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[Senate Hearing 109-132]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 109-132

PLANNING FOR AN AGING POPULATION: THE ADMINISTRATION'S RECOMMENDATIONS 
              FOR THE OLDER AMERICANS ACT REAUTHORIZATION

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

                                HEARING

                               BEFORE THE

             SUBCOMMITTEE ON RETIREMENT SECURITY AND AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING THE ADMINISTRATION'S RECOMMENDATIONS FOR THE OLDER AMERICANS 
ACT REAUTHORIZATION, FOCUSING ON THE NATIONAL FAMILY CAREGIVER SUPPORT 
 PROGRAM, PRIMARY LONG-TERM CARE ISSUES, AND THE AGING POPULATION AND 
                               WORKFORCE

                               __________

                              MAY 17, 2005

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

                    U.S. GOVERNMENT PRINTING OFFICE
21-351                      WASHINGTON : 2005
_____________________________________________________________________________
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

             Subcommittee on Retirement Security and Aging

                      MIKE DeWINE, Ohio, Chairman

JOHNNY ISAKSON, Georgia              BARBARA A. MIKULSKI, Maryland
ORRIN G. HATCH, Utah                 JAMES M. JEFFORDS (I), Vermont
JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
PAT ROBERTS, Kansas                  HILLARY RODHAM CLINTON, New York
MICHAEL B. ENZI, Wyoming (ex         EDWARD M. KENNEDY, Massachusetts 
officio)                             (ex officio)

                   Karla L. Carpenter, Staff Director

              Ellen-Marie Whelan, Minority Staff Director

                                  (ii)

  

                            C O N T E N T S

                               __________

                               STATEMENTS

                         TUESDAY, MAY 17, 2005

                                                                   Page
DeWine, Mike, Chairman, Subcommittee on Retirement and Aging, 
  opening statement..............................................     1
Mikulski, Barbara A., a U.S. Senator from the State of Maryland, 
  opening statement..............................................     2
    Prepared Statement...........................................     3
Carbonell, Josefina G., Assistant Secretary for Aging, U.S. 
  Department of Health and Human Services, Washington, D.C.......     5
    Prepared Statement...........................................     7
DeRocco, Emily Stover, Assistant Secretary for Employment and 
  Training, Employment and Training Administration, U.S. 
  Department of Labor, Washington, D.C...........................    15
    Prepared Statement...........................................    17

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Clinton, Hillary Rodham, a U.S. Senator from the State of New 
      York, prepared statement...................................    35

                                 (iii)

  

 
PLANNING FOR AN AGING POPULATION: THE ADMINISTRATION'S RECOMMENDATIONS 
              FOR THE OLDER AMERICANS ACT REAUTHORIZATION

                              ----------                              

                         TUESDAY, MAY 17, 2005

                                       U.S. Senate,
Subcommittee on Retirement Security and Aging, Committee on 
                    Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:10 a.m., in 
Room 430, Dirksen Senate Office Building, Hon. Mike DeWine, 
chairman of the subcommittee, presiding.
    Present: Senators Dewine, Mikulski, and Murray.

                  Opening Statement of Chairman DeWine

    Senator DeWine. Good morning. We welcome all of you this 
morning, welcome you to the Subcommittee on Retirement Security 
and Aging's first hearing on the reauthorization of the Older 
Americans Act.
    We thank Senator Mikulski for being here. It is a pleasure 
to always work with her. During the reauthorization process in 
the year 2000, we were the chair and ranking member, as well, 
and I look forward to again working with her on the Older 
Americans Act.
    Older Americans are an important and rapidly growing 
segment of our population. Over 36 million people living in the 
United States are over the age of 65, accounting for about 12 
percent of the population. The Census Bureau projects that 45 
years from now, people 65 and older will number nearly 90 
million in the United States and comprise 21 percent of our 
population.
    Further, we know that 4.6 million people age 65 and older 
are still employed. The Older Americans Act is an important 
service provider for these Americans. It makes a range of 
social services available for our aging population, including 
congregate and home-delivered nutrition programs, community 
service employment, and services to prevent the abuse, neglect, 
and exploitation of older Americans.
    As we work toward reauthorization, this subcommittee plans 
to hold a series of hearings on the Older Americans Act and 
other issues facing older Americans. Reauthorizing the act is a 
primary goal of this subcommittee and we look forward to 
reviewing and updating the Older Americans Act programs.
    We also look forward to the recommendations expected to 
come from the White House Conference on Aging, which will take 
place later this year. I am sure that they will provide 
recommendations that will be both informative and timely for 
this reauthorization.
    Today's senior population is very different from what it 
was in 1965, when the Older Americans Act was created. Our 
hearing will begin with an overview of the act, its history, 
how it operates today, some of its problems, and some suggested 
solutions.
    Senator Mikulski?

                 Opening Statement of Senator Mikulski

    Senator Mikulski. Thank you very much, Mr. Chairman. I, 
too, am pleased today to initiate the hearing on the 
reauthorization of the Older Americans Act. I, too, look 
forward to working with you. As I recall, we were the ones that 
actually got the job done and got it authorized----
    Senator DeWine. I wasn't going to say that, but--
    [Laughter.]
    Senator Mikulski. [continuing]. And look forward to the 
same collegial efforts that are a hallmark of you.
    This is the 40th anniversary of the Older Americans Act, 
and as we look forward to reauthorizing it, we have got to look 
at how we need to not only reauthorize, but how we have to 
refresh, reinvigorate, and even reexamine what needs to be 
done. I am looking forward to you, and I have several 
principles that I hope would guide reauthorization.
    No. 1, we do need a national program with national 
standards to ensure consistency of the administration, but 
allowing for local flexibility--a senior program in a rural 
area of Utah is very different than in the bustling metropolis 
of the Baltimore metropolitan area. So we want national 
standards, but the flexibility to adapt to local needs for both 
good delivery of care and for, as well, creativity in the area.
    Second, we have to recognize the changing demography, the 
growing number of seniors over 85, the baby boomers coming of 
age, and the growing number of seniors in minority groups, many 
of whom with different language and cultural demands.
    Third, we have to look forward to making sure that our 
ultimate goal is to make sure that seniors are independent.
    And fourth, that we also ensure that State and local 
programs have the resources they need in order to do this.
    It is vital to continue the core services. I particularly 
note that we need to continue the much beloved information and 
referral service, probably one of the most important services, 
and at the same time the meals, the whole issue of nutrition 
programs, whether delivered onsite or offsite, and then the 
other issues relating to helping people keep independence, and 
also how to protect our seniors against scams. Scams, scams, 
scams, scams, and there seems to be no end at how to do that. 
And then at the same time, look for independence, not only from 
the health standpoint, but also now many people are facing 
unexpected layoffs.
    Senator DeWine and I represent manufacturing areas. When 
this bill was passed 40 years ago, manufacturing was king in 
this country. Now it is changing. People have been laid off, 
whether it is my steelworker or his tire worker, and yet what 
then happens? Do we say goodbye to them or do we find a way for 
them? Before, we used to focus on the poor and how to get them 
back into the labor market, but now we have to look at the 
middle class, as well.
    We look forward to your ideas on modernizing the Older 
Americans Act in terms of the new demography and the new 
demands, and then it comes to the issue of independence. That 
is why I look forward to your insights on lessons learned from 
the national Caregiver Support program that we created, and 
caregiving, as we know, is so important.
    We look with such fondness and admiration to First Lady 
Nancy Reagan. She has emerged as really kind of the icon of 
caregiving. She had the will, she had the love, she had the 
affection, and she had the means. Usually, the people we are 
talking about have the will, but not the wallet. How can we 
help families by giving help to those that practice self-help, 
and we look forward to that.
    So rather than me talking, we want to hear from you and 
then have an ongoing dialogue.
    Mr. Chairman, I ask unanimous consent that my full 
statement be in the record.
    Senator DeWine. It will be made a part of the record, and 
as always, Senator, a very good statement. We thank you for 
that.
    [The prepared statement of Senator Mikulski follows:]

                 Prepared Statement of Senator Mikulski

    Good morning. I'm very pleased to be here this morning as 
we meet to discuss ways to improve the Older Americans Act--an 
extremely important act that meets the day-to-day needs of 
America's seniors. I would like to thank the new chairman, 
Senator DeWine, for calling this hearing today.
    I am looking forward to reauthorizing the Older Americans 
Act. It is an important responsibility that we have to our 
Nation's seniors. There are several principles that I believe 
must guide reauthorization. First, we must continue and improve 
the core services of this act to meet the vital needs of 
America's seniors. Secondly, we must modernize the act to meet 
the changing needs of America's senior population, including 
the growing number of seniors over 85, the impending senior 
boom, and the growing number of seniors in minority groups. 
Next, we must look for ways to help seniors live more 
independent and active lives. Finally, we must give national, 
State, and local programs the resources they need to carry out 
these vital responsibilities. Let me expand on these 
principles.

Core Services

    It is vital to continue and improve the core services of 
this act. Seniors have come to depend on the information and 
referral services, congregate and home-delivered meals, 
transportation, home care, and other OAA programs to meet their 
daily needs. Take information and referral services. Whether it 
is pension counseling or the long-term care ombudsman program--
these are vital to helping seniors navigate the complex 
financial and health care systems. Not all seniors have family 
and friends that can assist them with complicated decisions, 
like choosing a long-term care insurance plan or a nursing 
home. These programs put information in terms seniors can 
understand. These programs are a safety net for many. Where 
else would they get these services?

Modernization

    Our senior population is not the same as it was in 1965. 
This will be the first time the baby boomers will be eligible 
for services under this reauthorization of the Older Americans 
Act. That's why we must modernize the OAA to meet the changing 
needs and diversity of our seniors. What does this mean? Well, 
it means making sure we have programs and services to meet the 
needs of the growing population that is 85 or older. It means 
making sure that we are sensitive to the needs of minority, 
low-income, and hard-to-reach seniors. And it means preparing 
for the upcoming senior boom. By 2050 there will be nearly 90 
million seniors over age 65, more than twice their number in 
2003. We must take advantage of new technology and innovations 
like the Internet to reach out to these seniors.

Independence

    Seniors today are living longer, healthier lives. We must 
do what we can to help them be as independent and active as 
possible. The majority senior citizens with chronic conditions 
live in the community and has their care provided by spouses, 
adult children and other family members. With the 
reauthorization of OAA in 2000, we worked hard to create the 
National Family Caregiver Support Program. In 2003, this 
program provided assistance to nearly 600,000 caregivers. 
Services include respite care, caregiver counseling and 
training, information about available resources, and assistance 
in locating services. These services are invaluable to seniors 
and their families. We must ensure that we are doing what we 
can to help ALL seniors live healthy, independent lives for as 
long as possible.

Resources

    Finally, we must provide the resources necessary to meet 
these challenges and support our seniors. Too many Older 
Americans Act programs have been flat funded for too long. We 
must commit ourselves, our dollars, and our programs to meet 
the needs of our growing and changing senior population.
    I want us to reauthorize this act. This is our 
responsibility. We must not abandon it. I look forward to 
working with the Administration on Aging and the Department of 
Labor to get their input.
    I thank you for your testimony and I look forward to 
working with you in the coming months to improve the quality of 
life for all of America's seniors in 2005 and beyond.
    Senator DeWine. Let me introduce our witnesses today. 
First, I would like to introduce the Assistant Secretary for 
Aging, Josefina Carbonell. She was sworn in as Assistant 
Secretary for Aging at the Department of Health and Human 
Services on August 8, 2001. In her position at the 
Administration on Aging, she advocates for and works on issues 
concerning older Americans. The Administration on Aging reaches 
into every community by providing services, information, and 
referral on adult day care, elder abuse prevention, home-
delivered meals, in-home care, transportation, and caregiver 
supports.
    Prior to joining the Administration on Aging, Ms. Carbonell 
was President and CEO of the largest Hispanic geriatric health 
and human services organization in the Nation, Little Havana 
Activities and Nutrition Centers in Dade County, Florida. We 
welcome you being with us.
    Let me also introduce our second witness, Assistant 
Secretary Emily DeRocco. Ms. DeRocco was sworn in as the 
Assistant Secretary for Employment and Training at the 
Department of Labor on August 3, 2001. She is responsible for 
managing the over $11 billion budget that funds our Nation's 
public workforce investment system, which includes the 
Community Service Employment for Older Americans program.
    Ms. DeRocco has served in a number of high-level Federal 
positions, including serving cabinet officers at the Department 
of the Interior and the Department of Energy. She also spent 
over 10 years as the Executive Director of the National 
Association of State Workforce Agencies. We welcome you, as 
well.
    Ms. Carbonell, we will start with you.

  STATEMENT OF JOSEFINA G. CARBONELL, ASSISTANT SECRETARY FOR 
     AGING, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                        WASHINGTON, DC.

