Older Americans Act: Title III Nutrition Services Program
Released: 2014-03-24T00:00:00

The elderly nutrition services program, authorized under Title III of the Older Americans Act (OAA), provides grants to state agencies on aging to support congregate and home-delivered meals to people aged 60 and older. The program is the largest component of the act, accounting for $814.7 million, over 44%, of the act's total FY2014 funding of $1.871 billion. The program is designed to address problems of food insecurity, promote socialization, and promote the health and well-being of older persons through nutrition and nutrition-related services. It evolved from demonstration projects first funded in 1968. In 1972, Congress authorized the program as a separate title of the act and, in 1978, incorporated it into Title III. In 2006, Congress enacted P.L. 109-365 , which extended the act's authorizations of appropriations through FY2011. However, Congress has continued to appropriate funding for OAA activities. The 113 th Congress may consider reauthorization of the OAA and as a result may modify existing authorities, including those related to the nutrition services program.

This report describes the nutrition services program authorized under Title III of the Older Americans Act. Other federal and state programs, such as the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) and the Seniors Farmers' Market Nutrition Program, may provide similar nutrition services to older adults who meet certain income and other requirements. These programs, administered by the U.S. Department of Agriculture (USDA), are not the focus of this report. For further information on the range of domestic food assistance programs, see CRS Report R42353, Domestic Food Assistance: Summary of Programs , by [author name scrubbed] and [author name scrubbed].

Purpose

The Older Americans Act Amendments of 2006, P.L. 109-365 , added a new purpose statement for the nutrition services program emphasizing its nutritional and socialization aspects, as well as its importance in promoting the health of older people. The purposes of the program as stipulated in the law are 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 them to access 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. According to USDA analysis of Current Population Survey (CPS) data, 8.8% of U.S. households with one elderly member were food insecure in 2012, defined as households reporting low or very low food security. Households in which elderly lived alone reported a slightly higher rate of food insecurity, at 9.1% in 2012.

Nutrition Services Program

The Administration on Aging (AOA) in the Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) administers the nutrition services program, which includes (1) the Congregate Nutrition Services Program, (2) the Home-Delivered Nutrition Services Program, (3) and the Nutrition Services Incentive Program (NSIP). For the Congregate and Home-Delivered Programs, services must be targeted at persons with the greatest social and economic need, with particular attention to low-income older persons, including low-income minority older persons, older persons with limited English proficiency, older persons residing in rural areas, and older persons at risk for institutionalization. Means tests for program participation are prohibited, but older persons are encouraged to contribute to the costs of nutrition services, including meals. Older individuals may not be denied services for failure to contribute. The following describes these programs in greater detail.

Congregate Nutrition Services

Congregate nutrition services provide meals and related nutrition services to older individuals at a variety of sites, such as senior centers, community centers, schools, and adult day care centers. Congregate nutrition service providers can also offer a variety of nutrition related services at meal sites, such as nutrition education and screening, nutrition assessment, and counseling as appropriate. The program also provides seniors with opportunities for social engagement and volunteer opportunities.

Individuals aged 60 or older and their spouses of any age may participate in the congregate nutrition program. The following groups may also receive meals: persons under age 60 with disabilities who reside in housing facilities occupied primarily by the elderly where congregate meals are served; persons with disabilities who reside at home with, and accompany, older persons to meals; and volunteers who provide services during the meal hours.

In FY2011, the most recent year for which data are available, almost 4 in 10 meals (39%) were served in congregate settings. These meals were served to two-thirds of all OAA nutrition program participants. A total of 85.9 million congregate meals were served to more than 1.6 million meal participants (see Figure 1 ).

Home-Delivered Nutrition Services

Home-delivered nutrition services (commonly referred to as "meals on wheels") provide meals and related nutrition services to older individuals with priority to homebound older individuals. According to AOA, home-delivered meals are often the first in-home service that an older adult receives, and the program is a primary access point for other home and community-based services. Like congregate nutrition service providers, home-delivered service providers can offer services such as nutrition screening and education, nutrition assessment, and counseling as appropriate. Home-delivered meals are also an important service for many family caregivers as they may assist family members with their caregiving responsibilities and, for some, help them maintain their own health and personal well-being.

