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United States Government Accountability Office: 
GAO: 

Report to the Chairman, Special Committee on Aging, U.S. Senate: 

February 2011: 

Older Americans Act: 

More Should Be Done to Measure the Extent of Unmet Need for Services: 

GAO-11-237: 

GAO Highlights: 

Highlights of GAO-11-237, a report to the Chairman, Special Committee 
on Aging, U.S. Senate. 

Why GAO Did This Study: 

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. 

What GAO Found: 

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. 

What GAO Recommends: 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-11-237] or key 
components. For more information, contact Kay Brown at (202) 512-7215 
or brownke@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Estimates Show That Many Older Adults Likely Needed but Did Not 
Receive Meals and Home-Based Care: 

Agencies Transfer Funds among Programs and Use Funds from Multiple 
Sources to Provide Services: 

Lack of Federal Guidance and Data Make It Difficult for States to 
Fully Estimate Need and Unmet Need: 

Conclusions: 

Recommendations: 

Agency Comments: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Percentages of Low-Income Older Adults Receiving Home- 
Delivered and Congregate Meals: 

Appendix III: Likely Need and Receipt of Home-Delivered or Congregate 
Meals: 

Appendix IV: Likely Need for, and Receipt of, Home-Based Care: 

Appendix V: Likely Need for Transportation Services: 

Appendix VI: Responses to Selected Questions from GAO Survey of Area 
Agencies on Aging (Local Agencies): 

Appendix VII: Comments from the Department of Health and Human 
Services: 

Appendix VIII: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Number of Clients Who Received OAA Services in Fiscal Year 
2008: 

Table 2: Total Expenditures for Title III Services in Fiscal Year 
2008, including OAA Funds and Other Sources: 

Table 3: Percentages of Low-Income Older Adults with Each 
Characteristic of Likely Need and Percentages Who Did and Did Not 
Receive Meals Services: 

Table 4: Estimated Proportion and Number of Older Adults in Likely 
Need Who Received and Did Not Receive Home-based Care in 2008: 

Table 5: CPS Questions Included on the Food Security Scale: 

Table 6: CPS Questions Used to Measure Social Interaction: 

Table 7: CPS Questions Used to Identify Functional Impairments That 
May Pose Difficulties for Obtaining or Preparing Food: 

Table 8: HRS Variables Used to Identify Likely Need for Home-based 
Care Services: 

Table 9: Percentages of Low-Income Older Adults Receiving Home- 
Delivered or Congregate Meals among Various Likely Need and 
Demographic Groups: 

Table 10: Numbers and Percents of Individuals in the Different 
Categories of the Study Variables (Weighted Data): 

Table 11: Percentages of Individuals with Various Characteristics That 
Were Food Insecure, and Percentages That Had Received Home-Delivered 
Meals, Congregate Meals, or Either Type of Meal in the Past 30 Days: 

Table 12: Percentages of Individuals with Various Characteristics That 
Had Received Home-Delivered Meals in the Past 30 Days, and Odds and 
Odds Ratios Derived from the Observed Data (Unadjusted Odds Ratios) 
and Multivariate Models (Adjusted Odds Ratios): 

Table 13: Percentages of Individuals with Various Characteristics That 
Had Received Congregate Meals in the Past 30 Days, and Odds and Odds 
Ratios Derived from the Observed Data (Unadjusted Odds Ratios) and 
Multivariate Models (Adjusted Odds Ratios): 

Table 14: Percentage of Older Adults Age 60 and above with Various 
Characteristics with One or More Difficulties with Living Activities, 
and Odds and Odds Ratios Derived from Them: 

Table 15: Percentage of Older Adults Age 60 and Above with Various 
Characteristics with One or More Difficulties with Daily Activities 
That Do Not Receive Assistance with Any Difficulties, and Odds and 
Odds Ratios Derived from Them: 

Table 16: Percentage of Older Adults Age 65 and above with Various 
Characteristics Who Were Likely to Need Transportation Services, and 
Odds and Odds Ratios Derived from Them: 

Figures: 

Figure 1: Flow of Title III Funds: 

Figure 2: Funding and Sources of Support for Home-and Community-Based 
Services for Older Adults: 

Figure 3: Average Yearly Fund Transfers among Title III Programs, 
Fiscal Years 2000 through 2008: 

Figure 4: Estimated Average Percentage of Funds from Various Sources, 
Fiscal Year 2009: 

Figure 5: Percent of Local Agencies Who Transferred Funds between OAA 
Title III Part B and Part C, Fiscal Year 2009: 

Figure 6: Percent of Local Agencies Permitting Voluntary 
Contributions, Fiscal Year 2009: 

Figure 7: Percent of Local Agencies in States Permitting Cost Sharing: 

Figure 8: Percent of Local Agencies Permitted to Cost Share Who Do So: 

Figure 9: Change in Local Agency Funding Sources from Fiscal Year 2009 
to Fiscal Year 2010: 

Figure 10: Change in Requests for Services Since the Start of Economic 
Downturn: 

Figure 11: Administrative Changes from Fiscal Year 2009 to Fiscal Year 
2010: 

Figure 12: Administrative Changes from Fiscal Year 2010 to Fiscal Year 
2011: 

Figure 13: Change in Title III Services from Fiscal Year 2009 to 
Fiscal Year 2010: 

Figure 14: Expected Change in Title III Services from Fiscal Year 2010 
to Fiscal Year 2011: 

Figure 15: Local Agency Use of Recovery Act Congregate Meal Funds: 

Figure 16: Local Agency Use of Recovery Act Home-Delivered Meal Funds: 

Figure 17: Local Agency Challenges in Using Recovery Act Meal Funds: 

Abbreviations: 

ADL: Activities of daily living: 

AoA: Administration on Aging: 

CPS: Current Population Survey: 

HHS: Department of Health and Human Services: 

HRS: Health and Retirement Study: 

IADL: Instrumental activities of daily living: 

NASUAD: National Association of States United for Aging and 
Disabilities: 

OAA: Older Americans Act: 

SNAP: Supplemental Nutrition Assistance Program: 

USDA: United States Department of Agriculture: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

February 28, 2011: 

The Honorable Herb Kohl: 
Chairman: 
Special Committee on Aging: 
United States Senate: 

Dear Mr. Chairman: 

The Older Americans Act of 1965 (OAA) was enacted to provide services 
to older adults and help them remain in their homes and communities. 
[Footnote 1] In fiscal year 2008, about 2.9 million people, 
constituting approximately 5 percent of the nation's population age 60 
and over, received select home-or community-based services through 
programs[Footnote 2] authorized and funded by Title III of the OAA. 
[Footnote 3],[Footnote 4] Programs funded by Title III grants and 
other sources provide a broad range of vital assistance to older 
adults, including congregate and home-delivered meals, home-based 
care, and transportation services. Such services, as well as services 
provided by caregivers, help older adults stay in their homes and 
communities as long as possible. In order to help meet the needs of 
this vulnerable population, in fiscal year 2009 and 2010 approximately 
$1.3 billion and $1.4 billion, respectively, was provided for grants 
to states for home-and community-based services under Title III of the 
OAA. In addition to Title III programs, older adults, especially those 
with low incomes, may also receive similar services through other 
federal and state programs. For example, Medicaid authorizes multiple 
programs that provide home-and community-based services to qualifying 
older adults.[Footnote 5] 

Demographic studies reveal that in the next few decades, older 
Americans will make up an increasing proportion of the country's 
population. Consequently, those eligible for and in need of services 
like those provided by Title III programs will increase as well. In 
fact, U.S. Census projections estimate the number of Americans age 65 
and over will increase from 40 million in 2010 to 72 million in 2030. 
[Footnote 6] At the same time, expected fiscal constraints at the 
national, state, and local levels may limit the funds available to 
provide assistance to the growing population of older adults in need. 
[Footnote 7] 

It is within this context and amid continued concerns about the 
effects of the recent economic recession on many older adults and the 
agencies that serve them that Congress prepares for reauthorization of 
the OAA, which is scheduled to occur in 2011. You asked us to 
evaluate: (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 
American Recovery and Reinvestment Act of 2009 (Recovery Act)[Footnote 
8] funds, to meet program objectives; and (3) how have government and 
local agencies measured need and unmet need. 

To respond to these questions, we analyzed data from national surveys 
to estimate the percentage of older adults with limited incomes who 
are likely to need home-delivered or congregate meals but not receive 
them[Footnote 9] and the percentage of older adults likely to need and 
not receive any home-based care. Further, we also estimated the 
percentage of older adults likely to need transportation services, 
although data limitations did not allow us to estimate transportation 
services received. We utilized self-reported data from older adults 
responding to the 2008 Current Population Survey (CPS) to estimate 
need for meals services and the 2008 Health and Retirement Study (HRS) 
for our estimates related to home-based care and transportation 
services.[Footnote 10] Existing national data limited the extent to 
which we could identify some groups and demographics of people who 
either did receive assistance, or likely needed assistance. For 
example, our estimates for meal services were limited to older adults 
who were low-income. However, while the information available from 
these surveys has limitations, these data provide important 
information about older adults eligible for and potentially in need of 
Title III services and we consider them reliable for our purposes. We 
also conducted a Web-based survey of a random sample of 125 local area 
agencies on aging (local agencies)--the frontline administrators of 
Title III services for older adults. We received completed survey 
responses from July through September 2010. The results of this survey 
are generalizeable to the 629 local agencies in the United States. In 
our survey we asked for information on requests for and use of 
services, use of funds, and the impact of the economic climate on 
requests and availability of Title III services. Ninety-nine local 
agencies responded to our survey, achieving a response rate of 79 
percent.[Footnote 11] Throughout this report, survey results are based 
on the number of local agencies responding to a particular question. 
We also reviewed Administration on Aging (AoA) program data,[Footnote 
12] 51 state plans on aging covering a 2-, 3-, or 4-year period that 
states and the District of Columbia submit to the Department of Health 
and Human Services (HHS), select needs assessments from states, and 
relevant federal regulations and laws. We conducted site visits to 
four states--Illinois, Massachusetts, Rhode Island, and Wisconsin--
where we interviewed officials from state and local agencies. We 
selected these four states due to variation in the sizes of their 
populations age 60 and over, demographics, Title III expenditures, and 
geographic regions. We also conducted telephone interviews with 
officials from an additional 10 states using the selection criteria 
from our site visits. Lastly, we interviewed national officials 
involved in Title III programs. For more information on our scope and 
methodology, see appendix I. 

We conducted this performance audit from December 2009 to February 
2011, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions. 

Background: 

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.[Footnote 13] While Title III programs are not entitlements, all 
people age 60 and over, or approximately 54 million individuals in 
2008, are eligible for services.[Footnote 14] 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.[Footnote 15] 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. 

Types of Services and Eligibility: 

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.[Footnote 16] 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.[Footnote 17] 

* 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[Footnote 18].: 

Table 1: Number of Clients Who Received OAA Services in Fiscal Year 
2008: 

Title III B support services: 

Service: Chore; 
Number of clients: 37,498. 

Service: Personal care; 
Number of clients: 93,252. 

Service: Homemaker; 
Number of clients: 162,343. 

Service: Assisted transportation; 
Number of clients: 38,906. 

Service: Adult day care; 
Number of clients: 24,616. 

Service: Case management; 
Number of clients: 475,833. 

Title III C nutrition services: 

Service: Home-delivered meals; 
Number of clients: 899,224. 

Service: Congregate meals; 
Number of clients: 1,643,052. 

Service: Nutrition counseling; 
Number of clients: 27,491. 

Title III E National Family Caregiver Support Program Services: 

Service: All caregivers served; 
Number of clients: 223,626. 

Source: Administration on Aging. 

Notes: These figures are for the 50 states and the District of 
Columbia. The counts include all individuals regardless of their 
relationship to the poverty threshold or other demographic 
characteristics. Except in the case of caregivers, the numbers above 
do not account for any duplication in cases where one individual 
receives more than one service. For example, an individual receiving 
both personal care, such as help with self-care, and chore services, 
such as help with heavy housework and yard work, would be counted 
under each service. Therefore, the numbers above cannot be added to 
determine the total number of older adults receiving Title III 
services. AoA separately estimates an unduplicated count of 
individuals receiving at least one of the Part B and Part C 
"registered" services listed above. In fiscal year 2008, this totaled 
approximately 2.9 million individuals. AoA only collects information 
about the number of older adults receiving certain types of Title III 
services. For example, it does not track the number of older adults 
receiving general transportation services; although it does track the 
number of units (i.e., rides) provided through general transportation 
services. 

[End of table] 

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.[Footnote 19] 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.[Footnote 20] 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).[Footnote 21] 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.[Footnote 22] 

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.[Footnote 23] 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.[Footnote 24] 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.[Footnote 25] 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 figure 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.[Footnote 26] 

Figure 1: Flow of Title III Funds: 

[Refer to PDF for image: flow-chart] 

Administration on Aging, HHS: 
to: 
State units on aging. 

State units on aging: 
to: 
Area agencies on aging: 
to: 
Local service providers; 
Direct services. 

State units on aging: 
to: 
Local service providers; 
Direct services. 

Source: GAO. 

[End of figure] 

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.[Footnote 27] 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.[Footnote 28] 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. 
[Footnote 29] Those funds were available for obligation through 
September 30, 2010,[Footnote 30] 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.[Footnote 31] 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).[Footnote 32] 

Table 2: Total Expenditures for Title III Services in Fiscal Year 
2008, including OAA Funds and Other Sources: 

Title III B support services: 

Service: Other services; 
Total expenditures[A]: $636.8 million. 

Service: Personal care; 
Total expenditures[A]: $312.4 million. 

Service: Homemaker; 
Total expenditures[A]: $259.3 million. 

Service: Case management; 
Total expenditures[A]: $256.6 million. 

Service: Transportation; 
Total expenditures[A]: $201.0 million. 

Service: Information and assistance; 
Total expenditures[A]: $146.2 million. 

Service: Adult day care/health; 
Total expenditures[A]: $95.5 million. 

Service: Legal assistance; 
Total expenditures[A]: $51.1 million. 

Service: Outreach; 
Total expenditures[A]: $25.2 million. 

Service: Chore; 
Total expenditures[A]: $19.3 million. 

Service: Assisted transportation; 
Total expenditures[A]: $17.9 million. 

Title III C nutrition services: 

Service: Home-delivered meals; 
Total expenditures[A]: $748.9 million. 

Service: Congregate meals; 
Total expenditures[A]: $631.2 million. 

Service: Nutrition education; 
Total expenditures[A]: $6.2 million. 

Service: Nutrition counseling; 
Total expenditures[A]: $2.9 million. 

Title III E National Family Caregiver Support Program Services: 

Service: Respite care; 
Total expenditures[A]: $109.7 million. 

Service: Access assistance; 
Total expenditures[A]: $42.4 million. 

Service: Supplemental services; 
Total expenditures[A]: $24.8 million. 

Service: Counseling; 
Total expenditures[A]: $22.1 million. 

Service: Information services; 
Total expenditures[A]: $17.6 million. 

Source: Administration on Aging. 

Note: These figures are for the 50 states and the District of Columbia. 

[A] As described above, agencies provide Title III services through a 
variety of funding sources including OAA allocations and state funds. 
The expenditures totals listed here account for expenditures from 
these various sources. 

[End of table] 

Other Sources of Support for Older Adults: 

Other federal and state programs provide services similar to Title 
III, particularly for low-income older adults.[Footnote 33] 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.[Footnote 34] SNAP is the nation's 
largest food assistance program, providing benefits to 2.7 million 
people age 60 and over in fiscal year 2009.[Footnote 35] 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. 
[Footnote 36] 

* 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.[Footnote 37] 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.[Footnote 38] 
Medicare also provides home-based services to some adults age 65 and 
over who are receiving Medicare skilled care services at home. 
[Footnote 39] 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. 
[Footnote 40] Medicaid, for example, reimburses qualified recipients 
for the transportation costs they incur to reach medical appointments. 
[Footnote 41] 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.[Footnote 42] 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. 
[Footnote 43] 

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. 
[Footnote 44] Figure 2 illustrates the various funding sources and 
programs that help older adults receive meals, home-based care, and 
transportation services. 

Figure 2: Funding and Sources of Support for Home-and Community-Based 
Services for Older Adults: 

[Refer to PDF for image: illustration] 

Title III federal programs (FY2010 allocations): 
* Part B: Home-based care and transportation: $366 million; 
* Part C: $654 million: includes: 
- Congregate meals ($438); 
- Home-delivered meals ($216); 
* Part E: Caregiver support: $153 million. 

Other funding sources for Title III programs (Varies by state): 
* State and local programs; 
* Private contributions; 
* Voluntary contributions from clients. 

Other programs for seniors that provide similar services: 
* Food assistance (SNAP, Seniors Farmers Market Nutrition Program, 
etc.); 
* Home-based care (Medicare and Medicaid); 
* Transportation (15 key federal programs). 

Source: GAO analysis of federal program data. 

[End of figure] 

Planning Process and Data Collection Efforts: 

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.[Footnote 45] 
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. 

Estimates Show That Many Older Adults Likely Needed but Did Not 
Receive Meals and Home-Based Care: 

Many Older Adults with Low Incomes Who Were Likely to Need Meals 
Programs Did Not Receive Them: 

The meals services provided in 2008 did not serve most of the low- 
income older adults likely to need them.[Footnote 46] 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[Footnote 47]. 
However, many more older adults likely needed services, but did not 
receive them, as shown in table 3.[Footnote 48] For instance, an 
estimated 19 percent of low-income older adults were food insecure 
[Footnote 49] and about 90 percent of these individuals did not 
receive any meal services.[Footnote 50] 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.[Footnote 51] An estimated 83 percent of those 
individuals with such difficulties did not receive meal services. (See 
table 3.) 

Table 3: Percentages of Low-Income Older Adults with Each 
Characteristic of Likely Need and Percentages Who Did and Did Not 
Receive Meals Services: 

Food security: 

Characteristics of likely need: Food secure; 
Have each characteristic: 81.4%; 
Received home-delivered meals: 3.3%; 
Did not receive home-delivered meals: 96.7%; 
Received congregate meals: 5.7%; 
Did not receive congregate meals: 94.3%; 
Received either type of meal: 8.3%; 
Received neither type of meal: 91.7%. 

Characteristics of likely need: Food insecure; 
Have each characteristic: 18.6%; 
Received home-delivered meals: 7.4%; 
Did not receive home-delivered meals: 92.6%; 
Received congregate meals: 4.9%; 
Did not receive congregate meals: 95.1%; 
Received either type of meal: 11.1%; 
Received neither type of meal: 88.9%. 

