Nutrition Assistance: Additional Efficiencies Could Improve Services to Older Adults
Published: 2011-06-21T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: This testimony discusses our recent work on food insecurity among older adults and the nutrition assistance programs available to assist them, including nutrition assistance programs authorized under the Older Americans Act of 1965 (OAA). This work can help inform government policymakers as they address the needs of one of our nation's most vulnerable populations while ensuring the efficiency and effectiveness of federal programs given rapidly building fiscal pressures facing our national government. While the economy is still recovering and in need of careful attention, widespread agreement exists on the need to look not only at the near term but also at steps that begin to change the long-term fiscal path as soon as possible without slowing the recovery. Our recent work can help with this by identifying potential inefficiency and overlap among programs. At the same time, there is recognition that the services provided by the OAA can play an important role in helping older adults remain in their homes and communities. As the Congress takes steps to address the fiscal challenge, it will be important that these steps are balanced with efforts to ensure the health and well-being of older adults. This testimony today is based on two recent reports, our April 2010 report on domestic food assistance and our February 2011 report on the unmet need for services under the OAA. This testimony highlights key findings from each of these reports related to (1) the prevalence of food insecurity and the receipt of nutrition services among older adults; and (2) the extent to which nutrition assistance programs show signs of inefficiency or overlap. This statement will discuss some of the challenges related to ensuring the most efficient provision of services, and suggest how better information could help policymakers address overlap and duplication among programs while ensuring those most in need have access to services..
section_title: What GAO Found
paragraphs: Analysis of data from the Current Population Survey's (CPS) Food Security Supplement shows that in 2009, about 19 percent of households with adults ages 60 and over with low incomes--under 185 percent of the poverty line--were food insecure. These adults were uncertain of having or unable to acquire enough food because they lacked resources. In comparison, slightly less than 15 percent of all households were food insecure. A small but significant portion of households with older adults had very low food security in 2009--about 8 percent of those with households under 185 percent of poverty and about 14.5 percent of those with incomes under the poverty line. In these households, one or more household members' eating patterns were disrupted and their food intake reduced, at least some time during the year because they could not afford enough food. We have found that some of the domestic food assistance programs, including those serving older adults, provide comparable benefits to similar or overlapping populations. For example, the Elderly Nutrition Program administered by the Administration on Aging (AoA), provides home-delivered and congregate meals primarily to individuals 60 years and older. Separately, other programs administered by USDA, including the Commodity Supplemental Food Program, targets a similar population, providing food to older adults, as well as women, infants and children who are also served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. In addition, individuals eligible for groceries through the Commodity Supplemental Food Program or services through the Elderly Nutrition Program may also be eligible for groceries through the Emergency Food Assistance Program and for targeted benefits that are redeemed in authorized stores through the largest program, the Supplemental Nutrition Assistance Program (SNAP). In fact, a recent AoA report conducted by Mathematica found that seven percent of congregate meal recipients and 16 percent of home-delivered meal recipients were also receiving SNAP benefits. The availability of multiple programs with similar benefits helps ensure that those in need have access to nutritious food, but can also increase administrative costs, which account for approximately a tenth to more than a quarter of total costs among the largest of these programs. In addition, our previous work has shown that overlap among programs can lead to inefficient use of federal funds, duplication of effort, and confusion among those seeking services. We have found in previous work that despite the potential benefits of varied points of entry, program rules related to determining eligibility often require the collection of similar information by multiple entities. For example, an older adult might apply for congregate meals through the Elderly Nutrition Program at their local area agency on aging, electronic benefits through SNAP at the Health and Human Services office, and vouchers for fresh fruit and vegetables through the Senior Farmers' Market Nutrition Program at a local food bank. Most of the 18 programs have specific and often complex administrative procedures that federal, state, and local organizations follow to help manage each program's resources. According to our previous work and state and local officials, rules that govern these and other nutrition assistance programs often require applicants who seek assistance from multiple programs to submit separate applications for each program and provide similar information verifying, for example, household income. This can create unnecessary work for both providers and applicants and may result in the use of more administrative resources than needed.

