Older Americans Act: More Should Be Done to Measure the Extent of Unmet Need for Services
Published: 2011-02-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Older Americans Act (OAA) was enacted to help older adults remain in their homes and communities. In fiscal year 2008, about 5 percent of the nation's adults 60 and over received key aging services through Title III of the OAA, including meals and home-based care. In fiscal year 2010, states received $1.4 billion to fund Title III programs. Studies project large increases in the number of adults who will be eligible for services in the future and likely government budget constraints. In advance of program reauthorization scheduled for 2011, GAO was asked to determine: (1) what is known about the need for home- and community-based services like those funded by OAA and the potential unmet need for these services; (2) how have agencies used their funds, including Recovery Act funds, to meet program objectives, and (3) how government and local agencies measured need and unmet need. To do this, GAO analyzed national self-reported data; surveyed a random sample of 125 local agencies; reviewed agency documents; and spoke with officials from the Administration on Aging (AoA) and state and local agencies.
section_title: What GAO Found
paragraphs: National data show many older adults likely needed meals or home-based care in 2008, but they did not all receive assistance from Title III programs or other sources, like Medicaid. For instance, while about 9 percent of low-income older adults received meals services, many more were likely to need them due to financial or other difficulties obtaining food. Also, while most older adults who were likely to need home-based care because of difficulties with activities such as walking or bathing received at least some help completing such tasks, many received limited help and some did not receive any. Finally, an estimated 21 percent of people age 65 and older were likely to need transportation services due to their inability to drive or lack of access to a vehicle. Some aspects of need and receipt could not be captured with existing data. For example, GAO could not identify whether the meals and home-based care older adults received was adequate or estimate the number of individuals with transportation needs who did and did not receive such services. Many agencies utilize the flexibility afforded by the OAA to transfer funds among programs and use funds from multiple sources to provide services in their communities. State agencies annually transferred an average of $67 million from congregate meals to home-delivered meals and support services over the past 9 years. Agencies also use funds from other sources, such as Medicaid, state and local governments, and client contributions, to fund Title III services for clients. While client donations are common, formal arrangements with clients to pay a portion of the cost of services are limited. These payments by individuals with higher incomes could help defray the costs of serving others, as the demand for services increases in the future. The recent economic downturn affected agency resources and funding, with about 47 percent of local agencies reporting budget reductions in fiscal year 2010. To cope, many agencies cut administrative and operational costs and some reduced services. The Recovery Act temporarily replaced some lost funding by providing $97 million for meals, but ended in 2010. GAO spoke to 10 state agencies about how they will adjust to lost Recovery Act dollars and found 5 plan to cut services, 2 reserved funds from other sources, 2 are not sure how they will adjust, and 1 will maintain services. The OAA requires AoA to design and implement uniform data collection procedures for states to assess the receipt, need, and unmet need for Title III services. While AoA provides uniform procedures for measuring receipt of services, it does not provide standardized definitions or measurement procedures for need and unmet need that all states are required to use. Within this context, states use a variety of approaches to measure need and measure unmet need to varying extents. No agencies that GAO spoke with fully estimate the number of older adults with need and unmet need. AoA and state agency officials noted that there are various challenges to collecting more information, such as cost and complexity. However, as a result of limited and inconsistent information, AoA is unable assess the full extent of need and unmet need nationally, and within each state.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Department of Health and Human Services study the effectiveness of cost-sharing and definitions and measurement procedures for need and unmet need. The agency said they would explore options for implementing the recommendations.

section_title: Letter
paragraphs: The Older Americans Act of 1965 (OAA) was enacted to provide services  to older adults and help them remain in their homes and communities. In  fiscal year 2008, about 2.9 million people, constituting approximately 5  percent of the nation’s population age 60 and over, received select home-  or community-based services through programs authorized and funded by  Title III of the OAA. Programs funded by Title III grants and other  sources provide a broad range of vital assistance to older adults, including  congregate and home-delivered meals, home-based care, and  transportation services. Such services, as well as services provided by  caregivers, help older adults stay in their homes and communities as long  as possible. In order to help meet the needs of this vulnerable population,  in fiscal year 2009 and 2010 approximately $1.3 billion and $1.4 billion,  respectively, was provided for grants to states for home- and community- based services under Title III of the OAA. In addition to Title III programs,  older adults, especially those with low incomes, may also receive similar  services through other federal and state programs. For example, Medicaid  authorizes multiple programs that provide home- and community-based  services to qualifying older adults.
Demographic studies reveal that in the next few decades, older Americans  will make up an increasing proportion of the country’s population.  Consequently, those eligible for and in need of services like those provided  by Title III programs will increase as well. In fact, U.S. Census projections  estimate the number of Americans age 65 and over will increase from 40  million in 2010 to 72 million in 2030. At the same time, expected fiscal  constraints at the national, state, and local levels may limit the funds  available to provide assistance to the growing population of older adults in  need.
It is within this context and amid continued concerns about the effects of  the recent economic recession on many older adults and the agencies that  serve them that Congress prepares for reauthorization of the OAA, which  is scheduled to occur in 2011. You asked us to evaluate: (1) what is known  about the need for home- and community-based services like those funded  by OAA and the potential unmet need for these services; (2) how have  agencies used their funds, including American Recovery and Reinvestment  Act of 2009 (Recovery Act) funds, to meet program objectives; and (3)  how have government and local agencies measured need and unmet need.
To respond to these questions, we analyzed data from national surveys to  estimate the percentage of older adults with limited incomes who are  likely to need home-delivered or congregate meals but not receive them  and the percentage of older adults likely to need and not receive any  home-based care. Further, we also estimated the percentage of older  adults likely to need transportation services, although data limitations did  not allow us to estimate transportation services received. We utilized self- reported data from older adults responding to the 2008 Current Population  Survey (CPS) to estimate need for meals services and the 2008 Health and  Retirement Study (HRS) for our estimates related to home-based care and  transportation services. Existing national data limited the extent to  which we could identify some groups and demographics of people who  either did receive assistance, or likely needed assistance. For example, our  estimates for meal services were limited to older adults who were low- income. However, while the information available from these surveys has  limitations, these data provide important information about older adults  eligible for and potentially in need of Title III services and we consider  them reliable for our purposes. We also conducted a Web-based survey of  a random sample of 125 local area agencies on aging (local agencies)—the  frontline administrators of Title III services for older adults. We received  completed survey responses from July through September 2010. The  results of this survey are generalizeable to the 629 local agencies in the  United States. In our survey we asked for information on requests for and  use of services, use of funds, and the impact of the economic climate on  requests and availability of Title III services. Ninety-nine local agencies  responded to our survey, achieving a response rate of 79 percent.  Throughout this report, survey results are based on the number of local  agencies responding to a particular question. We also reviewed  Administration on Aging (AoA) program data, 51 state plans on aging  covering a 2-, 3-, or 4-year period that states and the District of Columbia  submit to the Department of Health and Human Services (HHS), select  needs assessments from states, and relevant federal regulations and laws.  We conducted site visits to four states—Illinois, Massachusetts, Rhode  Island, and Wisconsin—where we interviewed officials from state and  local agencies. We selected these four states due to variation in the sizes of  their populations age 60 and over, demographics, Title III expenditures,  and geographic regions. We also conducted telephone interviews with  officials from an additional 10 states using the selection criteria from our  site visits. Lastly, we interviewed national officials involved in Title III  programs. For more information on our scope and methodology, see  appendix I.
We conducted this performance audit from December 2009 to February  2011, in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions.
subsections: section_title: Background
paragraphs: Title III of the OAA is intended to help older adults maintain independence  in their homes and communities by providing appropriate support services  to address the various needs of individuals as they age. While Title III  programs are not entitlements, all people age 60 and over, or  approximately 54 million individuals in 2008, are eligible for services. The  OAA created the foundation for the current aging services network, which  is comprised of 56 state units on aging (state agencies) operated by  various state government agencies; 629 local agencies, which, at the  discretion of state agencies, may include nonprofit and/or government  organizations; 244 tribal and Native American organizations; and 2  organizations serving Native Hawaiians. The state and local agencies are  responsible for the planning, development, and coordination of an array of  home- and community-based services within each state, though states also  provide services to older adults through other funding, such as Medicaid,  and through separate programs and departments. Nearly 20,000 local  organizations provide services through this network.
subsections: section_title: Types of Services and Eligibility
paragraphs: The OAA authorizes a range of services to help older adults remain in their  homes and communities, primarily through Title III Parts B, C, and E (see  table 1).
Part B provides a variety of support services including transportation for  those with and without mobility impairments; home-based services for  older adults who have difficulty performing daily activities such as bathing  or keeping house; case management services; and adult day care. The  goal is to assist older adults in maintaining their independence in the  community for as long as possible.
Part C nutrition services are designed to provide balanced and nutritious  meals at home or in a congregate setting. The OAA identifies three  purposes for the nutrition programs: to (1) reduce hunger and food  insecurity; (2) promote socialization of older individuals; and (3) promote  the health and well-being of older individuals by assisting such individuals  in gaining access to nutrition and other disease prevention and health  promotion services. Home-delivered meals, commonly referred to as  “Meals on Wheels,” are typically provided to individuals who have health  difficulties that limit their ability to obtain or prepare food. Congregate  meals are served at a variety of sites, such as schools and adult day care  centers, and serve older adults’ social interaction needs, in addition to  nutrition.
Part E funds the National Family Caregiver Support Program, which  recognizes the extensive demands placed on family members and friends  who provide primary care for spouses, parents, older relatives, and friends  and provides assistance and support to such caregivers. Among other services, the program offers individual and group counseling, training for  caregivers, and respite care.
Although all adults age 60 and over and in need of assistance are eligible  for services, OAA requires Title III programs to target or make it a priority  to serve older adults with the greatest economic and social need. OAA  defines such older adults as those who have an income at or below the  poverty threshold, have physical and mental disabilities, or are culturally,  socially, or geographically isolated, including isolation caused by language  barriers, or racial or ethnic status. According to U.S. Census data, in  2008, approximately 5 million, or 10 percent of people age 60 and over had  incomes below the poverty threshold ($10,326 for one adult, age 65 and  over) and about 16.4 million, or 31 percent of older adults, had incomes  below 185 percent of the poverty threshold ($19,103 for one adult, age 65  and over). Targeting older adults who are most in need can be  approached in different ways. For example, a local agency may locate a  congregate meal site in a low-income neighborhood or work  collaboratively with other organizations that represent minority older  adults to provide services. OAA gives state and local agencies flexibility in  determining which populations to target and the methods used to do so.  Agencies are required to describe these targeting efforts as part of their  state planning requirements.
