also held 21 information sessions across the country 
for participants in newly trusteed plans. About 1,600 plan 
participants attended. These meetings help allay participant 
concerns and explain PBGC's insurance. Executive Director David 
Strauss attended each of the sessions to meet the participants 
and answer their questions.
    As a result of suggestions in the first round of 
practitioner focus groups, PBGC simplified the standard 
termination process. Practitioners told us that this is a big 
improvement. PBGC also issued a new publication to help small 
businesses understand their responsibilities under the pension 
insurance program.
    In 1999, PBGC made further significant changes based on 
what customers have told us. The agency moved the premium 
filing date to October 15 for calendar year plans to make it 
coincide with the filing date for the Form 5500 (with a 
parallel change for non-calendar year plans). Practitioners 
told us that this saves time and money. Practitioners also 
called for improvements in the processing of premium refunds 
and requests for waivers of premium penalties; PBGC initiated 
an aggressive effort to address pending refund and waiver 
requests and, by the end of the year, was processing these 
requests typically within 90 days of receipt.
    Other measures adopted during the year included rewriting 
premium-related form letters in plain language to make them 
easier to understand and a regulatory change that would provide 
additional relief from penalties imposed for late payment or 
underpayment of premiums.

                           problem resolution

    Participants in PBGC-trusteed plans may reach PBGC's 
Participant Problem Resolution Officer by calling 1-800-400-
PBGC or by e-mail at [email protected].
    Plan sponsors, plan administrators, and pension 
professionals may reach PBGC's Practitioner Problem Resolution 
Officer by calling 1-800-736-2444 (202-326-4242 if in the 
Washington, DC, metropolitan area) or by e-mail at 
[email protected].
    TTY/TDD users may call the Federal relay service toll-free 
at 1-800-877-8339 and ask the communications assistant to 
connect them to the appropriate telephone number.
    PBGC also made it easier for customers to get in touch with 
the agency. This year, PBGC set up a toll-free number, 1-800-
736-2444, for practitioner questions about premiums, standard 
terminations, and plan coverage. PBGC already had set up a 
toll-free number, 1-800-400-PBGC, for participant questions 
about benefits. In addition, PBGC now has two problem 
resolution officers, one for plan participants and another for 
practitioners, who can be reached through the toll-free 
numbers.
    PBGC's annual practitioner and participant surveys measure 
overall satisfaction with service and help PBGC track how well 
it has been doing. According to the most recent completed 
surveys, 70 percent of participants and 66 percent of 
practitioners rated PBGC's service as ``above average'' or 
``outstanding.'' Under the agency's five-year strategic plan, 
the goal is for 90 percent of participants and 81 percent of 
practitioners to rate PBGC's service as ``above average'' or 
``outstanding.''
    To help reach its service goals, PBGC instituted a ``one-
call'' approach. This means that PBGC staff will return phone 
calls within 24 hours. We will either answer the question with 
that first phone call, or we will let the customer know who 
will handle the problem and when an answer can be expected. If 
it is found that a request is going to take longer to answer 
than initially thought, we will call back to keep the customer 
informed of our progress. PBGC continues to explore ways to 
expand use of electronic communications to enhance service to 
plan participants, plan sponsors, and pension practitioners.
    PBGC is committed to being a premier customer service 
organization--for participants who depend on the agency for 
their pension benefits as well as for plan sponsors and the 
pension professionals who assist them. PBGC will continue its 
dialogue with customers through focus groups and surveys. We 
want and need their input on what is working and what needs 
improvement, so that we can meet their changing needs and 
expectations.

                          Protecting Benefits

    In 1999, PBGC assumed responsibility for the pensions of 
tens of thousands of additional people even though the pace of 
plan terminations slackened. The agency continued to issue 
benefit determinations at near-record levels. The separate 
multiemployer program again received relatively few requests 
for financial assistance but provided a far larger amount of 
assistance than in any other year since the current program's 
creation in 1980.

                        single-employer program

    Through its single-employer program, PBGC oversees 
terminations of fully funded plans and guarantees payment of 
basic pension benefits when underfunded plans must be 
terminated. The single-employer program covers nearly 34 
million workers and retirees in about 38,000 plans.
    During 1999 the agency completed the termination of 122 
underfunded plans, the vast majority of which were involuntary 
terminations by PBGC. In most cases termination was necessary 
because the sponsoring employer had gone out of business, 
sometimes in earlier years.
    After a plan has terminated, PBGC becomes trustee of the 
plan and administers benefits. During 1999, PBGC became trustee 
of 130 single-employer plans covering more than 50,000 people. 
At yearend, the agency was in the process of trusteeing an 
additional 48 plans terminated in 1999 or earlier. In all, 
including 10 multiemployer plans previously trusteed, PBGC was 
(or was becoming) trustee of a total of 2,785 terminated plans 
as of the end of the year. (This total also reflects the 
elimination of two single-employer plans included in last 
year's total, which no longer required PBGC to become trustee. 
One plan was converted to a standard termination; the 
termination of the other plan was cancelled.)
    Benefit Processing.--By the end of the year, PBGC was 
responsible for the current and future pension benefits of 
about 532,000 participants from single-employer and 
multiemployer plans. These included 214,890 retirees who 
received benefit payments totalling $902 million.
    In 1999, PBGC issued nearly 67,700 benefit determinations, 
marking the fifth straight year that the agency has produced 
more than 60,000 determinations. PBGC routinely pays benefits 
in estimated amounts until final determinations are completed. 
In the vast majority of cases, participants' final 
determinations were within 5 percent of their estimated 
benefit.
    PBGC has now completed benefit determinations for virtually 
all plans trusteed prior to 1994. The average age of unissued 
benefit determinations is down to 2.3 years, reflecting the 
fact that most pending determinations are for plans trusteed 
within the past two to three years. On average, in 1999 PBGC 
issued final benefit determinations 5.7 years after the date it 
had trusteed the participant's plan. The age of the 
determinations met the performance goal of 5-6 years set for 
1999 under PBGC's strategic plan.
    PBGC's Customer Service Center for participants in trusteed 
plans continued to handle a high volume of calls. During the 
past year, the center handled, on average, more than 21,400 
calls each month, spending about 2\1/2\ minutes per call. 
Another 504,000 calls were answered with automated information.
    Appeals Processing.--PBGC's Appeals Board reviews appeals 
of certain PBGC determinations. Most of the appeals are from 
people disputing their benefit determinations. Typically, about 
2 percent of all benefit determinations are appealed. During 
1999, the Appeals Board received 1,550 appeals. The Board 
decided 2,005 appeals during the year, more than twice the 
number of appeals closed in any prior year, and reduced its 
open case inventory by 10 percent.
    Standard Terminations of Fully Funded Plans.--The number of 
standard terminations continued to decline from their peak of 
about 11,800 in 1990, with 1,969 submitted to PBGC in 1999. 
Most of these plans had 50 or fewer participants.
    As a result of the agency's 1997 revisions to the standard 
termination regulation, PBGC is finding a higher rate of 
compliance with legal requirements, and very few errors or 
omissions that might force cancellation of a termination. The 
agency's increased flexibility in addressing administrative 
errors, in particular, is helping to avert many of the problems 
filers experienced in years past. In 1999, four terminations 
had to be cancelled for failure to comply with legal 
requirements, compared to 24 such cases in 1998 and 118 in 
1997.
    PBGC audits a statistically significant number of completed 
terminations to confirm compliance with the law and proper 
payment of benefits. These audits generally have found few and 
relatively small errors in benefit payments, which plan 
administrators are required to correct. The errors arise 
primarily from use of incorrect interest-rate assumptions in 
valuing lump-sum distributions to plan participants. Due to 
PBGC's audits, in 1999 some 4,500 participants (about 5 percent 
of all participants in audited plans) received about $2.7 
million of additional benefits.
    Pension Search Program.--PBGC's Pension Search Program 
consists of three separate, coordinated efforts to locate 
missing people owed a pension by a terminated plan. 
Historically, the agency has conducted extensive searches for 
people missing from underfunded pension plans for which PBGC 
has taken responsibility. Since January 1996, PBGC also has 
provided a ``missing participants clearinghouse'' to assist 
employers terminating fully funded plans; if an employer is 
unable to locate a former employee, PBGC will accept payment 
for the benefit and continue searching for the person to allow 
the employer to complete the termination. As a last means of 
finding people who have frustrated all previous searches by 
either their former employer or by PBGC, the agency has 
maintained a Pension Search listing on the Internet since 
December 1996. These efforts have helped PBGC locate thousands 
of people who were unaware they were owed a pension benefit.
    During 1999, 417 companies asked the clearinghouse to find 
5,611 missing people, some 4,500 of whom were due benefit 
payments totalling nearly $7.8 million. The other 1,100 people 
were covered by annuity contracts that will pay their benefits 
when they are found. PBGC was able to confirm addresses for 952 
of the missing people and to pay 706 of them nearly $2.1 
million in benefits. The Internet listing helped PBGC find 351 
other people who were owed about $1 million.
    The total Internet list, which included people PBGC was 
unable to find through the clearinghouse, identified almost 
9,900 people who were owed more than $19 million in pension 
benefits. Since inception, PBGC's Internet pension search has 
helped 1,745 people obtain more than $5 million in owed 
benefits plus interest. The Internet listing is found at http:/
/search.pbgc.gov.

                         multiemployer program

    The multiemployer program, which covers about 8.8 million 
workers and retirees in about 1,800 insured plans, is funded 
and administered separately from the single-employer program 
and differs from the single-employer program in several 
significant ways. The multiemployer program covers only 
collectively bargained plans involving two or more unrelated 
employers. For such plans, the event triggering PBGC's 
guarantee is the inability of a covered plan to pay benefits 
when due at the guaranteed level, rather than plan termination 
as required under the single-employer program. PBGC provides 
financial assistance through loans to insolvent plans to enable 
them to pay guaranteed benefits.
    Financial Assistance.--The multiemployer program continues 
to receive relatively few requests for financial assistance. 
Since 1980, PBGC has provided assistance to only 23 of the 
1,800 insured plans, with a total value of approximately $57 
million net of repaid amounts. In 1999, 21 of these plans 
received assistance totalling about $19 million, including a 
one-time payment of about $14 million to a terminated insolvent 
plan that merged into a large national plan during the year. 
PBGC's payment to the terminated plan facilitated the merger. 
As a result of the merger, retirees had their benefit levels 
restored and participants once again are earning benefits in an 
ongoing plan.

                Trends in Defined Benefit Pension Plans

    Since the early 1980s, there has been a gradual shift away 
from defined benefit pension plans in the private sector. The 
number of PBGC-insured defined benefit plans peaked in 1985 at 
about 112,000. Since then there has been a sharp decline to 
about 40,000 plans in 1999.
    This reduction has not been proportional across all plan 
sizes. Plans with fewer than 100 participants have shown the 
most marked decline, from about 90,000 in 1985 to less than 
24,000 in 1999. There also has been a sharp decline for plans 
with between 100 and 999 participants, from more than 19,000 in 
1985 to about 11,000 in 1999.
    In marked contrast to the trends for plans with fewer than 
1,000 participants, the number of plans with more than 1,000 
participants has shown modest growth. Since 1980, the number of 
plans with between 1,000 and 9,999 participants has grown by 
about 6 percent, from 4,017 to 4,257 in 1999. The number of 
plans with at least 10,000 participants has grown from 469 in 
1980 to 749 in 1999, an increase of nearly 60 percent.
    The growth in the number of large plans is attributable to 
two factors. First, the rapid increase in inactive participants 
(retirees and separated vested participants) has pushed some 
plans into higher size categories. Second, there has been 
considerable plan merger activity over the thirteen-year period 
from 1985 through 1997.
    In contrast to the dramatic reduction in the total number 
of plans, the total number of participants in PBGC-insured 
defined benefit plans has shown modest growth. In 1980, there 
were 35.5 million participants. By 1999, this number had 
increased to almost 43 million.
    These numbers, however, mask the downward trend in the 
defined benefit system because total participants include not 
only active workers but also retirees (or their surviving 
spouses) and separated vested participants. The latter two 
categories of participants reflect past coverage patterns in 
defined benefit plans. A better forward-looking measure is the 
trend in the number of active participants, workers currently 
earning pension accruals. Here, the numbers continue to 
decline.
    In 1988, there were 27.3 million active participants in 
defined benefit plans; by 1996 (the latest data available), 
this number had fallen to 22.6 million, a decrease of more than 
17 percent. At the same time, the number of inactive 
participants has been growing. In 1980, inactive participants 
accounted for only 23 percent of total participants in defined 
benefit plans. By 1988 this number had increased to 31 percent; 
and by 1996, more than 45 percent of the participants in 
defined benefit plans were inactive participants. If this trend 
continues, by the year 2003 the number of inactive participants 
will exceed the number of active workers.

                         legislative proposals

    The President's budget for fiscal year 2001 includes 
numerous provisions to encourage the expansion of retirement 
plan coverage, including under defined benefit plans. These 
provisions include:
           a simplified defined benefit plan called 
        SMART (Secure Money Annuity or Retirement Trust) for 
        small businesses with 100 or fewer employees;
           a reduced PBGC premium of $5 per participant 
        for the first five years of a small business's new plan 
        and phase-in of the variable-rate premium over five 
        years for new plans of all sizes;
           expansion of the missing participants 
        clearinghouse to other terminating plans, including 
        multiemployer defined benefit pension plans insured by 
        PBGC, certain other defined benefit pension plans not 
        insured by PBGC, and defined contribution plans;
           simplified rules governing PBGC's guarantee 
        of benefits for a partial owner of a company and the 
        allocation of plan assets to the benefits of these 
        owner-employees;
           doubling PBGC's benefit guarantee for 
        multiemployer plans, which has been at the same level 
        since 1980, from the current maximum guarantee of 
        $5,850 to $12,870 (the guarantee increase would require 
        no change in the multiemployer premium rate);
           a tax credit for part of the administrative 
        expenses that a small business incurs when setting up a 
        new plan;
           a tax credit for part of the cost of the 
        contributions a small business makes to a defined 
        benefit or defined contribution plan; and
           permitting accelerated funding of defined 
        benefit plans.

                         Safeguarding Solvency

                                  y2k

    Following extensive efforts to test and validate its 
information systems and software for the Year 2000 century-date 
change, PBGC announced in August 1999 that it was ready for 
Y2K. PBGC confirmed that all PBGC mission-critical and 
secondary systems were Y2K-compliant. PBGC also verified that 
all building systems at PBGC sites were Y2K-compliant and 
consulted with business partners on their Y2K readiness.
    PBGC focused on improving existing systems rather than on 
introducing new technology or applications. Enhancements 
improved the major business systems' overall performance and 
helped front-line staff provide better customer service. The 
agency also took steps to strengthen the security of 
information and automated systems and will continue to monitor 
and test the security of its systems.
    Although PBGC's premium income continued to decline, the 
agency benefited from the healthy economy and strong returns on 
its equity investments. The single-employer insurance program 
gained financial strength and the multiemployer program 
remained strong despite an unusually large loss for the year. 
The combination of financial gains, negotiated settlements 
under the Early Warning Program, and litigation to protect the 
insurance program kept PBGC on course toward its strategic goal 
of strengthening its financial programs and systems to keep the 
pension insurance system solvent.

                          financial management

    While PBGC's single-employer insurance program again posted 
a significant financial gain, the separate multiemployer 
program recorded the largest one-year loss in its history.
    The single-employer program's gain arose mainly from 
actuarial credits as the increase in interest rates lowered the 
value of the program's benefit liabilities. However, the 
increase in interest rates also resulted in a significant loss 
for the program's fixed-income investments, causing total 
investment income to fall to about $730 million. Premium income 
continued to decline due to companies' reduced risk-based 
premium obligations, falling to $902 million, nearly $250 
million less than the record level reached in 1996. At the same 
time, the single-employer program sustained sharply lower 
losses from plan terminations. The actuarial gains in 
combination with strong returns on equity investments enabled 
the single-employer program to record net income of more than 
$2 billion, increasing the program's net surplus to more than 
$7 billion. This surplus provides the insurance program with a 
cushion against future losses.
    The multiemployer program continued to be financially 
strong despite a net loss of $142 million. With assets of $692 
million and liabilities totalling $493 million primarily for 
nonrecoverable future financial assistance, the program still 
had an end-of-year surplus of $199 million. Two factors 
accounted for the net loss: an increase in the program's 
allowance for nonrecoverable future financial assistance 
because a significant portion of one large plan was 
reclassified as a probable loss for the insurance program, and 
a decline in value of the program's assets (most of which are 
invested in U.S. Treasury securities) due to the increase in 
interest rates in 1999.
    PBGC's financial statements have received their seventh 
consecutive unqualified opinion from the agency's auditors. The 
1999 audit was again performed by PricewaterhouseCoopers LLP 
under the direction and oversight of PBGC's Inspector General.
    Investment Program.--The Corporation's investable assets 
consist of premium revenues accounted for in the Revolving 
Funds and assets from terminated plans and their sponsors 
accounted for in the Trust Funds. By law, PBGC is required to 
invest the Revolving Funds in fixed-income securities; current 
policy is to invest these funds only in Treasury securities. 
The agency has more discretion in its management of the Trust 
Funds, which it invests primarily in high-quality equities. The 
asset allocation is designed to provide sound long-term 
performance.
    PBGC has structured its investment portfolio to improve the 
agency's financial condition in a prudent manner. The Revolving 
Fund assets are invested to earn a competitive return and 
partially offset changes in its benefit liabilities. The 
agency's investment in equities provides overall portfolio 
diversification and a higher long-term expected return, within 
prudent levels of risk. PBGC uses institutional investment 
management firms to invest its assets subject to PBGC 
oversight. PBGC continually reviews its investment strategy to 
ensure that the agency maintains an investment structure that 
is consistent with its long-term objectives and 
responsibilities.
    As of September 30, 1999, the value of PBGC's total 
investments, including cash, was approximately $18.6 billion. 
The Revolving Fund's value was $10.8 billion and the Trust 
Fund's value was $7.8 billion. PBGC's equity allocation 
increased during 1999 due primarily to strongequity returns. 
Cash and fixed-income securities represented 60 percent of the 
total assets invested at the end of the year, as compared to 66 
percent at the end of 1998, while the equity allocation stood 
at 39 percent of all investments compared to 33 percent one 
year earlier. A very small portion of the invested portfolio 
remains in real estate and other financial instruments.

                           Investment Profile
------------------------------------------------------------------------
                   September 30,                       1999       1998
------------------------------------------------------------------------
Fixed-Income Assets:
    Average Quality...............................        AAA        AAA
    Average Maturity (years)......................       20.0       21.3
    Duration (years)..............................       10.2       11.3
    Yield to Maturity (%).........................        6.4        5.1
Equity Assets:
    Average Price/Earnings Ratio..................       28.2       19.7
    Dividend Yield (%)............................        1.4        1.6
    Beta..........................................       1.03       1.04
------------------------------------------------------------------------

    The current allocation to equities is the maximum currently 
allowable to PBGC, given legislative restrictions limiting 
equity investments to the Trust Funds. The increased equity 
allocation, adopted in 1994 as part of a strategic change in 
the agency's investment policy, has significantly improved 
PBGC's overall financial condition, as equities have 
substantially outperformed long-term Treasury securities by 
more than 12 percentage points per year over the past 5 years 
(22.4 percent versus 10.0 percent). This change in policy has 
made an important contribution to the insurance program's 
current surplus and to PBGC's long-term financial viability.
    Results for fiscal year 1999 were mixed for capital market 
investments and PBGC's investment program. For the year, PBGC's 
fixed-income program returned a negative 7.9 percent while its 
equity program advanced 24.7 percent. PBGC's five-year returns 
approximated their comparable market indices, meeting the 
agency's strategic performance goal. For the year, PBGC 
reported a loss of $862 million from fixed-income investments 
and a gain of $1.5 billion from equity investments.

                                             Investment Performance
                                            [Annual Rates of Return]
----------------------------------------------------------------------------------------------------------------
                                                                           September 30,            Five Years
                                                                 --------------------------------      Ended
                                                                                                   September 30,
                                                                       1999            1998            1999
----------------------------------------------------------------------------------------------------------------
Total Invested Funds............................................             3.6            14.4            14.2
Equities........................................................            24.7             2.1            22.4
Fixed-Income....................................................           (7.9)            22.8            10.0
Trust Funds.....................................................            24.3             2.1            21.0
Revolving Funds.................................................           (7.7)            22.4             9.9
Indices:
    Wilshire 5000...............................................            27.0             3.3            22.7
    S&P 500 Stock Index.........................................            27.8             9.2            25.0
    Lehman Brothers Long Treasury Index.........................           (7.7)            22.1             9.9
----------------------------------------------------------------------------------------------------------------

                    single-employer program exposure

    PBGC's ``expected claims'' are dependent on two factors: 
the amount of underfunding in the pension plans that PBGC 
insures (i.e., exposure), and the likelihood that corporate 
sponsors of these underfunded plans encounter financial 
distress that results in bankruptcy and plan termination (i.e., 
the probability of claims).
    Over the near term, expected claims result from 
underfunding in plans sponsored by financially weak firms. PBGC 
treats a plan sponsor as financially weak based upon factors 
such as whether the firm has a below-investment-grade bond 
rating. PBGC calculates the underfunding for plans of these 
financially weak companies using the best available data, 
including the annual confidential filings that companies with 
large underfunded plans are required to make to PBGC under 
Section 4010 of ERISA.
    For purposes of its financial statements, PBGC classifies 
the underfunding of financially weak companies as ``reasonably 
possible'' exposure, as required under generally accepted 
accounting principles. As of December 31, 1998, as disclosed in 
the financial statements, PBGC's estimated ``reasonably 
possible'' exposure ranged from $17 billion to $19 billion.
    Over the longer term, exposure and expected claims are more 
difficult to quantify either in terms of a single number or a 
limited range. Claims are sensitive to changes in interest 
rates and stock returns, overall economic conditions, the 
development of underfunding in some large plans, the 
performance of some particular industries, and the bankruptcy 
of a few large companies. Large claims from a small number of 
terminations and volatility characterize the agency's 
historical claims experience and are likely to affect PBGC's 
potential future claims experience as well.
    Despite the exceptional economic conditions of recent 
years, it is not reasonable to assume that future experience 
will be as favorable to PBGC. PBGC has had a surplus for only 
four years after running a deficit for more than 20 straight 
years. Furthermore, with premium changes built into the reforms 
of the Retirement Protection Act of 1994, PBGC expects its 
variable-rate premium revenues to decline substantially after 
the year 2000.
    After reviewing PBGC's financial situation, the U.S. 
General Accounting Office concluded on October 16, 1998, that: 
``Although PBGC's financial condition has significantly 
improved over the past few years, risks remain from the 
possibility of an overall economic downturn or a decline in 
certain sectors of the economy, substantial drops in interest 
rates, and actions by sponsors that reduce plan assets. These 
risks could threaten the long-term viability of the insurance 
programs. Further, PBGC has only a limited ability to protect 
itself from risks to the insurance programs.''
    Methodology for Considering Long-Term Claims.--No single 
underfunding number or range of numbers--even the reasonably 
possible estimate--is sufficient to evaluate PBGC's exposure 
and expected claims over the next ten years. There is too much 
uncertainty about the future, both with respect to the 
performance of the economy and the performance of the companies 
that sponsor insured pension plans.
    PBGC uses a stochastic model--the Pension Insurance 
Modeling System (PIMS)--to evaluate its exposure and expected 
claims.
    PIMS portrays future underfunding under current funding 
rules as a function of a variety of economic parameters. The 
model recognizes that all companies have some chance of 
bankruptcy and that these probabilities can change 
significantly over time. The model also recognizes the 
uncertainty in key economic parameters (particularly interest 
rates and stock returns). The model simulates the flows of 
claims that could develop under thousands of combinations of 
economic parameters and bankruptcy rates. (For additional 
information on PIMS, see PBGC's Pension Insurance Data Book 
1998, pages 10-17, which also can be viewed on PBGC's website 
at www.pbgc.gov/databk98.pdf.)
    Under the model, median claims over the next ten years will 
be about $550 million per year (expressed in today's dollars); 
that is, half of the scenarios show claims above $550 million 
per year, and half below. The mean level of claims (that is, 
the average claim) is much higher, more than $850 million per 
year. The mean is higher because there is a chance under some 
scenarios that claims could reach very high levels. For 
example, under the model, there is a ten percent chance that 
claims could exceed $2.0 billion per year. Despite PBGC's 
recent favorable experience, the financial condition of the 
agency could seriously deteriorate.
    PIMS projects PBGC's potential financial position by 
combining simulated claims with simulated premiums, expenses, 
and investment returns. The mean outcome is an $11.7 billion 
surplus in 2009 (in present value terms). However, the model 
also shows the potential for significant downside outcomes. In 
particular, there is more than a 15 percent chance that the 
agency could return to a deficit in the next ten years and a 
ten percent chance that the deficit could exceed $6.3 billion 
in 2009 (in present value terms). These outcomes are most 
likely if the economy performs poorly, in which case PBGC may 
experience large claims amounts and investment losses. PBGC is 
continuing to analyze the best way to manage and reduce the 
risk of insolvency.

                            loss prevention

    Under its Early Warning Program, PBGC closely monitored 
about 1,150 companies with pension plans underfunded by at 
least $5 million in order to identify transactions that could 
jeopardize pensions and to arrange suitable protections for 
those pensions and the pension insurance program. During 1999, 
PBGC reached agreements valued at about $1.1 billion with 21 
companies, including RJR Nabisco Holdings Corp. and Republic 
Engineered Steels, Inc. These agreements provided 
contributions, security, and other protections for the pensions 
of about 129,000 workers and retirees. Loss prevention is 
PBGC's principal performance measure for its strategic goal of 
protecting existing defined benefit plans and their 
participants; PBGC's agreements with employers in 1999 
protected benefits beyond those the agency would guarantee by 
reducing plan underfunding. On average, PBGC's loss prevention 
rate was 161 percent.

                               litigation

    PBGC continued to face challenges in courts across the 
country, a number of which could impair the agency's ability to 
recover its losses for underfunded plans from the employers 
responsible for those plans. At the end of the year, PBGC had 
81 active cases in state and federal courts and 621 bankruptcy 
cases.
    Several of the most significant cases concerned the 
priority and value of PBGC's claims for losses from plan 
terminations:
    Copperweld Steel Company.--PBGC continued to pursue 
bankruptcy claims to recover amounts due PBGC and Copperweld's 
three terminated pension plans, which covered about 3,000 
workers and retirees. The company's liquidation trustee 
contests whether PBGC's claims for unpaid minimum funding 
contributions in excess of $1 million are entitled to tax 
priority, and whether the assumptions PBGC prescribes in its 
regulations appropriately measure PBGC's claims for unfunded 
benefit liabilities. In December 1997, the bankruptcy court 
ruled for the liquidation trustee's position on both issues. On 
PBGC's appeal, the district court affirmed the bankruptcy 
court's adverse decision. PBGC was appealing the lower court 
decisions to the Sixth Circuit Court of Appeals at yearend.
    CF&I Steel Corporation.--In June 1999, the U.S. Supreme 
Court declined PBGC's request to review an adverse appellate 
decision, ending the agency's litigation over claims against 
the reorganized CF&I for a plan that was underfunded by about 
$221 million when terminated in March 1992. The Tenth Circuit 
Court of Appeals had ruled against PBGC regarding the treatment 
of its claims in bankruptcy. The court had found that the 
regulatory measure of PBGC's claim for unfunded benefit 
liabilities conflicts with the Bankruptcy Code and affirmed 
lower court decisions reducing PBGC's claim to about $123 
million. The court also found that PBGC's claim for unpaid 
minimum funding contributions in excess of $1 million is not 
entitled to tax priority and that only a small portion of this 
claim is entitled to administrative priority. These issues are 
central to PBGC's ability to recover its losses from employers 
in bankruptcy. PBGC will continue to litigate similar cases in 
other circuits with the hope of convincing the high court to 
take up these issues at a later date.
    Other major cases in 1999 included:
    Pineiro, Brooks, and Beaumont v. PBGC.--In 1991, PBGC 
became trustee of three Pan Am pension plans underfunded by 
$914 million. Three former employees of Pan American World 
Airways later filed suit asking a district court to replace 
PBGC with an independent trustee. The court dismissed virtually 
all of the allegations as meritless, leaving open only an 
allegation concerning the timeliness of PBGC's notices of 
benefit determination to the Pan Am participants. The 
plaintiffs filed an amended complaint in January 1998 
realleging PBGC delays in issuing benefit determinations as 
well as most of the dismissed allegations. PBGC's motion to 
dismiss the amended complaint was pending action by the 
district court at yearend. Despite the exceedingly poor 
condition of company records and the difficulties caused by Pan 
Am's protracted bankruptcy proceedings, PBGC has been paying 
benefits to Pan Am retirees continuously since taking over the 
plans. The agency has completed all benefit determinations for 
the 53,000 former Pan Am workers and retirees.
    White Consolidated Industries, Inc.--In July 1999, the 
district court ruled that White is liable for the unfunded 
benefits of six pension plans that White transferred to the 
Blaw Knox Corporation in 1985. PBGC took over the plans because 
they ran out of money or would have been abandoned after Blaw 
Knox ceased business in 1994. PBGC seeks to recover 
approximately $120 million, plus interest, for the plans' 
underfunding. The court held that White's transfer of the plans 
was a sham transaction and that the company ``ultimately became 
solely motivated by a desire to unload the BK Plans.'' The 
court also held that a principal purpose of White in entering 
into the transaction was to evade its pension liabilities. The 
court subsequently dismissed White's misrepresentation 
counterclaim against PBGC, finding there had been no 
misrepresentation or misconduct on the part of the agency or 
its employees. White has appealed the court's decision to the 
Third Circuit and has filed an administrative appeal with PBGC 
challenging the agency's calculation of the unfunded benefit 
liabilities.
    Flo-Con Systems, Inc. v. PBGC.--During an audit of Flo-
Con's standard termination of its pension plan for hourly 
employees, PBGC determined that Flo-Con had underpaid plan 
participants by using improper interest rates to calculate lump 
sum distributions. Amendments to ERISA and the Internal Revenue 
Code superseded the PBGC regulation relied on by Flo-Con and 
required that the company use lower interest rates, which would 
provide participants with larger lump sums. Flo-Con sought a 
summary judgment that its plan termination met legal 
requirements. The company also argued that a favorable IRS tax 
qualification letter and a PBGC letter directing Flo-Con to 
proceed with the distribution reflected IRS and PBGC approval 
of the termination and legally prevented PBGC from challenging 
the benefit calculations. PBGC filed a counterclaim to enforce 
its determination and ensure that the participants received the 
amounts to which they were entitled. In December 1998, a 
district court rejected Flo-Con's arguments and granted PBGC's 
motion for summary judgment.