section_title: Letter
paragraphs: We appreciate the opportunity to discuss our recent work on food  insecurity among older adults and the nutrition assistance programs  available to assist them, including nutrition assistance programs  authorized under the Older Americans Act of 1965 (OAA).  This work can  help inform government policymakers as they address the needs of one of  our nation’s most vulnerable populations while ensuring the efficiency and  effectiveness of federal programs given rapidly building fiscal pressures  facing our national government. While the economy is still recovering and  in need of careful attention, widespread agreement exists on the need to  look not only at the near term but also at steps that begin to change the  long-term fiscal path as soon as possible without slowing the recovery.  Our recent work can help with this by identifying potential inefficiency  and overlap among programs. At the same time, there is recognition that  the services provided by the OAA can play an important role in helping  older adults remain in their homes and communities. As the Congress  takes steps to address the fiscal challenge, it will be important that these  steps are balanced with efforts to ensure the health and well-being of older  adults.
My testimony today is based on two recent reports, our April 2010 report  on domestic food assistance and our February 2011 report on the unmet  need for services under the OAA. My testimony highlights key findings  from each of these reports related to (1) the prevalence of food insecurity  and the receipt of nutrition services among older adults; and (2) the extent  to which nutrition assistance programs show signs of inefficiency or  overlap. This statement will discuss some of the challenges related to  ensuring the most efficient provision of services, and suggest how better  information could help policymakers address overlap and duplication  among programs while ensuring those most in need have access to  services.
To address the objectives, we drew upon our April 2010 report and our  February 2011 report. In this work, we employed an array of  methodologies including analysis of administrative data on program  expenditures and participation and national self-reported data on food  security status; a nationally representative survey of local agencies that  administer nutrition assistance programs funded by OAA; an analysis of  studies on program effectiveness; a review of relevant federal laws and  regulations and agency documents; and interviews with relevant experts,  federal officials, and staff of local agencies. We conducted our work 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  we obtained provides a reasonable basis for our findings and conclusions.
On March 1, 2011, we issued a report outlining opportunities to reduce  duplication across a wide range of federal programs raising attention to  these issues. That report was prepared in response to a new statutory  requirement that GAO identify and report annually on federal programs,  agencies, offices, and initiatives—either within departments or  governmentwide—that have duplicative goals and activities. In that work,  we also considered fragmentation and overlap among government  programs or activities as these can be harbingers of unnecessary  duplication. Fragmentation of programs exists when programs serve the  same broad area of need but are administered across different federal  agencies or offices. Program overlap exists when multiple agencies or  programs share similar goals, engage in similar activities or strategies to  achieve them, or target similar beneficiaries. Unnecessary duplication of  program services can occur when two or more programs are engaged in  the same activities or provide the same services to the same beneficiaries,  and this can in turn result in inefficient service delivery and unnecessary  program costs. Reducing or eliminating duplication, overlap, or  fragmentation could potentially save billions of tax dollars annually and  help agencies provide more efficient and effective services. These actions,  however, will require some difficult decisions and sustained attention by  the Administration and Congress.
subsections: section_title: In Recent Years Nearly a Fifth of Low- Income Older Adults Were Food Insecure and Most Did Not Receive Assistance from Meals Programs Despite Increased Demand
paragraphs: Analysis of data from the Current Population Survey’s (CPS) Food  Security Supplement shows that in 2009, about 19 percent of households  with adults ages 60 and over with low incomes—under 185 percent of the  poverty line—were food insecure. These adults were uncertain of having  or unable to acquire enough food because they lacked resources. In  comparison, slightly less than 15 percent of all households were food  insecure. A small but significant portion of households with older adults  had very low food security in 2009—about 8 percent of those with  households under 185 percent of poverty and about 14.5 percent of those  with incomes under the poverty line. In these households, one or more  household members’ eating patterns were disrupted and their food intake  reduced, at least some time during the year because they could not afford  enough food. (See Figure 1.)