Individuals aged 60 or older and their spouses of any age may participate in the home-delivered nutrition program. Services may be available to individuals who are under age 60 with disabilities if they reside at home with the older individual. In FY2011, approximately 6 in 10 meals (61%) were home-delivered. These meals were delivered to one-third of all OAA nutrition program participants. A total of 137.2 million home-delivered meals were provided to just under 847,000 meal participants (see Figure 1 ).

Congregate meal participants represent a larger proportion of all meal participants but a smaller proportion of total meals served. On the other hand, home-delivered meal participants are relatively fewer but likely to receive more meals. Many home-delivered meals participants receive more than one meal delivered during a week. Congregate meal settings are designed to serve many participants but may serve meals less frequently. In addition, congregate meal participants may partake in meals on a less than frequent basis, compared to home-delivered meals participants.

Nutrition Services Incentive Program

The Nutrition Services Incentive Program (NSIP) provides funds to states, territories, and Indian tribal organizations to purchase food or to cover the costs of food commodities provided by the USDA for the congregate and home-delivered nutrition programs. Originally established by the OAA in 1974 as the Nutrition Program for the Elderly and administered by USDA, Congress transferred the administration of NSIP from USDA to AOA in 2003. However, states and other entities may still choose to receive all or part of their NSIP allotments in the form of commodities. Obligations for commodity procurement for NSIP are funded under an agreement between USDA and HHS.

Funding

The AOA awards separate allotments of funds for the congregate nutrition services program and home-delivered nutrition services program to states and U.S. territories. State agencies or State Units on Aging (SUAs), in turn, award nutrition services funds to the 618 Area Agencies on Aging (AAAs) that administer the program in their respective planning and service areas. The AOA also awards a separate allotment to states, territories, and Indian tribal organizations for NSIP funds.

Funds for congregate and home-delivered nutrition services are allotted to states and U.S. territories according to a formula based on each entity's relative share of the population aged 60 and over; however, the law stipulates that no entity is to receive less than it received in FY2006. States are required to provide a matching share of 15% in order to receive funds for congregate and home-delivered nutrition programs.

NSIP funds are allotted to states and other entities based on each state's share of total meals served by the nutrition services program (both congregate and home-delivered meals) in all states, U.S. territories, and tribes during the prior year. As previously mentioned, entities receive their share of NSIP funds in cash, but may elect to use some or all of their funds to purchase commodities through the USDA. Most entities choose to receive their share of funds in cash, rather than commodities. There is no matching requirement for NSIP funds.

In FY2014, of the total $814.7 million appropriated for the Title III nutrition services program, $438.2 million was for congregate nutrition (54%), $216.4 million for home-delivered nutrition (27%), and $160.1 million for nutrition services incentive grants (19%) ( Table 1 ). Funding for nutrition services represents 64% of FY2014 funding for Title III ($1.281 billion); Title III also funds a wide array of social services, family caregiver support activities, and disease prevention and health promotion services for older individuals.

When adjusted for inflation, the total amount of funding appropriated for OAA nutrition services has decreased substantially over the past two decades ($814.7 million for FY2014 compared to $1,052.4 million in FY1990). This decline in relative funding has been experienced by the congregate meals and NSIP programs, while funding levels for the home-delivered meals programs have increased over the same time period.

In constant 2014 dollars, the total appropriation for congregate meals, home-delivered meals, and NSIP fell from $1,052.4 million in 1990 to $814.7 million in 2014, a decline of $237.7 million, or 23%. The amount appropriated for congregate meals fell from $644.7 million to $438.2 million, a decline of $206.5 million, or 32%. The amount appropriated for NSIP fell from $262.9 million to $160.1 million, a decline of $102.8 million, or 39%. Only the amount appropriated for home-delivered meals increased in real terms from 1990 to 2014, rising from $144.7 million to $216.4 million, an increase of $71.7 million, or 50%.