Numbers of difficulties with daily activities: 

Characteristics of likely need: None; 
Have each characteristic: 65.2%; 
Received home-delivered meals: 2.3%; 
Did not receive home-delivered meals: 97.7%; 
Received congregate meals: 5.1%; 
Did not receive congregate meals: 94.9%; 
Received either type of meal: 6.9%; 
Received neither type of meal: 93.1%. 

Characteristics of likely need: One; 
Have each characteristic: 18.0%; 
Received home-delivered meals: 3.6%; 
Did not receive home-delivered meals: 96.4%; 
Received congregate meals: 6.3%; 
Did not receive congregate meals: 93.7%; 
Received either type of meal: 8.8%; 
Received neither type of meal: 91.2%. 

Characteristics of likely need: Two or more; 
Have each characteristic: 16.8%; 
Received home-delivered meals: 11.5%; 
Did not receive home-delivered meals: 88.5%; 
Received congregate meals: 6.4%; 
Did not receive congregate meals: 93.6%; 
Received either type of meal: 16.7%; 
Received neither type of meal: 83.3%. 

Social isolation[A]: 

Characteristics of likely need: Less isolated; 
Have each characteristic: 31.8%; 
Received home-delivered meals: 2.5%; 
Did not receive home-delivered meals: 97.5%; 
Received congregate meals: 6.1%; 
Did not receive congregate meals: 93.9%; 
Received either type of meal: 7.9%; 
Received neither type of meal: 92.1%. 

Characteristics of likely need: More isolated; 
Have each characteristic: 41.4%; 
Received home-delivered meals: 5.0%; 
Did not receive home-delivered meals: 95.0%; 
Received congregate meals: 5.0%; 
Did not receive congregate meals: 95.0%; 
Received either type of meal: 9.0%; 
Received neither type of meal: 91.0%. 

Characteristics of likely need: Missing[B]; 
Have each characteristic: 26.8%; 
Received home-delivered meals: 4.5%; 
Did not receive home-delivered meals: 95.5%; 
Received congregate meals: 5.8%; 
Did not receive congregate meals: 94.2%; 
Received either type of meal: 9.7%; 
Received neither type of meal: 90.3%. 

Source: GAO analysis of 2008 CPS data. 

[A] We defined likely need for more social interaction as answering 
"no" to all of the questions in the CPS civic engagement supplement 
that asked about the older adult's participation in social activities. 
However, such survey data do can 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. (See appendix I for more information, 
including a full list of the survey questions included in our 
analysis.) 

[B] CPS questions related to social isolation were asked at a 
different time in the survey cycle than questions about receipt of 
meals services. Therefore, approximately 27 percent of the older 
adults with low incomes in our sample provided information about 
participation in meals programs, but not about participation in social 
groups. As a result, we could not measure whether they were more or 
less socially isolated. 

[End of table] 

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.[Footnote 
52] 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.[Footnote 53] 

Many People Age 60 and Older Who Had Difficulties with Daily 
Activities Received Limited or No Home-Based Care: 

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[Footnote 54] of older adults from all income levels reported 
difficulties with one or more activities such as walking or bathing. 
[Footnote 55] 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[Footnote 
56] programs and Medicaid or informally through family members. 
[Footnote 57] 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.[Footnote 58] 

Table 4: Estimated Proportion and Number of Older Adults in Likely 
Need Who Received and Did Not Receive Home-based Care in 2008: 

Type of difficulty: Difficulty with one or more IADLs; 
Percent and number who did not receive help with identified 
difficulties, from any source: 66 percent (4 million); 
Percent and number who received help with some, but not all identified 
difficulties, from any source: 10 percent (0.6 million); 
Percent and number who received help with all identified difficulties, 
from any source: 24 percent (1.5 million); 
Among those receiving any help, percent and number who received at 
least some help from professionals or organizations: 4 percent (0.1 
million). 

Type of difficulty: Difficulty with one or two ADLs[A]; 
Percent and number who did not receive help with identified 
difficulties, from any source: 48 percent (3.3 million); 
Percent and number who received help with some, but not all identified 
difficulties, from any source: 31 percent (2.1 million); 
Percent and number who received help with all identified difficulties, 
from any source: 22 percent (1.5 million); 
Among those receiving any help, percent and number who received at 
least some help from professionals or organizations: 8 percent (0.2 
million). 

Type of difficulty: Difficulty with three or more ADLs[A]; 
Percent and number who did not receive help with identified 
difficulties, from any source: 11 percent (0.3 million); 
Percent and number who received help with some, but not all identified 
difficulties, from any source: 68 percent (2.0 million); 
Percent and number who received help with all identified difficulties, 
from any source: 21 percent (0.6 million); 
Among those receiving any help, percent and number who received at 
least some help from professionals or organizations: 19 percent (0.5 
million). 

Source: GAO analysis of 2008 Health and Retirement Study. 

Note: The first three columns of each row may not add to 100 percent, 
due to rounding. 

[A] Individuals with one or more ADLs may or may not have any number 
of IADLs. 

[End of table] 

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.[Footnote 59] 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.[Footnote 60] 

Likely Need for Transportation Services Is Significant: 

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)[Footnote 61] were likely to need such 
services.[Footnote 62] 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.[Footnote 63] 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.[Footnote 64] 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.[Footnote 65] 

Agencies Transfer Funds among Programs and Use Funds from Multiple 
Sources to Provide Services: 

Agencies Transfer Funds among Title III Programs to Meet Needs, but 
Some Want Additional Flexibility: 

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.[Footnote 66] 
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 figure 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. 

Figure 3: Average Yearly Fund Transfers among Title III Programs, 
Fiscal Years 2000 through 2008: 

[Refer to PDF for image: illustration] 

Congregate meals: 
Transfers $34.4 million to Home delivered meals; 
Receives $87,000 from Home delivered meals; 
Transfers $32.6 million to Support Services; 
Receives $139,000 from Support Services. 

Home delivered meals: 
Transfers $3.5 million to Support Services; 
Receives $983,000 from Support Services. 

Source: GAO analysis of AoA Fiscal Year 2000-2008 State Program 
Reports. 

[End of figure] 

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. 

Title III Funding Is Supplemented by Other Funding Sources: 

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.[Footnote 67] 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. 

Figure 4: Estimated Average Percentage of Funds from Various Sources, 
Fiscal Year 2009: 

[Refer to PDF for image: vertical bar graph] 

Source of funding: OAA Title III; 
Average percentage of funding: 42%. 

Source of funding: Other OAA Titles; 
Average percentage of funding: 2%. 

Source of funding: Medicaid Home and Community Based Service Waivers; 
Average percentage of funding: 10%. 

Source of funding: Other federal programs; 
Average percentage of funding: 4%. 

Source of funding: State government; 
Average percentage of funding: 24%. 

Source of funding: Local or county government; 
Average percentage of funding: 8%. 

Source of funding: Voluntary client contributions; 
Average percentage of funding: 4%. 

Source of funding: Private sources; 
Average percentage of funding: 2%. 

Source of funding: Other; 
Average percentage of funding: 2%. 

Source: Analysis of GAO Survey of Area Agencies on Aging data. 

Note: The category "Other OAA Titles" could include funds from OAA 
Title IV research, training, and demonstration, OAA Title V the senior 
community service employment program, OAA Title VI grants for Native 
Americans, or OAA Title VII vulnerable elder rights protection 
activities. 

[End of figure] 

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.[Footnote 68] 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.[Footnote 69] 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.[Footnote 70] 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.[Footnote 
71] 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. 

Agencies Cut Costs and Utilized Recovery Act Funds to Cope with Recent 
Reductions in Funding: 

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.[Footnote 72] 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.[Footnote 73] 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.[Footnote 74] 
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. 

Lack of Federal Guidance and Data Make It Difficult for States to 
Fully Estimate Need and Unmet Need: 

States Lack Specific Guidance on How to Evaluate Need and Unmet Need: 

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.[Footnote 75] 
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.[Footnote 76] 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. 

State Agencies Assess Need and Some Assess Unmet Need, but None Fully 
Estimate the Number of Older Adults Likely in Need of Services: 

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.[Footnote 77] 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. 

Conclusions: 

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. 

Recommendations: 

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. 

Agency Comments: 

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 [hyperlink, 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. 

Sincerely yours, 

Signed by: 

Kay Brown: 
Director, Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

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.[Footnote 78] 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. 

Estimating Likely Need and Receipt of Meals Services: 

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.[Footnote 79] 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.[Footnote 80] 
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.[Footnote 81] 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[Footnote 82] about experiences and behaviors indicative of 
food insecurity (see table 5).[Footnote 83] 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. 

Table 5: CPS Questions Included on the Food Security Scale: 

Preamble to Q1: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: I worried 
whether our food would run out before we got money to buy more. 

Preamble to Q2: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: The food that 
we bought just didn't last, and we didn't have money to get more. 

Preamble to Q3: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: We couldn't 
afford to eat balanced meals. 

Preamble to Q4: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: In the last 12 
months, did you or other adults in your household ever cut the size of 
your meals or skip meals because there wasn't enough money for food? 

Preamble to Q5: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: How often did 
this happen--almost every month, some months but not every month, or 
in only one or two months? 

Preamble to Q6: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: In the last 12 
months, did you ever eat less than you felt you should because there 
wasn't enough money to buy food? 

Preamble to Q7: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: In the last 12 
months, were you ever hungry but didn't eat because you couldn't 
afford enough food? 

Preamble to Q8: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: Sometimes 
people lose weight because they don't have enough to eat. In the last 
12 months, did you lose weight because there wasn't enough food? 

Preamble to Q9: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: In the last 12 
months, did you or other adults in your household ever not eat for a 
whole day because there wasn't enough money for food? 

Preamble to Q10: 
Now I'm going to read you several statements that people have made 
about their food situation. Please tell me whether the statement was 
often, sometimes, or never true in the last 12 months: How often did 
this happen--almost every month, some months but not every month, or 
in only one or two months? 

Source: 2008 CPS. 

Note: Questions 4 and 5 and 9 and 10 were paired; questions 5 and/or 
10 would not have been asked of respondents who answered "No" to 
questions 4 and/or 9. 

[End of table] 

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).[Footnote 84] 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. 

Table 6: CPS Questions Used to Measure Social Interaction: 

Preamble: 
The next questions are about the groups or organizations in which 
people sometimes participate. I will read a list of types of groups 
and organizations. Please tell me whether or not you participated in 
any of these groups during the last 12 months, that is, between 
November 2007 and now: 

Q1: A school group, neighborhood, or community association such as PTA 
or neighborhood watch groups? 

Q2: A service or civic organization such as American Legion or Lions 
Club? 

Q3: A sports or recreation organization such as a soccer club or 
tennis club? 

Q4: A church, synagogue, mosque or other religious institutions or 
organizations, Not Counting your attendance at religious services? 

Q5: Any other type of organization that I have not mentioned? 

Source: 2008 CPS. 

[End of table] 

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. 

Table 7: CPS Questions Used to Identify Functional Impairments That 
May Pose Difficulties for Obtaining or Preparing Food: 

Because of a physical, mental, or emotional condition has difficulty 
doing errands alone such as visiting a doctor's office or shopping? 

Has serious difficulty walking or climbing stairs? 

Has difficulty dressing or bathing?. 

Because of a physical, mental, or emotional condition, has serious 
difficulty concentrating, remembering, or making decisions? 

Source: 2008 CPS. 

[End of table] 

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. 

Estimating Likely Need and Receipt of Home-Based Care and 
Transportation Services: 

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).[Footnote 85] 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).[Footnote 86] 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.[Footnote 87] 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.[Footnote 88] 
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. 

Table 8: HRS Variables Used to Identify Likely Need for Home-based 
Care Services: 

Homemaker and Chore (IADL): 
Difficulty preparing food; 
Difficulty grocery shopping; 
Difficulty making phone calls; 
Difficulty taking medication; 
Difficulty managing money. 

Personal Care (ADL): 
Difficulty dressing; 
Difficulty walking; 
Difficulty bathing; 
Difficulty eating; 
Difficulty getting in and out of bed; 
Difficulty using toilet. 

Source: 2008 HRS. 

[End of table] 

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. 
[Footnote 89] 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. 

Survey of Area Agencies on Aging (Local Agencies): 

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. 

Analysis of Expenditures Data: 

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. 

State Plan 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. 

Interviews with Agencies: 

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. 

[End of section] 

Appendix II: Percentages of Low-Income Older Adults Receiving Home- 
Delivered and Congregate Meals: 

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. 

Table 9: Percentages of Low-Income Older Adults Receiving Home- 
Delivered or Congregate Meals among Various Likely Need and 
Demographic Groups: 

Characteristic: Food security; 
Category: Food secure; 
Percent of low-income older adults: 81.4; 
Received home-delivered meals: 3.3; 
Did not receive home-delivered meals: 96.7; 
Received congregate meals: 5.7; 
Did not receive congregate meals: 94.3; 
Received either type of meal: 8.3; 
Did not receive either type of meal: 91.7. 

Characteristic: Food security;
Category: Food insecure; 
Percent of low-income older adults: 18.6; 
Received home-delivered meals: 7.4; 
Did not receive home-delivered meals: 92.6; 
Received congregate meals: 4.9; 
Did not receive congregate meals: 95.1; 
Received either type of meal: 11.1; 
Did not receive either type of meal: 88.9. 

Characteristic: Impairments; 
Category: None; 
Percent of low-income older adults: 65.2; 
Received home-delivered meals: 2.3; 
Did not receive home-delivered meals: 97.7; 
Received congregate meals: 5.1; 
Did not receive congregate meals: 94.9; 
Received either type of meal: 6.9; 
Did not receive either type of meal: 93.1. 

Impairments; 
Category: One; 
Percent of low-income older adults: 18; 
Received home-delivered meals: 3.6; 
Did not receive home-delivered meals: 96.4; 
Received congregate meals: 6.3; 
Did not receive congregate meals: 93.7; 
Received either type of meal: 8.8; 
Did not receive either type of meal: 91.2. 

Characteristic: Impairments; 
Category: Two or more; 
Percent of low-income older adults: 16.8; 
Received home-delivered meals: 11.5; 
Did not receive home-delivered meals: 88.5; 
Received congregate meals: 6.4; 
Did not receive congregate meals: 93.6; 
Received either type of meal: 16.7; 
Did not receive either type of meal: 83.3. 

Characteristic: Social isolation; 
Category: Less isolated; 
Percent of low-income older adults: 31.8; 
Received home-delivered meals: 2.5; 
Did not receive home-delivered meals: 97.5; 
Received congregate meals: 6.1; 
Did not receive congregate meals: 93.9; 
Received either type of meal: 7.9; 
Did not receive either type of meal: 92.1. 

Social isolation; 
Category: More isolated; 
Percent of low-income older adults: 41.4; 
Received home-delivered meals: 5.0; 
Did not receive home-delivered meals: 95.0; 
Received congregate meals: 5.0; 
Did not receive congregate meals: 95.0; 
Received either type of meal: 9.0; 
Did not receive either type of meal: 91.0. 

Characteristic: Social isolation; 
Category: Missing; 
Percent of low-income older adults: 26.8; 
Received home-delivered meals: 4.5; 
Did not receive home-delivered meals: 95.5; 
Received congregate meals: 5.8; 
Did not receive congregate meals: 94.2; 
Received either type of meal: 9.7; 
Did not receive either type of meal: 90.3. 

Characteristic: Food stamps; 
Category: No; 
Percent of low-income older adults: 86.8; 
Received home-delivered meals: 3.7; 
Did not receive home-delivered meals: 96.3; 
Received congregate meals: 5.3; 
Did not receive congregate meals: 94.7; 
Received either type of meal: 8.4; 
Did not receive either type of meal: 91.6. 

Characteristic: Food stamps; 
Category: Yes; 
Percent of low-income older adults: 13.2; 
Received home-delivered meals: 6.8; 
Did not receive home-delivered meals: 93.2; 
Received congregate meals: 6.9; 
Did not receive congregate meals: 93.1; 
Received either type of meal: 12.1; 
Did not receive either type of meal: 87.9. 

Characteristic: Age; 
Category: Under 60; 
Percent of low-income older adults: 8.9; 
Received home-delivered meals: 2.6; 
Did not receive home-delivered meals: 97.4; 
Received congregate meals: 3.0; 
Did not receive congregate meals: 97.0; 
Received either type of meal: 5.6; 
Did not receive either type of meal: 94.4. 

Characteristic: Age; 
Category: 60 to 69; 
Percent of low-income older adults: 38.1; 
Received home-delivered meals: 3.3; 
Did not receive home-delivered meals: 96.7; 
Received congregate meals: 4.2; 
Did not receive congregate meals: 95.8; 
Received either type of meal: 6.7; 
Did not receive either type of meal: 93.3. 

Characteristic: Age; 
Category: 70 to 79; 
Percent of low-income older adults: 32.2; 
Received home-delivered meals: 4.0; 
Did not receive home-delivered meals: 96.0; 
Received congregate meals: 6.4; 
Did not receive congregate meals: 93.6; 
Received either type of meal: 9.3; 
Did not receive either type of meal: 90.7. 

Characteristic: Age; 
Category: 80 plus; 
Percent of low-income older adults: 20.8; 
Received home-delivered meals: 6.3; 
Did not receive home-delivered meals: 93.7; 
Received congregate meals: 7.7; 
Did not receive congregate meals: 92.3; 
Received either type of meal: 13.4; 
Did not receive either type of meal: 86.6. 

Characteristic: Sex; 
Category: Male; 
Percent of low-income older adults: 38.7; 
Received home-delivered meals: 4.0; 
Did not receive home-delivered meals: 96.0; 
Received congregate meals: 4.6; 
Did not receive congregate meals: 95.4; 
Received either type of meal: 8.0; 
Did not receive either type of meal: 92.0. 

Characteristic: Sex; 
Category: Female; 
Percent of low-income older adults: 61.3; 
Received home-delivered meals: 4.1; 
Did not receive home-delivered meals: 95.9; 
Received congregate meals: 6.1; 
Did not receive congregate meals: 93.9; 
Received either type of meal: 9.4; 
Did not receive either type of meal: 90.6. 

Characteristic: Race; 
Category: White; 
Percent of low-income older adults: 80.8; 
Received home-delivered meals: 3.9; 
Did not receive home-delivered meals: 96.1; 
Received congregate meals: 5.3; 
Did not receive congregate meals: 94.7; 
Received either type of meal: 8.6; 
Did not receive either type of meal: 91.4. 

Characteristic: Race; 
Category: Black; 
Percent of low-income older adults: 13.6; 
Received home-delivered meals: 4.8; 
Did not receive home-delivered meals: 95.2; 
Received congregate meals: 6.3; 
Did not receive congregate meals: 93.7; 
Received either type of meal: 9.7; 
Did not receive either type of meal: 90.3. 