Older adults can and do access a number of resources to help alleviate  food insecurity; however, many low-income older adults likely to need  assistance from meals programs did not receive it, according to 2008 data.  Through our analysis of information from the CPS, we found that in 2008  approximately 9 percent of an estimated 17.6 million low-income older  adults received home-delivered or congregate meals services including  those provided by the OAA Elderly Nutrition Program: Home-Delivered  and Congregate Meals Services (Elderly Nutrition Program) and other  organizations such as churches or nonprofits. However, many more older  adults did not receive these meals services, but likely needed them due to  food insecurity, difficulties with daily activities, and/or limited social  interaction, as shown in table 1.
It should be noted that there are many reasons why older adults may not  receive nutrition assistance through the Elderly Nutrition Program. They  may not know about the available services, may not have access to  services due to limited supply in their area, may receive informal  assistance from family or neighbors, or may choose to remain self- sufficient rather than request government benefits. In addition, some older  adults may choose to participate in a separate program instead, such as  the Supplemental Nutrition Assistance Program (SNAP), formerly known  as Food Stamps, where they can purchase their preferred foods.
Requests for Elderly Nutrition Program services have increased and  demand will likely continue to grow. Through our survey of area agencies  on aging (local agencies) conducted during the summer of 2010, we found  that an estimated 79 percent of agencies had seen increased requests for  home-delivered meals, and 47 percent had seen increased requests for  congregate meals since the start of the economic downturn. Further,  requests for OAA services are increasing as more seniors stay in their  homes longer rather than move to assisted living facilities or nursing  homes, according to agency officials. According to U.S. Census data, more  than 9 million more Americans were 60 years and older in 2009 than in  2000, and the Census Bureau projects that population group will continue  to grow.
Further, demand for Elderly Nutrition Program home-delivered meals is  growing compared to congregate meals. In our 2010 survey, an estimated  22 percent of agencies reported they were generally or very unable to  serve all clients who request home-delivered meals, compared to an  estimated 5 percent of agencies who were generally or very unable to  serve all clients who requested congregate meals. To adjust to these  changes in requests for services, most state and some local agencies  utilized the flexibility provided by the law to transfer OAA funds among  Title III programs. Agencies most commonly transferred funds from  congregate meals to home-delivered meals or other Title III services.  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 Figure 2).
section_title: Actions Needed to Reduce Administrative Overlap among Domestic Food Assistance Programs
paragraphs: In part because food insecurity is a national problem that affects not only  older adults but also many other vulnerable groups, the federal  government spent more than $90 billion on domestic food assistance  programs in 2010. This represents an increase of approximately 44 percent  over 2008 spending, driven largely by increased spending on the SNAP. We  identified 18 different federal programs that provide nutrition assistance,  programs that emerged piecemeal over the past several decades to address  a variety of needs. Agency officials and local providers have indicated that  the multiple food assistance programs work together and provide various  points of entry to the system to help increase access to food for vulnerable  or target populations at high risk of malnutrition or hunger. Those officials  and providers told us that, since no one program alone is intended to meet  a household’s full nutritional needs, the variety of food assistance  programs can help households fill gaps and address the specific needs of  individual members. However, we have previously reported signs of  overlap and inefficient use of resources in the delivery of benefits through  these programs. In addition to the Departments of Agriculture (USDA),  Health and Human Services (HHS), and Homeland Security (DHS)  multiple state and local government and nonprofit organizations work  together to administer a complex network of programs and providers.
