Food Assistance: Options for Improving Nutrition for Older Americans
(Letter Report, 08/17/2000, GAO/RCED-00-238).

Pursuant to a congressional request, GAO determined (1) 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 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 Medicaid.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  RCED-00-238
     TITLE:  Food Assistance: Options for Improving Nutrition for Older
	     Americans
      DATE:  08/17/2000
   SUBJECT:  Disadvantaged persons
	     Nutrition research
	     Elderly persons
	     Food programs for the elderly
	     Future budget projections
IDENTIFIER:  USDA Child and Adult Care Food Program
	     FNS Nutrition Program for the Elderly
	     Commodity Supplemental Food Program
	     Food Stamp Program

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GAO/RCED-00-238

Appendix I: Objectives, Scope, and Methodology

22

Appendix II: Results of Telephone Survey of State Food
Stamp Directors

24

Appendix III: Food Stamp Program

35

Appendix IV: Elderly Nutrition Program

40

Appendix V: Commodity Supplemental Food Program

42

Appendix VI: Child and Adult Care Food Program

45

Appendix VII: GAO Contacts and Staff Acknowledgments

47

Table 1: Distribution of Elderly Food Stamp Households by State,
Fiscal Year 1998 37

Table 2: Characteristics of Older Persons Who Are Eligible for Food Stamps
39

Table 3: Characteristics of ENP Participants Compared With the
General Elderly Population 41

Table 4: Maximum Monthly Distribution Rates for Older Persons
and Certain Other Participants 43

Table 5: Characteristics of CACFP Adult Participants 46

Figure 1: Distribution of Food Stamp Benefits for Elderly
Households, Fiscal Year 1998 12

Figure 2: Participation Rates and Major Food Stamp Program
Legislation 18

Figure 3: Sample Food Stamp Allotment Calculation 36

CACFP Child and Adult Care Food Program

CSFP Commodity Suppemental Food Program

ENP Elderly Nutrition Program

HHS U.S. Department of Health and Human Services

USDA U.S. Department of Agriculture

SSI Supplemental Security Income

Resources, Community, and
Economic Development Division

B-285169

August 17, 2000

The Honorable Charles E. Grassley
Chairman
The Honorable John B. Breaux
Ranking Member
Special Committee on Aging
United States Senate

Many older persons cannot consistently obtain a nutritious diet,
particularly if their income is near the poverty level. In 1998, about 1.6
million to 2 million households with individuals age 60 and older (elderly
households) reported that they did not have enough of the right types of
food needed to maintain their health or simply did not have enough to eat.1
Lack of money was the underlying reason these households were unable to
obtain a sufficient quantity of food or had to reduce the quality of their
food. In some cases, older persons are forced to choose between buying food
or paying for medicine, utilities, or other needed items.

To address these problems, the Congress has authorized a number of programs
to help provide nutrition assistance to low-income households, including
those with older persons. You asked us to look at four of these programs.
The Food Stamp Program provides benefits that can be used to purchase food
at participating retail food stores. The Child and Adult Care Food Program
(CACFP) and the Elderly Nutrition Program (ENP) provide prepared meals in a
number of different settings. The CACFP serves participating day care
facilities, while the ENP serves senior persons in group settings, such as
senior centers, and offers home-delivered meals. Finally, the Commodity
Supplemental Food Program (CSFP) supplies federally donated foods to
participants. However, many older persons do not take advantage of these
programs, according to studies by government agencies and others.

Concerned about limited participation, you asked us to (1) determine why
some older persons do not use these programs and (2) identify strategies
that could be used to increase participation in these programs. To address
these questions, we examined, among other things, available documents and
studies discussing nutrition assistance for older persons and met with
officials from the federal agencies principally responsible for
administering these programs--the U.S. Department of Health and Human
Services' (HHS) Administration on Aging and the U.S. Department of
Agriculture's (USDA) Food and Nutrition Service. For the largest of these
programs, the Food Stamp Program, we conducted a telephone survey of the
directors of the 51 state agencies responsible for administering the program
at the state level.2 Appendix I discusses our scope and methodology in
detail, and appendix II presents the results of the survey of state food
stamp directors.

Older persons do not participate in federal food assistance programs for
many reasons. Some of these reasons cut across programs. For example, older
persons are often reluctant to accept food assistance because they believe
such acceptance would compromise their independence. Additionally, some
older persons associate accepting food assistance with welfare, which many
older persons view negatively. Furthermore, funding constraints limit
participation in several of the programs (for example, the Commodity
Supplemental Food Program is available in only 22 states and the District of
Columbia). Moreover, older persons' lack of awareness of the availability of
programs and problems with access to transportation hinder participation in
several of the programs. Other problems, however, are more program-specific.
For example, all state food stamp directors told us some eligible older
persons believe the burden of applying for food stamps outweighs the
expected low benefits. Finally, 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.

Program officials, providers, and advocacy groups have identified a number
of actions that might increase older persons' participation in nutrition
assistance programs. In some instances, the options suggested would likely
require a large infusion of resources. For example, nearly all of the state
food stamp directors endorsed increasing the minimum benefit level from $10
to $25 per month. We estimate that the annual cost of this increase in Food
Stamp Program benefits would be about $102 million for older persons who
currently participate and could increase participation resulting in
additional annual costs of about $26 million. 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. 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. Other
suggestions are not likely to be as costly. 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. (Older persons
receiving Supplemental Security Income are automatically eligible for food
stamp benefits). Additionally, program providers in the Commodity
Supplemental Food Program have suggested service improvements by, for
example, providing a greater variety of foods and smaller packaging sizes.
For the Child and Adult Care Food Program, officials noted that, in general,
expanding participation depends on increasing the number of adult care
facilities in the program.

Individuals who are 60 years of age and older represent about 17 percent of
the total U.S. population but are expected to increase to about 25 percent
by the year 2025. Adequate nutritional intake is essential for optimal
physical and mental activity and can help maintain the health and emotional
independence of older persons. Conversely, poor nutrition can contribute to
or exacerbate chronic and acute diseases, hasten the development of
degenerative diseases associated with aging, and delay recovery from
illness. Concerns have been raised about the nutrition of older persons and
whether their households have enough of the right kinds of foods or have
sufficient quantities of food to maintain their health and well-being.

Of the approximately 1.6 million to 2 million elderly households that
experienced problems in obtaining a sufficient amount or quality of food in
1998, about 1 million to 1.2 million, or 60 percent of these households,
were low-income, and approximately 500,000 to 660,000 reduced their food
intake to the point that they experienced hunger.3 A lack of financial
resources was the reason that all of these elderly households experienced
problems in obtaining a sufficient amount or quality of food.

The Food Stamp Program is by far the largest of the four programs serving
older persons in both the numbers of participants and cost. It had an
average monthly participation of 1.5 million elderly households in 1998,
spending about $1 billion in benefits for these households. According to the
Food and Nutrition Service, the average monthly benefit for elderly
households is $59. The program provides participants with food coupons or
electronic benefit transfer cards that can be used in authorized retail
stores to purchase food items.4 Older persons may also use these benefits,
if they so choose, as a donation towards their meals at ENP sites. In some
areas they may also use these benefits to purchase low-cost meals at
authorized restaurants. ENP program officials told us that the use of food
stamp benefits by older participants at sites serving group meals or for
home-delivered meals, while never extensive, has decreased even more with
the advent of electronic benefit transfer cards. This is because it is
costly to install electronic benefit transfer equipment at sites serving
group meals and administratively burdensome to use paper vouchers as an
alternative to electronic benefits for home-delivered meals.

The Food and Nutrition Service administers the Food Stamp Program through
agreements with state agencies, which conduct day-to-day operations. The
federal government pays all of the benefit costs and nearly one-half of the
administrative costs for each state.

See appendix III for more detailed information on the Food Stamp Program,
including special provisions for older persons and the method used to
calculate benefits.