Funding Title III Programs  Congress provided approximately $1.4 billion in fiscal year 2010 for OAA  Title III services. Funding for the program generally increased in small  increments over the past 5 years, while the number of people age 60 and  over increased from 48.9 million in 2004 to 55.4 million in 2009. AoA,  within HHS, distributes this funding through grants to the state agencies.  Through these grants, states receive a set amount of funding and are given  the flexibility to design and operate OAA programs within federal  guidelines. Grant amounts are generally based on funding formulas  weighted to reflect a state’s age 60 and over population. For example,  because of their respective numbers of older residents, Florida received  about $89 million in Title III dollars in fiscal year 2010 compared to  Montana, which received $6 million. A non-federal match of 15 percent is  required for Part B and C programs. State agencies typically allocate  these funds to local agencies that directly provide services, or local  agencies contract with local service providers. In a few states, state  agencies allocate funds directly to local providers or provide services  themselves. (See fig. 1.) In our past work we noted that the national  funding formula used to allocate funding to states does not include factors  to target older adults in greatest need, such as the very old and low- income older adults, although states are required to consider such factors  when developing the intrastate formulas they use to allocate funds among  their local agencies.
The federal grant amounts are further divided into separate allocations for  Title III Parts B, C, and E. In fiscal year 2010, the allocations by part were  as follows:    Part B support services such as home-based care and transportation  programs were allocated a total of $366 million.
Part C home-delivered meals programs were allocated $216 million and  Part C congregate meals programs were allocated $438 million.
Part E National Family Caregiver Support Program was allocated $153  million.
The OAA provides states with some authority to transfer federal funding  allocations among programs. A state may transfer up to 40 percent of  allocated funds for the home-delivered meals programs to the congregate  meals program, or visa versa, and the Assistant Secretary of Aging can  grant a waiver for a state to transfer an additional 10 percent. In addition,  a state may transfer up to 30 percent of allotted funds for Part B support  services to the meal programs and vice versa, and the Assistant Secretary  of Aging may grant a waiver of the 30 percent limit. Funds for Title III  Part E caregiver services cannot be transferred.
The Recovery Act appropriated an additional $65 million for congregate  meals and $32 million for home-delivered meals under Title III. Those  funds were available for obligation through September 30, 2010, and  according to AoA, states had until December 30, 2010, to expend them.  Unlike the annual appropriation, however, these funds could not be  transferred among Title III services.
In addition to these federal allocations, a significant amount of funding for  Title III services comes from other federal sources, state budgets, private  donors, and voluntary contributions from the clients themselves.  According to AoA data, total expenditures for Title III programs from all  sources totaled $3.6 billion in fiscal year 2008, including $973 million in  expenditures paid for with OAA funds (see table 2).
section_title: Other Sources of Support for Older Adults
paragraphs: Other federal and state programs provide services similar to Title III,  particularly for low-income older adults. Some of these programs are  administered by the same state agencies as Title III programs, while in  other states, the programs are administered by different state agencies.  Some of these programs’ expenditures are substantially larger than those  of Title III programs. The following are examples of other programs that  provide food assistance, home-based care, and transportation services:    Food Assistance: Older adults who meet certain income restrictions  and other requirements are entitled to receive food assistance through  the federally-funded Supplemental Nutrition Assistance Program  (SNAP)—formerly the Food Stamp Program. SNAP is the nation’s  largest food assistance program, providing benefits to 2.7 million  people age 60 and over in fiscal year 2009. In addition, other food  programs provide assistance to needy older adults. For example,  approximately 950,000 low-income older adults received produce  through the Seniors Farmers’ Market Nutrition Program.
Home-Based Care: State Medicaid programs provide substantial  funding for home-based care such as personal care and homemaker  services to low-income older adults and others who need help with  self-care due to disabilities or health conditions. These services are  provided through Medicaid home- and community-based services  waiver programs and other Medicaid benefits. According to a study  by the Kaiser Commission on Medicaid and the Uninsured, Medicaid  programs spent approximately $38.1 billion in 2006 on home and  community-based services to older adults and other eligible  individuals. Medicare also provides home-based services to some  adults age 65 and over who are receiving Medicare skilled care  services at home. Medicare expenditures on home health care in 2009  totaled $18.3 billion.
Transportation Services: In our past work we found that 15 key  federal programs, including the Title III program, focused on providing  or improving transportation services to older adults. Medicaid, for  example, reimburses qualified recipients for the transportation costs  they incur to reach medical appointments. The Department of  Transportation administers several programs to assist transit  organizations in purchasing equipment and training staff to facilitate  the use of their services by older adults and others with mobility  impairments. In addition, United We Ride, a federal interagency  initiative, works to increase access to transportation, reduce service  duplication, and improve the efficiency of federal transportation  services for older adults and other groups.
Local agencies play a key role in helping older adults locate and enroll in  these various programs and services. In fact, according to a study  conducted by the National Association of Area Agencies on Aging and  Scripps Gerontology Center of Miami University, over the past few years  local agencies have increasingly served as a single point of entry for older  adults, providing access to information on the array of home- and  community-based services for which they may be eligible, regardless of  which federal or state program funds the services. Figure 2 illustrates the  various funding sources and programs that help older adults receive  meals, home-based care, and transportation services.
section_title: Planning Process and Data Collection Efforts
paragraphs: For states to be eligible for Title III grants, OAA requires state agencies to  submit plans to the AoA for 2, 3, or 4 years. Among other types of  information, the plans must evaluate older adults’ needs for home- and  community-based services. In addition, OAA also requires that state  agencies develop a standardized process to determine the extent to which  public or private programs and resources (including volunteers and  programs and services of voluntary organizations) are capable of meeting  needs. Thus, the plans provide an opportunity to consolidate information  about services available to older adults from a variety of sources.
section_title: Estimates Show That Many Older Adults Likely Needed but Did Not Receive Meals and Home-Based Care
subsections: section_title: Many Older Adults with Low Incomes Who Were Likely to Need Meals Programs Did Not Receive Them
paragraphs: The meals services provided in 2008 did not serve most of the low-income  older adults likely to need them. Through our analysis of information  from the CPS, we found that approximately 9 percent of an estimated 17.6  million low-income older adults received meals services like those  provided by Title III programs. However, many more older adults likely  needed services, but did not receive them, as shown in table 3. For  instance, an estimated 19 percent of low-income older adults were food  insecure and about 90 percent of these individuals did not receive any  meal services. Similarly approximately 17 percent of those with low  incomes had two or more types of difficulties with daily activities that  could make it difficult to obtain or prepare food. An estimated 83 percent  of those individuals with such difficulties did not receive meal services.  (See table 3.)
Along the same lines, agency officials we spoke with identified several  reasons why an older adult may be likely to need meals services but not  receive them. Specifically, officials from several state agencies stressed  that need for home-delivered meals is greater than the level of services  they are able to fund. Through our survey of local agencies, we found that  an estimated 22 percent of agencies were generally or very unable to serve  all clients who request home-delivered meals. Some state and local  agencies we spoke with also noted that many older adults who would  benefit from meals services do not know that they exist or that they are  eligible to receive them and, therefore, do not contact the agencies to  request them.
We also found evidence suggesting that demand for home-delivered meals  is often higher than for congregate meals. Officials from a few state and  local agencies we spoke with acknowledged that some older adults do not  find the format of congregate meal programs appealing due to factors such  as the meals served or the time of day that they are provided. Therefore,  older adults may not access the services, though their circumstances  suggest that they may need them. An estimated 79 percent of local  agencies who tracked requests had greater numbers of older adults  request home-delivered meals than congregate meals in fiscal year 2009,  according to our survey of local agencies. Also, the Congressional  Research Service found that although congregate meal programs served  more clients than home-delivered meal programs in fiscal year 2008, from  1990 to 2008, the number of home-delivered meals served grew by almost  44 percent, while the number of congregate meals served declined by 34  percent.
section_title: Many People Age 60 and Older Who Had Difficulties with Daily Activities Received Limited or No Home-Based Care
paragraphs: While most older adults who had difficulties with daily activities such as  walking or bathing received at least some help completing such tasks,  many received limited help and some did not receive any help. Through  our analysis of 2008 HRS data, we found that an estimated 29 percent of  older adults from all income levels reported difficulties with one or more  activities such as walking or bathing. As shown in table 4, many of these  older adults either received no help, or received help with some, but not  all of their difficulties—either formally from sources such as Title III  programs and Medicaid or informally through family members. For  example, among older adults who reported three or more difficulties with  ADLs such as bathing and walking, approximately 21 percent received  help with all of the ADLs they identified, while 68 percent received help  with some of them, and 11 percent did not receive any help. In an  estimated 19 percent of the cases where these older adults received any  help, at least some of that help came from professionals or organizations  rather than family members. These older adults who had difficulties with  multiple types of ADLs are generally considered to have more severe  conditions than those who have difficulties with IADLs, such as shopping  or housework. We found that greater percentages of older adults with  multiple ADLs received help with some or all of their difficulties than  those with IADLs, but not ADLs (see table 4). However, the available data  did not allow us to assess whether the help an individual received for a  particular difficulty was sufficient to meet his or her needs. Several agency  officials and researchers we spoke with noted that even some of those  receiving help with their difficulties likely need more frequent or more  extensive help.
Officials and researchers we spoke with identified a number of difficulties  in meeting older adults’ needs for home-based care. Officials in most states  we contacted noted that funding from Title III and other sources like  Medicaid waiver programs is not enough to meet the need. Also, because  different states structure their Medicaid programs differently and some  also run separate state home-based care programs, the extent to which  older adults who need services are receiving them likely varies from state  to state. As shown in table 4, we found that most older adults receiving  assistance with some or all of their difficulties received all of this help  from informal sources, rather than from an organization or professional  caregiver. While this can reduce public expenditures, researchers from  one organization we spoke with expressed concern that providing  extensive informal care may strain family members who act as caregivers.  Some of the family members providing care may be receiving help through  Title III caregiver programs such as respite care. In fiscal year 2008, Title  III programs provided caregiver services to about 224,000 individuals,  according to AoA data. However, officials from a few states told us that  the likely need for such services was greater than available resources.
section_title: Likely Need for Transportation Services Is Significant
paragraphs: Many older adults were likely to need transportation services like those  provided by Title III programs due to circumstances such as being unable  to drive or not having access to a vehicle. According to our analysis of  2008 HRS data, an estimated 21 percent of people 65 and older (about 8  million) were likely to need such services. Our analysis also found that  some social and demographic characteristics were associated with an  increased likelihood of needing such services. In particular, after  controlling for other factors that may influence likely need for services, we  found that people who were age 80 or older, female, or living below the  poverty threshold were more likely to need services than people without  these characteristics. We also found that the odds that someone with  visual or mobility difficulties was likely to need services were about two  times as high as someone without such difficulties. Additional factors  also increased an individual’s likelihood of needing services as shown in  appendix V.