We have found that some of these programs, including those serving older  adults, provide comparable benefits to similar or overlapping populations.  For example, the Elderly Nutrition Program administered by the  Administration on Aging (AoA), provides home-delivered and congregate  meals primarily to individuals 60 years and older. Separately, other  programs administered by USDA, including the Commodity Supplemental  Food Program, targets a similar population, providing food to older adults,  as well as women, infants and children who are also served by the Special  Supplemental Nutrition Program for Women, Infants, and Children (WIC).  program. In addition, individuals eligible for groceries through the  Commodity Supplemental Food Program or services through the Elderly  Nutrition Program may also be eligible for groceries through the  Emergency Food Assistance Program and for targeted benefits that are  redeemed in authorized stores through the largest program, SNAP. In fact,  a recent AoA report conducted by Mathematica found that seven percent  of congregate meal recipients and 16 percent of home-delivered meal  recipients were also receiving SNAP benefits. The availability of multiple  programs with similar benefits helps ensure that those in need have access  to nutritious food, but can also increase administrative costs, which  account for approximately a tenth to more than a quarter of total costs  among the largest of these programs. In addition, our previous work has  shown that overlap among programs can lead to inefficient use of federal  funds, duplication of effort, and confusion among those seeking services.
We have found in previous work that despite the potential benefits of  varied points of entry, program rules related to determining eligibility  often require the collection of similar information by multiple entities.  For example, an older adult might apply for congregate meals through the  Elderly Nutrition Program at their local area agency on aging, electronic  benefits through SNAP at the Health and Human Services office, and  vouchers for fresh fruit and vegetables through the Senior Farmers’  Market Nutrition Program at a local food bank. Most of the 18 programs  have specific and often complex administrative procedures that federal,  state, and local organizations follow to help manage each program’s  resources. According to our previous work and state and local officials,  rules that govern these and other nutrition assistance programs often  require applicants who seek assistance from multiple programs to submit  separate applications for each program and provide similar information  verifying, for example, household income. This can create unnecessary  work for both providers and applicants and may result in the use of more  administrative resources than needed.
Moreover, not enough is known about the effectiveness of many of these  programs. Research suggests that participation in 7 of the 18 programs—  including the Elderly Nutrition Program and SNAP—is associated with  positive health and nutrition outcomes consistent with programs’ goals.  For example, studies on the Elderly Nutrition Program found that the  program increases socialization and may have a positive effect on food  security. In addition, research suggests the program improves participants’  dietary and nutrient intake—an outcome related to the program’s goal of  promoting the health and wellbeing of older individuals by assisting such  individuals to gain access to nutrition and other disease prevention and  health promotion services to delay the onset of adverse health conditions  resulting from poor nutritional health or sedentary behavior. However,  little is known about the effectiveness of the remaining 11 programs  because they have not been well studied.
Agencies do regularly collect performance and other data on nutrition  assistance programs but these data are not sufficient to determine  program effectiveness and do not always provide all the information  needed to effectively and efficiently manage their programs. Agency data  show that the 11 less-studied programs provide food and nutrition  assistance to millions of individuals and households each year—an  outcome related to their goals—however, this alone does not demonstrate  the overall effectiveness of these programs. Other data—such as on need  and unmet need for services—could help agencies better target limited  resources and more efficiently serve their target populations but agencies  often do not have this information. For example, while 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,  AoA does not provide standardized definitions or measurement  procedures for need and unmet need that all states are required to use.  Instead, AoA provides states with non-binding guidance on these issues  and an assortment of tools and resources that they can use to evaluate  need and limited information about measuring unmet need. States use a  variety of approaches to measure need and measure unmet need to  varying extents, but no agencies that we spoke with fully estimate the  number of older adults with need and unmet need in their service area.  Such information could help providers make informed decisions about  serving those most in need as the number of older adults increases and  resource constraints are likely to continue.
In April 2010, we recommended that USDA, as the principal administrator  of the federal government’s food assistance programs, identify and  develop methods for addressing potential inefficiencies among food  assistance programs and reducing unnecessary overlap among its smaller  food assistance programs while ensuring that those who are eligible  receive the assistance they need. These methods could include conducting  a study as a first step; convening a group of experts; identifying which of  the lesser-studied programs need further research and taking steps to fill  the research gap; or identifying and piloting proposed changes.
