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. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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. 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.