    Ms. Carbonell. Thank you, Mr. Chairman. Chairman DeWine, 
Senator Mikulski, distinguished members of the subcommittee, 
thank you for inviting me and Emily DeRocco to discuss the 
reauthorization of the Older Americans Act. In the 40th 
anniversary year of the Older Americans Act, it is appropriate 
to speak of the importance of modernizing this legislation to 
meet the needs of the next generation of elderly individuals, 
the baby boom generation.
    The Older Americans Act has produced a wide variety of 
programs to support the long-term care needs of elderly people. 
It brought Federal support to Meals on Wheels, making it one of 
the most worthwhile volunteer ventures in the history of this 
Nation. It brought quality to senior center programs, providing 
seniors an opportunity to socialize and to improve their health 
status through nutrition, health screening, medication 
management, and physical activity programs. More recently, the 
Older Americans Act brought recognition and support to family 
caregivers, who account for some two-thirds of all of the long-
term care provided to elderly and disabled people across the 
United States.
    AOA and its network of State and community-based 
organizations and volunteers successfully implemented the 2000 
reauthorization, including the Caregiver program, through which 
States and communities served almost 600,000 caregivers in 
fiscal year 2003, far exceeding client projections for the 
programs during its early years of implementation.
    Since the last reauthorization, we listen regularly to our 
customers and those who serve them to ensure that we can move 
the Older Americans Act and its programs forward in a way that 
will best serve elders, including the baby boom generations, 
for years to come.
    Perhaps the most significant contribution of the Older 
Americans Act over the past 40 years is the emergence of our 
long-term care service network, which is the largest provider 
of community-based care for the elderly in the United States, 
administering $3 to $4 billion each year in community-based 
care. Just as the Older Americans Act created this network that 
has provided so much in helping people maintain their 
independence in the community, the act should now be modernized 
to help the network and the country sustain community-based 
care.
    There are challenges to address with this reauthorization. 
The number of Americans is increasing at unprecedented rates, 
and those Americans reaching age 65 are living longer. As the 
baby boom ages, there will be far more people in need of long-
term care than there are today.
    The costs of long-term care are enormous. This year, $129 
billion will be spent on older individuals receiving paid care. 
Everyone agrees that there are major problems with our approach 
to long-term care, with its bias toward institution-based 
services, it is out of sync with people's needs and 
preferences. It is fragmented, confusing, and inefficient at 
times. It is financially unsustainable for individuals, for 
families, and our society at large.
    Just as the Older Americans Act was the solution for many 
significant policy challenges affecting frail elderly people in 
the past, the act should be a significant part of the Nation's 
solution to the challenges we face now. Consistent with the 
mission of the act and the President's new Freedom Initiative, 
our strategies for reauthorization of the Older Americans Act 
will focus on simple but relevant principles: Consumer 
information and consumer choice; support for those at highest 
risk of disability and poverty, before they become disabled and 
impoverished; providing care to people where they want it; and 
the prevention of conditions that cause disability and disease.
    We will pursue efficiency and integration in access to 
long-term care by those who need it. We will pursue changes 
that recognize that we cannot wait until people are old and 
frail and poor to begin to address their long-term care needs. 
This will require older people to be more engaged in the 
planning of their own long-term care and will require them to 
take steps to maintain their health and to reduce their risk of 
disease, disability, and injury.
    We will pursue changes that recognize people's preferences 
for long-term care. This means a greater focus on community-
based care and providing choice and control to consumers in the 
management of that care.
    We will continue to make it easier for consumers to learn 
about and access services and supports. We will strengthen our 
efforts to give people practical tools based on the best 
available science so that they can maintain their health and 
independence for as long as possible.
    Thank you, Mr. Chairman, for the opportunity to speak to 
you today about the reauthorization of the Older Americans Act. 
I have tremendous respect for and confidence in the long-term 
network that I have spoken about today, and many of which are 
present here today. I am proud to have served as a provider and 
a leader in this network for more than 30 of the 40 years since 
the Older Americans Act was created and I look forward to 
working with you on the reauthorization.
    Senator DeWine. We appreciate your testimony. Thank you 
very much.
    [The prepared statement of Ms. Carbonell follows:]

                Prepared Statement of Josefina Carbonell

                              INTRODUCTION

    Chairman DeWine, Senator Mikulski, distinguished members of the 
committee, thank you for inviting me here today to discuss the 
reauthorization of the Older Americans Act.
    In the 40th anniversary year of the Older Americans Act, it is 
appropriate to speak of the importance of this legislation to elderly 
people across the United States, especially those who are disabled and 
frail and at risk of institutionalization in nursing homes. The Older 
Americans Act has produced a wide array of programs to support the 
long-term care needs of elderly people. The act brought Federal support 
to meals-on-wheels, making it one of the most significant and 
worthwhile volunteer ventures in the history of this Nation. The Older 
Americans Act brought consistency and quality to senior center programs 
across the country, providing declining seniors an opportunity to 
socialize with each other, to improve their nutritional status with 
healthy meals, and to see other aspects of their health status 
addressed through health screening, medication management, and physical 
activity programs. More recently, the Older Americans Act brought 
recognition and support to family caregivers, who to this day account 
for some two-thirds of all of the long-term care provided to elderly 
and disabled people across the United States. In the 2000 
reauthorization, the act brought respite services to family caregivers, 
as well as information, access assistance, counseling, training and 
other supports.
    We saw to the successful implementation of the provisions of the 
reauthorization of 2000 by focusing closely on the implementation of 
the caregiver program, where we brought vision, strategic planning, and 
performance accountability to the day to day management of the program. 
We also recognized the capacity of the aging network of States, area 
agencies, and service providers, which assist frail elderly people with 
long-term care services. As a result, we steered our discretionary 
innovation resources to pursuing program efficiency in long-term care, 
and improving the well being of elderly clients by focusing on 
prevention. Finally, we listened regularly to our consumers and those 
who serve them to ensure that we can move Older Americans Act programs 
forward in a way that will best serve elders, including the baby boom 
generation for years to come.

   OLDER AMERICANS ACT ACCOMPLISHMENTS SINCE REAUTHORIZATION IN 2000

The National Family Caregiver Support Program

    The single most important new provision of the 2000 
reauthorization, and most significant accomplishment of AoA and the 
aging network since 2000, is the implementation of the National Family 
Caregiver Support Program. In the first 2 full years of the program's 
implementation, over 12 million people received information about the 
program, and many of these individuals have sought assistance through 
the aging network. At the time of the 2000 reauthorization, State and 
area agencies were projected to serve 250,000 caregivers with respite, 
access, counseling, training, or other forms of service. However, the 
number of caregivers served surpassed the projections so that States 
and area agencies provided access assistance services alone to almost 
600,000 caregivers, and also provided respite, counseling, training, 
and other forms of support in 2003.
    Soon after its initial implementation, the National Family 
Caregiver Support Program became a highly visible program that 
responded to the diversity of caregiver needs. At the same time, it 
forged connections to the home and community-based services (HCBS) 
system in each State. With AoA's emphasis on performance accountability 
and management, it became evident that resources provided under the 
caregiver program would not be the sole source of support for 
caregivers, but that Older Americans Act services provided to elderly 
people would also ease caregiver burden and help them care longer for 
the elderly they served.
    AoA provided flexibility in program structure and operations that 
has allowed States to focus on such issues as developing new 
infrastructures for caregiver support; reorganizing State aging 
networks to be better able to integrate the NFCSP; and developing 
partnerships with entities not traditionally part of the State's aging 
network. As a result of this flexibility, States have reported a number 
of efforts focused on integrating the NFCSP into the existing HCBS 
infrastructure. Some approaches involved blending the NFCSP with other 
existing services, while others incorporated the program in a way that 
allowed it to stand on its own as a unique program yet still connected 
to the broader array of HCBS.
    Ohio, for example, has approached integrating the FCSP by 
broadening its State care coordination policy to include many of Ohio's 
Federal and state-funded programs for older adults and caregivers. This 
new framework fosters awareness of the similarities among programs and 
draws attention to the under-served and unidentified caregivers in 
other programs. As the FCSP becomes integrated into the continuum of 
care already in place, a more seamless approach to service provision 
will result.
    Minnesota has utilized the development of the NFCSP to encourage 
AAAs, counties, providers and community organizations to examine other 
programs (Medicaid waiver, State respite programs, community service 
grants) to ensure that the NFCSP and HCBS programs offer a 
complementary array of services.
    Georgia, in collaboration with the Rosalynn Carter Institute for 
Human Development (RCI), has utilized demonstration grants available 
through the NFCSP to expand a collaborative network of professional and 
family caregiver groups known as Care-Nets. Composed of educational 
institutions, businesses, and family caregivers, Care-Nets develop 
service and educational programs to meet the needs of caregivers, 
oversee research conducted by RCI, and provide recognition and support 
for caregivers.
    Pennsylvania saw the NFCSP as a vehicle for expanding the scope of 
the existing state-funded caregiver support program and maximizing 
opportunities to get consumers into, and help them to navigate through, 
the long-term care system.
    Coordination of the FCSP and other HCBS programs has been a key to 
assuring access and reaching caregivers, as was developing partnerships 
with business, religious, ethnic, social service and community 
organizations. States reported similar ways of ensuring that their 
FCSPs are accessible to anyone seeking information and services, 
including:
    Alabama's ``care coordinators'' have taken a grassroots approach to 
doing outreach. Because a majority of the care coordinators have some 
direct experience with caregiving (either in the past or currently), 
they are able to understand caregivers' needs and use their personal 
experiences with caregiving as a tool for outreach and education.
    Alabama, California, Delaware, and Massachusetts have all utilized 
the concept of a ``mobile van tour'' to reach remote, hard-to-access 
areas of their States where caregivers have little opportunity to 
receive information, or because of the remote location, have difficulty 
getting to a central point such as a service center to obtain 
information and service.
    Maryland has adopted a proactive strategy of reaching out to 
caregivers early, before they are in crisis. To achieve this, printed 
materials (e.g., bookmarks) have been printed and disseminated broadly 
to promote the program to a wide group of prospective consumers of 
caregiver services.
    AoA commissioned the Family Caregiver Alliance to further document 
and summarize the States' efforts in implementing the caregiver program 
and to assess the States' performance in implementing the program. One 
interesting finding was that the vast majority (78 percent) of adults 
in the United States who receive long-term care at home, are cared for 
exclusively from unpaid family and friends. Other findings included the 
following: (1) More than one in three (36 percent) States began 
providing support to caregivers of older people for the first time as a 
result of the implementation of the NFCSP; (2) All States now provide 
some explicit caregiver support services as a result of the NFCSP; (3) 
The NFCSP is emerging as a key program in the States for enhancing the 
scope of services to caregivers and as fuel for innovation; (4) The 
NFCSP seems to be speeding the adoption of consumer direction in family 
caregiving programs; (5) Respite care is the service category most 
commonly offered to caregivers and is available in all 50 States and 
DC; and (6) State legislatures, recognizing family caregivers' roles, 
are enacting laws to fund caregiver support services, expand family and 
medical leave, and include family caregiving in State long-term care 
efforts.
    Throughout the Nation, States and communities committed the 
necessary resources, attention and commitment to the implementation of 
the National Family Caregiver Support Program that allowed the program 
to achieve the early results AoA sought for the program. States and 
communities served far more caregivers than early projections indicated 
would be served; and from the beginning, States and communities 
provided the full range of services to caregivers, such as respite, 
access, counseling, training and supplemental services. This 
accomplishment demonstrated the capacity, organization and skill of the 
aging network of Federal, State and community entities to implement a 
major new program to serve the long-term care needs of elderly people 
and their caregivers in a short period of time.

Accomplishments in Strategic Management of Network Capacity

    The reauthorization of the Older Americans Act in 2000 allowed the 
aging network to expand the reach and scope of support to the elderly. 
The act also fostered a more strategic approach to program management, 
whereby the activities and initiatives AoA undertakes are determined by 
their ability to produce the goals AoA established for the program. For 
example, AoA's initiatives to integrate long-term care in communities 
are designed to improve the efficiency of the program. States and 
communities are responding to these initiatives, and have increased the 
number of elders served per million dollars of AoA funding by over 10 
percent by 2003. AoA's emphasis on improving the health and nutritional 
status of elders through its meals programs and health promotion and 
disease prevention initiatives are expected to help Older Americans Act 
clients remain in the community. The fact that 86 percent of caregivers 
surveyed by AoA report that Older Americans Act services help them care 
longer for the elderly than they could without the services, indicates 
that States and communities are succeeding in maintaining the 
independence of vulnerable elderly clients. Since the reauthorization 
of the Older Americans Act in 2000, AoA has employed a mission-driven 
strategic plan and performance outcome measures to demonstrate the 
effectiveness of its network of State and local entities, and we will 
continue to use these tools to pursue additional program improvements.
    AoA program activities have a common purpose that reflects the 
primary legislative intent of the Older Americans Act: to make 
community-based services available to elders who are at risk of losing 
their independence, to prevent disease and disability through 
community-based activities, and to support the efforts of family 
caregivers. This fundamental purpose is accompanied by the following 
four strategic priorities: (1) Make it easier for older people to 
access an integrated array of health and social supports; (2) Help 
older people stay active and healthy; (3) Support families in their 
efforts to care for their loved ones at home and in the community; and 
(4) Ensure the rights of older people.
    This new focus on strategic management was accompanied by a strong 
commitment to measuring performance outcomes, which in turn required 
immediate improvements in the data AoA used to measure performance. 
With the cooperation of State and area agencies on aging, AoA has 
achieved two significant improvements related to performance outcome 
data. The first was to improve the quality and to reduce the time lag 
in making program data available to support budget and other management 
decisions. Since 2000, AoA has reduced the time lag from 28 months to 
11 months for the last budget cycle. AoA also instituted annual 
performance outcome measure surveys to obtain and use data reported by 
elderly individuals and caregivers about outcomes such as the 
usefulness and effects of Older Americans Act services and also about 
their satisfaction with the services they received.
    This effort has resulted in comprehensive performance measures that 
have led to a new understanding of the nature and effects of Older 
Americans Act programs and the entities across the Nation which 
administer services through these programs. We now measure the 
efficiency of Older Americans Act programs, and have documented 
significant efficiency improvements, noting again for our core programs 
an increase of 10 percent in the number of clients served per million 
dollars of AoA funding since 2001. We now measure our ability to target 
services to the most vulnerable of elderly individuals, noting again 
for our core programs that States and communities have increased the 
number of severely disabled clients who received selected in-home 
services by 15 percent over the fiscal year 2003 base level for this 
measure. We now measure how consumers assess our core programs, noting 
that the percentage of caregivers who report that our services 
definitely help them provide care longer has increased to 68 percent, 
and that 82 percent of clients receiving transportation services rated 
the services as very good to excellent.
    Our commitment to performance measures has guided and contributed 
significantly to: (1) our budget requests and initiatives over the past 
3 years, which document how demonstration initiatives can contribute to 
improved performance in core programs; (2) our establishment of 
comprehensive performance partnerships with the Centers for Medicare 
and Medicaid Services (CMS) and other HHS partners, which have allowed 
us to expand our demonstration initiatives beyond what AoA could 
support on its own; and (3) our proposals for the reauthorization of 
the Older Americans Act, which focus on modernizing the act to better 
empower community-based organizations and consumers to contribute even 
more to helping elderly individuals retain their health, independence 
and dignity in the community.