ENP provides grants and meal subsidies to state agencies on aging to support
meals for older persons in group settings and delivered to participants'
homes. Administered by the Administration on Aging, the program is designed
to address problems of dietary inadequacy and social isolation among older
persons. Meals served in ENP must meet nutrition standards, including
one-third of the recommended dietary allowances established by the Food and
Nutrition Board of the National Academy of Sciences, as well as the dietary
guidelines for Americans. While the program does not include means testing,
it targets its services to older people having the greatest economic or
social need, with special attention given to low-income minorities. For
example, 16 percent of home-delivered meal participants were low-income
minorities, while 4 percent of the overall U.S. population aged 60 and over
were low-income minorities. In administering the group meal program, state
agencies must ensure that sites are in close proximity to areas where most
participants reside.

The Administration on Aging estimated that ENP served about 244 million
meals in fiscal year 1998. An estimated 130 million, or 53 percent, of these
meals were home-delivered. This represents an approximate 11 percent
increase in home-delivered meals as a percentage of total ENP meals since
1990. During this same period, the number of meals served in group settings
decreased by about 20 percent. Organizations providing these meals, such as
senior centers and religious facilities, provide nutrition education in
addition to meals. They can also receive support from other sources, such as
local governments, as well as donated food and supplies, private donations,
and voluntary contributions from participants.

In addition to providing meals, the program has as a goal increasing
socialization opportunities for its participants. For participants receiving
meals in a group setting, such contacts usually involve considerable social
interaction. In contrast, for persons receiving home-delivered meals, social
interactions tend to be much shorter, but volunteers who deliver meals to
older persons are encouraged to spend some time with the recipients and to
check on their welfare.

See appendix IV for more detailed information on ENP.

CSFP provides free boxed and canned food (such as juice, canned vegetables
and meat, and powdered milk) and nutrition education to low-income
participants, including older persons. Older participants must have a
household income at or below 130 percent of the poverty level. The state may
also impose residency requirements.

CSFP participants pick up their food, generally once a month, from
distribution centers, which are in locations accessible to low-income
people, such as community centers or churches. Older participants who cannot
pick up their food can designate a representative to do so; in some
locations volunteers deliver food to older participants who are unable to
get to the distribution center. Currently, the program operates in 22
states, including 5 that joined the program in January 2000, as well as in
the District of Columbia and on the Red Lake (Minnesota) and Pine Ridge
(South Dakota) Indian Reservations. According to the Food and Nutrition
Service, with the exception of Nebraska, none of the participating states
provides CSFP coverage statewide. In most of the participating states, the
program operates in parts of the state; for example, in Illinois, the
program operates in only one county. For fiscal year 2000, $88.3 million was
appropriated for CSFP. In fiscal year 1999, about 71 percent of those
enrolled in this program were older (about 270,000 of the total enrollment
of almost 382,000 people).

See appendix V for more detailed information on CSFP.

Any person 60 years of age or older, and any person 18 years of age or older
who has a functional impairment, such as a mental disability, and attends a
nonresidential day care facility can qualify to participate in CACFP.5 The
participating care facility must be licensed or approved by the state. The
program provides meal reimbursements to the day care facility according to
the number of meals served and the income level of program participants. For
example, during the period from July 1, 1999, to June 30, 2000, for
participants from families with incomes at or below 130 percent of the
poverty level, the day care facility received a reimbursement of $1.09 for
breakfast, $1.98 for lunch or supper, and $0.54 for a snack. Participating
CACFP facilities cannot receive reimbursement for more than two meals and
one snack or one meal and two snacks for each adult in a single day.

The Food and Nutrition Service does not maintain statistics only for
participants aged 60 or older in this program. However, according to the
Service, in fiscal year 1999, average daily participation by all adults aged
18 or over was about 62,500. The number of adult day care facilities
participating in CACFP grew from 1,222 in fiscal year 1993 to 1,855 in
fiscal year 1999, an increase of almost 52 percent. In fiscal year 1999, the
Child and Adult Care Food Program received $1.6 billion in federal funds for
both the child and adult care components of the program.

See appendix VI for more detailed information on the CACFP.

Assistance Programs

A number of reasons account for older persons' nonparticipation in federal
nutrition assistance programs, according to program officials, providers,
and advocacy groups. Some reasons cut across programs, such as the belief
that accepting food assistance would compromise their independence and the
constraints on funding, which contribute to waiting lists for ENP
home-delivered meals or limit the range of CSFP services. Other reasons are
associated with a particular program, such as the perceived burdensome
application procedure for food stamps or a shortage of licensed adult care
facilities participating in CACFP.

Programs

According to the Food and Nutrition Service, the Administration on Aging and
our interviews with state officials and local providers, a number of factors
inhibit older persons' participation in food assistance programs.

Reluctance to Accept Food Assistance

Chief among many older persons' reasons for not participating in food
assistance programs is their reluctance to accept food assistance because
they take pride in their independence and believe that such assistance would
compromise that independence. For example, according to a 1996 Urban
Institute evaluation of ENP, 86 percent of older Americans eligible for, but
not participating in, the ENP home meal program said that they did not
believe they needed the program, even though about 35 percent of these
people had shown one or more signs of inadequate food intake in the previous
6 months. In addition, some older persons associate the acceptance of food
assistance with welfare, which many older persons view negatively.

Funding Limitations Constrain Increased Participation in Programs

Funding limitations also constrain participation in several of the food
assistance programs. For example, according to the Urban Institute study,
many older people who would like to participate in ENP cannot because the
providers have reached their capacity to serve or deliver meals. Forty-one
percent of the providers delivering meals to recipients at home and 9
percent of group meal providers reported having waiting lists. One provider
told us that it currently has a waiting list of 400 for ENP meals, while
another provider has a list of 100. According to the Urban Institute study,
the size of these waiting lists suggests a considerable unmet need among
older persons for ENP nutrition assistance. Furthermore, officials believe
that the degree of unmet need may be understated because many nutrition
programs with unmet needs for services do not maintain waiting lists.
Additionally, according to a 1999 HHS-sponsored study, the unmet need will
grow as the number of older persons increases, particularly the group aged
85 and over, which is the fastest growing part of the older population. The
study concludes that more older persons are likely to receive long-term care
in their homes, thereby increasing future demand for home-delivered meals.

According to the president of one of the organizations representing ENP
providers, some providers have transferred funds for group meals to
supplement funding for program services and home deliveries. The president
said the net result has been a "severe erosion of the congregate meal
program." Even though they are transferring funds from the congregate
program, providers continue to face unmet needs in the home delivery
program, according to the ENP providers we contacted.

Further expansion of CSFP to more counties in participating states or into
additional states is also constrained by funding limitations, according to
USDA. Federal funding for fiscal year 1999 represented an increase of less
than 2 percent from the level in fiscal year 1995. During the same period,
participation by older persons in CSFP increased from about 200,000 in 1995
to about 270,000 in 1999, a 35-percent increase. During this same period,
the number of women, infants, and children in CSFP decreased from about
164,000 to about 112,000, a 32-percent decrease, which was primarily due to
increased participation in the Special Supplemental Nutrition Program for
Women, Infants, and Children.

Several of the state food stamp directors we surveyed cited the lack of
available state resources as constraining them from expanding outreach
efforts. For example, they lack resources for developing and distributing
literature about the Food Stamp Program targeted to older persons or
locating food stamp employees to certify eligibility in places that would be
more accessible to older persons.

Lack of Awareness of Programs Deters Older Persons' Participation

Studies of ENP and other nutrition assistance programs indicate that while
older persons are vaguely aware that programs are available to meet their
needs, their understanding of the program services provided, as well as
where and how to apply, may be unclear. For example, according to the
president of an ENP provider organization, lack of program awareness is a
primary reason older persons do not participate. Similarly, for CSFP, the
providers we contacted told us that this lack of program awareness, as well
as the perceptions of a burdensome application process, limit program
participation. Furthermore, some older persons mistakenly believe that if
they enroll in the Food Stamp Program, they will not be eligible to
participate in other nutrition assistance programs. Many are also reluctant
to apply for food stamps because they believe they will only receive a small
monthly benefit.

Many Older Persons Lack Transportation

Finally, older persons may not be able to participate in food assistance
programs because they either do not have access to transportation,
particularly in rural areas, or because they are physically unable to leave
their home to go to locations where assistance is available. For example, in
rural areas, many older persons depend on others for transportation and may
not want to impose on their families and friends for transportation to apply
for benefits in government offices, which may involve multiple trips, and to
receive food assistance benefits at, for example, distribution centers.

