U.S. GOVERNMENT PRINTING OFFICE

72–959 WASHINGTON : 2001

S. HRG. 107–52

HEALTHY AGING IN RURAL AMERICA

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

WASHINGTON, DC

MARCH 29, 2001

Serial No. 107–1

Printed for the use of the Special Committee on Aging

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For sale by the U.S. Government Printing Office

Superintendent of Documents, Congressional Sales Office, Washington, DC. 20402

SPECIAL COMMITTEE ON AGING

LARRY CRAIG, Idaho, Chairman

JAMES M. JEFFORDS, Vermont

CONRAD BURNS, Montana

RICHARD SHELBY, Alabama

RICK SANTORUM, Pennsylvania

SUSAN COLLINS, Maine

MIKE ENZI, Wyoming

TIM HUTCHINSON, Arkansas

PETER G. FITZGERALD, Illinois

JOHN ENSIGN, Nevada

JOHN B. BREAUX, Louisiana

HARRY REID, Nevada

HERB KOHL, Wisconsin

RUSSELL D. FEINGOLD, Wisconsin

RON WYDEN, Oregon

EVAN BAYH, Indiana

BLANCHE L. LINCOLN, Arkansas

THOMAS R. CARPER, Delaware

DEBBIE STABENOW, Michigan

JEAN CARNAHAN, Missouri

LUPE WISSEL, Staff Director

MICHELLE EASTON, Minority Staff Director

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C O N T E N T S

Page

Opening statement of Senator Larry Craig ........................................................... 1

Statement of Senator Conrad Burns ...................................................................... 2

Statement of Senator Jean Carnahan ................................................................... 30

Statement of Senator John Breaux ........................................................................ 31

Statement of Senator Blanche Lincoln .................................................................. 32

PANEL I

Jon Burkhardt, Senior Study Director, WESTAT, Rockville, MD ....................... 3

Hilda Heady, Executive Director, West Virginia Rural Health Educations

Partnerships, Morgantown, WV, on behalf of the National Rural Health

Association ............................................................................................................ 36

James Sykes, Senior Advisor for Aging Policy, Department of Preventive

Medicine, University of Wisconsin Medical Center, Madison, WI ................... 48

Melinda M. Adams, Older Workers Coordinator, Idaho Commission on Aging,

Boise, ID ............................................................................................................... 57

Jane V. White, President, American Dietetic Association, Washington, DC ...... 66

APPENDIX

Additional comments submitted by James Sykes ................................................. 101

Response to question from James Sykes ............................................................... 104

Response to question from Ms. Heady ................................................................... 106

Response to questions from Jane White ................................................................ 108

Additional material submitted by American Dietetic Association ....................... 111

Administration on Aging State Program Report ................................................... 129

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HEALTHY AGING IN RURAL AMERICA

THURSDAY, MARCH 29, 2001

U.S. SENATE, SPECIAL COMMITTEE ON AGING, Washington, D.C.

The committee met, pursuant to notice, at 9:32 a.m., in room

SD–562, Dirksen Senate Office Building, Hon. Larry E. Craig,

(chairman of the committee) presiding.

Present: Senators Craig, Burns, Ensign, Breaux, Kohl, Lincoln,

Carper, and Carnahan.

OPENING STATEMENT OF SENATOR LARRY E. CRAIG,

CHAIRMAN

The CHAIRMAN. Good morning, everyone. I will convene this Special Committee on Aging hearing.

I want to thank all of you for attending the hearing this morning. I would first of all like to thank the witnesses for agreeing to

testify before our committee today on ‘‘Healthy Aging in Rural

America.’’

As the new chairman of this old and well-established committee,

I chose ‘‘Healthy Aging in Rural America.’’ as our hearing topic

today because it is a very important issue in my State of Idaho as

well as many other States across the country. It is time we stopped

thinking of aging as end of life, but as a continuation of living.

Most of us are living longer, healthier, and more productive lives,

and I am looking forward to hearing testimony that will ensure

that these opportunities are available to older Americans in rural

communities.

Some of the challenges facing the elderly in rural communities

are: transportation, nutrition, access to health care, employment,

and housing. Questions and testimonies today will focus on each of

these challenges. My priority is to look at constructive ideas that

address the challenges of older Americans in rural communities

and what they face on a day-to-day basis.

Ideas that allow our senior citizens the option of remaining in

their communities and living out vigorous and productive lives

ought to be a goal of this committee.

Again, I would like to thank the witnesses for sharing their expertise, and I would particularly like to thank Melinda Adams,

from my great State of Idaho, who made a detour, I understand,

to Washington today from her commitment with her daughter, who

is visiting colleges.

Our ranking member, Senator John Breaux of Louisiana, is off

on a phone call at the moment, but he will be back, so let me turn

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to my colleague from Montana, Senator Conrad Burns, for any

opening comments he may have.

Senator Burns.

OPENING STATEMENT OF SENATOR CONRAD BURNS

Senator BURNS. Thank you, Mr. Chairman, and thank you for

holding this hearing, and I want to thank the witnesses.

I will put a statement in the record, but I will say that in the

State of Montana, we are getting older, as all States are, to be

quite honest with you. The percentage of older people is becoming

a bigger part of our population and our demographics.

We started a center in Billings, MT, at Deaconess Medical Center, using telemedicine and new technologies, because we are going

to manage our older populations in rural areas in a different way.

I have 13 counties that have no doctors.

I can remember my father, who died at the age of 86 back in

1992, telling me just a week before he died—we were a farm family, a very close family—but my father said, ‘‘You know, I was

never afraid to grow old, but I was always afraid to get too old.’’

And that Monday night I flew back to Washington, and I said,

‘‘I will see you this weekend’’—I would go back through Missouri

on my way to Montana—and he said, ‘‘I will not be here, because

I am not going to get too old.’’ And by gosh, he wasn’t there the

next weekend.

We are going to use new technologies. We have a doctor in geriatrics at Deaconess now who designed these programs for rural

Montana using telemedicine and broad band services for interacting visibly with the patient and via computers and telephones and

a lot of things, and we use that same system in our distance learning. We also use it in the ways of rural doctors, because as soon

as they graduate from college—I have a daughter who is a doctor—

her education stops, and she wants to practice in a rural setting,

in that venue. That is her only way of continuing education.

So we have to start thinking about this. Instead of moving people, we have got to find those technologies that move us closer to

them from a major medical center so that we can manage our aging

and our health care for our aging in a different way.

So we thank you for coming today, and I look forward to your

testimony. But I will tell you as chairman of the Communications

Subcommittee over in Commerce, new and exciting technologies are

coming out, and we should be setting the environment where these

new technologies can be used, and then get out of the way and let

the people who really have the imagination to put them into use.

So thank you all for coming today, and I thank you, Mr. Chairman.

[The prepared statement of Senator Burns follows:]

PREPARED STATEMENT OF SENATOR CONRAD BURNS

Mr. Chairman, thank you. I’m excited to get the hearings of the Special Committee on Aging kicked off today. I look forward to working with you and the great staff

you have assembled for the betterment of senior citizens across America.

I’d like to start off by thanking today’s witnesses for taking time out of their

schedules to share their knowledge and experiences with the Committee today. The

Chairman and we have brought you here to learn from you so that we may better

legislate.

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By the year 2025, Montana will have the third highest concentration of senior citizens in America, behind Florida and your State, Ms. Heady, West Virginia. At the

present time, Montana is not ready for this demographic shift. Montana’s health

care system is not merely challenged by rural areas, it is DEFINED by rural and

frontier settings. Difficulties in transportation are exacerbated by tremendous distances and Montana’s own version of inclement weather. This hearing is especially

pertinent, therefore, to the concerns of my constituents.

As I mentioned earlier, we up here are here to learn from you, so I will keep this

short. But I am certain, however, that I will have some questions for you after your

testimony.

The CHAIRMAN. Conrad, thank you.

Senator Breaux is not back yet, and we have a vote at 9:45, so

we are going to start taking testimony, and Senator Breaux can

make his opening comments when he returns. We understand that

our first witness is time-sensitive—he is going to talk about transportation, but he needs to catch some transportation, which makes

him time-sensitive.

With that, let the committee turn to Jon E. Burkhardt, who is

Senior Study Director at WESTAT, who will be talking to us about

transportation.

Jon, welcome before the committee. Please proceed, and I will

ask the committee to stay at the 5-minute limit, if you would,

please.

STATEMENT OF JON BURKHARDT, SENIOR STUDY DIRECTOR,

WESTAT, ROCKVILLE, MD

Mr. BURKHARDT. Thank you very much. It is a pleasure to be

here. I have prepared written testimony that I would like to submit

for the record.

I am here to tell you that rural transportation is one of the best

investments that this country can make. It keeps people off of welfare; it keeps them out of nursing homes; it breaks down isolation;

it allows volunteers to volunteer; it connects people to health care,

commerce, and to each other; and it is especially important for

healthy aging in rural America.

I would like to point out four items today. One is that transportation is a key concern to elderly persons in rural areas. Travel demands of older persons will increase significantly. Our current Federal programs have offered a great deal of inspiration and assistance for both specific riders and our society. We need some improvements, and I would like to ask the committee’s assistance in

this.

The primary challenges in rural areas are the large proportions

of older persons and elderly poor who have few transportation options and have critical needs for long-distance transportation, particularly for treatments like dialysis and chemotherapy.

The numbers of our elderly are growing quite rapidly—this is

true for rural areas as well as our urban and suburban areas. Most

elderly in the future will live in areas that are now not well-served

by public transportation.