                       Annual Performance Report

    PBGC's five-year strategic plan has four broad goals that 
form the framework of the agency's short- and long-term plans. 
In 1999, PBGC updated the plan to cover the period 1999-2004, 
in some cases raising the performance targets for future years. 
The PBGC goals are to:
           (1) protect existing defined benefit plans 
        and their participants, thereby encouraging new plans;
           (2) provide high quality, responsive 
        services; and accurate and timely payment of benefits 
        to participants;
           (3) strengthen financial programs and 
        systems to keep the pension insurance system solvent; 
        and
           (4) improve internal management support 
        operations.
    The performance measures track specific results that are 
significant to PBGC's customers and gauge PBGC's solvency and 
customer service accomplishments. The following table shows the 
results achieved in 1999 and meets the annual reporting 
requirement established by the Government Performance and 
Results Act. More information on PBGC's strategic plan and 
annual performance plan may be found on PBGC's website at 
www.pbgc.gov/mission.htp.

                                                        1999 PBGC Corporate Performance Measures
--------------------------------------------------------------------------------------------------------------------------------------------------------
             Measure                      Applicable Goal               1999 Milestone                  1999 Result                Baseline (1997)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Pension Loss Prevention:
Increase pension funding
 protection and the number of
 participants helped through PBGC
 agreements with sponsors of
 underfunded pension plans
Total value of loss prevention as  (1).........................  *...........................  161%........................  88.5%
 compared to total underfunded
 vested benefits.
Number of participants helped....  (1).........................  *...........................  129,000.....................  140,000
Customer Satisfaction:
Achieve ``outstanding'' or
 ``above average'' ratings (on a
 five point customer satisfaction
 scale) for inquiries handled:
From people whose plans we         (2).........................  83%.........................  70%.........................  79%
 trustee.
From pension practitioners/        (2).........................  63%.........................  66%.........................  54%
 sponsors.
Operations:
Determine final benefit amount in  (2).........................  80%.........................  84%.........................  90%
 clear, understandable language
 and within 5% of the benefit
 PBGC estimated when it completed
 the audit of the pension plan.
Send final, accurate benefit       (2).........................  5-6 years...................  5.7 years...................  5.95 years
 determination to participants
 within 3-4 years of plan
 trusteeship.
Reduce the age of pre-trusteeship  (2).........................  100% 3 years or less........  99.6% 3 years or less.......  98.6% 4 years or less
 inventory to no more than 1 year.                                                                                            (1998)
Send the first benefit payment to  (2).........................  80%.........................  83%.........................  83% (1999)
 an eligible person within 3
 months of receiving his/her
 completed application.
Financial Management:
Collect 99% of pension insurance   (3).........................  99%.........................  99%.........................  97%
 premiums due.
Approximate comparable 5-year      (3).........................  *...........................  PBGC Index..................  PBGC Index
 investment indices for PBGC's
 portfolio performance.
                                   ............................  ............................  Equities 22.4% 22.7%........   Equities 20.6% 20.6%
                                   ............................  ............................  Fixed-Income 10.0% 9.9%.....  Fixed-Income 10.9% 8.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
*By their nature, these measures do not lend themselves to setting annual targets or milestones. PBGC measures performance annually based on actual
  results.

                     achieving performance targets

    Pension Loss Prevention:
           Loss prevention is PBGC's principal 
        performance measure for its strategic goal of 
        protecting existing defined benefit plans and their 
        participants. PBGC's negotiated agreements with 
        employers in 1999 resulted in a loss prevention rate of 
        161 percent. Loss prevention exceeds 100 percent when a 
        plan sponsor agrees to fund benefits beyond those that 
        the agency guarantees. These settlements helped 129,000 
        participants maintain their pension benefits.
    Customer Satisfaction:
           PBGC listens to its customers in a variety 
        of ways including annual satisfaction surveys, and has 
        set performance targets for both participants' and 
        practitioners' satisfaction through 2004.
           The 1999 survey of participants showed about 
        the same satisfaction as the previous year. Retired 
        participants receiving benefits were more satisfied 
        than those due a future pension. For the latter, lack 
        of information about the amount of their future 
        benefits largely explains their lower satisfaction. 
        PBGC is taking steps to improve the accuracy and 
        timeliness of benefit estimates and will be 
        communicating earlier and more frequently with future 
        payees. When these changes are in place, we expect an 
        increase in customer satisfaction.
           Sixty-six percent of pension practitioners 
        rated PBGC's overall service ``outstanding'' or ``above 
        average'' in 1999, up from 58 percent in 1998 and 
        exceeding the 1999 performance goal of 63 percent. PBGC 
        attributes the increase in satisfaction to: (1) its 
        shift of the premium filing due date to coincide with 
        other pension reporting requirements; (2) the launch of 
        the new premium payer customer service center and 1-800 
        telephone number; and (3) continued improvement of 
        service to standard termination filers.
    Operations:
           The principal measure of operations is to 
        ``send final, accurate benefit determination to 
        participants within 3-4 years of plan trusteeship.'' 
        Efforts to speed up processing have succeeded, allowing 
        PBGC to raise the performance target for this measure. 
        The agency now plans to issue determinations on average 
        within 3-4 years, versus 3-5 as in the original 
        strategic plan. This is another example of listening to 
        customers and changing processes to make improvements 
        they want. In addition, the average age of unissued 
        benefit determinations was reduced from 3.2 to 2.3 
        years.
           When PBGC issued final benefit 
        determinations, they were within 5 percent of earlier 
        estimates 84 percent of the time. However, this measure 
        can change significantly from year to year because of 
        the small number of benefit calculations currently used 
        for the measure. PBGC is continuing to monitor the 
        utility of this particular measure.
           PBGC made steady progress in reducing the 
        age of cases to be trusteed. The goal is that no 
        pending case be more than one year old by 2002, reached 
        in annual milestones. At the end of 1999, 99.6 percent 
        of cases to be trusteed were three years old or less.
           After eligible participants completed 
        applications, they received pension payments from PBGC 
        within three months 83 percent of the time. PBGC 
        continues to work to improve on this record.
    Financial Management:
            The premium collection rate is the amount 
        of premiums collected divided by the amount of premiums 
        due. PBGC achieved its 99 percent collection goal. 
        During the year, PBGC extended the final premium filing 
        date by one month to coincide with other reporting 
        requirements. This change demonstrates again how PBGC 
        listens to its customers.
           Investment management results are measured 
        against recognized industry indices aggregated over a 
        five-year period. The five-year period smooths out 
        volatility in annual market performance and provides a 
        more realistic, long-term view of investment success. 
        PBGC regularly approximates the two indices it tracks: 
        the Wilshire 5000 Index for equities, and the Lehman 
        Brothers Long Treasury Index for fixed income.

                           program evaluation

    PBGC conducted customer satisfaction surveys of 
participants in plans trusteed by PBGC, and of pension 
practitioners who have dealings with us on premium payment or 
standard termination matters. Evaluation of the survey 
responses resulted in improvements in program operations, as 
discussed earlier in the Annual Report.

                  Executive Director's Message (2000)

    I am pleased to report that the federal pension insurance 
system is in its best shape ever. For the fifth consecutive 
year, PBGC's insurance programs ended the year with a surplus. 
Despite declining premium revenues, with low claims and good 
investment returns PBGC ended Fiscal Year 2000 with a surplus 
of almost $10 billion. We have built a cushion to protect the 
insurance program in the event of an economic downturn.
    We have laid a firm foundation for the future. Over the 
past few years, we have made major changes in how we conduct 
business. We have harnessed the power of computers to improve 
our operations and lift our productivity. We have begun a new 
era of customer service, through dedicated customer service 
centers and use of the Internet. We have a stronger investment 
program and solid financial management. Although we have not 
yet mastered paperless transactions, we are moving rapidly 
toward ``electronic government.''
    It has been an honor and a privilege to serve as PBGC's 
Executive Director for the last 3\1/2\ years. I am proud of 
what we have accomplished toward making PBGC a financially 
strong, premier customer service agency. These accomplishments 
are due to PBGC's employees, who are dedicated to serving the 
43 million workers and retirees in the 38,000 plans that PBGC 
insures.
                                          David M. Strauss,
                                          Former Executive Director

                       Listening to our Customers

    The need to provide premier customer service shapes 
virtually every action now taken or planned by PBGC. Yet we 
continue to face rising customer expectations as customers 
become accustomed to higher service levels in other areas of 
their lives.
    The overarching principle of customer service, for federal 
agencies as well as the private sector, is to provide service 
to the public that matches or exceeds the ``best in the 
business.'' This means asking customers what kind and quality 
of service they want and how well we are meeting their needs. 
It also means giving customers choices about the services we 
provide and a means to complain that includes a mechanism to 
address their complaints.
    PBGC has taken this principle to heart. The agency works 
hard at communicating with and listening to its customers--
participants in PBGC-trusteed plans, and sponsors of PBGC-
insured plans and the pension professionals who assist them. 
Every year, PBGC conducts surveys and focus groups with both 
participants and practitioners. Through these focus groups and 
surveys, PBGC asks its customers about the quality of the 
agency's service and how that service can be improved. Then, 
under its ongoing Reach for Excellence and Customer Happiness 
(REACH) initiative, PBGC uses interdepartmental teams of 
employees to translate the focus group and survey findings into 
service improvements. One major component of our commitment to 
customer service, discussed later in the ``Protecting 
Benefits'' section of this Report, is the agency's continuing 
success in issuing more benefit determinations--and issuing 
them more quickly--than in any previous period in its history.
    In response to participant suggestions, in 2000 PBGC began 
providing benefit estimates to participants within 15 days of 
their request. The agency tested a new introductory package of 
customer-focused materials that will improve initial 
communications with participants in newly trusteed plans, which 
PBGC is refining based on initial results and customer 
reactions. As a means of keeping customers informed about their 
benefits, PBGC also tested use of an annual status report for 
participants who have not yet retired or received their benefit 
determination.
    At the same time, the agency initiated or continued 
developing a number of other important communication tools. 
Among these were a letter to remind participants of the 
approach of their retirement date and a pilot program that will 
use a special Web page to provide targeted services, including 
plan-specific information and benefit estimates for 
participants in newly trusteed large plans. Telephone system 
enhancements during the year included a new Spanish language 
greeting on the toll-free customer service number and useful 
messages providing information about PBGC's commitment to 
service and general retirement tips for callers who have to be 
put on hold until their call can be completed.
    PBGC continued to provide easy-to-find information for its 
customers on its Web site at www.pbgc.gov. The Web site now 
includes a ``Contact Us'' section that provides useful PBGC 
telephone numbers and e-mail addresses for the general public, 
participants in PBGC-trusteed plans, and pension professionals. 
During the year PBGC upgraded the Web site to ensure that the 
agency's information is accessible to users with disabilities.
    The agency has found meetings with large groups of 
participants from newly trusteed plans to be particularly 
useful in allaying participant concerns and explaining PBGC's 
insurance. PBGC held 54 such information sessions across the 
country in 2000, which about 3,400 plan participants attended. 
Executive Director David Strauss attended each of the sessions 
to meet the participants and answer their questions.
    PBGC continues to make changes to its policies, procedures 
and regulations to help its customers. For example, a new 
policy allows PBGC to increase the maximum guaranteed benefit 
to recipients who are older than 65 either when their plan 
terminates or, if later, when PBGC begins paying their 
benefits.
    PBGC also broadened its safe harbor relief from premium 
penalties, committed to publishing PBGC lump sum interest rates 
indefinitely, and sought the public's input on valuing cash 
balance plans. The agency also simplified its premium payment 
forms.

                     pbgc's customer service pledge

    Our customers deserve our best effort as well as our 
respect and courtesy.
    On the first call from you, our customer, we will say:
        What we can do immediately and what will take longer.
        When it will be done and
        Who will handle your request.
    We will call you if anything changes from what we first 
said, give you a status report, and explain what will happen 
next.

                          employee development

    PBGC primarily uses its own in-house facility, the Martin 
Slate Training Institute, for the training and development of 
agency staff. The Institute, established in November 1994 and 
subsequently named in memory of a former Executive Director, 
provides a structured learning and networking environment in 
which PBGC employees can avail themselves of a range of 
programs, including technical and computer training, customer 
service training and mentoring programs.
    The Institute relies on PBGC employees who serve as 
internally trained instructors and as subject matter 
specialists who develop the instructional materials. In keeping 
with the principle of ``listening to our customers,'' the 
Institute develops new courses with the assistance of focus 
groups of PBGC employees.
    The Institute adds about 9 new technical courses a year. In 
2000, the Institute offered a total of 185 courses, taught in 
nearly 400 sessions with a total enrollment of nearly 5,600. 
Among other achievements during the year, the Institute:
           developed its first two ``web-based'' 
        courses, which can be accessed by employees through 
        their desktop computers rather than in a classroom. 
        These courses allow interactive teaching using 
        multimedia formats. PBGC's use of this new technology 
        for employee development puts it in the forefront of 
        smaller government agencies. The Institute's future 
        programs will be a combination of web-based and 
        classroom instruction.
           launched and completed a new round of 
        customer service training, which emphasized practical 
        application of customer service skills. Previous 
        customer service training, which has been a staple of 
        the Institute's offerings for the past six years, was 
        intended to foster broad customer service awareness and 
        skills.
           continued to build its mentoring program, 
        through which experienced staff members share their 
        knowledge and insights with less seasoned co-workers.
           opened a new, state-of-the-art computer lab 
        for web-based training, testing software for training 
        purposes, and teaching computer systems and 
        applications.
    Shortly after the year ended, PBGC announced several 
additional changes in its premium regulations that simplify 
procedures and ease burdens for plan administrators. One of 
these changes allows plan administrators to pay a prorated 
premium for a short plan year rather than pay a full year's 
premium and request a refund or claim a credit against a future 
premium payment, as has been necessary up to the present. 
Another change narrowed the definition of ``participant'' for 
PBGC premium purposes by allowing administrators to exclude 
from their participant counts people who have not earned 
benefits and for whom the plan has no other benefit 
liabilities. With this latter change, a new plan will not have 
to pay a premium for its first year unless it provides credit 
for service before the plan began.
    As a result of suggestions from pension professionals, PBGC 
revised its criteria for taking action under the early warning 
program and published explicit guidance on the program's 
operation. The agency expects the new criteria to significantly 
circumscribe PBGC involvement in corporate transactions. PBGC 
also changed the orientation of the premium audit program from 
its traditional focus on premium collections to one that 
emphasizes helping premium payers comply with their premium 
obligations. In addition, the agency began working on ways to 
make termination- and premium-related audits more 
understandable and easier for plan sponsors and pension 
professionals.
    Vigorously encouraging customer feedback, PBGC has made it 
easier for customers to contact the agency and resolve issues 
affecting their benefits or plans. PBGC has two centralized 
customer service centers, one for participant inquiries and the 
other for practitioners, each with its own toll-free number. To 
improve the service center for practitioners, during 2000 PBGC 
installed a call tracking system similar to that used in the 
participant service center to ensure that calls are responded 
to correctly and timely, and that problems are identified so 
they can be dealt with quickly. PBGC's separate problem 
resolution officers for plan participants and for practitioners 
provide customers with a highly effective avenue for addressing 
difficult issues.

                           problem resolution

    Participants in PBGC-trusteed plans may reach PBGC's 
Participant Problem Resolution Officer by calling 1-800-400-
PBGC or by e-mail at [email protected].
    Plan sponsors, plan administrators, and pension 
professionals may reach PBGC's Practitioner Problem Resolution 
Officer by calling 1-800-736-2444 (202-326-4242 if in the 
Washington, DC, metropolitan area) or by e-mail at 
[email protected].
    TTY/TDD users may call the Federal relay service toll-free 
at 1-800-77-8339 and ask the communications assistant to 
connect them to the appropriate telephone number.
    To measure overall satisfaction with service and help PBGC 
track how well it has been doing, PBGC uses annual surveys and, 
beginning in 2000, customer comment cards. The comment cards 
are particularly useful in obtaining customer feedback soon 
after a service contact, when memory of the contact is still 
fresh. According to the most recent completed surveys, 71 
percent of participants and 62 percent of practitioners rated 
PBGC's service as ``above average'' or ``outstanding.'' Under 
the agency's five-year strategic plan, the goal is for 90 
percent of participants and 84 percent of practitioners to rate 
PBGC's service as ``above average'' or ``outstanding'' by the 
close of the year 2005.
    PBGC's ``one-call'' approach is perhaps the most critical 
element of the agency's service pledge. This means that, on the 
customer's first call, we will either answer the question 
immediately or we will let the customer know who will handle 
the problem and when an answer can be expected. If it is found 
that a request is going to take longer to answer than initially 
thought, we will call back to keep the customer informed of our 
progress.
    PBGC is committed to being a premier customer service 
organization--for participants who depend on the agency for 
their pension benefits as well as for plan sponsors and the 
pension professionals who assist them. The performance standard 
that customers now expect is ``online, on time, all the time.'' 
PBGC is working to keep up with the advances in technology to 
meet that goal.

                          Protecting Benefits

    While terminations of fully funded pension plans declined 
for the 10th straight year, terminations of underfunded plans 
fell to their lowest level since 1993. At the same time, the 
agency continued to show progress in its effort to speed up the 
issuance of final benefit determinations. Despite receiving 
relatively few requests for financial assistance, the separate 
multiemployer program provided in excess of $90 million in 
assistance in 2000, more than in any other year since the 
current program's creation in 1980.

                        single-employer program

    Through its single-employer program, PBGC oversees 
terminations of fully funded plans and guarantees payment of 
basic pension benefits when underfunded plans must be 
terminated. The single-employer program covers more than 34 
million workers and retirees in about 36,000 plans.
    During 2000 the agency completed the termination of 92 
underfunded plans, the vast majority of which were involuntary 
terminations by PBGC. In most cases termination was necessary 
because the sponsoring employer had gone out of business, 
sometimes in earlier years.
    After a plan has terminated, PBGC becomes trustee of the 
plan and administers benefits. In 2000, PBGC became trustee of 
103 single-employer plans covering about 27,500 people. By the 
end of the year, PBGC was responsible for a total of 2,840 
trusteed plans, including 10 multiemployer plans. An additional 
34 terminated single-employer plans were pending trusteeship as 
the year ended. (This total also reflects the elimination of 
three single-employer plans included in last year's total, 
which no longer required PBGC to become trustee. One plan was 
converted to a standard termination; the other two plans were 
merged into a third plan.)
    Benefit Processing.--By the end of the year, PBGC was 
responsible for the current and future pension benefits of 
about 541,000 participants from single-employer and 
multiemployer plans. These included 226,700 retirees who 
received benefit payments totaling $903 million for the year.
    The past year was a period of sustained progress as PBGC 
maintained the high pace of activity that has characterized the 
most recent years. During 2000, the agency issued nearly 63,500 
benefit determinations, exceeding 60,000 determinations for the 
sixth straight year. The number of outstanding determinations 
awaiting completion also declined for the sixth straight year, 
leaving about 156,000 determinations to be completed. This 
represents a dramatic reduction from the situation that 
prevailed in 1994, when the agency had about 300,000 
outstanding determinations and was making little headway in 
reducing this number. Moreover, this progress came during a 
six-year period in which PBGC assumed responsibility for the 
benefits of more than 240,000 additional people from newly 
trusteed plans.
    PBGC has now completed benefit determinations for virtually 
all plans trusteed prior to 1996. The average age of unissued 
benefit determinations is down to 2 years, reflecting the fact 
that most pending determinations are for plans trusteed within 
the past two to three years. On average, in 2000 PBGC issued 
final benefit determinations 4.9 years after the date it had 
trusteed the participant's plan, meeting the performance goal 
of 4-5 years set for 2000 under PBGC's strategic plan.
    PBGC routinely pays benefits in estimated amounts until 
final determinations are completed. Ninety-four percent of 
PBGC's final benefit determinations during 2000 were within 10 
percent of the estimated benefit provided earlier to 
participants.
    Appeals Processing.--PBGC's Appeals Board reviews appeals 
of certain PBGC determinations. Most of the appeals are from 
people disputing their benefit determinations. Typically, about 
2 percent of all benefit determinations are appealed. During 
2000, the Appeals Board received 1,275 appeals. The Board 
decided 1,583 appeals during the year and reduced its open case 
inventory by 8 percent. Shortly after the end of the year, PBGC 
began to re-engineer its appeals process with the assistance of 
a cross-functional team of agency staff and guidance from 
experts at the Federal Consulting Group. Completion of the 
effort, which is intended to improve organizational efficiency 
and customer service, is scheduled for later in 2001.
    Standard Terminations of Fully Funded Plans.--The number of 
standard terminations continued to decline steadily from their 
peak of about 11,800 in 1990, with 1,882 submitted to PBGC in 
2000. More than three-fourths of these plans had 50 or fewer 
participants.
    Compliance with the legal requirements for standard 
terminations remained high and PBGC again found very few errors 
or omissions that might force cancellation of a termination. 
The agency's increased flexibility in addressing administrative 
errors, in particular, is helping to avert many of the problems 
filers experienced in years past. In 2000, only two 
terminations had to be canceled for failure to comply with 
legal requirements, compared to 4 such cases in 1999, 24 in 
1998 and 118 in 1997.
    PBGC audits a statistically significant number of completed 
terminations to confirm compliance with the law and proper 
payment of benefits. These audits generally have found few and 
relatively small errors in benefit payments, which plan 
administrators are required to correct. The errors arise 
primarily from use of incorrect interest-rate assumptions in 
valuing lump-sum distributions to plan participants. Due to 
PBGC's audits, in 2000 some 2,300 participants (about 2.2 
percent of all participants in audited plans) received more 
than $1.5 million of additional benefits.
    Pension Search Program.--PBGC's Pension Search Program 
consists of three separate, coordinated efforts to locate 
missing people owed a pension by a terminated plan. 
Historically, the agency has conducted extensive searches for 
people missing from underfunded pension plans for which PBGC 
has taken responsibility. Since January 1996, PBGC also has 
provided a ``missing participants clearinghouse'' to assist 
employers terminating fully funded plans; if an employer is 
unable to locate a former employee, PBGC will accept payment 
for the benefit and continue searching for the person to allow 
the employer to complete the termination. As a last means of 
finding people who have not been found in all previous searches 
by either their former employer or by PBGC, the agency has 
maintained a Pension Search listing on the Internet since 
December 1996. These efforts have helped PBGC locate thousands 
of people who were unaware they were owed a pension benefit. 
PBGC's Pension Search Program received a boost during the year 
when the agency concluded an agreement with the Social Security 
Administration that allows PBGC to regularly search SSA's data 
base for names and current addresses.
    During this fiscal year, 340 companies asked the 
clearinghouse to find 3,901 missing participants, some 2,900 of 
whom were due benefit payments totaling nearly $6.8 million. 
The other 1,000 people were covered by annuity contracts that 
will pay their benefits when they are found. PBGC was able to 
confirm addresses for 3,465 of the missing people and to pay 
765 of them a total of more than $2.7 million in benefits.
    Additionally, the Pension Search listing on the Internet 
helped PBGC find 4,800 other people who were owed about $10 
million. When the year ended, the total Internet list, which 
included people PBGC was unable to find through the 
clearinghouse, identified more than 11,500 unlocated people who 
were owed about $27 million in pension benefits. Since 
inception, PBGC's Internet pension search has helped nearly 
6,600 people obtain more than $21 million in owed benefits plus 
interest. The Internet listing is found at http://
search.pbgc.gov.

                         multiemployer program

    The multiemployer program, which covers more than 9.1 
million workers and retirees in about 1,750 insured plans, is 
funded and administered separately from the single-employer 
program and differs from the single-employer program in several 
significant ways. The multiemployer program covers only 
collectively bargained plans involving two or more unrelated 
employers. For such plans, the event triggering PBGC's 
guarantee is the inability of a covered plan to pay benefits 
when due at the guaranteed level, rather than plan termination 
as required under the single-employer program. PBGC provides 
financial assistance through loans to insolvent plans to enable 
them to pay guaranteed benefits.
    Financial Assistance.--The multiemployer program continues 
to receive relatively few requests for financial assistance. 
Since 1980, PBGC has provided assistance to only 27 of the 
1,750 insured plans, with a total value of approximately $148 
million net of repaid amounts. During the year, 21 of these 
plans received assistance totaling about $91 million, including 
one-time payments totaling $87 million for two financially 
troubled multiemployer plans that merged into large national 
plans. PBGC's payments facilitated the mergers, as a result of 
which retirees continue to receive their full benefits and 
participants continue to earn benefits in an ongoing plan.

                Trends in Defined Benefit Pension Plans

    Since the early 1980s, there has been a gradual shift away 
from defined benefit pension plans in the private sector. The 
number of PBGC-insured defined benefit plans peaked in 1985 at 
about 114,000. Since then there has been a sharp decline to 
about 38,000 plans in 2000.
    This reduction has not been proportional across all plan 
sizes. Plans with fewer than 100 participants have shown the 
most marked decline, from about 90,000 in 1985 to less than 
23,000 in 2000. There also has been a sharp decline for plans 
with between 100 and 999 participants, from more than 19,000 in 
1985 to about 10,500 in 2000.
    In marked contrast to the trends for plans with fewer than 
1,000 participants, the number of plans with more than 1,000 
participants has shown modest growth. Since 1980, the number of 
PBGC-insured plans with between 1,000 and 9,999 participants 
has grown by about 4 percent, from 4,017 to 4,174 in 2000. The 
number of plans with at least 10,000 participants has grown 
from 469 in 1980 to 776 in 2000, an increase of 65 percent.
    The growth in the number of large plans is attributable to 
two factors. First, the rapid increase in inactive participants 
(retirees and separated vested participants) has pushed some 
plans into higher size categories. Second, there has been 
considerable plan merger activity over the fifteen-year period 
from 1985 through 2000.
    In contrast to the dramatic reduction in the total number 
of plans, the total number of participants in PBGC-insured 
defined benefit plans has shown modest growth. In 1980, there 
were 35.5 million participants. By 2000, this number had 
increased to more than 43 million.
    These numbers, however, mask the downward trend in the 
defined benefit system because total participants include not 
only active workers but also retirees (or their surviving 
spouses) and separated vested participants. The latter two 
categories of participants reflect past coverage patterns in 
defined benefit plans. A better forward-looking measure is the 
trend in the number of active participants, workers currently 
earning pension accruals. Here, the numbers continue to 
decline.
    In 1988, there were 27.3 million active participants in 
defined benefit plans; by 1998 (the latest data available), 
this number had fallen to 22.9 million, a decrease of more than 
16 percent. At the same time, the number of inactive 
participants has been growing. In 1980, inactive participants 
accounted for only 23 percent of total participants in defined 
benefit plans. By 1988 this number had increased to 31 percent; 
46 percent of the participants in defined benefit plans were 
inactive participants by 1998. If this trend continues, by the 
year 2003 the number of inactive participants will exceed the 
number of active workers.

