Content created by Assistant Secretary for Legislation (ASL)
on
Older Americans Act Testimony
before
Senate Committee on Health, Education, Labor & Pension
Good afternoon, Chairman Sanders, Ranking Member Cassidy, and members of the Committee. Thank you for the opportunity to provide testimony on the Older Americans Act (OAA) and for the Committee’s longstanding support of the OAA programs and interest in healthy aging. I am pleased to share information today about the Administration for Community Living’s recent efforts to ensure our nation’s ability to meet the needs of the growing population of older adults by strengthening the OAA programs and the national aging services network that implements them. These include the first comprehensive update to the OAA regulations in more than 30 years and a number of partnerships to address the issues most important to older Americans.
I am Alison Barkoff, the Principal Deputy Administrator and senior official performing the delegable duties of the Assistant Secretary for Aging and Administrator of the Administration for Community Living (ACL) at the U.S. Department of Health and Human Services (HHS). ACL was created around the fundamental principle that older adults and people with disabilities of all ages should be able to live where they choose, with the people they choose, and with the ability to participate fully in their communities. ACL makes this principle a reality for millions of older adults through implementation of the OAA, working with and through the national aging services network of states, tribes, area agencies on aging (AAAs), local service providers, and volunteers who provide services that enhance the health, independence, and dignity of our country’s older adults.
OAA Programs Are Critical to Meeting the Needs of America’s Growing Aging Population
The OAA programs provide a range of community-based services to help older adults age in place, which is the preference of the vast majority of older adults, and to maintain their health and engagement in their communities. These services include home-delivered and congregate meals, support for family caregivers, preventive health services, personal and home care services, transportation, senior centers, legal assistance, elder abuse prevention, and so much more. In addition, the OAA provides ombudsman services for people who live in long-term care facilities. The OAA programs reach nearly one in five adults in the United States.
OAA services are effective in helping millions of older adults stay in their own homes and communities instead of having to enter long-term care facilities. For example, over 65 percent of caregivers who receive OAA services like respite care and peer support report that without OAA services, their high-risk care recipients likely would have had to enter a nursing home or assisted living facility. Similarly, 82 percent of people who participate in the congregate meals program and 92 percent of home-delivered meal recipients report that meals received through the programs allowed them to continue to live independently. Likewise, 66 percent of older adults using transportation services rely on them for the majority of their trips to doctors’ offices, pharmacies, meal sites, and other critical daily activities that help them to remain in the community. OAA services help prevent older adults from having to spend down to become eligible for Medicaid to enter a long-term care facility.
For nearly 60 years, the structure of the OAA programs has been a hallmark of its success. The OAA and its implementing regulations provide broad policy and guidance while allowing states, tribes, and AAAs the flexibility to work together to design programs that are responsive to local needs. In addition, the OAA programs are an incredible value with a strong return on investment; with every OAA dollar provided, the aging services network leverages another four dollars from state, local, and private sources.
Despite the excellent return on investment and the broad reach of the OAA programs, the demand for OAA services far exceeds capacity. While anyone over the age of 60 is eligible to participate in the OAA programs, not every older person needs the services and supports equally. That is why the OAA requires services to be targeted to older adults in the greatest economic and social need. This includes those who are low income, as well as those whose needs are caused by noneconomic factors, such as physical and mental disabilities, language barriers, and cultural, social, or geographic isolation, such as minority older individuals, older persons with limited English proficiency, older persons residing in rural areas, older persons with disabilities, and older individuals who are LGBTQ or living with HIV/AIDS. For example, over 92 percent of OAA program participants have multiple chronic conditions and are at risk for hospitalization; over 69 percent of case management clients take five or more medications; and more than 40 percent of home-delivered meal clients need support with three or more activities for daily living. In addition, five million older individuals live below the federal poverty level, many of whom are served by the OAA programs.
The demand for – and importance of – the OAA programs continues to grow as the population in the United States rapidly ages. Every seven seconds today, and for the next 20 years, someone in America will join the ranks of becoming an older adult; that is a rate of 10,000 a day, or the equivalent of a small town in America. One in six people are currently aged 65 or older, a 35 percent increase since 2010. By 2040, that number will increase to one in five people. Helping people age in place and avoid costly institutional care will only become more important.