In the year 2030, we need to think about driving. Most of us

drive, and we have to start talking about transportation by talking

about driving. In 2030, the number of drivers 65 and older is going

to double. The proportion of older drivers on the roads will triple,

and one of the possibilities is that the number of fatalities involving older drivers will go up by three to four times what it is now.

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That will make it greater than the current level of alcohol-related

fatalities, and we know that that is unacceptable.

In my grandparents’ era, few people expected to retire from

working; in today’s era, not many of us think that we are going to

retire from driving. I would bet that a lot of people in this room

think that they will drive to their own funerals. This is not going

to happen.

A recent letter to Ann Landers said, ‘‘I have had two bypass surgeries, a hip replacement, new knees, fought breast cancer and diabetes. I am half-blind and cannot hear anything quieter than a jet

engine. I take 10 different medications that make me dizzy, windy,

and subject to blackouts. I have had bouts of dementia, poor circulation, I can hardly feel my hands and feet anymore. I am 85 or

87, but I do not know, and no one can tell me—all my friends are

dead. But thank God I still have my Florida driver’s license.’’

People do not want to give up driving. Driving is important. We

have had people tell us: ‘‘Driving is my life. If I lose my driver’s

license, I will curl up and die.’’

We need better options. We need better programs. In rural areas,

we have the Federal Transit Administration’s Section 5311 program; we have the Administration on Aging’s Title III Program,

and we have Medicaid. Those are the three big programs. They

work best when they work together.

In particular, the FTA’s 5311 program is a program that has had

great success in recent years in attracting many more riders and

doing this actually at a lower cost per ride, which is wonderful.

We did some studies of the economic benefits of rural public

transportation. It is a factor of three to one, and that is not even

counting all that we really could count.

The people who get this transportation tell us things like: ‘‘It is

a blessing to have the bus. ‘‘Thank God, you have helped us out.’’

‘‘This is what keeps me out of that nursing home.’’ It feels like letting a bird out of a cage.’’ These are very powerful testimonials

from older people.

We have many transportation services around the country that

serve as sparkling examples of what can be done to assist older

persons. In particular I would encourage people to look at the Independent Transportation Network in Portland, Maine, as a highly

customer-friendly and service-oriented operation.

I am running out of time, but I would like to say that we very

much appreciate the committee highlighting these issues, and we

look forward to the committee’s support for full and enhanced funding for current programs, activities like the Coordinating Council

on Access and Mobility. And I would like to ask that you look into

some changes in the current Medicare transportation provisions.

This is perhaps a $2 billion expenditure this year. It is not being

done as cost-effectively as it might be, and this is an area where

the committee could be of great assistance.

We need new kinds of vehicles, new forms of transportation services, and if we do that, we do not have to look at the isolation of

our older citizens and risks and avoidable traffic fatalities.

Thank you very much.

[The prepared statement of Mr. Burkhardt follows:]

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The CHAIRMAN. Jon, thank you very much.

We are going to allow questioning of Jon now, so that he can

have the flexibility of leaving before we go on with our panelists.

But first, another one of our committee members has joined us,

Senator Carnahan, so let me turn to her at this moment for any

opening comments she would like to make before we start the questioning of Jon.

Thank you.

STATEMENT OF SENATOR JEAN CARNAHAN

Senator CARNAHAN. Thank you, Mr. Chairman.

I am pleased to be here as a new member of this committee and

look forward to working with the committee to address issues that

affect seniors in Missouri and across the country.

From personal experience, I am happy to say that of all my committee assignments, aging is the subject I know the most about.

Mr. Chairman, the demographics of the United States are changing. We are an aging population. My home State of Missouri has

the 14th-largest population of senior citizens. We are experiencing

the effects of this change. The growth of Missouri’s 60-and-over

population now outpaces all other age categories. This group is expected to exceed 20 percent of Missouri’s total population by the

end of the decade. Even more rapid growth is expected in the 85-

and-over age group. By the year 2020, this group will comprise

more than 2 percent of the State’s population.

When looking at public policy, though, statistics are helpful, but

they do not tell the whole story. Behind the statistics are real people with real concerns about the future—seniors who suffer from

chronic illnesses without access to reliable and affordable health

care; seniors on fixed incomes who struggle with the escalating cost

of prescription drugs; adults who worry what the future holds for

an aging parent who can no longer live independently.

I believe these concerns affect us all, as they did me during the

8 years that I cared for my father, who was asthmatic and diabetic

and lived in our home during that time. So it is from that perspective that I will be approaching my work on this committee.

As policymakers, we have a responsibility to ask ourselves

whether our social infrastructure is prepared to meet the demands

on the horizon. There are two fundamental questions. First, how

can people maintain quality of life as they age, and second, how

can the Federal Government most effectively help seniors achieve

that quality of life? We cannot answer the second question without

keeping the larger context of the Federal budget in mind.

Decisions that we will make this year about taxes and the budget

could affect our ability to support our senior citizens 5 years or 10

years or even 30 years down the road.

As a member of this committee, I intend to examine these questions closely. I have a particular interest in exploring how we can

help seniors stay in their own homes and communities as they get

older.

The challenges that seniors face with aging in place are multiplied for those in rural areas. One critical issue in rural areas is

adequate transportation so that seniors can live independently, be

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able to travel to the grocery store or to the doctor’s office or to the

community center or to church.

In Missouri, we have two programs that provide door-to-door van

service. The vans are very helpful to many of our seniors. However,

some of Missouri’s area agencies on aging are reporting a decrease

in the use of these vans. There is a demand for more individualized

service, particularly among seniors in rural areas who are frail or

have a disability. For these seniors, it can be difficult to sit in a

van for a long period of time as the driver picks up other people

in neighboring small towns, towns that could be as much as an

hour away. The time that it takes a driver to pick up several passengers, deliver them to doctors’ appointments and return them to

their homes is just simply too long for some seniors.

However, individualized service is expensive. The area agencies

on aging have been relying on volunteers to assist with the driving.

But with the rising cost of gasoline, they have lost most of the volunteers.

The transportation example illustrates just one of the challenges

for rural seniors in Missouri. It underscores the importance of revising our understanding of the needs of today’s seniors. Once we

have explored the issues, we can adjust our public policy accordingly.

I applaud Chairman Craig for holding these hearings, and I am

optimistic that our panel today will educate us and guide us as we

develop a policy that meets the needs of our seniors in rural Missouri and throughout the Nation.

Thank you, Mr. Chairman.

The CHAIRMAN. Senator Carnahan, thank you.

I have watched my wife’s parents care for their aging parents—

and I think any of us who have done that bring a unique perspective to this committee, and I thank you for that contribution.

Let me turn now to our ranking member on the committee, John

Breaux of Louisiana. I think we have a vote starting in 3 or 4 minutes, John, so you can proceed with your opening comments, and

then, Senator Lincoln has joined us. The moment the vote starts,

I will step out, run and vote, so that we keep the committee functioning.

Please proceed, John, and I will turn it over to you at this time.

STATEMENT OF SENATOR JOHN B. BREAUX

Senator BREAUX. Thank you, Mr. Chairman.

We all welcome you as our new chairman. We sort of traded in

the old chairman for a new chairman who is a little younger, and

we look forward to having you at the leadership of our committee.

I think we start with a very important panel, talking about aging

particularly in rural America.

I think all of us on this committee share the common goal of not

only helping people extend their lives and live longer but also, an

equally important goal is to allow people to live better, not just

longer. All the issues that we will be discussing are really very important in ensuring that people live a better quality of life and not

just a longer life. So we are delighted and look forward to working

with you on a number of other issues throughout the year that will

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make a major contribution toward our aging population which is so

important to this country.

So I look forward to working with you, Mr. Chairman.

The CHAIRMAN. Thank you, Senator Breaux.

Now, let me turn to Senator Lincoln.

Blanche.

STATEMENT OF SENATOR BLANCHE L. LINCOLN

Senator LINCOLN. I too, Mr. Chairman, want to congratulate you

on your new role as our committee chairman.

These are exciting and challenging times for us as we attend to

the care needs of our seniors in this Nation, and I look forward to

working with you on these matters that are very near and dear to

my heart. As many have expressed here, caregiving is also a very

real experience that I am going through with my family as well.

Arkansas ranks fifth-highest for its population of 55-plus seniors

and first for the number of seniors living in poverty. And although

we do have the Donald W. Reynolds Center on Aging, which has

been a wonderful tool for us in Arkansas, out of 125 medical

schools in this country, we only have three that offer a residency

program in geriatrics. I do not know about you, but that tends to

make me a little paranoid about how ill-prepared we are in this

Nation for the increasing number of seniors who will come in with

the baby boomers.

Although we have the center, and it has been a great advantage

to us in Arkansas, I would also be delinquent in my duties if I did

not acknowledge the tireless efforts of our most fierce trailblazers,

the State’s Area Agencies on Aging. We have a very dynamic director in the State of Arkansas. His name is Herb Sanderson and he,

along with all of the county directors, is really clearing the way for

some truly outstanding services for the seniors of Arkansas. I have

thoroughly enjoyed my working relationship with Herb, and he

brings a great deal to this job.

Thinking out of the box is second nature for these State directors, as they are charged with creating aging programs that attend

to the very basic needs of one of our most precious populations. Oftentimes, in rural States like Arkansas, they really do have to be

creative.

I believe that if there were a message to take from this hearing

today, it would be that in spite of the great challenges that face

rural States, they remain our most fierce trailblazers when it

comes to the development of creative care delivery systems. I hope

that we can all talk about that; as we look forward to the testimony.