While there appears to be a significant need for transportation services,  data were not available to estimate the extent to which older adults’ likely  needs were met. Instead, available information provides only clues about  the extent to which older adults in likely need may be receiving services.  For example, AoA collects information about the number of people  receiving assisted transportation services through their programs and the  total number of rides provided. The agency also collects information about  the number of rides provided by its general transportation services, but  does not collect information on the number of older adults receiving those  services.
State and local agency officials provided anecdotal evidence suggesting  the existence of substantial unmet need for transportation services. For  example, officials in Tennessee said that some local agencies must limit  their transportation to essential medical treatments like dialysis because  they cannot afford to also transport older adults to activities that would  improve their quality of life, such as trips to senior centers and congregate  meals sites. Agency officials from several states noted that rural areas face  particular challenges, due to the long distances between destinations and  minimal public transit options. Through our survey of local agencies, we  found that an estimated 62 percent reported transportation services as  among the most requested support services. The survey also showed that  an estimated 26 percent of agencies that provide transportation services  were generally or very unable to meet all transportation requests. Our past  work also found that older adults’ transportation needs less likely to be  met included: (1) transportation to multiple destinations or for purposes  that involve carrying packages, such as shopping; (2) life-enhancing trips,  such as visits to spouses in nursing homes or cultural events; and (3) trips  in non-urban areas.
section_title: Agencies Transfer Funds among Programs and Use Funds from Multiple Sources to Provide Services
subsections: section_title: Agencies Transfer Funds among Title III Programs to Meet Needs, but Some Want Additional Flexibility
paragraphs: Most state and some local agencies utilize the flexibility provided by the  OAA to transfer funds among Title III programs. According to AoA data, 45  state agencies transferred funds among congregate meal programs, home- delivered meal programs, and support services in fiscal year 2008, and,  according to our survey results, an estimated 45 percent of local agencies  did so in fiscal year 2009. Agencies most commonly transferred funds  from congregate meals to home-delivered meals or support services. In  fact, nationally, from fiscal year 2000 through fiscal year 2008, states  collectively transferred an average of $67 million out of the congregate  meal program each year (see fig. 3). In fiscal year 2008, states transferred  nearly 20 percent of OAA funding out of congregate meals. As a result,  support services and home-delivered meal programs experienced an 11  percent and 20 percent net increase in Title III funds, respectively.
State and local officials told us they moved funds out of congregate meals  because of a greater need for home-delivered meals and support services.  According to AoA data, in fiscal year 2008, 34 states transferred funds from  congregate meals to home-delivered meals and 32 states transferred funds  from congregate meals to support services. Georgia state officials told us  they transferred funds because there is a greater need for home-delivered  meals, with a waitlist of about 12,000 people, compared to the congregate  meal waitlist of about 400. Nevada state officials said transferring funds  from congregate meals to support services is necessary because support  services are under-funded for meeting needs in their state.
Some state officials recommended consolidating funding for Title III Part  C meal programs into one single stream. For example, Wisconsin state  officials said maintaining separate funding for congregate and home- delivered meals creates a process in which the state has to deal with  multiple rules to allocate funds to services that are most needed. Georgia  state officials said the federal distribution of Title III C funds does not  reflect local variation in needs and a less restrictive funding allocation  would allow local officials to put funds where they are most needed.  However, some state officials, from New Jersey and Oregon for example,  did not see the need to change the current process of transferring Title III  funds. According to AoA data, five states and the District of Columbia did  not transfer any funds in fiscal year 2008 and only one state transferred the  maximum allowable amount.
section_title: Title III Funding Is Supplemented by Other Funding Sources
paragraphs: In addition to OAA funding allocations, agencies provide Title III services  using funds from other federal programs, state and local governments,  private sources, and clients. Agencies told us that to meet client needs,  they rely on other funding sources in addition to OAA funding. Our survey  found that, on average, OAA funds comprised an estimated 42 percent of  local agency’s Title III program budgets in fiscal year 2009. Some local  agencies rely more heavily on OAA funds than others. OAA funds ranged  from 6 to 100 percent of local agency budgets. State funds were the second  largest source, contributing an average of 24 percent of program funds.  While the funds contributed by local governments are a smaller part of  program budgets on average, according to AoA officials, a role of local  governments is to secure additional resources for Title III programs, such  as volunteers or private grants. See figure 4 for the average proportion of  Title III program funding provided by various sources.
The OAA gives state and local agencies some flexibility to allocate  program funds to services most needed and select which source of funds  to use to provide services. This flexibility includes the ability to transfer  funds, as well as the ability to decide which services to fund with Title III  resources, based on local priorities and needs. According to AoA officials,  the ability to decide which services to fund is most often the case with  Title III Part B support services, such as personal care and transportation  services, because Congress’ funding allocation is less restrictive than the  allocations for other parts of Title III. As an example, AoA officials told us  some states may choose to provide personal care services under their  Medicaid program, rather than use OAA Title III Part B funds and use the  OAA funds for other services. Additionally, some state officials we spoke  with told us OAA funds are used to fill gaps in state or Medicaid-funded  home- and community-based services programs.
In addition to receiving funds from governments and private sources,  clients can also contribute to the cost of services. In fact, according to our  survey, almost all local agencies permit voluntary contributions for Title  III services. On average, voluntary contributions comprised 4 percent of  local agency budgets in fiscal year 2009; yet, some agencies told us that  voluntary contributions are a significant portion of their meal program  budget. For example, Wisconsin state officials estimated that voluntary  contributions are between one-quarter to one-third of congregate meal  funding.
While the OAA allows for cost sharing for some OAA services wherein  clients are asked to pay a portion of the cost of services based on their  income, 5 of the 14 states we spoke with actually permit cost sharing.  States are required to have a formal cost share plan before  implementation, and the National Association of States United for Aging  and Disabilities (NASUAD)—formerly known as the National Association  of State Units on Aging—found in a 2009 survey that less than a quarter of  states had such a plan, which suggests that cost sharing is not being widely  used. NASUAD also found that cost sharing was most often used for  respite care and homemaker services. Our survey found that about three- fourths of local agencies whose states permitted them to cost share did  so. Even so, more local agencies would prefer to have the ability to cost  share. In fact, an estimated 39 percent of local agencies in states who do  not allow cost sharing said they would do so if given the opportunity.  Since Title III services are open to all older adults, additional cost-sharing  arrangements could generate income for programs by obtaining payments  from those with higher incomes. AoA officials noted that if individuals  with higher incomes see Title III programs as an attractive service option,  they could pay market value for the services through cost-sharing  arrangements, thereby subsidizing services to lower-income adults.
State officials cited administrative burden as a reason they do not permit  cost sharing or do not use it more extensively. On the other hand, several  states that have implemented cost sharing find it helpful. For example,  Illinois state officials told us they have not implemented cost sharing  because of the number of services that are exempt and likelihood that  implementation costs will exceed the revenue collected. Although Nevada  has a statewide cost-share policy, state officials told us few local agencies  have elected to use it because many of the older adults served are low- income and the agency cannot condition receipt of services upon paying  the cost-share amount. Although Georgia officials recognized cost sharing  was complicated to implement, they cost share for all allowable OAA  services and said it generates revenue and adds value to the services for  clients. While cost sharing has the potential to generate additional funds  for Title III services, for agencies this potential must be weighed against  the OAA’s cost-share restrictions and administrative requirements.
section_title: Agencies Cut Costs and Utilized Recovery Act Funds to Cope with Recent Reductions in Funding
paragraphs: While agencies rely on multiple sources of funds to provide services, many  agencies reported overall decreases in funds from fiscal year 2009 to fiscal  year 2010. In fact, according to our survey, an estimated 47 percent of local  agencies experienced reductions to their budgets in fiscal year 2010. These  budget cuts ranged from 1 to 30 percent of local agency budgets, and the  average budget cut was 8 percent, according to 29 local agencies that  provided more detailed information. Approximately 68 percent of local  agencies reported that state funds, the second largest source of funds for  Title III programs, were cut in fiscal year 2010. This is consistent with  research by NASUAD that found that most states reported state budget  shortfalls in fiscal year 2010 and reduced budgets for aging services.
While funding has recently decreased for many agencies, requests for  services have increased since the beginning of the economic downturn.  Since the downturn began in late 2007, based on our survey, an estimated  79 percent, 73 percent, and 67 percent of local agencies have received  increased requests for home-delivered meals, support services, and  caregiver services, respectively. A survey conducted by NASUAD in 2009  also found requests for the types of services provided by the OAA recently  increased, particularly for home-delivered meals, transportation, and  personal care. Local agencies responded to increased requests in various  ways. For instance, some local agencies told us they created waitlists,  secured additional funds, collaborated with other agencies, and utilized  Recovery Act funds.
Some local agencies reduced services as a result of funding cuts.  According to our survey, in fiscal year 2010, as compared to fiscal year  2009, an estimated 20 percent of local agencies said they reduced support  services. An estimated 18 percent said they reduced nutrition services, and  14 percent reduced caregiver services. In fact, a local agency in California  told us that they traditionally operated a state program that provided  services similar to OAA; however, the state-funded services ended on  January 1, 2010, due to the complete elimination of state funding. Our  survey also found that local agencies anticipated additional service  reductions in fiscal year 2011. About 21 percent anticipated additional cuts  to the meal programs, 16 percent anticipated cuts to support services, and  12 percent anticipated cuts to caregiver services. Some state and local  agencies we visited also told us they adapted to limited funding by  providing less service to all rather than full service to only some. For  example, a state official in Illinois said some local areas resolved the  funding shortfalls by reducing the number of hours they provide respite  services for each caregiver.
Alternatively, in response to these funding cuts, many local agencies said  they took steps to reduce administrative and operations costs. In fiscal  year 2010, an estimated 37 percent of local agencies cut capital expenses,  38 percent cut administrative expenses, and 45 percent cut operating  expenditures. Local agencies said they cut expenses in a variety of ways.  For example, local agencies relocated to a smaller office building with  lower overhead costs, stretched meal service supplies, decreased travel  expenses, and limited raises for employees. Additionally, an estimated 45  percent of local agencies did not fill vacant positions. In addition to  administrative and operations cuts during fiscal year 2010, an estimated 27  percent of local agencies anticipated additional reductions in fiscal year  2011. Consistent with our survey data, agency officials told us about  administrative and operations reductions. State officials in Wisconsin, for  example, told us that, as a result of the state’s budget deficit, the agency  was unable to fill vacant positions and cut planning, administration, and  monitoring activities in order to avoid cutting services to older adults.  Illinois state officials told us the last budget cycle included a 10 percent  decrease in state funds for aging services, and there were lay-offs, required  furlough days and positions left vacant as a result.