Learning What Needs To Be Done in This Reauthorization

    The upcoming reauthorization of the Older Americans Act provides an 
opportunity to build on the work of the current Older Americans Act. To 
guide us in identifying areas where the Older Americans Act can be 
improved, AoA has again used strategic management and performance 
results. Our commitment to improve the efficiency of our programs 
causes us to pursue greater integration of community-based long-term 
care services through the reauthorization of the act. The lack of 
integration, which is often characterized by duplicative, uncoordinated 
programs and systems in the community, causes inefficiency in the 
delivery of long-term care in the community. Likewise, our commitment 
to help elderly individuals maintain their health and independence in 
the community, causes us to pursue through this reauthorization the 
expansion of the use of evidence-based health promotion and disease 
prevention programs and practices that delay and prevent the chronic 
conditions that are known to result in disability among the elderly.
    Another significant source of information, which has guided AoA's 
activities over the past few years, is the numerous, grassroots 
conversations we had with the elderly people and caregivers we serve 
and with those in the States and communities who serve them. The 
listening sessions we have conducted around the Nation have presented 
us with a distinct opportunity to better serve our consumers and to 
more effectively implement our services in rural, urban, and suburban 
areas by listening to the concerns and challenges faced by older 
Americans and their caregivers. We have worked to ensure that we hear 
the voices of all of our consumers--including States, area agencies on 
aging, tribal organizations, service providers, volunteers, older 
persons and their caregivers, as well as, representatives of Federal, 
State and local policymakers and the media. Nearly half of the comments 
received addressed ideas for future amendments to the act, and those 
ideas focused primarily on allowing greater flexibility in implementing 
the Older Americans Act, allowing greater integration of long-term care 
programs and funding streams to create a more seamless program of 
services for elderly people and caregivers.

Principles To Be Achieved With This Reauthorization

    Perhaps the most significant contribution of the Older Americans 
Act over the past 40 years is the emergence of a long-term care service 
network, which is the largest provider of community-based long-term 
care for the elderly in the United States. The State and area agencies 
on aging, and the service providers that comprise this network have 
grown to be the most significant source of community-based care under 
the major national programs serving the elderly, including Medicaid 
waiver programs. In addition to administering our Older Americans Act 
investment in long-term care, and related State and community-funded 
programs, this community-based long-term care network now administers 
and manages almost two-thirds of this Nation's Medicaid investment in 
community-based long-term care for the elderly and disabled. Just as 
the Older Americans Act created this network that has provided so much 
in helping elderly people maintain their independence in the community, 
the act should now be modernized to help this network and the country 
adapt to the challenges of sustaining community-based long-term care.

Demographic Issues

    Many important changes are taking place in the elderly population, 
which are creating new challenges and opportunities for our society, 
families and individual citizens. The number of older Americans is 
increasing at unprecedented rates, and those Americans reaching age 65 
are living longer than ever before. Among those over the age of 85, the 
proportion of people who are impaired and require long-term care is 
about 55 percent. While the precise number of people who will need 
long-term care in the future could be affected by numerous variables, 
including possible declines in rates of impairment, the expected 
increase in the number of seniors as the baby boomers age is so great 
that most experts agree that there will be far more people in need of 
long term care in the future than there are today. By 2050, when all of 
the baby boomers will be age 85 and older, there will be over 86 
million people age 65+ living in the United States, compared to 35 
million today.

Primary Long-Term Care Issues

    Three major issues in particular must be addressed in the 
modernization of the Older Americans Act: (1) the growing demand for 
long-term care; (2) the future public and private costs of long-term 
care; and (3) the systemic problems inherent in our current approach to 
financing and delivering long-term care services and supports.
    Demand: The shift in our Nation's demography that I cited above 
will have profound implications for every aspect of our society, and 
particularly for the future of long-term care. The projected 
demographic changes that are influencing the demand for long-term care 
will also affect how this care is provided. Families are expected to be 
smaller in the future than they are today, and if current trends 
continue, a greater proportion of women may be in the labor force. Both 
shrinking family size and increasing workforce participation by women 
could make informal care less available (women currently provide the 
majority of such care) and thus lead to a greater potential reliance on 
care from other sources. In addition, ethnic and racial minorities age 
65 and over will grow faster than other segments of the population. By 
2050, the African-American proportion of the elderly population will 
increase by more than half--from 8.2 to 12.0 percent--and the 
proportion of Hispanics among the elderly will almost triple from 6 to 
16 percent. The issue of growing demand is directly linked with the 
baby boom generation. As the baby boom generation ages, the demand for 
long-term care services is certain to increase.
    Cost: Even before the aging of the baby boom generation, the costs 
of long-term care are enormous. This year, $129 billion will be spent 
on older individuals receiving paid care--or approximately $15,000 per 
impaired senior. The major sources of financing are: Medicaid (39 
percent); individual and private out-of-pocket expenses (36 percent); 
and Medicare (20 percent) which pays for some skilled nursing facility 
and skilled home health care.
    It is important to note that another significant source of care is 
donated or non-paid care provided by families, friends and neighbors. 
Over 95 percent of all chronically disabled elders living in the 
community receive at least some unpaid family care, and two-thirds rely 
exclusively on such help. The dollar value of informal care is 
estimated to be $257 billion per year. As the population ages and 
fiscal pressures on State budgets increase, it becomes increasingly 
important to find more effective ways to finance and deliver long-term 
care.
    System Problems: While views may vary on exactly what we should do 
to prepare for the baby boom, everyone agrees that there are major 
problems with our current approach to long-term care, and our system of 
care needs fundamental reform. It is out of sync with people's needs 
and preferences. It is fragmented, confusing and inefficient. And it is 
financially unsustainable for individuals, families and our society at 
large.
    Studies consistently show that seniors have an overwhelming 
preference to receive support at home. One recent study reports that 81 
percent of persons over age 50 would prefer to avoid nursing home care 
even if they needed 24-hour care. Another study reports that 30 percent 
of older people would rather die than move to an institutional setting. 
While nursing home care is a critically important component of our 
support system, most experts agree we need to provide more 
opportunities for home and community-based services.
    Another major problem with our current system is that it is 
fragmented, terribly confusing to consumers, and inefficient. Most 
people are simply unaware of their potential need for long-term care 
and their financial exposure to costs. Research shows that most 
Americans still equate long-term care with nursing homes and that many 
believe that Medicare pays for long-term care. When older people or 
their family members do seek out information or care, they face a 
complex, and often mind-boggling, maze of publicly supported and 
private options, administered by a wide variety of providers operating 
under different, sometimes conflicting--and often duplicative--rules 
and regulations. Consumers consistently report experiencing serious 
difficulty and frustration in trying to learn about and access 
available options. Compounding this situation is the fact that most 
individuals face difficult long-term care decisions amidst a crisis, 
such as an unexpected hospital admission (65 percent of nursing home 
admissions are directly from hospitals), or the collapse in a fragile 
unpaid caregiver support network. Under these circumstances, families 
have little time to explore the many options that might be available, 
and this often results in a nursing home admission or the unnecessary 
use of very expensive home health care.

Emerging Solutions

    Just as the Older Americans Act has been the solution for so many 
significant policy challenges affecting frail elderly people in the 
past, and the caregiver program in particular in the recent past, we 
believe the act is a very significant part of the Nation's solution to 
the emerging long-term care financing challenges that we face now. And 
this solution will build on policies that the President and the 
Secretary of HHS have already instituted.
    As evidenced by the New Freedom Initiative, the Administration is 
committed to creating a system of care that reflects the needs and 
preferences of Americans of all ages with disabilities, and the values 
of choice, control and independence. Since 2001, the Department of 
Health and Human Services, with the support of Congress, has provided 
the States and communities with a variety of new tools to help them 
advance the goals and values embedded in the New Freedom Initiative. 
These tools have included Medicaid demonstrations, including ``Money 
Follows the Person'' to fully fund 1 year of the cost of helping 
Medicaid nursing home residents return to the community; implementation 
of the National Family Caregiver Support Program; replication of the 
successful Cash and Counseling model; the Aging and Disability Resource 
Center Initiative; and the Own Your Future Campaign.
    It is noteworthy that many of these tools also support the 
integration of people with disabilities into the workforce. As more 
people continue working past the nominal retirement age of 65, the 
provision of supports and accommodations will enable some individuals 
with disabilities to extend their employability well into their senior 
years. For seniors with disabilities, income from employment or self-
employment will help improve their self-confidence and productivity as 
well as extend their independence and integration into their 
communities.
    Several of the Administration's long-term care initiatives address 
the needs of the entire population. There are three strategies that are 
particularly relevant: empowering consumers to make informed decisions; 
targeting limited public resources to help high-risk individuals to 
stay out of nursing homes; and promoting the use of programs that can 
help older people reduce their risk of disease, disability and injury.

Empowering Consumers

    Helping all individuals to make informed choices--including choices 
about their financing and care options--can enhance people's ability to 
stay at home and improve the quality of their lives. Increased 
awareness and use of two private financing options in particular would 
go a long way toward advancing these goals: private long-term care 
insurance and home equity programs. Both instruments are relatively new 
products and currently underutilized. Only about 4 percent of Americans 
aged 45 and older with incomes of at least $20,000 currently have long-
term care insurance. In addition to giving people greater control over 
their future, long-term care insurance can reduce both Medicaid and 
Medicare costs.
    One of the paradoxes of our current long-term care system is that 
impaired, older Americans are struggling to live at home at a time when 
they own more than $2 trillion in untapped housing equity. Over half of 
the net worth of seniors is currently illiquid in their homes and other 
real estate. Home equity instruments such as reverse mortgages enable 
older people to tap into the equity in their homes. It is estimated 
that 45 percent of households at financial risk for ``spending-down'' 
to Medicaid could take advantage of a reverse mortgage to help them pay 
for long-term care. On average, affected households could expect to get 
$62,800 from a reverse mortgage.
    The Administration has launched two interrelated, complementary 
initiatives to empower people to make informed decisions about their 
financing and care options. One initiative, the Own Your Future 
Campaign was launched this past year to encourage more people to plan 
ahead for their long-term care. The project is a joint effort of the 
Administration on Aging, the Assistant Secretary for Planning and 
Evaluation (ASPE), the Centers for Medicare and Medicaid (CMS), the 
National Governors Association, and the National Conference of State 
Legislators. It is currently being piloted in five States (Arkansas, 
Idaho, Nevada, New Jersey, and Virginia), and involves the targeted 
mailing of HHS materials and a letter from the Governor of each State 
to every household headed by an individual between the ages of 50 and 
70.
    The Aging and Disability Resource Center (ADRC) Program, which was 
launched in 2003 by the Administration on Aging and the Centers for 
Medicare and Medicaid Services, is also designed to help people plan 
ahead for their long-term care, as well as address the immediate 
problems consumers face when they try to learn about and access needed 
care. This program provides competitive grants to States to assist them 
in developing and implementing coordinated access to information, 
individualized advice to consumers on their options, and streamlined 
eligibility determination for programs. The long-range vision is to 
have ADRCs serving as ``visible and trusted'' places at the community 
level nationwide where people of any age or income can go to get 
information on all available options. The program also reduces 
government fragmentation, duplication, and inefficiencies.
    The Administration on Aging is also actively partnering with CMS to 
ensure that all older Americans take full advantage of the new 
prescription drug coverage available under the Medicare Modernization 
Act. This past year, we collaborated with CMS to inform seniors about 
the Medicare Drug Discount Card options and the transitional assistance 
program for low-income seniors. This AoA/CMS partnership provided 
almost $5 million in support to help community-based organizations 
assist low-income, limited-English speaking populations learn about and 
enroll in the transitional program. This year, we are working to help 
seniors to learn about and enroll in the Part D Program, including the 
low-income subsidy being made available through SSA. We have dedicated 
staff full-time to this effort in both our headquarters and regional 
offices, and have assigned them to work on various CMS and SSA teams to 
oversee this national outreach and enrollment effort. AoA's goal is to 
enlist the active support of at least 10,000 of our community-based 
aging services provider organizations in helping older people learn 
about and take full advantage of the new coverage.
    AoA is uniquely suited to add value to this partnership because it 
is inherent in our mission to provide access to information, resources, 
and services for older Americans. Our service providers can reach the 
homebound through home care and meals-on-wheels services. They can 
educate and advise senior beneficiaries who gather at senior centers 
and congregate programs. They can reach out to caregivers, who are 
known to help their frail family members make exactly the types of 
decisions that are needed for the drug benefit program. AoA's 
community-based organizations are experienced providers of services to 
the poor, minorities, and those in rural areas. The network will 
service as it does in communities across this country as the tool to 
inform, educate and enroll. AoA's activities will be focused on getting 
information and support to these community organizations to ensure that 
they can and will participate in the education and enrollment of 
elderly people.