In addition, given the magnitude and volume of challenges that

are facing Congress, I believe that a balanced approach for Government would be to continue our support for the creative programming that the States have initiated while the Federal debate continues.

I really look forward to your testimony here today, and thank

you all for participating in this discussion and certainly the opportunity to share some of Arkansas’ struggles as well as their successes. As Senator Breaux mentions we are striving—not just to

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provide a longer life to our seniors, but a quality of life for them

in their own homes and in their own communities.

Thank you, Mr. Chairman.

The CHAIRMAN. Blanche, thank you.

Now let us turn to our first witness, who has already given his

testimony in the area of transportation.

Jon, I suspect my greatest sense of freedom came the day that

I got my driver’s license. And out in rural Idaho, uniquely, that

came at 12 years of age, because I lived out on a rural ranch, and

the sheriff gave a special permit to let us kids drive—especially

when you had to drive 27 miles one way to school. That is just the

way it was.

At the same time, about 10 years ago, I was forced into the very

difficult situation, because of a close relationship with an elderly

aunt, where no one wanted to tell her that she should not drive

anymore. After three or four crashes, I was the one chosen to tell

her that she should not and could not. I can remember the look on

her face and the discussion we had. She was worried about her

freedom, her access—how would she do this, how would she do

that?

So your testimony today is most appropriate, and that is one of

the greatest hurdles if our citizens want to continue to live in rural

America where they would like to live, where oftentimes their life

style is much more acceptable to them than having to migrate toward urbanism, where they had never lived before.

In your testimony, you have cited a variety of programs, and you

have highlighted a couple of them and mentioned one that I believe

you said was not being cost-effective in the area of Medicare in

general. Now can you be specific and give us some examples of

your concerns and your suggestions as to how those might be improved in those program areas.

Mr. BURKHARDT. Thank you, Senator Craig.

I am concerned that under Medicare provisions, the only transportation authorized by law is by ambulance. This is for emergency

situations. We know from an Inspector General’s report from HHS

that this is not exactly what is happening in the world these days.

A very large concern is rural elderly persons who need dialysis

treatment. Clearly, if you do not get many dialysis treatments, you

will die. So that is a critical medical condition, but it generally does

not fall under what is considered emergency transportation, and it

does not require advanced life support, and it does not require

basic life support services that are provided by ambulances.

These trips to and from dialysis could be provided much more

cost-effectively by the kinds of rural public transportation services

and services from area agencies on aging that exist now. This is

not currently permitted under Medicare legislation, but we know

that it exists. I would encourage the committee to encourage the

Health Care Financing Administration to come up with a much

more comprehensive transportation policy; for them to do that, it

will require a change in the law.

The CHAIRMAN. You had mentioned the area of planning, and

your testimony acknowledges that there seems to be a lack of planning in the area of transportation services for the elderly. I too am

astounded by statistics in aging and where we are going to be 20,

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30, 50 years out. There was a gentleman in my office the other day

whose name I do not recall, but he is a renowned geriatrics doctor

in New York who has an aging clinic, and he said that at the end

of this century, and that seems to be plenty of time to plan, but

usually is not—we are going to have 5 million centenarians. That

is a bit mind-boggling for all of us, and as we bring about these

new health care applications that make our lives better and extend

that life, obviously, what you are talking about is very clear. You

mentioned a few number of accidents on roads and deaths that

might be caused by elderly people less capable of driving.

What kind of planning do you envision as it relates to communities and to the programs?

Mr. BURKHARDT. I envision planning that would focus on access

and mobility. When we interview older persons about driving, they

say two words to us—freedom and independence. These are both

very cherished American values.

I would like to believe that the automobile is not the only way

to achieve mobility and independence, but in fact in many communities that is true today. You have the operator of a very successful

service in Iowa saying, ‘‘I hope I never have to depend on my own

service.’’ Now, he is doing well, but what he is saying is that these

services are often 9 a.m. to 5 p.m., Monday through Friday; they

do not let you go to a movie; they do not get you to visit your wife

in the nursing home on Christmas Day; they do not provide lots of

really critical transportation services. And then, some people who

really need these services drive when they should not. By having

more choices, I believe we could improve the safety and health and

well-being of rural Americans by a substantial amount.

The CHAIRMAN. Jon, thank you.

Let me now turn to my colleague, Senator Breaux.

Senator BREAUX. Have the other panelists testified yet?

The CHAIRMAN. No, they have not, but Jon has a transportation

problem, so we are going to question him and then move to the rest

of the panel and then to questions and follow-up.

Senator BREAUX. I was just looking over the testimony, Mr.

Burkhardt, and I find it very interesting because you know, a lot

of times, we spend a great deal of effort trying to provide better facilities, but we never follow up to find out how you get from one

place to another. I think your testimony has been very helpful in

having us look into the whole question of transportation from one

facility to the next. It is a real challenge.

I know there will be more and more older people driving, which

creates safety problems. I am a big believer in one being able to

drive as long as he or she is capable of doing so. Let us test them

and make sure they are capable, but not have an arbitrary cutoff

date. So you raise some really interesting points that I think will

allow us to focus in on transportation problems, which we really

have not done a lot of as far as this committee is concerned.

Senator Lincoln, do you have questions or comments?

Senator LINCOLN. Yes, just briefly. We are preparing in Arkansas

for a forum that we have entitled, ‘‘Caring Across the Continuum,’’

to look at all of the needs of seniors. We plan to address service

delivery and barriers to access. Transportation has been a huge

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factor for some of our most frail seniors in areas like the delta

which is one of the highest poverty areas in the Nation.

Can you address any creative ways that you have seen through

public-private partnerships helping with rural transportation

needs? Is there anything specific there that comes to mind?

Mr. BURKHARDT. I think there are a number of solutions that

would lend themselves to the area that you are speaking of. One

of the best approaches is to look at transportation services that

serve everybody, that serve welfare-to-work clients, that serve older

people, that serve the general public, that serve kids getting home

after basketball practice—all very, very different kinds of clientele.

The funds are put together in a coordinated way so that no one

agency is responsible for all of the resources, and they operate cooperatively. Sometimes it is what we call a ‘‘brokerage,’’ where

there is a central information number to call and then, perhaps,

they will assign the trip to a taxi company or perhaps to an Area

Agency on Aging or to a developmental disability program or to a

public transportation provider. A brokerage often works very, very

well.

We should include car-pooling and van-pooling, we should include volunteer services, and we should caste as broad a net as possible to solve these problems.

Senator LINCOLN. Most of the solutions that you have mentioned

are public agencies or something under public auspices, other than

taxi services. Do you see any private entities playing a role in that,

or have you seen anything that stands out?

Mr. BURKHARDT. We have seen some wonderful efforts by corporations like FedEx to get their employees to work, and a number

of other large corporations have also been involved. I think we

want to reach out to private enterprise, but one of the important

points about planning is to have a focal point, and in particular one

point of access, especially for older persons, but let us say an 800

number that you can call. So it does not really matter what color

the van in which you ride is, and it does not matter so much what

it says on the side; what matters is that you get a ride.

This is what is called the new paradigm in freight transportation—the U.S. Postal Service buying services from FedEx, FedEx

shipping packages on UPS airplanes, and so on. We need to look

at this kind of approach for rural public transportation.

Senator LINCOLN. Thank you. I appreciate your comments.

Senator Breaux [presiding.] Senator Carnahan.

Senator CARNAHAN. Yes, clearly, access to transportation is a

major concern in our rural areas. In your testimony, you have listed several ways that you think Congress could improve transportation in the rural areas, including the sharing of information on

best practices.

Is there a clearinghouse for best practices that would be available to people?

Mr. BURKHARDT. The real focal point at the moment is the Coordinating Council on Access and Mobility, which is jointly staffed

by the U.S. Department of Transportation and the U.S. Department of Health and Human Services.

I will tell you that this is a voluntary effort, and it would help

that Council if its status were elevated and if it had some more

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funding. At the moment, it does not have a telephone number that

you can call, and it does not have stationery. It does have a web

page.

Also, I would like to point out the Rural Transportation Assistance Project from the Federal Transit Administration and the Community Transportation Assistance Project from the Department of

Health and Human Services. They are both staffed by the Community Transportation Association of America, and they have a large

amount of information available.

Senator CARNAHAN. Thank you.

Senator BREAUX. Mr. Burkhardt, we will excuse you. If you commuted in from Rockville this morning on 270, you understand what

transportation problems are all about. [Laughter.]

Thank you for your testimony.

Mr. BURKHARDT. Thank you, Senator Breaux. I appreciate the

committee’s assistance in my travel problems.

Senator BREAUX. We will now take testimony from our other distinguished panelists, and we will start with Ms. Hilda Heady.

Ms. Heady, we are pleased to have you before the committee.

STATEMENT OF HILDA HEADY, EXECUTIVE DIRECTOR, WEST

VIRGINIA RURAL HEALTH EDUCATION PARTNERSHIPS,

MORGANTOWN, WV, ON BEHALF OF THE NATIONAL RURAL

HEALTH ASSOCIATION

Ms. HEADY. Thank you, Senator.

I am also pleased to be here. I appreciate the committee’s invitation to testify. I am representing the National Rural Health Association as a member of their policy board. I am also the Executive

Director of a State-funded program in West Virginia where we require all of our health professions students to train in rural communities for at least 3 months before we let them out of the State

with their degree. Early on we had some resistance to the requirement but most students come out of it much wiser and much

happier.

We have a lot of exciting opportunities and challenges, as you

know, in rural America. West Virginia achieved the distinction last

year of becoming the oldest State in the Nation. We got older than

Florida. We are using our own rural values around collaboration

and partnerships to try to deal with some of these issues, but we

expect in the next 10 years in our own State that one out of every

four people will be over the age of 65.