In addition to the reasons for nonparticipation that are common to several
programs, we identified reasons that appear to be unique to some programs.

Food Stamp Program

According to a USDA estimate, only about 30 percent of elderly persons who
were eligible for food stamps in 1997 participated in the program. In
contrast, about 63 percent of all eligible persons participate in the
program.

Food stamp officials in the 51 states we surveyed said that some older
persons believe the burden of applying for food stamps outweighs the
expected benefits. For example, to calculate a food stamp applicant's
monthly allotment amount, using the available shelter and medical
deductions, the applicant must provide documentation of income,
rent/mortgage and utility expenses, and medical expenses. Applicants may
also have to provide information on their assets.6 Applicants must also
discuss with program officials details on their general living arrangements,
including, for example, who in the household purchases food and prepares
meals. In one state we examined, the application form for just the Food
Stamp Program was 15 pages. Participants must go through much of this
process at least once every 2 years to continue receiving benefits, and many
may only be eligible for the minimum monthly benefit of $10.

As shown in figure 1, in fiscal year 1998, about one-quarter of the elderly
households participating in the Food Stamp Program received the minimum
monthly benefit of $10 and another 16 percent received a monthly benefit
ranging from $11 to $25.

Source: Food and Nutrition Service, "Characteristics of Food Stamp
Households, Fiscal Year 1998," Mathematica Policy Research, Inc., February
2000.

Additional reasons for the lack of participation in the Food Stamp Program
that we identified through our survey are discussed in more detail in
appendix II.

Commodity Supplemental Food Program

According to the president of a CSFP provider organization and several local
service providers, older persons do not use CSFP for a number of reasons,
including the following:

ï¿½ the program provides a limited variety of foods,

ï¿½ the food is packaged in sizes that are often too large for older persons
living in one- to two-person households,

ï¿½ a number of the foods provided require too much preparation effort for
many older persons who have difficulty cooking, and

ï¿½ the food provided does not meet the needs of many older persons who are on
restricted diets.

Child and Adult Care Food Program

Older persons do not use CACFP, principally because not enough adult day
care facilities participate, according to program officials. The most recent
major study of the adult segment of the program reported that these
facilities do not participate for several reasons.7 According to the
Mathematica report, one-third of the directors of nonparticipating
facilities did not know the program existed. Furthermore, 20 percent of
these directors said they were not eligible for the program because they
were not licensed or approved by the state, as required. Finally, 26 percent
of the nonparticipating directors believed that CACFP requirements for
program administration were too burdensome, and 12 percent reported that
meal reimbursement rates were too low. While an insufficient number of these
facilities participate, program officials noted that the number of
participating facilities increased by almost 52 percent between fiscal years
1993 and 1999.

Nutrition Assistance Programs

Some options suggested by program officials, providers, and advocacy groups
for increasing participation by older persons, would require a large
infusion of resources, in some instances. Others would not likely require
significant amounts of additional funding. However, increasing older
persons' participation in federal nutrition assistance programs could be
difficult to achieve.

More resources would be needed to increase the participation of eligible
elderly persons in the Food Stamp Program, ENP, and CSFP, according to many
state program officials and service providers. For example, for the Food
Stamp Program, we estimate that the annual cost of increasing the minimum
benefit from $10 to $25 per month for only elderly households currently
participating in the program would be about $102 million. Moreover, higher
benefits would likely increase participation by about 89,000 elderly
households, resulting in additional annual costs of about $26 million. To
arrive at these estimates, we used a model developed by Mathematica Policy
Research, Inc. for the Food and Nutrition Service to, among other things,
estimate changes in participation rates and changes in program costs.8 Food
Stamp Program officials noted that the $10 minimum benefit, which has been
in place since 1979, is not always a sufficient incentive to overcome the
perceived obstacles to participation.

The Food Stamp Program's application process could also be simplified by
having a standard medical deduction. Although such a change could bring more
older people into the program, it could also be quite costly. Currently,
elderly persons may deduct medical expenses above $35 per month that are not
paid by insurance or someone who is not a household member. These expenses
must be documented, which many elderly persons find difficult to do.
Instituting a standard medical deduction of $35 for older persons would
eliminate the documentation now required for the first $35 of these
expenses, thereby easing older persons' record keeping burden somewhat and
simplifying the application process. Eighty-eight percent of the state
directors thought this was a strategy worth trying. Food and Nutrition
Service officials told us that--while they have not made any formal
estimates--implementing a standard medical deduction could significantly
increase the cost of the program. For example, according to these officials,
implementing a standard medical deduction of $35, while retaining the
current medical deduction for elderly households with out-of-pocket medical
costs over the $35 threshold, could increase program costs by about $200
million annually. Using the Mathematica model, we estimate the total annual
cost of a $35 standard medical deduction would be about $179 million. Of the
$179 million, about $145 million would derive from increased benefits to
931,000 elderly households already participating in the program. In
addition, according to the Mathematica model, the standard medical deduction
would likely entice another 83,000 elderly households into the program,
further increasing costs by about $35 million.

ENP, which operates at full capacity in some areas, would also require an
infusion of resources to expand service. For example, according to the Urban
Institute study, 41 percent of home-delivered and 9 percent of group meal
providers reported having waiting lists for the program. According to HHS
officials and service providers, additional funding would be needed to meet
this demand but at this time HHS has not estimated how much additional
funding would be needed.

Similarly, additional funding would be needed to expand CSFP. Program
officials and service providers told us that program expansion, both within
participating states and into states where it has not yet been established,
would require more funding but no estimates of this additional funding have
been prepared.

Program officials, providers, and others suggested several improvements to
program services that could help to increase older persons' participation in
the Food Stamp Program and CSFP, but that would not require significant
amounts of additional funding. For the Food Stamp Program, for example,
state directors suggested simplifying the application process by
automatically making older persons eligible for food stamps when they are
approved for other means-tested programs in addition to SSI, such as
Medicaid.

For CSFP, program providers have likewise suggested that in some parts of
the country they cannot serve all who wish to participate. However, some
CSFP providers suggested that services could be improved through such means
as providing a greater variety of foods and smaller, more manageable,
package sizes.

Some states have received waivers from the Food and Nutrition Service to
pilot other approaches to increase elderly participation in the Food Stamp
Program. For example, in South Carolina, one-person SSI households
automatically receive a standard food stamp benefit amount based on whether
or not they receive other unearned income. If these households are entitled
to a level of benefits higher than this standard amount because of high
medical expenses or shelter costs, then they have the option of applying for
food stamps under the standard rules for the Food Stamp Program. The Food
and Nutrition Service estimates that food stamp participation rates among
SSI recipients, many of whom are elderly, increased in South Carolina from
38 percent to 50 percent from 1994 (a year before the program began) to
1998. Other states, including Mississippi, New York, Tennessee, and
Washington, are planning to start, or have expressed interest in starting, a
similar program. The Food and Nutrition Service has approved waivers for
other states to, among other things, simplify the application process by
instituting a standard deduction for utilities and excluding one vehicle
from the asset calculation (Montana) and reduce the stigma associated with
receiving government assistance by depositing a cash benefit, instead of
food stamp coupons or an electronic benefit transfer card, in the bank
account of recipients age 65 or older (Vermont).

Finally, Food Stamp Program officials noted that older persons might be
encouraged to participate in the program if a public education campaign was
targeted to that population. Such a campaign could emphasize the provisions
that are in place to make the program more accessible to older persons
through, for example, using an authorized representative or completing the
application over the telephone. They added that such a campaign might be a
relatively inexpensive way to increase participation by older persons.

Although program officials agreed that more can be done to increase older
persons' participation in food assistance programs, they noted that
increasing participation will be difficult. For example, in an attempt to
encourage elderly persons to participate in the Food Stamp Program, the
Congress has relaxed program requirements over the years in the following
ways:

ï¿½ The Food Stamp Amendments of 1979 allowed elderly and disabled households
to deduct medical expenses over $35 per month from their gross income for
eligibility purposes and for determining benefits.

ï¿½ The Food Security Act of 1985 raised the asset limit for all elderly
households to $3,000, while keeping the limit at $2,000 for any nonelderly
household.