                         legislative proposals

    The Clinton Administration's budget for fiscal year 2001 
included numerous provisions to encourage the expansion of 
retirement plan coverage, including under defined benefit 
plans. These provisions included:
           a simplified defined benefit plan called 
        SMART (Secure Money Annuity or Retirement Trust) for 
        small businesses with 100 or fewer employees;
           a reduced PBGC premium of $5 per participant 
        for the first five years of a small business's new plan 
        and phase-in of the variable-rate premium over five 
        years for new plans of all sizes;
           expansion of the missing participants 
        clearinghouse to other terminating plans, including 
        multiemployer defined benefit pension plans insured by 
        PBGC, certain other defined benefit pension plans not 
        insured by PBGC, and defined contribution plans;
           simplified rules governing PBGC's guarantee 
        of benefits for a partial owner of a company and the 
        allocation of plan assets to the benefits of these 
        owner-employees;
           doubling PBGC's benefit guarantee for 
        multiemployer plans, which has been at the same level 
        since 1980, from the current maximum guarantee of 
        $5,850 to $12,870 (shortly after the year ended, the 
        Congress enacted the increase in the multiemployer 
        guarantee as part of the Consolidated Appropriations 
        Act, 2001--the guarantee increase requires no change in 
        the multiemployer premium rate);
           a tax credit for part of the administrative 
        expenses that a small business incurs when setting up a 
        new plan;
           a tax credit for part of the cost of the 
        contributions a small business makes to a defined 
        benefit or defined contribution plan; and
           permitting accelerated funding of defined 
        benefit plans.

                         Safeguarding Solvency

    Favorable economic conditions enabled PBGC to further 
strengthen its financial position. Terminations of underfunded 
plans fell to their lowest level since 1993, contributing to 
the increasing strength of PBGC's net financial position. 
Although premium income declined for the fourth straight year, 
strong returns on both fixed-income and equity investments 
enabled both insurance programs to report net income for the 
year. The agency's determined defense of its legal positions 
led to important outcomes as well, both in negotiated 
settlements and in court.

                    information systems and security

    PBGC's extensive efforts to prepare its information systems 
and software for the Year 2000 century-date change produced a 
seamless transition from 1999 to 2000. All PBGC mission-
critical and secondary systems continued to function normally 
with no Y2K problems.
    The agency's primary focus shifted during 2000 to enhancing 
the security of its existing information systems and data. 
Testing of the agency's computer systems by PBGC's Inspector 
General found PBGC's systems secure from penetration through 
the Internet but identified other vulnerabilities common in 
complex networks. The agency immediately took corrective 
actions to address these problems, in the process accelerating 
initiatives planned for future years. These measures included:
           new, more robust passwords for access to the 
        information systems and additional automated tools for 
        monitoring and testing compliance;
           an annual independent assessment of PBGC's 
        vulnerabilities;
           enhanced controls restricting high-level 
        access to authorized users backed by a strong hardware-
        based authentication mechanism;
           implementing an intrusion management program 
        to detect and address intrusion attempts;
           establishing and filling the new position of 
        Information Systems Security Officer; and
           enhancing corporate-wide computer security 
        awareness training and procedures for monitoring 
        compliance with security policies.
    PBGC also placed a major emphasis on improving its 
capabilities for conducting its business electronically. The 
ultimate goal is to provide electronic alternatives to paper 
forms and records within the next few years. In addition, the 
agency upgraded its Internet Web site to make the agency's 
information accessible to users with disabilities.

                          financial management

    Both of PBGC's insurance programs posted significant 
financial gains during 2000, with the single-employer program 
recording the largest one-year gain in its history. Both 
programs' gains came mainly from investment income.
    For the single-employer program, both fixed-income and 
equity investments contributed to the final result, producing 
total investment income of nearly $2.4 billion. However, due 
largely to companies' reduced risk-based premiums, premium 
income continued to decline from the record level reached in 
1996, falling to $807 million in 2000. Consistent with recent 
trends, losses from plan terminations continued to decline. The 
combination of low termination losses and strong returns on 
investments enabled the single-employer program to record net 
income of nearly $2.7 billion, increasing the program's net 
surplus to $9.7 billion. This current surplus provides the 
insurance program with a cushion against future sizeable losses 
that are unforeseen and episodic in nature.
    The multiemployer program reported net income of $68 
million, due almost entirely to investment returns on the 
program's fixed-income assets. With total assets of $694 
million and liabilities totaling $427 million primarily for 
nonrecoverable future financial assistance, the program had an 
end-of-year surplus of $267 million. The program's premium 
income increased slightly to about $24 million.
    PBGC's financial statements have received their eighth 
consecutive unqualified opinion from the agency's auditors. The 
2000 audit was again performed by PricewaterhouseCoopers LLP 
under the direction and oversight of PBGC's Inspector General.
    The Joint Financial Management Improvement Program (JFMIP) 
recognized the accomplishments of Chief Financial Officer N. 
Anthony Calhoun by presenting him with its annual Donald L. 
Scantlebury Memorial Award for distinguished leadership in 
financial management improvement in the public sector. The 
award cited Mr. Calhoun's ``exceptional leadership in improving 
financial management of the retirement benefits of millions of 
Americans,'' noting Mr. Calhoun's championing of innovative 
financial systems technology and implementation of a system of 
internal controls that assure the issuance of reliable 
financial information. The JFMIP is a joint program of the 
Department of the Treasury, Office of Management and Budget, 
and Office of Personnel Management that works with all federal 
agencies to improve financial management practices and 
policies.
    Investment Program.--The Corporation's investable assets 
consist of premium revenues accounted for in the Revolving 
Funds and assets from terminated plans and their sponsors 
accounted for in the Trust Funds. By law, PBGC is required to 
invest the Revolving Funds in fixed-income securities; current 
policy is to invest these funds only in Treasury securities. 
The agency has more discretion in its management of the Trust 
Funds, which it invests primarily in high-quality equities. The 
asset allocation is designed to provide sound long-term 
performance.
    PBGC has structured its investment portfolio to improve the 
agency's financial condition in a prudent manner. The Revolving 
Fund assets are invested to earn a competitive return and 
partially offset changes in its benefit liabilities. The 
agency's investment in equities provides overall portfolio 
diversification and a higher long-term expected return, within 
prudent levels of risk. PBGC uses institutional investment 
management firms to invest its assets subject to PBGC 
oversight. PBGC, with the advice of its Advisory Committee, 
continually reviews its investment strategy to ensure that the 
agency maintains an investment structure that is consistent 
with its long-term objectives and responsibilities.
    As of September 30, 2000, the value of PBGC's total 
investments in the single-employer and multiemployer programs, 
including cash, was approximately $21 billion. The Revolving 
Fund's value was $12.1 billion and the Trust Fund's value was 
$8.9 billion. Cash and fixed-income securities represented 61 
percent of the total assets invested at the end of the year, as 
compared to 60 percent at the end of 1999, while the equity 
allocation remained constant at 39 percent of all investments. 
A very small portion of the invested portfolio remains in real 
estate and other financial instruments.

                           Investment Profile
------------------------------------------------------------------------
                                                        September 30,
                                                   ---------------------
                                                       2000       1999
------------------------------------------------------------------------
Fixed-Income Assets
    Average Quality...............................        AAA        AAA
    Average Maturity (years)......................       21.1       20.0
    Duration (years)..............................       10.9       10.2
    Yield to Maturity (%).........................        6.0        6.4
Equity Assets
    Average Price/Earnings Ratio..................       29.7       28.2
    Dividend Yield (%)............................        1.1        1.4
    Beta..........................................        .98       1.03
------------------------------------------------------------------------

    The current allocation to equities is the maximum currently 
allowable to PBGC, given legislative restrictions limiting 
equity investments to the Trust Funds. The increased equity 
allocation, adopted in 1994 as part of a strategic change in 
the agency's investment policy, has significantly improved 
PBGC's overall financial condition, as PBGC's equity assets 
have substantially outperformed its long-term Treasury 
portfolio by more than 11 percentage points per year over the 
past 6 years (21.7% versus 9.9%). This change in policy has 
made an important contribution to the insurance program's 
current surplus and to PBGC's long-term financial viability.
    Results for fiscal year 2000 were favorable for capital 
market investments and PBGC's investment program. For the year, 
PBGC's fixed-income program returned 9.8 percent while its 
equity program advanced 18.2 percent. PBGC's five-year returns 
approximated their comparable market indices, meeting the 
agency's strategic performance goal. For the year, PBGC 
reported a gain of $1.1 billion from fixed-income investments 
and a gain of $1.3 billion from equity investments.

                                             Investment Performance
                                            [Annual Rates of Return]
----------------------------------------------------------------------------------------------------------------
                                                                           September 30,            Five Years
                                                                 --------------------------------      Ended
                                                                                                   September 30,
                                                                       2000            1999            2000
----------------------------------------------------------------------------------------------------------------
Total Invested Funds............................................            13.2             3.6            12.1
Equities........................................................            18.2            24.7            19.9
Fixed-Income....................................................             9.8           (7.9)             7.6
Trust Funds.....................................................            18.1            24.3            19.2
Revolving Funds.................................................             9.7           (7.7)             7.5
Indices
    Wilshire 5000...............................................            17.6            27.0            20.4
    S&P 500 Stock Index.........................................            13.3            27.8            21.7
    Lehman Brothers Long Treasury Index.........................             9.8           (7.7)             7.5
----------------------------------------------------------------------------------------------------------------

    Contract Management.--Following a review of PBGC's contract 
management, the U.S. General Accounting Office reported during 
the year that, although PBGC complied with all legal 
requirements, the agency's contract management might be 
improved through better contract procedures and monitoring. The 
GAO recommended measures that PBGC accepted and began 
implementing before the year ended. At the same time, PBGC 
significantly increased the training provided to its 
Contracting Officer's Technical Representatives (COTRs) and its 
contract monitors. By the end of the year, the agency had begun 
developing a COTR certification program to ensure that agency 
COTRs are and remain qualified for that function.
    Of the contracts issued during 2000, PBGC awarded 88 
percent through full and open competition. The remainder were 
sole-source contracts or set aside for minority bids.

                    single-employer program exposure

    PBGC's ``expected claims'' are dependent on two factors: 
the amount of underfunding in the pension plans that PBGC 
insures (i.e., exposure), and the likelihood that corporate 
sponsors of these underfunded plans encounter financial 
distress that results in bankruptcy and plan termination (i.e., 
the probability of claims).
    Over the near term, expected claims result from 
underfunding in plans sponsored by financially weak firms. PBGC 
treats a plan sponsor as financially weak based upon factors 
such as whether the firm has a below-investment-grade bond 
rating. PBGC calculates the underfunding for plans of these 
financially weak companies using the best available data, 
including the annual confidential filings that companies with 
large underfunded plans are required to make to PBGC under 
Section 4010 of ERISA.
    For purposes of its financial statements, PBGC classifies 
the underfunding of financially weak companies as ``reasonably 
possible'' exposure, as required under accounting principles 
generally accepted in the United States of America. As of 
December 31, 1999, as disclosed in the financial statements, 
PBGC's estimated ``reasonably possible'' exposure was $5 
billion.
    Over the longer term, exposure and expected claims are more 
difficult to quantify either in terms of a single number or a 
limited range. Claims are sensitive to changes in interest 
rates and stock returns, overall economic conditions, the 
development of underfunding in some large plans, the 
performance of some particular industries, and the bankruptcy 
of a few large companies. Large claims from a small number of 
terminations and volatility characterize the agency's 
historical claims experience and are likely to affect PBGC's 
potential future claims experience as well.
    Methodology for Considering Long-Term Claims.--No single 
underfunding number or range of numbers--even the reasonably 
possible estimate--is sufficient to evaluate PBGC's exposure 
and expected claims over the next ten years. There is too much 
uncertainty about the future, both with respect to the 
performance of the economy and the performance of the companies 
that sponsor insured pension plans.
    PBGC uses a stochastic model--the Pension Insurance 
Modeling System (PIMS)--to evaluate its exposure and expected 
claims.
    PIMS portrays future underfunding under current funding 
rules as a function of a variety of economic parameters. The 
model recognizes that all companies have some chance of 
bankruptcy and that these probabilities can change 
significantly over time. The model also recognizes the 
uncertainty in key economic parameters (particularly interest 
rates and stock returns). The model simulates the flows of 
claims that could develop under thousands of combinations of 
economic parameters and bankruptcy rates. (For additional 
information on PIMS, see PBGC's Pension Insurance Data Book 
1998, pages 10-17, which also can be viewed on PBGC's Web site 
at www.pbgc.gov/publications/databooks/databk98.pdf.)
    Under the model, median claims over the next ten years will 
be about $650 million per year (expressed in today's dollars); 
that is, half of the scenarios show claims above $650 million 
per year, and half below. The mean level of claims (that is, 
the average claim) is much higher, more than $1,050 million per 
year. The mean is higher because there is a chance under some 
scenarios that claims could reach very high levels. For 
example, under the model, there is a ten percent chance that 
claims could exceed $2.6 billion per year.
    PIMS projects PBGC's potential financial position by 
combining simulated claims with simulated premiums, expenses, 
and investment returns. The mean outcome is an $11.6 billion 
surplus in 2010 (in present value terms). However, the model 
also shows the potential for significant downside outcomes. In 
particular, there is nearly a 20 percent chance that the agency 
could return to a deficit in the next ten years and a ten 
percent chance that the deficit could exceed $12.0 billion in 
2010 (in present value terms). These outcomes are most likely 
if the economy performs poorly, in which case PBGC may 
experience large claims amounts and investment losses. PBGC is 
continuing to analyze the best way to manage and reduce the 
risk of insolvency.

                            loss prevention

    During the year, PBGC took a significant step toward easing 
employers' concerns about the Early Warning Program by issuing 
guidance clarifying the scope of the program's operation. Under 
the Early Warning Program, PBGC monitors certain companies with 
underfunded pension plans in order to identify corporate 
transactions that could jeopardize pensions and to arrange 
suitable protections for those pensions and the pension 
insurance program. Following a comprehensive internal review of 
the program, which included discussions with employers, pension 
professionals and others with interest in the program, PBGC 
adopted new more-restrictive screening criteria for determining 
when to contact companies about pending transactions. The 
agency then issued detailed guidance to help plan sponsors and 
pension professionals anticipate when PBGC is likely to be 
concerned about a business transaction and understand the types 
of pension protection PBGC may seek. The new guidance was well-
received, and PBGC anticipates that its new screening criteria 
will result in far fewer contacts with corporate sponsors of 
pension plans.
    During the year, PBGC reached agreements valued at about 
$66 million with 5 companies. These agreements provided 
contributions, security, and other protections for the pensions 
of about 31,000 workers and retirees.

                               litigation

    PBGC continued to face challenges in courts across the 
country, a number of which could impair the agency's ability to 
recover its losses for underfunded plans from the employers 
responsible for those plans. At the end of the year, PBGC had 
81 active cases in state and federal courts and 575 bankruptcy 
cases.
    Major cases in 2000 included:
    White Consolidated Industries, Inc.--In a July 1999 ruling, 
a district court found White liable for the unfunded benefits 
of six pension plans that White transferred to the Blaw Knox 
Corporation in 1985. PBGC later took over the plans because 
they ran out of money or would have been abandoned after Blaw 
Knox ceased business in 1994. PBGC sought to recover 
approximately $120 million, plus interest, for the plans' 
underfunding, alleging that a principal purpose of White's 
transaction was to evade its pension liabilities. This effort 
culminated in the district court ruling. White appealed to the 
Third Circuit Court of Appeals, which affirmed the district 
court's ruling in June 2000. In July 2000, PBGC and White 
reached an agreement settling the litigation and White's 
separate administrative appeal before PBGC challenging the 
agency's calculation of the unfunded benefit liabilities. Under 
the settlement, White agreed to resume sponsorship of the six 
pension plans and pay the plan participants their full plan 
benefits with a 5 percent increase, plus any benefits PBGC did 
not pay because of the legal limits on PBGC's guarantee. White 
also agreed to reimburse PBGC for its costs in paying benefits 
under the plans as well as its litigation costs. Certain 
aspects of the agreement are subject to approval by the 
Internal Revenue Service and the Department of Labor. Should 
the agreement not go forward for any reason, PBGC will keep the 
plans. White will then pay the plan participants the value of 
their unpaid non-guaranteed benefits and pay PBGC $180 million 
less the amount White pays directly to participants. This 
agreement is unprecedented in that it is the only time PBGC has 
conditioned settlement on getting participants benefits they 
would otherwise not be able to receive.
    Copperweld Steel Company.--PBGC continued to pursue 
bankruptcy claims to recover amounts due PBGC and Copperweld's 
three terminated pension plans, which covered about 3,000 
workers and retirees. The company's liquidation trustee 
contests whether PBGC's claims for unpaid minimum funding 
contributions in excess of $1 million are entitled to tax 
priority, and whether the assumptions PBGC prescribes in its 
regulations appropriately measure PBGC's claims for unfunded 
benefit liabilities. In December 1997, the bankruptcy court 
ruled for the liquidation trustee's position on both issues. On 
PBGC's appeal, the district court affirmed the bankruptcy 
court's adverse decision and, in November 2000, the Sixth 
Circuit Court of Appeals affirmed the lower court rulings. PBGC 
is considering whether to seek further review.
    Pineiro, Brooks, and Beaumont v. PBGC.--In 1991, PBGC 
became trustee of three Pan Am pension plans underfunded by 
$914 million. Three former employees of Pan American World 
Airways later filed suit asking a district court to replace 
PBGC with an independent trustee. In 1997, the court initially 
dismissed virtually all of the allegations as meritless, 
leaving open only an allegation concerning the timeliness of 
PBGC's notices of benefit determination to the Pan Am 
participants. The plaintiffs filed an amended complaint in 
January 1998 realleging PBGC delays in issuing benefit 
determinations as well as most of the dismissed allegations; 
PBGC responded with a motion to dismiss the amended complaint. 
In March 2000 the district court issued a new decision that 
vacated significant parts of its 1997 ruling, allowing several 
of the plaintiffs' claims to continue while dismissing others. 
The court's decision focused on the technical legal issue of 
whether PBGC operates as a ``trustee'' or as a ``statutory 
guarantor'' when calculating guaranteed benefits. The district 
court subsequently permitted PBGC to file an immediate appeal 
of its ruling and stayed all further proceedings in the case 
pending that appeal. PBGC's request to immediately appeal the 
district court decision was pending before the appellate court 
at yearend. Despite the exceedingly poor condition of company 
records and the difficulties caused by Pan Am's protracted 
bankruptcy proceedings, PBGC has been paying benefits to Pan Am 
retirees continuously since taking over the plans. The agency 
has completed all benefit determinations for the 53,000 former 
Pan Am workers and retirees.
    Raytech Corporation.--In 1986 Raymark Industries, Inc., 
formerly known as Raybestos-Manhattan, Inc., created Raytech 
Corporation as a wholly owned subsidiary. In doing so, Raytech 
acquired Raymark's profitable assets while leaving Raymark with 
asbestos-related liabilities and two pension plans that are 
underfunded by about $19 million. In 1999, while undergoing 
reorganization in bankruptcy, Raytech filed for a declaration 
that it was not liable for any minimum funding contributions to 
the Raymark pension plans after it ceased being a member of 
Raymark's controlled group. PBGC filed a counterclaim alleging 
that the spin-off of Raytech and Raymark was a scheme intended 
to defraud creditors and asking the court to order Raytech to 
maintain, administer and fund the plans. In December 1999, the 
bankruptcy court granted PBGC's motion for summary judgment and 
ordered Raytech to take full responsibility for the two pension 
plans. The court agreed with PBGC that the transactions that 
separated Raytech from Raymark were intended to defraud 
Raymark's creditors and that PBGC was entitled to relief under 
fraudulent conveyance law. Raytech's appeal was pending before 
the district court at yearend.

                       Annual Performance Report

    PBGC's five-year strategic plan has four broad goals that 
form the framework of the agency's short- and long-term plans. 
In 2000, PBGC updated the plan to cover the period 2000-2005, 
in some cases refining the performance measures to make them 
more meaningful to customers. The PBGC goals are to:
          (1)  protect existing defined benefit plans and their 
        participants, thereby encouraging new plans;
          (2)  provide high quality, responsive services, and 
        accurate and timely payment of benefits to 
        participants;
          (3)  strengthen financial programs and systems to 
        keep the pension insurance system solvent; and
          (4)  improve internal management support operations.
    The performance measures track specific results that are 
significant to PBGC's customers and gauge PBGC's solvency and 
customer service accomplishments. The following table shows the 
results achieved in 2000 and meets the annual reporting 
requirement established by the Government Performance and 
Results Act. More information on PBGC's strategic plan and 
annual performance plan may be found on PBGC's Web site at 
www.pbgc.gov/about--pbgc/mission/mission.htm.

                                    2000 PBGC Corporate Performance Measures
----------------------------------------------------------------------------------------------------------------
            Measure                Applicable Goal      2000 Milestone        2000 Result          Baseline*
----------------------------------------------------------------------------------------------------------------
Protecting the Interests of
 Participants:
Protect the interests of
 defined benefit pension plan
 participants by:
Resolution of bankruptcy         (1)................  **................  82 plans 56,800     92 plans 226,000
 actions with companies                                                    participants.       participants
 sponsoring plans.                                                                             (1999)
Finding and paying benefits to   (1)................  **................  8,265 participants  1,303 participants
 missing participants in plans.                                                                (1999)
Customer Satisfaction:
Achieve ``outstanding'' or
 ``above average'' ratings (on
 a five point customer
 satisfaction scale) for
 inquiries handled:
From people whose plans we       (2)................  74%...............  71%...............  79% (1997)
 trustee.
From pension practitioners/      (2)................  67%...............  62%...............  54% (1997)
 sponsors.
Operations:
Provide reliable estimated       (2)................  88%...............  94%...............  84% (1999)
 benefits to participants that
 are within 10% of final
 benefits and are in clear,
 understandable language.
Reduce from 5-6 years to 4-5     (2)................  4-5 years.........  4.9 years.........  5.95 years (1997)
 years the average time frame
 to send benefit determinations
 to participants in defined
 benefit plans taken over by
 PBGC.
Reduce the age of pre-           (2)................  100% 2 years or     98% 2 years or      98.6% 4 years or
 trusteeship inventory to no                           less.               less.               less (1998)
 more than 1 year.
Send the first benefit payment   (2)................  88%...............  91%...............  83% (1999)
 to an eligible person within 3
 months of receiving his/her
 completed application.
Financial Management:
Collect 99% of pension           (3)................  99%...............  99%...............  97% (1997)
 insurance premiums due.
Research and respond within 90   (3)................  99%...............  99%...............  90% (1999)
 days to requests for premium
 refunds, waiver of premium
 penalties, and
 reconsiderations of PBGC
 premium decisions.
Approximate comparable 5-year    (3)................  **................  PBGC Index........  (1997) PBGC Index
 investment indices for PBGC's
 portfolio performance.
                                   .................    ................  Equities 19.9%      Equities 20.6%
                                                                           20.4%.              20.6%
                                   .................    ................  Fixed-Income 7.6%   Fixed-Income 10.9%
                                                                           7.5%.               8.9%
----------------------------------------------------------------------------------------------------------------
Year in parentheses indicates the year in which the baseline value was set.
**By their nature, these measures do not lend themselves to setting annual targets or milestones. PBGC measures
  performance annually based on actual results.

                     achieving performance targets

    Protecting the Interests of Participants, Thereby 
Encouraging New Plans:
           Six times more missing participants were 
        located through PBGC's efforts during the year compared 
        to the prior year. This was due in part to an agreement 
        allowing PBGC to regularly search the Social Security 
        Administration data base for names and addresses. 
        Participants thus received millions of dollars in 
        pension benefits they otherwise would have lost.
           PBGC also protects participants' interests 
        by educating participants and pension practitioners 
        about defined benefit plans. PBGC conducted 54 group 
        meetings to inform participants in PBGC-trusteed 
        pension plans about the PBGC guarantee and what they 
        can expect. Similarly, PBGC officials participated in 
        59 meetings and conferences with pension practitioners 
        to address issues of mutual concern and to get their 
        feedback.
    Customer Satisfaction:
           PBGC continues to learn about customer 
        expectations and opinions through satisfaction surveys 
        and focus groups, and has set performance targets for 
        both participants' and practitioners' satisfaction 
        through 2005.
           In 2000, participant satisfaction remained 
        at the same level as the previous year. Retired 
        participants receiving benefits continue to report a 
        higher level of satisfaction with PBGC service than 
        those due a future pension. PBGC has taken steps to 
        improve the accuracy and timeliness of benefit 
        estimates and to communicate earlier and more 
        frequently with future payees. These changes will 
        address a major cause of dissatisfaction.
           62 percent of pension practitioners rated 
        PBGC's overall service ``outstanding'' or ``above 
        average'' in 2000, slightly down from the previous 
        year, but within the margin of error. PBGC's 2000 goal 
        was 67 percent. To address this, after year's end, PBGC 
        changed and simplified its premium regulations to ease 
        the burden for plan administrators: prorated premium 
        payments for short plan years are now allowed; the 
        definition of participant for premium purposes is 
        simpler; and the standard for claiming the variable-
        rate premium exemption for a fully insured plan is 
        simpler. By consistently meeting its customer service 
        pledge, and making changes based on practitioner 
        feedback, PBGC expects to improve overall satisfaction 
        in 2001.
    Operations:
           The principal measure of operations is to 
        ``reduce to 3 to 4 years the average time frame to send 
        benefit determinations to participants in defined 
        benefit pension plans taken over by PBGC.'' Efforts to 
        speed up processing have succeeded. Participants 
        received benefit determinations in 2000 almost one year 
        faster on average than participants in the previous 
        year. As an indication of continued improvement in 
        processing times in the future, the average age of 
        unissued benefit determinations was reduced from 2.3 
        years to 2 years.
           During the year, participants received final 
        benefits within 10 percent of the earlier estimated 
        benefits in 94 percent of the cases. PBGC revised this 
        measure, broadening it to include all participants 
        versus the small number of participants included in the 
        old definition. The new definition is more meaningful 
        to the participant universe.
           PBGC further reduced the age of cases 
        awaiting trusteeship. The goal is that no pending case 
        be more than one year old by 2002, reached in annual 
        milestones. At the end of the fiscal year, 98 percent 
        of cases to be trusteed were two years old or less.
           91 percent of eligible participants who 
        completed applications received pension payments from 
        PBGC within three months, a significant improvement 
        over the previous year.
    Financial Management:
           The premium collection rate is the amount of 
        premiums collected divided by the amount of premiums 
        due. PBGC achieved its 99 percent collection goal.
           Practitioners now routinely receive 
        responses to requests for premium refunds, waiver of 
        penalties, and reconsiderations of premium decisions 
        within ninety days 99 percent of the time. 
        Practitioners said this is an important service 
        element, and PBGC responded.
           Investment management results are measured 
        against recognized industry indices aggregated over a 
        five-year period. The five-year period smooths out 
        volatility in annual market performance and provides a 
        more realistic, long-term view of investment success. 
        This year, PBGC's performance approximated the indices 
        for equities and fixed-income investments.

                           program evaluation

    PBGC conducted customer satisfaction surveys of 
participants in plans trusteed by PBGC, and of pension 
practitioners who have dealings with us on premium payment or 
standard termination matters. Evaluation of the survey 
responses resulted in improvements in program operations, as 
discussed earlier in the Annual Report.

