Older Americans Act:
More Should Be Done to Measure the Extent of Unmet Need for Services
GAO-11-237: Published: Feb 28, 2011. Publicly Released: Mar 30, 2011.
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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.
Recommendations for Executive Action
Status: Closed - Implemented
Comments: Since 2010, the Administration on Aging (AoA) has solicited input from thousands of consumers of Older Americans Act (OAA) services through online comments and over 60 listening sessions. As a result of this feedback, AoA developed a series of recommendations for OAA reauthorization, including a recommendation to expand state options for implementing cost-sharing. Specifically, AoA suggests expanding the range of services for which cost-sharing is permitted beyond the limited list of services OAA currently allows. States would need a waiver to test cost-sharing for nutrition and case management services and a waiver to deny service to an individual for failure to pay. In addition, states must demonstrate that there is no negative impact from implementing cost-sharing prior to waiver approval.
Recommendation: To maximize program resources during a time of increasing demand and fiscal constraints, the Secretary of Health and Human Services should 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.
Agency Affected: Department of Health and Human Services
Status: Closed - Not Implemented
Comments: The Administration on Aging (AoA) within the Administration for Community Living (ACL) has begun exploring how need and unmet need may be measured at the national level, but does not plan to develop consistent methods for measuring need and unmet need at the state level. ACL noted that estimating need and unmet need is complex because, for example, what qualifies as unmet need may vary based on individual circumstances. They stated that national level estimates of unmet need may be available through surveys such as the National Health and Aging Trends Study (NHATS). However, ACL declined to establish methods for estimating unmet need at the state level, citing the cost and complexity of replicating the NHATS methodology. As noted in our report, we recognize the complexity and potential challenges of estimating need and unmet need. However, we continue to believe that states will face ever-increasing demands for the services that exceed supply, and that that pursuing alternative, cost effective, methods of estimating need at the state level would help states and local providers better plan and direct scarce resources.
Recommendation: To help ensure that agencies have adequate and consistent information about older adults' needs and the extent to which they are met, the Secretary of Health and Human Services should 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.
Agency Affected: Department of Health and Human Services