Characteristic: Race; 
Category: Other; 
Percent of low-income older adults: 5.6; 
Received home-delivered meals: 4.7; 
Did not receive home-delivered meals: 95.3; 
Received congregate meals: 7.4; 
Did not receive congregate meals: 92.6; 
Received either type of meal: 11.3; 
Did not receive either type of meal: 88.7. 

Characteristic: Hispanic origin; 
Category: Hispanic; 
Percent of low-income older adults: 13.2; 
Received home-delivered meals: 5.0; 
Did not receive home-delivered meals: 95.0; 
Received congregate meals: 5.9; 
Did not receive congregate meals: 94.1; 
Received either type of meal: 10.2; 
Did not receive either type of meal: 89.8. 

Characteristic: Hispanic origin; 
Category: Non-Hispanic; 
Percent of low-income older adults: 86.8; 
Received home-delivered meals: 3.9; 
Did not receive home-delivered meals: 96.1; 
Received congregate meals: 5.5; 
Did not receive congregate meals: 94.5; 
Received either type of meal: 8.7; 
Did not receive either type of meal: 91.3. 

Characteristic: Marital status; 
Category: Married; 
Percent of low-income older adults: 45.8; 
Received home-delivered meals: 2.3; 
Did not receive home-delivered meals: 97.7; 
Received congregate meals: 4.0; 
Did not receive congregate meals: 96.0; 
Received either type of meal: 5.9; 
Did not receive either type of meal: 94.1. 

Characteristic: Marital status; 
Category: Widowed; 
Percent of low-income older adults: 29.3; 
Received home-delivered meals: 6.1; 
Did not receive home-delivered meals: 93.9; 
Received congregate meals: 7.5; 
Did not receive congregate meals: 92.5; 
Received either type of meal: 12.6; 
Did not receive either type of meal: 87.4. 

Characteristic: Marital status; 
Category: Other; 
Percent of low-income older adults: 25.0; 
Received home-delivered meals: 5.1; 
Did not receive home-delivered meals: 94.9; 
Received congregate meals: 6.1; 
Did not receive congregate meals: 93.9; 
Received either type of meal: 10.0; 
Did not receive either type of meal: 90.0. 

Characteristic: Income; 
Category: Less than $10,000; 
Percent of low-income older adults: 16.1; 
Received home-delivered meals: 7.3; 
Did not receive home-delivered meals: 92.7; 
Received congregate meals: 7.3; 
Did not receive congregate meals: 92.7; 
Received either type of meal: 13.1; 
Did not receive either type of meal: 86.9. 

Characteristic: Income; 
Category: $10,000 -$19,999; 
Percent of low-income older adults: 40.0; 
Received home-delivered meals: 4.4; 
Did not receive home-delivered meals: 95.6; 
Received congregate meals: 6.5; 
Did not receive congregate meals: 93.5; 
Received either type of meal: 9.9; 
Did not receive either type of meal: 90.1. 

Characteristic: Income; 
Category: $20,000 - $29,999; 
Percent of low-income older adults: 34.8; 
Received home-delivered meals: 2.6; 
Did not receive home-delivered meals: 97.4; 
Received congregate meals: 4.0; 
Did not receive congregate meals: 96.0; 
Received either type of meal: 6.3; 
Did not receive either type of meal: 93.7. 

Characteristic: Income; 
Category: $30,000 or more; 
Percent of low-income older adults: 9.2; 
Received home-delivered meals: 2.5; 
Did not receive home-delivered meals: 97.5; 
Received congregate meals: 4.1; 
Did not receive congregate meals: 95.9; 
Received either type of meal: 6.4; 
Did not receive either type of meal: 93.6. 

Characteristic: Household size; 
Category: Living alone; 
Percent of low-income older adults: 36.7; 
Received home-delivered meals: 6.4; 
Did not receive home-delivered meals: 93.6; 
Received congregate meals: 8.0; 
Did not receive congregate meals: 92.0; 
Received either type of meal: 13.0; 
Did not receive either type of meal: 87.0. 

Characteristic: Household size; 
Category: Two persons; 
Percent of low-income older adults: 40.9; 
Received home-delivered meals: 2.6; 
Did not receive home-delivered meals: 97.4; 
Received congregate meals: 4.4; 
Did not receive congregate meals: 95.6; 
Received either type of meal: 6.6; 
Did not receive either type of meal: 93.4. 

Characteristic: Household size; 
Category: Three or more persons; 
Percent of low-income older adults: 22.4; 
Received home-delivered meals: 2.9; 
Did not receive home-delivered meals: 97.1; 
Received congregate meals: 3.5; 
Did not receive congregate meals: 96.5; 
Received either type of meal: 6.2; 
Did not receive either type of meal: 93.8. 

Characteristic: Education; 
Category: Less than high school; 
Percent of low-income older adults: 35.0; 
Received home-delivered meals: 5.2; 
Did not receive home-delivered meals: 94.8; 
Received congregate meals: 5.7; 
Did not receive congregate meals: 94.3; 
Received either type of meal: 9.9; 
Did not receive either type of meal: 90.1. 

Characteristic: Education; 
Category: High school graduate; 
Percent of low-income older adults: 38.0; 
Received home-delivered meals: 3.9; 
Did not receive home-delivered meals: 96.1; 
Received congregate meals: 5.6; 
Did not receive congregate meals: 94.4; 
Received either type of meal: 8.9; 
Did not receive either type of meal: 91.1. 

Characteristic: Education; 
Category: Some college; 
Percent of low-income older adults: 18.6; 
Received home-delivered meals: 3.2; 
Did not receive home-delivered meals: 96.8; 
Received congregate meals: 4.9; 
Did not receive congregate meals: 95.1; 
Received either type of meal: 7.3; 
Did not receive either type of meal: 92.7. 

Characteristic: Education; 
Category: College graduate; 
Percent of low-income older adults: 8.4; 
Received home-delivered meals: 2.7; 
Did not receive home-delivered meals: 97.3; 
Received congregate meals: 5.8; 
Did not receive congregate meals: 94.2; 
Received either type of meal: 7.9; 
Did not receive either type of meal: 92.1. 

Characteristic: Employment status; 
Category: Employed; 
Percent of low-income older adults: 16.4; 
Received home-delivered meals: 1.5; 
Did not receive home-delivered meals: 98.5; 
Received congregate meals: 2.7; 
Did not receive congregate meals: 97.3; 
Received either type of meal: 4.2; 
Did not receive either type of meal: 95.8. 

Characteristic: Employment status; 
Category: Retired; 
Percent of low-income older adults: 62.0; 
Received home-delivered meals: 4.2; 
Did not receive home-delivered meals: 95.8; 
Received congregate meals: 6.1; 
Did not receive congregate meals: 93.9; 
Received either type of meal: 9.5; 
Did not receive either type of meal: 90.5. 

Characteristic: Employment status; 
Category: Disabled; 
Percent of low-income older adults: 14.5; 
Received home-delivered meals: 7.1; 
Did not receive home-delivered meals: 92.9; 
Received congregate meals: 6.1; 
Did not receive congregate meals: 93.9; 
Received either type of meal: 12.0; 
Did not receive either type of meal: 88.0. 

Characteristic: Employment status; 
Category: Other; 
Percent of low-income older adults: 7.1; 
Received home-delivered meals: 2.9; 
Did not receive home-delivered meals: 97.1; 
Received congregate meals: 5.6; 
Did not receive congregate meals: 94.4; 
Received either type of meal: 7.8; 
Did not receive either type of meal: 92.2. 

Characteristic: Home owner; 
Category: Owner; 
Percent of low-income older adults: 71.6; 
Received home-delivered meals: 3.2; 
Did not receive home-delivered meals: 96.8; 
Received congregate meals: 4.8; 
Did not receive congregate meals: 95.2; 
Received either type of meal: 7.7; 
Did not receive either type of meal: 92.3. 

Characteristic: Home owner; 
Category: Rent or other; 
Percent of low-income older adults: 28.4; 
Received home-delivered meals: 6.4; 
Did not receive home-delivered meals: 93.6; 
Received congregate meals: 7.3; 
Did not receive congregate meals: 92.7; 
Received either type of meal: 11.8; 
Did not receive either type of meal: 88.2. 

Characteristic: Metropolitan status; 
Category: Metropolitan; 
Percent of low-income older adults: 76.6; 
Received home-delivered meals: 3.9; 
Did not receive home-delivered meals: 96.1; 
Received congregate meals: 5.1; 
Did not receive congregate meals: 94.9; 
Received either type of meal: 8.3; 
Did not receive either type of meal: 91.7. 

Characteristic: Metropolitan status; 
Category: Non-metropolitan; 
Percent of low-income older adults: 23.4; 
Received home-delivered meals: 4.6; 
Did not receive home-delivered meals: 95.4; 
Received congregate meals: 7.0; 
Did not receive congregate meals: 93.0; 
Received either type of meal: 10.9; 
Did not receive either type of meal: 89.1. 

Characteristic: Region; 
Category: Northeast; 
Percent of low-income older adults: 18.1; 
Received home-delivered meals: 4.3; 
Did not receive home-delivered meals: 95.7; 
Received congregate meals: 5.0; 
Did not receive congregate meals: 95.0; 
Received either type of meal: 8.9; 
Did not receive either type of meal: 91.1. 

Characteristic: Region; 
Category: Midwest; 
Percent of low-income older adults: 20.7; 
Received home-delivered meals: 4.0; 
Did not receive home-delivered meals: 96.0; 
Received congregate meals: 7.3; 
Did not receive congregate meals: 92.7; 
Received either type of meal: 10.4; 
Did not receive either type of meal: 89.6. 

Characteristic: Region; 
Category: South; 
Percent of low-income older adults: 42.0; 
Received home-delivered meals: 4.2; 
Did not receive home-delivered meals: 95.8; 
Received congregate meals: 3.9; 
Did not receive congregate meals: 96.1; 
Received either type of meal: 7.4; 
Did not receive either type of meal: 92.6. 

Characteristic: Region; 
Category: West; 
Percent of low-income older adults: 19.2; 
Received home-delivered meals: 3.7; 
Did not receive home-delivered meals: 96.3; 
Received congregate meals: 7.6; 
Did not receive congregate meals: 92.4; 
Received either type of meal: 10.4; 
Did not receive either type of meal: 89.6. 

Source: GAO analysis of 2008 Current Population Survey data. 

Note: Data in the table are derived from individuals in the sample of 
households with incomes below 185 percent of the poverty threshold 
that were represented in the 2008 Current Population Survey Food 
Security Supplement. Information on social isolation is from the Civic 
Engagement Supplement and is missing for that segment of the sample 
(roughly one-fourth) that did not complete both the Food Security 
Supplement and the Civic Engagement Supplement. Unless otherwise 
noted, percentage estimates in this table have a maximum margin of 
error at the 95 percent confidence interval of plus or minus 4 
percentage points. The estimate of individuals receiving either 
congregate meals or home-delivered meals and identified as being in 
the "other" race category has a margin of error at the 95 percent 
confidence interval of plus or minus 4.7 percentage points. 

[End of table] 

[End of section] 

Appendix III: Likely Need and Receipt of Home-Delivered or Congregate 
Meals: 

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.[Footnote 90] 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.[Footnote 91] 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.[Footnote 92] 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 10: Numbers and Percents of Individuals in the Different 
Categories of the Study Variables (Weighted Data): 

Study variables: Home-delivered meal; 
Categories: No; 
Number: 16,894,404; 
Percent: 95.9. 

Study variables: Home-delivered meal; 
Categories: Yes; 
Number: 720,530; 
Percent: 4.1. 

Study variables: Congregate meal; 
Categories: No; 
Number: 16,640,297; 
Percent: 94.5. 

Study variables: Congregate meal;
Categories: Yes; 
Number: 974,637; 
Percent: 5.5. 

Study variables: Home or congregate meal; 
Categories: No; 
Number: 16,053,102; 
Percent: 91.1. 

Study variables: Home or congregate meal; 
Categories: Yes; 
Number: 1,561,832; 
Percent: 8.9. 

Study variables: Food security; 
Categories: Food secure; 
Number: 14,326,026; 
Percent: 81.4. 

Study variables: Food security; 
Categories: Food insecure; 
Number: 3,268,691; 
Percent: 18.6. 

Study variables: Impairments; 
Categories: None; 
Number: 11,477,521; 
Percent: 65.2. 

Study variables: Impairments;
Categories: One; 
Number: 3,175,807; 
Percent: 18.0. 

Study variables: Impairments;
Categories: Two or more; 
Number: 2,961,606; 
Percent: 16.8. 

Study variables: Social isolation; 
Categories: Less isolated; 
Number: 5,593,634; 
Percent: 31.8. 

Study variables: Social isolation; 
Categories: More isolated; 
Number: 7,295,912; 
Percent: 41.4. 

Study variables: Social isolation; 
Categories: Missing; 
Number: 4,725,389; 
Percent: 26.8. 

Study variables: Food stamps; 
Categories: No; 
Number: 15,282,437; 
Percent: 86.8. 

Study variables: Food stamps; 
Categories: Yes; 
Number: 2,332,497; 
Percent: 13.2. 

Study variables: Age; 
Categories: Under 60; 
Number: 1,567,689; 
Percent: 8.9. 

Study variables: Age; 
Categories: 60 to 69; 
Number: 6,712,470; 
Percent: 38.1. 

Study variables: Age; 
Categories: 70 to 79; 
Number: 5,664,734; 
Percent: 32.2. 

Study variables: Age; 
Categories: 80 plus; 
Number: 3,670,042; 
Percent: 20.8. 

Study variables: Sex; 
Categories: Male; 
Number: 6,818,181; 
Percent: 38.7. 

Study variables: Sex; 
Categories: Female; 
Number: 10,796,753; 
Percent: 61.3. 

Study variables: Race; 
Categories: White; 
Number: 14,234,874; 
Percent: 80.8. 

Study variables: Race; 
Categories: Black; 
Number: 2,388,732; 
Percent: 13.6. 

Study variables: Race; 
Categories: Other; 
Number: 991,327; 
Percent: 5.6. 

Study variables: Hispanic origin; 
Categories: Hispanic; 
Number: 2,322,010; 
Percent: 13.2. 

Study variables: Hispanic origin; 
Categories: Non-Hispanic; 
Number: 15,292,924; 
Percent: 86.8. 

Study variables: Marital status; 
Categories: Married; 
Number: 8,059,955; 
Percent: 45.8. 

Study variables: Marital status; 
Categories: Widowed; 
Number: 5,155,315; 
Percent: 29.3. 

Study variables: Marital status; 
Categories: Other; 
Number: 4,399,664; 
Percent: 25.0. 

Study variables: Income; 
Categories: Less than $10,000; 
Number: 2,830,485; 
Percent: 16.1. 

Study variables: Income; 
Categories: $10,000 - $19,999; 
Number: 7,044,383; 
Percent: 40.0. 

Study variables: Income; 
Categories: $20,000 - $29,999; 
Number: 6,124,270; 
Percent: 34.8. 

Study variables: Income; 
Categories: $30,000 or more; 
Number: 1,615,796; 
Percent: 9.2. 

Study variables: Household size; 
Categories: Living alone; 
Number: 6,466,525; 
Percent: 36.7. 

Study variables: Household size; 
Categories: Two persons; 
Number: 7,207,386; 
Percent: 40.9. 

Study variables: Household size; 
Categories: Three or more persons; 
Number: 3,941,023; 
Percent: 22.4. 

Study variables: Education; 
Categories: Less than high school; 
Number: 6,164,711; 
Percent: 35.0. 

Study variables: Education; 
Categories: High school graduate; 
Number: 6,691,173; 
Percent: 38.0. 

Study variables: Education; 
Categories: Some college; 
Number: 3,284,988; 
Percent: 18.6. 

Study variables: Education; 
Categories: College graduate; 
Number: 1,474,062; 
Percent: 8.4. 

Study variables: Employment status; 
Categories: Employed; 
Number: 2,884,745; 
Percent: 16.4. 

Study variables: Employment status; 
Categories: Retired; 
Number: 10,927,729; 
Percent: 62.0. 

Study variables: Employment status; 
Categories: Disabled; 
Number: 2,549,658; 
Percent: 14.5. 

Study variables: Employment status; 
Categories: Other; 
Number: 1,252,802; 
Percent: 7.1. 

Study variables: Home owner; 
Categories: Owner; 
Number: 12,606,239; 
Percent: 71.6. 

Study variables: Home owner; 
Categories: Rent or other; 
Number: 5,008,695; 
Percent: 28.4. 

Study variables: Metropolitan status; 
Categories: Metropolitan; 
Number: 13,391,203; 
Percent: 76.6. 

Study variables: Metropolitan status; 
Categories: Non-metropolitan; 
Number: 4,094,764; 
Percent: 23.4. 

Study variables: Region; 
Categories: Northeast; 
Number: 3,190,655; 
Percent: 18.1. 

Study variables: Region; 
Categories: Midwest; 
Number: 3,642,014; 
Percent: 20.7. 

Study variables: Region; 
Categories: South; 
Number: 7,402,132; 
Percent: 42.0. 

Study variables: Region; 
Categories: West; 
Number: 3,380,134; 
Percent: 19.2. 

Source: GAO analysis of 2008 CPS data. 

Note: Percentage estimates in this table have a maximum margin of 
error at the 95 percent confidence interval of plus or minus 2 
percentage points. Data in the table are derived from individuals in 
the sample of households with incomes below 185 percent of the poverty 
threshold that were represented in the 2008 Current Population Survey 
Food Security Supplement. Information on social isolation is from the 
Civic Engagement Supplement and is missing for that segment of the 
sample (roughly one-fourth) that did not complete both the food 
security supplement and the Civic Engagement Supplement. 

[End of table] 

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. 

Table 11: Percentages of Individuals with Various Characteristics That 
Were Food Insecure, and Percentages That Had Received Home-Delivered 
Meals, Congregate Meals, or Either Type of Meal in the Past 30 Days: 

Characteristic: Food security; 
Category: Food secure; 
Food secure: N/A; 
Home-delivered meal: 3.3; 
Congregate meal: 5.7; 
Home or congregate meal: 8.3. 

Characteristic: Food security; 
Category: Food insecure; 
Food secure: N/A; 
Home-delivered meal: 7.4; 
Congregate meal: 4.9; 
Home or congregate meal: 11.1. 

Characteristic: Impairments; 
Category: None; 
Food secure: 14.9; 
Home-delivered meal: 2.3; 
Congregate meal: 5.1; 
Home or congregate meal: 6.9. 