Overall, this reduction in purchasing power has affected the number of meals served, which declined by 21.1 million meals (or 8.6%) from FY1990 to FY2011, the most recent year for which data are available. Over this same time period, the number of individuals age 60 and older has increased substantially from just under 42 million in1990 to about 62 million in 2013, an increase of almost 50%. Another way to look at the decline in purchasing power compared to the potential increase in demand for services is to compare per person spending in constant 2013 dollars, which has declined by about half during this time period. In 1990, total federal funding for nutrition services was about $25 per older individual, as compared to just over $12 per older individual in 2013.

It is important to note that OAA funding is not the only source of funding that state agencies use to provide nutrition services to older individuals. States rely on other funding sources, such as funding from other federal programs (e.g., Social Services Block Grant, Medicaid home- and community-based services), state and local governments, private sources, and clients. GAO found that OAA funds comprised an estimated 42% of local AAA's Title III program budgets for FY2009.

Meals Served

In FY2011, more than 223 million meals were provided to older adults (see Table 2 ). While overall the number of meals served has declined over the past two decades, proportionately the number of home-delivered meals served has increased. In FY1990, home-delivered meals represented 42% of total meals served, but by FY2011, the share had climbed to 62% of total meals. From 1990 to 2011, the number of home-delivered meals served grew by 35%, while the number of congregate meals served actually declined by 40%.

A number of reasons account for this, including the trend by states to transfer funds from their congregate services allotments to home-delivered services; greater growth in federal funding for home-delivered services relative to the congregate nutrition program funds; state initiatives to expand home care services for frail older persons; and successful leveraging of non-federal funds for home-delivered services.

With respect to state transfer of funds, as previously mentioned, states receive separate allotments for congregate and home-delivered nutrition services, as well as for supportive services. However, they are allowed to transfer allotted funds among these three programs (up to 40% of funds between congregate and home-delivered nutrition services allotments with waivers for higher amounts if approved by the Assistant Secretary for Aging; and up to 30% among supportive services and congregate and home-delivered nutrition services allotments). States may not transfer NSIP allotted funds among these programs.

In recent years, state funding transfers have resulted in a decrease of funds available for congregate nutrition services. In FY2012, states transferred $82.3 million out of their congregate nutrition services allotments to either the home-delivered nutrition or supportive services allotments. These funding transfers resulted in a decrease of 18.8% in funds that were originally allotted to states for the congregate program. As a result of funding transfers, available funds for home-delivered meals and supportive services increased by 14.7% and 13.8%, respectively. State initiatives to respond to the demand for home-based services by frail homebound older persons are an important factor in their decisions to transfer funds. According to GAO, state and local officials reportedly moved funds out of congregate meals because of a greater need for home-delivered meals and supportive services.

AOA data show that for FY2011, the U.S. average expenditure for congregate meals was $7.31, ranging from $1.56 in Puerto Rico to $18.81 in Alaska. The average expenditure for home-delivered meals in 2011 was $5.61, ranging from $1.66 in Puerto Rico to $12.61 in Alaska.

Service Delivery Requirements

Congregate and home-delivered nutrition services providers are required to offer at least one meal per day, five or more days per week (except in rural areas where less frequency is allowed). Meals provided must comply with the Dietary Guidelines for Americans published by the Secretary of HHS and the Secretary of Agriculture. Providers must serve meals that meet certain dietary requirements based on the number of meals served by the project each day. Providers that serve one meal per day must provide to each participant a minimum of one-third of the daily recommended dietary reference intakes (DRIs) established by the Food and Nutrition Board of the Institute of Medicine (IOM). Providers that serve two meals per day must provide a minimum of two-thirds of the DRIs, and those that serve three meals per day must provide 100% of the DRIs. Providers must provide meals that comply with state or local laws regarding safe and sanitary handling of food, equipment, and supplies that are used to store, prepare and deliver meals, and must carry out meal programs using the advice of dietitians and meal participants. The law requires providers to offer nutrition screening and education to participants, and where appropriate, nutrition assessment and counseling. Providers are encouraged to make arrangements with schools and other facilities serving meals to children in order to promote intergenerational meals programs.