The congressional fixes that have been instituted to the Balanced

Budget Act present hope for us, but one of the greatest impacts

which represents our short-term challenge, is in the area of home

health. We have had 24 agencies close and a 48 percent drop in the

number of home health visits. That presents challenges to our local

communities with existing providers and their need to collaborate

and to develop other stopgap measures.

One example that I want to use is the system of free clinics that

we have in our State. We have nine free clinics that provide $13

million worth of free drugs to elderly who are on Medicare and do

not have a prescription benefit. So we know that we have a number

of rural elderly who could use a prescription drug benefit in Medicare.

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There are other examples of collaborations and partnerships in

our State and in others that I would like to highlight. These are

also included in my written testimony. In West Virginia we have

a program called Aging Well in Calhoun County. There are 8,000

people in that county, and the program was started by a group of

people who wanted to volunteer to transport elderly clients to

health care facilities both in and out of the State; but before they

started that program, they knew that they needed to be trained in

how to care for the elderly and deal with circumstances if they

came up during transportation.

Another program is the Integrated Health and Service Council of

Ritchie County, that has the senior citizens’ program, the nutrition

site, and a child day care center in the same facility with an adult

day care center. I was there last week with an Alzheimer’s patient

and two other seniors, playing dominoes, and one of the elders was

101-year-old Nellie. Her 55-year-old grandson had taken her to the

doctor that morning, and she was telling me stories about living in

her trailer on her grandson’s buffalo farm.

One of the exciting opportunities I have is working with students

when they are out on rural rotation, working with the elderly and

learning skills to work with this population. Our program last year

served 185,000 rural citizens. We had medical students, nursing

students, a variety of students, working with that many people in

health promotion activities.

Another program that I would like to mention is the Partnership

for Rural Elderly in Dahlonega, GA. This is a collaborative of a

number of different health and social service agencies, and all of

these programs have the objective of trying to keep the elderly

healthy and in their home communities.

One of the prime examples that we have in the Federal Government for the elderly that do require this type of collaboration and

use of local resources is through the Federal Office of Rural Health

Policy and their Rural Outreach Grants. It is one of the most flexible funding streams and allows communities to innovate as much

as possible to be creative to meet their challenges.

I would also like to bring up a topic that we rarely see when we

talk about the aging or even in rural health circles, and that is the

problems we are seeing with the aging rural veteran. I am a member of a support group, the Significant Others Support Group of

Vietnam Wives, at our Vietnam Readjustment Center in Morgantown, WV. That center serves 18 counties in West Virginia and

Southern Pennsylvania, and more than 50 percent of the people

who come to the center come from rural areas.

One thing we do know—Vietnam was always called ‘‘the war that

was fought from Harlem to the hollows’’—so we do know that we

have a disproportionate share of aging veterans who are poor and

that a significant number of them are rural.

In preparing my testimony, I called all the veteran outreach centers in the States of Iowa, Idaho, Louisiana, and West Virginia,

and every one of them reported that anywhere from one-third to

two-thirds of their clients come from rural areas.

We also know that 50 percent of all veterans who get services

from the Veterans’ Administration get them from these outreach

centers. They are concerned about long-term care, particularly for

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the World War II veteran. Every center needs a family therapist,

because there currently is not one in the Veterans’ Administration

to staff them.

Among the things that the Federal Government can do at this

point are to look seriously at the prescription benefit for all Medicare recipients; improve home health care and community-based

services; develop more funding streams for partnerships with

States to train health professionals in rural areas that focus on

rural content for the rural elderly; fund a national study on the

aging veteran—the last time we looked at this population was in

1988; and provide increased funding for transportation.

Thank you so much for your time and your attention. I want to

let you know that the National Rural Health Association is very

ready to work with you.

Thank you.

The CHAIRMAN. Thank you very much.

Mr. Sykes.

[The prepared statement of Ms. Heady follows:]

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STATEMENT OF JAMES SYKES, SENIOR ADVISOR FOR AGING

POLICY, DEPARTMENT OF PREVENTIVE MEDICINE, UNIVERSITY OF WISCONSIN MEDICAL CENTER, MADISON, WI

Mr. SYKES. Thank you, Senator. It is a real pleasure for me to

be before the committee to speak about something that has been

the heart and soul of my life for 30 years.

Where one lives is simply the most important daily fact of one’s

life. When that place is supportive, familiar, navigable, that is a

good place to live, and people who have that have high levels of life

satisfaction. Those for whom their housing situation is not good

live each day with a series of problems that housing itself, the shelter, makes more onerous.

In my brief time here, Senators, I would like to mention three

programs—one, a community program; one, a State policy; and

third, a HUD policy—that are critical to the well-being of people

living in rural America. And I would like to very briefly mention

lessons from each of these.

Let me go first to Sun Prairie, WI where, some years ago, a

group of people with some leadership from the corporate world,

local government, religious groups, decided that the elders in their

community needed some place to go, something to do, and out of

that, the corporation gave leadership to the development of a senior

center and provided the money.

With the partnership of others in the community, that program

evolved into an exciting program with a whole range of services including, later on, adult day care as a freestanding facility, the

meals, the transportation, the counseling, and opportunities for

personal growth.

From that experience, which is sustainable through a wide range

of support, initially brought into being by a very small Older Americans Act grant that was important, the Colonial Club continues to

make life in a relatively small community in Northeast Dane County livable and provides a great deal of support to the people, knowing that in their community, they are cared for. And for the children, it provides a great deal of confidence that their parent or parents are cared for.

Under every good local program, there needs to be a policy, a

program that sustains it, and in this respect, Wisconsin again provided very important leadership, including support when Senator

Feingold was one of our State Senators in Wisconsin, when we developed a Community Options Program which simply said that everyone in the State was entitled to an assessment of functional capacity, that they were entitled to some effort to devise a care plan

so that they could be cared for in the least restrictive setting, in

the most effective way, and that, using Medicaid waiver moneys

and State general-purpose revenues, the State had both an obligation and an opportunity to enable people to continue to live in the

community and in their homes.

It was not the principal goal of the program, but it certainly has

been a favorable consequence, that there has been serious diversion

from nursing home placements because of this program, and it is

in place.

So a little program like this one in Sun Prairie and many other

towns throughout rural Wisconsin has under it a foundation of

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public support through the Community Options Program, and there

are some lessons to be drawn from that.

Third, in each of the programs that I have seen across this country, something had to make it start, something had to get it going.

In many of the communities during my tenure as chair of the

State’s Housing, Finance, and Economic Development Authority,

we found that what it took was somebody coming into that town,

listening to the people talk about what they wanted to do for their

citizens, but with the knowledge and the ability to access the

funds, to show how other programs have developed and have been

successful.

So in the whole area of technical assistance, including the Rural

Housing and Economic Development Assistance Program and other

HUD technical assistance moneys, there is now the capacity within

an organization like ours, the Wisconsin Partnership for Housing

Development, to in fact pay for the technical assistance, but that

it is spent and allocated to a particular community with its own

goals.

Those are three very small and very brief examples of a community development that needs some assistance, some catalytic

agents, some partnership at the local level. The second is that we

do need a State policy that really provides financial assistance and

enables communities to build, finance, and sustain the kind of infrastructure that is necessary for people to live a good life and to

move ahead on many fronts. We need people who are knowledgeable, who can provide technical assistance, and help communities

move from where they are to where they want to be.

Across this Nation, I have not seen a religious organization, a

civic group, a local government, or others that has not had as a

part of its intention to serve their elders well. They have had lots

of problems making it happen, and we know through examples how

it can happen, how it can be successful, and how it can be sustained.

Thank you, Mr. Chairman.

The CHAIRMAN. Mr. Sykes, thank you very much.

[The prepared statement of Mr. Sykes follows:]

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The CHAIRMAN. Before I turn to the next witness, do either of my

colleagues who have joined us here have an opening statement?

Now let me turn to Melinda Adams, who is the Older Worker Coordinator at the Idaho Commission on Aging. She will be talking

to us about employment of our elderly.

Melinda, again, welcome to the committee.

STATEMENT OF MELINDA M. ADAMS, OLDER WORKER STATEWIDE COORDINATOR, IDAHO COMMISSION ON AGING,

BOISE, ID

Ms. ADAMS. Senator Craig, thank you for your kind welcome. I

appreciate this opportunity to testify.

To start, a few words about our home State’s work force initiatives. Idaho’s older worker programs have been regarded as models

of coordination and have achieved excellent results. For 7 of the

past 10 years, the U.S. Department of Labor has ranked Idaho’s

Senior Community Service Employment Program first in the Nation for success in placing low-income seniors in jobs.

I am also pleased to report that, with the able leadership of our

former State Aging Director, now Staff Director Lupe Wissel, Governor Kempthorne’s Workforce Council approved second-year funding for our Statewide Workforce Investment Act Project. Since the

elimination of Federal set-aside money for older workers, Idaho

was the first State to designate State-level WIA funding for older

job-seekers. Other States are finally beginning to follow. That

should not be the case in an economy where the numbers of disadvantaged older workers are growing far faster than any other

age group and where low-income older workers constitute the most

computer-illiterate group of workers in a labor market where 70

percent of jobs require computer literacy.

Also, the need for dislocated worker resources for older workers

is on the increase. Idaho’s rural areas have an above-average share

of older people who can no longer depend on agriculture, timber,

and mining for their support. The Sunshine Mine closures in the

Silver Valley, and the impending Boise Cascade closures, announced in recent weeks, are unfortunate examples of the devastation caused by layoffs in our small communities.