Characteristic: Impairments; 
Category: One; 
Food secure: 22.1; 
Home-delivered meal: 3.6; 
Congregate meal: 6.3; 
Home or congregate meal: 8.8. 

Characteristic: Impairments; 
Category: Two or more; 
Food secure: 29.2; 
Home-delivered meal: 11.5; 
Congregate meal: 6.4; 
Home or congregate meal: 16.7. 

Characteristic: Social Isolation; 
Category: Less isolated; 
Food secure: 17.7; 
Home-delivered meal: 2.5; 
Congregate meal: 6.1; 
Home or congregate meal: 7.9. 

Characteristic: Social Isolation; 
Category: More isolated; 
Food secure: 18.9; 
Home-delivered meal: 5.0; 
Congregate meal: 5.0; 
Home or congregate meal: 9.0. 

Characteristic: Social Isolation; 
Category: Missing; 
Food secure: 19.0; 
Home-delivered meal: 4.5; 
Congregate meal: 5.8; 
Home or congregate meal: 9.7. 

Characteristic: Food stamps; 
Category: No; 
Food secure: 14.8; 
Home-delivered meal: 3.7; 
Congregate meal: 5.3; 
Home or congregate meal: 8.4. 

Characteristic: Food stamps; 
Category: Yes; 
Food secure: 42.9*; 
Home-delivered meal: 6.8; 
Congregate meal: 6.9; 
Home or congregate meal: 12.1. 

Characteristic: Age; 
Category: Under 60; 
Food secure: 30.6*; 
Home-delivered meal: 2.6; 
Congregate meal: 3.0; 
Home or congregate meal: 5.6. 

Characteristic: Age; 
Category: 60 to 69; 
Food secure: 24.3; 
Home-delivered meal: 3.3; 
Congregate meal: 4.2; 
Home or congregate meal: 6.7. 

Characteristic: Age; 
Category: 70 to 79; 
Food secure: 14.7; 
Home-delivered meal: 4.0; 
Congregate meal: 6.4; 
Home or congregate meal: 9.3. 

Characteristic: Age; 
Category: 80 plus; 
Food secure: 8.8; 
Home-delivered meal: 6.3; 
Congregate meal: 7.7; 
Home or congregate meal: 13.4. 

Characteristic: Sex; 
Category: Male; 
Food secure: 18.0; 
Home-delivered meal: 4.0; 
Congregate meal: 4.6; 
Home or congregate meal: 8.0. 

Characteristic: Sex; 
Category: Female; 
Food secure: 18.9; 
Home-delivered meal: 4.1; 
Congregate meal: 6.1; 
Home or congregate meal: 9.4. 

Characteristic: Race; 
Category: White; 
Food secure: 16.5; 
Home-delivered meal: 3.9; 
Congregate meal: 5.3; 
Home or congregate meal: 8.6. 

Characteristic: Race; 
Category: Black; 
Food secure: 26.9; 
Home-delivered meal: 4.8; 
Congregate meal: 6.3; 
Home or congregate meal: 9.7. 

Characteristic: Race; 
Category: Other; 
Food secure: 28.3*; 
Home-delivered meal: 4.7; 
Congregate meal: 7.4; 
Home or congregate meal: 11.3*. 

Characteristic: Hispanic origin; 
Category: Hispanic; 
Food secure: 30.6*; 
Home-delivered meal: 5.0; 
Congregate meal: 5.9; 
Home or congregate meal: 10.2. 

Characteristic: Hispanic origin; 
Category: Non-Hispanic; 
Food secure: 16.7; 
Home-delivered meal: 3.9; 
Congregate meal: 5.5; 
Home or congregate meal: 8.7. 

Characteristic: Marital status; 
Category: Married; 
Food secure: 16.6; 
Home-delivered meal: 2.3; 
Congregate meal: 4.0; 
Home or congregate meal: 5.9. 

Characteristic: Marital status; 
Category: Widowed; 
Food secure: 15.1; 
Home-delivered meal: 6.1; 
Congregate meal: 7.5; 
Home or congregate meal: 12.6. 

Characteristic: Marital status; 
Category: Other; 
Food secure: 26.3; 
Home-delivered meal: 5.1; 
Congregate meal: 6.1; 
Home or congregate meal: 10.0. 

Characteristic: Income; 
Category: Less than $10,000; 
Food secure: 27.8; 
Home-delivered meal: 7.3; 
Congregate meal: 7.3; 
Home or congregate meal: 13.1. 

Characteristic: Income; 
Category: $10,000 - $19,999; 
Food secure: 19.3; 
Home-delivered meal: 4.4; 
Congregate meal: 6.5; 
Home or congregate meal: 9.9. 

Characteristic: Income; 
Category: $20,000 - $29,999; 
Food secure: 12.4; 
Home-delivered meal: 2.6; 
Congregate meal: 4.0; 
Home or congregate meal: 6.3. 

Characteristic: Income; 
Category: $30,000 or more; 
Food secure: 22.3*; 
Home-delivered meal: 2.5; 
Congregate meal: 4.1; 
Home or congregate meal: 6.4. 

Characteristic: Household size; 
Category: Living alone; 
Food secure: 16.9; 
Home-delivered meal: 6.4; 
Congregate meal: 8.0; 
Home or congregate meal: 13.0. 

Characteristic: Household size; 
Category: Two persons; 
Food secure: 14.6; 
Home-delivered meal: 2.6; 
Congregate meal: 4.4; 
Home or congregate meal: 6.6. 

Characteristic: Household size; 
Category: Three or more persons; 
Food secure: 8.4; 
Home-delivered meal: 2.9; 
Congregate meal: 3.5; 
Home or congregate meal: 6.2. 

Characteristic: Education; 
Category: Less than high school; 
Food secure: 25.1; 
Home-delivered meal: 5.2; 
Congregate meal: 5.7; 
Home or congregate meal: 9.9. 

Characteristic: Education; 
Category: High school graduate; 
Food secure: 14.7; 
Home-delivered meal: 3.9; 
Congregate meal: 5.6; 
Home or congregate meal: 8.9. 

Characteristic: Education; 
Category: Some college; 
Food secure: 16.2; 
Home-delivered meal: 3.2; 
Congregate meal: 4.9; 
Home or congregate meal: 7.3. 

Characteristic: Education; 
Category: College graduate; 
Food secure: 14.0*; 
Home-delivered meal: 2.7; 
Congregate meal: 5.8; 
Home or congregate meal: 7.9. 

Characteristic: Employment status; 
Category: Employed; 
Food secure: 16.8; 
Home-delivered meal: 1.5; 
Congregate meal: 2.7; 
Home or congregate meal: 4.2. 

Characteristic: Employment status; 
Category: Retired; 
Food secure: 13.1; 
Home-delivered meal: 4.2; 
Congregate meal: 6.1; 
Home or congregate meal: 9.5. 

Characteristic: Employment status; 
Category: Disabled; 
Food secure: 38.4*; 
Home-delivered meal: 7.1; 
Congregate meal: 6.1; 
Home or congregate meal: 12.0. 

Characteristic: Employment status; 
Category: Other; 
Food secure: 29.5; 
Home-delivered meal: 2.9; 
Congregate meal: 5.6; 
Home or congregate meal: 7.8. 

Characteristic: Home owner; 
Category: Owner; 
Food secure: 15.1; 
Home-delivered meal: 3.2; 
Congregate meal: 4.8; 
Home or congregate meal: 7.7. 

Characteristic: Home owner; 
Category: Rent or other; 
Food secure: 27.3; 
Home-delivered meal: 6.4; 
Congregate meal: 7.3; 
Home or congregate meal: 11.8. 

Characteristic: Metropolitan status; 
Category: Metropolitan; 
Food secure: 19.3; 
Home-delivered meal: 3.9; 
Congregate meal: 5.1; 
Home or congregate meal: 8.3. 

Characteristic: Metropolitan status; 
Category: Non-metropolitan; 
Food secure: 16.3; 
Home-delivered meal: 4.6; 
Congregate meal: 7.0; 
Home or congregate meal: 10.9. 

Characteristic: Region; 
Category: Northeast; 
Food secure: 15.4; 
Home-delivered meal: 4.3; 
Congregate meal: 5.0; 
Home or congregate meal: 8.9. 

Characteristic: Region; 
Category: Midwest; 
Food secure: 16.8; 
Home-delivered meal: 4.0; 
Congregate meal: 7.3; 
Home or congregate meal: 10.4. 

Characteristic: Region; 
Category: South; 
Food secure: 20.8; 
Home-delivered meal: 4.2; 
Congregate meal: 3.9; 
Home or congregate meal: 7.4. 

Characteristic: Region; 
Category: West; 
Food secure: 18.5; 
Home-delivered meal: 3.7; 
Congregate meal: 7.6; 
Home or congregate meal: 10.4. 

Source: GAO analysis of 2008 CPS data. 

Note: Data in the table are derived from individuals in the sample of 
households with incomes below 185 percent of the poverty threshold 
that were represented in the 2008 Current Population Survey Food 
Security Supplement. Information on social isolation is for that 
segment of the sample (roughly three-fourths) that also completed the 
Civic Engagement Supplement. Unless otherwise noted, percentage 
estimates in this table have a maximum margin of error at the 95 
percent confidence level of plus or minus 4 percentage points. 
Percentages marked with an * have a margin of error that is between 
4.2 and 6.7. Because the different likely need measures and 
demographic factors were in many cases associated with one another, a 
somewhat better way to look at the difference between groups involves 
using multivariate models to estimate the net effects of each 
variable, or the effect of each variable when the effects of the 
others are statistically controlled, rather than ignored. We, 
therefore, estimated group differences using odds rather than 
percentages to estimate the likelihood of each subgroup receiving the 
two types of meals, and odds ratios to estimate the difference between 
subgroups. These are shown in tables 12 (for home-delivered meals) and 
13 (for congregate meals). 

[End of table] 

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. 

Table 12: Percentages of Individuals with Various Characteristics That 
Had Received Home-Delivered Meals in the Past 30 Days, and Odds and 
Odds Ratios Derived from the Observed Data (Unadjusted Odds Ratios) 
and Multivariate Models (Adjusted Odds Ratios): 

Characteristic: Food security; 
Category: Food secure; 
Percent receiving home-delivered meals: 3.3; 
Odds on receiving home-delivered meal: 0.0343; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Food security; 
Category: Food insecure; 
Percent receiving home-delivered meals: 7.4; 
Odds on receiving home-delivered meal: 0.0799; 
Unadjusted odds ratios compared to reference category: 2.33*; 
Adjusted odds ratios compared to reference category: 1.93*. 

Characteristic: Impairments; 
Category: None; 
Percent receiving home-delivered meals: 2.3; 
Odds on receiving home-delivered meal: 0.0235; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Impairments; 
Category: One; 
Percent receiving home-delivered meals: 3.6; 
Odds on receiving home-delivered meal: 0.0379; 
Unadjusted odds ratios compared to reference category: 1.61*; 
Adjusted odds ratios compared to reference category: 1.28. 

Characteristic: Impairments; 
Category: Two or more; 
Percent receiving home-delivered meals: 11.5; 
Odds on receiving home-delivered meal: 0.1302; 
Unadjusted odds ratios compared to reference category: 5.54*; 
Adjusted odds ratios compared to reference category: 3.53*. 

Characteristic: Social isolation; 
Category: Less isolated; 
Percent receiving home-delivered meals: 2.5; 
Odds on receiving home-delivered meal: 0.0257; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Social isolation;
Category: More isolated; 
Percent receiving home-delivered meals: 5.0; 
Odds on receiving home-delivered meal: 0.0531; 
Unadjusted odds ratios compared to reference category: 2.07*; 
Adjusted odds ratios compared to reference category: 1.90*. 

Characteristic: Social isolation;
Category: Missing; 
Percent receiving home-delivered meals: 4.5; 
Odds on receiving home-delivered meal: 0.0471; 
Unadjusted odds ratios compared to reference category: 1.84*; 
Adjusted odds ratios compared to reference category: 1.68*. 

Characteristic: Food stamps; 
Category: No; 
Percent receiving home-delivered meals: 3.7; 
Odds on receiving home-delivered meal: 0.0382; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Food stamps; 
Category: Yes; 
Percent receiving home-delivered meals: 6.8; 
Odds on receiving home-delivered meal: 0.0726; 
Unadjusted odds ratios compared to reference category: 1.90*; 
Adjusted odds ratios compared to reference category: 1.12. 

Characteristic: Age; 
Category: Under 60; 
Percent receiving home-delivered meals: 2.6; 
Odds on receiving home-delivered meal: 0.0266; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Age; 
Category: 60 to 69; 
Percent receiving home-delivered meals: 3.3; 
Odds on receiving home-delivered meal: 0.0342; 
Unadjusted odds ratios compared to reference category: 1.28; 
Adjusted odds ratios compared to reference category: 1.26. 

Characteristic: Age; 
Category: 70 to 79; 
Percent receiving home-delivered meals: 4.0; 
Odds on receiving home-delivered meal: 0.0414; 
Unadjusted odds ratios compared to reference category: 1.55; 
Adjusted odds ratios compared to reference category: 1.60. 

Characteristic: Age; 
Category: 80 plus; 
Percent receiving home-delivered meals: 6.3; 
Odds on receiving home-delivered meal: 0.0678; 
Unadjusted odds ratios compared to reference category: 2.54*; 
Adjusted odds ratios compared to reference category: 2.02*. 

Characteristic: Sex; 
Category: Male; 
Percent receiving home-delivered meals: 4.0; 
Odds on receiving home-delivered meal: 0.0422; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Sex; 
Category: Female; 
Percent receiving home-delivered meals: 4.1; 
Odds on receiving home-delivered meal: 0.0430; 
Unadjusted odds ratios compared to reference category: 1.02; 
Adjusted odds ratios compared to reference category: 0.78. 

Characteristic: Race; 
Category: White; 
Percent receiving home-delivered meals: 3.9; 
Odds on receiving home-delivered meal: 0.0408; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Race; 
Category: Black; 
Percent receiving home-delivered meals: 4.8; 
Odds on receiving home-delivered meal: 0.0509; 
Unadjusted odds ratios compared to reference category: 1.25; 
Adjusted odds ratios compared to reference category: 1.17. 

Characteristic: Race; 
Category: Other; 
Percent receiving home-delivered meals: 4.7; 
Odds on receiving home-delivered meal: 0.0490; 
Unadjusted odds ratios compared to reference category: 1.20; 
Adjusted odds ratios compared to reference category: 1.23. 

Characteristic: Hispanic origin; 
Category: Hispanic; 
Percent receiving home-delivered meals: 5.0; 
Odds on receiving home-delivered meal: 0.0529; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Hispanic origin; 
Category: Non-Hispanic; 
Percent receiving home-delivered meals: 3.9; 
Odds on receiving home-delivered meal: 0.0411; 
Unadjusted odds ratios compared to reference category: 0.78; 
Adjusted odds ratios compared to reference category: 0.68. 

Characteristic: Marital status; 
Category: Married; 
Percent receiving home-delivered meals: 2.3; 
Odds on receiving home-delivered meal: 0.0230; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Marital status; 
Category: Widowed; 
Percent receiving home-delivered meals: 6.1; 
Odds on receiving home-delivered meal: 0.0654; 
Unadjusted odds ratios compared to reference category: 2.84*; 
Adjusted odds ratios compared to reference category: 1.42. 

Characteristic: Marital status; 
Category: Other; 
Percent receiving home-delivered meals: 5.1; 
Odds on receiving home-delivered meal: 0.0533; 
Unadjusted odds ratios compared to reference category: 2.31*; 
Adjusted odds ratios compared to reference category: 1.23. 

Characteristic: Income; 
Category: Less than $10,000; 
Percent receiving home-delivered meals: 7.3; 
Odds on receiving home-delivered meal: 0.0788; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Income; 
Category: $10,000 - $19,999; 
Percent receiving home-delivered meals: 4.4; 
Odds on receiving home-delivered meal: 0.0462; 
Unadjusted odds ratios compared to reference category: 0.59*; 
Adjusted odds ratios compared to reference category: 0.96. 

Characteristic: Income; 
Category: $20,000 - $29,999; 
Percent receiving home-delivered meals: 2.6; 
Odds on receiving home-delivered meal: 0.0272; 
Unadjusted odds ratios compared to reference category: 0.35*; 
Adjusted odds ratios compared to reference category: 0.93. 

Characteristic: Income; 
Category: $30,000 or more; 
Percent receiving home-delivered meals: 2.5; 
Odds on receiving home-delivered meal: 0.0257; 
Unadjusted odds ratios compared to reference category: 0.33*; 
Adjusted odds ratios compared to reference category: 1.06. 

Characteristic: Household size; 
Category: Living alone; 
Percent receiving home-delivered meals: 6.4; 
Odds on receiving home-delivered meal: 0.0686; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Household size; 
Category: Two persons; 
Percent receiving home-delivered meals: 2.6; 
Odds on receiving home-delivered meal: 0.0271; 
Unadjusted odds ratios compared to reference category: 0.40*; 
Adjusted odds ratios compared to reference category: 0.63*. 

Characteristic: Household size; 
Category: Three or more persons; 
Percent receiving home-delivered meals: 2.9; 
Odds on receiving home-delivered meal: 0.0301; 
Unadjusted odds ratios compared to reference category: 0.44*; 
Adjusted odds ratios compared to reference category: 0.56*. 

Characteristic: Education; 
Category: Less than high school; 
Percent receiving home-delivered meals: 5.2; 
Odds on receiving home-delivered meal: 0.0543; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Education; 
Category: High school graduate; 
Percent receiving home-delivered meals: 3.9; 
Odds on receiving home-delivered meal: 0.0400; 
Unadjusted odds ratios compared to reference category: 0.74*; 
Adjusted odds ratios compared to reference category: 1.11. 

Characteristic: Education; 
Category: Some college; 
Percent receiving home-delivered meals: 3.2; 
Odds on receiving home-delivered meal: 0.0330; 
Unadjusted odds ratios compared to reference category: 0.61*; 
Adjusted odds ratios compared to reference category: 1.02. 

Characteristic: Education; 
Category: College graduate; 
Percent receiving home-delivered meals: 2.7; 
Odds on receiving home-delivered meal: 0.0280; 
Unadjusted odds ratios compared to reference category: 0.52*; 
Adjusted odds ratios compared to reference category: 0.89. 

Characteristic: Employment status; 
Category: Employed; 
Percent receiving home-delivered meals: 1.5; 
Odds on receiving home-delivered meal: 0.0153; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Employment status; 
Category: Characteristic: Retired; 
Percent receiving home-delivered meals: 4.2; 
Odds on receiving home-delivered meal: 0.0439; 
Unadjusted odds ratios compared to reference category: 2.87*; 
Adjusted odds ratios compared to reference category: 1.53. 