P.L. 109-365 noted that while diet is the preferred source of nutrition, evidence suggests that the use of a single daily multivitamin-mineral supplement may be an effective way to address poor nutrition among older people. Also, it noted that Title III nutrition service providers should consider whether congregate and home-delivered participants would benefit from a multivitamin-mineral supplement that is in compliance with government quality standards and that provides at least two-thirds of essential vitamins and minerals at 100% of daily value levels as determined by the Commissioner of Food and Drugs. The act, however, did not authorize Title III providers to actually provide a daily vitamin to meals participants.

Program Participation

A National Survey of OAA participants shows that in 2012, 53% of congregate nutrition survey respondents were age 75 and older; 46% lived alone; 11% had annual income of $10,000 or less; more than half (51%) reported that the congregate meals program provided one-half or more of their daily food intake. Furthermore, many congregate nutrition recipients reported these meals have fostered greater socialization, with 81% saying that they see friends more often due to meals.

This 2012 survey found that 70% of home-delivered respondents were age 75 and older; 58% lived alone; 22% had annual income of $10,000 or less; and 54% said that the home-delivered meals program provided at least one-half of their daily food intake. According to the survey, home-delivered meals recipients are particularly frail and are at risk for institutionalization, in part due to the requirement that participants be homebound. Almost four out of ten recipients (38%) reported needing assistance with one or more activities of daily living (ADLs, such as bathing, dressing, eating, and using the toilet); 11% of these recipients needed assistance with three or more ADLs. In addition, 83% reported needing assistance with one or more instrumental activities of daily living (IADLs, such as shopping, telephoning, housework, and getting around inside the home).

Program Evaluation

The last major national evaluation of the nutrition program was completed in 1996. It showed that, compared to the total elderly population, nutrition program participants were older and more likely to be poor, to live alone, and to be members of minority groups. Almost half of home-delivered meal recipients and more than one-third of congregate meal recipients had income below the federal poverty level, compared to about 15% of the total U.S. population age 60 and over (at the time of the evaluation). Recipients were also more likely to have health and functional limitations that place them at nutritional risk. The report found the program plays an important role in participants' overall nutrition and that meals consumed by participants are their primary source of daily nutrients. The evaluation also found that the program leverages a fairly significant amount of nonfederal dollars: for every federal dollar spent, the program leveraged (at that time) on average $1.70 for congregate meals, and $3.35 for home-delivered meals from a variety of sources, including state, local, and private funds as well as participant contributions toward the cost of meals.

The 2006 reauthorization legislation stipulated that the Institute of Medicine (IOM) conduct an evidence-based study of the program. The study is to include (1) an evaluation of the effect of nutrition projects on the health and nutrition status of participants, prevention of hunger and food insecurity, and ability of participants to remain living independently; (2) a cost-benefit analysis of nutrition projects, including their potential to affect Medicaid costs; and (3) recommendations on how nutrition projects may be modified to improve outcomes, and the nutritional quality of meals. To date, AOA has not conducted this study. However, prior to the 2006 reauthorization AOA had begun the process to conduct a new evaluation of the Title III nutrition services program. According to AOA, this evaluation will contain (1) an evaluation of program impacts on participants' nutrition, health and well-being, socialization, and food insecurity; (2) a cost analysis that describes the cost per meal by cost categories and method of meal production; and (3) a process evaluation that examines the implementation of the program at the state and local levels and includes an assessment of the nutritional quality of the program meals. The participant outcomes component will involve a matched comparison group and similar survey methods as those used in the National Health and Nutrition Examination Study (NHANES) to allow for comparison of research results to the previous evaluation, a matched comparison group, and national estimates from NHANES and other national data.

Issues for Congress

As the nation prepares for a growing older population and potential increase in demand for health and social services that can promote the well-being of older persons to assist them in living independently in the community, ensuring access to home- and community-based long-term services and supports will likely be an issue for federal policymakers. The OAA Amendments of 2006 ( P.L. 109-365 ) authorized appropriations for OAA-funded activities, including the Title III nutrition programs, through FY2011. The 113 th Congress may choose to reauthorize the act. In doing so, federal policymakers may consider amending or deleting existing authorities under the act or establishing new authorities, including those related to nutrition services. In addition, Congress will likely consider annual appropriations for these activities.