Many agencies used Recovery Act funds—comprising about 13 percent of  the total OAA amount for meals in fiscal year 2009—to temporarily fill  budget gaps and expand existing nutrition programs. In addition, some  agencies created new meal programs such as breakfast at congregate meal  sites. However, many state and local agencies expressed concern about  how to continue the same level of services after the Recovery Act funding  ends. According to our survey, an estimated 79 percent of local agencies  said sustaining services currently paid for with Recovery Act funds would  be a moderate to extreme challenge. Of the 10 state agencies we spoke  with in early fall 2010, 5 told us that they will have to cut back services, 2  told us that they reserved funds from other sources to compensate for  some of the lost Recovery Act funds, 2 states had not decided how to  make up for the lost Recovery Act funds, and 1 state will maintain  services.
section_title: Lack of Federal Guidance and Data Make It Difficult for States to Fully Estimate Need and Unmet Need
subsections: section_title: States Lack Specific Guidance on How to Evaluate Need and Unmet Need
paragraphs: The OAA requires AoA to design and implement uniform data collection  procedures that include procedures for states to assess the receipt, need,  and unmet need for Title III services. Additionally, state agencies’ plans  on aging must stipulate that states will in fact use AoA’s uniform  procedures to evaluate the need for services under Title III. Previous  GAO work has found that using standardized definitions and measurement  procedures helps state and federal agencies gather useful information to  plan and evaluate programs.
AoA issues standardized definitions and measurement procedures to state  agencies for collecting information on the receipt of Title III services. For  Title III services provided more than once and over a period of time—such  as home-delivered meals and home-based care—state agencies must  collect data on the number of older adults who receive services. State  agencies also collect data on the demographic characteristics of  recipients, such as their race, age, gender, and disabilities. AoA also  requires state agencies to report the number of service units provided for  services that clients receive more sporadically, such as general  transportation. Because AoA issues standardized definitions and  measurement procedures to state agencies, data on the receipt of services  are relatively consistent within and across states. As a result, this data can  be used to make comparisons of the type and quantity of Title III services  delivered and to support AoA’s budget requests and performance  evaluations.
In contrast, AoA does not provide standardized definitions and procedures  for states to use when measuring need or unmet need for services.  Researchers have generally defined need for a particular service as having  characteristics, health conditions, or circumstances that make individuals  likely to need the service and defined unmet need as fitting the definition  of need, but not receiving the service. However, the specifics of defining  need and unmet need can be challenging and can lead to variation without  a standardized definition. For example, one can define unmet need for a  service as no assistance at all, or one could define it as an inadequate level  of assistance in one or more service areas. Rather than requiring that  states measure need in a standardized manner or requiring states to  measure unmet need, AoA provides states with non-binding guidance on  these issues. AoA, through a grant to NASUAD, provides state agencies  with an assortment of tools and resources that they can use to evaluate  need and limited information about measuring unmet need. Tools for  measuring need include needs assessment surveys and links to Census  information. This guidance is optional and does not identify specific  measurement procedures that all state agencies should use or information  they should collect.
section_title: State Agencies Assess Need and Some Assess Unmet Need, but None Fully Estimate the Number of Older Adults Likely in Need of Services
paragraphs: Without standardized definitions and measurement procedures, states use  a variety of approaches to measure need and measure unmet need to  varying extents. Some state agencies maintain and review waiting lists;  host discussions with, and obtain data from, local service providers; and  conduct surveys of current recipients, among other approaches. State  agencies use the information they collect for a variety of planning  purposes such as identifying greatly needed services and focusing  resources in these areas. For example, one state agency we spoke with  found that transportation services were of particular need. As a result,  they directed local agencies to prioritize transportation programs.
Nonetheless, these various approaches have a number of limitations and,  as a result, no state agencies that we asked fully estimate the number of  older adults with need or unmet need. First, officials from some state  agencies and AoA told us that waiting lists are not effective tools for fully  estimating need and unmet need. For example, waiting lists are only a  lower-bound estimate of those who are likely to need services but not  receive them. A local agency official we spoke with in Illinois said that  needs assessments and anecdotal information indicate a much greater  need for services than requests to the agency indicate. Also, some of these  approaches, such as surveys of current clients, only collect information on  those who already receive services. None of these approaches either  collect or quantify information on older adults who need services but do  not request them.
In addition to the above approaches, some state agencies we spoke with  utilize other means to obtain information on the potential need and unmet  need of older adults who do not currently request or receive services,  although they still do not fully estimate need and unmet need for Title III  services. For example, some state agencies use Census data to identify the  number of older individuals with characteristics that indicate potential  need for services, including those who do not currently receive services.  Florida’s state agency uses the Elders Needs Index available through the  NASUAD Web site to identify and direct funds to geographic areas with  high concentrations of older adults who have demographic characteristics  often associated with need for Title III services such as age, race, or  disability. However, this index does not show other factors indicating  likely need. For example, it does not include information about whether an  older adult in a particular area is food insecure or whether or not he or she  received meal services from any source. Some state and local agencies  also conduct surveys of older individuals, including those who do not  currently receive Title III services. For instance, one state agency we  spoke with described a survey conducted by university researchers as a  part of the state’s planning process for Title III programs and other  services for older adults. Among other components, the survey included  information about older adults’ awareness of various services and whether  they received services. State agency officials said that this survey could be  used to generate an estimate of older adults with need and unmet need for  services, although they do not currently generate such estimates.
Overall, AoA and state agency officials noted that there are various  challenges to fully estimating need and unmet need. For example, state  officials in one state told us that representative surveys of older adults are  too costly and officials in another state said that they lack capacity or  expertise at the state level to conduct comprehensive evaluations of need  and unmet need. In addition, comprehensive evaluations of unmet need  would require states to account for whether or not older adults in need  were receiving services from other sources such as Medicaid home-based  care programs. This would require states to collaborate and partner with  other state agencies to account for needs met by other programs. This  could be difficult to do because states differ in how they choose to use and  administer their Title III funds and other federal, local, and state funding  sources to support older adults. Some state agencies that administer Title  III programs would have limited information on older adults who receive  services from other programs, administered by other agencies.
As a result of limited and inconsistent state knowledge about need and  unmet need, AoA is unable to measure the extent of need and unmet need  for the different home- and community-based services nationally or  consistently across states—information that could help them to best  allocate their limited resources. When asked to provide such information  to Congress in 2008, AoA was unable to do so, but did suggest that it was  possible to gather information on need from local agencies and partners in  the aging network. While AoA officials told us they have the authority to  require that state agencies collect more complete information on need and  unmet need, they have not done so to date because they are unaware of a  specific set of criteria to use that would address various data challenges.  They also expressed concern about creating a reporting burden for states  and about the utility of obtaining data on unmet need within the context of  a formula-based program where set funding levels would not necessarily  allow them to address all unmet needs.
section_title: Conclusions
paragraphs: OAA Title III programs, in tandem with other government services such as  Medicaid, are an invaluable support mechanism for many older adults,  helping them stay in their homes and communities and maintain dignity  and independence. The broad eligibility criteria for the program opens  services to any older adult who seeks them, and, although programs are  expected to, and do, target certain groups, our estimates show that in  2008, many additional older adults who would have likely benefited from  services like those provided by OAA Title III programs did not receive  them. Although, as AoA officials acknowledged, the law requires AoA to  design and implement uniform procedures for assessing need and unmet  need, AoA has not required states to use them. And as they currently  operate, many programs have no way of knowing whether they are serving  those who have the greatest need because they do not have information  about those in need who do not receive or request services.
As the number of older adults grows, demand for services will also grow.  This, combined with resource constraints, prompt concerns about how the  needs of this growing population can be met. As a result, states and local  providers will likely face increasingly difficult decisions about how to  serve older adults; yet, they will lack valuable information needed to help  them identify those most in need.
Although there are cost and methodological challenges to assessing need  and unmet need, they are not insurmountable. Various approaches to  estimating need and unmet need could be used and the effort would not  necessarily require detailed analysis of a nationally representative survey.  Also, AoA could provide guidance and technical assistance to state  agencies in order to meet reporting requirements around quantifying need  and unmet need. In addition, AoA could partner with other programs  providing similar and complementary services in order to consolidate  knowledge on how to better serve the needs of the community and  minimize additional data collection and reporting burdens. Partnering  would also assist the states to better map out approaches that will help  ensure that they are making the best use of their various funding sources  during times of increasing demand. This information could help the home-  and community-based services network make informed funding and  programmatic decisions that optimize their resources and provide vital  services to older adults in greatest need.
section_title: Recommendations
paragraphs: To maximize program resources during a time of increasing demand and  fiscal constraints, we recommend that the Secretary of Health and Human  Services study the real and perceived burdens to implementing cost  sharing for OAA services and identify ways to help interested agencies  implement cost sharing, which could include recommending legislative  changes to the restrictions in the OAA, if warranted.
To help ensure that agencies have adequate and consistent information  about older adults’ needs and the extent to which they are met, we  recommend that the Secretary of Health and Human Services partner with  other government agencies that provide services to Older Americans and,  as appropriate, convene a panel or work group of researchers, agency  officials, and others to develop consistent definitions of need and unmet  need and to propose interim and long-term uniform data collection  procedures for obtaining information on older adults with unmet needs for  services provided from sources like Title III.
section_title: Agency Comments
paragraphs: We provided HHS with the opportunity to comment on a draft of this  report. The written comments appear in appendix VII. HHS indicated that  it would review our recommendations and explore the options available to  implement them. However, it raised several concerns in response to our  recommendation that it partner with other government agencies to  develop agreed-upon definitions and data collection procedures to assess  need and unmet need.
HHS noted that states and local agencies currently target services to those  older adults and family caregivers in greatest social and economic need.  The department described the existing guidance and technical assistance  it provides states and local agencies to help them understand need and  unmet need in their communities and target services. While these efforts  may be useful to states, we believe that more can be done to provide the  uniform definitions and data collection procedures required by the OAA.  Further, HHS acknowledged that states are already making difficult  choices about how to serve seniors in need because the demand for  services exceeds supply. It is, in fact, for these reasons that we have  recommended a more systematic approach to identifying need. Due to the  projected increase in the older population, and in the face of current fiscal  constraints, it is more important than ever to have good information about  need and unmet need in order to adequately plan and direct resources to  those in greatest need.
HHS also commented on factors that complicate development of a  standardized definition and methodology for measuring unmet need.  These factors include differences among states in how the programs are  administered and the multiple funding streams that are often used to  provide services for older adults in need. Our recommendation recognizes  this circumstance by calling for HHS to partner with other agencies that  fund similar services to work together to agree on definitions and  procedures. We believe that AoA, as the responsible federal entity for Title  III- funded services, is well-positioned to lead this effort. In this era of  scarce resources, and in those cases where multiple funding streams and  programs are offering services to similar populations, it is vital to ensure  that all funding sources are used to their best advantage and programs are  not duplicating efforts.