                        ITEM 26--POSTAL SERVICE

                              ----------                              


                   Programs Affecting Older Americans

                         carrier alert program

    Carrier Alert is a voluntary community service provided by 
city and rural delivery letter carriers who watch participant's 
mailboxes for mail accumulation which might signal illness or 
injury. Letter carriers report mail accumulations to their 
supervisors, who then notify a sponsoring agency, through 
locally developed procedures, for follow-up action. The program 
completed its 18th year of operation in 2000 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 upon 
hardship or special needs. This policy accommodates the special 
needs of 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 
retail services they have come to expect from the rural ``post 
office on wheels.'' Retail services provided include registered 
and certified mail, accepting parcels for mailing, and taking 
applications for money orders. Rural carriers also provide 
customers with receipts for such services.
    Retail services are available to all customers served by 
rural carriers but are most beneficial to those individuals who 
are elderly or have physical limitations that adversely impact 
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 postal customers who are unavailable to receive 
parcels, but who normally are at home, our letter carriers will 
automatically redeliver the article the following day. In 
addition, if the mailer requests, uninsured parcels are left at 
customer homes or businesses provided there is reasonable 
protection from weather and theft. Both of these policies make 
it easier for customers, particularly the elderly, 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 Postal Service Handbook RE-4, Standards for 
Facility Accessibility by the Physically Handicapped.
    Significant progress continues to be made to increase the 
accessibility of 36,000 Postal Service facilities. Enhanced 
facility features such as accessible routes, handrails, ramps 
and automatic doors benefit physically challenged and elderly 
customers. In 1999 and 2000, 231 accessibility projects were 
completed in existing postal facilities at a cost of $8.8 
million. Our commitment to barrier-free facilities is apparent 
by our continued effort toward retrofitting historic 
facilities. The Postal Service values its elderly customers and 
feels they will benefit from our efforts to make facilities 
more accessible.

                consumer education and fraud prevention

    The U.S. Postal Inspection Service endeavors to alert 
consumers and businesses to various types of postal crimes by 
attracting media attention to crime trends, publicizing 
positive law enforcement accomplishments, circulating media 
releases and hosting crime prevention presentations.
    Older citizens and disadvantaged groups are especially 
dependent on mail delivery for vital purchases, and can be 
particularly susceptible to fraudulent schemes. Illegal schemes 
that rely on the use of the mail are limited only by the 
imagination of con artists. For over 200 years Postal 
Inspectors have been protecting postal customers from 
fraudulent schemes involving the U.S. Mail including 
investment, insurance, health care, telemarketing, loan, and 
merchandise misrepresentation schemes.

                   national consumer protection week

    In 1999 and 2000, the Postal Inspection Service and the 
Postal Service Consumer Advocate's Office joined the AARP, 
Consumer Federation of America, Department of Justice, Federal 
Trade Commission, National Association of Consumer Agency 
Administrators and National Association of Attorneys General to 
launch National Consumer Protection Week (NCPW).
    In 1999 the NCPW theme was ``Know the Rules, Use the 
Tools,'' and focused on educating consumers, particularly 
seniors, about their rights and empowering them to protect 
themselves from fraud and abuse in the marketplace. A variety 
of special events were held across the country and supported by 
informational Web sites, the distribution of consumer awareness 
brochures and consumer fairs.
    The NCPW theme for 2000 was ``Armchair Armor-Shopping 
Safely from Home,'' and was selected because this type of 
consumer fraud is big business. Marketing and 
telecommunications advances in the ``information age'' have 
given everyone, even con artists, the power to boost the 
sophistication and reach of a sales pitch. Fraud promoters now 
masquerade as national firms, using telemarketing, direct mail, 
television or other methods to reach potential victims. Efforts 
by the NCPW partners focused on educating consumers and 
advising them to contact consumer protection agencies prior to 
making purchases to avoid becoming a victim. In an effort to 
reach as many individuals as possible, the Inspection Service 
procured ad space on the Next Generation Network (NGN), which 
has monitors located at convenience stores, gas stations, and 
office buildings in 18 major media markets throughout the 
country, including 8 of the top 10. Six million people view 
NGN's monitors at approximately 5,000 locations each day. The 
number of E*billboard ads totaled over 21 million for the week, 
reaching approximately 42 million Americans at 5,228 locations.

                           deceptive mailings

    Postal Inspectors worked closely with the Senate Permanent 
Subcommittee on Investigations regarding sweepstakes and 
deceptive mailings legislation. As a result, the Deceptive Mail 
Prevention and Enforcement Act was passed and signed into law 
on December 12, 1999. It became Public Law 106-168, and was 
effective in April 2000. The new law protects consumers, 
especially seniors, against deceptive mailings and sweepstakes 
practices by:
           establishing standards for sweepstakes 
        mailings, skill contests and facsimile checks,
           restricting government look-alike documents, 
        and
           creating a uniform notification system 
        allowing individuals to remove their names and 
        addresses from all major sweepstakes mailing lists at 
        one time.
    Additionally, disclosures will make sure that no purchase 
is necessary to enter a sweepstakes and that a purchase will 
not improve consumers' chances of winning a prize. The law also 
creates strong financial penalties for companies that do not 
disclose all terms and conditions of a contest.
    To make the most effective use of the new statute and 
protect consumers, the Inspection Service recently established 
a Deceptive Mail Enforcement Team, composed of Postal 
Inspectors, Inspector Attorneys and Inspection Service fraud 
analysts. The team reviews complaints related to promotional 
mailings to assess their compliance with the Act. As of 
September 30, 2000, 12 subpoenas have been issued, allowing 
Inspection Service personnel to develop information on 
questionable promotions. To date, approximately 57 suspect 
mailings have been reviewed and found to be in compliance with 
the law.

              prize promotions--``project prize fighter''

    Prize promotion fraud continues to target unwary consumers 
who lose millions of dollars each year to fraudulent 
promotions. To combat scams of this nature, the Postal 
Inspection Service joined the Federal Trade Commission, State 
Attorneys General and other law enforcement agencies in 
``Project Prize Fighter.'' The project focused on bogus prize 
promoters who preyed on consumers who had previously entered 
sweepstakes, informing victims they had won a prize, but had to 
pay fees to get them. None of the victims received a prize, 
regardless of how much money they mailed to the unscrupulous 
promoters. ``Project Prize Fighter'' resulted in 24 law 
enforcement actions against more than 40 defendants in 9 
states; the Postal Inspection Service alone brought 10 of the 
enforcement actions.

                           lottery promotions

    Similar to prize promotions, lottery promotions that 
promise large winnings for little effort also target consumers 
and are often aimed at senior citizens who are most vulnerable 
to such scams. In one case, a major international lottery 
promoter was sentenced in Seattle to six months in prison, 
three years' probation and ordered to forfeit $12 million. 
Inspectors seized his assets for restitution to the victims and 
in partial satisfaction of a prior consent agreement.

             work-at-home schemes--``operation job fraud''

    Older Americans are often interested in supplementing their 
income by seeking employment opportunities. Unfortunately, some 
have limited mobility and are enticed by work-at-home 
opportunities promising big earning possibilities. To address 
the continuing problem of fraudulent work-at-home promotions, 
the Postal Inspection Service and numerous offices of the 
Better Business Bureau formed ``Operation Job Fraud.'' 
Operation Job Fraud's mission was three-fold: to alert the 
public to work-at-home schemes, expose these practices and 
operators that deceive and rob the public, and help law 
enforcement in criminal prosecutions.
    The task force identified a variety of work-at-home 
companies, including envelope stuffing, product assembly, 
medical billing, and mystery shopping. Business opportunities, 
such as vitamin sales, auto-dialing machines, selling 
advertising on the Internet, and telemarketing of videotapes, 
books and seminars were also identified. As the task force 
gathered results, information was shared with Postal Inspectors 
to assist in arrests and prosecution. The effort is ongoing.

                               know fraud

    In November 1999, during a weekly radio address, President 
Clinton launched the initial KNOW FRAUD campaign and cited the 
project as ``an excellent example of coordination among federal 
government's consumer protection agencies.'' The campaign, said 
to be the largest consumer protection effort ever undertaken, 
included a postcard mailing to 120 million American households 
alerting consumers to the dangers of telemarketing and mail 
fraud, a national press conference, and more than 100 press 
conferences in cities across the country. To date, the campaign 
has generated well over 100,000 consumer inquiries via the 
established toll-free telephone number and Web site as well as 
through written inquiries. Partners of the national campaign 
included the Council of Better Business Bureaus, AARP, 
Department of Justice, Federal Bureau of Investigation, Federal 
Trade Commission, National Association of Attorneys General, 
Securities and Exchange Commission, and United States Postal 
Inspection Service.
    As a result of the KNOW FRAUD initiative, consumers have 
been educated about unscrupulous telemarketing and mail fraud 
promotions and have learned where to receive help and report 
possible telemarketing and/or mail fraud schemes. In addition 
to the multi-media approach taken by KNOW FRAUD to get the 
message to consumers, North American Precis Syndicate (NAPS) 
reported that 1,276 news articles related to KNOW FRAUD have 
been printed in 36 states with readership of 93.5 million. 
Additionally, 845 radio stations ran KNOW FRAUD broadcasts to 
an audience of 18.5 million.

       fraud and deception on the internet--``getrichquick.con''

    In February 2000, Postal Inspection Service representatives 
were leading participants in the Federal Trade Commission's 
(FTC) ``GetRichQuick.con'' surf project, the largest ever 
international law enforcement project to fight fraud and 
deception on the Internet. During the surf, participants from 
150 organizations in 28 countries discovered and reported on 
approximately 1,600 different Web sites making suspect get-
rich-quick claims. As a result, warning E-mails were sent to 
the targeted sites with hyperlinks to the partners' consumer 
and business education materials.

                             identity theft

    In an effort to educate consumers about identity theft, in 
Fiscal Year 2000, an Inspection Service video news release 
aired on 132 stations, and was seen by 5.6 million viewers. A 
print news release was picked up by 144 newspapers that reached 
7.3 million readers, and a radio broadcast was aired by 271 
stations with a total audience of 8.5 million.

  consumer protection initiatives committee of the attorney general's 
                     council on white collar crime

    In response to President Clinton's request that a long 
lasting partnership of leading private and government agencies 
continues, the Department of Justice formed the Consumer 
Protection Initiatives Committee of the Attorney General's 
Council on White Collar Crime. At monthly meetings, agency 
representatives meet to discuss how to prevent consumer fraud 
and improve coordination among federal government agencies in 
planning consumer protection efforts. Joining the Postal 
Inspection Service are the Federal Trade Commission, Securities 
and Exchange Commission, Department of Treasury and Food and 
Drug Administration. Non-governmental organizations include the 
AARP, Council of Better Business Bureau Foundation, National 
White Collar Crime Center and North American Securities. 
National consumer organizations, as well as state and local law 
enforcement agencies also participate on the committee. This 
multi-agency committee membership allows for the development of 
interagency consumer protection initiatives that target 
enforcement, deterrence and public awareness.

                           health care fraud

    The National Health Care Anti-Fraud Association honored the 
U.S. Postal Inspection Service with its 1999 Investigation of 
the Year award and honorable mention awards for performance in 
two investigations. ``Operation Takeback'' was a four-year task 
force operation that consisted of Florida Division Postal 
Inspectors, officials from Blue Cross Blue Shield of Florida 
and other federal, state and local agencies. The task force 
targeted health care providers that paid illegal rebates, 
bribes and kickbacks in return for patient referrals. Over $2 
million in fines and restitution was ordered by the courts and 
another $1.77 million was returned to the Medicare Trust Fund. 
Additionally, the Inspection Service was recognized for its 
participation in MEDWEB, another Florida Division task force 
case, involving the illegal sales of Medicare patients' names, 
account numbers and prescriptions. To date, 39 convictions have 
been obtained.

                stamps by automated teller machine (atm)

    Stamps by ATM is a convenient way to purchase stamps at a 
bank's automated teller machine. There are currently over 
18,000 ATMs nationwide that dispense stamps. Because many ATMs 
are accessible 24 hours a day, our customers are able to do 
banking and buy postage stamps at their convenience. A 
specially designed sheetlet of 18 First-Class stamps is 
dispensed at the touch of a button. Financial institutions may 
add a surcharge to the face value of the stamps to cover their 
processing costs. The cost is debited from the customer's 
checking or savings account and treated like a cash withdrawal.

                             stamps by mail

    Stamps by Mail is a service that allows customers to 
purchase stamps in booklets, sheets and coils along with other 
products such as post 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. Once the form is completed it can be 
returned to the carrier or dropped 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. Customers utilizing this 
service can call a toll-free number (1-800-STAMPS-24), 24 hours 
a day, 7 days a week, and order from a menu of postal products. 
There is no minimum purchase amount, and customers receive 
their orders within 3 to 5 business days.

                     alternate postal retail sites

    Alternate postal retail sites include grocery stores and 
other retail stores that offer stamps for sale through a 
consignment agreement, and contract Postal Units that offer a 
wider variety of services. Stamps offered through consignment 
agreements are sold at no more than face value at retailer 
checkstands. Contract postal units provide more convenient 
locations for our customers to mail packages, purchase stamps 
and postal money orders, send registered mail, and obtain 
postal services.
    In 1998, the Postal Service began testing a partnership 
with Mail Boxes Etc. (MBE) to sell stamps and postal services 
at 250 MBE locations throughout the United States. In 2000, the 
test partnership expanded to 700 MBE locations. By providing 
services at numerous alternate locations, the Postal Service 
provides greater access and flexibility for all customers to 
obtain stamps and other postal services, which generally means 
less wait time to obtain these retail services. This enables 
customers to combine their mailing needs and other errands into 
a single trip to the neighborhood shopping center or grocery 
store. This is especially convenient for our elderly customers 
who may have limited access to transportation.

                     stamps via the world wide web

    On November 8, 2000, the Postal Service launched the new 
Postal Store, an online retail channel. Accessed through our 
homepage, www.usps.com, The Postal Store offers USPS customers 
an alternative channel for buying stamps and stamp products 
without having to visit a physical retail outlet. With just a 
click of their mouse, customers can browse through ``aisles'' 
displaying a variety of stamps, stationery, Pro Cycling gear 
and phone cards. To provide ease of use, stamps and other 
products are organized and displayed according to categories 
and/or stamp release dates. As an added convenience, credit 
cards are processed and validated at the time orders are 
placed. Security is enhanced through the application of the 
Address Verification System, which verifies a customer's 
billing address through their credit card company. State-of-
the-art order processing and automated fulfillment equipment 
systems ensure the efficient delivery of orders within 3-5 
days.
    This convenient, secure, and easy-to-use web site 
especially benefits customers who, because of special needs, 
prefer to purchase postal and non-postal products from the 
comfort of their homes.

                    stamps highlighting aging issues

    On September 7, 2000, the Postal Service honored the memory 
and work of former U.S. Senator Claude D. Pepper of Florida by 
issuing a commemorative stamp bearing his image. The stamp, 
which is part of the Postal Service's Distinguished Americans 
stamp series, helped celebrate the life of a man who was known 
as a champion for the rights of Senior Citizens in his home 
state of Florida and across the country.

                   ITEM 27--RAILROAD RETIREMENT BOARD

                              ----------                              


Annual Report on Program Activities for the Elderly for the U.S Senate 
                Special Committee on Aging 1999 and 2000

    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 widow(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 2000, retirement and survivor benefit 
payments under the Railroad Retirement Act amounted to nearly 
$8.3 billion, $46 million more than the prior year. The number 
of beneficiaries on the retirement-survivor rolls on September 
30, 2000, totaled 673,000. The majority (85 percent) were age 
65 or older.
    At the end of the fiscal year, 309,000 retired employees 
were being paid regular annuities averaging $1,381 a month. Of 
these retirees, 138,000 were also being paid supplemental 
railroad retirement annuities averaging $42 a month. In 
addition, some 161,000 spouses and divorced spouses of retired 
employees were receiving monthly spouse benefits averaging $530 
and, of the 211,000 survivors on the rolls, 175,000 were aged 
widow(er)s receiving monthly survivor benefits averaging $826. 
About 8,000 retired employees were also receiving spouse or 
survivor benefits based on their spouse's railroad service.
    Some 621,000 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 2000. Of these, 
607,000 (98 percent) were also enrolled for supplementary 
medical insurance.
    Gross unemployment and sickness benefits paid under the 
Railroad Unemployment Insurance Act totaled $111.2 million 
during fiscal year 2000, while net benefits totaled $78.8 
million after adjustments for recoveries of benefit payments, 
some of which were made in prior years. Total gross and net 
payments decreased by approximately $9.9 million and $9.6 
million, respectively, from fiscal year 1999. Unemployment and 
sickness benefits were paid to 35,000 railroad employees during 
the fiscal year. However, only about $0.4 million (less than 1 
percent) of the benefits went to individuals age 65 or older.

                               financing

    At the end of fiscal year 2000, the balance in the Railroad 
Retirement Board's accounts was $18.6 billion, registering an 
increase of $0.6 billion over the previous year, and earnings 
on investments, including capital gains, totaled $1.2 billion 
for the year.
    The Board's 21st triennial actuarial valuation, submitted 
to Congress in June 2000, was generally favotable. The 
valuation concluded that, barring a sudden, unanticipated, 
large drop in railroad employment, the railroad retirement 
system will experience no cash-flow problems during the next 35 
years. The long-term stability of the system, however, is not 
assured. Under the current financing structure, actual levels 
of railroad employment over the coming years will determine 
whether additional corrective action is necessary.
    The Board's 2000 railroad unemployment insurance financial 
report was also favorable, indicating that even as maximum 
benefit rates increase 50 percent from $46 to $69 from 1999 to 
2010, experience-based contribution rates maintain solvency 
even under the Board's most pessimistic employment assumption. 
The report also predicted average employer contribution rates 
well below the maximum throughout the projection period. but a 
periodic resumption of the surcharge required to maintain a 
minimum account balance.
    No increases in the tax rates provided under current law 
were recommended by the Board for the railroad retirement or 
unemployment insurance systems.

                              legislation

    Public Law 106-182, enacted April 7, 2000, eased the 
earnings restrictions affecting social security beneficiaries 
working after full retirement age. The legislation also applied 
to annuitants covered by the Railroad Retirement Act.
    Under the two-tier railroad retirement system, tier I 
railroad retirement benefits and vested dual benefits paid by 
the Board to employees, spouses and survivors, as well as the 
tier II benefits paid to survivors, are subject to earnings 
deductions just like social security benefits, if post-
retirement earnings exceed certain exempt amounts.
    Retroactive to January 1, 2000, the amendments eliminated, 
for those of full social security retirement age, deductions of 
$1 in benefits for every $3 of earnings over and indexed 
earnings limit that previously applied until age 70. Earnings 
deductions, however, remain in effect for beneficiaries who 
have not yet attained full retirement age, and this legislation 
did not eliminate the railroad retirement work restrictions 
which are not included in the Social Security Act.

                               officials

    On May 24, 2000, the Senate confirmed President Clinton's 
nominations of Management Member Jerome F. Kever and Labor 
Member V.M. Speakman, Jr., for reappointment to the Board. 
Cherryl T. Thomas continues to serve as Chair.
    Mr. Kever was first appointed to the Board on the 
recommendation of the Association of American Railroads and the 
Ameridan Short LIne Railroad Association in 1992. He was 
reappointed to another term of office in 1995. Prior to joining 
the Board, Mr. Kever served as a financial consultant to 
private industry and was Vice President and Corporate 
Controller for the Santa Fe Pacific Corporation. His 
reappointment was for a term expiring in August 2003.
    Mr. Speakman was first appointed to the Board on the 
recommendation of the Railway Labor Executives' Association in 
1992. He was reappointed to another term of office in 1995. 
Before joining the Board, Mr. Speakman served as President of 
the Brotherhood of Railroad Signalmen. His reappointment was 
for a term expiring in August 2004.

                service and administrative improvements

    The Railroad Retirement Board implemented various 
initiatives during 1999 and 2000 to improve agency operations 
and provide the best possible service to its customers.
    Customer Service.--For fiscal year 2000, the Board's 
performance versus its customer service standards remained at 
the same high level when compared to fiscal year 1999 
performance.
    Performance improved from fiscal year 1999 levels for 
retirement applications, initial survivor applications, 
survivor conversions, sickness insurance applications, 
unemployment and sickness insurance claims, disability 
decisions and disability payments.
    The most marked improvement came in the rendering of 
disability decisions. For disability applications processed in 
fiscal year 2000, 63.6 percent of applicants received a 
decision within 105 days of their filing dates as compared to 
50.6 percent in fiscal year 1999; and the average processing 
time for decisions improved to 94.7 days, as compared to 116 
days the previous year. In fiscal year 1998, only 28.1 percent 
of applicants received a decision witin 105 days and the 
average processing time was 143.9 days.
    Only in the handling of lump-sum death benefits, 
unemployment applications and correspondence were there very 
slight declines in performance from fiscal year 1999, (0.1 
percent, 0.2 percent and 0.1 percent, respectively). Even with 
these minimal declines in performance, the Board still exceeded 
its annual performance plan targets for the handling of lump-
sum death benefits and unemployment applications.
    New Medicare Carrier Selected.--In April 2000, the Board 
selected Palmetto Government Benefits Administrators LLC, a 
subsidiary of BlueCross BlueShield of South Carolina, to 
process the Medicare Part B medical insurance claims for 
physicians' services to about 650,000 railroad retirement 
annuitants. Palmetto GBA took over the existing Medicare claims 
operations facility of the Board's previous carrier, Uniprise, 
which had informed the Health Care Financing Administration and 
the Board that it was withdrawing from the Medicare program as 
a claims processing contractor.
    Railroad retirement beneficiaries are covered by Medicare 
on the same basis as social security beneficiaries, and the 
Board, which enrolls, annuitants for Part B medical coverage 
and collects premiums, also has authority to select a Part B 
carrier. Carriers for Part A hospital insurance claims are 
selected by the Health Care Financing Administration, which 
runs the Medicare program.
    New Internet Services.--Beginning November 2000, railroad 
retirement beneficiaries and rail employees can access a number 
of new Internet services through the Railroad Retirement 
Board's Web site at www.rrb.gov. The services available include 
requests for:
           Statements of individual railroad service 
        and compensation history
           Replacement Medicare cards
           Duplicate benefit information statements for 
        income tax purposes
           Annuity rate verification letters
    Individuals accessing the Board's Web site for these 
services are asked to complete and submit an on-line form. The 
agency is utilizing the most secure encryption technology 
available to ensure all information it receives through the 
Internet remains confidential and safe from unauthorized 
access. While these same services are available through the 
Board's toll-free automated Help Line at 1-800-808-0772, or 
through any of the agency's 53 field offices nationwide, this 
marks the first time such transactions have been available 
through the Internet. AccessRRB, a new section on the Board's 
Web site, outlines plans for additional services and provides a 
description of the security features that will be employed. 
Also included is an Internet Customer Survey to allow visitors 
to provide feedback on the types of services they would like to 
see the Board offer over the Internet.
    Year 2000 Project.--The Railroad Retirement Board began the 
year 2000 with all its computer systems operating smoothly and 
benefit payments being issued without delay. The Board spent an 
estimated $14 million over a 5-year period to make sure that 
all its computer programs and systems would handle the rollover 
to the year 2000 without interruption. This successful project 
was the largest system development initiative ever undertaken 
by the agency in terms of scope, impact and visibility.
    Data Center.--The Board continued its data center 
improvement program with new tape storage and handling 
equipment replacing a variety of aging tape drives that 
required manual handling and continual oversight. The new 
system, which uses a ``virtual tape server,'' has allowed for 
more efficient data storage, lower operating costs and a 
permanent reduction in staffing requirements.
    Frame Relay Communications.--During fiscal year 1999, the 
Board completed implementation of high speed communications via 
frame relay technology. All field and regional offices as well 
as the agency's Office of Legislative Affairs now have local 
area networks connected to the virtual local area network at 
Chicago headquarters. Frame mainframe databases and systems 
through the network, and access the Internet and in-house 
Intranet. Agency employees can now provide faster, more 
complete service to their customers with significantly less 
telecommunication costs.
    Document Imaging.--During fiscal year 1999, the Board 
completed the first phase of a document imaging initiative to 
reduce use of paper documents in claims processing operations. 
This phase replaced an obsolete imaging system servicing the 
Board's unemployment and sickness benefits system. Initial 
implementation of this initiative into retirement, survivor and 
disability benefit operations took place in fiscal year 2000, 
with additional phases planned through fiscal year 2002.
    Document imaging helps move the agency closer to its goal 
of ``one and done'' service for customers by eliminating the 
need to have a folder in hand to service beneficiaries. The 
agency will save money by eliminating expenses associated with 
storing and transporting folders between the storage facility 
and headquarters.
    Finally, the system's workflow software package, which 
allows users to easily control, assign and track pending work 
assignments, will also help the Board establish new and better 
interfaces with the Social Security Administration since that 
agency uses the same workflow software.

                      office of inspector general

    During fiscal year 2000, the Railroad Retirement Board's 
Office of Inspector General maintained its efforts to assist 
management in increasing the efficiency of agency programs. 
Sixteen audits and reviews issued during the year contained 
findings concerning internal controls, benefit payment 
accuracy, financial reporting and program operations. The 
Office of Inspector General continued to monitor the agency's 
Investment Committee activities and the security controls for 
its automated information systems. It requested that the 
National Security Agency conduct an information systems 
security assessment. As a result of the review findings, the 
agency developed plans to address most of the identified 
weaknesses. The Office of Inspector General also consulted with 
managers concerning the Document Imaging Implementation Plan to 
ensure agency compliance with all applicable laws and 
regulations. Investigative activities resulted in 66 criminal 
convictions, 35 indictments/informations, 45 civil judgments 
and approximately $4 million in investigative financial 
accomplishments.

                     public information activities

    The Board maintains direct contact with railroad retirement 
beneficiaries through its 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 sponsored by the Labor 
Member's Office of the Board 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. 
Approximately 2000 railroad labor union officials attended 39 
informational conferences held in cities throughout the United 
States during 2000. In addition, railroad labor unions 
frequently request that a Board representative speak before 
their meetings, seminars and conventions.
    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 2000, the Management 
Member's Office of the Board sponsored its fourth national 
employer training seminar as well as 10 seminars for railroad 
officials. It also conducted pre-retirement counseling seminars 
attended by railroad employees and their spouses, and benefit 
update presentations.
    The Board's headquarters is located at 844 North Rush 
Street, Chicago, Illinois 60611-2092, phone (312) 751-4500; the 
agency's Web site is www.rrb.gov. 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 28--SMALL BUSINESS ADMINISTRATION

                              ----------                              

    While 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.
    The SBA is the sponsoring Federal agency for the Service 
Corps of Retired Executives (SCORE) program. SCORE is an 
organization of approximately 11,400 retired individuals 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 
former corporate executives. SCORE counseling is confidential 
and free of charge and is provided at more than 386 locations 
in the United States and its territories. E-mail counseling is 
also available through SCORE's web site at www.score.org.