Lessons Learned from the Pandemic and Updated Regulations Have Well-Positioned the Aging Services Network for the Future
Older adults were among the most impacted by the COVID-19 pandemic, at highest risk for severe complications, illness, and even death. The aging services network quickly pivoted with innovation and creativity, working with ACL to find new ways to use the OAA’s flexibilities to serve older adults. For example, they modified programs to provide contactless service, grab-and-go meals, and virtual wellness checks to assess needs and combat social isolation. Supplemental funding from Congress was also critical to their success. Throughout the pandemic, the aging services network increased coordination and forged new partnerships, including with public health and emergency management entities, faith-based organizations, and other community groups. At the federal level, ACL partnered with sister HHS agencies, including the Administration for Strategic Preparedness and Response (ASPR), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA), to bridge gaps, pool resources, and leverage each of our networks to meet the unique needs of older adults and address barriers to accessing vaccines, treatment, and supports and services.
The pandemic underscored the need for ACL to update the OAA regulations, which had last been updated in 1988. Rulemaking was an opportunity not only to imbed lessons learned from the pandemic, such as the importance of the flexibilities allowable under the OAA and of inclusive disaster preparedness and response, but also to provide guidance for programs that had been authorized after the last regulations, such as the family caregiver programs. ACL also used the rulemaking process to align the regulations with changes made during reauthorizations of the OAA, including clarifying and answering questions that had arisen in the field about statutory updates.
In updating the regulations, ACL sought the input of states, tribes, AAAs, service providers, and older Americans themselves. ACL held listening sessions and sought public comment through a formal request for information in May 2022 and a notice of proposed rulemaking in June 2023. During this process, ACL heard from commenters – including state agencies and AAAs – seeking greater clarity from ACL on various statutory requirements, including fiscal requirements. At the same time, commenters also underscored the importance of flexibility to address local community-level needs within the framework of the statute.
The final rule strikes this balance, and sets forth an updated, modern framework that reflects best practices from the field and strengthens the aging services network. The regulations make clear that state plans must describe how state agencies and AAAs will use OAA funding, and how requirements for public participation are met. They also require state agencies and AAAs to ensure coordination between programs that serve all older adults, including tribal elders. Other requirements clarify the state agency’s responsibility to establish and maintain policies and procedures to monitor the programmatic and fiscal performance of programs and activities.
The regulations also detail how greatest economic need and greatest social need are determined. Prioritizing people who have the greatest economic and social needs has always been a basic tenet of the OAA; the updated rule clarifies this requirement and sets expectations for serving these older adults and ensuring that their perspectives are incorporated into planning efforts by state agencies and AAAs. Consistent with ACL’s approach to rulemaking, this portion of the rule also gives states flexibility to include additional populations based upon local considerations.
The final rule addresses questions from the field about how the aging services network can engage in business relationships to expand their reach, such as partnering with health plans to deliver services to older adults that address their health-related social needs. The final rule sets forth the appropriate roles, responsibilities, and oversight of such activities, and requires state agencies to establish flexible and streamlined processes for AAAs to receive approval for contracts and commercial relationships. The provision is intended to promote and expand the ability of the aging network to engage in business activities while ensuring that the unique roles of OAA grantees are preserved. Relatedly, the regulations define “conflicts of interest” and establish several requirements to prevent them. These provisions are intended to ensure the integrity of – and trust in – the activities carried out under the OAA, while preserving the ability of the aging network to innovate and partner with other entities that serve older adults.
The final rule also modernizes the OAA’s senior nutrition programs. These essential programs not only reduce hunger and food insecurity, but they also improve health and address social isolation by providing opportunities for older adults to engage with other people and to be screened for other needs before they become crises. The COVID-19 pandemic both necessitated popular innovations across the programs and brought to light limitations in the previous regulations. For example, the new regulations clarify that home-delivered meals may be provided via home delivery, pick-up, carry-out, or drive-through; eligibility for home-delivered meals is not limited to people who are “homebound”; and home-delivered meal participants may also participate in congregate meals programs. The rule also clarifies that the OAA allows for grab-and-go meals to be provided through the congregate meals program in some circumstances. The regulation also clarifies requirements for transfers of funds between the congregate and home-delivered meals programs, as well as between the senior nutrition programs and supportive services and senior centers. These flexibilities allow states to tailor their programs to local needs and older adults’ preferences.
Just as the pandemic led to innovations in the senior nutrition program, it also required the aging services network to think creatively about other services, including senior centers. The pandemic showed that for many older adults, especially those living in rural areas, virtual senior center activities were welcomed and helped foster important social connections. In the process of seeking input from the field and stakeholders to inform the regulations, ACL heard from many participants that they prefer senior centers be a part of larger community centers, in part to encourage intergenerational opportunities. Based on this, ACL has been testing approaches to modernize senior centers, including transforming them into community hubs, expanding programming to support overall wellness, and improving their relevance to the current generation of older adults. The updated regulations provide flexibilities that will allow senior centers to evolve to continue to meet the needs and preferences of older adults.