Finally, HHS expressed concern that such standardization could increase  the reporting burden for states. It also commented that GAO was “…not  able, using existing resources, to develop workable measures for  determining the extent of unmet need….” However, it is important to note  that it was not the purpose of this report to develop measures for states  and local agencies to use, which AoA is required to do. Rather, our  objective was to assess likely unmet need on a national scale using  sophisticated analyses of national databases to shed light on whether  further focus on unmet need was warranted. We continue to believe that  convening a panel would allow stakeholders to explore options for  collecting meaningful data on need and unmet need in a manner that  would not require the extent of analyses we conducted or impose an  onerous burden on state or local agencies. Such an effort developed in  collaboration with other aging services programs could also facilitate  information-sharing across programs.
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies of this report to the  Department of Health and Human Services, relevant congressional  committees, and other interested parties. Copies will also be made  available to others upon request. The report will also be available at no  charge on GAO’s Web site at http://www.gao.gov.
Please contact me on (202) 512-7215 if you or your staff has any questions  about this report. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of the report.  Key contributors to this report are listed in appendix VIII.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: Our objectives were to identify: (1) what is known about the need for  home- and community-based services like those funded by the Older  Americans Act (OAA) and the potential unmet need for these services; (2)  how have agencies used their funds, including Recovery Act funds, to meet  program objectives; and (3) how have government and local agencies  measured need and unmet need. To identify what is known about the  receipt and potential unmet need for home- and community-based  services, we analyzed data from national surveys about older adults in  likely need of meals services or home-based care and whether those in  likely need received services. We also estimated the percentages of older  adults likely to need transportation services, although data limitations did  not allow us to estimate transportation services received. To identify how  agencies have used funds, including Recovery Act funds, we conducted a  Web-based national survey of a random sample of 125 local area agencies  on aging (local agencies)—the frontline administrators of Title III services  for older adults and reviewed Administration on Aging (AoA)  documentation about state expenditures. To identify how government and  local agencies measure need and unmet need, we reviewed 51 state plans  on aging, select needs assessments from states, and reviewed relevant  laws. To address all three objectives, we conducted site visits to four  states—Illinois, Massachusetts, Rhode Island, and Wisconsin—where we  interviewed officials from state and local agencies and conducted  telephone interviews with officials from an additional 10 states. Lastly, we  also interviewed national officials involved in Title III programs and  reviewed relevant federal laws and regulations. These research methods  are described in more detail below. We assessed the reliability of the data  we used by reviewing pertinent system and process documentation,  interviewing knowledgeable officials, and conducting electronic testing on  data fields necessary for our analysis. We found the data we reviewed  reliable for the purposes of our analysis.
subsections: section_title: Estimating Likely Need and Receipt of Meals Services
paragraphs: The OAA Title III meals programs are designed to aid older adults and  certain individuals living with older adults by: (1) reducing hunger and  food insecurity; (2) promoting socialization; and (3) promoting health and  well-being. The home-delivered meals program in particular is also  designed to assist individuals who have difficulty obtaining or preparing  food due to difficulties with daily activities (i.e., with functional  impairments). While the eligibility criteria for Title III programs are very  broad, we focused our analysis on identifying eligible older adults who  were particularly likely to need the services based on exhibiting (1) food  insecurity; (2) difficulties with daily activities (i.e., with functional  impairments); (3) limited social interaction, or a combination of these  characteristics. Data limitations did not allow us to identify individuals  likely to need and/or receive services based on the third identified purpose  of promoting health and well-being. To conduct our analysis, we used  nationally representative data from the 2008 Current Population Survey  (CPS), including the Food Security Supplement and the Civic Engagement  Supplement. As described below, the CPS includes various questions  related to receipt of meals services like those provided by Title III and  having characteristics that indicate likely need.
Our analyses focused on people age 60 and over as well as spouses of  older adults and individuals with disabilities living with older adults  because they are also eligible for meals services. Our analysis was limited  to older adults living in households with incomes that were below 185  percent of the poverty threshold and is not generalizable to older adults  with higher incomes. As described below, our analysis included this  income restriction because the questions related to participation in the  two meals programs of interest were not asked of all respondents to the  survey. The only group that was completely sampled and asked those  questions were the respondents who were in households with incomes  that were below 185 percent of the poverty threshold. While the exclusion  of individuals living in households with higher incomes from our study is  unfortunate, the sample we are using does represent the large majority of  people who were food insecure and likely to need one of the two meal  programs based on one of the key purposes of OAA nutrition programs.  Other indicators of likely need such as difficulties with daily activities and  limited social interaction were also more prevalent among the low-income  population than among those with household incomes above 185 percent  of the poverty threshold.
To determine whether older adults were food insecure and whether or not  they received home-delivered or congregate meals, we used the Food  Security Supplement. The Food Security Supplement is sponsored by the  United States Department of Agriculture (USDA), and USDA’s Economic  Research Service compiles the responses. The 2008 food security survey  interviewed members of roughly 44,000 households that comprised a  representative sample of the U.S. civilian population of 118 million  households. The survey queried one adult respondent in each household  about experiences and behaviors indicative of food insecurity (see table  5). If they were living in households below 185 percent of the poverty  threshold, or if they had previously indicated some degree of food  insecurity, survey respondents were also asked whether they, or anyone in  their household, had received a home-delivered meal in the past 30 days,  or whether they had received a meal in a congregate setting within the  past 30 days.
To determine whether older adults had limited social interaction, we used  a series of questions from the CPS Civic Engagement Supplement from  November 2008 that asked respondents whether they participated in  various community groups (see table 6). Determining likely need for  social interaction was particularly difficult. Lack of participation in  community groups provides a partial indicator that an older adult may be  likely to need meals programs for social reasons. However, such survey  data do not capture more qualitative aspects of an individual older adults’  likely need for social interaction such as personality and individual  preference. The data also do not allow us to identify individuals who may  interact socially outside of organized groups and activities.
To determine whether older adults had functional impairments that may  have made it difficult to obtain or prepare meals, we used three questions  from the CPS designed to identify difficulties with instrumental activities  of daily living (IADL), activities of daily living (ADL) and one question  used to identify cognitive impairments (see table 7). We included the  question regarding cognitive impairments because older adults may have  difficulties obtaining or preparing food due to cognitive or memory  difficulties, which may not be captured through questions about IADLs  and ADLs.
We used the questions relevant to food insecurity, limited social isolation,  and functional impairments to estimate older adults and other eligible  individuals who were likely to need and/or receive meals services. First,  we estimated the percentages of eligible individuals in low-income  households that were (1) food insecure, (2) had one or more types of  difficulties with daily activities, and/or (3) had limited social interaction.  We then identified the number of individuals with or without one or more  of these types of likely need who were and were not receiving home- delivered or congregate meals. Because the CPS questions asked whether  older adults received meals services in general, rather than Title III meals  programs in particular, our analysis is indicative of all congregate and  home-delivered meals services, rather than just those provided by Title III  meals programs. We also looked at how the likely need characteristics and  the receipt of meals varied across demographic groups generally. We used  individual weights to derive estimates of the numbers and percentages of  individuals in the entire population of low-income older adult households  of interest to us. Unless otherwise noted, our estimates based on the CPS  data have a 95 percent margin of error of 4 percentage points or less of the  estimate. Existing CPS data did not allow us to estimate the number of  older adults likely to need and receive meals services at the state level.  Specifically, making state-level reliable estimates would require using data  from multiple years of survey data and key survey questions about older  adults’ difficulties with daily activities and their participation in meals  programs were added to the survey too recently to allow analysis using  multiple years of data.
In addition, we used logistic regression models to estimate the net effects  of the likely need characteristics and demographic variables on the  likelihood of receiving either type of meal services. Logistic regression  analysis is a method to examine factors associated with a variable of  interest such as receipt of meal services, controlling for the potential  effect of other factors on that variable, such as likely need or demographic  characteristics. One of our primary reasons for using the multivariate  models is to determine whether demographic differences in the likelihood  of receiving meals were accounted for by differences in food insecurity,  isolation, or difficulties with daily activities. The logistic regression models  we used could not control for all variables potentially related to food  insecurity and the likelihood of receiving the different types of meals. For  example, we could not control for differences between states’ funding and  programmatic decisions for meal programs or older adults’ preferences for  receiving meals. To the extent omitted but relevant variables are  correlated with those factors that were incorporated into our models, the  estimates we present are subject to potential bias.
section_title: Estimating Likely Need and Receipt of Home-Based Care and Transportation Services
paragraphs: To examine factors associated with likely need for and receipt of home- based care services, and likely need for transportation services, we used  data from the 2008 wave of the University of Michigan’s Health and  Retirement Study (HRS). The HRS is a nationally representative  longitudinal survey of older adults sponsored by the National Institute on  Aging and the Social Security Administration. The survey is administered  in waves (generally every 2 years) and includes information on respondent  demographics, health status, service receipt, and household  characteristics, among other things. An additional HRS dataset, produced  by the Rand Corporation, includes recoded variables and more detailed  information on household finances. To generate a dataset for analysis, we  combined data from the University of Michigan with Rand HRS files. As  appropriate, we limited our analysis to those respondents age 60 or above  (for home-based care services) or age 65 and above (for transportation).  We weighted the data to obtain national-level estimates and used robust  estimation to account for the impact of the complex survey design on  variance estimates. Unless otherwise noted, percent estimates based on  HRS data have a 95 percent margin of error of +/- 6 percentage points of  the estimate.
To identify older adults likely to need home-based care services, we used  HRS questions about difficulties with IADLs and ADLs as listed in table 8.  We decided to estimate likely need in terms of these types of difficulties,  rather than the existence of particular medical conditions, because the  services provided by Title III home-based services are designed to address  such difficulties and the questions concerning IADLs and ADLs are  designed to capture difficulties with particular actions, regardless of  which particular health or memory conditions cause these difficulties.
We coded individuals who responded that, as a result of a health or  memory problem, they had difficulty doing a given activity, or could not or  did not do the activity as having a likely need for services. For respondents  that reported difficulty with one or more IADLs or ADLs, we examined  whether they received help with each identified activity. To identify  differences in the extent to which older adults received help from any  source, including Title III programs, we calculated the difference between  the number of IADL and ADL difficulties each respondent had and the  number of identified difficulties for which they received assistance.  However, the available data did not allow us to identify whether the  assistance an individual received for each identified IADL or ADL was  adequate to address their difficulties. HRS data did not allow us to make  state-level estimates because the survey is not designed to be  representative at the state level.