Idaho is not unique in this respect. These dynamics are at play

throughout rural America with the demise of the family farm, the

decline of other natural resource-based industries, and the impact

of global economics.

The data clearly show that older persons who lose their jobs experience far more difficulty than other age groups in becoming reemployed. At both the Federal and State levels, rural older worker

employment should be a focus in economic and dislocated worker

initiatives.

Accordingly, as Congress reconsiders reauthorization of the

Workforce Investment Act, we urge added emphasis on older workers.

New opportunities to serve our most geographically isolated seniors are finally presenting themselves, thanks to the new technologies. An older worker in Salmon, Idaho can now support herself as a medical transcriptionist, operating out of her home, with

the right training and the right equipment. Thus, our recommendaVerDate 11-MAY-2000 09:03 Jul 11, 2001 Jkt 000000 PO 00000 Frm 00061 Fmt 6633 Sfmt 6602 C:\DOCS\72959.TXT saging1 PsN: saging1
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tion for expanded flexibility and increased funding to use Title V

funds for self-employment and cottage-based entrepreneurial activities.

Similarly, expanded flexibility to use these funds for private sector work experience will allow us to better serve our most rural

seniors who reside in locales with few, if any, eligible host sites.

Distance learning innovations also offer hopeful solutions to the

rural senior in need of training. Many rural communities have limited public transportation systems; the more remote areas have

none at all. As a solution, we challenge our educational system to

expand lifelong and affordable distance learning opportunities.

We also support policy changes that eliminate disincentives to

work—the removal of provisions in pension plans that penalize individuals for working after retirement; the encouragement of

phased retirement and tailored benefit packages to facilitate the

hiring of mature workers in flexible work arrangements.

In closing, both job-seekers and incumbent workers need a voice.

It is ironic that, at the very time that aging workforce issues

should be a focus, Federal legislation eliminated dedicated funding

for mature workers.

Strategies on how to address the physical, educational and training needs of disadvantaged older workers should be a focus now.

For these reasons, we urge the U.S. Department of Labor to establish a position at the assistant secretary level for oversight of workforce issues impacting older individuals and employers.

Thank you for this opportunity to testify.

The CHAIRMAN. Ms. Adams, thank you very much for that valuable testimony.

[The prepared statement of Ms. Adams follows:]

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The CHAIRMAN. Now let me turn to Jane White, President of the

American Dietetic Association, who will be talking to us about diet

and nutrition.

Jane, welcome before the committee. We are pleased to have you.

STATEMENT OF JANE V. WHITE, PRESIDENT, AMERICAN

DIETETIC ASSOCIATION, WASHINGTON, DC

Ms. WHITE. Thank you, Chairman Craig.

I am pleased to be here to discuss nutrition and its importance

to healthy aging in rural America. I represent the largest association of food and nutrition professionals in this country. Our 70,000

members serve the public through the promotion of optimal nutritional health and well-being.

I live and work in rural East Tennessee. As a registered dietitian, professor of family medicine, and a member of the ADA’s Nutrition Screening Initiative, I see the difference that optimizing nutrition status makes in the lives of older Americans.

The Institute of Medicine has observed that poor nutritional status is a major problem among our Nation’s elderly. Inadequate intake is estimated to affect 37 to 40 percent of free-living elderly.

Diet quality ratings in these people show that about 80 percent

have diets that need improvement or that are poor. Among hospitalized and nursing home elderly, undernutrition is especially

prevalent. In addition, 86 percent of older Americans have one or

more chronic diet-related diseases, including hypertension, diabetes, and dyslipidemia, singly or in combination. Adverse health outcomes are prevented or reduced with appropriate nutrition intervention.

Healthy aging requires adequate nutrition. However, rural America offers some unique challenges due to distance, topography, and

limited availability of health care options that are widely present

in more urban settings. Seniors who routinely eat nutritious food

and drink adequate amounts of fluids are less likely to have complications from chronic disease or to require care in a hospital,

nursing home, or other facility. It makes sense to emphasize routine nutrition screening for all Americans, but especially for seniors

living in rural areas.

Isolated individuals are more susceptible to poor control of chronic disease states due to difficulty in accessing available nutritional

care. Nutrition screening can identify seniors at increased risk for

poor nutritional status and can facilitate intervention to improve

health. The Determine Check List and Nutrition Care Alerts developed by ADA’s Nutrition Screening Initiative were designed for this

purpose.

Take the Nevada Division of Aging Services’ pilot program. It

provides 120 at-risk seniors with nutrition screening and intervention that includes medical nutrition therapy, home-delivered meals,

and dietary supplements. A homebound older gentleman was

screened after spending 2 weeks in the hospital to treat a sore on

his foot. The healing process was impaired by poorly controlled diabetes. His doctor was concerned that if the wound did not heal, amputation might be necessary. Medical nutrition therapy, in this

case, meal planning and food selection and preparation education

provided by a registered dietitian, and home-delivered meals

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helped this man control his diabetes, resulting in the rapid healing

of his foot wound.

The total cost of this nutrition intervention was $350—far less

than the cost of even one day in the hospital, not to mention the

additional costs in health care and support services had the man’s

foot been amputated.

Meals programs and other nutrition-related services offered

through the Administration on Aging are vital to maintaining the

health and well-being of our Nation’s elderly. These programs do

a good job. Between 80 and 90 percent of participants have incomes

below 200 percent of poverty level. Two-thirds of participants are

either over-or underweight, placing them at increased risk for nutrition and health problems. Those receiving home-delivered meals

have more than twice as many physical impairments compared to

the general elderly population. But the wait time to access these

services is 2 to 3 months in many areas, and the lines are long.

Funding for these programs are at 50 percent of 1973 levels.

Seniors must be able to access dietitians who can determine

what will best meet their needs and who can teach them how to

apply that knowledge in their daily lives. Programs like the National Health Service Corps could help bridge the gap between

need and access. ADA believes that dietetics professionals should

again be included in this program.

Recognition of telemedicine technology as the vehicle for nutrition services delivery also could facilitate access to dietitians when

none is available in the immediate area.

HCFA requires nursing homes to have a dietitian. However, in

many States, they set a minimum of 3 hours per week for dietetic

presence in a facility. Most facilities comply with the bare minimum. Considering the widespread nutrition-related problems so

prevalent in nursing homes, 3 hours per week is not enough time

for dietitians to oversee the paperwork that is required, let alone

to fulfill the active role of facilitator and manager of nutrition and

hydration care.

Research indicates that the more time dietitians spend in nursing homes, the less time the nursing home residents spend in hospitals. It is critical to have a dietitian in every nursing home fulltime.

Chairman Craig, nutritional well-being is critical in assuring

quality of life for our seniors. We hope that Congress will pass your

legislation, the Medical Nutrition Therapy Amendment Act, so that

nutrition services for cardiovascular disease, the leading cause of

death in men and women in this country, may be covered. This will

ensure access to life-enhancing and life-saving therapy for seniors

who suffer these debilitating conditions.

To summarize, frail elderly living in rural areas face unique and

difficult challenges, not the least of which is accessing a nutritious

meal daily and accessing preventive and curative nutrition services.

Thanks for the opportunity to testify. I would be pleased to answer any questions.

[The prepared statement of Ms. White follows:]

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The CHAIRMAN. Thank you very much, Ms. White. We appreciate

your testimony.

I am going to adhere to a 5-minute round of questioning for all

of us, and of course, we can repeat as often as is necessary to complete; so if staff would take care of the lights for us, that would be

appreciated.

I apologize, Ms. Heady. I did not get a chance to hear your testimony. I will read it, and I do have some questions that I would like

to start with you on.

You mention in your testimony that several obstacles prevent the

elderly from accessing quality health care in rural areas. What do

you think is the single biggest obstacle that is the challenge out

there that we should be tackling?

Ms. HEADY. I think there are two things—transportation and

providers; having the appropriate level of care and services as close

to the elderly as possible, and their transportation to even get to

it.

One thing that we see happening, particularly with some of our

primary care centers—in West Virginia, we have some of the most

per capita—we have 102 primary care centers right now in our

State. And when reimbursement to those centers becomes a problem, and they have to close some of their satellite operations, we

see that the elderly are the ones who suffer the most, because they

are most of the population who patronize those service centers.

The CHAIRMAN. Are you experiencing in West Virginia something

similar to what we are experiencing in Idaho—and Ms. Adams

mentioned it—that when we lose employment that is traditional to

the region that oftentimes provides the economics that maintain

the infrastructure of health care—hospitals—the seniors who are

staying there, or living there still, oftentimes are tremendously disadvantaged because the younger worker has lost his or her job and

moves elsewhere, and the economy changes?

Ms. HEADY. Exactly. In fact, that is one reason why West Virginia is getting as old as it is, because we have the generation of

workers who can support that population, and the younger population is actually leaving our State to find employment.

The other thing that is unique in rural areas is that in many,

many rural communities, the health care industry, if it is not the

first employer is the second or third-largest employer in that particular county. Just for example, with the 24 closures of home

health agencies that we have had in our State, we lost 1,000 jobs,

and those 1,000 jobs are in predominantly rural communities. So

it is a domino effect; we not only impact the direct services to the

elderly, but long term, we impact it even greater when we impact

the economy of the health care delivery system. So it is true that

we are experiencing the same thing in our State.

The CHAIRMAN. Thank you.

Mr. Sykes, again, thank you for your testimony. You have been

working with the elderly and housing for 30-plus years. From your

own experience, what do you see as the benefit of keeping seniors

in their own homes and in their own communities?