ï¿½ The Personal Responsibility and Work Opportunity Reconciliation Act of
1996 extended the maximum certification period for elderly households to 24
months.

However, as shown in figure 2, despite these and other actions, older
persons' participation rates have remained fairly stable since 1977, in
contrast to the participation rates for all food stamp participants during
this period.

In an attempt to increase older persons' participation, USDA recently
developed a handbook for state agencies and others on ways to increase
access to the Food Stamp Program.9 Many of the strategies suggested in this
access guide, while considered worthwhile, had previously been attempted,
according to state food stamp directors. State directors' views on the
access handbook and other strategies are included in appendix II.

We provided a draft copy of this report to the Department of Health and
Human Services' Administration on Aging and to the U.S. Department of
Agriculture's Food and Nutrition Service for review and comment. We met with
Food and Nutrition Service officials, including the Director, Program
Development Division, Food Stamp Program, and with Administration on Aging
officials, including the Director of the Office of State and Community
Programs. Overall, both the Food and Nutrition Service and Administration on
Aging generally concur with the information in the report. The Food and
Nutrition Service, however, expressed concern that establishing a standard
medical deduction for older persons could result in considerable cost to the
Food Stamp Program and therefore probably should not be included in the
section entitled "Options Not Requiring Substantially Higher Expenditures."
We agreed and moved this discussion to the section entitled
"Resource-Intensive Options." In addition, the agencies provided technical
suggestions, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days from
the date of this letter. At that time, we will send copies to congressional
committees with jurisdiction over nutrition assistance programs; the
Honorable Dan Glickman, Secretary of Agriculture; the Honorable Donna E.
Shalala, Secretary of Health and Human Services; the Honorable Jacob J. Lew,
Director, Office of Management and Budget; and other interested parties. We
will also make copies available to others upon request.

If you or your staff have any questions about this report, please contact me
at (202) 512-5138. The key contributors to this report are listed in
appendix VII.

Robert E. Robertson,
Associate Director, Food and
Agriculture Issues

Objectives, Scope, and Methodology

We were asked to (1) determine the reasons some older citizens do not use
the Food Stamp, Elderly Nutrition, Commodity Supplemental Food, and Child
and Adult Care Food programs and (2) identify strategies for increasing
older persons' participation in these programs. To address these objectives,
we examined laws and program regulations and reviewed studies by, among
others, Mathematica Policy Research, Inc. and the Urban Institute. We also
met with officials from the U.S. Department of Agriculture's (USDA) Food and
Nutrition Service and the Department of Health and Human Services' (HHS)
Administration on Aging. We also contacted representatives of associations
of nutrition providers, including the National Association of Nutrition and
Aging Services Programs, the Meals on Wheels Association of America and the
National Commodity Supplemental Food Program Association. We also contacted
organizations that directly provide food assistance to older persons,
including the Community Food Resource Center (New York), Catholic Charities
(Archdiocese of New Orleans), Focus: Hope (Detroit), and Project Bread
(Massachusetts). We also contacted human services advocacy groups, including
the American Association of Retired Persons, American Public Human Services
Association, the Center on Budget and Policy Priorities, and the Food
Research and Action Center.

For the largest of these programs, the Food Stamp Program, we conducted a
telephone survey of the directors of the 51 state agencies responsible for
administering the program at the state level.10 For the Elderly Nutrition
Program, we contacted the president and several members of the National
Association of Nutrition and Aging Services Programs and the executive
director of the Meals on Wheels Association of America, which are
organizations representing nutrition service providers. For the Commodity
Supplemental Food Program (CSFP), we contacted the president and several
members of the National Commodity Supplemental Food Program Association, an
organization representing CSFP providers.

To determine the number of elderly households that have experienced problems
in obtaining a sufficient amount or quality of food, we analyzed data
collected by the U.S. Bureau of the Census and reported in the 1998 Food
Security Supplement to the Current Population Survey; these numbers are
presented at the 95-percent confidence level.

To estimate the increase in program cost if the minimum food stamp benefit
was increased from $10 to $25, we consulted with representatives of
Mathematica Policy Research, Inc. and used their model--known as MATH
(Micro-Analysis of Transfers to Households)--which utilizes data from the
Bureau of the Census' Current Population Survey. We also used this model to
estimate costs from implementing a standard medical deduction. Mathematica
verified our estimates by duplicating the modeling results of both analyses.

We conducted our work between February and July 2000 in accordance with
generally accepted government auditing standards.

Results of Telephone Survey of State Food Stamp Directors

This appendix presents a copy of the telephone questionnaire used to survey
51 state food stamp directors or their designees (including the District of
Columbia), and the results of that survey.11

Telephone Survey

Hello, my name is _______________ with the U.S. General Accounting Office.
GAO is a nonpartisan agency of the U.S. Congress. As part of a study we are
conducting on food stamps for the elderly, we are calling the states to ask
about their experiences in targeting elderly participation. Are you the
right person to talk with? (If caller answers no, obtain the name and phone
number of a better contact.) Did you receive the letter we sent?

It will probably take between 45 minutes and an hour to answer our
questions. Is now a good time to talk or would you rather schedule another
time? During this interview I may ask you some questions that you cannot
answer because someone else in your state government handles that. Whenever
this happens, just tell me and we'll skip on to the next question, OK?

In this survey, we'll be using the word elderly. As we understand, the Food
Stamp Program considers the elderly to be adults 60 years and older.

 1. To start our interview, I'd
 like to ask you some background
 questions about how your state
 operates the Food Stamp Program.
 First, we'd like to ask whether
 your state has integrated or        80% Integrated/consolidated
 consolidated procedures that        application includes food stamps
 cover food stamp applications.
 Which of the following choices      6% Food stamp application is separate
 best describes your state's
 procedures. First, an integrated    14% Depends on the situation
 or consolidated application
 includes food stamps, or second,
 the food stamp application is
 separate. N=51
 2 . How often does your state
 generally require recertification   61% Annually
 for the elderly households for
 food stamps? Is it quarterly,       33% Every 2 years
 annually, every two years, or
 some other time period? N=51        6% Other

 3 . Is that recertification         78% Yes
 period different for elderly and
 nonelderly food stamp households?   20% No
 N=51
                                     2% Other
                                     69% Yes, currently use EBT

                                     10% Yes, but not yet in all parts of
 4 . Does your state currently use   state
 electronic benefit transfer
 cards, EBT for food stamp           12% No, no implementation date planned
 participants? N=51
                                     8% No, but plan to implement

                                     2% Other
 [If state has already implemented
 EBT:]

 5. We're interested in your
 opinion about these electronic
 benefits and whether you think
 they affect food stamp
 participation by the elderly. You   12% Increased moderately
 might think the EBT cards
 increase participation, decrease    24% No effect
 it, or maybe you think they have
 no impact. Let me read the          27% Decreased moderately
 categories, and tell me which one
 best describes the effect that      32% Can't say
 electronic benefits have on
 elderly participation in your       5% Other
 state. Would you say electronic
 benefits have increased
 participation , decreased
 participation , had no effect on
 participation , or would you say
 you have no opinion? N=41

                                     Major      Minor    Not a
                                                                No opinion
                                    Reason     Reason    reason
                                      (1)        (2)                (4)
                                                          (3)
 6. USDA has stated that 65
 percent of the elderly who are
 eligible for food stamps do not
 receive them. We've made a list
 of reasons to explain why many of
 the elderly do not participate
 and we'd like to get your state's
 perspective on this list. For
 each one I read, I'll ask whether
 your state experienced this as a
 major reason, a minor reason, or
 not a reason to explain why many
 of the elderly who are eligible
 do not participate in the Food
 Stamp Program.
 a. The first one is … Some
 elderly don't like the intrusive
 questions in the eligibility
 certification. How does that
 explain why some elderly in your
 state do not participate in the   41%        51%        2%     6%
 Food Stamp Program? Would you say
 that is a major reason, a minor
 reason, not a reason, or would
 you say you don't have an opinion
 on that one? N=51
 b . Some elderly think the effort
 needed to apply is not worth the  86%        14%        0%     0%
 food stamp benefit received. N=51
 c. Some elderly cannot afford the
 transportation costs to make the
 necessary trips to the food stamp 8%         51%        31%    10%
 office. N=51
 d. Some elderly cannot deal with
 the difficulty of filling out the 24%        43%        29%    4%
 application form. N=51
 e. Some elderly do not realize
 that they are eligible for food   31%        53%        10%    6%
 stamps. N=51
 f. Some elderly feel that others
 need the food stamps more than
 they do, so they do not apply.    12%        39%        35%    14%
 N=51
 g. Some elderly feel embarrassed
 to be a food stamp recipient
 because of the stigma associated  67%        28%        2%     4%
 with it. N=51
 h. Are there any other reasons
 why elderly in your state do not
 participate in the Food Stamp     43% gave comments
 Program when they are eligible?