To estimate the number of older adults likely to need transportation  services like those provided by Title III programs, we examined HRS  questions on driving and car access. We coded older adults who said they  could not or did not drive, and individuals who said they could drive but  lacked access to a car, as likely to need transportation services, unless  such services were available through an individual’s assisted living facility.  The available data did not allow us to factor public transportation use or  spouses’ driving abilities into our estimate of likely need for transportation  services. Our estimates related to transportation are restricted to those  individuals age 65 and above, because younger HRS respondents were not  asked about their driving capabilities.
To identify factors associated with likely need for home-based care  services, and likely need of transportation services, we used descriptive  statistics and multiple logistic regression analyses. We estimated the  prevalence of IADLs and ADLs, and the extent and nature of help received,  across different demographic characteristics such as race, age, sex,  education, and homeownership, and whether an individual received  Medicaid. These cross-tabulations reveal differences in the proportion of  individuals likely to need home-based services across demographic  groups, but do not control for other factors that also might relate to likely  need. Therefore, we next estimated logistic regression models to predict  which factors were associated with having one or more reported IADLs or  ADLs, controlling for other characteristics. We also estimated logistic  regression models to examine, among those individuals with one or more  IADLs or ADLs, what factors were associated with a failure to receive  assistance for any one of those IADLs or ADLs, controlling for other  factors. Similarly, for transportation services, we began by examining the  relationship between being likely to need services and individual  demographic factors. We also used logistic regression analysis to predict,  controlling for other factors, which characteristics were associated with  likely need of transportation services. Unlike our analysis related to meals  services and home-based care, we were not able to estimate the number of  older adults likely to need transportation services that were and were not  receiving such services, because such data were not available.
For each of our logistic regression models, we tested various model  specifications to assess the model fit and stability of our estimates.  Nevertheless, our logistic regression models could not control for all  variables potentially related to each variable of interest, such as whether  an individual had access to public transportation. To the extent omitted  but relevant variables are correlated with those factors that were  incorporated into our models, the estimates we present are subject to  potential bias.
section_title: Survey of Area Agencies on Aging (Local Agencies)
paragraphs: To determine agencies’ use of federal funds, including American Recovery  and Reinvestment Act (Recovery Act) funds, we conducted a web-based  national random sample survey of 125 local agencies. The survey included  questions about: (1) utilization of OAA Title III services, (2) requests for  OAA Title III services, (3) approaches to target resources to areas of  greatest need, (4) use of OAA Title III funds, and (5) the economic climate  and use of Recovery Act funds. We drew a simple random sample of 125  agencies, from a population of 638 agencies. This included all 629 local  agencies that operate in the 50 states and District of Columbia, as well as 9  state units on aging (state agencies) in states that do not have local  agencies. We included these nine state agencies in our pool for sample  selection because the state units on aging perform the function of local  agencies in those states. We conducted four pretests to help ensure that  survey questions were clear, terminology was used correctly, the  information could be obtained, and the survey was unbiased. Agencies  were selected for pre-testing to ensure we had a group of agencies with  varying operating structures, budget sizes, and geographic regions of the  country. As a result of our pretests, we revised survey questions as  appropriate. In June 2010, we notified the 125 local agencies that were  selected to complete our survey and e-mailed a link to complete the Web  survey to these agencies beginning July 1, 2010. We sent e-mail reminders  and conducted follow-up calls to increase the response rate. Ninety-nine  local agencies responded to our survey, resulting in a response rate of 79  percent. Some individual questions have lower response rates. The survey  percentages in this report are subject to margins of error of no more than  plus or minus 12 percentage points at the 95 percent confidence level.  Because we followed a probability procedure based on random selections,  our sample is only one of a large number of samples that we might have  drawn. Since each sample could have provided different estimates, we  express our confidence in the precision of our particular sample’s results  as a 95 percent confidence interval (e.g., plus or minus 12 percentage  points). This is the interval that would contain the actual population value  for 95 percent of the samples we could have drawn. Instances where the  margin of error falls outside of the overall rate are footnoted throughout  the report. The practical difficulties of conducting any survey may  introduce nonsampling errors. For example, difficulties in interpreting a  particular question, sources of information available to respondents, or  entering data into a database or analyzing them can introduce unwanted  variability into the survey results. We took steps in developing the  questionnaire to minimize such nonsampling error. The results of this  survey are generalizable to the 629 local agencies in the United States.
section_title: Analysis of Expenditures Data
paragraphs: In addition to our survey, to determine agencies’ use of funds we analyzed  AoA State Program Report data from fiscal years 2000 through 2008  available on the agency’s Web site and provided by AoA officials. We  assessed the reliability of this data by interviewing AoA officials, assessing  official’s responses to a set of standard data reliability questions, and  reviewing internal documents used to edit and check data submitted by  states. We determined the data were sufficiently reliable for purposes of  this review.
section_title: State Plan Review
paragraphs: To determine how agencies measure receipt of services, need and unmet  need, we also reviewed guidance on creating state aging plans and  measuring receipt of services, need and unmet need distributed by AoA  and the National Association of States United for Aging and Disabilities  (NASUAD). We then analyzed the most recently available state aging plan  for the 50 states and the District of Columbia, as of spring 2010. Each state  is required to submit a state aging plan to AoA for review and approval  covering a 2-, 3-, or 4-year period. The aging plan should include state long- term care reform efforts with an emphasis on home- and community-based  services, strategies the state employs to address the growing number of  older adults, and priorities, innovations and progress the state seeks to  achieve in addressing the challenges posed by an aging society. We also  reviewed selected states’ needs assessments.
section_title: Interviews with Agencies
paragraphs: To determine state and local agencies’ use of funds and how agencies  measure need and unmet need, we reviewed relevant statutory provisions  and interviewed state, local, and AoA officials. In March 2010, we visited  Illinois, Massachusetts, Rhode Island, and Wisconsin. These states were  selected due to varying sizes of the population age 60 and over and Title III  expenditures. Additionally, we considered geographic region, proximity to  AoA regional support centers, and a desire to interview at least one state  without local agencies (Rhode Island). Using the same selection criteria,  we conducted semi-structured interviews with an additional 10 state  agencies in late September and early October 2010: Arizona, California,  Florida, Georgia, Indiana, Montana, Nevada, New Jersey, Oregon, and  Tennessee. During these interviews, we discussed the types of information  states collect on need, their ability to measure need and guidance used to  do so, their ability to meet identified needs, the transfer of Title III funds,  and use of Recovery Act funds, among other topics.
section_title: Appendix II: Percentages of Low-Income Older Adults Receiving Home-Delivered and Congregate Meals
paragraphs: Table 9 shows the percentages of low-income older adults with different  characteristics who had received home-delivered meals, congregate meals,  or either home-delivered or congregate meals in the 30 days prior to  completing the survey. Additional information can be found in appendix  III.
section_title: Appendix III: Likely Need and Receipt of Home-Delivered or Congregate Meals
paragraphs: In our analyses of factors related to likely need and receipt of meals, we  used data from the 2008 Current Population Survey (CPS) and focused on  the population 60 and older (or in about 9 percent of the cases, on their  younger spouses or household members with disabilities), who were in  households with incomes that were below 185 percent of the poverty  threshold. Our results are not generalizable to older adults with higher  incomes. The reason for the income restriction is because the questions  related to participation in the two meals programs of interest were not  asked of all respondents in the CPS, and the only group that was  completely sampled and asked those questions was the respondents in  households with incomes that were below 185 percent of the poverty  threshold. While the exclusion of others with higher incomes from our  study is unfortunate, the sample we are using does represent the large  majority of people who were food insecure and decreasing food insecurity  is a key goal of both meal programs. While roughly 19 percent of the  individuals in households with incomes below 185 percent of the poverty  threshold were food insecure, using the U.S. Department of Agriculture’s  (USDA) measure of food insecurity; only 4 percent of the individuals in  households with incomes above 185 percent of the poverty threshold were  food insecure. Other indicators of likely need such as difficulties with  daily activities and limited social interaction were also more prevalent  among the low-income population than among those with household  incomes above 185 percent of the poverty threshold. For additional  information about our methodology, see appendix I.
Table 10 shows the characteristics of the population represented by our  sample. Just over 4 percent of the population had received a home- delivered meal in the past 30 days, 5.5 percent had received a congregate  meal, and nearly 9 percent had received either one or the other. These  percentages are far lower than the percentage of individuals in the  population who were in food insecure households, which comprised  nearly 19 percent of the population. Table 10 also shows that roughly one- third of eligible low-income individuals had at least one type of functional  impairment (i.e., difficulty with daily activities), and 17 percent had two or  more types of impairments. When we measured social isolation rather  crudely, by contrasting individuals for whom no group memberships were  reported with individuals who belonged to at least one group, we found  that more than half of this elderly subpopulation for whom isolation could  be measured were somewhat isolated. We also found that 13 percent of  the individuals in this group of low-income seniors had received food  stamps in the past year. With respect to demographic characteristics, 91  percent of the population was over 60 (and 21 percent were over 80), 61  percent were female, 19 percent were non-white, and 13 percent were  Hispanic. Slightly less than half were married, 29 percent were widowed,  and 25 percent were in the “other” marital status category, which includes  divorced individuals and individuals who were never married. More than  half of this group had incomes below $20,000. More than one-third were  living alone, and fewer than one in four were living in households with  more than two persons. Nearly three-fourths of this largely elderly  subpopulation had a high school education or less, and only 16 percent  were still employed. Nearly three-fourths of the persons in low-income  households were living in homes that were owned and more than three- fourths were living in metropolitan areas. Roughly one in five were from  the Northeastern United States, and similar percentages were living in  Midwestern and Western states. The remaining two-fifths were from the  South.
Table 11 shows how food insecurity varied across different subgroups in  these older adult low-income households and how the percentages  receiving home-delivered meals, congregate meals, or either home- delivered or congregate meals varied across subgroups.
Clearly, food insecurity was a decidedly greater problem for some groups  than others. The first two columns of numbers in table 11 show the  percentages of individuals with various characteristics that were food  insecure, and the margins of error associated with those percentages. They  reveal that:    Persons with impairments were more likely to be food insecure than  persons without impairments; i.e., the percentage of food insecure  individuals is nearly twice as high for those with multiple impairments (29  percent) than those with none (15 percent).
Food insecurity did not vary by level of social isolation.
Individuals who had received food stamps over the past year were nearly  2.5 times more likely than individuals who had not received food stamps to  be food insecure (43 percent vs. 15 percent).
Older individuals were less likely to be food insecure than younger ones,  though there was little difference in the food insecurity of men and  women.
Larger percentages of individuals from minority groups than white  individuals were food insecure, and Hispanic individuals were more likely  to be food insecure than non-Hispanics. Food insecurity was also more  prevalent in larger households (with two or more persons) and among  individuals that had less than a high school diploma, had disabilities  related to work, or were in rented homes. Food insecurity was only  slightly higher in metropolitan areas relative to non-metropolitan areas,  and slightly higher in the South than in other regions of the country.