Characteristic: Employment status; 
Category: Disabled; 
Percent receiving home-delivered meals: 7.1; 
Odds on receiving home-delivered meal: 0.0767; 
Unadjusted odds ratios compared to reference category: 5.02*; 
Adjusted odds ratios compared to reference category: 1.82*. 

Characteristic: Employment status; 
Category: Other; 
Percent receiving home-delivered meals: 2.9; 
Odds on receiving home-delivered meal: 0.0296; 
Unadjusted odds ratios compared to reference category: 1.94; 
Adjusted odds ratios compared to reference category: 1.40. 

Characteristic: Home owner; 
Category: Owner; 
Percent receiving home-delivered meals: 3.2; 
Odds on receiving home-delivered meal: 0.0327; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Home owner; 
Category: Rent or other; 
Percent receiving home-delivered meals: 6.4; 
Odds on receiving home-delivered meal: 0.0685; 
Unadjusted odds ratios compared to reference category: 2.09*; 
Adjusted odds ratios compared to reference category: 1.46*. 

Characteristic: Metropolitan status; 
Category: Metropolitan; 
Percent receiving home-delivered meals: 3.9; 
Odds on receiving home-delivered meal: 0.0410; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Metropolitan status; 
Category: Non-metropolitan; 
Percent receiving home-delivered meals: 4.6; 
Odds on receiving home-delivered meal: 0.0483; 
Unadjusted odds ratios compared to reference category: 1.18; 
Adjusted odds ratios compared to reference category: 1.32. 

Characteristic: Region; 
Category: Northeast; 
Percent receiving home-delivered meals: 4.3; 
Odds on receiving home-delivered meal: 0.0453; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Region; 
Category: Midwest; 
Percent receiving home-delivered meals: 4.0; 
Odds on receiving home-delivered meal: 0.0418; 
Unadjusted odds ratios compared to reference category: 0.92; 
Adjusted odds ratios compared to reference category: 0.98. 

Characteristic: Region; 
Category: South; 
Percent receiving home-delivered meals: 4.2; 
Odds on receiving home-delivered meal: 0.0437; 
Unadjusted odds ratios compared to reference category: 0.96; 
Adjusted odds ratios compared to reference category: 0.96. 

Characteristic: Region; 
Category: West; 
Percent receiving home-delivered meals: 3.7; 
Odds on receiving home-delivered meal: 0.0388; 
Unadjusted odds ratios compared to reference category: 0.86; 
Adjusted odds ratios compared to reference category: 0.88. 

Source: GAO analysis of 2008 Current Population Survey data. 

Note: Asterisks denote odds ratios that are significant at the 0.05 
level. 

[End of table] 

Table 13: Percentages of Individuals with Various Characteristics That 
Had Received Congregate Meals in the Past 30 Days, and Odds and Odds 
Ratios Derived from the Observed Data (Unadjusted Odds Ratios) and 
Multivariate Models (Adjusted Odds Ratios): 

Characteristic: Food security; 
Category: Food secure; 
Percent receiving congregate meals: 5.7; 
Odds on receiving congregate meal: 0.0601; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Food security; 
Category: Food insecure; 
Percent receiving congregate meals: 4.9; 
Odds on receiving congregate meal: 0.0517; 
Unadjusted odds ratios compared to reference category: 0.86; 
Adjusted odds ratios compared to reference category: 0.82. 

Characteristic: Impairments; 
Category: None; 
Percent receiving congregate meals: 5.1; 
Odds on receiving congregate meal: 0.0538; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Impairments; 
Category: One; 
Percent receiving congregate meals: 6.3; 
Odds on receiving congregate meal: 0.0671; 
Unadjusted odds ratios compared to reference category: 1.25; 
Adjusted odds ratios compared to reference category: 1.07. 

Characteristic: Impairments; 
Category: Two or more; 
Percent receiving congregate meals: 6.4; 
Odds on receiving congregate meal: 0.0680; 
Unadjusted odds ratios compared to reference category: 1.26; 
Adjusted odds ratios compared to reference category: 0.92. 

Characteristic: Social isolation; 
Category: Less isolated; 
Percent receiving congregate meals: 6.1; 
Odds on receiving congregate meal: 0.0647; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Social isolation; 
Category: More isolated; 
Percent receiving congregate meals: 5.0; 
Odds on receiving congregate meal: 0.0522; 
Unadjusted odds ratios compared to reference category: 0.81; 
Adjusted odds ratios compared to reference category: 0.80. 

Characteristic: Social isolation; 
Category: Missing; 
Percent receiving congregate meals: 5.8; 
Odds on receiving congregate meal: 0.0613; 
Unadjusted odds ratios compared to reference category: 0.95; 
Adjusted odds ratios compared to reference category: 0.93. 

Characteristic: Food stamps; 
Category: No; 
Percent receiving congregate meals: 5.3; 
Odds on receiving congregate meal: 0.0562; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Food stamps; 
Category: Yes; 
Percent receiving congregate meals: 6.9; 
Odds on receiving congregate meal: 0.0743; 
Unadjusted odds ratios compared to reference category: 1.32; 
Adjusted odds ratios compared to reference category: 1.35. 

Characteristic: Age; 
Category: Under 60; 
Percent receiving congregate meals: 3.0; 
Odds on receiving congregate meal: 0.0310; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Age; 
Category: 60 to 69; 
Percent receiving congregate meals: 4.2; 
Odds on receiving congregate meal: 0.0437; 
Unadjusted odds ratios compared to reference category: 1.41; 
Adjusted odds ratios compared to reference category: 1.30. 

Characteristic: Age; 
Category: 70 to 79; 
Percent receiving congregate meals: 6.4; 
Odds on receiving congregate meal: 0.0689; 
Unadjusted odds ratios compared to reference category: 2.22*; 
Adjusted odds ratios compared to reference category: 2.04*. 

Characteristic: Age; 
Category: 80 plus; 
Percent receiving congregate meals: 7.7; 
Odds on receiving congregate meal: 0.0830; 
Unadjusted odds ratios compared to reference category: 2.68*; 
Adjusted odds ratios compared to reference category: 2.29*. 

Characteristic: Sex; 
Category: Male; 
Percent receiving congregate meals: 4.6; 
Odds on receiving congregate meal: 0.0484; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Sex; 
Category: Female; 
Percent receiving congregate meals: 6.1; 
Odds on receiving congregate meal: 0.0651; 
Unadjusted odds ratios compared to reference category: 1.34*; 
Adjusted odds ratios compared to reference category: 1.21. 

Characteristic: Race; 
Category: White; 
Percent receiving congregate meals: 5.3; 
Odds on receiving congregate meal: 0.0556; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Race; 
Category: Black; 
Percent receiving congregate meals: 6.3; 
Odds on receiving congregate meal: 0.0675; 
Unadjusted odds ratios compared to reference category: 1.21; 
Adjusted odds ratios compared to reference category: 1.53*. 

Characteristic: Race; 
Category: Other; 
Percent receiving congregate meals: 7.4; 
Odds on receiving congregate meal: 0.0798; 
Unadjusted odds ratios compared to reference category: 1.43; 
Adjusted odds ratios compared to reference category: 1.59*. 

Characteristic: Hispanic origin; 
Category: Hispanic; 
Percent receiving congregate meals: 5.9; 
Odds on receiving congregate meal: 0.0622; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Hispanic origin; 
Category: Non-Hispanic; 
Percent receiving congregate meals: 5.5; 
Odds on receiving congregate meal: 0.0580; 
Unadjusted odds ratios compared to reference category: 0.93; 
Adjusted odds ratios compared to reference category: 0.65*. 

Characteristic: Marital status; 
Category: Married; 
Percent receiving congregate meals: 4.0; 
Odds on receiving congregate meal: 0.0411; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Marital status; 
Category: Widowed; 
Percent receiving congregate meals: 7.5; 
Odds on receiving congregate meal: 0.0809; 
Unadjusted odds ratios compared to reference category: 1.97*; 
Adjusted odds ratios compared to reference category: Characteristic: 
0.99. 

Characteristic: Marital status; 
Category: Other; 
Percent receiving congregate meals: 6.1; 
Odds on receiving congregate meal: 0.0655; 
Unadjusted odds ratios compared to reference category: 1.59*; 
Adjusted odds ratios compared to reference category: 1.09. 

Characteristic: Income; 
Category: Less than $10,000; 
Percent receiving congregate meals: 7.3; 
Odds on receiving congregate meal: 0.0787; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Income; 
Category: $10,000 - $19,999; 
Percent receiving congregate meals: 6.5; 
Odds on receiving congregate meal: 0.0695; 
Unadjusted odds ratios compared to reference category: 0.88; 
Adjusted odds ratios compared to reference category: 1.07. 

Characteristic: Income; 
Category: $20,000 - $29,999; 
Percent receiving congregate meals: 4.0; 
Odds on receiving congregate meal: 0.0415; 
Unadjusted odds ratios compared to reference category: 0.53*; 
Adjusted odds ratios compared to reference category: 0.89. 

Characteristic: Income; 
Category: $30,000 or more; 
Percent receiving congregate meals: 4.1; 
Odds on receiving congregate meal: 0.0427; 
Unadjusted odds ratios compared to reference category: 0.54*; 
Adjusted odds ratios compared to reference category: 1.46. 

Characteristic: Household size; 
Category: Living alone; 
Percent receiving congregate meals: 8.0; 
Odds on receiving congregate meal: 0.0873; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Household size; 
Category: Two persons; 
Percent receiving congregate meals: 4.4; 
Odds on receiving congregate meal: 0.0461; 
Unadjusted odds ratios compared to reference category: 0.53*; 
Adjusted odds ratios compared to reference category: 0.66*. 

Characteristic: Household size; 
Category: Three or more persons; 
Percent receiving congregate meals: 3.5; 
Odds on receiving congregate meal: 0.0363; 
Unadjusted odds ratios compared to reference category: 0.42*; 
Adjusted odds ratios compared to reference category: 0.42*. 

Characteristic: Education; 
Category: Less than high school; 
Percent receiving congregate meals: 5.7; 
Odds on receiving congregate meal: 0.0602; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Education; 
Category: High school graduate; 
Percent receiving congregate meals: 5.6; 
Odds on receiving congregate meal: 0.0597; 
Unadjusted odds ratios compared to reference category: 0.99; 
Adjusted odds ratios compared to reference category: 1.14. 

Characteristic: Education; 
Category: Some college; 
Percent receiving congregate meals: 4.9; 
Odds on receiving congregate meal: 0.0519; 
Unadjusted odds ratios compared to reference category: 0.86; 
Adjusted odds ratios compared to reference category: 1.00. 

Characteristic: Education; 
Category: College graduate; 
Percent receiving congregate meals: 5.8; 
Odds on receiving congregate meal: 0.0616; 
Unadjusted odds ratios compared to reference category: 1.02; 
Adjusted odds ratios compared to reference category: 1.20. 

Characteristic: Employment status; 
Category: Employed; 
Percent receiving congregate meals: 2.7; 
Odds on receiving congregate meal: 0.0280; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Employment status; 
Category: Retired; 
Percent receiving congregate meals: 6.1; 
Odds on receiving congregate meal: 0.0654; 
Unadjusted odds ratios compared to reference category: 2.34*; 
Adjusted odds ratios compared to reference category: 1.63*. 

Characteristic: Employment status; 
Category: Disabled; 
Percent receiving congregate meals: 6.1; 
Odds on receiving congregate meal: 0.0647; 
Unadjusted odds ratios compared to reference category: 2.31*; 
Adjusted odds ratios compared to reference category: 2.32*. 

Characteristic: Employment status; 
Category: Other; 
Percent receiving congregate meals: 5.6; 
Odds on receiving congregate meal: 0.0594; 
Unadjusted odds ratios compared to reference category: 2.12*; 
Adjusted odds ratios compared to reference category: 1.99*. 

Characteristic: Home owner; 
Category: Owner; 
Percent receiving congregate meals: 4.8; 
Odds on receiving congregate meal: 0.0508; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Home owner; 
Category: Rent or other; 
Percent receiving congregate meals: 7.3; 
Odds on receiving congregate meal: 0.0786; 
Unadjusted odds ratios compared to reference category: 1.55*; 
Adjusted odds ratios compared to reference category: 1.25. 

Characteristic: Metropolitan status; 
Category: Metropolitan; 
Percent receiving congregate meals: 5.1; 
Odds on receiving congregate meal: 0.0539; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Metropolitan status; 
Category: Non-metropolitan; 
Percent receiving congregate meals: 7.0; 
Odds on receiving congregate meal: 0.0758; 
Unadjusted odds ratios compared to reference category: 1.41*; 
Adjusted odds ratios compared to reference category: 1.62*. 

Characteristic: Region; 
Category: Northeast; 
Percent receiving congregate meals: 5.0; 
Odds on receiving congregate meal: 0.0527; 
Unadjusted odds ratios compared to reference category: reference; 
Adjusted odds ratios compared to reference category: reference. 

Characteristic: Region; 
Category: Midwest; 
Percent receiving congregate meals: 7.3; 
Odds on receiving congregate meal: 0.0788; 
Unadjusted odds ratios compared to reference category: 1.49*; 
Adjusted odds ratios compared to reference category: 1.55*. 

Characteristic: Region; 
Category: South; 
Percent receiving congregate meals: 3.9; 
Odds on receiving congregate meal: 0.0410; 
Unadjusted odds ratios compared to reference category: 0.78; 
Adjusted odds ratios compared to reference category: 0.81. 

Characteristic: Region; 
Category: West; 
Percent receiving congregate meals: 7.6; 
Odds on receiving congregate meal: 0.0824; 
Unadjusted odds ratios compared to reference category: 1.56*; 
Adjusted odds ratios compared to reference category: 1.73*. 

Source: GAO analysis of 2008 Current Population Survey data. 

Note: Asterisks denote odds ratios that are significant at the 0.05 
level. 

[End of table] 

[End of section] 

Appendix IV: Likely Need for, and Receipt of, Home-Based Care: 

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.[Footnote 93] 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.[Footnote 
94] 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.[Footnote 95] 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. 

Table 14: Percentage of Older Adults Age 60 and above with Various 
Characteristics with One or More Difficulties with Living Activities, 
and Odds and Odds Ratios Derived from Them: 

Characteristic: Age; 
Category: 60 to less than 70; 
Reports one or more IADL or ADL difficulties: 21.6; 
Odds on having one or more IADL or ADL difficulties: 0.28; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Age; 
Category: 70 to less than 80; 
Reports one or more IADL or ADL difficulties: 29.1; 
Odds on having one or more IADL or ADL difficulties: 0.41; 
Unadjusted odds, compared to reference category: 1.49*; 
Adjusted odds, compared to reference category[B]: 1.20*. 

Characteristic: Age; 
Category: 80 and above; 
Reports one or more IADL or ADL difficulties: 52.8; 
Odds on having one or more IADL or ADL difficulties: 1.12; 
Unadjusted odds, compared to reference category: 4.05*; 
Adjusted odds, compared to reference category[B]: 3.05*. 

Characteristic: Sex; 
Category: Male; 
Reports one or more IADL or ADL difficulties: 30.2; 
Odds on having one or more IADL or ADL difficulties: 0.43; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Sex; 
Category: Female; 
Reports one or more IADL or ADL difficulties: 28.9; 
Odds on having one or more IADL or ADL difficulties: 0.41; 
Unadjusted odds, compared to reference category: 0.94*; 
Adjusted odds, compared to reference category[B]: 0.70*. 

Characteristic: Race; 
Category: White; 
Reports one or more IADL or ADL difficulties: 28.8; 
Odds on having one or more IADL or ADL difficulties: 0.40; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Race; 
Category: African American; 
Reports one or more IADL or ADL difficulties: 34.8; 
Odds on having one or more IADL or ADL difficulties: 0.53; 
Unadjusted odds, compared to reference category: 1.32*; 
Adjusted odds, compared to reference category[B]: 0.90. 

Characteristic: Race; 
Category: Other[A]; 
Reports one or more IADL or ADL difficulties: 34.0; 
Odds on having one or more IADL or ADL difficulties: 0.51; 
Unadjusted odds, compared to reference category: 1.27*; 
Adjusted odds, compared to reference category[B]: 1.05. 

Characteristic: Ethnicity; 
Category: Non-Hispanic; 
Reports one or more IADL or ADL difficulties: 29.0; 
Odds on having one or more IADL or ADL difficulties: 0.41; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Ethnicity; 
Category: Hispanic; 
Reports one or more IADL or ADL difficulties: 36.7; 
Odds on having one or more IADL or ADL difficulties: 0.58; 
Unadjusted odds, compared to reference category: 1.42*; 
Adjusted odds, compared to reference category[B]: 0.81*. 

Characteristic: Marital status; 
Category: Married; 
Reports one or more IADL or ADL difficulties: 25.8; 
Odds on having one or more IADL or ADL difficulties: 0.35; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Marital status; 
Category: Widowed; 
Reports one or more IADL or ADL difficulties: 38.7; 
Odds on having one or more IADL or ADL difficulties: 0.63; 
Unadjusted odds, compared to reference category: 1.81*; 
Adjusted odds, compared to reference category[B]: 1.23*. 

Characteristic: Marital status; 
Category: Other; 
Reports one or more IADL or ADL difficulties: 28.8; 
Odds on having one or more IADL or ADL difficulties: 0.40; 
Unadjusted odds, compared to reference category: 1.16*; 
Adjusted odds, compared to reference category[B]: 1.24*. 

Characteristic: Family poverty status; 
Category: Above 185% of poverty threshold; 
Reports one or more IADL or ADL difficulties: 25.5; 
Odds on having one or more IADL or ADL difficulties: 0.34; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Family poverty status; 
Category: Above poverty threshold through 185% of poverty threshold; 
Reports one or more IADL or ADL difficulties: 41.8; 
Odds on having one or more IADL or ADL difficulties: 0.72; 
Unadjusted odds, compared to reference category: 2.10*; 
Adjusted odds, compared to reference category[B]: 1.39*. 

Characteristic: Family poverty status; 
Category: At or below poverty threshold; 
Reports one or more IADL or ADL difficulties: 43.8; 
Odds on having one or more IADL or ADL difficulties: 0.78; 
Unadjusted odds, compared to reference category: 2.28*; 
Adjusted odds, compared to reference category[B]: 1.25*. 

Characteristic: Homeowner status; 
Category: Homeowner; 
Reports one or more IADL or ADL difficulties: 25.9; 
Odds on having one or more IADL or ADL difficulties: 0.35; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Homeowner status; 
Category: Non-homeowner; 
Reports one or more IADL or ADL difficulties: 44.7; 
Odds on having one or more IADL or ADL difficulties: 0.81; 
Unadjusted odds, compared to reference category: 2.31*; 
Adjusted odds, compared to reference category[B]: 1.56*. 