                ITEM 29--SOCIAL SECURITY ADMINISTRATION

                              ----------                              


 Programs Administered by the Social Security Administration, Calendar 
                               Year 1999

    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 46 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 1999.

     i. old-age, survivors, and disability insurance benefits and 
                             beneficiaries

    At the beginning of 1999, about 96 percent of all jobs were 
covered under the Social Security program. 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 
governments have not elected Social Security coverage.
    At the end of December 1999, 44.6 million people were 
receiving monthly Social Security cash benefits. Of these 
beneficiaries, 27.8 million were retired workers, 3.3 million 
were dependents of retired workers, 6.5 million were disabled 
workers and their dependents, 7.0 million were survivors of 
deceased workers.
    The monthly amount of benefits being paid at the end of 
December 1999 was $32.6 billion. Of this amount, $23.7 billion 
was payable to retired workers and their dependents, $4.0 
billion was payable to disabled workers and their dependents, 
and $4.9 billion was payable to survivors.
    Retired workers were receiving an average benefit at the 
end of December 1999 of $804, and disabled workers received an 
average benefit of $754.
    During the 12 months ending December 1999, $386 billion in 
Social Security cash benefits were paid. Of that total, retired 
workers and their dependents received $258.9 billion, disabled 
workers and their dependents received $51.3 billion, and 
survivors received $75.3 billion.
    Monthly Social Security benefits were increased by 1.3 
percent for December 1998 (payable beginning January 1999) to 
reflect a corresponding increase in the Consumer Price Index 
(CPI).

      ii. supplemental security income benefits and beneficiaries

    In January 1999, SSI payment levels (like Social Security 
benefit amounts) were automatically adjusted to reflect a 1.3 
percent increase in the CPI. From January through December 
1999, the maximum monthly Federal SSI payment level for an 
individual was $500. The maximum monthly benefit for a married 
couple, both of whom were eligible for SSI, was $751.
    As of December 1999, 6.6 million aged, blind, or disabled 
people received Federal SSI or federally administered State 
supplementary payments. Of the approximately 6.6 million 
recipients on the rolls during December 1999, about 2.0 million 
were aged 65 or older. Of the recipients aged 65 or older, 
about 711,000 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 1999, 
Federal SSI benefits and federally administered State 
supplementary payments totaling about $2.6 billion were paid.
    For calendar year 1999, $30.1 billion in benefits 
(consisting of $26.8 billion in Federal funds and $3.3 billion 
in federally administered State supplementary payments) were 
paid.

      iii. special benefits to certain world war ii veterans and 
                             beneficiaries

    Under Public Law 106-169, special benefits may be paid to 
certain World War II veterans. The law applies to veterans who 
served in the active military, naval, or air services of the 
United States. It also includes Filipino veterans of World War 
II who served in the organized military forces of the 
Philippines while those forces were in the service of the U.S. 
Armed Forces.
    Qualified veterans will receive a monthly special veterans 
benefit equal to 75 percent of the current SSI Federal benefit 
rate less the amount of any recurring pension benefit income 
for the month. There is no provision for payments to dependents 
or survivors.
    The program began in May 2000; therefore, annual figures 
for numbers of individuals made eligible and benefits paid are 
not yet available. However, as of December 1999, 1,400 
individuals had been found eligible under this program.

               iv. 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.)
    In September 1997, SSA negotiated an agreement with DOL 
under which DOL handles most of SSA's Part B black lung work on 
a reimbursable basis. Under the agreement, SSA is continuing to 
take Part B initial applications for black lung benefits and is 
processing any hearings before administrative law judges. DOL 
performs the following activities for SSA on a reimbursable 
basis: 1) processes Part B black lung claims applications and 
reconsideration's; 2) maintains claims files; 3) processes 
post-entitlement actions; 4) processes benefit payment 
adjustments required for each active, suspended, or terminated 
Part B claim; and 5) prepares and delivers the monthly roll of 
eligible Part B beneficiaries by magnetic media to the 
appropriate disbursing center of the Department of Treasury.
    As of the end of March 1999, about 106,000 individuals 
(85,000 aged 65 or older) were receiving $46 million in monthly 
Part B black lung benefits. These benefits are financed from 
general revenues. Of these individuals, 15,000 miners were 
receiving $10 million, 72,000 widows were receiving $34 
million, and 19,000 dependents and survivors other than widows 
were receiving $2 million. During fiscal year (FY) 1999 SSA 
paid out black lung payments in the amount of $550 million.
    Consistent with the general pay increase for Ferderal 
employees, excluding locality pay adjustments, black lung 
benefits payments increased by 3.8 percent effective January 
2000. The average monthly payment to a coal miner disabled by 
black lung disease increased from $469.50 to $487.40. The 
average monthly benefit for a miner or widow with one dependent 
increased from $704.30 to $731.00 and with two dependents from 
$821.60 to $852.80. The maximum monthly benefit payable when 
there are three or more dependents increased from $939.00 to 
$974.70.
    The conference committee report on FY1998 appropriations 
specified that the SSA and DOL Inspectors General prepare a 
joint report assessing the agreement between the two agencies 
on the handling of Part B black lung claims. The Senate 
Appropriations Committee Report on FY2000 appropriations notes 
that DOL and SSA have agreed to implement a recommendation from 
the report that the two agencies study the feasibility of 
transferring the entire Part B program from SSA to DOL. The 
agencies are directed to report the results of that study to 
the Committee, when completed, and to incorporate those results 
in their subsequent appropriation requests.

                     v. communication and services

    SSA's public information activities are aimed at more than 
44 million Social Security beneficiaries, more than six million 
SSI recipients, and about 154 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 October 1999, SSA began sending a Social Security 
Statement to all workers aged 25 and older. Between October 
1999 and September 2000. SSA mailed about 133 million 
Statements-at the rate of more than 500,000 per day. The 
Statement provides the worker with an estimate of the 
retirement, disability, and survivors benefit they and their 
family may be eligible for. It also lists the worker's earnings 
recorded in Social Security records.
    To help publicize the Statement, SSA released a public 
service campaign in October 1999. It included television, radio 
and print media and garnered more than $9 million in 
advertising space. A new public service campaign, released in 
November 2000, talks about the importance of the Statement, as 
well as inform workers that they should not count on Social 
Security as their sole source of retirement income.
    The agency also produces a wide range of publications on 
all Social Security programs. More than 100 consumer booklets 
and fact sheets keep the public informed about programs and 
policies affecting them. Many publications also are available 
in Spanish, and SSA is developing more informational materials 
in other languages. Many of the publications are available on 
the Internet at SSA's web site, http://www.ssa.gov.

           vi. summary of legislation that affects ssa, 1999

P.L. 106-69 (H.R. 2084), Department of Transportation and Related 
        Agencies Appropriations Act 2000, signed on October 9, 1999
           Provides funding for necessary expenses for 
        the National Transportation Safety Board. It repeals 
        Section 355, Section 656(b) of division C of the 
        Omnibus Consolidated Appropriations Act of 1997, which 
        required Social Security numbers on drivers' licenses.
P.L. 106-169 (H.R. 3443), The Foster Care Independence Act of 1999, 
        signed on December 14, 1999
           Establishes the new title VIII under the 
        Social Security Act and entitles certain SSI-eligible 
        World War II veterans to a benefit payable under this 
        new title. Includes provisions affecting the treatment 
        of SSI resources in countable resources for assets held 
        in trust, imposes penalties for the disposal of 
        resources at less than fair market value, and imposes 
        new nonpayment penalties for false or misleading 
        statements used to establish benefit eligibility. SSI 
        overpayment provisions include increased liability of 
        representative payees for overpayments to deceased 
        recipients, recovery of overpayments of SSI benefits 
        from lump sum SSI benefit payments, and extends to the 
        SSI program all of the debt collection authorities 
        currently available for the collection of overpayments 
        under the OASDI program. Includes a requirement that 
        SSA provide State prisoner information to Federal and 
        federally assisted benefit programs. Includes several 
        systems-based approaches to controlling fraud, e.g., 
        computer matches among Federal and State programs and a 
        provision granting SSA greater access to the financial 
        records of applicants and beneficiaries. Requires SSA 
        to complete a study of denial of SSI benefits for 
        family farmers and to submit this report to Congress.
P.L. 106-170 (H.R. 1180), The Ticket to Work and Work Incentives 
        Improvement Act of 1999, signed on December 17, 1999
           Directs the SSA Commissioner to establish a 
        Ticket to Work and Self-Sufficiency Program under which 
        a disabled beneficiary may use a ticket issued by the 
        Commissioner to obtain at SSA expense, employment and 
        vocational rehabilitation services or other support 
        services, pursuant to an appropriate individual work 
        plan, with services provided by Employment Network, 
        paid under either an outcome or an outcome-milestone 
        payment system, or by established State VR agencies. 
        Establishes a Work Incentive Advisory Panel and a Work 
        Incentives Outreach program and authorizes the 
        Commissioner to make payments to protection and 
        advocacy systems established in each State. Eliminates 
        work activity as a basis for conducting continuing 
        disability reviews for individuals entitled to 
        disability benefits for at least 2 years, establishes 
        an expedited reinstatement process for former 
        beneficiaries whose benefits were terminated due to 
        work, and directs the Commissioner to conduct 
        demonstration projects (such as $1-for$2 benefit offset 
        program) to test the effects of possible national 
        program modifications on beneficiary behavior. Extends 
        the incentive payment provisions in effect for SSI 
        prisoners to OASDI, and authorizeds the Commissioner of 
        Social Security to provide, on a reimbursable basis, 
        this reported information to any ageny administering a 
        Federal or federally assisted cash, food, or medical 
        assistance program for the purpose of determining 
        program eligibility.

                ITEM 30--DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                            I. INTRODUCTION

    The Department of Veterans Affairs has the potential 
responsibility for a beneficiary population of more than 25 
million veterans. The median age of veterans is approximately 
58 years old compared to a median age of approximately 34 years 
old for the general U.S. population. Over thirty-six percent 
(or more than 9 million) 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.
    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 healthcare 
services. The number of physician visits, short-term hospital 
stays, and number of days in the hospital, as well as need for 
long-term care services, 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 facility 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 healthcare system in the Nation, 
encompassing 172 hospitals, 132 nursing home care units, 40 
domiciliaries, and over 600 outpatient clinics. VA also 
contracts for care in non-VA hospitals and in community nursing 
homes, provides fee-for-service visits by non-VA physicians and 
dentists for outpatient treatment, and supports care in 93 
State Veterans Homes in 43 States. As part of a broader VA and 
non-VA network, affiliation agreements exist between virtually 
all VA healthcare facilities and nearly 1,000 medical, dental, 
and associated health schools. This affiliation program with 
academic health centers results in approximately 91,000 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 and 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 diseases, hearing and vision 
disorders, and a variety of other illnesses and disabilities 
are all more prevalent in those persons 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

                   A. Office of Patient Care Services

    The Office of Patient Care Services comprises thirteen 
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 healthcare system from a bed-
based, hospital inpatient system to one rooted in ambulatory 
care.

                Geriatric Primary Care Education Program

    The Employee Education System, Northport Center, sponsored 
a national conference for the purpose of providing an 
integrated Geriatric Primary Care Education Program that would 
allow each VHA Network to develop and implement a Geriatric 
Primary Care model. The emphasis was on continuity of care, 
care management, and assessment/triage, based on an 
interdisciplinary approach. The conference also provided a 
forum for discussion of a variety of successful VA and non-VA 
Geriatric Primary Care models of care, and attempted to link 
the models to FY99 Performance Measures.
    Conference participants included a multidisciplinary team 
composed of a geriatrician and various primary care providers 
(physician, physician assistant, nurse practitioner, clinical 
nurse specialist and social worker) from each Network. In 
addition, the Northport Center purchased Geriatric Primary Care 
pocket guides and pocket pals for all conference participants 
and for each VA facility.
    The Employee Education System, Northport Center, will 
continue to coordinate the activities of VHA's National Primary 
and Ambulatory Care Education. The Northport Center, in 
collaboration with Primary and Ambulatory Care, Geriatric Care 
and Mental Health is planning to present a Strategic 
Integration Conference.

                               Dentistry

    Oral/dental care for the geriatric patient involves the 
restoration of the dentition and the elimination of pain and 
suffering attributable to oral disease. Microorganisms 
originating in the mouth have been identified as the causative 
agents for life-threatening infections of the heart, brain, 
lung, kidney, spine, and joints. There is growing evidence, 
much of it deriving from longitudinal studies at several VA 
facilities, that chronic periodontal (gum) disease plays a role 
in causing heart attacks and stroke.
    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 age 40. Tobacco, alcohol, 
and advanced age are important risk factors in the development 
of this disease. Through a long-standing program of oral 
screening examinations, VA dentists have been able to 
expeditiously detect incipient oral cancers in veterans. Such 
interventions minimize mortality rates and the need for 
ablative surgery, which often results in severe disfigurement 
and functional difficulties in eating, speaking, and 
swallowing.
    It is important for older veterans to be able to masticate 
a variety of foods so that daily maintenance of caloric and 
nutritive intake, as well as convalescence after surgery, 
chemotherapy, or other significant radical interventions, is 
expedited. Elimination of the causes of oral pain and 
replacement of missing oral structures both work to enhance the 
amount and number of choices of foods that can be eaten. 
Interpersonal skills, which are highly dependent upon physical 
appearance, and effective communication are enhanced by 
improving the patient's appearance and by properly aligning and 
restoring anterior teeth to maintain clarity of speech.
    Destruction of tissues due to dental decay and the 
periodontal diseases is chronic and, in the elderly, usually 
asymptomatic. For this reason, public and private healthcare 
payers may perceive oral healthcare directed at dental and 
periodontal diseases as a low priority or even a luxury. In 
older patients, dental and periodontal diseases are often 
aggravated by coexistent medical problems; the oral disease in 
turn contributes to systemic illness, and in this way drives up 
healthcare costs. The relatively minor expense associated with 
preventive dentistry thus represents a net saving in overall 
health costs. Preventive modalities can include the use of 
home-applied fluoride solutions, anti-microbial mouth rinses, 
specially fabricated toothbrushes, instruction to family or 
caregivers on oral hygiene techniques, and more frequent dental 
examinations.
    Most VA facilities have a Geriatric Evaluation and 
Management (GEM) Program. The goals for all disciplines 
involved in geriatrics--to maximize function and to foster 
independence--are reflected in dentistry's goals for elderly 
veterans.
    Patients are rehabilitated more rapidly with properly 
staged and coordinated care. To that end, Dental Services 
contribute to the 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. The VA Program Guide, ``Oral Health Guidelines 
for Long-Term Care Patients,'' developed by the Offices of 
Patient Care Services, the Office of Dentistry, and the Office 
of Geriatrics and Extended Care, continues to serve as the 
primary handbook for management of the geriatric oral health 
efforts. It describes the goals, implementation and monitoring 
of oral care provision for patients in VA long-term care 
programs.
    VA dentistry is an undisputed leader in geriatric oral 
healthcare training. GEMs and nursing homes serve as training 
sites for all of the existing advanced formal training programs 
in geriatric dentistry in the United States. VA-trained 
geriatric dentists have appointments on a majority of the 
dental school faculties in the United States. More than one 
fourth of all hospital-based general dentistry post-graduate 
education takes place in VA medical centers, where the 
residents devote much of their educational efforts to the 
clinical management of older veterans.
    The impact of VA programs in geriatric dentistry is not 
limited to VA's healthcare system, but extends to a broader 
level. VA dentistry is represented on National Institute of 
Dental Research reviews, a U.S. Surgeon General's workshop on 
oral health promotion and disease prevention, the development 
of the first Surgeon General's Report on Oral Health, and on 
review panels for programs in medical and dental geriatric 
education funded by the Department of Health and Human 
Services, Health Resources and Services Administration.
    VA dentists are and have been long involved at the highest 
levels of leadership in the professional organizations 
(American Society for Geriatric Dentistry, American Association 
of Hospital Dentists, Federation of Special Care Organizations 
in Dentistry, American College of Prosthodontists, American 
Association for Dental Research, Gerontological Society of 
America) most heavily concerned with oral care issues for older 
adults. 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, and VA dentists have 
been noteworthy contributors to these efforts to define 
geriatric educational objectives and identify source materials 
for dental faculty members.
    VA dentists have been leaders and active participants in 
recent projects involving health services and basic research 
relevant to the older adult. One investigator has developed 
measures to assess the relationship between oral health and 
overall quality of life in older patients. Longitudinal studies 
of older veterans in Massachusetts and Michigan have yielded a 
wealth of knowledge on the relationships between age, systemic 
disease, oral diseases, and diet. VA researchers have surveyed 
VA dental services to determine the effectiveness of smoking 
cessation interventions; others have investigated the education 
of both dental and non-dental health providers with respect to 
oral cancer risk factors and screening.
    Multicenter longitudinal clinical studies through VA have 
examined the Efficacy of metal, ceramic, and ceramo-metal 
crowns. Another VA cooperative study has amassed the largest 
database in the world on the emerging alternative to 
toothlessness, osseointegrated implants, and the factors that 
predict their successful implementation. VA clinical studies on 
preventive strategies and materials in oral cancer patients 
have set the standards for management of such patients 
internationally. Finally, research, in collaboration with NIH, 
is ongoing to discover biological markers for the detection of 
oral cancer.
    In summary, VA dentistry and the Office of Dentistry 
continue to support efforts that will benefit older veterans in 
the three general areas that define the mission of the 
Department. First, the provision to elderly veterans of quality 
oral healthcare, of both preventive and restorative character, 
is recognized by and practiced within VA as an important and 
cost-effective component of total health maintenance. Second, 
education in geriatric oral health is critical on many levels, 
and will continue to be a VA focus directed at veterans; VA 
dental staff and residents; the dental profession and dental 
education communities; and non-dental providers such as nurses, 
physicians, and family members. Third, VA dental research has 
enhanced and will continue to broaden our understanding of oral 
disease, its relationship to general health, and its treatment 
in older adults.
Acute Care Strategic Health Care Group (SHG)
    The Acute Care Strategic Health Care Group (ACSHG) serves 
the elderly veteran in a variety of ways. In FY1999, 54 percent 
of the patients on inpatient medical services and 47 percent on 
the inpatient surgical services were over 65. This age group 
accounted for 58 percent of Intensive Care Unit (ICU) days and 
50 percent of Outpatient Care (OPC) surgery. The ACSHG 
continues to serve as the primary source of physicians trained 
in medical specialties for the care of all veterans, including 
the elderly. Elderly patients tend to have more complex medical 
problems and require more frequent hospitalizations than other 
age groups. It is necessary that acute care services continue 
to be available and adequately staffed to meet these demands. 
This is particularly true in medical specialty areas such as 
cardiology, pulmonology, endocrinology, rheumatology, oncology 
and the surgical specialty areas of urology, cardiothoracic, 
vascular, and orthopedic surgery. Most medical problems 
afflicting the geriatric patient can be handled by Primary Care 
physicians on a general medicine ward. However, there is also a 
need for areas such as Geriatric Medicine within the acute 
hospital setting to provide the specialized care needed by the 
complex geriatric patient. These Geriatric Medicine Sections 
not only emphasize clinical care, but also coordinate research 
and education efforts related to geriatrics. The implementation 
of Primary Care within Acute and Ambulatory Care has 
facilitated a smoother transition for the elderly patient from 
outpatient to inpatient care as the need arises.
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 (NHCUs), 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 1999, more than 46,000 veterans were treated in 
VA's 132 NHCUs. The average daily census of patients provided 
care on these units was 12,653.
    Plans are underway for systemwide implementation of the 
Resident Assessment Instrument/Minimum Data Set (RAI/MDS) in VA 
NHCUs. The (RAI/MDS) is a valid and reliable standardized 
multidisciplinary assessment database and treatment planning 
process. The RAI/MDS has been in use in community nursing homes 
since 1990 when it was mandated by Health Care Finance 
Administration (HCFA) as a provision of the Omnibus 
Reconciliation Act of 1987.
    Implementation of the RAI/MDS will enhance care provided 
nursing home patients. The MDS gathers comprehensive functional 
status information on residents admitted to nursing homes. The 
interaction of the elements of the MDS triggers problem areas 
that are highlighted to facilitate the development of 
individualized treatment plans. The interaction of elements of 
the MDS also determines Resource Utilization Groups (RUGs). 
RUGs are used for identifying case mix and determining resource 
allocation to meet the needs of patients served. The RUGs can 
additionally serve as indicators of outcomes of care delivered. 
Finally, and perhaps, most importantly, the MDS will generate 
information regarding the quality of care patients receive. VA 
is providing interdisciplinary NHCU staff educational programs 
in the use of the RAI/MDS and automation required to support 
this initiative.

                      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 six months. Selection of 
nursing homes for VA contracts 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. In Fiscal Year 1999, more than 28,900 veterans were 
treated and the average daily census of veterans in these homes 
was 4,537.

                          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 an 
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 1999, 24,161 veterans were treated in 40 VA 
domiciliaries resulting in an average daily census of 5,235. Of 
these numbers, nearly 5,000 veterans, with 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 43.7 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 93 state homes in 43 states. Currently, a total of 
24,154 state home beds are 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 1999, state veterans homes provided care to 
6,032 veterans in domiciliaries and 21,220 veterans in nursing 
homes. The average daily census of veteran patients was 3,680 
for domiciliary care and 15,014 for nursing home care.

                      Hospice and Palliative 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/palliative concept of care is 
incorporated into VA facility approaches to the care of the 
terminally ill. All VA facilities have appointed a hospice 
consultation team, which is responsible for planning, 
developing, and implementing the hospice and palliative care 
program.

                        Home-Based Primary 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 
home-based interdisciplinary treatment team. The team 
prescribes the needed medical, nursing, social, rehabilitation, 
and dietetic regimens, and provides training to family members 
and the patient in supportive care.
    Seventy-eight VA medical centers are providing home-based 
primary care (HBPC) services. In fiscal year 1999, home care 
was provided by VA health professionals to an average daily 
census of 6,828 patients, treating a total of 13,880 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 
1999 with an average daily attendance of 462 patients. VA also 
continued a program of contracting for ADHC services in 83 
medical centers. The average daily attendance in contract 
programs was 809 in Fiscal Year 1999.

               Community Residential Care/Assisted Living

    The Community Residential Care/Assisted Living program 
provides residential care, including room, board, personal 
care, and general healthcare 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 or 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 1999, 
an average daily census of 7,964 veterans was maintained in 
this program, utilizing approximately 2,100 homes.

                   Homemaker/Home Health Aide (H/HHA)

    VA provided homemaker/home health aide services for 
veterans needing nursing home care. These services are offered 
in the community by public and private agencies under a system 
of case management provided directly by VA staff. One hundred 
and eighteen VAMCs purchased H/HHA services in Fiscal Year 1999 
with an average daily census of 3,141.

                  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 healthcare 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 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. In 1999, there were 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. While they range in size, each program typically 
provides care to approximately five veterans on any given day.
    An earlier formal evaluation of the program 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 Group in VA 
Headquarters. Veterans with these diagnoses participate in all 
aspects of the healthcare system.
    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 (GRECCs), and which is supported through the 
VA Office of Research and Development as well as extramural 
sources. In Fiscal Year 1999, VA investigators were involved in 
266 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, some of which are 
available to the general public through inter-library loan.
    In Fiscal Year 1999, staff at the Minneapolis GRECC 
continued work on a professional caregiver version of 
Alzheimer's Caregiving Strategies, a multimedia computer 
program (CD-ROM) that VA previously produced for education and 
training of family caregivers for patients with dementia. This 
interactive program provides basic information on Alzheimer's 
disease; guidelines with examples for assessing the functional 
capacity, or stage, of dementia; and strategies for dementia 
care that are appropriate at each stage. The Minneapolis GRECC 
also produced a four-part satellite video conference series on 
the diagnosis and treatment of Alzheimer's disease.
    Also in Fiscal Year 1999, a field-based work group 
completed a VA clinical guideline on Pharmacological Management 
of Cognitive Changes in Alzheimer's Disease.
    Another major activity in Fiscal Year 1999 was VA's 
continued participation, through its Upstate New York 
Healthcare Network, in a national demonstration project on 
Alzheimer's disease and managed care. This project, ``Chronic 
Care Networks for Alzheimer's Disease,'' is being co-sponsored 
by the Alzheimer's Association and the National Chronic Care 
Consortium. With funding from the Robert Wood Johnson 
Foundation and other sources, the implementation phase of the 
project is now underway.
    As part of a project examining ways to improve home- and 
community-based end of life care for persons with advanced 
dementia, a national survey of caregivers was conducted in 
Fiscal Year 1999. With additional funding from the national 
Alzheimer's Association, this ongoing Dementia End of Life Care 
project is now developing instruments to measure key outcomes 
of this type of care. Principal investigators for this project 
are at the GRECC in Bedford, Massachusetts.

          Geriatric Research, Education, and Clinical Centers

    Geriatric Research, Education and Clinical Centers (GRECCs) 
are designed to enhance 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 GRECCs continue to 
serve an important role in further developing the capability of 
the VA healthcare 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 GRECC's coordination with VA's 
Health Services Research and Development 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 networks in which each GRECC is located.
    In Fiscal Year 1999, GRECCs continued to make a number of 
contributions to the field of aging and care of the elderly. 
Some examples of these contributions are: further research on 
the Alzheimer's gene discovered by researchers at the GRECC in 
Seattle, Washington; the dissemination of a CD-ROM for family 
caregivers of Alzheimer's patients (developed at the 
Minneapolis GRECC); and an evaluation by the Sepulveda, 
California, GRECC of an interdisciplinary model of geriatric 
primary care for elderly patients.
           Researchers at the West Los Angeles, 
        California, GRECC are studying how a special bicycle 
        exercise program affects muscle strength and movement 
        speed in patients with strokes. Results to date show 
        improved knee muscle strength in both legs with most 
        subjects also having greater walking speed and improved 
        stability on one leg. Results indicate that the 
        recumbent bicycle is a safe and inexpensive tool to 
        improve or maintain muscle strength necessary for 
        walking in patients who have had strokes.
           At the Madison, Wisconsin, GRECC, 
        investigators are examining tongue strength and 
        swallowing in the elderly. Previous research has shown 
        that tongue strength decreases with age and appears to 
        be associated with diminished tongue muscle mass, 
        slower swallowing, and higher incidence of choking on 
        liquids. A new exercise program to strengthen tongue 
        muscle has increased strength and speed of swallowing 
        and has eliminated choking in the elderly people who 
        have participated to date.
           At the Durham, NC, GRECC, investigators 
        recently completed a five-year, randomized, clinical 
        trial that compared two exercise programs among 
        community-dwelling elders: spinal-flexibility plus 
        aerobic exercise versus aerobic-only exercise. Both 
        groups improved significantly on the primary measures 
        of impairment, movement of the spine and the body's 
        ability to use oxygen. Participants in both groups also 
        reported significant improvements in overall health, 
        total number of symptoms reported, and the effect of 
        symptoms on functional limitations.
           Ann Arbor, MI, GRECC, researchers have 
        studied immune function and survival in mice treated 
        daily with the male hormone, dihydroepiandosterone 
        (DHEA). Their results demonstrate that lifelong 
        consumption of DHEA does not extend the life span of 
        experimental animals. Mice given DHEA also showed no 
        improvement in their immune function when tested late 
        in middle age. These data provide no support for the 
        popular idea that exposure to DHEA is likely to lead to 
        dramatic improvements in immunity or disease resistance 
        in the aging human population.
           Bedford, MA, GRECC researchers have studied 
        the effectiveness of antibiotic therapy in advanced 
        dementia. In their work, they consider the burden of 
        treatment as well as its potential for effectiveness. 
        Bedford researchers have demonstrated that antibiotics 
        are no more effective than palliative care in 
        preventing death from infection in persons with 
        advanced dementia. Results indicate that the use of 
        antibiotics in advanced dementia has very limited 
        benefit, while producing significant burden for 
        patients due to stressful, invasive diagnostic 
        procedures as well as side effects from the antibiotic 
        therapy. Therefore, these researchers recommend a 
        ``high-touch,'' palliative treatment strategy when 
        planning end of life care for these patients.
           At the Miami, FL, GRECC, investigators 
        evaluated the effectiveness of research-based 
        interventions in preventing falls in a hospital 
        setting. Structured education on fall prevention was 
        initiated for nursing staff in all units. The fall rate 
        two years after the intervention was significantly 
        lower. The patients who fell were identified to be at 
        risk and had a history of falls. The most common site 
        for falls was at bedside. Most falls occurred during 
        walking, climbing over the siderails, or accidentally 
        rolling out of bed. The investigators concluded that a 
        research-based fall prevention program is effective in 
        reducing falls.
           Bedford, MA, GRECC researchers have 
        developed ``Bright Eyes,'' an innovative, group 
        treatment program providing sensory stimulation 
        experiences to patients with advanced Alzheimer's 
        disease. The goal is to combat the effects of sensory 
        deprivation while promoting engagement and 
        socialization. The sensory cues are organized around a 
        specific theme and are selected to represent familiar 
        experiences for the veterans, such as going to a 
        baseball game. Because persons with Alzheimer's disease 
        are often unable to initiate activity, the ``Bright 
        Eyes'' program provides an important opportunity for 
        patients to participate in meaningful activity.
    During 1998, VHA solicited proposals from VA facilities and 
networks for establishing new GRECCs. In FY1999, 2 new GRECCs 
were designated at the Cleveland VA and Pittsburgh VA 
facilities, bringing the total number of GRECCs to 18. A 
solicitation to expand the program further was also initiated 
in 1999.
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 psychogeriatric 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 both clinic and other community-based programs and a 
growing continuum of residential care, acute, subacute, and 
long-term hospital programs in each of the 22 Veterans 
Integrated Service Networks (VISNs). Close collaboration with 
Geriatric and Extended Care Services at the medical centers is 
strongly recommended. Some of the specific activities in Fiscal 
Year 1999 are noted below:

                  New Mental Health Program Guidelines

    The VHA Program Guide (1103.22) called Integrated 
Psychogeriatric Patient Care published March 26, 1996, was 
updated and condensed as a chapter in a new publication, Mental 
Health Program Guidelines for the New Veterans Health 
Administration (1103.3). Both program guides are recommended as 
a resource for clinicians serving elderly veterans and non-
veterans alike.

    UPBEAT (Unified Psychogeriatric Biopsychosocial Evaluation and 
                               Treatment)

    UPBEAT, a controlled demonstration project at 9 VA 
facilities costing $2 million annually, 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 and treatment 
plan, care coordinators follow patients with positive symptoms 
for a two-year period. With only a year until the project is 
completed, preliminary results of 887 patients show 
statistically significant (p=0.029) savings of 3.66 days per 
patient for UPBEAT care in the first year of enrollment (as 
compared to 935 ``usual care'' patients)--an estimated savings 
of over $3.4 million. Eight VA medical centers outside of the 
demonstration project are also interested in adopting the 
UPBEAT intervention.