The other columns of table 11 show the percentages receiving home- delivered meals, congregate meals, or either home-delivered or congregate  meals in the last 30 days. The percentages in each subgroup who received  either one or the other type of meal is nearly always smaller than the sum  of the percentages who received home-delivered meals and congregate  meals, since some individuals had received both home-delivered and  congregate meals.
With respect to home-delivered meals, we found that:    Food insecurity, having impairments, being more isolated, and receiving  food stamps were all strongly and positively associated with whether  individuals received home-delivered meals.
Because of the pronounced effect of food insecurity on the receipt of  home-delivered meals, the differences across demographic groups in the  percentage of persons who received home-delivered meals tracks (or co- varies) in most cases with the percentages of the different demographic  groups that are food insecure. The percentages receiving home-delivered  meals were higher for widowed and other non-married individuals,  individuals with household incomes less than $10,000, individuals with less  than a high school education, and individuals who are retired or could not  work due to disability.
The major exception to this pattern involves age. While the younger  categories of individuals in this group had higher percentages of food  insecure individuals, smaller percentages of the individuals in the younger  categories than in the older categories received home-delivered meals.
With respect to congregate meals, we found that:    Food insecurity, having impairments, being more isolated, and receiving  food stamps all have little or no association with whether individuals  received congregate meals in the last 30 days.
The demographic characteristics that appear to be most strongly related to  whether people received congregate meals were age (people 70 and older  were decidedly more likely to receive them than people under 70), marital  status (non-married individuals were more likely than married individuals  to receive them), and household size (people living alone were more likely  than others to receive congregate meals). Also, people who were retired or  had a disability that related to work were more likely to receive  congregate meals than those who were employed.
The first column of numbers in table 12 simply reproduces the percentages  of individuals in each group that had received home-delivered meals,  which were shown in table 11. Taking the first percentages as an example,  these imply that 3.3 out of every 100 individuals in food secure households  received a home-delivered meal, 7.4 out of every 100 individuals in food  insecure households received a home-delivered meal, and so on. The odds  in the next column of the table can be calculated from these percentages,  by taking, for example, the percentage of food secure individuals who  received a home-delivered meal (3.3 percent) and dividing it by the implied  percentage of food secure individuals who did not (100 – 3.3 = 96.7) to  obtain 3.3/96.7 = 0.034. In this case, the odds imply that 0.034 food secure  individuals received a home-delivered meal for every 1 that did not, or that  3.4 food secure individuals received a home-delivered meal for every 100  that did not. The odds of 0.080 (after rounding) for food insecure  individuals implies that, among them, 0.08 received home-delivered meals  for every 1 that did not, or that 8 food insecure individuals received a  home-delivered meal for every 100 that did not.
By taking ratios of the odds for different subgroups, or odds ratios, we can  get a simple and straightforward estimate of the differences between  groups in, in this case, the odds on having received a home-delivered meal.  In the third column we see, for example, that food insecure individuals  had higher odds of receiving a home-delivered meal than individuals in  food secure households, by a factor of 0.080/0.034 = 2.3. When multiple  categories are to be compared, as in the case of individuals with none,  one, or two or more types of impairments, we choose one category as the  referent category and take ratios of the other categories relative to that  one. In that case, we find that individuals with one type of impairment had  higher odds of receiving home-delivered meals than individuals with none,  by a factor of 1.6, and that individuals with two or more types of  impairments had higher odds of receiving home-delivered meals than  individuals with none, by a factor of 5.5.
The asterisks beside the unadjusted odds ratios indicate which of the odds  ratios, and differences between groups they are estimating, are statistically  significant and reflect real differences, or differences that are not due to  sampling fluctuations. These are of interest, and where significant, they  reflect genuine differences between groups (e.g., people who are more  socially isolated have odds of receiving home-delivered meals that are  more than twice as high as those who are less socially isolated). However,  they are somewhat limited in the sense that they are derived by  considering each factor’s association with receiving home-delivered meals  one at a time, ignoring the fact that each of the factors may be related to  other factors which, in turn, may be related to having received home- delivered meals. To derive “adjusted” odds ratios, we used multivariate  models to estimate them. Specifically, we used logistic regression models  in this study, since the outcomes of interest (receiving or not receiving  home-delivered meals in this table, and congregate meals in the next) are  both dichotomous. The odds ratios from these models, given in the final  column of the table, estimate the group differences related to each factor  in the likelihood of receiving home-delivered meals after we take account  of the effects of the factors, rather than before, or while ignoring them.
What we find with respect to home-delivered meals when we consider the  adjusted or net effect estimates of each factor (or the adjusted odds ratios  in the table) is that:    Food insecurity, having multiple types of impairments, and being socially  isolated are significantly related to receiving home-delivered meals, while  receiving food stamps is unrelated to whether individuals received home- delivered meals. The odds that food insecure individuals received home- delivered meals are nearly twice the odds for food secure individuals, and  more isolated individuals have odds nearly twice as high as less isolated  individuals of receiving home-delivered meals. Impairments have an even  larger effect. People with multiple types of impairments are much more  likely than those with none to receive home-delivered meals, with odds  more than three times higher.
The demographic variables that have significant effects are age, household  size, employment status, and home ownership. Individuals over 80 are  twice as likely as individuals under 60 to receive home-delivered meals, by  a factor of nearly two. By implication, they are also more likely to receive  them than people 60-69, their odds being greater by a factor of 2.02/1.26 =  1.60, apart from rounding. Individuals in two-person households and in  households with three or more persons were less likely to receive home- delivered meals than persons living alone, by a factor of roughly 0.6 in  both cases. Also, individuals who were unemployed because of disabilities  had odds of receiving home-delivered meals nearly two times higher than  employed individuals, and individuals who did not own their homes had  odds of receiving home-delivered meals about 1.5 times higher than those  who did.
When we consider congregate meals, we found that:    Food insecurity, number of impairments, social isolation and the receipt of  food stamps were all unrelated to having received congregate meals.
A number of the demographic variables are, however associated with  whether individuals had received congregate meals. The odds on having  done so were more than twice as high for individuals over 70 than for  those under 60 (and by implication about 1.5 to 2 times as high for  individuals over 70 than for those 60 to 69). The odds that African  American older adults and other older adults from minority groups  received congregate meals were about 1.5 times higher than for white  older adults, and Hispanic older adults had similarly larger odds than non- Hispanic older adults of receiving congregate meals (i.e., 1.0/0.65 = 1.5,  apart from rounding). People who were not living alone were less likely to  have received congregate meals (the odds were smaller by a factor of 0.7  for those in two-person households and a factor of 0.4 for those in  households with three or more persons). Persons who were not employed  were more likely to have received congregate meals than persons who  were employed. Finally people in non-metropolitan regions were more  likely to receive congregate meals than people in metropolitan regions  (with odds higher by a factor of 1.6) and people in the Midwest and West  were more likely than people in the Northeast (and, by implication, the  South) to have received a congregate meal.
section_title: Appendix IV: Likely Need for, and Receipt of, Home-Based Care
paragraphs: To examine factors associated with likely need for and receipt of home- based care, we used data from the 2008 HRS to identify older adults age 60  and above that reported that they had difficulty doing specific activities as  a result of a health or memory problem. The specific activities included  IADLs, for which Title III programs provide assistance through  homemaker and chore care, as well as ADLs, for which Title III programs  provide personal care services. We assume that older adults with one or  more IADL or ADL restrictions have a likely need for home based care,  and examined the likelihood that a older adult with one or more IADL or  ADL difficulties failed to receive any help with those restrictions. Our  analysis did not consider the sufficiency of help received; that is, among  those who received help for a given difficulty, whether they received  sufficient help for that difficulty.
Table 14 shows the estimated proportion of older adults within different  demographic groups reporting one or more IADL or ADL difficulty, the  odds that older adults with the specific characteristic report one or more  difficulties (that is, the percent reporting one or more difficulties divided  by the percent not reporting any difficulties), and the comparative odds  between older adults with different demographic characteristics compared  to a reference group. Table 14 illustrates notable demographic differences  in the proportion of older adults reporting one or more IADL or ADL  difficulties.
The proportion of older adults with at least one IADL or ADL difficulty  increased dramatically with age: while an estimated 22 percent of older  adults age 60 through 69 reported one or more IADL or ADL restrictions,  an estimated 29 percent of those ages 70 through 79, and an estimated 53  percent of those aged 80 and above, reported such difficulties.
We found modest differences among racial and ethnic groups in the  proportion reporting one or more IADL or ADL difficulties, with fewer  white older adults estimated to have difficulties (29 percent) compared to  African American older adults (35 percent), and more Hispanic older  adults than non-Hispanic older adults estimated to have difficulties (37  percent compared to 29 percent).
The proportion of older adults reporting IADL or ADL difficulties also  varied by income, with fewer individuals living in families above 185  percent of the poverty threshold reporting restrictions (26 percent)  compared to an estimated 42 to 44 percent of those with lower incomes.  The proportion of older adults estimated to have one or more IADL or ADL  difficulties also varied by homeownership status, with an estimated 26  percent of homeowners and an estimated 45 percent of non-homeowners  reporting one or more IADL or ADL difficulties.
A substantially larger proportion of older adults with low levels of  education reported IADL or ADL difficulties than those with higher levels  of education: an estimated 46 percent of those with less than a high school  education reported difficulties, compared to 29 percent of those with high  school degrees or equivalents and 20 percent of those with a college  degree or more. Medicaid recipients were also more likely to report  difficulties, with 54 percent of recipients, compared to 27 percent of non- recipients, reporting IADL or ADL difficulties.
There was little difference in the estimated proportion of older adults  reporting IADL and ADL difficulties between men and women, between  those living alone and those living with others, and between those who  had children living within 10 miles and those who did not.
We used logistic regression analysis to predict which factors were  associated with reporting one or more IADL or ADL difficulties, after  controlling for other factors. These “adjusted odds” showing the  comparative odds of having a difficulty among older adults with different  characteristics are shown in the final column of table 14. Notably:    After controlling for other factors, age appeared to have among the most  pronounced effects on whether an older adult reported having one or  more IADL or ADL difficulty: the odds that an adult age 80 or above  reported one or more difficulties was approximately three times higher  than those for an adult age 60 through 69.
After controlling for other factors, race was not significantly related to the  likelihood of reporting one or more difficulties, though Hispanic older  adults had lower odds of having one or more IADLs or ADLs than non- Hispanic older adults.
Income remained a significant predictor of the likelihood of reporting an  IADL or ADL difficulty, with the odds of reporting a difficulty  approximately 25 percent to 40 percent higher for those in families making  less than 185 percent of the poverty threshold compared to those with  higher incomes. Similarly, non-homeowners had higher odds of reporting  one or more difficulties than homeowners, by a factor of 1.6.