The following sections discuss several issues for congressional consideration, such as measuring unmet need for nutrition services, additional funding flexibility, and increased cost-sharing. These issues were among those discussed by GAO in its February 11, 2011 report, Older Americans Act: More Should Be Done to Measure the Extent of Unmet Need for Services (GAO-11-23711), and in GAO testimony before the Subcommittee on Primary Health and Aging, Senate Committee on Health, Education, Labor, and Pensions on June 21, 2011 (GAO-11-782T).

Unmet Need

According to a national analysis by GAO, meals services provided in 2008 served some, but not most, low-income older adults who are likely in need of such services. State agency officials identified several reasons why an older adult may need but not receive meals services, including (1) greater demand for home-delivered meals than available funds can provide, (2) lack of knowledge or awareness among eligible older adults that meals services exist, and (3) lack of appeal with the meals served or the time of day meals are provided in congregate settings.

Overall, GAO found that the lack of federal guidance and data make it difficult for states to estimate the full extent of need and unmet need for OAA Title III services, including nutrition services. The OAA requires that AOA design and implement uniform data collection procedures for states to assess receipt of services, as well as need and unmet need for Title III services. Although AOA does provide uniform procedures for states to measure receipt of services, the agency does not provide standardized definitions or measurement for states to use in measuring need or unmet need for services. As a result, states use a variety of approaches that are often limited in their ability to fully estimate need and unmet need among older adults. These approaches include maintaining waitlists, obtaining information and data from service providers, and surveying current recipients. GAO recommends that HHS partner with governmental agencies that provide services to older Americans and convene researchers and agency officials to develop consistent definitions of need and unmet needs for uniform data collection purposes.

Funding Flexibility

Most states and a number of AAAs use the statutory flexibilities under current law to transfer funding among Title III programs. According to GAO, some states recommended consolidating funding for nutrition services programs into one single funding stream. However, other state officials did not see the need to alter the current process for transferring Title III funds. The AOA also identifies consolidating nutrition program funding between home-delivered and congregate nutrition programs as a targeted change for the next OAA reauthorization, so as to allow "states more flexibility to direct services to identified needs, and allow more local input into funding allocations."

Congress may consider whether additional flexibilities are necessary, possibly consolidating Title III funding streams or increasing the proportion of funds available for states and AAAs to transfer, affording those entities that choose to transfer funds greater latitude to do so. Conversely, Congress may be concerned that funding transfers provide states and AAAs the ability to reallocate funding to services at a level different than otherwise appropriated. As a result, Congress may seek to further specify or limit funding flexibility. Congress may also decide that funding flexibilities under current law are sufficient for states and AAAs current needs and choose to maintain the status quo.

Client Cost-Sharing

Clients can, and some do, contribute to the cost of their meals. GAO found that almost all local AAAs permit voluntary contributions for Title III services, including the nutrition services program. For FY2009, voluntary contributions comprised 4% of AAA budgets. Some AAAs indicated to GAO that voluntary contributions make up a significant portion of their nutrition services program budget. Although the OAA authorizes states to implement cost-sharing as a requirement for some Title III services, the act does not permit cost-sharing as a requirement for participation in congregate and home-delivered meals programs. According to GAO, additional cost-sharing arrangements could provide additional funding for Title III programs. GAO also recommends that the HHS Secretary study the implementation of cost-sharing for OAA services with respect to "the real and perceived burdens to implementing cost sharing for OAA services," which could include recommending legislative changes to the act. The AOA also identifies expanding consumer contributions as a targeted change for the next OAA reauthorization. Under this proposal, states could request a waiver to test either cost-sharing for nutrition and case management services, or to deny service to an individual for failure to make cost-sharing payments. Prior to waiver approval, states would be required to demonstrate no negative results from cost-sharing implementation. Furthermore, low-income individuals would continue to be excluded from these cost-sharing arrangements.