Mr. SYKES. I am delighted to say that as a gerontologist over

these years that we have come to the conclusion that the benefits

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are so substantial that we have to use all of the energy and policy

and resources that we can find to accomplish that goal.

First and foremost, it is where most elders want to be; it is what

gives them emotional support as well as the feeling that they can

retain their independence for as long as possible.

It is not simply, in my judgment, a diversion from skilled care.

There comes a time in people’s lives when they need that level of

care. But we have also discovered to an extraordinary degree in

Wisconsin and elsewhere that with certain kinds of supports, timely supports at the right time in the individual’s life, with careful

assessment, with a care plan that works, and with the monitoring

of the quality of the care that one is receiving, people who just 5

and 10 years ago in our own independent housing would have had

to move out are now able to stay in their homes.

Part of this is due to medical advances, but far more of it is because we have made policy commitments to support those persons

who are in fact providing the care that individuals need.

The CHAIRMAN. We have been joined by Senator Carper. He does

not have an opening statement. We are pleased, Senator, that you

could spend some time with the committee this morning.

Senator Carper. Thank you, Mr. Chairman.

Mr. Sykes, do you have an example of best practice that highlights the type of community partnership that you described with

a combination of Federal, State, local governments, private corporations, religious groups, hospitals—and then again, in all of that,

what are the greatest challenges of these kinds of collaborations,

and how do we overcome those challenges?

Mr. SYKES. I am pleased to say that in many parts of our State

and country, we have found ways to bring together the kinds of resources that we are talking about. I am thinking of a low-income

housing tax credit project where the private sector is putting up

the funds necessary to do the construction of the project; I am looking at some of the community development block grant moneys

that become available for programs that are serving people in transition of one kind or another, another channel of resources. There

is private fundraising, either with or around the United Way; efforts to bring those programs.

Your question had to do with best practices. I cannot look at a

project across the State of Wisconsin that I have had some role in

in my State Housing Finance chairmanship that does not reflect

the kind of partnership of a variety of sources. Frequently, it is the

donation of a piece of land that gets it started in the right place

at the right time, and then come, with some careful planning, the

resources to sustain it.

Terribly important to most of the lowest-income people in both

rural and other parts of America is the Section 8 subsidy, a sufficient subsidy to enable somebody to pay whomever owns or manages that property a fair market rate so that that property, that

program, can be sustained.

It takes all of the above to make a good project, and we have lots

of wonderful examples, whether they were begun by churches or a

trade union or a rural hospital or a corporation, as in the case of

the Sun Prairie story.

The CHAIRMAN. Thank you.

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Let me turn now to Senator Kohl.

Herb.

Senator KOHL. Thank you very much, Senator Craig.

Mr. Sykes, you have highlighted several examples of Wisconsin

businesses and hospitals that took the initiative to address the

needs of the elderly in their communities. Ideally, we would like to

see more businesses take a more active role in this area. Is there

anything that the Congress or the Government can do to encourage

this?

Mr. SYKES. That is a tough one, and speaking as a corporate officer myself for many years, I realize that there was not a particular

program that induced us to start building elderly housing.

I think that what is needed is a public awareness campaign that

says that to be successful, a corporation—especially a large company in a small town—the responsibility goes beyond adequate pay

to the workers, adequate retirement benefits to the workers, but to

help create within that community the kinds of conditions and environment in which people can grow old, can live comfortably, can

have a high level of satisfaction.

Most of the successful corporations in the country have either a

foundation or have reasonable pots of resources that they can make

available within their community.

So I do not see, other than programs that generally encourage—

obviously, the 5 percent write-off that we get as a cost of doing

business is an initial kind of incentive—but I think it is going to

take a good effort at public information.

HUD’s Best Practices Program highlights a lot of successful

projects. I think that when we show other corporations that they

can do what we have done in a community, that is the single best

thing. I am sorry, I do not have a good answer for what the Government’s role should be to help the private sector take the initiatives that my company did.

Senator KOHL. Mr. Sykes, as you know, the Senate will take up

the budget next week. In your opinion, which programs affecting

housing for the elderly in rural areas should we continue to make

a priority in this year’s budget?

Mr. SYKES. Thank you. That is a really important question.

First, let me say that working with the Elderly Housing Coalition here in Washington and the National Council on Aging in that

group, we clearly came to the conclusion that right now, with approximately 1.5 million elders in subsidized housing, and with that

population growing old very rapidly and becoming increasingly

frail, the most cost-effective and humane policy for the Government

is to support such initiatives as I will mention one quick moment

that will enable those people to stay where they are and not to

move.

The first is the whole idea of service coordinators within subsidized housing. That has shown that we can connect people who

are frail with resources extant in the community to enable them to

stay in their homes. That is an important program; it is in the

budget at $50 million. It should be expanded. It should be available

to every housing project, even some of the small ones that do not

seem to support that level of responsibility.

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Second, I think we need to use the resources of both HHS and

HUD to be certain that people who are in or need to be in subsidized housing have those benefits brought together. That requires

some level of flexibility; it has required funds from more than one

place. But when they come together—and my example would be the

HUD Congregate Housing Services Program that has been funded

and revised, but it has always been so marginal that it is a token

program, very much as the Title V program is a token program— we know how many people could benefit from this. If we could just

move it ahead another $50 million for service coordinators, another

$50 million for the Congregate Housing Services Program, we will

be making important steps toward enabling people to remain in

their homes.

And third, we have a lot of projects that need retrofitting. Where

there are already 24 people living in a rural area or community,

by just some modifications in that facility itself, we can provide the

community spaces, we can collocate community service providers in

that facility that will enable those people to continue to live in

their homes longer.

Those are important initiatives. They are not new. We certainly

need substantially more resources to make them effective across

the country.

Senator KOHL. Thank you.

My last question is for all the members of the panel. What are

the most critical programs for our rural elderly that need additional Government support? What are one or two of the most critical programs, in your opinion, that we need to focus on this year

in terms of supplying resources?

Ms. Heady.

Ms. HEADY. I would say any of the Federal programs, and particularly the rural health outreach grants, should fund groups to do

partnership services in other words, to go into an area where you

have low density numbers who are participating in the program— and require those groups to come together to make available their

unduplicated services. This approach is probably the smartest

thing that we can do with what money we have available for rural

communities.

Programs that provides for existing health care providers to be

much more innovative, to go out of their dependency on their reimbursement stream and to really innovate and try to do ‘‘push the

envelope’’ for rural seniors should be supported.

Senator KOHL. Thank you.

Ms. Adams.

Ms. ADAMS. I would have to say that the recent wave of layoffs

and business closures both in Idaho and throughout many other

States is something that we really need to take a hard look at now.

We need to look at the past and take some preventive action

based on that. About 14 years ago, when the bottom fell out of silver, smelters and mines shut down in Northern Idaho; there were

widespread layoffs. The incidence of suicide among older males in

the Silver Valley section of our State skyrocketed.

We cannot let unemployment do that to our seniors again. Reemployment can be a very, very difficult problem in rural America.

You cannot just pick up and leave when your life savings are tied

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up in your house, and homes are not selling. Even though you have

a lifetime of very substantive experience, let us say in refrigeration

systems for mining, how can you transfer that when the industry

is so very depressed?

On top of that, many of our older people are very entrenched in

their rural communities—they are third- and fourth-generation

families.

Dr. Barbara McIntosh at the University of Vermont is a business

professor who is looking into the whole issue of older workers being

dislocated from their jobs, and what she is finding is that those

older people who succeed in getting reemployed are those who get

connected with the dislocated worker initiatives that are triggered

now, when there are massive layoffs.

That is a long answer to your question, but what we need to do

is make sure that there is legislative emphasis on older worker

service within the dislocated worker section of the Workforce Investment Act. That is sorely missing right now.

Unfortunately, when this new legislation was passed in 1998, it

even removed as an eligibility criterion long-term unemployed, and

that is how, in previous legislation, we made many of our older individuals eligible for those very services.

So I would encourage legislative emphasis in the Workforce Investment Act.

Senator KOHL. Thank you.

Ms. White.

Ms. WHITE. I think it is critical that we fund elderly nutrition

programs at an appropriate level. Many of the communities—for

example, the one in Knoxville—have doubled the number of people

they serve with home-delivered meals over the last 4 years, with

no increasing in funding, and funding is at 50 percent of 1973 levels.

I also think it is critical that elders have access to nutrition services through Medicare, particularly for cardiovascular disease, hypertension, congestive heart failure, and the dyslipidemias, which

are major contributors to poor health and limited functional status

in our elderly.

Senator KOHL. Thank you.

Thank you, Senator Craig.

The CHAIRMAN. Thank you.

Senator Ensign.

Senator ENSIGN. Thank you, Mr. Chairman.

I have a few questions, first for Mr. Sykes. I have dealt a lot in

the past with the low-income housing tax credit, and one of my

first experiences with it was when I was on the Ways and Means

Committee in the House, and we were trying to eliminate the lowincome housing tax credit because there had been a lot of problems

with it in the past.

After doing a lot of research, I actually became a big supporter

of the low-income housing tax credit because I realized what an efficient use of Government tax dollars it is versus normal public

housing.

It was an experience with senior housing with the low-income

housing tax credit that really turned me around. At the opening of

one of these projects, in Las Vegas there were a lot more people

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there who wanted to get into the place than there were available

units.

This brings me to the point that I would like you to comment on.

We talked about Section 8 and some of the other types of things

that the elderly utilize, and some of our public housing things with

the elderly do seem to me to be the most successful parts of our

public housing. Additionally, the tax credits seem to be the most

efficient use of the money.

