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.