The pandemic also highlighted that emergencies and disasters have disproportionate impacts on older adults and family caregivers, and often create unique challenges for the aging services network. However, the previous OAA regulations included limited guidance addressing these situations. The updated regulations create a new subpart regarding supports for older adults and family caregivers, including those in tribal communities, during emergencies and disasters. The new regulations require state agencies and AAAs to establish emergency plans and have policies and procedures in place for communicating and coordinating with state, tribal, and local emergency management entities within their jurisdictions. State agencies may set aside funding to exercise flexibilities during a major disaster declaration and procure items on a statewide level, subject to certain conditions. To further be responsive to the need for flexibility, the rule makes clear that the Assistant Secretary for Aging may modify emergency and disaster-related provisions in the regulation when a major disaster or public health emergency is declared.
The regulations also include important updates to OAA programs that protect the rights of older adults and prevent and address abuse and neglect. An estimated one in 10 adults over the age of 60 have experienced some form of elder abuse, which can reduce their quality of life and limit their independence. OAA programs play a critical role in promoting elder justice, ensuring that older adults can live safely in the community or in long-term care settings, and upholding older adults’ rights to participate in decisions about their lives. The regulations outline how states must ensure the independence of long-term care ombudsman programs that work to resolve problems related to the health, safety, welfare, and rights of individuals who live in nursing homes, assisted living facilities, and other residential care communities. The updates also specify that efforts related to guardianship must include assisting older adults with less restrictive, more person-directed decisional supports whenever possible. Our elder abuse work under the OAA is coordinated with ACL’s programs under the Elder Justice Act, including adult protective services (APS). We are in the process of the first-ever rulemaking for APS, following the first-ever annual appropriations for that program.
Finally, the updated OAA regulations provide guidance for the first time on the OAA’s family caregiver programs, which were added as part of the OAA’s 2000 reauthorization. The programs provide a range of supports, including counseling, case management, and respite care, to nearly 800,000 informal caregivers. Studies show that these services enable caregivers to provide care longer, making it possible for older adults to remain in their own homes and avoid or delay the need for costly institutional care. The regulations provide key definitions, implement statutory mandates, and clarify requirements for family caregiver support services, allowable uses of funds, and the method of funds distribution.
The final rule goes into effect on March 15, 2024, and the network has until October 1, 2025, to implement its changes. Over the coming months, ACL will continue to share resources and provide robust technical assistance to support states, tribes and tribal organizations, AAAs, and others in the aging services network in meeting the requirements of the new regulations. ACL also will work with states and other network partners in a supportive corrective action process if more time is needed to fully comply with specific provisions.
Through Partnerships, ACL and the Aging Services Network Are Helping Address the Most Pressing Issues Facing Older Adults
ACL and the aging services network are able to have an outsized impact on issues critical to older adults through partnerships, leveraging our programs and network and coordinating across federal government programs to ensure there is no duplication. For example, healthy aging is an important issue, particularly as people are living longer. ACL and the aging services network promote healthy aging by implementing an array of evidence-based and evidence-informed health promotion and disease prevention interventions – many developed by NIH and CDC – that have been proven to improve overall health, better manage chronic disease and illness, reduce falls and risks of injury, and reduce healthcare expenditures. Falls prevention interventions are a particular focus for ACL, given the significant financial, physical, and social impacts falls can cause. Under the authority granted in the most recent reauthorization of the OAA and with funding first provided in fiscal year 2023, ACL is designing a research, demonstration, and evaluation center to study an expanded set of effective falls prevention approaches that can be implemented by the aging services network. In addition, ACL is collaborating with more than a dozen federal agencies, including NIH and CDC, to create a strategic framework for a national plan on aging through the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities (ICC), an interagency working group created by Congress in the 2020 reauthorization of the OAA and that ACL recently launched after receiving funding for the ICC for the first time in fiscal year 2023.
Social isolation is an epidemic that poses serious health risks to millions of older adults. To increase the impact and reach of the OAA programs that address social isolation, ACL has partnered with the HHS Office of the Assistant Secretary for Health, the aging services network, and non-profit organizations to establish Commit to Connect, a cross-sector initiative to reach people who are socially isolated. Commit to Connect has catalyzed a nationwide network of champions to increase awareness and availability of programs and strategies that address social isolation and loneliness and to strengthen partnerships to leverage efforts, resources, innovations, and activities related to social isolation.