In contrast, those older adults living alone had lower odds of reporting one  or more difficulties. The odds were approximately 35 percent lower than  those living with others, after controlling for other factors.
With respect to education, compared to older adults without a high school  degree, older adults with higher levels of education had significantly lower  odds of reporting one or more difficulties. In contrast, retired and older  adults otherwise not employed had notably higher odds of reporting one  or more difficulties, after controlling for other factors.
After controlling for other factors, Medicaid recipients were more likely  than non-recipients to report one or more IADL or ADL difficulties.  However, there were not statistically significant differences across those  with and without children living nearby in the odds of having one or more  difficulties, after controlling for other factors.
When we limited our analysis to older adults reporting one or more IADL  or ADL difficulties, we also found demographic differences in the  likelihood that older adults did or did not receive any assistance. Table 15  illustrates the risk that an older adult with one or more restrictions did not  receive any help with their difficulties, and shows important demographic  differences in the estimated proportion of older adults with difficulties  that did not receive help. These older adults are potential candidates for  home-based care assistance. Our analysis could not determine whether  older adults that received some help with difficulties received sufficient  assistance.
The proportion of older adults that failed to receive any assistance with  any reported difficulties declined with age. For example, an estimated 34  percent of older adults ages 80 and above did not receive any assistance  with difficulties, compared to an estimated 55 percent of older adults ages  60 through 69.
Women were less likely than men to report that they did not receive any  assistance (39 percent compared to 57 percent). Compared to married  individuals, widowed older adults were less likely to say that they received  no assistance (an estimated 54 percent of married older adults, and 36  percent of widowed older adults, did not receive assistance).
A greater proportion of white older adults was estimated not to receive  assistance (49 percent) compared to African American older adults (35  percent).
Older adults in families with higher incomes were more likely to fail to get  any assistance than those living in families at or below the poverty  threshold. A greater proportion of those in families with incomes  exceeding 185 percent of the poverty threshold compared to those with  lower incomes did not get any assistance: an estimated 52 percent of those  living in families with incomes exceeding 18 percent of the poverty  threshold, compared to 33 percent for those in families with incomes  below the poverty threshold and 41 percent of those in families above the  poverty threshold through 185 percent of the poverty threshold reported  not receiving assistance.
Homeowners were more likely to report not receiving assistance than non- homeowners (53 percent compared to 33 percent).
Education was inversely related to the receipt of assistance: among older  adults with college degrees or higher, an estimated 61 percent went  without any assistance, compared to an estimated 39 percent among those  with less than a high school degree. Similarly, a much higher proportion of  older adults currently employed reported not receiving any assistance (an  estimated 80 percent) compared to retired or otherwise not employed  older adults (46 percent and 34 percent respectively).
In addition to being more likely to report having one or more IADL or ADL  difficulties, Medicaid recipients were more likely to receive at least some  assistance. An estimated 27 percent of Medicaid recipients with  difficulties, compared to an estimated 51 percent of non-recipients with  difficulties, went without any assistance.
Logistic regression analysis revealed that, after adjusting for other  characteristics, several of the factors significantly associated with whether  an older adult with difficulties received or did not receive assistance were  similar to those associated with whether an older adult reported having  one or more IADLs or ADLs.
For example, after controlling for other factors, the odds that an older  adult age 80 or above went without assistance were nearly half of the odds  for an older adult age 60 through 69.
Compared to older adults that were active in the workforce, older adults  that were not employed (either retired or otherwise not working) were  dramatically less likely not to get any assistance, with odds approximately  70 to 75 percent lower than those for employed older adults.
Women were substantially less likely than men to go without assistance  (odds ratio of 0.62), and Medicaid recipients were half as likely as non- recipients to go without assistance (odds ratio of 0.50).
The odds that African American older adults with difficulties went without  assistance were lower than those for white older adults, by approximately  30 percent, whereas the odds that Hispanic older adults went without  assistance were somewhat higher than those for non-Hispanic older  adults, by approximately 35 percent.
While those older adults living alone had notably higher odds of going  without assistance compared to those living with others (odds ratio 1.8),  there was not a statistically significant difference between those with  children living nearby and those without children living nearby.
section_title: Appendix V: Likely Need for Transportation Services
paragraphs: To assess the number of older adults likely to need transportation  services, we used data from the 2008 HRS to identify those older adults  over age 65 that reported they could not drive, could drive but lacked  access to a car, or did not have access to transportation services through  their living facility. By this definition, an estimated 21 percent of older  adults age 65 and over were likely to need transportation services. This  estimate does not account for the fact that some older adults likely to need  services may obtain transportation from other sources, such as through a  spouse, friends, or public transportation.
When we considered the likely need for transportation services among  respondents with different characteristics, we found that many  demographic factors were associated with an increased likelihood of  needing services. Table 16 presents the estimated percentages of older  adults within different demographic groups who were likely to need  transportation services. For example:    Age and sex were related to likely need for transportation services. An  estimated 41 percent of those age 80 and above were likely to need  transportation services, compared to just 12 percent of those ages 65  through 69. A much larger proportion of women than men were likely to  need transportation services (an estimated 29 percent compared to 12  percent).
Likely need for transportation services also varied by race and ethnicity.
Prior to controlling for other factors, approximately two times as many  African American older adults than white older adults had a likely need for  transportation services, with an estimated 39 percent of African Americans  likely to need transportation services, compared to 20 percent of white  older adults. Among Hispanic older adults, an estimated 46 percent were  likely to need transportation services, compared to 20 percent of non- Hispanic older adults.
Likely need for transportation services was higher among those with lower  incomes and lower net wealth as measured by homeownership. An  estimated 53 percent of older adults living in families below the poverty  threshold were likely to need transportation services, compared to an  estimated 16 percent of those living in families with incomes exceeding  185 percent of the poverty threshold. Compared to non-homeowners, a  much smaller proportion of homeowners were likely to need services: an  estimated 15 percent of homeowners, compared to 45 percent of non- homeowners, were likely to need services.
Older adults with higher levels of education were less likely to need  transportation services than older adults with a high school degree or less.  An estimated 40 percent of those with less than a high school degree, and  an estimated 20 percent of those with high school degrees or equivalents,  were likely to need transportation services compared to just 10 percent of  those with college degrees or above.
Prior to controlling for other factors, older adults that lived alone were  slightly more likely to need transportation services than those that lived  with other people (an estimated 25 percent compared to 20 percent).  Additionally, an estimated 35 percent of widowed older adults and an  estimated 22 percent of older adults in other marital status categories  (never married, separated, divorced, or unknown) were likely to need  transportation services, compared to an estimated 14 percent of married  older adults.
Likely need for transportation services also varied by health-related  factors: a greater proportion of respondents with sight, health, depression,  and mobility problems were likely to need services when compared to  their counterparts without sight, health, depression, or mobility problems.
Additionally, an estimated 54 percent of Medicaid recipients were likely to  need transportation services, compared to just 18 percent of older adults  that did not receive Medicaid.
The odds of being likely to need transportation services for each  demographic category are defined as the proportion of the group in likely  need compared to the proportion of the group not likely to need services.  Odds ratios provide a comparative measure of how the likely need for  transportation services varies by different demographic variables. For  example, among adults ages 65 through 69, an estimated 11.6 percent of  older adults are likely to need transportation services, and an estimated  88.4 percent are not. The odds that an adult age 65 to less than 75 is likely  to need services are thus 11.6 to 88.4, or 0.13. In comparison, the odds that  an older adult age 80 or above is likely to need transportation services is  41.0 percent to 59.0 percent, or 0.69. The unadjusted odds ratio comparing  the two groups (0.69 to 0.13, or 5.3) shows that prior to controlling for  other factors, older adults age 80 and above are more than five times more  likely than their counterparts ages 65 through 69 of being in likely need of  transportation services.
The penultimate column of table 16 shows unadjusted odds ratios among  different groups of older adults compared to a reference group within each  variable, prior to controlling for other factors. The final column of table 16  presents “adjusted” estimates of these comparative odds ratios. These  adjusted estimates are derived from logistic regression analysis, and show  the comparative odds after controlling for other variables that also  influence whether an older adult is likely to need transportation services.  Asterisks indicate that the estimated odds ratios are significant at the 95  percent significance level.
Table 16 illustrates that, even after controlling for other factors, certain  groups are significantly more likely than others to be likely to need  transportation services.
For example, age, sex, race, and ethnicity are all significantly related with  the odds of having a likely need for transportation services. Older  individuals, females, African American older adults, and Hispanic older  adults had higher odds of being likely to need than younger older adults,  men, white older adults and non-Hispanic older adults, respectively.  However, after controlling for other factors, the odds of being likely to  need transportation services among the “other” race category were not  significantly higher than those for white older adults.
Older adults with low incomes and low assets (as measured by non- homeownership) had significantly higher odds of being likely to need  transportation services than older adults with higher incomes and  homeowners, even after controlling for other factors.
After controlling for other factors, several health-related factors including  poor sight, poor overall health and limited mobility were still significantly  associated with differential likelihood of needing transportation services,  though the magnitude of the differences in relative odds was reduced.  Additionally, after controlling for other factors, there was no statistical  difference in being likely to need transportation services between those  who were and were not depressed.
section_title: Appendix VI: Responses to Selected Questions from GAO Survey of Area Agencies on Aging (Local Agencies)
paragraphs: Appendix VI: R Quest on Aions from GAO Survey of Area Agencies  ging (Local Agencies)
We distributed a Web-based survey to a random national sample of 125  area agencies on aging (local agencies) to obtain officials views on the use  of Older Americans Act (OAA) Title III funds, among other topics. We  received completed surveys from 99 of 125 local agencies, for a response  rate of 79 percent. Figures 5 through 17 show responses to select  questions from the survey, which are generalizable to the 629 local  agencies in the United States and were discussed in the body of the report.  The percentages in this report are generally subject to margins of error of  no more than plus or minus 12 percentage points at the 95 percent  confidence level. Instances were the margin of errors falls outside of this  range are indicated. For more information about our methodology for  designing and distributing the survey, see appendix I.
section_title: Appendix VII: Comments from the Department of Health and Human Services
section_title: Appendix VIII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact person named above, Kimberley M. Granger- Heath, Assistant Director; Ramona Burton, Analyst-in-Charge; Jameal  Addison; James Bennett; David Chrisinger; Andrea Dawson; Nancy J.  Donovan; Gregory Dybalski; Justin Fisher; Gene Kuehneman; Luann Moy;  Grant Mallie; Ruben Montes de Oca; Anna Maria Ortiz; Douglas Sloane;  Barbara Steel-Lowney; Craig Winslow; and Amber Yancey-Carroll made  key contributions to this report. Lise Levie, Ben Pfeiffer, Beverly Ross, Jeff  Tessin and Monique Williams verified our findings.