 7. The next set of questions concerns the Access Guide that the
 Food and Nutrition Service, FNS, distributed to the states in
 March 2000. It is called, "Help for the Elderly and Disabled."     92% Yes
 It shows how to increase food stamp participation for those two    8% No
 groups. Are you familiar with that guide?

Even though the Access Guide covers disabled participation, our survey
questions today are limited to food stamp participation by the elderly. We'd
like to read you a list of suggestions that FNS makes in that guide and ask
your opinion on each one. These suggestions are made to improve elderly
participation in the Food Stamp Program. As I read each one, I'll ask you to
rate the suggestion as excellent, good, fair, or poor. If you haven't tried
the suggestion yet, please rate the suggestion considering how well you
think it would work in your state to increase elderly participation. Please
consider the practical issues of implementing each suggestion such as
quality control and available resources. OK?

After you rate a suggestion, I'll ask you whether or not your state has
actually tried that suggestion in the last 3 years. You might have sponsored
a pilot project, you might have implemented the suggestion statewide, or
maybe one of your counties tried it.

                                                 No
                    Excellent  Good Fair Poor  opinion Yes   No   Uncertain
                       (1)     (2)  (3)  (4)           (1)  (2)     (3)
                                                (5)
 8. Our first set
 of suggestions is
 about marketing
 the Food Stamp
 Program to the
 elderly.
 a . Let's try the
 first one…
 Design materials
 that advertise the
 Food Stamp Program
 as nutrition
 assistance rather
 than "welfare."
 How would you rate
 that for
 increasing elderly
 participation in   26%       51%   16%  4%   4%       43%  55%  2%
 your state? Would
 you say it's
 excellent, good,
 fair, poor, or
 would you say you
 have no opinion?

 Has your state
 tried that in the
 last 3 years? N=51
 b. Target
 nutrition
 education programs
 to the elderly.
                    33%       51%   10%  6%   0%       53%  45%  2%
 Has your state
 tried that in the
 last 3 years? N=51
 c. Design
 promotional
 materials on food
 stamps that are
 targeted to the
 elderly.           28%       53%   18%  2%   0%       41%  57%  2%

 Has your state
 tried that in the
 last 3 years? N=51
 d. Distribute
 flyers to
 locations where
 the elderly are
 likely to go such
 as grocery stores. 35%       45%   18%  2%   0%       57%  39%  4%

 Has your state
 tried that in the
 last 3 years? N=51
 e. Promote the
 minimum benefit of
 $10 a month as an
 annual value of
 $120.              10%       14%   31%  43%  2%       20%  77%  4%

 Has your state
 tried that in the
 last 3 years? N=51
 f. Emphasize to
 elderly persons
 that many will be
 eligible for more
 than the minimum
 benefit of $10 a   12%       24%   41%  20%  4%       10%  84%  6%
 month.

 Has your state
 tried that in the
 last 3 years? N=51

                                                No
                   Excellent Good  Fair Poor  opinion  Yes   No   Uncertain
                      (1)    (2)   (3)  (4)            (1)  (2)     (3)
                                               (5)
 9. The next set
 of suggestions
 from the FNS
 Access Guide is
 about your Food
 Stamp Program
 staff.
 a. The first one
 is. . . Give
 staff special
 training to
 assist elderly
 applicants. Would
 you say it's
 excellent, good,
 fair, poor, or    16%       43%  28%   8%   6%        31%  65%  4%
 would you say you
 have no opinion?

 Has your state
 tried that in the
 last 3 years?
 N=51
 b. Provide
 training on how
 the medical
 deduction works
 for the elderly.
                   28%       33%  22%   14%  4%        69%  31%  0%
 Has your state
 tried that in the
 last 3 years?
 N=51
 c. Train workers
 to be more
 personal with the
 elderly such as
 giving them the
 worker's business
 card.             16%       41%  29%   8%   6%        43%  51%  6%

 Has your state
 tried that in the
 last 3 years?
 N=51
 d. Encourage
 staff to provide
 timely, courteous
 and dignified
 service.
                   69%       18%  8%    6%   0%        96%  4%   0%
 Has your state
 tried that in the
 last 3 years?
 N=51
 e. Place food
 stamp workers in
 locations that
 serve the elderly
 such as
 hospitals,
 community
 centers, and      28%       53%  16%   4%   0%        49%  45%  6%
 congregate
 feeding sites.

 Has your state
 tried that in the
 last 3 years?
 N=51
 f. Encourage
 workers to spend
 extra time with
 the elderly such
 as making
 speeches at
 senior centers.   22%       59%  14%   4%   2%        65%  29%  6%

 Has your state
 tried that in the
 last 3 years?
 N=51
 g. Set up a
 separate unit
 that focuses on
 the needs of
 elderly
 participants.     12%       45%  22%   16%  6%        31%  65%  4%

 Has your state
 tried that in the
 last 3 years?
 N=51

                                                 No
                     Excellent Good Fair Poor  opinion  Yes  No   Uncertain
                       (1)     (2)  (3)  (4)           (1)  (2)     (3)
                                                (5)
 10. The next set
 of suggestions
 from the FNS
 Access Guide is
 about certifying
 participants. Let
 me remind you that
 our categories are
 excellent, good,
 fair, poor, and no
 opinion.
 a. The first one
 is. . .Lengthen
 the certification
 period to 24
 months for the     33%        29%  18%  12%  8%       45%  55%  0%
 elderly.
 Has your state
 tried that in the
 last 3 years? N=51
 b. Promote the use
 of authorized
 representatives
 who can apply for
 food stamps or
 purchase food on   35%        47%  10%  6%   2%       78%  20%  2%
 behalf of the
 elderly.
 Has your state
 tried that in the
 last 3 years? N=51
 c. Promote the use
 of collateral
 contacts such as
 neighbors to
 reduce the
 documentation
 required for food  14%        20%  24%  41%  2%       33%  63%  4%
 stamp
 applications.
 Has your state
 tried that in the
 last 3 years? N=51
 d. Waive some or
 all fraud
 prevention
 procedures for
 elderly
 applicants. For
 example, waive     18%        26%  14%  28%  14%      12%  86%  2%
 finger printing
 for the elderly.
 Has your state
 tried that in the
 last 3 years? N=50
 e . Waive
 face-to-face
 interview for all
 food stamp
 applicants over 60 26%        33%  24%  12%  6%       28%  73%  0%
 years of age.
 Has your state
 tried that in the
 last 3 years? N=51
 f. Promote the use
 of scheduled home
 visits to reduce
 the documentation
 required for food
 stamp              12%        29%  26%  33%  0%       24%  77%  0%
 applications.
 Has your state
 tried that in the
 last 3 years? N=51
 g. Promote the use
 of medical
 deductions for
 elderly applicants
 for food stamps.   29%        41%  18%  10%  2%       55%  41%  4%
 Has your state
 tried that in the
 last 3 years? N=51
 h. Create special
 forms for the
 elderly such as
 large type
 versions.          24%        56%  12%  6%   2%       14%  86%  0%
 Has your state
 tried that in the
 last 3 years? N=50

                                                 No
                    Excellent Good Fair Poor  opinion   Yes  No   Uncertain
                      (1)     (2)  (3)  (4)            (1)  (2)     (3)
                                                (5)
 11. [Skip if
 state not fully
 EBT implemented:]
 The next set of
 suggestions from
 the FNS Access
 Guide is about
 electronic
 benefits. Again,
 I'll remind you
 that our
 categories are
 excellent, good,
 fair, poor, and
 no opinion .
 a. The first one
 is. . .Give
 qualified elderly
 households 6
 months rather
 than 3 months to
 use electronic
 benefits. How
 would you rate
 that for          39%        24%  9%   9%   20%       20%  80%  0%
 increasing
 elderly
 participation in
 your state?