Targeting High-Risk Individuals

    Another strategy is targeting limited amounts of public resources 
under capped appropriations to help individuals who are at high risk of 
nursing home placement to remain at home for as long as possible. These 
individuals are usually in a situation where they have neither the time 
nor the ability to do anything but use their liquid assets. The 
research shows that effectively targeting individuals who, without some 
form of help would have gone into a nursing home, is key to saving 
public dollars. Every day you help an individual stay out of a nursing 
home, you are helping them use their own personal and financial 
resources on less expensive forms of care for a longer period of time.
    Seven States have implemented programs, all administered by their 
State aging offices in coordination with their regular Older Americans 
Act programs, and these are targeted explicitly at people who are at 
risk of nursing home placement. These States include Minnesota, 
Nebraska, New Jersey, New York, Rhode Island, Utah, and Wisconsin.

Building Prevention Into Long-Term Care

    Most long-term care needs emerge from chronic diseases and other 
conditions, such as arthritis, diabetes, heart or lung disease, stroke 
and dementia, as well as from injuries suffered as a result of a fall 
or other accident. We now know these conditions and their effects can 
be mitigated, even for people who are very old, through lifestyle 
changes and disease management programs. Yet, our formal system of 
long-term care--like our acute care system--still emphasizes medical 
services over prevention. While changes are occurring in Medicare to 
give more emphasis to prevention and chronic care management, much more 
can be done through our public health and social service programs.
    There is a growing body of scientific research, being generated by 
the National Institutes of Health, the Centers for Disease Control and 
Prevention, and the Agency for Healthcare Research and Quality and 
others, documenting evidence-based programs that have proven effective 
in reducing the risk of disease, disability and injury among the 
elderly. Deploying these programs at the community level through 
venues, like senior centers and congregate meal programs, that can 
reach large numbers of older people when the opportunities for 
prevention are optimal (i.e., long before they become seriously 
disabled and/or spend down to Medicaid) can improve the quality of life 
and reduce health care costs.
    One example is the Chronic Disease Self-Management Program (CDSMP), 
a model developed at Stanford University. This program is a 6-week 
workshop designed to empower people with various chronic diseases to 
take control of their health. The program has been shown to 
significantly improve participant health status and reduces the use of 
hospital care and physician services. Another example is a program 
developed at Yale University to prevent falls--a leading cause of 
serious injury and death among the elderly--and a major contributor to 
health costs. The Yale program uses a multifaceted approach to help 
older individuals cope with key risk factors. Participants are trained 
to improve balance, gait and posture, better manage their medication, 
and to remove home hazards. The program significantly reduces the 
incidence of falls among participants.
    In an effort to begin bringing these types of programs ``up to 
scale'' nationwide, the Administration on Aging launched an Evidence-
Based Prevention Program in 2003 in partnership with NIA, CDC, AHRQ, 
CMS and the John A. Hartford, Robert Wood Johnson, and several smaller 
foundations. The program is designed to demonstrate the efficacy of 
implementing evidence-based models at the community level through aging 
service provider organizations such as senior centers, nutrition 
programs, faith-based organizations, and senior housing projects. A 
dozen local projects are being funded for a 3-year period. They focus 
on disease self-management, fall prevention, nutrition, physical 
activity, medication management, and depression. Each project is being 
evaluated to ensure that they maintain fidelity with the original 
research design and outcomes.
    The employment of strategies such as these provide us a basis for 
hope that we can sustain our national support for the long-term care 
needs of the Nation, even with the aging of the baby boom generation. 
The strategies focus on several principles that are simple but 
relevant: consumer information and choice; support for those at high-
risk of disability and poverty before they are disabled and poor; 
prevention of conditions that cause disability and disease.

Reauthorization: The Opportunity for Policy Changes in Long-Term Care

    The 2005 reauthorization of the Older Americans Act provides a 
unique and timely vehicle for accelerating the long-term care policy 
development that is needed to fully prepare the United States for the 
aging of the baby boom and the emergence of long-term living as a 
common experience of life. The Older Americans Act was passed in 1965 
to promote the dignity and independence of older Americans and to help 
society prepare for an aging population. It was designed to complement 
two other programs enacted that year: Medicare and Medicaid. Congress 
charted out a vision in the OAA for a nationwide network of public and 
private agencies organized around the common purpose of promoting the 
development of a comprehensive and coordinated system of care designed 
to help older people live at home for as long as possible and avoid 
unnecessary placement in nursing homes.
    The system envisioned in the OAA has become a consumer-driven, 
locally designed service program, supported by multiple funding 
streams, and capable of reaching people with low-cost social 
interventions long before they needed intensive services so that 
preventive opportunities could be optimized. The system was to be 
available to people of all income levels, and service resources were to 
be targeted at those most in need, especially low-income minority, 
isolated and limited-English speaking populations. Early 
reauthorizations of the Older Americans Act created area agencies on 
aging and fostered the principle of local flexibility and the use of a 
``bottom-up'' planning process to ensure that OAA programs would 
reflect local needs and conditions. Over the last 4 decades, the 
Administration on Aging has guided the development of the national 
aging services network that today consists of 56 State units on aging, 
655 area agencies on aging, almost 250 Tribal organizations, 29,000 
community-based provider organizations, over 500,000 volunteers, and a 
wide variety of national non-profit organizations. This nationwide 
infrastructure currently provides a wide array of home and community-
based services to over 8 million elderly individuals each year, which 
is 17 percent of all people aged 60 and older, including 3 million 
individuals who require intensive services and meet the functional 
requirements for nursing home care. It also provides direct services to 
over 600,000 informal caregivers each year, who are struggling to keep 
their loved ones at home.
    Many States have looked to their aging services networks to lead 
the development of their long-term care systems, including States that 
have created the most balanced and cost-efficient systems of care such 
as Oregon, Washington and Vermont. The OAA network is one of the 
largest providers of home and community-based care. It manages between 
$3 and $4 billion each year in public and private resources. All State 
units on aging have been given responsibility to administer State 
revenue programs; over 30 State units administer Medicaid Waiver 
Programs and State Health Insurance Counseling Programs; over 25 States 
have expanded the authority of the State aging units to serve younger 
populations with disabilities; and 22 States have authorized their 
State units to administer the Aging and Disability Resource Center 
program.
    In short, the network created by the Older Americans Act and led by 
the Administration on Aging is positioned to help ensure the 
modernization of long-term care under the Older Americans Act. The 
network has experience in serving all populations. It has experience in 
serving the older population and those that are not elderly. It has 
served the caregivers of the elderly and disabled, and has reached out 
to these varied service populations with models of integration that can 
simplify access to services and provide choice to consumers. Community-
based organizations across the Nation have emerged as leaders in 
bringing evidence-based health promotion and disease prevention 
practices to the elderly in senior centers and in their homes.
    The single most important goal of the Older Americans Act 
reauthorization should be to strengthen the act so it can play a more 
central role in helping our Nation prepare for the baby boom and long-
term living. Consistent with act's mission and the President's New 
Freedom Initiative, the reauthorization should reflect the values of 
consumer choice, control and independence, and the principle of 
providing care to people where they want it.
    With the reauthorization of the Older Americans Act, AoA and HHS 
will propose forms of modernization along the lines that I have 
addressed here. We will pursue changes that will improve the efficiency 
and effectiveness of the largest long-term care provider network in the 
country. Prominent among those changes will be the integration of long-
term care and efficiency in access to care by those who need it. We 
will pursue changes that recognize that we cannot wait until people are 
old and frail and poor to begin to address their long-term care needs. 
This will require that those who are not old should plan for their own 
long-term care. It will require the elderly who are not poor to make 
creative use of their existing resources to finance and support their 
care, with limited government assistance, to prevent poverty and the 
loss of independence. We will pursue changes that recognize the 
preferences of people for long-term care, which means a greater focus 
on community-based care and providing choice and control to consumers 
in the management of that care.
    Thank you, Mr. Chairman, for the opportunity to speak to you today 
about the reauthorization of the Older Americans Act. I have tremendous 
respect for and confidence in the long-term network I have spoken about 
today. I am proud to have served as a community-based provider and a 
leader in this network for more than 30 of the 40 years that have 
passed since the Older Americans Act created it.

    Senator DeWine. Ms. DeRocco?

  STATEMENT OF EMILY STOVER DEROCCO, ASSISTANT SECRETARY FOR 
       EMPLOYMENT AND TRAINING, EMPLOYMENT AND TRAINING 
   ADMINISTRATION, U.S. DEPARTMENT OF LABOR, WASHINGTON, DC.

    Ms. DeRocco. Thank you, Mr. Chairman, Senator Mikulski. I 
am delighted to join my distinguished colleague here to talk 
about the reauthorization of the Older Americans Act.
    As you have cited, the U.S. economy is entering a period of 
dramatic demographic changes as our population ages. The 
changing demographics of the labor force in combination with 
the ever-increasing skill needs of employers have made it more 
critical than ever before that every available worker, 
including older Americans, be able to join or remain in the 
workforce.
    Yet we know older workers face significant challenges to 
full participation in our workforce. Employment barriers 
include difficulties keeping pace with changing skill 
requirements and technology, the lack of opportunities for 
skills training and professional development, some 
misperceptions among some employers about the abilities of 
older workers, the lack of flexible work schedules and certain 
financial disincentives to working that may encourage early 
retirement.
    We know many older workers want to remain in the workforce 
and many need to continue working for financial reasons, and 
there is a resource available to help. Currently, our Nation's 
taxpayers invest about $15 billion a year in the workforce 
investment system, and this system, as you know, includes the 
Senior Community Service Employment program and we have an 
important role to play in helping older workers obtain the 
necessary skills and access the opportunities that will enable 
them to continue working.
    At the Department of Labor, we are taking steps to enhance 
the effectiveness of this system to serve workers, and my 
testimony describes our Older Worker Task Force, our protocol 
for serving older workers, and other initiatives that I hope 
you will read in the written testimony.
    But I would like to turn now specifically to the Senior 
Community Service Employment program, which, as you know, is 
the Workforce Investment program targeted exclusively to low-
income seniors. We currently have 69 SCSEP grantees, including 
13 national grantees and 56 units of State and Territorial 
governments that assist in the operation of this program 
throughout the Nation.
    In 2000, Congress enacted the Amendments to the Older 
Americans Act, including our SCSEP program, and the Department 
of Labor subsequently issued regulations implementing your 
changes. The program has clearly evolved from being focused 
largely on community services to a program that increasingly 
emphasizes the achievement of economic self-sufficiency and 
independence through unsubsidized employment.
    In 2002, the Department conducted the first open national 
competition for the SCSEP grants. Our purposes were to ensure 
that the best providers working with this population had an 
opportunity to compete and be selected to provide services, as 
well as to infuse new and innovative service delivery methods 
and ideas into the program and improve our efficiency and our 
services so more seniors could be served.
    We also are implementing the rigorous performance measures 
that the Congress called for in your amendments in 2000. 
Beginning July 1, 2005, our grantees will be held accountable 
for achieving specific performance outcomes related to 
placement in unsubsidized employment, retention, earnings 
increases, and customer satisfaction.
    In view of the increasing importance of older workers in 
our economy, it is fortuitous that reauthorization of the 
Workforce Investment Act and the Older Americans Act are before 
the Congress this year. We have worked to closely link these 
two systems and believe that that ought to be an additional 
part of our goal in reauthorization of Title V of the Older 
Americans Act.
    I would like to just articulate five principles that we 
believe ought to be considered in that reauthorization. First, 
in order to help meet employers' demands for skilled workers, 
we need to attract additional older workers at all income 
levels to our labor force, encourage others to remain in the 
workforce, and offer opportunities for older workers to update 
their skills. SCSEP and the Workforce Investment System are 
each avenues to do this and we will be recommending specific 
improvements in both to do it more effectively.
    Second, we must make the One-Stop Career Center system more 
responsive to the specialized needs of older individuals 
seeking to work or upgrade their skills. Specifically, we need 
to better integrate services for older workers into that One-
Stop Ccareer Center system in order to truly provide universal 
service and assist more older workers, regardless of income, to 
gain skills which are in demand.
    Third, we need to tailor SCSEP services to meet the needs 
of individual older workers by providing a range of training 
experiences, including on-the-job and classroom training or 
retraining, depending upon the individual's background and 
experience.
    Fourth, we must target our SCSEP resources to effectively 
serve those older workers in need of work experience, including 
low-income older workers who lack basic skills or who are 
unable to obtain private sector employment immediately.
    And finally, we need to streamline the SCSEP program to 
make it easier to administer in order to improve program 
performance, serve more participants, and get return on the 
investment for the Federal taxpayers' dollars. We will have 
specific proposals to address each of these issues and to 
improve program accountability and administration.
    Mr. Chairman, Senator Mikulski, we look forward to working 
with you, this subcommittee, and your House counterparts on 
reauthorizing the Older Americans Act.
    Senator DeWine. Great. Good testimony. Thank you very much.
    [The prepared statement of Ms. DeRocco follows:]

               Prepared Statement of Emily Stover DeRocco

    Mr. Chairman and members of the subcommittee, I am pleased to have 
the opportunity to testify before you today with my distinguished 
colleague, Josefina Carbonell, Assistant Secretary for the 
Administration on Aging, to discuss the reauthorization of the Older 
Americans Act (OAA). For over 35 years, the Department of Labor has 
administered the Senior Community Service Employment Program (SCSEP), 
authorized by Title V of the Older Americans Act.
    Before discussing what we believe to be the important principles to 
consider in reauthorizing title V, I would like to say a few words 
about America's aging population and workforce and provide context on 
where SCSEP fits in the broader workforce investment system.