Characteristic: Living arrangement; 
Category: Living with others; 
Reports one or more IADL or ADL difficulties: 28.7; 
Odds on having one or more IADL or ADL difficulties: 0.40; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Living arrangement; 
Category: Living alone; 
Reports one or more IADL or ADL difficulties: 31.4; 
Odds on having one or more IADL or ADL difficulties: 0.46; 
Unadjusted odds, compared to reference category: 1.14*; 
Adjusted odds, compared to reference category[B]: 0.65*. 

Characteristic: Education; 
Category: Less than high school; 
Reports one or more IADL or ADL difficulties: 46.0; 
Odds on having one or more IADL or ADL difficulties: 0.85; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Education; 
Category: High school or GED; 
Reports one or more IADL or ADL difficulties: 28.5; 
Odds on having one or more IADL or ADL difficulties: 0.40; 
Unadjusted odds, compared to reference category: 0.47*; 
Adjusted odds, compared to reference category[B]: 0.65*. 

Characteristic: Education; 
Category: Some college; 
Reports one or more IADL or ADL difficulties: 25.8; 
Odds on having one or more IADL or ADL difficulties: 0.35; 
Unadjusted odds, compared to reference category: 0.41*; 
Adjusted odds, compared to reference category[B]: 0.62*. 

Characteristic: Education; 
Category: College degree or above; 
Reports one or more IADL or ADL difficulties: 19.9; 
Odds on having one or more IADL or ADL difficulties: 0.25; 
Unadjusted odds, compared to reference category: 0.29*; 
Adjusted odds, compared to reference category[B]: 0.48*. 

Characteristic: Metropolitan status; 
Category: Urban; 
Reports one or more IADL or ADL difficulties: 29.1; 
Odds on having one or more IADL or ADL difficulties: 0.41; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Metropolitan status; 
Category: Suburban; 
Reports one or more IADL or ADL difficulties: 30.1; 
Odds on having one or more IADL or ADL difficulties: 0.43; 
Unadjusted odds, compared to reference category: 1.05*; 
Adjusted odds, compared to reference category[B]: 1.01. 

Characteristic: Metropolitan status; 
Category: Exurban; 
Reports one or more IADL or ADL difficulties: 29.6; 
Odds on having one or more IADL or ADL difficulties: 0.42; 
Unadjusted odds, compared to reference category: 1.02; 
Adjusted odds, compared to reference category[B]: 0.97. 

Characteristic: Census region; 
Category: Northeast; 
Reports one or more IADL or ADL difficulties: 32.4; 
Odds on having one or more IADL or ADL difficulties: 0.48; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Census region; 
Category: Midwest; 
Reports one or more IADL or ADL difficulties: 27.7; 
Odds on having one or more IADL or ADL difficulties: 0.38; 
Unadjusted odds, compared to reference category: 0.80*; 
Adjusted odds, compared to reference category[B]: 0.85. 

Characteristic: Census region; 
Category: South; 
Reports one or more IADL or ADL difficulties: 30.0; 
Odds on having one or more IADL or ADL difficulties: 0.43; 
Unadjusted odds, compared to reference category: 0.89*; 
Adjusted odds, compared to reference category[B]: 0.97. 

Characteristic: Census region; 
Category: Pacific; 
Reports one or more IADL or ADL difficulties: 28.1; 
Odds on having one or more IADL or ADL difficulties: 0.39; 
Unadjusted odds, compared to reference category: 0.82*; 
Adjusted odds, compared to reference category[B]: 0.90. 

Characteristic: Employment status; 
Category: Actively employed; 
Reports one or more IADL or ADL difficulties: 12.9; 
Odds on having one or more IADL or ADL difficulties: 0.15; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Employment status; 
Category: Retired; 
Reports one or more IADL or ADL difficulties: 32.7; 
Odds on having one or more IADL or ADL difficulties: 0.49; 
Unadjusted odds, compared to reference category: 3.29*; 
Adjusted odds, compared to reference category[B]: 2.12*. 

Characteristic: Employment status; 
Category: Other; 
Reports one or more IADL or ADL difficulties: 40.5; 
Odds on having one or more IADL or ADL difficulties: 0.68; 
Unadjusted odds, compared to reference category: 4.60*; 
Adjusted odds, compared to reference category[B]: 2.93*. 

Characteristic: Medicaid status; 
Category: Not a Medicaid recipient; 
Reports one or more IADL or ADL difficulties: 27.3; 
Odds on having one or more IADL or ADL difficulties: 0.37; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Medicaid status; 
Category: Medicaid recipient; 
Reports one or more IADL or ADL difficulties: 54.2; 
Odds on having one or more IADL or ADL difficulties: 1.18; 
Unadjusted odds, compared to reference category: 3.16*; 
Adjusted odds, compared to reference category[B]: 1.84*. 

Characteristic: Children live nearby[C]; 
Category: No children or no nearby children; 
Reports one or more IADL or ADL difficulties: 28.1; 
Odds on having one or more IADL or ADL difficulties: 0.39; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[B]: reference. 

Characteristic: Children live nearby[C]; 
Category: Children live nearby; 
Reports one or more IADL or ADL difficulties: 30.7; 
Odds on having one or more IADL or ADL difficulties: 0.44; 
Unadjusted odds, compared to reference category: 1.13*; 
Adjusted odds, compared to reference category[B]: 1.04. 

Source: GAO analysis of 2008 HRS data. 

Note: Unless otherwise noted, percentage estimates in table 14 have a 
margin of error for a 95 percent confidence interval of less than 5 
percentage points of the estimate itself. Asterisks denote odds ratios 
that are significant at the 0.05 level. Regressions included an 
additional variable to control for individuals whose homeownership 
status could not be determined. 

[A] Margin of error is +/-6.4 percentage points. 

[B] The Cox-Snell R^2 for the model is 0.12. 

[C] Defined as whether a respondent reports having a child living 
within 10 miles of the respondent. 

[End of table] 

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. 

Table 15: Percentage of Older Adults Age 60 and Above with Various 
Characteristics with One or More Difficulties with Daily Activities 
That Do Not Receive Assistance with Any Difficulties, and Odds and 
Odds Ratios Derived from Them: 

Characteristic: Age; 
Category: 60 to less than 70; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 55.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.23; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Age; 
Category: 70 to less than 80; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 51.6; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.06; 
Unadjusted odds, compared to reference category: 0.87*; 
Adjusted odds, compared to reference category[C]: 1.04. 

Characteristic: Age; 
Category: 80 and above; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 34.2; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.52; 
Unadjusted odds, compared to reference category: 0.42*; 
Adjusted odds, compared to reference category[C]: 0.56*. 

Characteristic: Sex; 
Category: Male; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 57.3; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.34; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Sex; 
Category: Female; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 39.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.65; 
Unadjusted odds, compared to reference category: 0.48*; 
Adjusted odds, compared to reference category[C]: 0.62*. 

Characteristic: Race; 
Category: White; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 48.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.95; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Race; 
Category: African American; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 34.7; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.53; 
Unadjusted odds, compared to reference category: 0.56*; 
Adjusted odds, compared to reference category[C]: 0.70*. 

Characteristic: Race; 
Category: Other[A]; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 50.0; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.00; 
Unadjusted odds, compared to reference category: 1.05*; 
Adjusted odds, compared to reference category[C]: 1.55. 

Characteristic: Ethnicity; 
Category: Non-Hispanic; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 47.7; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.91; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Ethnicity; 
Category: Hispanic; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 43.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.77; 
Unadjusted odds, compared to reference category: 0.84*; 
Adjusted odds, compared to reference category[C]: 1.34*. 

Characteristic: Marital status; 
Category: Married; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 53.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.16; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Marital status; 
Category: Widowed; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 35.6; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.55; 
Unadjusted odds, compared to reference category: 0.47*; 
Adjusted odds, compared to reference category[C]: 0.75*. 

Characteristic: Marital status; 
Category: Other; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 50.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.02; 
Unadjusted odds, compared to reference category: 0.87*; 
Adjusted odds, compared to reference category[C]: 1.01. 

Characteristic: Family poverty status; 
Category: Above 185% of poverty threshold; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 52.2; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.09; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Family poverty status; 
Category: Above poverty threshold through 185% of poverty threshold; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 41.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.70; 
Unadjusted odds, compared to reference category: 0.64*; 
Adjusted odds, compared to reference category[C]: 0.82*. 

Characteristic: Family poverty status; 
Category: At or below poverty threshold; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 32.6; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.48; 
Unadjusted odds, compared to reference category: 0.44*; 
Adjusted odds, compared to reference category[C]: 0.79. 

Characteristic: Homeowner status; 
Category: Homeowner; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 53.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.13; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Homeowner status; 
Category: Non-homeowner; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 33.3; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.50; 
Unadjusted odds, compared to reference category: 0.44*; 
Adjusted odds, compared to reference category[C]: 0.61*. 

Characteristic: Living arrangement; 
Category: Living with others; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 47.9; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.92; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Living arrangement; 
Category: Living alone; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 46.3; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.86; 
Unadjusted odds, compared to reference category: 0.94*; 
Adjusted odds, compared to reference category[C]: 1.80*. 

Characteristic: Education; 
Category: Less than high school; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 38.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.63; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Education; 
Category: High school or GED; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 47.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.89; 
Unadjusted odds, compared to reference category: 1.40*; 
Adjusted odds, compared to reference category[C]: 1.06. 

Characteristic: Education; 
Category: Some college; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 51.6; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.06; 
Unadjusted odds, compared to reference category: 1.68*; 
Adjusted odds, compared to reference category[C]: 1.20. 

Characteristic: Education; 
Category: College degree or above; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 60.7; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.55; 
Unadjusted odds, compared to reference category: 2.44*; 
Adjusted odds, compared to reference category[C]: 1.47*. 

Characteristic: Metropolitan status; 
Category: Urban; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 48.3; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.94; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Metropolitan status; 
Category: Suburban; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 47.9; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.92; 
Unadjusted odds, compared to reference category: 0.98*; 
Adjusted odds, compared to reference category[C]: 0.94. 

Characteristic: Metropolitan status; 
Category: Ex-urban; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 45.6; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.84; 
Unadjusted odds, compared to reference category: 0.90*; 
Adjusted odds, compared to reference category[C]: 0.79*. 

Characteristic: Census region; 
Category: Northeast; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 46.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.87; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Census region; 
Category: Midwest; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 48.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.95; 
Unadjusted odds, compared to reference category: 1.10*; 
Adjusted odds, compared to reference category[C]: 1.08. 

Characteristic: Census region; 
Category: South; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 48.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.95; 
Unadjusted odds, compared to reference category: 1.10*; 
Adjusted odds, compared to reference category[C]: 1.12. 

Characteristic: Census region; 
Category: Pacific; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 43.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.77; 
Unadjusted odds, compared to reference category: 0.89*; 
Adjusted odds, compared to reference category[C]: 0.78. 

Characteristic: Employment status; 
Category: Employed[B]; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 79.8; 
Odds on not receiving assistance for any IADL/ADL difficulties: 3.95; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Employment status; 
Category: Retired; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 45.9; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.85; 
Unadjusted odds, compared to reference category: 0.21*; 
Adjusted odds, compared to reference category[C]: 0.31*. 

Characteristic: Employment status; 
Category: Other; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 34.4; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.52; 
Unadjusted odds, compared to reference category: 0.13*; 
Adjusted odds, compared to reference category[C]: 0.26*. 

Characteristic: Medicaid status; 
Category: Not a Medicaid recipient; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 50.9; 
Odds on not receiving assistance for any IADL/ADL difficulties: 1.04; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Medicaid status; 
Category: Medicaid recipient; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 27.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.37; 
Unadjusted odds, compared to reference category: 0.36*; 
Adjusted odds, compared to reference category[C]: 0.50*. 

Characteristic: Children live nearby; 
Category: No children or no nearby children; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 49.1; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.97; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category[C]: reference. 

Characteristic: Children live nearby; 
Category: Children live nearby; 
Does not receive any assistance for any reported IADL/ADL 
difficulties: 46.0; 
Odds on not receiving assistance for any IADL/ADL difficulties: 0.85; 
Unadjusted odds, compared to reference category: 0.88*; 
Adjusted odds, compared to reference category[C]: 0.92. 

Source: GAO analysis of HRS data. 

Note: Unless otherwise noted, percentage estimates in table 15 have a 
margin of error for a 95 percent confidence interval of less than 6 
percentage points of the estimate itself. Asterisks denote odds ratios 
that are significant at the 0.05 level. Regressions included an 
additional variable to control for individuals whose homeownership 
status could not be determined. 

[A] Margin of error is +/-9.7 percentage points. 

[B] Margin of error is +/-7.4 percentage points. 

[C] The Cox-Snell R^2 for the model is 0.13. 

[End of table] 

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. 

[End of section] 

Appendix V: Likely Need for Transportation Services: 

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.[Footnote 96] 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. 

Table 16: Percentage of Older Adults Age 65 and above with Various 
Characteristics Who Were Likely to Need Transportation Services, and 
Odds and Odds Ratios Derived from Them: 

Characteristic: Age; 
Category: 65 to less than 70; 
Likely to need transportation services: 11.6; 
Odds on needing transportation services: 0.13; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Age; 
Category: 70 to less than 80; 
Likely to need transportation services: 17.5; 
Odds on needing transportation services: 0.21; 
Unadjusted odds, compared to reference category: 1.61*; 
Adjusted odds, compared to reference category: 1.50*. 

Characteristic: Age; 
Category: 80 and above; 
Likely to need transportation services: 41.0; 
Odds on needing transportation services: 0.69; 
Unadjusted odds, compared to reference category: 5.28*; 
Adjusted odds, compared to reference category: 4.24*. 

Characteristic: Sex; 
Category: Male; 
Likely to need transportation services: 12.0; 
Odds on needing transportation services: 0.14; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Sex; 
Category: Female; 
Likely to need transportation services: 28.5; 
Odds on needing transportation services: 0.40; 
Unadjusted odds, compared to reference category: 2.92*; 
Adjusted odds, compared to reference category: 2.76*. 

Characteristic: Race; 
Category: White; 
Likely to need transportation services: 19.6; 
Odds on needing transportation services: 0.24; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Race; 
Category: African American; 
Likely to need transportation services: 39.1; 
Odds on needing transportation services: 0.64; 
Unadjusted odds, compared to reference category: 2.64*; 
Adjusted odds, compared to reference category: 1.79*. 

Characteristic: Race; 
Category: Other; 
Likely to need transportation services: 30.1[A]; 
Odds on needing transportation services: 0.43; 
Unadjusted odds, compared to reference category: 1.77*; 
Adjusted odds, compared to reference category: 1.23. 

Characteristic: Ethnicity; 
Category: Non-Hispanic; 
Likely to need transportation services: 20.0; 
Odds on needing transportation services: 0.25; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Ethnicity; 
Category: Hispanic; 
Likely to need transportation services: 45.6; 
Odds on needing transportation services: 0.84; 
Unadjusted odds, compared to reference category: 3.36*; 
Adjusted odds, compared to reference category: 2.10*. 

Characteristic: Marital status; 
Category: Married; 
Likely to need transportation services: 13.7; 
Odds on needing transportation services: 0.16; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Marital status; 
Category: Widowed; 
Likely to need transportation services: 35.0; 
Odds on needing transportation services: 0.54; 
Unadjusted odds, compared to reference category: 3.40*; 
Adjusted odds, compared to reference category: 1.59*. 

Characteristic: Marital status; 
Category: Other; 
Likely to need transportation services: 22.0; 
Odds on needing transportation services: 0.28; 
Unadjusted odds, compared to reference category: 1.78*; 
Adjusted odds, compared to reference category: 1.29. 

Characteristic: Family poverty status; 
Category: Above 185% of poverty threshold; 
Likely to need transportation services: 15.7; 
Odds on needing transportation services: 0.19; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Family poverty status; 
Category: Above poverty threshold through 185% of poverty threshold; 
Likely to need transportation services: 31.2; 
Odds on needing transportation services: 0.45; 
Unadjusted odds, compared to reference category: 2.43*; 
Adjusted odds, compared to reference category: 1.47*. 

Characteristic: Family poverty status; 
Category: At or below poverty threshold; 
Likely to need transportation services: 52.8; 
Odds on needing transportation services: 1.12; 
Unadjusted odds, compared to reference category: 5.98*; 
Adjusted odds, compared to reference category: 2.83*. 

Characteristic: Homeowner status; 
Category: Homeowner; 
Likely to need transportation services: 15.4; 
Odds on needing transportation services: 0.18; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Homeowner status; 
Category: Non-homeowner; 
Likely to need transportation services: 44.7; 
Odds on needing transportation services: 0.81; 
Unadjusted odds, compared to reference category: 4.43*; 
Adjusted odds, compared to reference category: 2.32*. 

Characteristic: Living arrangement; 
Category: Living with others; 
Likely to need transportation services: 20.0; 
Odds on needing transportation services: 0.25; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Living arrangement; 
Category: Living alone; 
Likely to need transportation services: 24.5; 
Odds on needing transportation services: 0.33; 
Unadjusted odds, compared to reference category: 1.30*; 
Adjusted odds, compared to reference category: 0.42*. 

Characteristic: Education; 
Category: Less than high school; 
Likely to need transportation services: 40.4; 
Odds on needing transportation services: 0.68; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Education; 
Category: High school or GED; 
Likely to need transportation services: 19.6; 
Odds on needing transportation services: 0.24; 
Unadjusted odds, compared to reference category: 0.36*; 
Adjusted odds, compared to reference category: 0.60*. 

Characteristic: Education; 
Category: Some college; 
Likely to need transportation services: 15.3; 
Odds on needing transportation services: 0.18; 
Unadjusted odds, compared to reference category: 0.27*; 
Adjusted odds, compared to reference category: 0.52*. 

Characteristic: Education; 
Category: College degree or above; 
Likely to need transportation services: 10.1; 
Odds on needing transportation services: 0.11; 
Unadjusted odds, compared to reference category: 0.17*; 
Adjusted odds, compared to reference category: 0.46*. 

Characteristic: Metropolitan status; 
Category: Urban; 
Likely to need transportation services: 23.0; 
Odds on needing transportation services: 0.30; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Metropolitan status; 
Category: Suburban; 
Likely to need transportation services: 21.0; 
Odds on needing transportation services: 0.27; 
Unadjusted odds, compared to reference category: 0.89*; 
Adjusted odds, compared to reference category: 0.84*. 