 Has your state
 tried that in the
 last 3 years?
 N=46, 40
 b. Provide
 training on the
 use of Automatic
 Teller Machines,
 with EBT cards.
                   50%        39%  4%   4%   2%        93%  5%   3%
 Has your state
 tried that in the
 last 3 years?
 N=46, 40
 c. Follow up on
 non-users of EBT
 cards to find out
 if they need help
 accessing the
 benefits.         39%        46%  11%  2%   2%        58%  35%  8%

 Has your state
 tried that in the
 last 3 years?
 N=46, 40

                                                 No
                    Excellent Good Fair  Poor opinion   Yes  No   Uncertain
                       (1)    (2)  (3)   (4)           (1)  (2)     (3)
                                                (5)
 12 . The last
 group of
 suggestions from
 the FNS Access
 Guide is about
 partnerships with
 other agencies and
 organizations.
 Again, our
 categories are
 excellent, good,
 fair, poor, and no
 opinion.
 a. The first one
 is. . .Locate food
 stamp staff at the
 Social Security
 Administration who
 accept
 applications from
 the elderly even   12%       33%  22%  29%   4%       8%   88%  4%
 if they are not
 applying for SSI.

 Has your state
 tried that in the
 last 3 years?
 N=51
 b. Work with staff
 at the Social
 Security
 Administration to
 increase elderly
 participation in
 the Food Stamp     24%       47%  16%  10%   4%       37%  57%  6%
 Program.

 Has your state
 tried that in the
 last 3 years?
 N=51
 c . Work with
 companies and
 community
 organizations to
 promote elderly
 participation in
 the Food Stamp     38%       54%  4%   4%    0%       67%  29%  4%
 Program.

 Has your state
 tried that in the
 last 3 years? N=50
 [If respondent
 answered "poor" to
 any of Access
 Guide questions
 (Q8 to Q12
 above):] You
 mentioned that one
 or more            80% gave additional comments
 suggestions in the
 Access Guide were
 "poor." We'd like
 to know more about
 your thinking on
 that.

 13. Based on your reading of the Access Guide and
 the things you've learned about it in our
 interview today, we want to know how useful you      16% Very useful
 think it is. We want you to consider its
 usefulness for helping your state increase food      35% Moderately useful
 stamp participation among the elderly. Our
 categories are very useful, moderately useful,       37% Somewhat useful
 somewhat useful, and not useful. Which of those
 categories best describes how your state feels       10% Not useful
 about the Access Guide. Would you say… it
 is very useful, moderately useful, somewhat          2% No opinion
 useful, not useful or don't you have an opinion
 on that?                                             0% Other

                                                      0% All or almost all

 14. Considering the suggestions in the Access        0% More than half
 Guide that we covered, we'd like to know how many
 of them are new ideas for your state. Please tell    12% About half
 me which of the following categories best answers
 that question. Would you say all of the ideas are    29% Less than half
 new, more than half, about half, less than half,
 few, if any are new, or can't you say?               53% Few, if any

                                                      6% None

                                                      0% Can't say

 15. Before we go on to the next series of
 questions, would you like to add any comments   69% gave additional
 about your reaction to the Access Guide?        comments

                                                          Does
                                  Greatly   Increases      not   No opinion
                                 increases  somewhat     affect
                                   (1)                               6)
                                               (2)
                                                          (3)
 16. The next series of
 questions asks about elements
 of food stamp participation
 rules that the federal
 government designed to increase
 elderly participation. Some
 have been made over the last
 few years; others have been in
 place for a while. We'd like to
 ask you about the effect of
 each of these rules on the
 elderly in your state. That is,
 whether the rule increases,
 decreases, or does not affect
 food stamp participation by the
 elderly.
 a . The first one is…
 Eligibility is relaxed for
 elderly households by allowing
 $3,000 in resources. Would you
 say it increases, decreases,    6%       55%           31%      8%
 does not affect participation,
 or would you say no opinion?
 N=51
 b. Elderly persons in
 institutions are eligible for
 food stamps under certain       4%       41%           43%      12%
 conditions. N=51
 c. Medical costs over $35 a
 month are deductible from       12%      45%           39%      4%
 income. N=51
 d. Excess shelter costs are
 deductible from income for      14%      63%           24%      0%
 elderly households. N=51
 e. An authorized representative
 can be designated by the
 household for food stamp        16%      53%           31%      0%
 application and using benefits.
 N=51
 f. The face-to-face interview
 must be waived, if requested,
 in situations where an elderly
 household can neither appoint   16%      57%           27%      0%
 an authorized representative
 nor come to the food stamp
 office. N=51
 g. The Social Security office
 must help SSI applicants apply  8%       29%           60%      4%
 for food stamps. N=51
 h. The elderly are allowed to
 qualify by meeting only a net   14%      63%           20%      4%
 income standard. N=51
 i. Households that receive
 public assistance or SSI
 benefits are categorically      22%      55%           22%      2%
 eligible for food stamps. N=51
 j. A 24-month certification
 period is allowed for elderly   14%      32%           36%      18%
 households. N=50

 17. [Ask as necessary:] Does your state use the 24-month         46% Yes
 certification period statewide for elderly households? N=48      48% No
                                                                  6% Other

                            High     Medium      Low    No change    No
                          Priority  priority   priority  needed   opinion
                            (1)                  (3)
                                      (2)                 (4)       (5)
 18 . Finally, we'd like
 to ask you about a list
 of possible changes to
 improve participation in
 the food stamp program
 by the elderly. We'd
 like for you to think
 about the priority that
 you think the federal
 government should place
 on these changes. As I
 read each one, please
 tell me if the change
 should be a high
 priority, a medium
 priority, a low
 priority, or if you
 think the change is not
 needed.
 a. The first one is
 … Adjust minimum
 benefit level from $10
 to $25. What is your
 opinion about that
 change? Would you say
 that it should be a high 94%      4%          0%      0%         2%
 priority, a medium
 priority, a low
 priority, no change is
 needed, or would you say
 you don't have an
 opinion? N=50
 b. Set a standard
 deduction for medical
 costs for the elderly.   68%      20%         6%      4%         2%
 N=50
 c . Use adjunct
 eligibility so that the
 elderly automatically
 receive food stamps if   56%      16%         12%     10%        6%
 they are eligible for
 related benefits. N=50
 d. Mandate passive
 certification for the
 elderly for periods of
 two years and adjust     44%      34%         12%     6%         4%
 quality control
 procedures to account
 for it. N=50
 e. Increase a
 recipient's SSI check to
 include the value of any
 food stamp benefit.

                          34%      26%         16%     16%        8%

 [As necessary:] Some
 states call this "cash
 out." N=50
 f. Increase a
 recipient's Social
 Security payment to      30%      22%         18%     16%        14%
 include the value of any
 food stamp benefit. N=50
 g. Give the elderly a
 cash benefit in place of
 food stamp coupons or    26%      12%         38%     18%        6%
 EBT cards. N=50
 h. Adjust resource
 eligibility for          20%      42%         12%     16%        10%
 household size. N=50
 i. Provide more
 flexibility to states
 for elderly eligibility. 55%      28%         14%     2%         2%
 N=51

 18a. [Probe answer to "i":] Just to follow-up on
 that answer, could you tell me what you have in  80% gave additional
 mind for more flexibility? N=51                  comments
 18b . Are there any other suggestions that you
 have for changes that the federal government     55% gave comments
 should consider? N=51
 18c . Do you have any ideas for simplifying the
 application procedures? N=51                     61% gave comments

 19. I also wanted to ask you whether your state  8% Yes
 has done any research to find out why some
 elderly do not participate in the Food Stamp     88% No
 Program. Have you done anything like that? N=51
                                                  4% Other
 20. Another thing I wanted to ask is whether
 your state has tried any other ideas that you
 would recommend to other states to improve       63% gave comments
 elderly participation in the Food Stamp Program?
 N=51
 21. That's all the questions I have for our
 telephone survey. Before we finish today, would  43% gave comments
 you like to add anything else? N=51

Food Stamp Program

This appendix contains information on the Food Stamp Program and
characteristics of participating and nonparticipating eligible households.