The Aging Population and Workforce

    As you know, the U.S. economy is entering a period of dramatic 
demographic change as our population ages. According to the Department 
of Labor's Bureau of Labor Statistics, by 2030, as the baby boom 
generation ages, 24.2 percent of the civilian noninstitutional 
population, or about 66.2 million Americans, will be 65 or older, 
compared to just 15.6 percent in 2000. Further, as a result of lower 
birth rates in recent years, combined with the aging and retirement of 
the baby boom generation, the American workforce is growing more 
slowly.
    The changing demographics of the labor force, in combination with 
the ever-increasing skill demands of employers, have made it more 
critical that every available worker, including older Americans, be 
able to join or remain in the workforce to enable the continued 
competitiveness of American businesses in the 21st Century.

Barriers to Employment Faced by Older Workers

    Yet, older workers face significant challenges to full 
participation in our workforce. Employment barriers include 
difficulties keeping pace with changing skill requirements and 
technology, the lack of opportunities for skills training and 
professional development, misperceptions among some employers about the 
abilities of older workers, the lack of flexible work schedules, and 
certain financial disincentives to working that may encourage early 
retirement. Many older workers want to remain in the workforce and many 
need to continue working for financial reasons.
    There is a resource available to help: currently, our Nation's 
taxpayers invest about $15 billion in the workforce investment system. 
The workforce investment system, which includes SCSEP, has an important 
role to play in helping some older workers to obtain the necessary 
skills and access to opportunities that will enable them to continue 
working.

Response by the Department of Labor to an Aging Population

    Our workforce investment system has an important role to play as 
well for employers who need a skilled workforce in order to grow and be 
competitive. If we are to meet the rapidly-changing skills demands of 
business and address potential labor shortages, we will need to help 
employers seek out untapped labor pools, like older workers. Some 
employers already recognize the value that older workers bring to the 
workplace: they know that older workers are a human capital asset; 
bring responsibility, loyalty, dedication, experience and skills to the 
workplace; and serve as effective mentors to younger employees.
    Still, more needs to be done to provide job training opportunities 
for mature workers and better connections to older workers for 
employers looking to hire.
    At the Department of Labor we are taking steps to enhance the 
effectiveness of the workforce investment system to serve older 
workers, and we are pursuing new strategies and special initiatives to 
link mature workers to employers.

Older Worker Projects and Initiatives

Older Worker Task Force
    In November 2004, the Employment and Training Administration 
convened an interagency taskforce comprised of representatives from the 
Office of the Assistant Secretary for Policy, the Bureau of Labor 
Statistics, the Employee Benefits Security Administration, and the 
Bureau of International Labor Affairs to focus on the older worker 
population. Its charge is to develop a comprehensive policy and 
investment strategy designed to address the key issues related to the 
participation of older workers in the labor market.
    Three objectives have been identified for the taskforce:
    1. Identifying and filling knowledge gaps that currently exist 
regarding older workers' employment opportunities.
    2. Strengthening the capacity of the workforce investment system to 
provide comprehensive, integrated employment and training services to 
older workers.
    3. Identifying and addressing the barriers to employment faced by 
older workers in order to improve employment outcomes for this 
population.
    The taskforce's recommendations are under review, and I look 
forward to working with our public and private partners to move the 
recommendations from ideas into reality.
Protocol for Serving Older Workers
    In January 2005, the Department of Labor released a written 
``Protocol for Serving Older Workers'' to the over 1,900 comprehensive 
One-Stop Career Centers of the workforce investment system. The goal of 
this protocol is to enhance the services provided to older workers, and 
to promote the One-Stop Career Center system's adoption of innovative 
strategies for tapping into this labor pool.
    We know the workforce investment system must do a better job 
serving a larger number of older workers and we must forge new 
partnerships with business and industry and organizations representing 
the interests of mature workers to ensure successful placement of older 
workers in jobs.
    Now I would like to turn to the Senior Community Service Employment 
Program (SCSEP), a workforce investment program targeted exclusively to 
low-income seniors.

Title V--The Senior Community Service Employment Program

    SCSEP serves persons 55 years of age or older whose family incomes 
are no more than 125 percent of the Federal poverty level. Participants 
are placed in a part-time community service assignment in a local non-
profit agency so that they can gain on-the-job experience, and prepare 
for unsubsidized employment.
    The fiscal year 2005 appropriation for SCSEP is $436,678,400. This 
funding will support over 61,050 SCSEP positions, and will result in 
approximately 91,500 people participating during Program Year 2005 
(July 1, 2005-June 30, 2006).
    There are currently 69 SCSEP grantees, including 13 national 
grantees (12 national non-profit organizations and one Federal public 
agency), and 56 units of State and territorial governments. The 13 
national grantees are:

     the AARP Foundation;
     Asociacion Nacional Pro Personas Mayores (ANPPM);
     Easter Seals, Inc.;
     Experience Works, Inc.;
     Mature Services, Inc.;
     National Able Network;
     National Asian Pacific Center on Aging (NAPCA);
     National Caucus and Center on Black Aged, Inc. (NCBA);
     National Council on the Aging, Inc. (NCOA;
     National Indian Council on Aging (NICOA);
     Senior Service America, Inc.;
     SER-Jobs for Progress National, Inc.; and
     The United States Forest Service.

    Program participants receive training and work experience in a wide 
variety of occupations, including nurse's aides, teacher aides, 
librarians, gardeners, clerical workers, and day care assistants at 
non-profit 501(c)(3) organizations and public agencies. Program 
participants also work in the health care industry, such as in 
hospitals, as well as in recreation parks and forests, education, 
housing and home rehabilitation, senior centers, and nutrition 
programs. They are paid the highest applicable minimum wage, be it 
Federal, State or local, or the prevailing rate of pay for persons 
employed in similar public occupations by the same employer.
    The typical SCSEP participant is a woman with a high school 
education in her mid-sixties. At the end of Program Year 2003 (June 30, 
2004), 73 percent of the participants were women, 44.3 percent were 
minority, 81.5 percent were age 60 or older, 8.7 percent were age 75 or 
older, and 70.8 percent had a high school education or less.
    SCSEP can make a difference for these individuals. A recent article 
on the SCSEP Web site featured the successful placement of an Ohio 
woman laid off from her 5-year secretarial job at a local hospital. She 
came to SCSEP for help, was found to be SCSEP-eligible and placed in a 
community service assignment in the grantee's resource room. In that 
capacity, she helped to provide services to other older workers as she 
pursued her own job search. Initially reluctant, she agreed to 
participate in the grantee's WIA-funded Job Club, refreshing her 
interviewing and job-seeking skills, and benefiting from shared 
information on job openings. As a result of a Job Club lead and these 
services, she is now employed at a mass transit company as the 
Administrative Assistant to the Executive Director--a challenging and 
interesting position. The SCSEP gave this participant an opportunity to 
earn money and engage in meaningful work while she gained the self-
confidence to engage in a successful job search.

SCSEP Reforms

    In 2000, the Congress enacted Amendments to the OAA, including the 
SCSEP program. The Department of Labor subsequently issued implementing 
regulations. As a result, there are a number of changes that have been 
made to SCSEP since 1999 when the last reauthorization hearings were 
held.
    The program has evolved from being focused largely on community 
services to a program that increasingly emphasizes the achievement of 
economic self-sufficiency through unsubsidized employment. While the 
statutory goal for private-sector placement is a minimum of 20 percent, 
our grantees place approximately 35 percent of participants in 
unsubsidized employment each year. Our goal is to increase this 
percentage. In fact, some of our best-performing grantees place from 
50-75 percent of their participants each year. A community service 
assignment is the first stop in the SCSEP program, not the last 
station.
    Currently, we estimate that SCSEP serves less than \1/2\ percent of 
the eligible population--and, as we are all aware, the baby boomer 
aging cohort continues to grow. Therefore, achieving unsubsidized 
placements for employment-ready participants enables grantees to serve 
more eligible applicants. The new regulations tighten income 
eligibility guidelines to ensure that the statutory mandate to serve 
our neediest seniors is met. Further, the Amendments and the 
implementing Final Rule also require that grantees apply certain 
priorities and preferences in recruiting and selecting eligible 
individuals for SCSEP to serve those individuals with multiple barriers 
to employment.
    In 2002-03, the Department conducted the first open national 
competition for the national SCSEP grants. The Department made this 
decision to ensure that the best providers were selected, as well as to 
infuse the program with new and innovative ideas to improve its 
efficiency so more seniors could be served. Over 60 organizations 
applied and 13 organizations were awarded national grants--9 incumbents 
and 4 new grantees. The Department ensured a smooth transition through 
a variety of mechanisms, including: (1) permitting voluntary slot 
swaps; (2) providing additional resources to avoid potential layoffs of 
program participants due to over-enrollment; (3) convening a PY 2003 
Orientation and Training Conference for all national grantees; (4) 
establishing an internal Transition Management Group; (5) instituting 
weekly conference calls between the Department and the national 
grantees; and (6) using the Department's Toll-Free Help Line to respond 
to questions about the transition.
    The coordination roles and responsibilities between SCSEP grantees 
as One-Stop partner programs and the One-Stop Career Center system have 
now been clarified and strengthened. The Department has been committed 
to helping this system forge relationships that leverage resources to 
serve more older individuals.
    Beginning July 1, 2005, SCSEP grantees will be held accountable for 
achieving specific performance measures relating to placements in 
unsubsidized employment, retention, earnings increase, and customer 
satisfaction. This means that the Department will have specific outcome 
data to show the Congress about the value-added we provide to older 
individuals.
    Administrative procedures have also been strengthened. Grantees 
must now meet fiscal accountability provisions such as assuring there 
is no fraud and abuse in the grantee organization or failure to repay 
debts, similar to those required under the Workforce Investment Act.
    The State Plan is now known as the State Senior Employment Services 
Coordination Plan, reflecting the new emphasis on collaboration and 
partnership. In order to improve the ability of States to coordinate 
services, grantees must arrange for the participation of a broad array 
of stakeholders in the development of an annual plan to ensure an 
equitable distribution of projects within the State.
    Section 502(e) of the 2000 Amendments is now a separate employer-
based subsidized training program. These projects utilize innovative 
strategies and new work modes, such as flex-time, flex-place, and job 
sharing, to provide SCSEP participants with second career training and 
to prepare them for placements with private sector employers in high-
growth industries. This program was designed to enhance the employer 
connections of the SCSEP grantees and increase placements of 
participants in jobs.
    To support these legislative and regulatory changes, the Department 
has undertaken a number of initiatives. We are working with the 
business community--especially in high-growth sectors such as health 
care, retail, information technology and hospitality--to promote the 
benefits of hiring older workers. We are also providing technical 
assistance to our grantees to help them recruit participants who meet 
the new eligibility criteria. Finally, we have developed outreach 
materials to inform both employers and potential participants about 
opportunities to hire SCSEP participants, and will be mounting a high-
profile celebration of the 40th anniversary of the program during Older 
Workers Week, September 18-24.

Principles for SCSEP Reauthorization

    In view of the increasing importance of older workers in our 
economy, it is fortuitous that the reauthorization of both the Older 
Americans Act and the Workforce Investment Act are before the Congress 
this year. As you know, SCSEP is closely linked to the Workforce 
Investment System. It is a required partner in the WIA One-Stop 
delivery system. Additional provisions in both WIA and title V link the 
two programs together. After considering our experience administering 
the program and input we have received from our grantees through 
``SCSEP Reauthorization Town Hall Forums'' that we held earlier this 
month, we propose five principles for title V reauthorization, which 
view SCSEP within the larger framework of the Workforce Investment 
System.
    First, we need to help meet employers' demands for skilled workers 
by attracting additional older workers into the labor force, 
encouraging others to remain in the workforce, and by offering 
opportunities for older workers to update their skills. SCSEP and WIA 
are each avenues to do this, and we will be recommending specific 
improvements to both programs to do it more effectively.
    Second, we must make the One-Stop Career Center system more 
responsive to the specialized needs of older individuals seeking to 
work or upgrade their skills. Specifically, we need to better integrate 
services for older workers into the One-Stop Career Center system, in 
order to provide truly universal service and assist more older workers, 
regardless of income, to gain skills in demand. One-Stop Career Centers 
should be a primary destination for older workers seeking to work or 
upgrade their skills. An ideal One-Stop Career Center would have a 
resource room with a wide variety of worker information and might offer 
older workers information on job search and placement assistance, 
training and supportive services, starting a business, and 
volunteering, as well as retirement planning. It also would help older 
workers find opportunities for job sharing, part-time employment, and 
other work modes for older workers who want to or need to continue 
working, perhaps in second careers, but possibly not full-time, or who 
simply seek to ease into retirement.
    SCSEP serves the low-income segment of the older worker population, 
and SCSEP grantees, often the experts on serving older workers in the 
One-Stop Career Centers, must be integrally involved in this effort to 
integrate services for all older workers into the One-Stop Career 
Center system. They cannot do it alone, however. The larger WIA system 
must do a better job of serving older workers in general and it must 
serve more of them in order to meet employers' demand for skilled 
workers. The Protocol for Serving Older Workers was a step in this 
direction.
    Third, we need to tailor SCSEP services to meet the needs of 
individual older workers by providing a range of training experiences, 
including on-the-job and classroom training or re-training, depending 
on the individual's background and experience. This range of training 
options will allow us to better address individual needs and prepare 
low-income older workers at varying skill levels for private sector 
employment.
    Fourth, we must target SCSEP resources to effectively serve those 
older workers in need of work experience, including low-income older 
workers who lack basic skills or are unable to obtain private sector 
employment immediately. As I noted earlier, SCSEP currently serves only 
a small percentage of the eligible population. This principle therefore 
fits hand-in-glove with our second principle: as we target resources to 
meet the needs of the low-income senior population, we must ensure that 
other older workers can access appropriate and effective services 
through WIA.
    Finally, we need to streamline the SCSEP program to make it easier 
to administer, in order to improve program performance, serve more 
participants, and get return on investment for the Federal taxpayers' 
dollar. Some of the features and provisions of SCSEP have been in place 
for many decades and no longer make sense in view of the changing 
economy, increased longevity, and the current geographic distribution 
of the target population. We will have specific proposals to address 
these issues, as well as to improve program accountability and 
administration.
    Mr. Chairman and members of this subcommittee, I look forward to 
working with you and your House counterparts on reauthorizing the Older 
Americans Act. Working together, I am hopeful that we can obtain 
enactment of this important legislation later this year. I also look 
forward to working with you on the reauthorization of the Workforce 
Investment Act.
    Mr. Chairman, this concludes my prepared statement. At this time I 
would be pleased to answer any questions that you or other subcommittee 
members may have.