ACL is also partnering across the federal government to address one of the most pressing issues facing older adults – the direct care workforce crisis and its impact on family caregivers. Because of workforce shortages, many older adults who need services to remain in the community cannot get them, and those who do receive services often experience disruptions and inconsistent quality, both of which jeopardize the health and safety of the people receiving services and increase demands on family caregivers. ACL launched the Direct Care Workforce Strategies Center (Strategies Center) in collaboration with the Department of Labor, the Centers for Medicare & Medicaid Services (CMS), and the HHS Office of the Assistant Secretary for Planning and Evaluation. The Strategies Center provides technical assistance and resources to strengthen collaboration across state agencies (including aging, disability, Medicaid, and workforce development), direct care professionals, people receiving services, and other stakeholders in order to improve recruitment, retention, and development of this critical workforce. ACL just announced several intensive technical assistance opportunities available to states through the Strategies Center, funded in part by the fiscal year 2023 OAA funding Congress directed towards workforce issues.
Interagency partnership and collaboration with stakeholders also are critical to ACL’s efforts to support the more than 53 million family caregivers in the United States, including grandparents raising grandchildren. ACL facilitated the development of the first-ever National Strategy to Support Family Caregivers, submitted to Congress in September 2022, which included more than 300 commitments from almost 15 federal agencies and recommendations for state and local government, business, and other stakeholders. ACL is leading the implementation and update of the strategy. With OAA funding provided to ACL in fiscal year 2023, ACL recently awarded the first-ever Caregiver Projects of National Significance to focus on implementation of recommendations in the strategy by the aging services network.
Older adults are the fastest growing age group among those experiencing homelessness, currently comprising nearly half of the homeless population, and their numbers are estimated to triple by 2030. To address this serious issue, ACL leads the Housing and Services Resource Center (HSRC), a partnership between the Department of Housing and Urban Development (HUD) and HHS, to coordinate across the healthcare, aging, disability, housing, and homeless sectors the affordable housing and community services that many older adults and people with disabilities need to remain stably housed in the community. The HSRC is funded in part through the OAA Aging Network Support Activities, and the aging network is a key partner and beneficiary of the HSRC activities. Jointly funded by ACL, HUD, and the Substance Abuse and Mental Health Services Administration, the HSRC recently launched a year-long intensive technical assistance initiative with nine states focused on coordinating housing and services to address homelessness, including among older adults.
Inclusive disaster preparedness and response is another priority area where ACL and the aging services network are leveraging partnerships to meet the unique needs of older adults during disasters. Inability to evacuate, loss of services, inaccessible shelters, and other issues can result in unnecessary institutionalization, poor health outcomes, and even death for older adults during disasters. Through ACL initiatives and supplemental funding during the pandemic, the aging services network built partnerships with their state and local public health and emergency management agencies to provide expertise and fill gaps in addressing the needs of older adults. ACL has partnered with other federal agencies, including ASPR, CDC, HRSA, and the Federal Emergency Management Agency, to build upon and strengthen those partnerships. Recognizing the important role that ACL’s programs and the aging and disability networks can play in disasters, HHS has established a Disaster Human Services Coordinating Council, co-chaired by ACL, the Administration for Children and Families, and ASPR, with participation of over a dozen HHS agencies, and HHS’s legislative proposals related to disaster preparedness and response in the Fiscal Year 2024 President’s Budget include a disaster human services emergency fund that would allow the HHS Secretary to provide real-time funding during disasters to vulnerable populations, including people with disabilities, older adults, and children and families.
Finally, ACL and the aging services network closely collaborate with CMS and state Medicaid agencies and service providers on the delivery of Medicaid-funded home and community-based services (HCBS). Many in the aging network partner to expand the reach of the OAA programs by also providing HCBS to low-income older adults, and as discussed above, through commercial relationships with health plans, many are able to help address health-related social needs like food insecurity.
Conclusion
The OAA and its aging services network proves its worth every day in the lives of older adults throughout the country. The importance of the OAA programs and the demand for its services have never been stronger and both continue to grow as the American population rapidly ages. The OAA has a long history and strong record of providing cost-effective services that successfully help older adults remain in their own homes and communities and avoid unnecessary and costly care in long-term care facilities. Key to the OAA’s success has been the flexibility it provides to states to design programs responsive to local needs and the input received from older adults and the organizations that serve them. ACL is pleased to have had the opportunity to develop a comprehensive set of regulations that both maintains these critical features and the longstanding processes for effective stewardship of federal resources and provides new opportunities to modernize and strengthen the OAA programs. ACL is excited to implement these regulations in partnership with the aging services network to build on the decades of successful programming and to position the aging services systems in the United States for tomorrow’s challenges.
Thank you for the opportunity to participate in today’s hearing. ACL has appreciated the Committee’s support of the Older Americans Act and the national aging services network in the past, and we look forward to working with you in the future. I am happy to answer any questions you may have.