Characteristic: Metropolitan status; 
Category: Exurban; 
Likely to need transportation services: 19.3; 
Odds on needing transportation services: 0.24; 
Unadjusted odds, compared to reference category: 0.80*; 
Adjusted odds, compared to reference category: 0.82*. 

Characteristic: Census region; 
Category: Northeast; 
Likely to need transportation services: 26.6; 
Odds on needing transportation services: 0.36; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Census region; 
Category: Midwest; 
Likely to need transportation services: 17.9; 
Odds on needing transportation services: 0.22; 
Unadjusted odds, compared to reference category: 0.60*; 
Adjusted odds, compared to reference category: 0.66*. 

Characteristic: Census region; 
Category: South; 
Likely to need transportation services: 21.7; 
Odds on needing transportation services: 0.28; 
Unadjusted odds, compared to reference category: 0.77*; 
Adjusted odds, compared to reference category: 0.63*. 

Characteristic: Census region; 
Category: Pacific; 
Likely to need transportation services: 20.3; 
Odds on needing transportation services: 0.25; 
Unadjusted odds, compared to reference category: 0.70*; 
Adjusted odds, compared to reference category: 0.64*. 

Characteristic: Overall health status; 
Category: Good, very good, or excellent; 
Likely to need transportation services: 14.3; 
Odds on needing transportation services: 0.17; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Overall health status; 
Category: Fair or poor; 
Likely to need transportation services: 38.1; 
Odds on needing transportation services: 0.61; 
Unadjusted odds, compared to reference category: 3.69*; 
Adjusted odds, compared to reference category: 1.69*. 

Characteristic: Mental health; 
Category: Not depressed; 
Likely to need transportation services: 18.7; 
Odds on needing transportation services: 0.23; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Mental health; 
Category: depressed; 
Likely to need transportation services: 26.3; 
Odds on needing transportation services: 0.36; 
Unadjusted odds, compared to reference category: 1.55*; 
Adjusted odds, compared to reference category: 0.88. 

Characteristic: Sight; 
Category: Good, very good, or excellent; 
Likely to need transportation services: 15.8; 
Odds on needing transportation services: 0.19; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Sight; 
Category: Fair or poor; 
Likely to need transportation services: 40.8; 
Odds on needing transportation services: 0.69; 
Unadjusted odds, compared to reference category: 3.68*; 
Adjusted odds, compared to reference category: 1.90*. 

Characteristic: Mobility; 
Category: Able to walk; 
Likely to need transportation services: 15.2; 
Odds on needing transportation services: 0.18; 
Unadjusted odds, compared to reference category: reference; 
Adjusted odds, compared to reference category: reference. 

Characteristic: Mobility; 
Category: Unable to walk; 
Likely to need transportation services: 47.5; 
Odds on needing transportation services: 0.90; 
Unadjusted odds, compared to reference category: 5.05*; 
Adjusted odds, compared to reference category: 2.34*. 

Source: GAO analysis of 2008 HRS data. 

Note: Unless otherwise noted, percentage estimates in table 16 have a 
margin of error for a 95 percent confidence interval of less than 5 
percentage points of the estimate itself. Asterisks denote odds ratios 
that are significant at the 0.05 level. Regressions included an 
additional variable to control for individuals whose homeownership 
status could not be determined. 

[A] Margin of error is +/-6.1 percentage points. 

[B] The Cox-Snell R^2 for the model is 0.24. 

[End of table] 

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. 

[End of section] 

Appendix VI: Responses to Selected Questions from GAO Survey of Area 
Agencies on Aging (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. 

Figure 5: Percent of Local Agencies Who Transferred Funds between OAA 
Title III Part B and Part C, Fiscal Year 2009: 

[Refer to PDF for image: vertical bar graph] 

Funds: Transferred funds; 
Percentage of agencies: 45%. 

Funds: Did not transfer funds. 
Percentage of agencies: 55%. 

N = 85. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

[End of figure] 

Figure 6: Percent of Local Agencies Permitting Voluntary 
Contributions, Fiscal Year 2009: 

[Refer to PDF for image: vertical bar graph] 

Permitted voluntary contributions: Agency permitted; 
Percentage of agencies: 97%. 

Permitted voluntary contributions: Agency did not permit; 
Percentage of agencies: 3%. 

N = 94. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

[End of figure] 

Figure 7: Percent of Local Agencies in States Permitting Cost Sharing: 

[Refer to PDF for image: vertical bar graph] 

Permitted cost sharing: State permits; 
Percent of local agencies in states: 49%. 

Permitted cost sharing: State does not permit; 
Percent of local agencies in states: 51%. 

N = 97. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

[End of figure] 

Figure 8: Percent of Local Agencies Permitted to Cost Share Who Do So: 

[Refer to PDF for image: vertical bar graph] 

Use of cost sharing: Cost share; 
Percent of agencies permitted to cost share: 77%. 

Use of cost sharing: Do not cost share; 
Percent of agencies permitted to cost share: 23%. 

N = 47. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The margin of error for this survey question was outside of our 
overall range and is plus or minus 15 percentage points at the 95 
percent confidence level. 

[End of figure] 

Figure 9: Change in Local Agency Funding Sources from Fiscal Year 2009 
to Fiscal Year 2010: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Funding source: Total funding from all sources; 
Increased: 32%; 
No change: 21%; 
Decreased: 47%. 

Funding source: State funds; 
Increased: 12%; 
No change: 20%; 
Decreased: 68%. 

Funding source: Local funds; 
Increased: 10%; 
No change: 43%; 
Decreased: 47%. 

Funding source: In-kind or voluntary contributions; 
Increased: 13%; 
No change: 37%; 
Decreased: 50%. 

Funding source: Private funding or donations; 
Increased: 14%; 
No change: 43%; 
Decreased: 43%. 

Funding source: Other types of funding; 
Increased: 50%; 
No change: 29%; 
Decreased: 21%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by type of funding source. Eighty-nine agencies provided answers to 
total funding from all sources, 94 agencies provided answers to state 
funds, 90 agencies provided answers to local funds, 86 agencies 
provided answers to in-kind or voluntary contributions, 70 agencies 
provided answers to private funding or donations, and 24 agencies 
provided answers to other types of funding. 

[End of figure] 

Figure 10: Change in Requests for Services Since the Start of Economic 
Downturn: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Service type: Title III Part B Support Services; 
Increased: 73%; 
No change: 23%; 
Decreased: 3%. 

Service type: Title III Part C Congregate Meals; 
Increased: 47%; 
No change: 43%; 
Decreased: 10%. 

Service type: Title III Part C Home-delivered Meals; 
Increased: 79%; 
No change: 18%; 
Decreased: 3%. 

Service type: Title III Part E Caregiver Services; 
Increased: 67%; 
No change: 32%; 
Decreased: 1%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by service. Ninety agencies provided answers to Title III Part B 
support services, 89 agencies provided answers to Title III Part C 
congregate meals, 90 agencies provided answers to Title III C home- 
delivered meals, and 89 agencies provided answers to Title III Part E 
caregiver services. 

[End of figure] 

Figure 11: Administrative Changes from Fiscal Year 2009 to Fiscal Year 
2010: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Type of administrative change: Ability to fill vacant positions; 
Increased: 9%; 
No change: 46%; 
Decreased: 45%. 

Type of administrative change: Administrative expenses; 
Increased: 19%; 
No change: 43%; 
Decreased: 38%. 

Type of administrative change: Capital expenses; 
Increased: 9%; 
No change: 54%; 
Decreased: 37%. 

Type of administrative change: Operational expenses; 
Increased: 21%; 
No change: 34%; 
Decreased: 45%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by administrative expense. Ninety-three agencies responded to ability 
to fill vacant positions, 94 agencies responded to administrative 
expenses, 81 agencies responded to capital expenses, and 91 agencies 
responded to operational expenses. 

[End of figure] 

Figure 12: Administrative Changes from Fiscal Year 2010 to Fiscal Year 
2011: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Type of administrative change: Ability to fill vacant positions; 
Increased: 5%; 
No change: 60%; 
Decreased: 35%. 

Type of administrative change: Administrative expenses; 
Increased: 13%; 
No change: 60%; 
Decreased: 27%. 

Type of administrative change: Capital expenses; 
Increased: 4%; 
No change: 64%; 
Decreased: 32%. 

Type of administrative change: Operational expenses; 
Increased: 16%; 
No change: 50%; 
Decreased: 34%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by administrative expense. Eighty-six agencies responded to ability to 
fill vacant positions, 88 agencies responded to administrative 
expenses, 72 agencies responded to capital expenses, and 82 agencies 
responded to operational expenses. 

[End of figure] 

Figure 13: Change in Title III Services from Fiscal Year 2009 to 
Fiscal Year 2010: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Service type: OAA Title III B services; 
Increased: 21%; 
No change: 59%; 
Decreased: 20%. 

Service type: OAA Title III C services; 
Increased: 29%; 
No change: 53%; 
Decreased: 18%. 

Service type: OAA Title III E services; 
Increased: 13%; 
No change: 73%; 
Decreased: 14%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by service. Ninety-four agencies provided answers to Title III Part B 
services, 93 agencies provided answers to Title III Part C services, 
and 93 agencies provided answers to Title III E services. 

[End of figure] 

Figure 14: Expected Change in Title III Services from Fiscal Year 2010 
to Fiscal Year 2011: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Service type: OAA Title III B services%; 
Increased: 10%; 
No change: 75%; 
Decreased: 16%. 

Service type: OAA Title III C services%; 
Increased: 10%; 
No change: 69%; 
Decreased: 21%. 

Service type: OAA Title III E services%; 
Increased: 8%; 
No change: 80%; 
Decreased: 12%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by service. Eighty-three agencies provided answers to Title III Part B 
services, 84 agencies provided answers to Title III Part C services, 
and 83 agencies provided answers to Title III Part E services. 

[End of figure] 

Figure 15: Local Agency Use of Recovery Act Congregate Meal Funds: 

[Refer to PDF for image: vertical bar graph] 

Use of funds: Replaced any decreased state or local funding; 
Percent of agencies: 66%. 

Use of funds: Expanded existing programs; 
Percent of agencies: 67%. 

Use of funds: Created new programs; 
Percent of agencies: 29%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by use of funds. Seventy agencies provided answers to "replaced any 
decreased state or local funding," 78 agencies provided answers to 
"expanded existing programs," and 65 agencies provided answers to 
"created new programs." The margin of error for "created new programs" 
was outside of our overall range and is no more than plus or minus 13 
percentage points at the 95 percent confidence level. 

[End of figure] 

Figure 16: Local Agency Use of Recovery Act Home-Delivered Meal Funds: 

[Refer to PDF for image: vertical bar graph] 

Use of funds: Replaced any decreased state or local funding; 
Percent of agencies: 61%. 

Use of funds: Expanded existing programs; 
Percent of agencies: 66%. 

Use of funds: Created new programs; 
Percent of agencies: 15%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by use of funds. Sixty-seven agencies provided answers to "replaced 
any decreased state or local funding," 76 agencies provided answers to 
"expanded existing programs," and 55 agencies provided answers to 
"created new programs." The margin of error for "replaced any 
decreased state and local funding" was outside of our overall range 
and is no more than plus or minus 13 percentage points at the 95 
percent confidence level. 

[End of figure] 

Figure 17: Local Agency Challenges in Using Recovery Act Meal Funds: 

[Refer to PDF for image: vertical bar graph] 

Percent of agencies: 

Type of challenge: Allocation could not be transferred between 
congregate and home-delivered meals; 
Extremely challenging: 28%; 
Very challenging: 24%; 
Moderately challenging: 12%; 
Slightly challenging: 6%; 
Not challenging: 30%. 

Type of challenge: Allocation could not be used for capital 
expenditures; 
Extremely challenging: 13%; 
Very challenging: 15%; 
Moderately challenging: 22%; 
Slightly challenging: 7%; 
Not challenging: 43%. 

Type of challenge: Allocation was more needed for other OAA Title III 
services, but could not be transferred; 
Extremely challenging: 23%; 
Very challenging: 19%; 
Moderately challenging: 14%; 
Slightly challenging: 10%; 
Not challenging: 33%. 

Type of challenge: Services provided for with allocation will need to 
be sustained without that money in the future; 
Extremely challenging: 34%; 
Very challenging: 27%; 
Moderately challenging: 18%; 
Slightly challenging: 11%; 
Not challenging: 10%. 

Source: Analysis of GAO Survey of Area Agencies on Aging. 

Note: The number of local agencies responding to this question varied 
by specific challenge. Ninety agencies provided answers to "services 
provided for with allocation will need to be sustained without that 
money in the future," 90 agencies provided answers to "allocation was 
more needed for other OAA Title III services, but could not be 
transferred," 86 agencies provided answers to "allocation could not be 
used for capital expenditures," and 89 agencies provided answers to 
"allocation could not be transferred between congregate and home- 
delivered meals." 

[End of figure] 

[End of section] 

Appendix VII: Comments from the Department of Health and Human 
Services: 

Department Of Health And Human Services: 
Office of the Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

February 11, 2011: 

Kay E. Brown, Director: 
Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Brown: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "OLDER AMERICANS ACT: More Should be Done 
to Measure the Extent of Unmet Need for Services" (GAO-11-237).
The Department appreciates the opportunity to review this report 
before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Older Americans Act: More Should Be Done To Measure The Extent Of 
Unmet Need For Services" (GA0-11-237): 

The Department of Health and Human Services appreciates the 
opportunity to review and comment on this draft report. This report 
focuses on need and unmet need for home and community based services 
under the Older Americans Act (OAA). In working with the 
Administration on Aging (AoA), GAO learned much about the needs of 
older Americans and the methods used by states and area agencies on 
aging to measure and meet those critical long term service and support 
needs. 

As noted in the report, available data indicate that great need exists 
for home and community based services for older adults and their 
family caregivers. In response to that need, states and local 
community agencies across the country actively seek additional 
funding, more than doubling the funding received through the Older 
Americans Act (OAA). In addition, states leverage those funds with a 
variety of other funding sources, like Medicaid. These organizations 
make concerted efforts and difficult choices in targeting those older 
adults and family caregivers in greatest social and economic need. 
Despite these efforts, states report that across programs they are not 
able to serve all of the older individuals in need. States believe OAA 
administrative flexibility is one tool that assists them in maximizing 
their resources. 

AoA provides a number of resources to state and area agencies on aging 
to assist them in their efforts to understand need and unmet need in 
the communities they serve. State plan guidance reinforces 
requirements in the OAA related to the identification of need and 
unmet need as well as targeting services. This guidance links to an 
AoA-supported web-based technical assistance resource center that 
provides the tools needed to understand OAA requirements, and provides 
specific assistance in planning strategically to understand and meet 
the needs of older residents and their caregivers. Further, extensive 
technical assistance is provided to support states in these efforts. 

AoA has explicitly shared the many factors complicating the 
development of a standardized definition and methodology to use when 
measuring unmet need. States differ in how they are structured and 
administer diverse funding for home and community-based services. In 
some states, such funding is administered across multiple agencies and 
the state office on aging may not have access to information on older 
adults receiving services from sister agencies. Requiring surveys can 
be complicated, costly and once gathered, the resulting information 
may become outdated quickly. AoA is cautious about increasing 
reporting burden when the efficacy of doing so is not certain and 
states are facing real and dramatic fiscal pressures. While the work 
by GAO was considerable, it was also not able, using existing 
resources, to develop workable measures for determining the extent of 
unmet need for services like those under Title III of the OAA. 

We appreciate that the GAO report recognizes the balance between 
burden and utility that agencies must weigh when directing states on 
issues such as measuring need and unmet need. While seeking 
standardization can have value, the real value for older adults will 
come from the judicious use of current resources, empowering states to 
use the flexibility available to them and supporting our nation's 
elders and family caregivers in their efforts to remain independent in 
their homes and communities. 

Again, we appreciate the opportunity to work with GAO on this report. 
The Department of Health and Human Services will review GAO's 
recommendations related to cost-sharing and developing consistent 
definitions of need and unmet need and explore the options available 
to implement them. 

[End of section] 

Appendix VIII GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Kay Brown (202) 512-7215 or brownke@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] 42 U.S.C. §§ 3001 and 3003. 

[2] This estimate is the number of older adults who received 
registered services in 2008. The Administration on Aging collects 
demographic information on the number of older adults who receive 
"registered services" like home-delivered meals and home-based care 
but does not collect this information about older adults receiving 
unregistered services such as general transportation or information 
and assistance. For a list of the Title III services included in this 
estimate, see table 1. 

[3] Pub. L. No. 89-73, §§ 79 Stat. 219 (codified as amended at 42 
U.S.C. §§ 3021-3030s-2). It was most recently reauthorized by the 
Older Americans Act Amendments of 2006, Pub. L. No. 109-365, 120 Stat. 
2522. 

[4] Fiscal year 2008 is the most recent year for which state-level 
data were available. 

[5] 42 U.S.C. § 1396(a)(10)(A)(ii)(VI). 

[6] Population Division, U.S. Census Bureau, "Table 2. Projections of 
the Population by Selected Age Groups and Sex for the United States: 
2010 to 2050 (NP2008-T2)." Released August 14, 2008. Our analysis is 
of people age 60 and over. 

[7] For more information about projected fiscal challenges, see GAO, 
The Federal Government's Long-Term Fiscal Outlook, Fall 2010 Update, 
[hyperlink, http://www.gao.gov/products/GAO-11-201SP] (Washington, 
D.C.: November 2010) and State and Local Governments' Fiscal Outlook, 
March 2010 Update, [hyperlink, http://www.gao.gov/products/GAO-10-358] 
(Washington, D.C.: March 2010). 

[8] Pub. L. No. 111-5, 123 Stat. 115. 

[9] Our estimates of need for meals services were limited to those 
eligible for services that had incomes at or below 185 percent of the 
poverty threshold, due to the design of the Current Population Survey. 

[10] To estimate those in need, we used national survey questions 
about older adults' likely need for meals, home-based care or 
transportation. The surveys also included questions that allowed us to 
estimate the number of individuals who were receiving services for 
meals and home-based care, but did not include questions about receipt 
of transportation services. After identifying those likely to need 
services and whether they received them, we conducted regression 
analyses to determine which, if any, demographic characteristics made 
someone likely to need meals or home-based care but not receive them 
or to be in need of transportation services. 

[11] The local agency 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, unless otherwise noted. 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. 

[12] Based on our review, we considered these data reliable for our 
purposes. 

[13] 42 U.S.C. § 3021(a). 

[14] 42 U.S.C. § 3002(40). In addition to all people age 60 years and 
over, some individuals under age 60 are eligible for meals programs. 
For example, spouses of individuals age 60 and over and individuals 
with disabilities who live with older adults are eligible for meals 
programs. 42 U.S.C. § 3030g-21(2)(I). 