    Aging, Mental Health, Substance Abuse, and Primary Care Program

    The Veterans Health Administration, through its offices of 
Mental Health, Geriatrics and Extended Care, and Primary and 
Ambulatory Care, has established an interagency Memorandum of 
Agreement with the Department of Health and Human Services, 
Substance Abuse and Mental Health Services Administration 
(SAMHSA) and Bureau of Primary Health Care (BPHC) of Health 
Resources and Services Administration (HRSA). This agreement is 
intended to support a cross-cutting initiative to determine if 
there are statistically significant differences over a full 
range of access, clinical functional, and cost variables 
between primary care clinics that are referring elderly 
patients to specialty mental health or substance abuse (MH/SA) 
services outside the primary care setting and those that are 
providing such services in an integrated fashion within the 
primary care setting. It will also address improving the 
knowledge base of primary health care providers to recognize 
MH/SA problems in older adults. During this year, six VA and 
five non-VA sites have agreed to participate by developing the 
necessary clinical resources and rigorous research protocols.
Physical Medicine and Rehabilitation Strategic Healthcare Group (SHG)
    Physical Medicine and Rehabilitation services strive 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, the prescription of adaptive equipment 
and provide treatment to enhance function in activities of 
daily living, vocational/avocational activities, 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 and social 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 (VHA). There has been some 
shifting of acute rehabilitation beds to less resource 
intensive subacute beds. The subacute rehabilitation setting 
affords VHA 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 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) monitors outcomes of care and increases 
the accuracy of developing predictors and ideal methods of 
treatment for the older veteran with various diagnoses. Through 
a national contract with UDS/mr, facilities with rehabilitation 
programs provide data and receive outcome reports as part of a 
national and international UDS/mr data bank. Use of the FIM as 
a functional assessment tool is available to all VA medical 
centers through connectivity to the Functional Status and 
Outcomes Database (FSOD) for Rehabilitation housed at the VA 
Austin Automation Center, Austin, TX. The FSOD allows tracking 
of rehabilitation outcomes across the full continuum of care 
based upon a severity of illness index, the Function Related 
Groups.
    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, 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 
percent 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 an inpatient, outpatient, residential or independent living, 
therapeutic recreation services focus on restoring or 
maintaining optimum independent living and quality of life. 
Recreation therapists:
           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 skill training programs 
        within the patients' range of abilities and facilitate 
        community integration through the use of existing 
        resources.
    The Department of Veterans Affairs is actively involved in 
a partnership with the Very Special Arts Organization. In 1974, 
Very Special Arts was founded by Jean Kennedy Smith as an 
affiliate of The John F. Kennedy Center for the Performing 
Arts. The VA/VSA Art Program was developed to provide VA 
medical center patients with quality arts experiences through 
workshops, art residencies and community-based activities. The 
program encourages patients' artistic talents, and strengthens 
independent living and communications skills through creative 
writing, dance, drama, music, and the visual arts. A revised 
artist-in-residence brochure that highlights the program was 
recently distributed to all Veterans Health Administration 
medical centers.
    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 of the United States. Numerous 
corporate sponsors provide financial support, and hundreds of 
local volunteers provide on-site assistance each year.
    The 1999 NVGAGs were hosted by the VA Healthcare Network 
Upstate New York. The 2000 program will be hosted by the VA 
Eastern Kansas Healthcare System during the week of September 
4-9, in Topeka, KS.
Nursing Strategic Healthcare Group (SHG)
    Nursing Service, in support of VHA's reorganization and 
``Journey of 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 greater 
collaborative teamwork as nursing strives to integrate advances 
in technology and 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 initiative, 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 have facilitated 
interdisciplinary leadership to create and strengthen programs 
to help keep patients in their homes as long as possible. These 
include Adult Day Care Programs, Home-Based Primary Care, and 
Case Management to coordinate multiple health services. 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 health care 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 healthcare. 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 as clinical care managers, coordinators of care, and case 
managers. Through sustained patient partnerships, APNs provide 
healthcare 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 the 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 services for veterans in the 
community-at-large.
    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. Nurses have responded to 
the growing emphasis upon end-of-life issues by providing 
training and local programs for palliative care, including 
hospice programs. Pain management in the elderly has been 
identified as a major problem and will be part of the National 
Pain Management Strategy. These collaborative experiences 
promote a culture and image of an agency that is committed to 
quality care and quality of life for aging veterans.
    To assist facilities in meeting performance measures, 
nurses have been involved in developing creative alternatives 
to acute inpatient care. This includes chronic ventilator 
programs, which extend into nursing home and even home 
settings. There is also increased emphasis upon defining VA 
Nursing Home Care Unit (NHCU) programs as transitional and 
rehabilitative, providing a realistic discharge option for 
patients continuing to require nursing intervention and who 
were previously confined to acute wards. VA NHCUs continue to 
demonstrate a significant restraint reduction. 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 restraint 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 and VA NHCUs success 
in reducing the use of chemical and physical restraints in care 
of the elderly. Such an environment enhances resident behaviors 
in independence, decision making and socialization.
    Multi-arts programs have been developed including Tai Chi, 
Dance, Art Appreciation, Hands on Art, Sign Language and 
Creative Writing. Patient outcomes include an increase in 
mobility and functions and an increase in spontaneity and 
happiness as measured by standardized instruments.
    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 Minimalization and 
        Interdisciplinary Assessment Tool Effectiveness;
           Patient Education, Health Promotion and 
        Maintenance;
           National Minimum Data Set Implementation;
           Clinical Pathways; and,
           Assessment of Pain/Implementation of Pain as 
        the 5th Vital Sign.
    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. 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 
healthcare team continues to focus on specific patient care 
outcomes including quality of life, assessment of pain, 
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 FY1996 to provide a 
focus within the Veterans Health Administration (VHA) 
concerning the appropriate use of pharmaceuticals in the 
healthcare of veterans. A secondary goal was to decrease the 
overall cost of healthcare through achievement of the PBM's 
primary goal. As VHA has transitioned from an emphasis on 
inpatient care to ambulatory/primary care, pharmaceutical 
utilization has increased dramatically and will continue to do 
so.
    One of the key organizational elements of VHA's PBM is its 
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 bring consistently best 
pharmaceutical practices into the VA healthcare 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 
that 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. To date, eleven Pharmacologic Management 
Guidelines, sixteen Drug Class Reviews, five Clinical Practice 
Guidelines, and nine Criteria for Use documents have been 
developed and promulgated for use in the VA healthcare system. 
Many areas of interest and merit in addressing the health 
conditions of elderly patients are included in the published 
drug treatment guidelines; they include depression, congestive 
heart failure, benign prostatic hyperplasia, Alzheimer's 
disease, Erectile Dysfunction, and Criteria for Use for COX-2 
Inhibitors. In addition, to improve the use of drugs in elderly 
patients, VA is implementing a screening tool in VISTA 
(formerly known as the Decentralized Hospital Computer Program) 
to identify patients receiving medications known to require 
close monitoring in elderly patients. Facilities will use this 
tool to individually tailor the patient's drug therapy.
    During FY1998 and FY1999, dramatic increases in the 
utilization of pharmaceuticals and the dollars expended on 
pharmaceuticals occurred across VHA. Through the use of 
effective contracting strategies tied to the development of 
disease management guidelines, the ability of VHA to provide 
quality medical care at an affordable price was achieved. 
Members of Congress, members of veterans service organizations, 
and individual patients generated considerable interest in VA's 
National Formulary and related processes. Initiatives in 
applied research regarding formulary decisions and in 
medication data management began in 1998. These efforts are 
crucial to the continued evolution and future value of the PBM 
to VHA's mission.
Allied Clinical Services Strategic Healthcare Group (SHG)

                       nutrition and food service

    A new Interdisciplinary Task Group was established to 
develop Nutrition Performance Measures that identify nutrition 
indicators for patients at risk for malnutrition. These 
performance measures will provide a nutrition profile of acute 
care, chronic and elderly long-term veteran patients.

                          social work service

    Meeting the biopsychosocial healthcare needs of an aging 
population of veterans and the needs of 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 healthcare environment, as well as 
cost-effective and efficient in addressing the social 
components of healthcare, has led to a re-examination of social 
work priorities and their relevance to VA's healthcare mission, 
with special reference to the needs of chronically ill, frail 
elderly veterans. Without a support network of family, friends, 
and community health and social services, healthcare gains 
would be lost and VHA acute care resources would be over-
burdened. Frequently, it is 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 and 
Adult Day Health Care 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 and 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 veteran 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 healthcare 
team and as a key player in the provision of healthcare 
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 for the 
elderly is provided in the home by family, neighbors and 
others. The family, ordinarily the veteran's spouse, is the key 
decision-maker concerning health insurance issues, access to 
health resources and community support services.
    As VHA transitions from an acute care to a primary care/
community interactive healthcare 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, and Case Management Outcomes and Measures: 
A Social Work Source Book, in August 1997. These standards are 
used as a starting point and part of the educational process 
that takes place at each VA facility 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 healthcare 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 veterans' 
healthcare needs and those of their caregivers. During 2000, 
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 healthcare in terms of 
its absolute relevance to successful healthcare outcomes. In a 
revitalized and reconfigured VA healthcare system with expanded 
entitlement for long-term care service, issues of coordination, 
access, cost, and appropriateness of VA and community services 
will be determined not only by the needs of the veterans, 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 appropriate 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 
the prosthetic equipment needs of the disabled veteran.
    Currently, the majority of geriatric veteran patients 
treated in VHA's primary care clinics receive some type of 
prosthetic appliance. Prosthetic and Sensory Aids Service 
(PSAS) furnishes such appliances as eyeglasses, canes, 
crutches, wheelchairs, hearing aids, orthopedic shoes, arch 
supports, artificial limbs, and home oxygen equipment. PSAS 
also arranges for training and instructions on the use of these 
prosthetic appliances.
    PSAS employees simplify the geriatric patients' 
communication difficulties with private home care durable 
medical equipment companies. They arrange for delivery and 
training on a variety of devices such as hospital beds, patient 
lifts, and environmental control appliances that the geriatric 
patient would have considerable difficulty in arranging 
themselves. Vendors have to have in-depth prescription and 
unique needs of the patients explained to them by PSAS 
employees prior to delivery, installation and instructions.
    PSAS employees are also a vital link between the local VAMC 
clinic teams and geriatric veteran patients in developing the 
prescription needs of patients with catastrophic disabilities. 
The knowledge of appliances and componentry available in the 
private sector and VA sources is used to complete the 
prosthetic appliance prescription in the manner that meets the 
veterans prescription needs as well as maximizing the VA 
resources at hand.
Telemedicine Strategic Healthcare Group (SHG)
    The Telemedicine Strategic Healthcare Group has the mission 
of furthering the innovative use of information and 
communications technologies to provide and support healthcare 
for veterans across distance and time barriers. VHA has played 
a leadership role in telemedicine, which involves the use of 
different communication technologies to transmit diagnostic and 
therapeutic information across significant distances. 
Telemedicine is expected to play an increasingly important role 
in improving healthcare for veterans by providing greater 
access to care, continuity and timeliness of care, reduction in 
travel time, and connectivity between providers and patients at 
remote locations.
    Clinicians throughout VHA in many clinical specialties have 
used different telemedicine technologies to improve access, 
coordination and continuity of care for veterans. The 
Telemedicine Strategic Healthcare Group will continue to 
evaluate and recommend strategies to improve the capabilities 
for new information technologies to assist clinicians in 
bringing down the barriers of distance and time and, thereby, 
enhance the support of healthcare delivery to the older 
veteran.
Spinal Cord Injury/Disorders Strategic Healthcare Group (SHG)
    The Spinal Cord Injury and Disorders (SCI&D) Strategic 
Healthcare Group (SHG) provides primary, specialty, and 
rehabilitation care for veterans with spinal cord injuries and 
disorders. Due to health care interventions and improved 
methods of long-term management, veterans with SCI&D are living 
longer. The average current age of veterans with SCI has been 
estimated to be twelve years older than the average current age 
in the general SCI population. Over twenty percent of the 
general SCI population is over the age of 61, and since the 
veteran geriatric population is proportionately larger than the 
general population, this percentage is also significantly 
larger. A recent program review, noted that twenty-eight 
percent of veterans offered initial VHA rehabilitation for new 
SCI onset are over the age of sixty-five while only nine 
percent are over the age of sixty-five in other modes of SCI&D 
care. There have been increases in the incidence of aging-
related spinal cord problems and increasing survival rates for 
older persons with SCI in addition to basic demographic 
changes. Major clinical issues related to aging with a spinal 
cord injury being addressed in VHA include recurrent pressure 
ulcers, degenerative processes related to overuse syndromes, 
long-term urinary tract and gastrointestinal tract 
complications, cardiovascular changes and silent ischemia, 
pulmonary complications, assisted living, home care services, 
and the psychological and social impact of losing caregiver 
support.
    With over thirty-six percent of the total veteran 
population being 65 years old or older (compared with thirteen 
percent of the general population), long-term care is a 
critical issue for America's veterans. VA is intensifying its 
strategy development for providing long-term care for elderly 
veterans. VISN 8, with the support of regional Paralyzed 
Veterans of America (PVA) chapters, is taking steps to assure 
high-quality institutional and non-institutional long-term care 
to paralyzed veterans enrolled in Network 8. The VISN8/PVA 
Long-Term Care Working Group has established estimates of need 
among Network 8 paralyzed veterans across all elements of long-
term care, and identified additional VA and State of Florida 
resources that can serve these needs. The group recognizes 
unmet needs in Puerto Rico and is working to find ways to 
address those needs. The VISN8/PVA Long-Term Care Working Group 
is a positive model for constructive partnership. The SCI&D SHG 
is also working collaboratively with a veterans service 
organization on policies regarding follow-up care for veterans 
with spinal injury and disorders who use community nursing 
homes. Certain SCI Centers have significant long-term care 
components to their missions and goals.
    Research on aging and SCI&D is a high priority in VA. The 
SCI Quality Enhancement Research Initiative has several concept 
papers and research initiatives pertinent to issues of aging 
with a disability. Service directed research on SCI and 
surgical risk may address aging as a moderating variable, while 
aging issues could also be addressed in response to a Request 
for Applications (RFA) regarding pressure ulcer prevention and 
management. The important scientific and clinical knowledge 
gaps identified by consumers and providers related to the 
unique issues of aging with an SCI injury are being summarized 
from work with regional focus groups. Research on SCI 
preventive medicine and health promotion issues may also have 
findings related to aging. The SCI Quality Enhancement Research 
Initiative (QUERI) has also identified a sub-committee to 
address aging, disability, and long-term care research issues. 
Over the next three years, solicitations will be developed 
regarding aging and clinical areas for which additional 
research is needed. Both the Rehabilitation Research Center at 
the Houston VAMC and the Geriatric Research, Education, and 
Clinical Center (GRECC) at the Brockton/West Roxbury VA are 
focusing research on aging with a spinal cord injury.
Forensic Medicine Strategic Healthcare Group (SHG)
    Forensic Medicine SHG operates to coordinate the interface 
between law and medicine in VHA. Within this context, Forensic 
Medicine is involved in VHA support to Veterans Benefits 
Administration (VBA) claims processing activities. This 
primarily involves Headquarters coordination for compensation 
and pension examinations in support of veterans' claims for 
benefits. These examinations are required by VBA to enable the 
adjudication of most disability claims. Although not 
specifically focused on aging veterans, the work of this SHG, 
particularly in the compensation and pension process, directly 
affects benefits to elderly veterans, surviving spouses and 
dependents.

                 B. Office of Research and Development

    Because of the often unique and difficult health problems 
of the elderly, VA is engaged in a vigorous research effort 
that approaches aging from a number of directions reflecting 
the multi-faceted nature of aging.
    The commitment to research on aging veterans is 
demonstrated by the fact that the Office of Research and 
Development has established aging as one of nine Designated 
Research Areas (DRA) under which virtually all VA Research and 
Development programs and projects fall. For clarity, a DRA is 
defined as an area of research in which VA has a particularly 
strong strategic interest because of the prevalence of 
conditions within the VA patient population, the uniqueness of 
a specific patient population and its disease burden to the VA 
system or the importance of the question to healthcare delivery 
within VA. Clearly, veteran aging and its associated problems 
fall within this definition. VA research that is considered to 
fall primarily within the Aging DRA includes:
           Normal age-related changes in the body's 
        structure and function;
           Aging syndromes, such as frailty, 
        immobility, falls, cognitive impairment;
           Compound problems and co-morbidities, such 
        as dementia and hip fractures;
           Care of elderly veterans; and,
           End-of-life issues hospice care, ``quality 
        of dying'', and similar areas.
    Below are highlights of recent advances in research on 
aging veterans from each of the Office of Research and 
Development's programs: Medical Research, Health Services 
Research and Development, Co-operative Studies, and 
Rehabilitation Research and Development.

                   medical research service overview

    Medical Research Service (MRS) administers VA biomedical 
research focussed on the etiology, pathogenesis, diagnosis, and 
treatment of diseases affecting veterans. Aging research 
continues to be a priority area within MRS. The studies 
comprising the aging research portfolio examine many aspects of 
the wide spectrum of changes that occur during normal aging as 
well as syndromes associated specifically with the elderly, 
e.g., dementia, osteoporosis, etc.
    MRS administers scientific research via several mechanisms 
intended to support the most scientifically meritorious work by 
investigators. Investigator-initiated proposals submitted to 
the MRS Merit Review program are peer-reviewed prior to 
funding; the funded programs form the backbone of our 
biomedical research. (See studies described below.) 
Additionally, MRS supports young investigators through several 
mechanisms, including a new training program initiative, the 
Associate Investigator (AI) program. Scientists may then elect 
to submit to the Career Development or the Merit Review Entry 
Program, each of which provides research support in a mentoring 
environment as the applicants progress toward independent 
research careers. These early awards are considered crucial to 
our efforts to attract and retain investigators interested in 
working in geriatric research.
    In addition to individual awards, MRS established the 
Research Enhancement Award Program (REAP) during this fiscal 
year to promote and support groups of VA investigators studying 
medical areas of importance to the veteran population. The REAP 
program enables collaborating researchers to integrate basic 
science and clinical research approaches with understanding and 
treatment of these conditions. The goals of the REAP are to 
train new investigators, develop new and innovative research 
approaches to medical problems, and foster collaboration among 
investigators working in common areas. More than half of the 
funded REAPs are studying problems related to aging, including:
           pathogenesis, prevention and treatment of 
        bone disease;
           molecular mechanisms of lung host defense;
           chronic obstructive pulmonary disease;
           defense mechanisms in colonic epithelia;
           diagnosis and management of dementing 
        disorders;
           pathogenesis and treatment of cerebral 
        ischemia;
           neurogenetics and neuroendocrinology of 
        dementia;
           cellular activation in prostate cancer;
           mechanisms of neuronal degeneration;
           cardiac remodeling and arrhythmogenesis; and
           basic mechanisms of cardiac hypertrophy and 
        failure.
    Previously established research centers, where scientists 
are working collaboratively on a specific medical condition, 
continue to be supported by MRS. Research centers with 
components related to aging include:
           alcoholic liver disease;
           schizophrenia; and
           diabetes.
    MRS also supports the Geriatric Research Education and 
Clinical Care (GRECC) program by funding the pilot projects in 
the GRECCs that have been peer-reviewed and determined to 
bescientifically meritorious. Ongoing pilot project work 
includes:
           a study of the factors that may increase the 
        risk of post-stroke depression, and similarities and 
        differences between post-stroke depression and 
        depression in neurologically normal geriatric patients;
           the epidemiology of resistant pathogens in 
        residents admitted to an acute care facility from long-
        term care facilities;
           examination of the post-infarction recovery 
        of elderly patients; and
           comparison of two models of mental health 
        and alcohol abuse service delivery to determine 
        effective strategies for older veterans.
Merit Review Programs
    MRS currently supports over 100 research projects related 
to aging. Listed below are the objectives of some of the 
programs that received funding during this fiscal year.

                         normal aging processes

           Determine if difficulties in performing 
        tasks of daily living by older adults may be related to 
        the oxygen deficit that occurs when older subjects are 
        physically active.
           Examine whether transplants integrate with 
        the host and provide functional recovery in aged as 
        well as middle-aged and young subjects.
           Examine the relationship between age-
        dependent alterations in oxidative DNA damage and the 
        increased vulnerability of dopaminergic neurons to 
        toxins, early senescence, and cell death.
           Determine the factors that may explain why 
        certain infections (e.g., sepsis) are more damaging in 
        aged patients compared to younger patients.
           Understand how human aging alters lipid-
        mediated gene expression in the immune system, which 
        may provide insight into age-related problems in 
        immunologic defense mechanisms.
           Examine night-time incontinence in older 
        males via a pilot test of a treatment based on hormonal 
        therapy.
           Understand the role of the Werner Syndrome 
        gene to elucidate the basic sequence of aging events, 
        as well as obtain clues for therapeutic intervention in 
        some of the common geriatric disorders.

                                 stroke

           Obtain new information concerning the role 
        of neurite growth regulating factors in brain 
        connectivity and recovery following stroke in the aged 
        central nervous system.

                             mental health

           Examine the benefit of treating alcohol 
        dependence in older adults who are receiving treatment 
        for major depression where subjects will be randomly 
        assigned to receive either naltrexone or placebo in 
        addition to sertraline and compliance enhancement 
        therapy.

                             schizophrenia

           Study the contribution of certain brain 
        neurotransmitters (glutamate and GABA) to schizophrenia 
        and determine if they differentially are related to 
        cognitive deficits in elderly schizophrenics.

                                 cancer

           Determine how older oncology patients are at 
        increased risk for cardiotoxicity from anthracyclines 
        used to treat different cancers.
           Increase the understanding of the regulation 
        of certain enzymes, matrix metalloproteases (MMP), in 
        neoplastic prostate growth, especially in relation to 
        tumor grade in specimens from patients and in the 
        induction or repression of tumor metastasis. These 
        studies should determine if certain MMPs would be good 
        candidates as bioindicators in future studies 
        predicting the latent or aggressive nature of prostate 
        tumors.

                                obesity

           Determine if sequence variances in a gene 
        (lipoprotein lipase) affects the amount of weight loss 
        and metabolic responses during a hypocaloric diet 
        treatment for obesity.
           Determine how age-related changes in muscle 
        may be responsible for the decrements in energy 
        expenditure and thus contribute to obesity.

                                anorexia

           As older people ingest less food than do 
        younger, they are at risk of developing severe 
        malnutrition in the presence of a disease. Study will 
        examine reasons for the physiological anorexia of 
        aging.

                      neurodegenerative disorders

           Determine if treatment with estrogen 
        enhances cognition and skills of independent living for 
        postmenopausal women with Alzheimer's disease.
           Determine whether overcoming insulin 
        resistance by administering insulin intravenously 
        enhances cognitive performance in patient with 
        Alzheimer's.
           Examine the basic mechanisms underlying the 
        interactions between glutamate neurotoxicity and the 
        inflammatory second-messenger system.
           Examine whether progressive neuronal loss 
        may be related to environmental factors and genetically 
        determined susceptibility, and determine if there are 
        intermediate declines that might be identified before a 
        full-blown Parkinson's Disease is diagnosed.
           Examine the pathology of Alzheimer's disease 
        through a murine slice culture study of the mechanisms 
        of amyloid B protein deposition.

                               alcoholism

           Determine if aging and alcohol dependence 
        involve similar stresses on neurochemical transmission.
           Examine the benefit of treating alcohol 
        dependence in older adults who are receiving treatment 
        for major depression.

                              osteoporosis

           Understand the underlying pathology for the 
        changes in parathyroid gland function that occurs with 
        aging and its impact on bone and mineral metabolism in 
        the elderly.
           Enhance current knowledge of the cellular 
        and molecular basis of osteoarthritis.

            health services research and development (hsr&d)

    Research supported by the Health Services Research and 
Development Service (HSR&D) is designed to enhance veterans' 
health and functional status and the quality of care provided 
to elderly veterans. HSR&D researchers focus on identifying 
effective and cost effective strategies for the organization 
and delivery of health services and for optimizing patient- and 
system-level outcomes. They employ the expertise and 
perspectives of clinicians, social scientists, and managers to 
advance the field of health services research and answer 
practical questions that are important both inside and outside 
VA. Elderly veterans and their special health care needs have 
always been a major focus of HSR&D activity.
    Through its various programs, HSR&D supports both research 
that is (1) pertinent to aging, and (2) research that addresses 
unique aspects of aging. In the first case, a large proportion 
of HSR&D projects active in FY1999 addressed health care for 
chronic diseases and conditions that are especially common in 
the elderly. For example, in the Investigator-Initiated 
Research (IIR) program, 12 projects focused on treatment and 
outcomes for cardiac disease, including hypertension, coronary 
artery disease, acute myocardial infarction, chronic lung 
disease, and stroke. Six IIR projects focused on prostate 
cancer, emphasizing patient preferences for treatment and 
quality of life. Additional IIR projects as well as projects 
funded under other HSR&D programs, addressed health care for 
cancer, depression, diabetes, osteoarthritis, pressure ulcers, 
and other conditions for which elderly veterans seek or receive 
care. In this research, HSR&D investigators are examining 
access to care, clinical decision-making, health care costs, 
utilization patterns, and a wide range of patient outcomes, 
including quality of life and functional status. Several of 
these projects address racial and ethnic variations in health 
care utilization and seek explanations for observed 
disparities.
    This report emphasizes HSR&D research activity in areas 
unique to aging, as defined in the Designated Research Area. 
Presently, this includes research related to:
           Aging syndromes, such as frailty, 
        immobility, falls, cognitive impairment;
           Care of elderly veterans; and
           End-of-life issues.

             A. HSR&D Investigator-Initiated Research (IIR)

    HSR&D's IIR program supports research projects proposed and 
carried out by investigators at VA medical centers throughout 
the Nation. This includes projects proposed in response to 
special solicitations initiated in VA Headquarters. All 
proposals undergo rigorous peer review to assure scientific/
technical merit and importance to VA. IIR projects range in 
duration from one to four years.
    In FY1999, HSR&D supported 12 continuing IIRs and initiated 
6 new IIRs with a specific focus on aging. (Asterisk identifies 
projects scheduled for completion during FY1999.). These 
address the following:

                            Aging syndromes:

           the effect of clinical guidelines on 
        pressure ulcer care in nursing homes (Berlowitz);
           trial of a physical restoration intervention 
        to reduce falls in the frail elderly; (deVito)*; and
           assessment of physical health status in 
        older adults using Item Response Theory (McHorney IIR 
        95-033).

                                  new

           effectiveness of health education to improve 
        well-being and reduce health care utilization and costs 
        for frail elderly outpatients (Engelhardt).

                            Care of Elderly:

           decline in functional status as a quality 
        indicator for long-term care (Rosen);
           a system for case-finding and referral of 
        elderly veterans in primary care (Rubenstein);
           the effect of patient- and system-level 
        factors on the use of VA and non-VA health services 
        among elderly veterans (Morgan);
           patient outcomes and treatment preferences 
        for prostate cancer (2 projects) (Bennett*, Clark); and
           process, structure and outcomes of post-
        stroke rehabilitation care (Duncan).

                                  new

           patient decision-making regarding hormone 
        replacement therapy (Schapira);
           assessment of pressure ulcers via 
        telemedicine (Lowery); and
           validation of a Spanish translation of a 
        cognitive assessment tool (Morgan-de Vito).

                          End-of-Life Issues:

           attributes of the quality of dying, from the 
        perspective of patients, family members, and providers 
        (Tulsky)*; and
           an intervention to encourage comprehensive 
        advance care planning (Pearlman)*.

                                  new

           study of terminally ill older persons, their 
        families and physicians, to better understand 
        preferences and communication issues at the end of life 
        (Fried); and
           the needs and concerns of patients with 
        advanced cancer (Schiller).