Food stamp benefit allotments vary with the type and amount of income,
household size and some nonfood expenses (such as high shelter costs or
medical costs). Benefits are provided monthly, and recipients are expected
to contribute a portion of their net income to their food expenses. The
program has also established some special rules for households with older
persons (elderly households). For example, while the general population must
meet both gross and net income limits, elderly households need to meet only
the net income limit. Therefore, they could have a higher gross income than
other food stamp households and still be eligible once their allowable
deductions are calculated. These deductions include a standard deduction of
$134 for all food stamp households; a medical expenses deduction for elderly
or disabled members if these expenses are more than $35 for the month, after
insurance or government reimbursement or payment by someone who is not a
household member; and a deduction for shelter costs that exceed one-half of
household income after all other deductions. 12 Households with elderly
members also have a higher limit on allowable assets ($3,000) than other
households ($2,000). Additionally, applicants who have difficulty getting to
the Food Stamp Program office or food retailer may appoint an authorized
representative to apply for and use their food stamp benefits.

The maximum food stamp allotment is set annually at the cost of the U.S.
Department of Agriculture's "Thrifty Food Plan" for the household's size,
and indexed annually for food price inflation. Food stamp allotments are
based on the maximum allotment, adjusted for household size, less 30 percent
of monthly net income. Figure 3 shows a sample benefit calculation, using
the most common deductions for elderly households. The calculation is for a
one-person, elderly household with income of $750, monthly medical expenses
of $175 and monthly shelter costs of $350.

Table 1 presents information, by state, on the number and percentage of
elderly households receiving food stamps in fiscal year 1998--the most
recent year for which complete data are available.

                        Number of elderly
        State               households           Percent of food stamp
                         (in thousands)     households with elderly members
 Total                1,500                 18.2
 Alabama              37                    21.9
 Alaska               1                     8.8
 Arizona              13                    11.8
 Arkansas             25                    24.9
 California           30                    3.4
 Colorado             16                    19.1
 Connecticut          15                    16.4
 Delaware             2                     11.6
 District of Columbia 6                     15.0
 Florida              120                   27.9
 Georgia              58                    22.5
 Hawaii               10                    19.0
 Idaho                4                     16.0
 Illinois             71                    18.1
 Indiana              23                    18.1
 Iowa                 11                    19.4
 Kansas               11                    20.5
 Kentucky             29                    17.7
 Louisiana            40                    19.7
 Maine                16                    28.4
 Maryland             18                    13.2
 Massachusetts        18                    13.3
 Michigan             44                    13.5
 Minnesota            17                    17.4
 Mississippi          39                    30.2
 Missouri             34                    19.6
 Montana              4                     17.4
 Nebraska             7                     18.7
 Nevada               7                     22.0
 New Hampshire        3                     19.1
 New Jersey           40                    21.5
 New Mexico           10                    15.2
 New York             147                   19.4
 North Carolina       60                    26.8
 North Dakota         3                     21.2
 Ohio                 74                    22.2
 Oklahoma             28                    23.2
 Oregon               21                    18.5
 Pennsylvania         76                    19.0
 Rhode Island         5                     15.0
 South Carolina       31                    22.7
 South Dakota         3                     15.4
 Tennessee            62                    26.8
 Texas                103                   17.2
 Utah                 4                     12.8
 Vermont              5                     21.2
 Virginia             41                    24.1
 Washington           18                    11.5
 West Virginia        22                    20.0
 Wisconsin            15                    19.7
 Wyoming              1                     12.5

Notes: The data in this table are from the Food and Nutrition Service's
fiscal year 1998 food stamp quality control database. This database contains
detailed demographic, economic, and food stamp eligibility information for a
nationally representative sample of 47,145 food stamp households. The
national sample is stratified by month and by the 50 states, the District of
Columbia, Guam, and the U.S. Virgin Islands. The Food and Nutrition Service
weights the file so that the data replicate, by state, the monthly number of
Food Stamp Program households as reflected in the program operations data.

Table 2 lists some of the demographic characteristics of older participants
in the Food Stamp Program, and shows how they compare with those who are
eligible but do not participate. USDA has only limited information on
eligible elderly households that did not participate.

                              Eligible population
 Characteristic               Participantsa         Nonparticipantsb
 Average age                  66                    67
 Gender                       73% female            73% female
 Average gross monthly income $589                  Not available
 Average net monthly income   $334                  Not available
 Live alone                   79%                   52%
 Average household size       1.3                   1.9
 Urban/rural                  69% urban             Not available
 Race
                              53% Caucasian         65% Caucasian
                              29% African American  27% African American
                              13% Hispanic          5% Hispanic

aFood and Nutrition Service's quality control data, 1998.

b1999 pre-test survey by Mathematica Policy Research, Inc. The limitations
of these data include (1) small sample size, which made results not
nationally representative, and (2) some nonparticipants who are probably
ineligible for benefits.

Elderly Nutrition Program

This appendix contains information on the Elderly Nutrition Program's (ENP)
resources and on the characteristics of the population served by the
program.

The number of older persons, particularly those with impairments, has
increased during a time in which funding for programs authorized by the
Older Americans Act of 1965 has remained relatively flat. There are waiting
lists for ENP services in various parts of the country, especially for
home-delivered meals.

The Administration on Aging provides grants under title III of the Older
Americans Act to state agencies that are based on a state's relative share
of the population aged 60 and over. In fiscal year 1999, the Administration
on Aging provided about $486 million for meal programs and support services,
including the nutrition education required by the Older Americans Act. In
addition, the Food and Nutrition Service provided state agencies with $140
million in meal subsidies for ENP, at a rate of about 55 cents per meal.
States may opt to receive the Food and Nutrition Service reimbursement in
the form of cash or commodities; most states opt for cash.

About 41 percent of the providers that arrange or provide home-delivered
meals reported waiting lists in the home-delivered meal program, according
to a 1996 study. For providers maintaining waiting lists, the average number
of older persons on the list is 85, and the median is 35--about one-third of
the average daily number of homebound recipients served. The average length
of time spent on a home meal waiting list is 2 to 3 months. Roughly 9
percent of the group meal programs reported waiting lists for elderly
participants. The average size of these waiting lists is 52 persons, while
the median is 47--about 20 percent of the average number of participants
served. The average stay on such waiting lists is 2 months.

Table 3 identifies some of the demographic characteristics of ENP
participants, and compares them with the general population, aged 60 and
over.

 Characteristics         Participants in Home-delivery     General elderly
                         group meals     participants      population, 60+
 Average age (years)     76              78                72
 Percent living alone    57              60                25
 Percent with income
 below 100% of the       34              48                15
 federal poverty level
 Percent female          69              70                58
 Percent in rural areas  28              16                25
 Percent racial/ethnic
 minorities              27              25                14

Source: HHS, Administration on Aging, Serving Elders at Risk: The Older
Americans Act Nutrition Programs--National Evaluation of the Elderly
Nutrition Program 1993-1995, July 1996.

Commodity Supplemental Food Program

This appendix contains information on the Commodity Supplemental Food
Program (CSFP) and on the characteristics of the population served by the
program.

CSFP provides food and nutrition education to low-income participants; it is
authorized under section 4(a) of the Agriculture and Consumer Protection Act
of 1973. The program is available to low-income infants; children up to age
6; pregnant, postpartum, or breastfeeding women; and persons aged 60 and
older. Older persons participating in CSFP must have household income at or
below 130 percent of the federal poverty level and meet state residency
requirements. The program gives preference to women, infants and children at
each site; eligible low-income elderly persons can participate in CSFP if
there are resources available after all eligible women, infants and children
have been served. While women, infants, and children have preference under
the program, their participation has been declining since 1993, principally
because of the expansion of the Special Supplemental Nutrition Program for
Women, Infants, and Children, which also provides benefits to these groups.

CSFP participants receive, at no cost, boxed and canned goods, which are
generally distributed once a month. In some locations, participants who are
unable to pick up their food at the distribution centers can have it
delivered to their homes, generally by volunteers. Participants also receive
nutrition education provided by the local CSFP agency. USDA provides
guidance to participating states on the type and amount of food that should
be provided to older CSFP recipients. The maximum monthly distribution rates
for older persons and certain other participants are shown in table 4.