[15] The 56 state agencies include states, the District of Columbia, 
Puerto Rico, American Samoa, Guam, the Northern Mariana Islands, and 
the Virgin Islands. 

[16] 42 U.S.C. § 3030d. AoA uses the following categories to describe 
Part B services: transportation, information and assistance, case 
management, homemaker, legal assistance, personal care, adult day 
care/health, outreach, chore, assisted transportation, and other 
services. 

[17] 42 U.S.C. §§ 3030e-3030g-22. Title III Part C also authorizes 
nutrition counseling and education programs. 

[18] 42 U.S.C. §§ 3030s-3030s-2. For this study, GAO focused primarily 
on Title III Parts B and C. Part E services receive lower funding 
levels than Parts B and C and are provided to caregivers. Identifying 
the caregiver population and determining their need requires a 
methodological approach that is different than what was used for this 
report. Part D authorizes health promotion activities for older 
adults, and the funding level is much lower than for services 
authorized under Parts B, C, and E. Part A includes general 
provisions, for example, the purpose of the title and definitions of 
terms used in the law. 

[19] 42 U.S.C. § 3025(a)(1)(E) and (2)(C) and (E). 

[20] 42 U.S.C. § 3002(23) and (24). 

[21] Based on 2008 Current Population Survey data. 

[22] 42 U.S.C. § 3027(a)(4). 

[23] Compiled by AoA using U.S. Census Bureau population estimates. 
According to AoA documents, Congress provided $1.098 billion for FY 
2005, $1.091 billion in FY 2006, $1.111 billion in FY 2007, $1.124 
billion in FY 2008, and $1.178 billion in FY 2009. 

[24] 42 U.S.C. § 3024. 

[25] The non-federal match for Parts B and C are generally 15 percent 
and for Part E is 25 percent. 42 U.S.C. §§ 3024(d)(1)(D) and 3030s- 
1(g)(2)(A). 

[26] 42 U.S.C. § 3025(a)(1)(E). GAO, Older Americans Act: Funding 
Formula Could Better Reflect State Needs, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-94-41] (Washington, D.C.: May 
1994). 

[27] 42 U.S.C. § 3028(b)(4). 

[28] 42 U.S.C. § 3028(b)(5) and 3030c-3(b)(4). 

[29] 123 Stat. 179. There was also $3 million appropriated for 
nutrition services for Native Americans under title VI. 

[30] § 1603, 123 Stat. 302. 

[31] AoA requires state agencies to report yearly on both OAA funds 
and all other funds used by state or local agencies to provide 
services meeting the definition of OAA services. State agencies are 
asked to report expenditures for all service categories whether or not 
AoA funds were utilized for that purpose. 

[32] This $973 million in expenditures from OAA funds is lower than 
the $1.124 billion OAA allocation in FY 2008 for several reasons. For 
example, AoA officials told us that calculations of various types of 
expenditures do not account for administrative costs. Also, states can 
carry over allotment funds from 1 year to the next. 

[33] Responsibility for the day-to-day operation of these services 
vary by program. 

[34] 7 U.S.C. §§ 2011-2036. 

[35] U.S. Department of Agriculture Food and Nutrition Service, 
Characteristics of Supplemental Nutrition Assistance Program 
Households: Fiscal Year 2009, SNAP-10-CHAR (Washington, D.C.: October 
2010). 

[36] 7 U.S.C. § 3007. USDA FY 2010 Budget Summary and Annual 
Performance Plan. For more information about SNAP and other federal 
assistance programs available to low-income older adults, see GAO, 
Domestic Food Assistance: Complex System Benefits Millions, but 
Additional Efforts Could Address Potential Inefficiency and Overlap 
among Smaller Programs, [hyperlink, 
http://www.gao.gov/products/GAO-10-346] (Washington, D.C.: April 2010). 

[37] Home-and community-based waivers are a diverse group of programs 
authorized under section 1915(C) of the Social Security Act. 42 U.S.C. 
§ 1396n. States are allowed wide latitude in the populations served 
and the specific services provided. In addition to waivers, Medicaid 
has a mandatory home health benefit and states have the option of 
providing personal care services through their regular Medicaid 
program without seeking waivers. 42 U.S.C. § 1396(a)(10)(D) and (24). 

[38] Kaiser Commission on Medicaid and the Uninsured, Medicaid Home 
and Community-Based Service Programs: Data Update, The Henry J. Kaiser 
Family Foundation (Washington, D.C.: November 2009). 

[39] 42 U.S.C. § 1395d(a). Medicare is the federal health insurance 
program for people over age 65, individuals under age 65 with certain 
disabilities, and individuals diagnosed with end-stage renal disease. 
42 U.S.C. §§ 1395-1395hhh. 

[40] For more information about transportation programs available to 
older adults, See GAO, Transportation Disadvantaged Seniors: Efforts 
to Enhance Senior Mobility Could Benefit from Additional Guidance and 
Information, [hyperlink, http://www.gao.gov/products/GAO-04-971] 
(Washington, D.C.: August 2004). In addition to these 15 key programs, 
other federal programs and policies are designed to provide or improve 
access to transportation services for other disadvantaged populations, 
including older adults among those populations. 

[41] 42 U.S.C. § 1396a(70). 

[42] 49 U.S.C. §§ 5307, 5309, 5310, and 5311. 

[43] Executive Order No. 13,330, 69 Fed. Reg. 9,185 (Feb. 26, 2004). 

[44] Suzanne R. Kunkel, Abbe E. Lackmeyer, Jane K. Straker, and Sandy 
Markwood, Area Agencies on Aging: Advancing Access for Home and 
Community-Based Services, Scripps Gerontology Center, Miami University 
(Oxford, Ohio: 2009). 

[45] 42 U.S.C. § 3027(a). 

[46] In addition to people age 60 and over, younger spouses living 
with people age 60 and over and people with disabilities of all ages 
who live with someone age 60 and over are also eligible for meals 
services through Title III. 42 U.S.C § 3030g-21(2)(I). Our estimates 
of older adults who are likely to need meals services also include 
these additional individuals. Our analysis of meal program recipients 
and non-recipients was limited to those living in households below 185 
percent of the poverty threshold because the CPS did not collect 
generalizable information for individuals with higher incomes. An 
estimated 31 percent of people age 60 and over were below 185 percent 
of the poverty threshold. 

[47] These older adults received at least some services, but we did 
not determine whether the services were adequate to meet all their 
needs. For example, as shown in table 3, some people receiving meals 
services were still food insecure. 

[48] We defined likely need to align with the program purposes, as 
described in 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, according to the OAA. 42 U.S.C. § 
3030d-21. Given available data, we could not estimate the number of 
older adults likely to need services based on the third purpose of 
promoting health and well-being. 42 U.S.C. § 3030d-21. The home- 
delivered meals program in particular is also designed to assist 
individuals who have difficulty obtaining or preparing food due to 
health conditions. Unless otherwise noted, our estimates of low-income 
older adults likely to need or receive meals services have a maximum 
confidence interval of +/-3.2 percentage points of the estimate. 

[49] We used a series of CPS questions commonly used to measure food 
insecurity. While some older adults who were food insecure prior to 
receiving meals may have become food secure due to the meals services, 
the proportion of food insecure older adults who did not receive meals 
is still very significant. An estimated 70 percent of low-income older 
adults who were food insecure and not receiving meals services were 
also not receiving SNAP benefits, which are another source of 
nutrition assistance. 

[50] For a more detailed table, see appendix II. For addition 
information about the relationship between various likely need and 
demographic characteristics and a person's likelihood of receiving 
services, see appendix III. 

[51] We used four CPS questions about functional impairments including 
having cognitive impairments and/or difficulties with instrumental 
activities of daily living (IADL)or activities of daily living (ADL) 
to identify older adults likely to have need for meals programs based 
on potential difficulties preparing or obtaining food. (See appendix I 
for more information about these survey questions.) 

[52] An estimated 92 percent of agencies tracked requests in fiscal 
year 2009. 

[53] See Kirsten J. Colello, Older Americans Act: Title III Nutrition 
Services Program, Congressional Research Service, RS21202 (Feb. 1, 
2010). 

[54] Unless otherwise noted, our estimates of older adults likely to 
need home-based care, and our estimates related to receipt of help 
among those with likely need for assistance have a maximum confidence 
interval of +/-6 percentage points of the estimate. 

[55] Unlike our estimates related to meals services, our discussions 
of home-based care and transportation are not restricted to low-income 
individuals. 

[56] Three Title IIIB services provide home-based care: homemaker, 
chore and personal care services. AoA defines homemaker services as 
assistance such as preparing meals, shopping for personal items, 
managing money, using the telephone or doing light housework. Chore is 
defined as assistance such as heavy housework, yard work or sidewalk 
maintenance for a person. Personal care is defined as personal 
assistance with bathing and other self-care tasks. 

[57] We defined likely need for Title III home-based care services as 
having difficulties with IADLs or ADLs, based on the types of help 
provided through these services. For more information on how we 
measured difficulties with IADLs and ADLs, see appendix I. 

[58] We also found that several demographic characteristics were 
associated with differences in whether or not an older adult received 
help, even after controlling for other factors. See appendix IV. 

[59] Available data did not allow us to estimate likely need and 
receipt of home-based services at the state level. 

[60] The HRS data did not allow us to determine whether family members 
providing help were receiving services from Title III or other sources. 

[61] Unless otherwise noted, our estimates related to older adults' 
likely need for transportation services have a maximum confidence 
interval of +/-5 percentage points of the estimate. 

[62] While people age 60 and older are eligible to receive Title III 
transportation services, the HRS only collects the information we used 
in our analysis for those who are 65 and above. Our definition of 
likely need for Title III transportation programs includes those who 
(1) were unable to drive; (2) had not driven in the past month; and/or 
(3) were able to drive, but did not have a car available. We excluded 
all older adults who lived in assisted living facilities that provide 
transportation services, because the availability of such services 
would make them unlikely to need Title III services. Although some 
older adults may be less likely to need Title III transportation 
services because they use public transportation, we were not able to 
exclude these individuals from our estimates of likely need, due to a 
lack of data. Researchers analyzing 2001 National Household Travel 
Survey data estimated that people 65 and above make an estimated 1 
percent of their trips by public transit, 0.4 percent by bicycle and 9 
percent on foot. John Pucher and, John L Renne, "Socioeconomics of 
Urban Travel: Evidence from the 2001 NHTS," Transportation Quarterly, 
57(3) (2003), pp. 49-77. See appendix I for more information about how 
we estimated likely need for transportation services. 

[63] About 43 percent of the people 65 and older who we estimate were 
likely to need transportation services had mobility difficulties. An 
AoA official told us that individuals with such difficulties may need 
specialized transportation services in particular, such as those 
provided under the Title III assisted transportation program. 
According to AoA documents, assisted transportation involves providing 
assistance and transportation, including escort, to a person who has 
difficulties (physical or cognitive) using regular vehicular 
transportation. 

[64] The upcoming National Health and Aging Trends Study, funded by 
the National Institute on Aging, may provide information that would 
allow such estimates in the future. This study will be designed to 
provide nationally representative data about Medicare recipients age 
65 and older. One of the researchers charged with designing and 
implementing the study said that the survey will include questions to 
obtain information about whether or not older adults are able to 
participate in certain activities due to lack of transportation. 

[65] [hyperlink, http://www.gao.gov/products/GAO-04-971], p. 4. 

[66] We conducted a survey of 125 local agencies, with 99 agencies (79 
percent) responding. The 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, unless otherwise noted. See appendix 
VI for additional survey data. Fiscal year 2008 is the most recent 
year for which state level data are available. 

[67] AoA requires state agencies to report yearly on Title III 
expenditures and total service expenditures for Title III Parts B, C, 
and E services. Total service expenditures are defined as OAA 
expenditures plus all other funds administered by the state and/or 
local agencies on behalf of elderly individuals and caregivers for 
services meeting the definition of OAA services--both services that 
are means tested, such as Medicaid, and those that are not. State 
agencies are encouraged to report expenditures in these service 
categories whether or not AoA funds were utilized for that purpose. 
However, the group of services administered by state agencies varies. 
For example, some state agencies administer OAA programs, Medicaid 
home-and community-based services programs, and a state-funded home-
and community-based service program. In other states, separate state 
agencies operate the various programs for older adults. Therefore, 
total expenditures for aging programs reported by state agencies 
likely include varying sources of funds and may not include all 
resources for aging programs within each state. 

[68] The OAA allows agencies to solicit voluntary contributions from 
clients for all services and encourages agencies to solicit voluntary 
contributions from individuals with incomes above 185 percent of the 
poverty line. 42 U.S.C. § 3030c-2(b). 

[69] 42 U.S.C. § 3030c-2(a). The OAA requires states to develop a cost-
share plan prior to implementing cost sharing. States are prohibited 
from including low-income older adults, those at or below the federal 
poverty threshold, in cost-share plans. States may also exclude other 
low-income older adults with incomes above the federal poverty 
threshold. Cost-share payments are on a sliding fee scale based on a 
client's income. Income is self reported with no verification 
requirement. Agencies may not deny services to clients who fail to 
make cost-share payments. Cost sharing is not permitted for 
information and assistance, outreach, benefits counseling, case 
management services, ombudsman, elder abuse prevention, legal 
assistance, other consumer protection services, congregate and home-
delivered meals, and any services delivered through tribal 
organizations. 

[70] National Association of States United for Aging and Disabilities, 
State of Aging: 2009 State Perspectives on State Units on Aging 
Policies and Practices (October 2009). Also, in 2006, the Department 
of Health and Human Services Office of Inspector General reported that 
only 12 states had implemented cost sharing for at least one OAA 
service and, in at least 6 of 12 states, fewer than 350 individuals 
participated in cost sharing. Department of Health and Human Services 
Office of Inspector General, Cost Sharing for Older Americans Act 
Services, OEI-02-04-00290 (September 2006). 

[71] The margin of error for this survey question was outside of our 
overall range and is plus or minus 15 percentage points at the 95 
percent confidence level. 

[72] An estimated 47 percent of local agencies had increased requests 
for congregate meals, even as long-term trends show a decline in use 
of this service. 

[73] National Association of States United for Aging and Disabilities, 
The Economic Crisis and Its Impact on State Aging Programs: Results of 
All-State Survey (November 2009). 

[74] The Recovery Act provided $65 million for congregate meals and 
$32 million for home-delivered meals. 123 Stat. 179. 

[75] 42 U.S.C. § 3012(a)(26)(A)-(E). Such procedures should also 
include uniform definitions and nomenclature, standardized data 
collection procedures, and a participant identification and 
description system. 

[76] 42 U.S.C. § 3027(a)(2)(A). AoA officials confirmed our 
understanding that the reference to 42 U.S.C. § 3012(a)(29) in this 
provision reflects a technical error and should be read as a reference 
to 42 U.S.C. 3012(a)(26). 

[77] The information that we used to estimate likely need for meals, 
home-based care, and transportation services was not available in a 
way that allowed for estimates at the state level. 

[78] We obtained feedback on our preliminary approaches for estimating 
likely need and receipt of services from officials and researchers at 
eight organizations with expertise in aging services and/or analytical 
methods and incorporated their comments as appropriate. 

[79] 42 U.S.C. § 3030d-21. 

[80] 42 U.S.C. § 3030g-21(2)(I). About 9 percent of the persons in 
these households were younger spouses or household members with 
disabilities. 

[81] Nineteen percent of individuals in this group were food insecure, 
using USDA's measure of food insecurity as described below; only 4 
percent of the elderly sample that were not asked questions about 
meals, and are excluded from our study, were food insecure. 

[82] The CPS includes some questions where respondents provide 
information about individuals and some questions where they provide 
information about households. In instances where the questions 
pertained to households, we assumed that the answer pertained to the 
older adults within that household. For example, if the response to a 
survey question indicated that the household was food insecure, we 
assumed that the older adults in that household were food insecure. 

[83] For a more complete description of the data, see Nord, Mark, 
Margaret Andrews, and Steven Carlson. Household Food Security in the 
United States, 2008. ERR-83, United States Department of Agriculture, 
Economic Research Service.(November 2009). 

[84] Information on social isolation is for the segment of the CPS 
2008 sample that completed the food security supplement and also 
completed the Civic Engagement Supplement (roughly three-fourths). 

[85] We used the Core Early Release (Version 2.0) of the 2008 data. 

[86] While older adults 60 and above are eligible for transportation 
services, our analysis related to transportation was restricted to 
older adults 65 and older due to data limitations. 

[87] Three Title III services provide home-based care: homemaker, 
chore and personal care services. AoA defines homemaker services as 
assistance such as preparing meals, shopping for personal items, 
managing money, using the telephone or doing light housework. Chore is 
defined as assistance such as heavy housework, yard work or sidewalk 
maintenance for a person. Personal care is defined as personal 
assistance with bathing and other self-care tasks. Individuals who 
have trouble performing activities such as shopping and housework are 
described as having difficulties with IADLs and those who have trouble 
with activities such as bathing and dressing are described as having 
difficulties with ADLs, the later usually considered to be more severe 
than the former. We are defining likely need for Title III home-based 
care services as having difficulties with IADLs and ADLs, based on the 
types of help provided through Title III services. 

[88] We coded individuals who reported using equipment to assist with 
walking and/or getting in and out of bed as receiving assistance for 
that activity. 

[89] In generating regression estimates, we examined model fit 
statistics to ensure that the predictive power of our models exceeded 
that of the null model. The Cox-Snell R-squared for our models ranged 
between 0.12 and 0.24. 

[90] Because the population estimates in tables 1 and 2 are derived 
from sample data, they are subject to sampling error. In tables 1 and 
2, therefore, we include the margin of error associated with our 
results. 

[91] We used four CPS questions about functional impairments including 
having cognitive impairments and/or difficulties with IADLs or ADLs to 
identify older adults likely to need meals programs based on 
difficulty preparing or obtaining food. (See appendix I for more 
information about these survey questions and our decisions to include 
them.) 

[92] Also known as Supplemental Nutrition Assistance Program (SNAP) 
benefits. 

[93] We also coded individuals who said they did not do the activity 
as having difficulty. 

[94] IADLs include food preparation, grocery shopping, making phone 
calls, taking medication, or managing money. ADLs include getting 
dressed, walking, bathing, eating, getting in and out of bed, and 
using the toilet. 

[95] Because we used different data sources to estimate older adults 
likely need for home-based care or transportation services than for 
our estimates of meals receipt, the demographic factors and categories 
we use do not perfectly parallel those estimates. 

[96] Respondents younger than 65 were not asked about their ability to 
drive in the HRS. 

[End of section] 

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