                  B. Nursing Research Managed by HSR&D

    In 1995, VA's Research and Development Office, in 
collaboration with the Nursing Strategic Healthcare Group, 
implemented a program to encourage new research on nursing 
topics and to expand the pool of nurse investigators in VA. The 
Nursing Research Initiative (NRI) invites proposals for health 
services research, medical research and rehabilitation 
research. Of the 19 projects funded under this initiative to 
date, several focus on treatment or management of conditions 
that occur most frequently in the elderly (e.g., heart failure, 
COPD).
    NRI research that addresses aspects of the Aging DRA 
includes one new project and nine ongoing projects, as follows:

                            Aging Syndromes:

           Gait and balance training to reduce falls 
        and fear of falls (Galindo-Ciocon)
           Measure of risk of developing a pressure 
        ulcer (Wilson)

                            Care of Elderly:

           Nurse managed clinic for dementia patients 
        and family caregivers (Maddox)
           Effect of activity on sleep in cognitively-
        impaired veterans (Richards)
           Informal caregivers of veterans with 
        dementia (Clipp)
           Managing resistance to care in patients with 
        Alzheimers Disease (Hurley)
           Pain management and behavioral outcomes in 
        dementia (Buffum)
           Nurse counseling for physical activity in 
        primary care patients (Dubbert)

                                  new

           dementia outcomes assessment module (Cody)

                          End-of-Life Issues:

           Use of pain resource nurses to improve 
        outcomes of cancer pain (Hagan)

                   C. Service-Directed Research (SDR)

    This is a centrally-directed program of health services 
research carried out by VA field staff, VHA Headquarters staff, 
and/or contractors engaged to analyze specific problems. 
Projects include program evaluations, information syntheses, 
feasibility studies, new initiatives and other research 
projects responsive to specific needs identified by Congress, 
other federal agencies, or Department of Veterans Affairs 
executives and managers.
    Ongoing HSR&D Service-Directed Research (SDR) projects 
focus on issues relevant to aging veterans. These projects 
include a study of patient preferences in advanced metastatic 
prostate cancer and costs, quality of life and functional 
outcomes of veterans treated for multiple sclerosis. A study to 
improve the quality of ambulatory care focuses on six health 
care conditions important to elderly veterans (angina, 
obstructive lung disease, depression, diabetes, hypertension, 
and problem drinking).
    Five continuing HSR&D projects related to women's health 
are expected to benefit aging female veterans. These projects 
address issues of access to VA care; rehabilitation concerns of 
women with spinal cord injuries; depression, surgical risks and 
outcomes; alcohol prevalence, screening and self-help; and 
gender differences in compensation and pension claims for PTSD.
    During FY1999, researchers completed two SDRs related to 
aging veterans. One study focused on the clinical management of 
veterans with stroke. A second study developed and tested 
measures of health-related quality of life applicable to 
veterans.

           D. Quality Enhancement Research Initiative (QUERI)

    HSR&D is leading the new Quality Enhancement Research 
Initiative (QUERI) launched in FY1998 by the Office of Research 
and Development to create and implement a national system to 
translate research discoveries, innovations and proven clinical 
strategies into patient care. QUERI is a comprehensive, data-
driven, outcomes-based quality improvement program promoting 
excellence in outpatient, inpatient, and long-term care. This 
initiative currently focuses on eight specific clinical 
conditions: mental health, substance abuse, diabetes, chronic 
heart failure, ischemic heart disease, stroke, spinal cord 
injury, and HIV/AIDS. While these conditions are not uniquely 
related to aging, all are important in elderly veterans and 
account for a major component of their health care use.
    In FY1999, as part of QUERI, HSR&D initiated two projects 
focused on diabetes care; five projects on ischemic heart 
disease, and one project on mental health. Additional aging-
related QUERI research is anticipated in FY2000 and beyond.

           E. Management Decision and Research Center (MDRC)

    HSR&D's Management Decision and Research Center (MDRC) 
translates research into practice by bringing technology 
assessment, management consultation, and research findings to 
managers, policymakers and clinicians within and outside of VA. 
For example, MDRC's Information Dissemination Program (IDP) has 
created a wide variety of products utilizing both print and 
electronic mechanisms to disseminate important research 
information. Communication media include televideo broadcasts, 
R&D's web page and fax on demand system, and various print 
publications such as a series of primers, Management Briefs, 
and a biannual newsletter. Another IDP publication is VA 
Practice Matters, which summarizes the results of important 
research within VA and promotes its application by describing 
the potential impact and possible implementation strategies and 
resources. In FY1999, one issue of Practice Matters focused on 
Primary Stroke Prevention, a topic of importance in elderly 
veterans.
    Also in 1999, MDRC's Technology Assessment Program produced 
two evaluations on topics relevant to elderly patients: shared 
decision-making programs for patients with prostate cancer, and 
the use of stereotactic pallidotomy for treatment of 
Parkinson's disease. Other relevant assessments currently 
underway include evaluations of brachytherapy (a radiation 
therapy) for prostate cancer; systematic reviews of impotence 
therapies; minimally invasive treatment options for abdominal 
aortic aneurysms; and an update on the assessment of the use of 
positron emission tomography as a diagnostic test for cancer 
and Alzheimer's disease. The Technology Assessment Program has 
also produced (released in January, 1999) a systematic review 
of treatments for erectile dysfunction, a common complaint 
among elderly males. Currently underway is another systematic 
review, requested by VA's Rehabilitation Strategic Health Care 
Group, assessing a new computerized lower limb prosthesis. Leg 
amputation is a relatively frequent complication of vascular 
disease in the elderly, whose difficulty learning to walk with 
a prosthesis may be reduced by technologic improvements.
    In addition, MDRC's Management Consultation Program 
initiated an evaluation of a demonstration hospice program at 
the request of the VHA Medical Sharing Office and the VA Palo 
Alto Health Care System (HCS) and in collaboration with VA's 
Office of Geriatrics and Extended Care. Under new VA sharing 
authority, the Palo Alto HCS is expanding its inpatient hospice 
beds to serve additional veterans and, for the first time, non-
veterans referred under contracts with community hospice 
agencies. The evaluation is designed to determine whether the 
revenues from non-veterans cover the costs of caring for them 
and to assure that preference for veterans and quality of care 
are maintained in the service. This project will be completed 
in FY2002.

                     F. HSR&D Centers of Excellence

    HSR&D's Centers of Excellence conduct research and support 
the integration of research and practice. Each Center develops 
its own research agenda, is hosted by a collaborating VA 
Medical Center and maintains affiliations with community 
institutes and schools of public health, university health 
administration programs, and research institutes to support its 
goals and objectives. Of the eleven ongoing HSR&D Centers, 
seven are conducting aging research in addition to the work 
highlighted above (IIRs, SDRs, and QUERI).
    The Northwest Center for Outcomes Research in Older Adults 
in Seattle, Washington, is a collaboration of VA Puget Sound 
Health Care System and the Portland VA Medical Center. Major 
community institutions supporting Center research are the 
University of Washington School of Public Health and Community 
Medicine and the Kaiser Permanente Center for Health Research 
in Portland. Research focuses on three areas: (1) primary and 
specialty care management of chronic disease; (2) preservation 
of independence in older adults; and (3) evaluation of 
alternative systems of health care delivery. In FY1999, VA 
researchers at the Seattle Center were involved in 117 
individual projects. Illustrative research on aging addresses: 
Chronic diseases that are common among the elderly, including 
heart disease, depression, urinary tract infections and 
diabetes; identification and treatment of hearing impairment 
(Yueh); predictors of better outcomes of community residential 
care (Hedrick); and effectiveness of rehabilitation services 
(Evans).
    The Midwest Center for Health Services and Policy Research, 
in Hines, Illinois, is a joint program of Hines VA Hospital, 
North Chicago VA Medical Center and the Chicago VA Health Care 
System. The Center currently maintains academic affiliations 
with all of the major universities in the Chicago area and has 
an established program of research in long-term care and 
geriatrics, as well as other aspects of health services 
research. Examples of research at Hines include projects 
focused on assisted living (Guihan), risk factors for 
femorodistal bypass surgery or amputation (Fineglass, Cowper), 
and the effects of exercise on aerobic capacity and quality of 
life in heart failure patients (Collins). In addition, HSR&D 
researchers at the new VA Information Resource Center (VIREC) 
are working to merge VA data with Medicare data. This project 
(Hynes) is a collaboration of VA's Office of Policy and 
Planning and the Health Care Financing Administration. The 
merged data will be a valuable resource for studying care of 
the elderly within and outside VA.
    The Center for Health Services Research in Primary Care at 
the Durham, North Carolina VAMC emphasizes projects that 
enhance the delivery, quality and efficiency of primary care 
provided to veterans. The Center's academic affiliations with 
Duke University and the University of North Carolina at Chapel 
Hill support a variety of research collaborations. Of the 79 
research projects underway in FY1999, many specifically address 
age-related conditions seen in primary care and other aspects 
of health care for elderly veterans. Ongoing research at the 
Durham Center includes projects focused on defining best 
practices for patients with stroke (Oddone) and diabetes 
(Edelman); understanding the influence of race on access to 
care; and examining the utility of telemedicine in diagnosing 
dermatologic lesions (Whited).
    The Center for Health Quality, Outcomes and Economic 
Research based in Bedford, Massachusetts, emphasizes research 
related to improving the quality of health care for elderly 
veterans. Ongoing projects focus on quality of long-term care 
(Rosen), veterans' hospice care (Hickey), and other issues in 
end-of-life care. Other studies focus on care for particular 
conditions that are very common in elderly veterans, including 
hypertension (Berlowitz), diabetes, osteoporosis (Miller), 
prostate disease (Boehmer); and oral health (Jones).
    The HSR&D Center for Practice Management and Outcomes 
Research in Ann Arbor, Michigan, emphasizes outcomes research 
and studies to improve the quality of clinical practice. The 
Center is affiliated with the University of Michigan Hospitals, 
Medical School and School of Public Health. Additionally, this 
Center is fully integrated with VA's Serious Mental Illness 
Treatment Research and Evaluation Center (SMITREC), a special 
evaluation and research field program of the Mental Health and 
Behavioral Sciences Strategic Healthcare Group (at VA 
Headquarters). Aging research at the Ann Arbor Center addresses 
quality improvement; costs and quality of diabetes care; 
prostate cancer treatment (Wei); and mental health issues 
relevant to older veterans (Kales).
    The Sepulveda, California, HSR&D Center for the Study of 
Healthcare Provider Behavior has affiliates at the West Los 
Angeles campuses of the VA Greater Los Angeles Healthcare 
System and the San Diego VA Healthcare System and collaborates 
with two non-VA institutions--the University of California 
(campuses at Los Angeles and San Diego) and the RAND Health 
Program. The Center seeks to build a knowledge base that will 
help researchers, policy makers, and health care managers 
design, implement and evaluate policies and programs to improve 
health outcomes. During FY1999, investigators at Sepulveda 
conducted over 80 research projects at VA and non-VA locations. 
Research relevant to aging addresses variations in VA primary 
care delivery and the implications for facility performance 
(Yano); improving care for depression (Rubenstein); and 
provider adherence to smoking cessation guidelines (Sherman). 
Additionally, an evaluation of intervention strategies to 
improve prevention activities among elderly veterans was 
completed in 1999 (Shekelle).
    The Center for Chronic Disease Outcomes Research at 
Minneapolis, MN, has a broad-based research portfolio, with 
programs in prevention, treatment outcomes, quality of care, 
and gender issues. HSR&D research underway at Minneapolis 
includes an assessment of physician knowledge, attitudes, and 
practices regarding adult immunization (Nichol); an evaluation 
of the determinants of osteoporotic fractures in men (Ensrud); 
and a study of the effectiveness of an organizational strategy 
to increase provider compliance with smoking cessation 
guidelines (Joseph).
Cooperative Studies Program FY99 Aging Research Activities
    The Cooperative Studies Program (CSP) is a component of the 
Office of Research and Development and supports multi-center 
clinical studies where multiple VA medical centers study 
collectively a selected medical problem. The Cooperative 
Studies Program (CSP) is comprised of four Coordinating Centers 
(CSPCCs), a Clinical Research Pharmacy, and three 
Epidemiological Research and Information Centers (ERICs). The 
CSP exists to provide credible, consistent, and effective 
answers to major scientific questions that determine evidence-
based medical practice in VA and in the country.
Outcomes of specialized care for elderly patients evaluated
    The proportion of veterans over age 65 will increase from 
26 percent in 1990 to 46 percent in 2020. VA must be prepared 
to serve the needs of this growing population. A large, multi-
outcome study will determine whether specialized inpatient and 
outpatient units are the best way for VA to care for elderly 
patients. The impact of this study will extend far beyond VA, 
as millions of older Americans come under managed care. No 
other study is likely to provide the conclusive evidence needed 
to guide policy in this critical area.
Seizures
    New-onset epilepsy occurs among 45,000 to 50,000 elderly 
people every year. These patients are especially vulnerable to 
side effects from drug treatments and often have other 
conditions for which they take medication. This study will 
compare the effects of two drugs recently approved for the 
treatment of seizures, gabapentin and lamotrigine, with a 
standard drug, carbamazepine, in elderly patients. 
Identification of a more effective drug for elderly people 
would allow these patients to live better, more seizure-free 
lives with fewer side effects.
Cholesterol Reduction in the Elderly
    The objective of this study is to determine the extent to 
which various lipid parameters predict the risk of coronary 
heart disease among those 65 years or older, compared with 
younger individuals. Better estimates of risk associated with 
lipid abnormalities, as well as the risks, benefits, and costs 
of cholesterol reduction in the elderly, will aid in the 
refinement of guidelines targeted for the aging US population.
Major trial launched to test new vaccine against shingles
    Shingles in older people is extremely painful and 
disabling. There is no effective treatment (lasting more than a 
month) for people who suffer from shingles; nor is there an 
effective method to prevent shingles. This study will test a 
promising new vaccine to prevent shingles and reduce its 
severity and complications. The randomized, controlled trial 
will enroll 35,000 older veterans for a minimum of three years. 
If the vaccine proves successful, it will supply a safe and 
cost-effective means for reducing the severe impact of shingles 
and its complications on the health of older veterans.
Heart Disease--COURAGE Trial
    Heart disease affects more than 7 million people in the US 
and is the leading cause of death among Americans. The COURAGE 
study is a large-scale, multi-center, randomized controlled 
trial comparing the effectiveness of angioplasty with medical 
therapy to medical therapy alone in treating patients with 
coronary heart disease.
Heart Failure--WATCH Study
    Congestive heart failure remains an important clinical 
problem for the elderly. This study will compare the 
effectiveness of three antibiotic therapies (warfarin, aspirin, 
and clopidigrel) in patients with congestive heart failure. 
This international study will involve 4,500 patients across 150 
medical centers among VA, non-VA US hospitals as well as 
centers in the UK and Canada.
Prostate Cancer--PIVOT
    Prostate cancer is the most common cancer among men and 
second leading cause of death in men. The management of 
localized prostate cancer in older men has generated 
considerable debate due to risks and potential benefits 
associated with different treatment options. Research shows 
that patients' treatment preferences vary significantly, 
depending on the risk associated with surgery, their life 
expectancy, their symptoms and tolerance for their symptoms.
    Important questions remain concerning long-term outcomes 
for prostate cancer treatment. VA, in collaboration with the 
National Cancer Institute (NCI) and the Agency for Health Care 
Policy and Research (AHCPR), is addressing these questions 
through a landmark study that compares the two most widely used 
treatment methods: radical prostatectomy, in which the prostate 
is surgically removed, and expected management or ``watchful 
waiting,'' in which only the disease symptoms are treated. The 
Prostate Cancer Intervention Versus Observation Trial (PIVOT) 
is a 15-year, randomized study involving 2,000 men.
Prostate Cancer--SELECT Study
    VA has entered collaborations with the NCI and the 
Southwest Oncology Group to study the effects of Vitamin E and 
Selenium in the primary prevention of prostate cancer. The 
proposed Selenium Vitamin E Cancer Prevention Trial (SELECT) is 
a randomized, double-blind, placebo controlled, factorial 
design trial among 30,000 healthy men without prostate cancer.
Prostate Cancer--Racial Differences
    Another study on prostate cancer will look at the racial 
differences in the incidence and mortality of the disease. 
Among African Americans, the incidence and mortality from 
prostate cancer is highest. This research will provide insight 
into genetic-environmental interactions that initiate and 
promote prostatic neoplasia, as well as address whether there 
are differences in patterns of care that impact morbidity and 
survival.
Colorectal Cancer
    The relative five-year survival for colorectal cancer is 
approximately 40 percent among veterans, substantially lower 
than the general population of 61.7 percent (colon) and 59.3 
percent (rectum). Colorectal cancer is preventable through 
screening, and, if diagnosed in an early stage, is curable.
    This is the first study to examine factors that may explain 
the worse prognosis for veterans with colorectal cancer. If 
modifiable factors such as physician and patient delay in 
diagnosis, or poverty explain the increased mortality among 
veterans, educational programs and interventions that improve 
the process of care associated with screening and diagnosis can 
be instituted.
Positron Emission Tomography (PET) to Detect Solitary Lung Nodules
    Accurate non-invasive identification of cancerous lung 
tumors may expedite the removal of potentially surgically 
curable cancerous lesions and minimize the number of benign 
masses and surgically incurable lung cancers for which chest 
surgery is done. This study is evaluating the utility of PET in 
differentiating benign from cancerous tumors in patients with 
solitary lung nodules. It is anticipated that PET will be more 
accurate than chest x-ray and CAT scan.
Influenza Virus Infection in Patients with Chronic Obstructive 
        Pulmonary Disease
    Influenza infections are a source of significant morbidity 
among patients with underlying respiratory illnesses such as 
chronic obstructive pulmonary disease (COPD). COPD is a common 
health problem among patients in the VA health care system. The 
primary question is whether or not co-administration of live, 
cold-adapted influenza virus vaccine (CAIV-T) with intra-
muscular inactivated influenza virus vaccine (TVV) is more 
efficacious in preventing natural, wild-type influenza virus 
infection than inactivated influenza virus vaccine given intra-
muscularly (TVV) alone in patients with COPD.

                  research consortia and partnerships

Alzheimer's Disease VA Consortium
    Alzheimer's Disease (AD) is the third most expensive 
chronic disease to treat following cancer and heart disease. It 
is estimated that by the year 2000, there will be 600,000 
veterans with severe dementia.
    The principal goal of this consortium is to take advantage 
of existing VA resources to address important issues in the 
management of AD and other progressive dementias. The main 
objectives of the consortium are: (1) to identify VA medical 
facilities with substantial numbers of patients suffering from 
AD and related progressive dementias that possess the 
infrastructure, interest and expertise to conduct informative 
clinical trials; (2) to identify and prioritize areas of 
investigation that should be pursued in consultation with other 
research organizations (e.g., NIH Consortium, Reagan Institute, 
Harmonization Group); (3) to implement a number of clinical 
trials in VA facilities which are prepared to embark on these 
studies; (4) to develop promising clinical trials in 
collaboration with pharmaceutical and biotech industries; and 
(5) to integrate results of these studies into the practice of 
VA physicians.
VA Clinical Oncology Research Network (VACORNET)
    The VA Clinical Oncology Network (VACORNET) is a group of 
VA clinician investigators interested in oncology research and 
multi-site trials. The mission of the VA CORNET is to:
           promote oncology research relevant to the 
        health of veterans;
           promote oncology research with 
        pharmaceutical companies, especially multi-site trials, 
        and promote investigator-initiated research;
           foster communication among oncology 
        researchers;
           develop an infrastructure to support 
        national studies;
           encourage supportive care trials; and
           offer assistance to VA investigators who 
        need multiple sites to answer a clinical research 
        question.
VA Cardiology Consortium
    The VA Cooperative Studies Program has considerable 
experience with cardiovascular clinical trials. The distributed 
nature of scientific expertise in VA is both an advantage and a 
barrier to involvement with this area of research. To ensure 
that VA patients have access to the latest innovations in care 
and that study design is responsive to the needs of VA, it is 
desirable to facilitate the collaboration between VA 
cardiologists and the principal sponsors of cardiology 
research. This initiative will develop a process for expediting 
the involvement of VAMCs in such cardiology trials.
VA/National Institutes of Health (NIH), National Institute on Aging 
        (NIA)
    In collaboration with the National Institute on Aging, CSP 
seeks to conduct a series of multi-site, randomized clinical 
trials to enhance VA's efforts to treat its rapidly growing 
population of elderly veterans. These studies include 
investigations of osteoporosis in men, focusing on fracture 
prevention; androgen replacement therapy in men; preoperative 
interventions for older patients undergoing non-cardiac 
surgery; approaches to cardiovascular surgery in older 
patients; and treatment for diastolic dysfunction for patients 
with coronary heart failure and normal systolic function. CSP 
also may conduct studies in long-term care settings, including 
ways to prevent lower respiratory infections and catheter-
related urinary tract infections in nursing home units.
    Other research projects may focus on ways to improve 
chronic disease management; the use of alternative treatment 
approaches for patients with potentially terminal illnesses; 
and the management of behavioral disturbances among patients 
institutionalized with Alzheimer's disease. CSP will also study 
the impact of nutritional interventions in vulnerable geriatric 
populations; the effectiveness of a variety of interventions in 
treating fall-related fractures; and the appropriateness, cost-
effectiveness, and incidence of adverse effects of prescription 
drugs for geriatric patients.
VA and the National Parkinson Foundation
    VA and the National Parkinson Foundation, Inc. (NPF) have 
joined forces to seek a cure and improve treatments for 
Parkinson's disease. The Alliance to Cure Parkinson's disease 
between VA and NPF has launched a variety of activities. They 
include: a series of symposia highlighting state-of-the-art 
research for scientists and policy makers; educational programs 
for VA medical personnel that are focused on advances in the 
understanding and treatment of Parkinson's; information 
products for public dissemination on VA's research and 
treatment programs in Parkinson's; continuing medical education 
training for VA clinicians who treat patients with Parkinson's; 
and jointly-funded research initiatives to expand the medical 
community's understanding of the causes, mechanisms, and 
treatment of this disease.
VA/National Institutes of Health, National Heart Lung & Blood Institute 
        (NHLBI)
    VA, in collaboration with the NHLBI and Intercardia 
Incorporation, is conducting a major study entitled, ``Beta-
blocker Evaluation of Survival Trial (BEST),'' to determine 
whether beta-blockers extend the lives of patients with chronic 
heart failure. The implications of this trial, involving 2,800 
patients with moderate to severe congestive heart failure, are 
substantial. In addition to prolonging patients' lives, 
researchers conservatively predict that successful use of these 
drugs will save the VA system approximately $9.4 million 
annually.
Rehabilitation Research and Development
    Over 9 million of the veteran population is now over 65 
years of age. As the veteran population continues to age, most 
veterans will experience more medical complications from 
multiple illnesses and new disabilities including loss of 
hearing and vision which further limits their function, 
mobility, and quality of life. In addition to their physical 
limitations, many elderly veterans are further isolated as a 
result of living in remote rural areas or far from medical 
facilities. Due to increasing disability and poor vision, many 
veterans are unable to drive and lack the support systems 
needed to obtain adequate health care. Maximizing remaining 
function and enabling aging veterans to stay healthy in their 
own home environment are critical goals.
    Rehabilitation Research and Development (Rehab R&D) Service 
is one of four services within the VA Office of Research and 
Development that is forging ahead to provide quality research 
resulting in new knowledge leading to improved health care 
delivery services for veterans. Rehabilitation research, new 
interventions, development of new technology, and adaptation of 
existing technology, all offer a wider range of options and 
opportunities to the growing population of aging veterans with 
disabilities. Rehab R&D initiatives are designed to monitor, 
prevent, and provide treatment interventions through the use of 
cutting edge technology which would allow aging veterans to 
have an improved quality of life in their own home.
    The ultimate goals of (Rehab R&D) Service include 
achievement of actual functional return, compensatory therapies 
to maximize remaining function and to mitigate secondary 
conditions, corralling cutting edge technologies to compensate 
for lost function, and fostering better ways for living with 
disability. This is especially important for the aging 
population. To this end, over 200 VA researchers have dedicated 
themselves in a comprehensive effort to advance the health care 
needs of veterans with disabilities.
    Nine Rehabilitation R&D Centers located at VA facilities 
around the country function to attract the best and brightest 
minds from academia, industry, and medicine to VA to study 
specific aspects of aging and disability research, as well as 
to work together as a national network. Here, investigators 
renew half a century of commitment to seeking solutions to 
rehabilitation's most challenging research problems. Moreover, 
in looking toward a new generation of researchers, a research 
career development program has been initiated to mentor 
doctoral-level rehabilitation clinical professionals. These men 
and women will help guide the future of rehabilitation research 
and development.
    In order to disseminate research results, the Rehab R & D 
Service has committed to publishing its efforts, through 
outlets such as a bi-monthly peer-reviewed journal, an annual 
reporting of progress in rehabilitation research throughout the 
world, clinical monographs, and data sheets. Each of these 
activities stimulates new research ideas and keeps clinicians 
and consumers on the cutting edge of new ideas in disability 
management. The Journal of Rehabilitation Research and 
Development has a long history of disseminating research 
results related to prosthetic and rehabilitative care. Although 
largely oriented towards engineering and assistive technology, 
the Journal has made an impact on the general rehabilitation 
research community. To increase dissemination and cut mailing 
and publication costs, in 1999, the Journal and progress 
reports became available on the Internet.

                            new initiatives

           VA Rehabilitation Research and Development Centers

    In July of 1999, the VA Rehabilitation Research and 
Development Service added three new R&D Centers to its 
portfolio. The newest of the now nine Centers focus on 
Cognitive and Motor Impairment Rehabilitation (including 
Alzheimer's and stroke) (Gainesville, FL), Restoration of 
Function in SCI and Multiple Sclerosis (West Haven, CT), and 
Wheelchair and Related Technology (Pittsburgh, PA). This group 
complements the six established Centers in Geriatric 
Rehabilitation (Atlanta, GA), Aural Rehabilitation (Portland, 
OR), Prosthetics and Consequences of Amputation (Seattle, WA), 
Mobility (Palo Alto, CA), and Aging with a Disability (Houston, 
TX). It is anticipated that these Centers will sponsor research 
and attract funding from many sources to advance knowledge in 
these important areas. In addition, Centers mentor young 
investigators thus, building capacity for future research. 
These initiatives will provide a new knowledge base for 
clinicians as they work to rehabilitate and maximize remaining 
function of elderly veterans.

                       VA R&D Technology Transfer

    To further maximize technology transfer productivity, the 
Director of Rehab R&D Service has been recently charged with 
assessing, coordinating and maximizing technology transfer 
activities and opportunities within VA. Technology Transfer 
efforts within Rehab R&D have traditionally been focused on 
evaluating prototypes of developed assistive technology. These 
evaluations are helpful in furthering the commercialization of 
developed devices, but not enough to assure that promising 
prototypes reach the commercial market. In addition, 
rehabilitation research results not only in new technology, but 
also in therapies, practices and new knowledge. These results 
must be translated into clinical care. Availability of an 
individually prescribed wheelchair, new and improved hearing 
aids, and new visual adaptive devices are all-important in 
increasing the aging veteran's quality of life. Advances in 
these areas frequently benefit the general non-veteran aging 
population as well.
    In FY98 and FY99 Rehab R&D expanded its scope of technology 
transfer activities to include pursuing patents and developing 
the capacity for conducting clinical trials. A workshop was 
presented at the June 1999 VA Rehabilitation Clinical Symposium 
in Houston to introduce clinicians to opportunities for 
translating research findings into practice that results in 
improved patient care.

                   Multiple Sclerosis: A Step Forward

    Multiple sclerosis (MS) attacks the nervous system creating 
multiple disabilities, from paralysis to impaired vision, and 
sometimes blindness. Veterans with MS are predominantly male 
and older than the typical MS patient. Due to its patient 
population and its research capacity in the areas of disability 
prevalent in the MS patient community, VA is in a unique 
position to advance research. For example, ongoing research 
funded by Rehabilitation Research and Development will impact 
MS care. Rehabilitation research in dysphasia, physical 
therapies, dementia, audiology and vision also applies to some 
or all of this patient population.
    In February of 1999, Rehabilitation Research and 
Development, in collaboration with the National MS Society, 
Eastern Paralyzed Veterans of America, and Paralyzed Veterans 
of America, organized a research agenda setting symposium to 
usher in the beginning of a new focus on applying 
rehabilitation disciplines to treating and alleviating the 
symptoms of multiple sclerosis. The proceedings of the 
symposium were published in September 1999. A collaborative 
effort to study the sensory impairments (speech, vision, and 
hearing) affected by MS is currently underway. Other issues to 
be addressed immediately include coordinating the several 
registries already in existence, encouraging more ``cross 
talk'' and collaboration between disciplines and, ultimately, 
finding ways to translate research results into accepted 
clinical protocol.
    In FY99, Rehabilitation Research and Development issued a 
program announcement to guide the rehabilitation field in 
submitting appropriate proposals in response to this need. 
Funding for these proposals will begin in FY2000.

                          NeuroRehabilitation

    NeuroRehabilitation is a young and exciting science on the 
cusp of therapeutic breakthroughs which promise to return 
useful function. For instance, in stroke therapies, patients 
are often taught adaptive strategies to compensate for 
paralyzed muscles. However, it has been shown in rat models 
that forced use of affected areas can actually return useful 
function to those areas. Research in NeuroRehabilitation stands 
to benefit many veteran populations with neurologic disorders, 
including those with spinal cord injuries, multiple sclerosis, 
Parkinson' disease, or consequences of stroke. Capitalizing on 
these opportunities requires coordinating the intersection of 
basic and applied sciences, a step already taken this year 
through the development of a NeuroRehabilitation scientific 
review panel with expertise from both areas.