In rural and in fast-growing areas, however, the tax credit seems

to be totally inadequate. That is why I have sponsored legislation

in the past and will continue to do so. To expand the tax credit and

to look for other ways to make more affordable housing for people,

especially our senior population, who need it the most, and for

those in rural areas where it is going to be critical.

I would just like your comments on that.

Mr. SYKES. First, in candor, I must say that any effort to meet

a substantial major national problem by using tax expenditures as

opposed to budget outlays is not efficient. As one who has used tax

credits and as one who is part of a profitable corporation, to be able

to make a community investment, if you will, and also pay in effect

less taxes by doing good within the local community is a very attractive alternative. Certainly all the housing bonds that I signed

during my years on the State Housing Finance Agency, it was always with a little bit of difficulty in my hand, because it just

seemed to me like a less direct way to bring the resources of our

Nation to bear on a very large problem.

However, in the meantime, it does work, and one reason why the

low-income housing tax credit works efficiently is because it does

target a population that really needs support; it puts them in a

project which is not only built for the poorest of the poor, but it

provides for some market-rate rents as well. So the result is a more

habitable environment for those who live in a low-income housing

tax credit program.

Equally important to me is that in order for one of those to go

up, you have already to have achieved a very high level of cooperation among many people within the community—not only the Government, but also private business, with personal contributors, to

those who are supporting the programs that the people who live in

that housing need as well.

So it is an effort to really bring the community together, and to

that extent I think has worked very well. I am frankly distressed

with the amount of resources, when they are finally added up, that

go to accountants and lawyers and bankers to comply with all the

provisions of it. There is a better way to do it, and it is called outlays. It is not a politically achievable thing, so I am just going to

wish for a better time.

Senator ENSIGN. Thank you.

Ms. White, I would like to address quickly—because when I was

in the House, I was very involved, as Senator Craig was here on

the Senate side—the Medical Nutrition Therapy Act. Having a lot

of experience in our family with a diabetic and seeing the horrible

things that diabetes can do to a person, but also seeing over the

years how much dietitians have helped her, there is no question

that more of these kinds of things are going to be important. But

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even if we have the Medical Nutrition Therapy Act, where Medicare is paying for some of these diseases—and obviously, we are

happy that they are now paying for kidney and diabetes treatments, but there are a few other diseases like heart diseases and

cancer that we still need to be paying for—what about rural Nevada? Are there adequate supplies of registered dietitians to be

able to meet the needs, even through Medicare?

Ms. WHITE. Again, that is why I was talking about ways to increase access of dietitians in rural areas. An example is the National Health Service Corps that dietitians were a part of in earlier

years and are now excluded from. I think that is one way.

I think that distance learning modalities that are interactive,

that would allow individuals to access nutrition services via computer or telemedicine—we are using telemedicine in our family

practice program with resident education and the delivery of some

types of health care services—just think what we could do if we

could utilize this technology to provide nutrition education and

counseling to people in remote areas.

I also think that we have to recognize that the meals programs

through the Older Americans Act do offer medical nutrition therapy as well as food. In urban areas, they are required to provide

five meals a week home-delivered, but in rural areas, it may be

only two or three meals a week that are provided.

I think we have to expand the opportunities for our seniors not

only to receive home-delivered meals—and now, with the waiting

lists 2 months, 3 months, 4 months in Knox County, and with 85

or more individuals on that list, only the most critical are being

served. We are not preventing; we are just putting a bandaid on

food needs in this population.

Senator ENSIGN. Thank you.

Ms. Heady.

Ms. HEADY. I would like to comment on your question as well.

My mother, who lives in rural North Alabama, was just diagnosed

with diabetes, and from West Virginia, I attempted to find a registered dietitian or a certified diabetes educator to work with her

in her home, because she is currently not driving. The closest person I could find who would actually make a home visit—and my

mother is fortunate—she has kids who can pay for it—was 3 hours

away in Tennessee. She could get a diabetic class, and she could

receive instruction at the local hospital, but not follow-up care.

That is part of the problem with the reimbursement that we have

seen with home health agencies that can only take the very ill, as

Ms. White was saying.

Ms. WHITE. That is right, and there is no provision for medical

nutrition therapy services in home health. I think that if we had

that option, dietitians could go out, either with home health agencies or even through the local health department, and provide some

of these services.

Senator ENSIGN. When you were talking about the telemedicine

and some of the things via computer, that might be one thing we

will have to look at utilizing in places like senior centers. In Nevada—and I am sure that all of us on the campaign trail learn

where the senior centers are—every small community has a senior

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center, and a lot of the seniors go to those places, and that might

be a place to provide some of these services.

Ms. WHITE. Right. And the congregate meals at the senior centers do offer the opportunity for elders to get together and socialize.

The problem is that those areas of the elderly nutrition program

really have not been able to grow because the demands are so high

for home-delivered meals, and transportation is so difficult in these

areas.

Senator ENSIGN. Thank you.

Thank you, Mr. Chairman.

The CHAIRMAN. Thank you.

Senator Breaux.

Senator BREAUX. I want to thank the panel for the very important and educational statements from each and everyone of you. As

we try to get this committee to concentrate on helping to provide

quality of life for seniors, everything that you all are involved in

is part of that equation.

Ms. White, the whole area of nutrition is so critically important.

Why is it that the Meals-on-Wheels are unable to provide more

services in rural areas than they do in urban areas? Is it just a

funding problem?

Ms. WHITE. It is a funding issue; it is an issue of access, transportation, volunteers needed to deliver the meals. For example, in

Knox County, we have 450 volunteers a year, 55 per meal delivery,

period. But we need 75 in order to reach the number of people who

need to be served.

Senator BREAUX. So it is more expensive in rural areas.

Ms. WHITE. Oh, yes, it is more expensive because of the transportation costs involved. If we could bring people to the senior centers,

we have screening, and we could have dietitians available to work

with them.

Senator BREAUX. I imagine that for many of the seniors who are

living alone and who depend on Meals-on-Wheels, it may be just

about the only contact they have with the outside world and perhaps the only meal they get.

Ms. WHITE. Absolutely. I have a number of examples from

Houma, LA, which is where I was born and where I cared for my

parents, showing that for very elderly individuals who have lost

their spouses and have no living family members, this meal is a

lifeline for them both from the standpoint of social contact and just

from the standpoint of food.

The one meal a day with the senior nutrition program supplies

two-thirds of the calories and nutrients that those individuals need.

It is an incredible boon and really allows folks to live in their own

homes.

Senator BREAUX. Which is a savings in the long term by a big

margin. I wonder what it would take if we wanted to make a commitment that the Government would ensure that we would fully

fund or help to fund a Meals-on-Wheels program for rural America.

I think it would be a good investment, because in the long-term,

if a person is not adequately fed with a Meals-on-Wheels program,

he is going to end up in a nursing home or a hospital, and it is

going to cost us a lot more per day to have him served there than

to spend another year or two in his own home, receiving food.

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Ms. WHITE. Absolutely. Food helps to maintain function, it helps

to maintain quality of life. Appropriate food really helps to prevent

some of the complications associated with many of the chronic dietrelated diseases that are killers.

Senator BREAUX. We just have to be smarter, I think, Mr. Chairman, on how we spend money in order to be more efficient and

more effective. I am a firm believer that sometimes a little bit of

money spent up front saves us a lot of money in the long term

down the road. Adequate health care in the beginning for children

prevents us from spending a great deal more because they do not

have health care and we wait until it becomes an emergency in the

emergency room. Something as simple as Meals-on-Wheels in a

home setting could save us a lot of money in nursing home costs

and hospital costs if we do not provide that.

So I think we need to really be looking at the budget in that regard as an investment and as a long-term savings. I do not think

anybody on the Joint Committee on Taxation could give us a scoring on this, but common sense would give us a scoring that says

that we save money by keeping people in their own home settings

and adequately feeding them instead of putting them in a nursing

home at $1,000 per week or more.

I thank all of you. It has been very helpful, and everything that

you have said will be very important to this committee.

Thank you, Mr. Chairman.

The CHAIRMAN. Thank you, John.

Ms. White, you kept using the figure 50 percent of 1973 funding

levels. Could you expand on that for us? That is a fairly alarming

statement.

Ms. WHITE. Right. That figure comes directly from information

provided by the Administration on Aging regarding funding levels

for these programs.

The CHAIRMAN. Is that an aggregate figure, or is that specific to

nutrition programs?

Ms. WHITE. That is specific to the elderly nutrition programs.

The CHAIRMAN. OK.

Ms. WHITE. In Knox County, I have been very involved with the

feeding program there, and we have only been able to increase

numbers served from 400 to 800 through an aggressive community

funding outreach program. And again, the waiting list in Knox

County is 4 months. We have 85 people on that list. I work with

family physicians in the area to try to get an elderly person who

is being released from the hospital on that meals program, and it

is almost impossible, even if they can pay for the cost of the meal.

We simply do not have the resources transportation-wise and volunteer-wise to get the meals there.

The CHAIRMAN. And as you have mentioned, any of us who spend

time in the senior centers of our communities in our States see a

phenomenal stretching of the dollar—I am absolutely amazed—and

a very large voluntary effort to do what they get done. They have

truly taken the dollar available and stretched it probably more

than they ever thought they could or would.

Ms. Adams, let me turn to you for a couple of questions before

I come back to Ms. White. Recent data indicates that staying active

in the workplace keeps seniors healthier longer and can contribute

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to a higher quality of life. Because of this new data, I am especially

interested in ways that employers can help those seniors who still

want to work. From your experience, how does employer behavior

affect seniors working, and are there ways for this relationship to

improve?