    Senator DeWine. Let me ask both of you when you believe 
that we will have specific legislative recommendations on 
reauthorization from you all.
    Ms. Carbonell. Our proposals are currently being vetted by 
the administration and we hope shortly. We don't know the exact 
time frame, but----
    Senator DeWine. You don't know what ``shortly'' means yet?
    Ms. Carbonell. We have been working on this for quite a 
long time and getting input from the field and from our 
providers in the aging network. The proposal is being fine-
tuned right now by the administration and we hope to be able to 
come with the overall white paper on the principles of the 
reauthorization and look forward to working with you, 
hopefully--I don't want to say a time frame, but I hope that in 
the next month, we should be able to do that.
    Senator DeWine. Good. Obviously, the sooner the better. We 
appreciate that very much and look forward to working with you.
    Ms. Carbonell, you talked in your--and 5 minutes is always 
a tough time frame to say anything, certainly Senators can't do 
it in 5 minutes. I don't know how we expect you to do it in 5 
minutes. But you talked about the need to keep people in their 
own homes, the need to provide services in their own homes. I 
wonder if you could reflect a little bit more in detail about 
the Older Americans Act and as we move toward reauthorization 
how that pertains to what we will be doing. I mean, it affects 
so much of what the States are doing with health care, so much 
of what we are looking at at the Federal level, so much in the 
jurisdiction of the Finance Committee, for example, but I 
wonder if you could reflect on what we are doing with the Older 
Americans Act.
    Ms. Carbonell. Well, one of the first things that I did 
when I came into office was go out back into the community to 
talk to caregivers, to talk to seniors, to talk to our aging 
services providers, to see which way we could not only 
implement the amendments and the changes and the strengthening 
of the Act of 2000, but most importantly, how we could move the 
act and the services within it, modernize them and improve the 
efficiency to better serve the people.
    One of the continuing comments that have circulated in 
almost all venues, whether you talk to, most importantly, the 
seniors, older Americans, their caregivers, is they want to 
have a choice to stay at home as long as possible and to live 
as independently, quality of life as long as possible.
    So that means that that served as the core value that when 
we develop our strategic vision, our strategic plan, as we 
implemented the changes of 2000, as we move the act forward, to 
make sure that we looked at the consumer and their wish to 
remain at home as the central focus of what we did throughout 
the entire network.
    And then the implementation of the new Family Caregiver 
program gave us the ability to not only continue to expand the 
services to seniors across this country, but to serve a 
different kind of client that gave us the complete picture on 
the kinds of challenges that caregivers, mostly women, working 
women in families that have both children and older adults, are 
facing in caring for their loved ones.
    So being able to assist them and support them with services 
and information and giving them availability and brokering 
those resources to those caregivers and to the older Americans 
gave us, again, another opportunity to expand and build upon 
the core programs of the Older Americans Act, under supporting 
services, nutrition services, elder abuse prevention, and 
Native American programs, to build upon additional services to 
maintain people at home.
    Again, the ability and the fragmentation of some of the 
services, having been on the other side of this table and 
having been a provider for over 30 years, we knew how difficult 
it was sometimes to try to really meet the needs of the entire 
consumer when someone showed up at your doorstep needing help. 
And it was the fragmentation of services with different funding 
sources and different requirements which made it very difficult 
to try to serve the whole person and their needs.
    So we know that home- and community-based care is the 
number one priority. They want to remain at home. They want to 
age in place. They want to be able to receive services at home, 
to maintain independence, to have the ability, for those that 
are able and capable of working, to have the ability to 
maintain active and independent, to have the ability to 
volunteer and to be engaged in their community. So that is one 
of the most important principles that was implemented in the 
strategic vision and, of course, in the implementation of all 
the amendments of the Older Americans Act.
    The other very important factor is that throughout the 40 
years, we have built one of the most impressive community-based 
care systems that is locally based, locally managed, from the 
local community up to the Federal level, by States and local 
communities developing their own priorities based on their own 
community needs, and we have built the largest--we are the 
largest provider of home- and community-based care in our 
country. We also manage about two-thirds of the Medicaid waiver 
programs in States throughout this country.
    So we know that we are in the right position to modernize 
the act and to bring it to the next level to address not only 
the current challenges of people living longer, needing more 
forms of support, but also the ability of the act to maintain 
independence and to reach younger folks, people, by serving 
people 60-plus.
    Senator DeWine. Very good. Thank you.
    Senator Mikulski?
    Senator Mikulski. Thank you very much, both of you, for 
very dynamic presentations. Ms. Carbonell is someone whose 
social work background and Master's degree--actually, my first 
job out of graduate school was working in a rural and poverty 
program getting ready for this bill. So it is great to talk to 
somebody who likes to go into the street in the community to 
know what is up.
    Let me go right to the questions about keeping people in 
their home. In 1965, we designed this. We were a booming 
economy. There was a smaller proportion of elderly. And we were 
focusing more on loneliness and isolation and so on.
    Now, how would you see the top three things you would like 
to focus on if we were just starting this program now? How 
would you--what here would you keep as core, or what would you 
change, or what would you add, or what would you subtract?
    Ms. Carbonell. I think that the principles that the 
administration is looking at and the Administration on Aging 
definitely have been working on is we have built the system and 
we have a core set of programs that have been very effective in 
keeping people out of homes. Particularly, we are serving 8.2 
million persons under the Older Americans Act, 3 million of 
which received intensive services at home. These 3 million 
actually would qualify for a nursing home right now because 
they have more than three ADLs and they would qualify right now 
for institutional care should they wish to seek that choice. 
That means that we are being very successful in keeping people 
at home.
    So what we are looking at, and I think the basic principles 
is that we built upon the core programs and the strengths----
    Senator Mikulski. Let me go through this list. No. 1, would 
you keep information and referral?
    Ms. Carbonell. Information and referral has been proven to 
be one of the most important services for older Americans and 
caregivers across this country.
    Senator Mikulski. Second, would you keep the nutrition 
programs, Meals on Wheels and congregate meals?
    Ms. Carbonell. Nutrition programs have been extremely 
effective in keeping people healthy, particularly because we 
are targeting those at most risk, with high nutritional risk 
factors and other nutrition intervention services that help 
people remain healthy and are part of the overall prevention 
and wellness programs of the success of the programs.
    Senator Mikulski. Senator DeWine said we are going to be 
holding other hearings on the Meals on Wheels and the Eating 
Together programs. That is the term we use for congregate meals 
in Maryland. Do you face challenges, for example, the decline 
of the number of volunteers? Gosh, skyrocketing gas prices when 
many of the volunteers are elderly themselves. Are there 
challenges in maintaining the Meals on Wheels program as we 
know it?
    Ms. Carbonell. Well, the Meals on Wheels program, again, is 
one of the most successful, and the recruitment of volunteers, 
again, in that area, is extremely high. You know that overall 
in the Older Americans Act, we have over 500,000 volunteers 
that provide services directly. A large portion of them are in 
the Meals on Wheels program. So the continuous building upon 
the ability of the act that we have already the authority, to 
build upon the act, to recruit more volunteers, to engage more 
people in meaningful activities of volunteering, in programs 
such as these and with other programs in the community, is 
going to be a critical point of--will continue to be a critical 
point of our programs.
    Senator Mikulski. So that would be also part of the ``must 
do.'' Now, one of the things that we added was the National 
Family Caregiver Support program, and it is something I am very 
keenly interested in. It, of course, goes to the independence 
principle that we both--we all endorse.
    What have we learned from the National Caregiver Support 
program so far? What aspects have been successful? What can we 
do to improve the program? Do you see holes or gaps in the 
program?
    Ms. Carbonell. Well, first of all, the National Family 
Caregiver, like I expressed before, has given us the 
opportunity to serve a whole array of providers. They are 
helping us provide the care that is being given to older 
Americans and disabled Americans across this country. So 
Caregiver is a critically important program and it is a core 
program that we have embedded into the Older Americans Act rest 
of the program.
    Senator Mikulski. But what about it was successful?
    Ms. Carbonell. It has been extremely successful not only in 
reaching----
    Senator Mikulski. But what aspects of it?
    Ms. Carbonell. All of the aspects. I think that the 
Congressional vision to identify the key importance of 
information and assistance as one of the most important 
services that caregivers need in their search for being able to 
care for their loved ones better and quality of care and 
accessing resources. So information and assistance has been a 
critical service area, and in that area, we have been able to 
serve 12 million caregivers so far. We are very proud of that.
    Senator Mikulski. That is great.
    Ms. Carbonell. So we know that information assistance, like 
you mentioned, Senator Mikulski, is a very, very important 
service, whether it is given through the Caregiver program, but 
we are looking at the Caregiver program as an integral 
component of the overall core programs of the Older Americans 
Act.
    Senator Mikulski. Absolutely. Have you found gaps in the 
program or areas that need greater support, either financial, 
the supplemental services in particular, or the caregiver----
    Ms. Carbonell. We have been able to----
    Senator Mikulski. I note your comments on transportation 
and----
    Ms. Carbonell. Yes.
    Senator Mikulski. Those things that don't require actual 
home health, but they require assistance for independence, 
whether it is the chore service, the transportation service----
    Ms. Carbonell. The beauty about the Family Caregiver 
program, the way it was designed by the Congress, it gave us 
the flexibility to give to States that flexibility to design 
the program based on caregiver needs in that local community. 
So it allowed us to, for instance, if the caregiver needed a 
ramping built in their home and that meant the difference 
between somebody being active and social and being able to be 
transported out of their home safely, then the ramp was allowed 
to be built. That means that we gave that provider the 
flexibility to do that.
    Consumer training, that means caregiver training. You know, 
many caregivers, unfortunately, are faced with caring for their 
loved ones and not knowing how to pick up people and not be 
injured, you know, from beds, and transporting people. One of 
the abilities that we had was through the demonstration grants 
that were funded under the Caregiver program, there were 
several programs that tested other innovative ideas, including 
in, of course, your district, the ARC of the United States 
actually did cross-training between the disability networks and 
the aging networks on the needs of caregivers----
    Senator Mikulski. Ms. Carbonell, I see that my time is up. 
When we come back, either for a second round of questioning, 
but in our ongoing work, what you are saying is that the 
original pillars of the program stand. The program will stand 
on that and then there has to be changing demography, since we 
need to look at it in a creative way. But this Family Caregiver 
program is really one of the new pillars----
    Ms. Carbonell. That is right.
    Senator Mikulski. [continuing]. That will be a cornerstone 
to independence, is that correct?
    Ms. Carbonell. That is so correct.
    Senator Mikulski. We will forward actual specific 
suggestions, and thank you for your insightful testimony.
    Senator DeWine. Senator Murray?
    Senator Murray. Mr. Chairman, thank you very much. There is 
a lot going on in the Senate, but I did want to come by for a 
couple minutes of this hearing to thank you and Senator 
Mikulski for the hearing today and for your work on this issue.
    Certainly, the Older Americans Act is something I think is 
extremely important and I hope we can move through the process 
and reauthorize this quickly and strengthen the program, not 
dismantle it. It is one that I hear about everywhere I go in my 
community. People say how important this legislation is to them 
personally, in their own lives, and certainly as we see the 
baby boomers retire and a number of pension systems that are 
under duress right now, we are going to see a greater need for 
this program. We need to make sure that we are doing the right 
thing.
    So I really wanted to especially come and say I support you 
in the work on this and want to work with you.
    But I did want to ask, as we begin the process of 
reauthorizing this act, I am really interested in getting some 
more specific information on how HHS and DOL have improved 
outreach, especially to minority groups. I know that during the 
last reauthorization, we focused a lot on diversity within the 
programs, but we still today have a lot lower participation 
rates for most minority populations, and in my State, I am 
especially concerned about aging Pacific Islanders and Native 
Americans.
    I realize that, nationwide, these are smaller minority 
populations, but in some regions of the country, they make up a 
larger share of the population, and I think we should be 
looking more at minority outreach and participation rates on a 
more regional basis.
    So, Ms. Carbonell, I know in your prepared statement I had 
a chance to look at, you mentioned that one of the four 
strategic priorities for implementation for the 2000 
reauthorization was to make it easier for older people to 
access an integrated array of social supports. I am concerned 
that we still have a lot of work to do to achieve that goal, 
especially with the Asian Pacific and Native American 
communities.
    You might know that in 2004, I got funding for a specific 
outreach effort in Indian Country in Washington State, and that 
was sort of due in part to my frustration in making sure that 
Native Americans, especially older, low-income elders, were 
aware of a lot of these important social services. So could you 
provide for us today an update on diversity in all the programs 
and how the administration is working to make sure it is 
culturally sensitive, the manner that they work in these 
minority communities?
    Ms. Carbonell. Thank you, Senator Murray. I think that we 
have a good report on the targeting issue. I think that, number 
one, it is a requirement of the Older Americans Act, and as you 
have said, the 2000 amendments strengthen our commitment to 
targeting vulnerable populations throughout the country and we 
have got a good story to tell.
    I think, overall, the percentage of Older Americans Act 
clients that are being served that are poor almost tripled the 
poverty rate. That means that we are serving three times the 
number of poverty-level individuals that we did some years 
back.
    The percentage of the Older Americans Act clients that are 
minority was almost 20 percent higher than the minority rate 
for all elderly people in 2001, and rose over 40 percent higher 
by 2003.
    Specifically, minority participation in OAA programs have 
increased in the last 4 years, especially for Hispanics and 
Asian Pacific Islander categories, including extra efforts with 
Native American programs and increases that we have dedicated 
to specifically resource centers and to improve the training 
and technical assistance to minority communities. So we are 
very proud of the work that we have done in the area of 
minority and then targeting those in most risk.
    We have also made some very important strides in serving 
clients in rural areas. For instance, the Older Americans Act 
clients that live in rural areas is at least 25 percent higher 
than the rural rate for all elderly people, and we have 
certainly seen just in the last 3 years a tremendous increase 
both in the minority participation in centers, and that is 
thanks to a very concerted effort by us and all of the network 
providers at the State and local level to make sure that we 
have created and continue to build upon improved access to 
services, information, and programs and resources for this 
population----
    Senator Murray. I really appreciate it. I think that is 
really an important emphasis that we have to maintain and 
continue.
    I know my time is up. I just want to ask, Mr. Chairman, if 
you don't mind, one quick question, and that is I know an 
important part of the Older Americans Act is coordination of 
services and programs. We have a lot of veterans who are aging, 
who need assistance, and I would like to know if you are 
working with the VA, because I am finding that a lot of those 
veterans don't know of the services that are available to them. 
So do you coordinate with the VA?
    Ms. Carbonell. Yes. There is continuous coordination with 
the VA, particularly as we develop the Caregiver program. We 
have had specific coordination efforts for caregiving support, 
technical assistance. We have also coordinated at the local 
level with the Area Agencies as we develop plans to serve the 
needs of communities. We see that coordination happening at the 
local level and at the State level. So we see that continuing 
to grow and expand as we move forward. And, of course, Senator 
Craig is now chairing the Veterans' Affairs Committee and we 
look forward to working and to continue to work with our 
counterparts----
    Senator Murray. I think it is really important that we 
continue to do that because it is a population that often gets 
lost, doesn't know of those services, and it is a great way to 
avail those veterans who served our country with the knowledge 
of what is out there to support them.
    So, Mr. Chairman, I thank you very much for having this 
hearing and I look forward to working with you and Senator 
Mikulski on the reauthorization of this bill.
    Senator DeWine. Good. Ms. DeRocco, you say that you would 
like to increase the number of participants who receive jobs in 
the private sector. What is the Department doing now to help 
SCSEP grantees find jobs for participants, and also is the dual 
purpose of SCSEP, valuable community service activities, and 
unsubsidized employment outcomes, working as intended?
    Ms. DeRocco. Absolutely. Yes. Let me say that the dual 
mission, dual purpose of SCSEP is an important and not 
exclusive set of focus. They work together well. The community 
service opportunities for our older Americans to actually learn 
new job skills is a tremendous opportunity for them to gain the 
skills necessary to move into unsubsidized employment.
    We are finding that the more we can integrate the SCSEP 
program with the Workforce Investment System and assure that 
the services of both and the participants in both understand 
the array of resources, services, and opportunities available 
to them, the better off our mature workers are going to be 
coming out of or through either of those programs.
    We have established a strong relationship between the SCSEP 
program and the One-Stop Career Centers across the country. As 
I indicated, we have issued a protocol to our one-stops about 
serving older workers and assuring that older workers who 
access services in the one-stops understand what the SCSEP 