                          ``Elder Technology''

    ``Elder Technology'' is an application of existing creative 
technologies and development of new technologies which help 
overcome the impairment and disabilities associated with aging 
(i.e., loss of memory, vision, hearing and mobility). ``Elder 
Technology'' is a stated priority of the White House Office of 
Science and Technology Policy. The growing population of older 
adults will change many aspects of health care. One change will 
be an increase in the number of people who experience a 
disabling condition as a result of aging and, consequently, 
need to use some form of assistive technology. During inpatient 
rehabilitation, an adult receives an average of eight devises 
to use at home for dressing, mobility, seating, bathing, 
grooming, and feeding. Safety monitoring devises for geriatric 
patients are helping to heal an industry beset by liability 
costs due to falls and accidents. These problems are not 
limited to just slipping on floors and tumbling or sneaking out 
of bed.

                           Telerehabilitation

    Telerehabilitation is an emerging health care delivery tool 
that uses electronic information and communications 
technologies to provide and support health care when distance 
separates the participants. Because of many unresolved 
questions, there is a need for specific evidence of efficacy/
therapeutic, diagnostic impact/cost analysis, and the 
development of baseline data in many areas of 
telerehabilitation. Issues of diagnostic/therapeutic efficacy, 
privacy and security of information transmission, clinical 
standards and guidelines for practice, technical 
interoperability of systems and technology, and human resource 
planning all must be addressed. Statistically significant 
outcome studies on the effectiveness of telerehabilitation as 
compared to conventional rehabilitation service delivery models 
are required

                  Neuro-Rehabilitation Robotic Systems

    Conventional rehabilitation for sensorimotor impairment 
includes physical and occupational therapy programs. These 
require labor intensive individualized exercises with a 
therapist. Typical exercise activities include manual 
manipulations of the patient's limb, either as the patient 
remains passive or actively assists with the movement. As an 
alternative clinical intervention, robotic technology may 
assist the therapist in the rehabilitation of neurological 
impaired patients.
    In April of FY99, Rehab R&D issued three RFPs calling for 
proposals to: 1) evaluate new and emerging ``elder 
technologies,''; 2) conduct studies which systematically and 
scientifically evaluate existing telerehabilitation 
applications and/propose demonstration projects for new 
applications; and 3) evaluate and develop innovative robotic 
systems for therapeutic application after the onset of 
neurologic disorders such as multiple sclerosis (MS), stroke, 
and traumatic brain injury (TBI). It is anticipated that these 
studies will be designed to use robotics as training aids, 
assisting patients to regain the ability to become ambulatory.
    In addition to the above initiatives, Rehab R& D Service 
conducts an on-going investigator-initiated peer review 
research program. A wide spectrum of research activities 
includes studies on amputation, spinal cord injury, vision 
impairment, hearing loss, and other disabilities associated 
with aging.
    Examples of approved studies in 1999 with relevance to 
impairments that are commonly associated with aging are:
Stroke
    Stroke is the leading cause of disability among the aging 
population. Stroke disability persists for life and limits the 
function and quality of life of stroke survivors. They have 
significant deficits in building blocks of function, which 
include strength, balance, and endurance.

     Restoration of Gait in Acute Stroke Patients Using Functional 
                    Neuromuscular Stimulation (FNS)

    Conventional rehabilitation post stroke is inadequate to 
restore safe, independent gait for many stroke patients. The 
purpose of this study is to determine the efficacy of 
Functional Neuromuscular Stimulation with implanted electrodes 
in improving lower extremity motor recovery and gait pattern of 
acute stroke patients. Preliminary results indicate that 
patients tolerate the procedure and treatment well. Gains have 
been noted in impairment and disability measures.

 Coordination of Hemiparetic Movement after Post-Stroke Rehabilitation

    This study will supplement a NIH-funded, randomized 
clinical trial to evaluate a post-stroke exercise program 
designed to increase, balance, strength, and endurance of aging 
veterans. Investigators have developed a therapeutic exercise 
program that targets functional recovery of aging persons with 
acute stroke. Pilot data suggest that the intervention improved 
lower extremity motor recovery and gait velocity following 
stroke.

    Development of a Quality of Life Instrument for Stroke Survivors

    With recent changes in conflicting approaches of medical 
and social models of health, the development of new models have 
yielded to a more integrated biopsychosocial approach in which 
the measurements of health outcomes have been extended beyond 
the traditional indicators of mortality and morbidity, to 
include measures of the consequences of health conditions on 
daily activities and quality of life. Most generic functional 
disability and health-related quality of life measures used in 
rehabilitation and long-term care settings, fail to adequately 
assess the consequences of communication impairments on daily 
activity. This study is designed to develop a population-
specific quality-of-life-assessment instrument to measure 
quality of life in stroke survivors whose constructs are 
theoretically linked to all relevant domains of functioning, 
their disorders, and interventions.

   Portable Monitoring of Physical Activity and Depression in Stroke 
                             (Telemedicine)

    Physical inactivity worsens cardiovascular risk and can be 
promulgated by perceived fatigue, as well as depression and 
including prevalent post-stroke factors linked to poorer 
activities of daily living (ADL). The study tests the validity 
and reliability of integrated physiological and kinematic 
personal status monitoring as outcome measures of community-
based physical activity. This study involves testing the 
validity of using telemedicine instrumentation to accurately 
monitor the activity levels of this at-high-risk population in 
the home environment, and to intervene early to encourage 
adequate levels of physical activity to prevent further 
deterioration and institutionalization.

 VA Stroke Rehabilitation Outcomes: Barriers to Efficient Performance 
                            (Outcomes Study)

    This investigation will study barriers to the delivery of 
rehabilitation services to VA stroke patients and their effects 
on rehabilitation outcomes. Significant barrier-outcome 
associations have been found in several patient groups or 
health delivery systems: cancer treatment, diabetes control, 
continuum of care, outpatient and short-stay surgeries, 
pharmacotherapy compliance, depression, early thrombolytic 
treatment, spinal pain, and preventive care. Clinicians from 
multiple disciplines are being surveyed to obtain a composite 
estimate of barriers to the provision of rehabilitation 
services. The barriers database will be merged with an existing 
VA structural database containing a comprehensive array of 
physical and organizational variables describing the entire 
Physical Medicine and Rehabilitation Services (PM&RS).

  Video-Based Functional Performance and Assessment Following Stroke 
                             (Telemedicine)

    For people who have hemiplegia as a result of stroke, a 
critical safety-related retraining area for physical functions 
is wheelchair transfers. To incorporate the relatively 
unsupervised home care into the rehabilitation process, 
clinicians require a better means to assess functional gains 
and provide effective training tools. To fill these two needs, 
the goal of this project is to develop a personalized training 
and clinical assessment instrument based on the Video-Based F-
PAT (Functional Performance Assessment and Training), which 
relies on the manipulation of digitized videoclips. An 
Occupational Therapist will be trained to create the 
personalized videotapes distributed to patients who undergo 
acute rehabilitation at the VA Comprehensive Rehabilitation 
Center and are discharged to their homes or a sub-acute 
facility. The effectiveness of the personalized training 
videotapes and the video-based assessment methodology will be 
evaluated.

                          Parkinson's Disease

    Parkinson's disease is one of the most common serious 
neurological disorders. This disease stems from a loss of 
dopaminergic neurons in the substantia nigra of the midbrain; 
this deficit produces a complex disorder of motor function 
including symptoms of both underactivity (hypokinesia) and 
overactivity (tremor and rigidity). Clinical depression occurs 
in up to 50 percent of all Parkinson's patients.

Transcranial Magnetic Stimulation for Depression in Parkinson's Disease

    Transcranial magnetic brain stimulation appears to be an 
effective treatment for refractory depression, can replicate 
the beneficial effects of electroconvulsive therapy more easily 
and safely, and, with less risk. It may thereby improve both 
mood and motor performance of patients with Parkinson's 
disease. The objective of this project is to explore and 
develop safer, more effective methods for treatment of 
Parkinson's disease and depression, and to improve the utility 
of transcranial magnetic stimulation as an alternative 
therapeutic modality.

  Motion or Velocity Encoder for Monitoring Essential or Neurological 
                           Tremor (Movement)

    This study involves the development of software for 
commercially available palm computers (PDAs) that allows for 
easy and user-friendly capture of handwriting and of graphical 
drawings, tracings and tracking in a clinical setting from 
individuals with Parkinsonian and other neurological tremors or 
spasms. The captured images can be analyzed to yield various 
indices of spatial performance and temporal performance that 
previous investigators have suggested may be potentially valid 
metrics for quantifying neurological tremor or spasm, and that 
might change in response to therapeutic intervention. This 
device is designed to help quantify the effect of 
pharmacological regimens or evaluate other possible 
interventions. This device will provide a tool to clinicians to 
more easily and accurately quantify outcome measures.

                    Auditory and Visual Impairments

    Disabilities in these functional areas increase as the 
aging process continues and the aging veteran experiences 
increasing isolation.

        Measurement and Prediction of Outcomes of Amplification

    The long-term goal of this project is to develop methods 
whereby clinicians can predict both the benefit and the 
satisfaction those individual hearing-impaired patients will 
derive from amplification in daily life.

  Evaluation of Treatment Methods for Clinically Significant Tinnitus

    Tinnitus is a growing auditory problem among the aging 
veteran population. In this study, investigators are evaluating 
two different approaches to the alleviation of tinnitus 
symptoms by comparing changes from baseline performance on the 
Tinnitus Severity Index. An unbiased evaluation of competing 
methodologies is being conducted.
    The design is one in which pairs of prospective subjects 
are randomly assigned to one or two treatment groups. Changes 
in group performance will be compared for selected measures. 
Tinnitus is one of several studies being conducted at the Rehab 
R& D Center of Aural Rehabilitation in Portland, Oregon.

 A Measurement of the Efficacy of an Adult Aural Rehabilitation Program

    This study will evaluate the effectiveness of providing a 
hearing aid together with adjunctive aural rehabilitation 
therapy as compared to providing a hearing aid without aural 
rehabilitation. An aural rehabilitation program will be 
evaluated in terms of the improvement in quality of life as 
measured by disease specific and generic instruments. 
Differential treatment effects will be evaluated immediately 
after intervention and at six months and one year post-
intervention. The cost-effectiveness of the approach will be 
evaluated using the Hearing Quality Adjusted Life Years Index.

    Veterans with Cataracts: Visual Disability in Nighttime Driving

    In this project, investigators propose to evaluate how 
glare disability associated with various stages of cataract 
affects veterans' ability to read traffic control devices 
(TCDs) during nighttime driving. Four groups of veterans with 
differing stages of cataract will be tested using 1) clinical 
visual psychophysical measures believed to be sensitive to the 
effects of glare disability, and 2) engineering-based field 
experiments to measure subjects' performance in detecting and 
reading common TCDs. The primary outcome of this study will be 
a better understanding of veterans with cataract and the 
disability they experience in nighttime driving under glare 
conditions. Expected secondary outcomes include improvements in 
TCD design and more functionally-based classification systems 
for designating cataracts as ``visually significant.''

       Predictors of Driving Performance and Successful Mobility 
         Rehabilitation in Patients with Medical Eye Conditions

    In this study, investigators have collected a large amount 
of data that demonstrates the significant effects of vision 
loss on driving and mobility. Glaucoma and diabetic retinopathy 
are two diseases that are most common among aging veterans. 
Both diseases can potentially result in significant peripheral 
visual field loss, sometimes coupled with decreased visual 
acuity. They also have serious consequences for driving and 
mobility. Based on this data, predictive models of automotive 
driving performance and accidents for patients with retinal 
diseases will be developed. Based on the specific visual 
disease, individual predictive models of driving rehabilitation 
curriculums will be developed as well as training patients to 
use low-vision aids to improve driving and mobility.

   The Impact of Blind Rehabilitation on Quality of Life in Visually 
                           Impaired Veterans

    The VA health care delivery system is currently 
experiencing many changes as it is being reshaped to provide 
more efficient and effective services. Assessing the impact 
that blind rehabilitation has on the quality of life of those 
receiving it is a way of evaluating the effectiveness of this 
service that the VA provides. Quality of life factors will be 
compared before and after rehabilitation for both veterans and 
their caregivers. Quality of life measures, because they are 
broadly based, easy to administer, and assess the whole 
individual may provide the best means of achieving this goal.
Nutrition and Oropharyngeal Swallowing
    The compromised physiologic, mental, and socioeconomic 
status of many in the growing aging population in general, and 
aging veterans in particular, raises the real possibility of 
malnutrition which, if left unchecked, can quickly become a 
precursor to greater disability. It is extremely difficult and 
expensive to treat once progressed, but it can also be 
preventable and modifiable.

  Nutrition & Clinical Status of Disabled Older Veterans in Long-Term 
                                  Care

    The primary objective of this study is to identify 
physiologic problems accompanying nutritional deficiencies 
manifested by elderly patients receiving rehabilitation 
services in extended care over time. Data collected will be 
used to develop an operational definition of ``malnutrition.'' 
The resulting hypothesis statements will be used in future 
intervention studies to address this problem. This is one of 
several other projects on aging currently in progress at the 
Houston Rehab R& D Center on Aging with A Disability.

           Oropharyngeal Swallowing Function in Normal Adults

    Appraisal of abnormal swallowing (dysphagia) includes 
separating the stages of swallowing into clearly defined 
anatomic regions and reporting the time it takes for a bolus to 
travel from one anatomic region to the next. Unfortunately, few 
normative data on these duration measures for bolus sizes 
employed in typical modified barium swallow examinations are 
available. Data that are available were collected on bolus 
sizes that are too small for clinical use or include only one 
consistency. Thus, differentiating normal from abnormal 
duration measures is not possible for the majority of clinical 
patients. The proposed study is designed to develop normal 
values means, ranges, and standard deviations for 11 measures 
of swallowing duration. Availability of normative data will 
assist clinicians in determining the presence of a swallowing 
disorder, specifying severity, focusing treatment, and 
measuring outcome.
Chronic Obstructive Pulmonary Disease (COPD)
    COPD is one of the most common chronic illnesses in the 
adult population and is the second leading cause of Social 
Security disability payments. This condition is prevalent among 
aging veterans with a history of smoking.

    Effectiveness of a Home-Based Pulmonary Rehabilitation Program 
                             (Telemedicine)

    The objective of this project is to determine whether a 
newly designed home-based pulmonary rehabilitation program is 
as effective as a more traditional, outpatient, hospital-based 
program. The underlying goal is to improve the care of veterans 
with chronic lung disease. Such a home-based program will meet 
the needs of the rural veteran population and can be readily 
adapted systemwide. If effective, such a program will increase 
access to care with more efficient use of resources. 
Demonstration of the effects of such a program should have 
implications for the dissemination of pulmonary rehabilitation 
programs to smaller VA facilities that do not now have the 
specialists required in traditional, hospital-based 
rehabilitation programs.

  Home-Based Pulmonary Rehabilitation via a Telecommunications System

    This study is evaluating a computer-based 
telecommunications system designed to promote moderate physical 
activity for pulmonary rehabilitation as an alternative to 
traditional inpatient or outpatient pulmonary rehabilitation. 
This Telephone-Linked Computer-based Pulmonary Rehabilitation 
system (TLC-PR) has many advantages such as: 1) it does not 
require specialized facilities to administer as the COPD 
patient can use it at home; 2) it is very low cost; 3) the 
intervention can be sustained for an indefinite period; and 4) 
it can be easily disseminated widely as it is transmitted over 
the telephone. Due to expected lower initial level of fitness, 
and prior observations that the elderly make more extensive use 
of other TLC systems, the benefits of TLC-PR may be greatest in 
elderly veterans.
Dementia
    People with dementia comprise a significant part of the 
total population of older veterans, many of whom are patients 
in VA nursing homes.

   Development and Evaluation of an Activity Monitor for People with 
                                Dementia

    The objective of this project is to develop and evaluate a 
wearable activity monitor for older veterans with dementia that 
will be given to clinicians to use as a means of remotely 
monitoring patient compliance with prescribed exercise 
regimens. This monitor will also provide expended energy and 
range of motion measures, which can be used to quantify 
improvements in performance and function.

 Behavioral and Functional Problems in Dementia Patients with Sensory 
                                  Loss

    This study describes functional and behavioral problems of 
demented nursing home patients with sensory impairments and 
analyzes the relationships among cognition, vision, hearing, 
functional status, and behavioral disturbance. Interventions 
with the potential to reduce excess disability in self-care 
functioning and dementia-related behavioral disturbance will be 
identified. Long-term study results will be used to focus 
controlled intervention studies. This project is one among 
several other studies relating to aging, falls, exercise and 
dementia that are in progress at Rehab R& D Atlanta Geriatric 
Rehabilitation Center.

                Diabetes and Peripheral Neuropathy Falls

    Adult onset diabetes is becoming increasingly widespread as 
the population ages. This is especially true among aging 
veterans. Patients with peripheral neuropathy experience 
increased incidences of slips and falls due to decreased 
somatic sensation as well as decreased motor responses.

  Threshold Detection of Postural Control in Diabetic Neuropathy and 
                                 Aging

    This is one of a few studies that focus on how somatic 
sensory dysfunction contributes to slips and falls among aging 
veterans. The focus of this study is to compare the 
acceleration threshold sensitivity differences between persons 
with diabetic neuropathy and age-matched adult controls. The 
results will be compared with results from a previous study on 
young adults. The outcome will be a test consisting of a set of 
supra-threshold stimuli that can be used to check specific 
populations for balance deficits without the need for a more 
complicated device presently in use. This study may assist in 
developing more effective evaluations and therapies for persons 
with diabetic and other neuropathies.

   Pressure/Motion Feedback To Protect Skin of Sensorimotor Impaired 
                                 Elders

    The objective of this study is to test the hypothesis that 
a wearable motion analysis and pressure feedback system will 
help prevent skin breakdown in elderly individuals who need to 
monitor soft tissue pressure. The integration of motion and 
pressure sensing will allow for the monitoring of patient 
compliance with therapeutic pressure-relief regimens. This 
integrated system will interact with other measurement devices, 
provide real-time sensory feedback (visual, tactile, auditory) 
to the user, communicate patient status to a remote clinician, 
and recognize if it is unused or incorrectly used when the 
patient is not complying with instructions. Specific parameters 
will be recorded for each participant.

    Orthopedic Footwear CAD/CAM System for Diabetic Pedal Ulceration

    This project in involves using the latest technology in the 
automated design and manufacturing of custom orthopedic 
footwear for diabetic patients.

                   C. Office of Academic Affiliations

    All short- and long-range plans for the Veterans Health 
Administration (VHA) that address the healthcare needs of the 
Nation's growing population of elderly veterans include health 
professional training activities supported by the Office of 
Academic Affiliations (OAA). Clinical experiences with 
geriatric patients are an integral part of healthcare education 
for approximately 91,000 VHA health trainees, including 31,012 
resident physicians and fellows, 18,771 medical students, and 
42,048 nursing and associated health students. Each year these 
residents and students train in VA medical centers 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 increasing 
size of the aging veteran population, VHA continues to promote, 
coordinate, and support geriatric education and training 
activities for physicians, dentists, nurses and other 
associated health professional trainees.

                           geriatric medicine

    The demand for physicians with special training in 
geriatrics and gerontology continues because of the rapidly 
growing numbers of elderly veterans and aging Americans. The VA 
healthcare system offers clinical, rehabilitation, and follow-
up patient care services as well as education, research, and 
interdisciplinary programs that constitute the support elements 
required for the training of physicians in geriatric medicine. 
This special training has been accomplished through the 
Physician Fellowship Program in Geriatrics from Fiscal Years 
(FY) 1978 to 1989 and through specialty residency training 
since FY1990. In FY1999, VA supported 169.8 physicians 
receiving advanced education in geriatric medicine and 28 
physicians receiving advanced education in geriatric 
psychiatry. VA also supported 6 physicians pursuing post-
residency fellowship education in geriatric neurology.
    The Accreditation Council for Graduate Medical Education 
(ACGME) approved geriatric medicine as an area of special 
competence in September 1987. 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 VAMC may 
conduct training in geriatrics provided that an ACGME 
accredited program is in place.
    Over the past five years, VHA has restructured its medical 
residency portfolio and as a result, geriatric medicine 
positions have increased. In the fall of 1995, the Under 
Secretary for Health appointed an expert committee, the 
Residency Realignment Review Committee (RRRC), to advise him 
about recommended changes needed to ensure that VHA's graduate 
medical education programs meet present and future healthcare 
needs of both VA and the Nation. The RRRC recommended that VHA 
restructure its 8,900 medical resident positions and increase 
the percentage in primary care from 38 percent to 48 percent. 
This realignment of VHA's graduate medical education portfolio 
will continue VHA's progress in training a greater proportion 
of generalist physicians while protecting specialties 
particularly germane to special VHA programs. Geriatric 
medicine is one of the primary care disciplines that has 
experienced growth as a result of residency realignment. 
Geriatric medicine resident positions increased from 104 
positions in Academic Year (AY) 1995-1996 to 169.8 in AY 1999-
2000. That is a 61 percent increase.

                          geriatric dentistry

    In July 1982, a two-year Postdoctoral Fellowship in 
Geriatric Dentistry began 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 FY1993, the number of training sites 
increased to six for a final three-year cycle. As of June 1994, 
52 geriatric dentistry fellows had completed their special 
training. The Postdoctoral Fellowship in Geriatric Dentistry 
changed in 1994 to the VA Dental Research Fellowship to expand 
research training for dentists.
    The Postdoctoral Fellowship in Geriatric Dentistry proved 
to be an excellent recruitment source for dentists uniquely 
trained in the care of the elderly. Graduates have assumed 
leadership positions in geriatric dentistry at academic 
institutions, enhanced patient care and other geriatric 
initiatives in VA facilities, and contributed to geriatric 
efforts in affiliated health centers and the community. 
Nationally, former fellows have made significant contributions 
to the professional literature and are actively involved in 
geriatric dental research.
    Since the change in the Postdoctoral Fellowship in 
Geriatric Dentistry to the VA Dental Research Fellowships, OAA 
has initiated individual awards in dental research. Candidates 
from any VAMC with the appropriate resources may now compete 
for postdoctoral dental research fellowships.

               nursing and associated health professions

    Based on its large number of elderly patients, VA offers 
all affiliated students clinical opportunities in the care of 
the elderly. VA also has special programs that focus on 
geriatrics.

        interprofessional team training and development program

    The Interprofessional Team Training and Development Program 
(ITT&D) 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 medicine, nursing, psychology, 
social work, pharmacy, and occupational and physical therapy. 
The goal of ITT&D is to develop a cadre of health practitioners 
with the knowledge and competencies required to provide 
interprofessional team care to meet the wide spectrum of 
healthcare and service needs for veterans, to provide 
leadership in interprofessional team delivery and training to 
other VAMCs, 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 healthcare, 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 ITT&D, which began in 1978, is based at 12 VAMCs: 
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. During 
FY1999, 177 students from a variety of healthcare disciplines 
received funding support at the 12 ITT&D 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, 
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 and 
nurse practitioner students for their clinical practice at 
VAMCs affiliated with the academic institutions at which the 
students are enrolled. During FY1999, VA supported 499 master's 
level advanced practice nurse student positions.

                va predoctoral nurse fellowship program

    Gerontological nursing has been a nursing specialty since 
the mid-1960s. Doctoral level nurse gerontologists are prepared 
for advanced clinical practice, teaching, research, 
administration, and policy formulation in adult development and 
aging.
    In FY1985, VA initiated a two-year nurse fellowship program 
for registered nurses who were doctoral candidates and who had 
dissertations focused on clinical research in geriatrics/
gerontology. The first competitive review for fellows was 
conducted in 1986. One nurse fellow was selected for the FY1986 
funding cycle. Since that time, two nurse fellowship positions 
have been available for selection at approved VAMC sites each 
fiscal year. In FY1994, the program was changed to the VA 
Predoctoral Nurse Fellowship Program to include all clinical 
areas relevant to the care of veterans.

 geriatric expansion program and the geriatric research, education and 
                        clinical centers (grecc)

    A special priority for geriatric education and training is 
recognized in the allocation of associated health training 
positions and funding support to VAMCs hosting GRECCs and to 
VAMCs (non-ITT&D sites) offering specific educational and 
clinical programs for the care of older veterans. In FY1999, a 
total of 176 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 postdoctoral fellowship

    In FY1993, OAA began a one-year Geropsychology Postdoctoral 
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 VA. 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 
ten VAMCs: 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-focused programs and accredited 
psychology internship programs.
    In summary, through its fellowship, residency, and 
associated health training VA continues to make outstanding 
contributions to the Nation's health professions workforce and 
to foster excellence and leadership in the care of elderly 
veterans.

                    D. 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. The Office of Employee Education 
through the Employee Education System (EES) works with medical 
centers, Veterans Integrated Service Networks (VISNs), and 
Headquarters' program officials to develop educational 
activities that respond to the needs of healthcare personnel 
throughout VHA. Funding is provided to the VISNs to support 
employee education at the local level, to the GRECCs for 
educational programming, and to program offices for national or 
systemwide activities.
    With assistance from the EES, approximately 40 single 
medical center programs were conducted during fiscal year 1999. 
A number of multi-facility and VISN-wide programs were also 
presented during this time. Topics included Advances in 
Geriatrics, Quality of Life and the Elderly, Assessment and 
Treatment of Geriatric Mental Disorders, Geriatric 
Periodontics, Essentials of Geriatric Nursing, New Concepts: 
Diagnosis and Treatment of Alzheimer's, Falls in the Elderly, 
Aging in Men and Women: Current Health Care Issues, and 
Pharmacology in the Elderly. National or systemwide activities 
included Domiciliary Clinical Care Conference and programs on 
Primary Care for the Elderly, and Improving Care at the End of 
Life. A national satellite conference on Assessment and 
Treatment of Geriatric Mental Disorders was broadcast to all VA 
medical centers.
    A major effort during the fiscal year was the ongoing 
implementation of the Resident Assessment Instrument/Minimum 
Data Set project. Other emphasis was placed on developing 
faculty to expand the end of life and palliative care 
initiative and developing strategies for further 
implementation.
    GRECCs utilized their funding to present training programs 
on subjects such as Religion/Spirituality and Health; 
Nutritional Syndromes in the Elderly; Falls and Function; 
Critical Clinical Issues in the Care of the Older Adult: Bone 
and Joint Disorders in the Elderly; End of Life Decision 
Making; Advances in Geriatrics; Aging in Women/Aging in Men; 
and Promoting Quality of Life for Persons with Advanced 
Dementia. All GRECCs presented activities that were attended by 
VA staff as well as providers from universities and the private 
sector.

                      E. Chief Information Office

                  health information resources service

    The widespread education and training activities in 
geriatrics have generated systemwide requirements for 
information throughout VA. 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 audiovisuals on topics related to 
geriatrics and aging.
    The VHA Satellite Television network carried eleven live 
broadcasts targeted to providers who work with aged patients. 
The topics included Stroke Prevention; Pharmacologic Management 
of Cognitive Changes in Alzheimer's Disease; Practical 
Approaches for the Care of Patients with Alzheimer's; Cox-2 
Drugs in the Treatment of Rheumatoid and Osteoarthritis; 
Erectile Dysfunction in the Elderly Male; Pharmacological 
Advances in Secondary Stroke Prevention; Excellence in VA Home 
Care; Osteoporosis; Pharmacologic Advances in the Treatment of 
Alzheimer's Disease; and VA Homecare: A New Approach to 
Advanced Heart Failure.
    Additionally, five videos were purchased and distributed 
systemwide.

                 III. Veterans Benefits Administration

                      A. 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 1,567,692 persons age 
65 or older. This total includes 1,156,080 veterans; 400,717 
spouses; 9,761 mothers; and 1,134 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 need for economic security of the 
Nation's oldest veterans. The current amount added to the basic 
pension rate is $2,037 as of December 1, 1999.

                              B. Outreach

    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.
    This liaison is enhanced by VA's Fiduciary Program. VBA 
Regional Office staff provide oversight in the management of VA 
benefits paid on behalf of incompetent beneficiaries. Many of 
these beneficiaries are elderly and have been found to be 
mentally incapable of handling their financial affairs. This 
oversight includes appointment and supervision of suitable 
payees, as well as routine personal visits with the 
beneficiaries to ensure that their needs are being met.
    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 pamphlets and other materials 
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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