Ms. ADAMS. Those employers who show that they value the experience of older workers make a huge difference in terms of that

older worker wanting to stay employed and working longer.

Those employers who will take a look at their fringe benefit

packages and structure those packages to better meet the needs of

an older employee as opposed to just a younger employee who

might have a need for child care and other kinds of benefits, those

employers who really look at the needs of an older worker and offer

flexible work arrangements that meet the older person’s need to

visit their grandchildren in the summer or work part-time or work

half a year as opposed to a full year, those are the employers, I

think, who are really the employers that older workers want to

stay with.

There are a number of large corporations, too, that are beginning

to actually look at their pension plans and restructure them to

make them more older-worker-friendly, to encourage older workers

to work beyond normal retirement age.

Polaroid Corporation has done some very interesting things in

terms of phased retirement, allowing an older individual to take 6

months off and then come back and work the remainder of the

year.

There is much that employers can do to encourage a longer work

life.

The CHAIRMAN. You mentioned in your testimony that the loss

of traditional jobs in rural areas—and you have highlighted several

in Idaho in logging, agriculture, and mining—is forcing workers out

of work, or at least, certainly, older workers. What types of programs are working in Idaho to retain these displaced workers, and

do you think these applications would work in other States?

Ms. ADAMS. We do have a very effective dislocated worker program in Idaho. Rapid response teams are put together around

plant closures and layoffs, and those response teams consist of

labor and management and worker representation as well as our

State Department of Labor. We need to make sure that older worker staff are looped into those kinds of rapid response teams so that

they can focus on the needs of the older dislocated worker who has

a much more difficult time getting reemployed.

We also need more Senior Community Service Employment Program funds to help serve this need. We have been at flat funding

for years, and the current program only serves 2 percent of the eligible population. So if we had more funds, we could focus more emphasis on these dislocated people.

The CHAIRMAN. Thank you.

Ms. White, the Senator from Nevada mentioned, and we worked

cooperatively together, both the House and Senate, last year on legislation to provide for medical nutrition therapy and coverage for

diabetes and kidney disease. This year, I am working to expand

coverage for people with cardiovascular disease, and I am enlisting

the support of my colleagues to get this done.

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Can you briefly discuss the types of benefits that nutrition therapy provides to seniors? You have already highlighted some, but I

am always amazed to see the role of good nutrition in both the

quality of life of the individual senior but also the extension of life

and the vibrancy of the life that they have.

Ms. WHITE. Absolutely. Good nutrition, particularly for people

with diabetes or the dyslipidemias, can No. 1 reduce complications.

We know that if you normalize blood sugar, if you get lipid levels

to less than 200 total, and for people with established disease less

than 100 LDL, you can significantly reduce complications, you can

reduce the need for medications, you can reduce readmission rates

to acute care systems, you can reduce length of stay in acute care

settings, you can improve wound healing and enhance immune

function.

Nutrition is integral to life, and you can just improve all of these

factors. There is a lot of evidence to show—some people think that

older people really are not motivated to change life styles—but in

fact, older people are probably more receptive than any other age

group. They would much rather modify diet and life style than add

another drug to an already often very complicated drug system.

Again, this saves money.

The CHAIRMAN. Thank you.

Senator Kohl.

Senator KOHL. Thank you, Senator Craig.

Well, you have made it very clear that there is a desperate need

for increased funding to improve the quality of life of people who

live in the rural areas of our country and who are elderly, and that

there would be a significant improvement in their lives if we could

get just 5 or 10 percent more funding. It is not like you are suggesting that there is so much funding out there that there is not

much more we can do—it is to the contrary—that there are enormous things that could be accomplished if we could get just a little

bit more funding.

So when we look at our Federal budget as citizens, and read

about what it is we are proposing to do, and how we are thinking

about spending the surplus, and just for example, spending $1.6

trillion over 10 years on tax cuts—which I am not quarreling with,

and I am not being critical about—but you wonder whether we

should be able to find some additional funding for some of these

needs that you are talking about this morning. Do you think that

if you had a chance to work on that budget, you might be able to

figure out how we can use our resources here at the Federal level

to do a better job with the rural elderly in our country, Ms. White?

Ms. WHITE. Absolutely. Food is such a basic need, and we have

such an abundance of food in this country; it is a shame that we

cannot find the funds and the means to get this food to the people

who are in desperate need of it and to whom it would make an

enormous difference in health and in quality of life.

Senator KOHL. Ms. Adams.

Ms. ADAMS. I think that we probably need to do a better job of

looking at the return on investment that these programs really provide and communicate that to lawmakers. When you look at our

older worker programs in terms of those people who get jobs off the

program, and when you look at how much money those people are

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generating via paychecks that they earn, taxes that they pay—I

know that our Idaho older worker programs pay for themselves in

just 11 months.

So this is a very wise investment of tax dollars. Furthermore, we

also need to look at the value that the Senior Community Service

Employment Program brings to our communities in the form of

public service; they also provide infrastructure support for all of

the aging programs that you have heard described today.

So maybe we need to do a better job of communicating the value

of these programs, again, to decisionmakers like yourselves.

Senator KOHL. Thank you.

Mr. Sykes.

Mr. SYKES. I do not want to be cynical in regard to the last point,

but during the time when I was on the Federal Council on Aging,

we did a very major study of the Title V program, and the evidence

was overwhelming that the purposes were being fulfilled, the eligibility was carefully targeted, the results were incredible. And we

barely kept from losing the program totally, and it has been flatfunded for years despite that reality.

So yes, Melinda, we do need to deliver those facts. I would go to

housing quickly and show the 202 program. There is none within

the housing area that has wider public support, and we who have

put 202 programs together have daily evidence of a program that

works, and it works well. It is expensive, but it works, and it keeps

people from laying out money in another way.

We could easily and effectively double or triple the number of

units in the 202 program, and communities across this country

would be beneficiaries, and many elders would find alternatives to

either neglect, which is all too often the situation, or institutionalization.

I would like to join the force and help to figure out some ways

not simply to divert from a tax refund, but I know in terms of the

elders of America and rural elders that there will be a much higher

return on investment, if you will, and a much greater benefit for

doing things to increase the likelihood that that local environment

will support them in their homes, with the services they need, than

any amount of money that will pass to me or to my rich children

in terms of a tax children.

Senator KOHL. Thank you, Mr. Sykes.

Ms. Heady.

Ms. HEADY. Thank you.

I would like to offer something that would be a mere drop or

even less than a drop in the Federal budget, and that is to look

at studying the next generation, the rural aging veteran. We have

a window of opportunity right now to start looking at and preventing some serious, serious problems in the future. Right now, we

have 1.5 million elderly who are in subsidized housing, and right

now, we have diagnosed 1.5 million veterans with PTSD, and these

are guys whose families are disintegrating, they are winding up on

park benches, and they are becoming part of the rural homeless as

well.

We have outreach centers, and if we can get some better knowledge about what they need, how to survey that population—we

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have not even looked at that population since 1988—we can gear

ourselves up.

One thing that I find most frustrating about this issue is that

whenever I say the word ‘‘veteran,’’ everybody immediately sends

everything to the Veterans’ Administration. They think that that is

where it all belongs. But that is not true. Particularly in rural communities, when these veterans are spread out among the rural population—and we do know that there are more aging Vietnam-era

veterans in rural areas than any place else in the country—it is an

issue that we really do need to look at. And unfortunately, we do

not even know enough about it to talk about it intelligently in a

policy arena. Only those of us who have been personally affected

by it and have tried to get services for either the veteran or his

family through the outreach centers can really see the tip of the

iceberg.

From what I have learned personally—and I know women who

now, for 30 years, have slept every night with a man who keeps

a loaded weapon under his bed because that is the only way he can

sleep—we really have a serious problem that we need to look at.

Senator KOHL. Say that again, please.

Ms. HEADY. I personally know women whose veteran husbands

sleep with loaded weapons. They feel that they need to have that

level of security to be able to get whatever sleep they can get for

the night—and that has been going on in their relationships for 30

years.

Senator KOHL. Well, thank you. You have been a great panel.

The CHAIRMAN. Let me extend that thanks, too. You have all

been a great panel. There are a good many more questions that we

could ask, but time is not going to allow that to happen.

We will leave the record open for several days, and we may extend to you some questions in writing to complete the record and

would appreciate your cooperation there.

Again, we have obviously just surfaced the tip of the iceberg on

this issue, and as it grows and as our communities grow older, we

would hope that the programs that we can make available will be

well-funded and flexible enough to adjust to the changes occurring

out there with an aging America.

I am fascinated by the sheer numbers and the length of health.

I tell this story because it is real, and I think it well-illustrates it.

My wife’s parents are in their eighties and are alive and healthy,

going strong, living in a retirement center in Tucson. We visit them

as often as we can, and during the holidays of this past winter, we

were down there. They live in a very lovely retirement center, and

they are fully active, so they can still interact well with their community.

We were sitting in the dining room having dinner, and two fellows walked through—you are only allowed to use canes in that

dining room; you cannot access it with wheelchairs or walkers—

and they came roaring through on their canes, and as they passed

by, my father-in-law said, ‘‘There is 100 and so many months and

another 100 and so many months.’’ There were two living, active

members of that immediate community who were 100 years old or

better.

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It kind of washed over me—oh, my goodness—and that is happening everywhere else in America, and it continues to increase. So

we have a job to get done.

Thank you all very much for being with us this morning. We appreciate it.

The committee will stand adjourned.

[Whereupon, at 11:17 a.m., the committee was adjourned.]

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