program is and what services it might provide, especially for 
low-income workers or those who need the work experience in 
order to then gain the skills to access employment in the job 
market.
    We have had from both programs an aggressive outreach to 
employers, and quite frankly, the employers are the ones now 
aggressively outreaching to us in their wisdom, understanding 
the demographics of this workforce and the fact that mature 
workers are a critical component, a solution for the workforce 
challenges that lie ahead. They are interested in making the 
connections and the arrangements with our Workforce Investment 
System and with the SCSEP program to offer job opportunities, 
training opportunities, and then integration into eventually 
unsubsidized employment.
    So we have a focus on integrating these two systems and a 
focus on assuring employers recognize the value of mature 
workers in their solutions, human capital solutions, for the 
future.
    Senator DeWine. We have heard--and I appreciate your 
answer--there have been some who have said that since the 2000 
amendments were implemented, there has been too much emphasis 
on placement in unsubsidized jobs and really not enough on 
community service aspects of the program. Do you want to 
comment on that?
    Ms. DeRocco. Well, again, we don't see these as mutually 
exclusive missions.
    Senator DeWine. I understand.
    Ms. DeRocco. They are very complementary missions. But 
still, it is our mission at the Department of Labor and through 
the Workforce Investment System, of which SCSEP is a part, to 
provide as many opportunities as possible for individuals to 
gain the kind of independence Senator Mikulski spoke about, 
which means the independence of having a job and a job at a 
wage and with benefits that assure opportunities for families 
and within the communities.
    We use the work experience in community service, both to 
benefit the community during the term of community service, but 
also to gain the skills necessary for unsubsidized employment. 
And it is important, I think, that Congress recognized this 
when you reauthorized in 2000 and amended the Older Americans 
Act.
    There are two huge benefits to focusing on the 
opportunities for those, where it is appropriate, to move from 
community service to unsubsidized employment, and that is 
number one, that they do gain more income, which means more 
independence for them individually. But it also means that they 
move out of a slot and additional older Americans who need the 
services of the SCSEP can move in. So it expands our 
opportunity to serve more low-income Americans who need work 
experience.
    Senator DeWine. Ms. Carbonell, the OAA Title 3(d) program 
provides funding for disease prevention and health promotion 
services. This program has become increasingly really 
invaluable, as recent evidence-based research continues to 
prove that health promotion, disease prevention, not only 
contributes significantly to an individual's quality of life, 
but also really are cost-effective means of reducing the key to 
chronic care costs.
    How do you see this program fulfilling today's needs and 
how can the aging network's role in disease prevention and 
health promotion be enhanced?
    Ms. Carbonell. Well, the preventative health line item is a 
very important service that is provided to communities across 
this country. Thanks to your support in the innovations line 
item, we have invested in looking at the evidence-based science 
that is coming out of the Institutes of Health and implementing 
the best science into community-based programs that are simple 
and understandable by lay people so they can maintain their 
health at an optimal level.
    So it means that we have built upon the existing core 
programs under preventative health and added that extra 
component of modernizing and testing ways in which our core 
programs, our aging services network providers at the community 
level, whether it be an adult day care facility, whether it be 
a senior center, whether it be a nutrition program or a home-
bound program, can instill in their clients the ability to give 
them tools to take care of themselves better, to manage chronic 
conditions, which is going to be one of the toughest challenges 
facing an older population in the United States, giving them 
proven techniques and tools to maintain independence.
    For instance, in Maryland, we are funding a very important 
health promotion program which looks at wellness and instills 
the wellness and prevention techniques into programs. In 
Washington, Senator Murray's State, we are implementing the 
models that Susan Snyder implemented in Washington State for 
wellness programs and physical activity and chronic disease 
management. We are looking at nutrition. We are looking at 
physical activity. We are looking at chronic disease 
management. And, of course, we are looking at falls prevention, 
which is another area of high cost, both dollar-wise and in 
quality of life for many seniors, to prevent falls and to 
improve the quality of health care for individuals.
    In the medication management, you know Congress has 
dedicated a certain amount that is being spent on improving 
people's abilities to understand proper medication management, 
particularly when there are complex or there are multiple 
medications being taken. So efforts at the community level are 
being improved by this special emphasis on medication 
management to assist people to look at their medications and 
the safety of those medications and how they take them, both in 
our congregate programs and our home-delivered programs.
    We see that as the reauthorization is upon us, we see 
another unique opportunity to build on the work that we have 
done in the preventative health area and to take it to the next 
level, modernize it, bring the best science to bear, and to 
have that as a central focus as we look at long-term care. It 
is not only giving people better choices to remain at home and 
better control and independence in their own lives, it is also 
giving them adequate tools and simple tools that they can 
follow that science has proven that with physical activity and 
improved health and improved nutrition, health status can be 
maintained even in later years even with people with chronic 
conditions.
    So that is what we are trying to look for as we look at 
reauthorization, being health and wellness as a key component 
as we look at modernizing long-term care.
    Senator DeWine. Good. Senator Mikulski?
    Senator Mikulski. Thank you, Mr. Chairman.
    I would like to come back to the jobs issue, the so-called 
title V. The chairman asked many of the questions I had related 
to community service, but could you refresh my memory? What is 
the One-Stop Career Center? Is that----
    Ms. DeRocco. Certainly. The One-Stop Career Center is the 
service delivery system for the entirety of the Workforce 
Investment Act System. Seventeen mandatory partners that are 
federally funded, employment and job training programs----
    Senator Mikulski. I have got it. So it is for everybody.
    Ms. DeRocco. [continuing]. All come together at a 
community-based job resource center, so that in Maryland, your 
One-Stop Career Centers are where both your job seekers of all, 
a universal population----
    Senator Mikulski. Are they tend to be run out of the 
unemployment offices?
    Ms. DeRocco. Pardon?
    Senator Mikulski. Do they tend to be run out of the 
unemployment offices?
    Ms. DeRocco. I think when they were created in 1998, many 
of the One-Stop Career Centers were built on the old 
Unemployment Insurance Employment Service local office 
structure, but many are also new. Many are on community college 
campuses. Many are in community-based organizations. It is up 
to each State to determine where, in conjunction with local 
elected officials, the best place is.
    Senator Mikulski. Let me tell you where I am heading with 
this----
    Ms. DeRocco. OK.
    Senator Mikulski. [continuing]. Because usually, it 
requires them knowing about a center and going to it. That 
doesn't always happen, and it doesn't happen in many ways, 
which I am sure you have already identified. But let us go to 
one, just think older, and deciding you would want to return to 
the labor market because your money is running out and you want 
to come back part-time, don't even know where to begin. So you 
go to maybe Ms. Carbonell, or you don't know and you are 
immobilized. So that is one issue.
    The other issue is what I know is something Senator DeWine 
and I have faced, which is the collapse, say, in the 
manufacturing base. All of a sudden, you are a steelworker. You 
have worked there 30-some years. You are now maybe 58. Maybe 
you are 60. You are one or two--you are not going to be 
eligible for Medicare, Social Security, etc. Pow! Are you 
involved in where we see plant closings?
    Our last minivan rolled out of General Motors. I can't 
believe a Baltimore that doesn't make steel or doesn't make 
cars, but that is the reality. And what we see is particularly 
men, particularly men. They are going to sit around the union 
hall. They are going to go to local cafes. How can we reach out 
to them to even know that there are services, and not only the 
resume class and so on. These are guys who don't even like to 
dial their own phone to talk to their granddaughter.
    Ms. DeRocco. Oh, absolutely.
    Senator Mikulski. Do you know what I mean?
    Ms. DeRocco. I sure do.
    Senator Mikulski. It is a cultural thing that we see. It 
is, one, a terrible emotional shock. It is a terrible financial 
shock. Then we are seeing a whole other category, which is 
people who thought they had pensions. It has not been dumped 
into Pension Guaranty, like what we are dealing with here, and 
those pensions are gapped. So even for the middle-income, where 
they thought they were going to have a pension, say, of 50, it 
might now be 35, no small change, the poor would tell you. If 
you have planned on a certain income, here is the shock.
    So they are going to want to work, and they had skills. 
Where are you going to come in here----
    Ms. DeRocco. Those are exactly the reasons----
    Senator Mikulski. [continuing]. Modernization, this is what 
I am thinking about.
    Ms. DeRocco. Those are exactly the reasons why we cite the 
integration with the One-Stop Career Center. When a plant 
closes in your State or district, the One-Stop Career Center is 
the place that sends in the rapid response team that brings, 
for example, trade adjustment assistance, and for older 
workers, the alternative trade adjustment assistance for 
individuals over 55. They bring in all of the job training 
resources for individuals at whatever age that want to learn a 
new skill. They bring in the job availability list, who is 
hiring and who is not. And SCSEP, as a part of this, is a 
service that can be offered to older workers who need a 
different work experience.
    But primarily, your workers who are in a dislocation or an 
economic dislocation have skills that are either transferrable 
to another hiring industry or they at least have work readiness 
and we can provide some job training for some additional skills 
that would make them ready for another business or industry 
that is hiring or interested in moving into your community.
    But the fact of the matter is, each of these programs now 
have different eligibility, different sets of resources, and 
different services. Bringing them together at the community 
level and providing the flexibility that you spoke about to 
respond specifically to the needs of those workers, whether it 
is an age requirement or issue, a skills requirement or issue, 
an education, remedial education that might be needed, the fact 
that they all come together in the One-Stop Career Center 
allows us to best serve the workers and the employers----
    Senator Mikulski. Do you go back--I know my time is up, but 
let us say the crisis happens. The plant closes, and often, 
there is the appropriate notification that is required by law. 
But, you know, hope springs eternal. They either think that 
something is going to happen that is going to be different, or 
there might be initially where we just, after hard, hard work, 
but then all of a sudden, reality sets in and even a form of, I 
don't want to say depression, but sadness, melancholy. Then is 
there an organized outreach, particularly where maybe there has 
been a workers' association, a union, any number of types of 
organizations, do you all then go back to them?
    Ms. DeRocco. Absolutely. Our State and local workforce 
systems are always outreaching, not only in areas where there 
have been dislocations and layoffs, but in areas where there 
are individuals, disadvantaged individuals who haven't--they 
have been marginalized in our labor force, because now 
employers need them. So there is a constant marketing to the 
individuals and to the employers to bring them together in this 
community-based job center to ensure that we can make the best 
matches possible.
    The coordination with the Agencies on Aging is critically 
important for older workers who do go to those agencies to 
access supportive services----
    Senator Mikulski. I see.
    Ms. DeRocco. [continuing]. That they, in turn, can then 
refer to the job opportunities, and SCSEP and the workforce 
system.
    Senator Mikulski. As we move on, we look forward to 
creativity.
    Ms. DeRocco. Great.
    Senator DeWine. We thank you both very much.
    Senator Mikulski. Before we end, could I come back to Ms. 
Carbonell?
    Senator DeWine. Sure.
    Senator Mikulski. Ms. Carbonell, I essentially have two 
areas of questions, one of which is the success of the Older 
Americans Act has been based on the concept of the senior 
center that is a multipurpose center, that provides organized 
and structured activities and then partnerships like Meals on 
Wheels. However, new generations, the caregiving generation and 
so on, how do you see using the Internet for news that you can 
use? In other words, when my sisters and I were caring for our 
mother, we knew what to do. I am a social worker. Another 
sister was a lab technician with expertise in orthopedics. So 
we knew how. But a lot of people have to get information on 
just very different times.
    Are you using the Internet? I know that one of the most 
interesting and dynamic places in centers that I visit were 
seniors themselves learning to be the e-generation now. But how 
do you see this, even in the integration of services for 
information and referral, for news that you can use, both to 
the senior or to the family who wants to support independence? 
And do we have the framework to support that, because it bears 
its own expense?
    Ms. Carbonell. It goes back again to the ability that we 
have had, thanks to Congressional support, to invest in 
particular efforts. For instance, the Aging and Disability 
Resource Centers are so-called One-Stop Centers in which we 
access information for the long-term care. In addition to that, 
we have invested in improving our elder care locator number, 
which is a toll-free number. We have expanded the Web site to 
have access, so anyone in the United States--for instance, I as 
a caregiver was able to locate--even having worked in the 
system for a while and knowing the ropes, it takes a little bit 
of help and it takes a little bit of navigation to go through.
    That is why we are trying to be able to integrate the 
services, both the social support services and working with CMS 
on health care, particularly for long-term care, as we look at 
being able to give better access to information and assistance 
to seniors, not only through technology. Obviously, technology 
is improving in the areas of both health care and access to 
information of all sorts. I think baby boomers will demand to 
have--you know, we are used to going to the computer and 
finding the answer right there and we are building. We are 
building and improving the infrastructure and strengthening the 
aging services network's capacity to meet the growing demands, 
including technology.
    So a very important part of the Aging and Disability 
Resource Initiative, which we fund in 24 States to date, 
including one right in your State, Senator, is technology. That 
means the improvement of technology not only to create access 
and improve access, but also in the efficiency of the programs, 
how we provide that information to seniors and how we can track 
clients and also build multiple funding sources----
    Senator Mikulski. That will be fantastic.
    Ms. Carbonell. Right.
    Senator Mikulski. What I will be looking forward to in the 
information as you come back in the next month or so, or even 
as we get information from the White House Conference, will be 
the use of technology to support the seniors and those who love 
them in terms of their goals of independence. And I am 
particularly interested in the areas of information and 
referral, in wellness and nutrition, and also kind of a 
resource base. Where can they go on their own?
    And if I might add, alerts on scams, because this alerts on 
scams, we have areas that are often flooded with schemes for 
investment, schemes for home-based work, etc, and we find that 
the alert system that is now in some places in the senior 
network really works well. So that would be very important.
    Ms. Carbonell. Thank you. We look forward to providing 
extra information on that.
    Senator Mikulski. The next area is, are you familiar with 
the Natural Occurring Retirement Community effort?
    Ms. Carbonell. Yes, I am.
    Senator Mikulski. The aging in place? We funded some 
demonstration projects even through an earmark process, 
otherwise known as Congressional designated projects. I am a 
big believer in the NORCs, and Senator, just maybe to help you, 
this is where often there is a zip code where people have aged 
in place. Like after World War II, you know, where people--yes, 
some neighborhoods, and people are independent, they have got 
their homes. They are aging in place. Their housing is aging in 
place. Like Mom once said to me, ``Barb, I don't know what is 
going to give out first, my pipes or my knees.''
    [Laughter.]
    Could you have ideas and recommendations on what we could 
do in terms of the NORCs, because I think this goes to your 
coordinated, systematic way of bringing fragmented or 
smokestack, we will call them programs, stovepipe, and so on. 
Do you think they have been effective, and can you bring us 
recommendations on that area, as well?
    Ms. Carbonell. Well, we thank you for your interest in that 
area, and I know that there is a lot of Congressional interest 
because there are over 40 sites, 40 NORCs, Naturally Occurring 
Retirement Communities, throughout the county that have been 
funded through Congressional action.
    Again, I don't have any up-to-date data. There are 
different levels of performance in the sites. Some are smaller, 
some are larger. But it certainly affirms--the NORC concept 
certainly affirms the aging in place and the community-based 
care that we have been working on and that the act is so 
central to. So we look forward to, as the proposals get fine-
tuned, the details get out, we look forward to working with you 
on that.
    Senator Mikulski. I would like you to look at the 40 that 
are on the books and just preliminarily, not some complicated 
one, but what are we learning from lessons learned, best 
practices, and what have been, quite frankly, duds, so that we 
can make sure we get on the track, in a no-fault environment so 
that we can really look at this, because I think this is going 
to be an accelerating issue and if we can get our arms around 
it in this reauthorization and give you the tools you need to 
sponsor these programs on a competitive basis based on what we 
already know so we can make wise use of taxpayers funds, and 
yet an opportunity that presents itself.
    Ms. Carbonell. Thank you. We look forward to that.
    Senator Mikulski. So we want to have you tell us about the 
NORCs. I was thinking about ``Knock on the NORCs'' or 
something, but you get what I am saying.
    Ms. Carbonell. Well, we know that the NORCs--clearly, the 
NORCs is a perfect example of how people are wanting to remain 
at home in their own communities and the support services that 
are brought to and the coordination and the improvement of the 
coordination of care and support between all the services that 
are being provided, whether public or private, come to bear to 
keeping people quality of life in their later years.
    Senator Mikulski. Thank you, Mr. Chairman. You have been 
very generous. I appreciated the extra time.
    Senator DeWine. Well, we appreciate both of your testimony 
and we look forward to your recommendations and we look forward 
to working with both of you.
    Ms. Carbonell. Thank you.
    Senator DeWine. This committee will hold additional 
hearings in the future. Thank you very much.
    Ms. Carbonell. Thank you.
    Senator DeWine. The subcommittee is adjourned.
    [Additional material follows.]