Further, in February 2011 we recommended that, to help ensure that  agencies have adequate and consistent information about older adults’  needs and the extent to which they are met, the Secretary of Health and  Human Services partner with other government agencies that provide  services to older adults 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.
In addition to our specific recommendations to USDA and HHS, we have  also noted in prior work that agencies can reduce program inefficiencies  by broadening their efforts to simplify, streamline, or better align eligibility  procedures and criteria across programs to the extent that it is permitted  by law. Consolidating or eliminating overlapping programs also have the  potential to reduce administrative costs but may not reduce spending on  benefits unless fewer individuals are served as a result. More broadly,  essential to all these efforts is collaboration among many entities.  Achieving meaningful results in many policy and program areas, including  food and nutrition services, requires some combination of coordinated  efforts among various actors across federal agencies with other  governments at state and local levels and nongovernmental organizations.
section_title: Conclusion
paragraphs: In conclusion, as I have outlined in my testimony, opportunities exist to  streamline and more efficiently carry out these important domestic food  assistance programs. Specifically, addressing duplication, overlap, and  fragmentation could help to minimize the administrative burdens faced by  those entities—including states and localities as well as nonprofit  organizations—that are delivering these programs’ services. Such  administrative burdens range from eligibility requirements and the  application process to costs associated with carrying out the program and  reporting requirements. Improving consistency among these various  requirements and processes as well as considering how multiple agencies  could better coordinate their delivery of programs could result in benefits  both for those providing and those receiving the services. In addition,  collection of adequate and consistent information about older adults’  needs and the extent to which they are met could help providers make  informed decisions about serving those most in need. It is particularly  important to use resources efficiently given that the need for meals  programs among low-income older adults will likely continue to outpace  available services given the growing older population and continued  economic constraints.
Careful, thoughtful actions will be needed to address issues involving  potential duplication, overlap, and fragmentation among federal programs  and activities. These are difficult issues to address because they may  require agencies and Congress to re-examine within and across various  mission areas the fundamental structure, operation, funding, and  performance of a number of long-standing federal programs or activities.  Continued oversight will be critical to ensuring that unnecessary  duplication, overlap, and fragmentation are addressed.
Thank you, Mr. Chairman, Ranking Member Paul, and Members of the  Subcommittee. This concludes my prepared statement. I would be pleased  to answer any questions you may have.
For further information on this testimony, please contact Kay Brown,  Director, Education, Workforce, and Income Security, who may be  reached at (202) 512-7215, or BrownKE@gao.gov.
section_title: Appendix I: Selected Federal Food and Nutrition Assistance Programs, by Agency
paragraphs: Child and Adult Care Food Program    Community Food Projects Competitive Grant Program  Food Distribution Program on Indian Reservations   Fresh Fruit and Vegetable Program    Nutrition Assistance for Puerto Rico    Senior Farmers’ Market Nutrition Program  12.    Supplemental Nutrition Assistance Program (SNAP)
The Emergency Food Assistance Program   15.    WIC Farmers’ Market Nutrition Program  DHS Federal Emergency Management Agency  16.    Emergency Food and Shelter National Board Program  17.    Elderly Nutrition Program: Home-Delivered and Congregate Nutrition Services  18.    Grants to American Indian, Alaska Native, and Native Hawaiian Organizations for Nutrition and Supportive Services  nity Food Project Competitive Grnt Progrm i dminitered y the Ntionl Intitte  of Food nd Agricltre (formerly the Coopertive Ste Rerch, Edtion, nd Extenion Service,  CSREES) of USDA. All other USDA progr lited above re dminitered y the Food nd  Ntrition Service. Commnity Food Project Competitive Grnt Progrm prticiption informtion i  from CSREES Updte: Septemer 17, 2009, Office of the Adminitrtor, CSREES, USDA.
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