                                                              Total maximum
 Food Item                   Package size    Packages per     amount per
                                             month
                                                              month
 Cereal (one of the
 following)
 Dry, ready-to-eat cereal    18-ounce package2 packages       36 ounces
 Farina                      14-ounce package2 packages       28 ounces
 Rolled oats                 3-pound package 1 package        48 ounces

 Grits                       5-pound package 1 package every  2.5 pounds
                                             other month
 Fruit juice                 46-ounce can    3 cans           138 ounces
 Meat/poultry (one of the
 following)
 Meat/poultry                29-ounce can    1 can            29 ounces
 Meatball stew               15-ounce can    2 cans           30 ounces
 Tuna fish                   12.5-ounce can  2 cans           25 ounces
 Salmon                      14.75-ounce can 2 cans           29.5 ounces
 Egg mix, dry                6-ounce package 2 packages       12 ounces
 Milk (both types)
 Evaporated milk             12-ounce can    3 cans           36 ounces

 Instant nonfat dry milk     25.6-ounce      1 package every  12.8 ounces
                             package         other month
 Peanut butter or dry
 peas/beans (one of the
 following)
 Peanut butter               18-ounce package1 package        18 ounces
 Dry peas/beans              2-pound package 1 package        2 pounds
 Pasta, etc. (one of the
 following)
 Dehydrated potatoes         1-pound package 1 package        1 pound
 Macaroni                    1-pound package 2 packages       2 pounds
 Spaghetti                   2-pound package 1 package        2 pounds
 Rice                        2-pound package 1 package        2 pounds

 Grits                       5-pound package 1 package every  2.5 pounds
                                             other month
 Process American cheese     2-pound package 1 package        2 pounds

 Fruits                      15- or 16-ounce 2 cans           2 pounds
                             can

 Vegetables                  15- or 16-ounce 4 cans           4 pounds
                             can

Note: Participants may choose to select one package of cereal and one
package of farina, rather than two packages of either cereal or farina.
Participants may also choose to select one can of tuna fish and one can of
meatball stew, for example, rather than two cans of the same meat item.

Source: Food and Nutrition Service.

Federal funding for CSFP has varied somewhat over the past several fiscal
years. Appropriations for fiscal years 1997 through 2000 were $76 million,
$96 million, $86 million, and $88.3 million, respectively. In addition to
appropriations, unused food funds can be carried over from one fiscal year
to the next. For example, in fiscal year 1999, because of carryover funding,
$96.1 million was available for program expenditures, while in fiscal year
2000, a total of $97 million was available. By law, no more than 20 percent
of the total appropriation and carryover funds can be used to cover state
and local administrative costs.

USDA does not maintain a comprehensive database describing the
characteristics of older persons served by CSFP. According to Food and
Nutrition Service officials, since CSFP is relatively small compared with
other federal food assistance programs and is not nationwide in scope, the
program has not been subjected to as much study as some of the larger food
assistance programs. Our discussions with the National Commodity
Supplemental Food Program Association and CSFP service providers in several
states suggest that a large number of older persons participating in CSFP
are female and live alone.

Child and Adult Care Food Program

This appendix contains information on the Child and Adult Care Food Program
(CACFP) and on the characteristics of the population served by the program.

The adult segment of CACFP was initially authorized under the Older
Americans Act Amendments of 1987. The Child Nutrition and WIC
Reauthorization Act of 1989 changed the name to reflect the addition of the
adult component. Any adult, aged 60 or older and any person aged 18 and over
who has a functional impairment and attends a nonresidential day care
facility can qualify to participate in CACFP. Participants from families
with incomes at or below 130 percent of the poverty level qualify for free
meals, while those with incomes between 130 and 185 percent of the poverty
level qualify for reduced-price meals. Meals served to those with incomes
above 185 percent of the poverty level are reimbursed at a lower rate.

CACFP services are provided by licensed adult day care centers
(nonresidential) operated by public agencies, or private nonprofit and
for-profit organizations meeting certain criteria. Participants do not pay
for individual meals; instead the fee participants pay to attend the center
includes meals and snacks, along with other program services. Meals served
must meet minimum nutrition criteria as set forth in program regulations;
participants cannot receive more than two meals and one supplement (snack)
or one meal and two snacks in a single day. USDA reimburses the day care
center for a portion of the cost of all meals and snacks served to adult
participants.

Adult participation in CACFP has increased every year since fiscal year
1993. For example, average daily attendance has increased from about 36,000
in fiscal year 1993 to about 63,000 in fiscal year 1999, a 75-percent
increase. During the same period, federal reimbursement to adult day care
centers for meals more than doubled to approximately $36.5 million in fiscal
year 1999 and the number of participating facilities has increased from
1,222 to 1,855.

The most recent information describing the characteristics of adult CACFP
participants is from an October 1993 Mathematica study done for the Food and
Nutrition Service. Table 5 provides information from the study.

 Characteristics                                CACFP participants
 Average age                                    59
 Not married, living alone                      19%
 Not married, living alone in a group setting   21%
 Income below 130% of the federal poverty level 84%
 Female                                         62%
 Participating in other federal programs:
 SSI                                            57%
 Medicaid                                       68%
 Food stamps                                    18%
 Percent racial/ethnic minorities               43%

Source: National Study of the Adult Component of the Child and Adult Care
Food Program (CACFP): Final Report, Mathematica Policy Research, Inc., for
USDA, October 15, 1993.

GAO Contacts and Staff Acknowledgments

Robert E. Robertson, (202) 512-5138
Robert C. Summers, (404) 679-1839

In addition to those named above, Eugene W. Wisnoski, Clifford J. Diehl,
Kerry D. Hawranek, Fran A. Featherston, Carol E. Bray, and Carol Herrnstadt
Shulman made key contributions to this report.

(150174)

Table 1: Distribution of Elderly Food Stamp Households by State,
Fiscal Year 1998 37

Table 2: Characteristics of Older Persons Who Are Eligible for Food Stamps
39

Table 3: Characteristics of ENP Participants Compared With the
General Elderly Population 41

Table 4: Maximum Monthly Distribution Rates for Older Persons
and Certain Other Participants 43

Table 5: Characteristics of CACFP Adult Participants 46

Figure 1: Distribution of Food Stamp Benefits for Elderly
Households, Fiscal Year 1998 12

Figure 2: Participation Rates and Major Food Stamp Program
Legislation 18

Figure 3: Sample Food Stamp Allotment Calculation 36
  

1. Food Security Supplement to the Current Population Survey, U.S. Bureau of
the Census, August 1998.

2. Including the District of Columbia; does not include Guam and the U.S.
Virgin Islands.

3. Low-income households are those with average monthly income up to 130
percent of the Federal Poverty Income Guidelines, referred to as the poverty
level. The Guidelines are updated annually.

4. As of May 2000, 41 states, including the District of Columbia, have
operational on-line food stamp electronic benefit transfer systems (37
statewide). The Personal Responsibility and Work Opportunity Reconciliation
Act of 1996 requires that all states switch to electronic benefit issuance
for food stamps by October 2002.

5. Adults aged 60 and over can live in a group setting outside of their
homes or in a group living arrangement on less than a 24-hour basis.

6. Assets of households in which all members are receiving Supplemental
Security Income (SSI), or of individuals receiving SSI are not counted for
food stamp purposes.

7. National Study of the Adult Component of the Child and Adult Care Food
Program (CACFP): Final Report. Prepared by Mathematica Policy Research,
Inc., for USDA. October 15, 1993.

8. The model generated point estimates rather than ranges with confidence
intervals. Mathematica verified through duplication the modeling results.

9. The Nutrition Safety Net--Help for the Elderly and Disabled: A Primer for
Enhancing the Nutrition Safety Net for the Elderly and Disabled. Spring,
2000.

10. Our response rate was 100 percent, including the District of Columbia.

11. Percentages do not add up to 100% for all questions due to rounding.

12. These are the deductions most commonly used by elderly households.
Deductions for child support and dependent care are also available if
applicable. The standard deduction is adjusted annually and is higher in
Alaska and Hawaii.
*** End of document. ***