                          Additional Material

                 Prepared Statement of Senator Clinton

    I would like to thank Subcommittee Chairman DeWine and 
Senator Mikulski for holding this important hearing. In less 
than 10 years, the first wave of Baby Boomers will turn 65. As 
Americans are living longer, we will continue to see increasing 
demands on our local, State, and Federal health systems over 
the next 30 years.
    As we prepare for the upcoming reauthorization of the Older 
Americans Act, we must take a long hard look at how well 
prepared we are to meet the increasing needs of our country's 
older adult population.
    Today, the Older Americans Act is the major vehicle for the 
delivery of social and nutrition services for older persons. 
Originally enacted in 1965, the act supports a wide range of 
social services for older persons, including the congregate and 
home-delivered nutrition program; community service employment; 
the long-term care ombudsman program; services to prevent the 
abuse, neglect, and exploitation of older persons; grants to 
Native Americans; and research, training, and demonstration 
activities.
    There are a variety of areas which I believe will be 
important to examine as we prepare for the next generation of 
older adults and consider this reauthorization.
    The first issue of considerable importance is caregiving. 
Caregiving issues touch the lives of families from all 
socioeconomic, ethnic, and educational backgrounds. Research 
suggests that more than a quarter of adults are currently 
providing care for a chronically ill, disabled, or aging family 
member or friend, while 59 percent of adults will care for a 
loved one at some point in their lifetime.
    Caregivers today are not simply family members lending a 
hand, but rather, providers of a large portion of our health 
and long-term care for the aging. Older adults are now the 
fastest growing segment of the U.S. population, and almost half 
require some help with personal care and daily needs.
    Grandparents or other relatives caring for children 
referred to as ``kinship caregivers'' comprise another growing 
group of family caregivers. According to the 2000 U.S. Census, 
kinship care families are growing with more than 4.5 million 
children living in grandparent-headed households.
     Some people are caring for children or grandchildren with 
special needs and older adult parents at the same time. Many 
have referred to people in these circumstances as the 
``sandwich'' generation, sandwiched between the caregiving 
demands of children or grandchildren and the caregiving demands 
of aging parents.
    Although the role of family caregiver can be personally 
rewarding, it can also result in substantial psychological, 
physical, and financial hardship. Research suggests that 
caregivers often put their own health and well being at risk 
while assisting loved ones. These difficult demands can lead to 
depression, relationship stressors, physical illness, anxiety, 
and emotional strain.
    As you know, my husband signed the National Family 
Caregiver Support Program into law as part of the 2000 
amendments to Title III of the Older Americans Act. This was a 
tremendous step toward recognizing the heroic efforts of our 
family caregivers.
    Prior to the establishment of this program, there was no 
comprehensive Federal program for family caregivers.
    One way in which to reduce the burden of caregiving on 
those providing this labor of love is through respite care. 
Respite care provides a much needed break from the daily 
demands of caregiving for a few hours or a few days. These 
welcome breaks help protect the physical and mental health of 
the family caregiver, making it possible for the individual in 
need of care to remain in the home.
    Unfortunately, in New York and across our country quality 
respite care remains hard to find and too many caregivers do 
not know how to find information about available services. Even 
when community respite care services exist, there are often 
long waiting lists. There are more caregivers in need of 
respite care than there are respite care resources available.
    Although the National Family Caregiver Support Program took 
a step in the right direction, further efforts are necessary to 
meet the increasing needs of family caregivers.
    That is why I introduced the Lifespan Respite Care Act. 
This legislation would improve efficiency and reduce 
duplication in respite service development and delivery, and 
make quality respite available and accessible to families and 
family caregivers, regardless of their Medicaid status, 
disability, or age. It assures that quality respite care is 
available for all caregivers who provide this labor of love to 
individuals across the lifespan.
    My legislation picks up where the National Family Caregiver 
Support Program leaves off by recognizing respite as a priority 
for caregivers and elevating respite as a policy priority at 
the Federal and State levels.
    A second important issue that I believe we must focus on 
during the upcoming reauthorization of the Older Americans Act 
relates to the growing mental health needs of our older adult 
population. Although most older adults enjoy good mental health 
it is estimated that nearly 20 percent of Americans age 55 or 
older experience a mental disorder. It is anticipated that the 
number of seniors with mental and behavioral health problems 
will almost quadruple, from 4 million in 1970 to 15 million in 
2030.
    Among the most prevalent mental health concerns older 
adults encounter are anxiety, depression, and cognitive 
impairment. These disorders, if left untreated, can have severe 
physical and psychological implications. In fact, older adults 
have the highest rates of suicide in our country and depression 
is the foremost risk factor.
    The physical consequences of mental health disorders can be 
both expensive and debilitating. Depression has a powerful 
negative impact on ability to function, resulting in high rates 
of disability. The World Health Organization projects that by 
the year 2020, depression will remain a leading cause of 
disability, second only to cardiovascular disease. Even mild 
depression lowers immunity and may compromise a person's 
ability to fight infections and cancers. Research indicates 
that 50-70 percent of all primary care medical visits are 
related to psychological factors such as anxiety, depression, 
and stress.
    In order to address this issue I am preparing to 
reintroduce the Positive Aging Act with my co-sponsor Senator 
Collins later this month during Older Adult Mental Health Week.
    This legislation would amend the Older Americans Act to 
make mental health services for older adults an integral part 
of primary care services in community settings and to extend 
them to other settings where seniors reside and receive 
services, such as naturally occurring retirement communities, 
NORCs.
    This legislation will not only increase opportunities to 
diagnose and treat mental health problems in our seniors, but 
will lessen the burden on their families and our health care 
system.
    Finally, the growing longevity of Americans has created a 
long term care crisis in our country. While we consider the 
reauthorization of the Older Americans Act, we must look for 
solutions to this growing problem.
    As the number of individuals in need of long-term care 
rises, issues such as financing, quality of care, family 
involvement, quality of life, end-of-life care, and overall 
service delivery are growing in importance and impact.
    And although Medicaid does provide some home and community-
based services and supports, the program is weighted towards 
institutional care, even when many seniors would be able to--
and most times would prefer to--stay in their own homes.
    Home and community-based services are not only the 
preference of seniors, but they are also a more cost-effective 
means of providing care. As the baby-boomers continue to age, 
our current infrastructure for delivering services needs to 
adjust to reflect this preference and help ease the cost of 
providing care to this burgeoning group.
    I am currently working on legislation that would amend the 
Older Americans Act to assist older adults who are capable of 
and would prefer to remain in the community. This legislation 
would assist seniors, who are just above the Medicaid 
threshold, to obtain the supportive services necessary to 
remain safely in the community.
    This consumer directed model would not only respect the 
preferences of our seniors who would like to age in place, but 
would also help to reduce some of the burden that long term 
care services place on the Medicaid system.
    We have an exciting and important challenge ahead of us as 
our country's aging boom begins. What we do to prepare now will 
have a tremendous impact on our systems of care tomorrow.
    Again, I thank you for holding this important hearing today 
and look forward to continuing to explore these and other 
important issues as we prepare for the reauthorization of the 
Older Americans Act.
    [Whereupon, at 11:16 a.m., the subcommittee was adjourned.]

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