[Senate Hearing 107-52]
[From the U.S. Government Publishing Office]
S. Hrg. 107-52
HEALTHY AGING IN RURAL AMERICA
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
MARCH 29, 2001
__________
Serial No. 107-1
Printed for the use of the Special Committee on Aging
U.S. GOVERNMENT PRINTING OFFICE
72-959 WASHINGTON : 2001
_______________________________________________________________________
For sale by the U.S. Government Printing Office
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DC. 20402
?
SPECIAL COMMITTEE ON AGING
LARRY CRAIG, Idaho, Chairman
JAMES M. JEFFORDS, Vermont JOHN B. BREAUX, Louisiana
CONRAD BURNS, Montana HARRY REID, Nevada
RICHARD SHELBY, Alabama HERB KOHL, Wisconsin
RICK SANTORUM, Pennsylvania RUSSELL D. FEINGOLD, Wisconsin
SUSAN COLLINS, Maine RON WYDEN, Oregon
MIKE ENZI, Wyoming EVAN BAYH, Indiana
TIM HUTCHINSON, Arkansas BLANCHE L. LINCOLN, Arkansas
PETER G. FITZGERALD, Illinois THOMAS R. CARPER, Delaware
JOHN ENSIGN, Nevada DEBBIE STABENOW, Michigan
JEAN CARNAHAN, Missouri
Lupe Wissel, Staff Director
Michelle Easton, Minority Staff Director
(ii)
C O N T E N T S
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Page
Opening statement of Senator Larry Craig......................... 1
Statement of Senator Conrad Burns................................ 2
Statement of Senator Jean Carnahan............................... 30
Statement of Senator John Breaux................................. 31
Statement of Senator Blanche Lincoln............................. 32
Panel I
Jon Burkhardt, Senior Study Director, WESTAT, Rockville, MD...... 3
Hilda Heady, Executive Director, West Virginia Rural Health
Educations Partnerships, Morgantown, WV, on behalf of the
National Rural Health Association.............................. 36
James Sykes, Senior Advisor for Aging Policy, Department of
Preventive Medicine, University of Wisconsin Medical Center,
Madison, WI.................................................... 48
Melinda M. Adams, Older Workers Coordinator, Idaho Commission on
Aging, Boise, ID............................................... 57
Jane V. White, President, American Dietetic Association,
Washington, DC................................................. 66
APPENDIX
Additional comments submitted by James Sykes..................... 101
Response to question from James Sykes............................ 104
Response to question from Ms. Heady.............................. 106
Response to questions from Jane White............................ 108
Additional material submitted by American Dietetic Association... 111
Administration on Aging State Program Report..................... 129
(iii)
HEALTHY AGING IN RURAL AMERICA
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--
THURSDAY, MARCH 29, 2001
U.S. Senate,
Special Committee on Aging,
Washington, D.C.
The committee met, pursuant to notice, at 9:32 a.m., in
room SD-562, Dirksen Senate Office Building, Hon. Larry E.
Craig, (chairman of the committee) presiding.
Present: Senators Craig, Burns, Ensign, Breaux, Kohl,
Lincoln, Carper, and Carnahan.
OPENING STATEMENT OF SENATOR LARRY E. CRAIG, CHAIRMAN
The Chairman. Good morning, everyone. I will convene this
Special Committee on Aging hearing.
I want to thank all of you for attending the hearing this
morning. I would first of all like to thank the witnesses for
agreeing to testify before our committee today on ``Healthy
Aging in Rural America.''
As the new chairman of this old and well-established
committee, I chose ``Healthy Aging in Rural America.'' as our
hearing topic today because it is a very important issue in my
State of Idaho as well as many other States across the country.
It is time we stopped thinking of aging as end of life, but as
a continuation of living. Most of us are living longer,
healthier, and more productive lives, and I am looking forward
to hearing testimony that will ensure that these opportunities
are available to older Americans in rural communities.
Some of the challenges facing the elderly in rural
communities are: transportation, nutrition, access to health
care, employment, and housing. Questions and testimonies today
will focus on each of these challenges. My priority is to look
at constructive ideas that address the challenges of older
Americans in rural communities and what they face on a day-to-
day basis.
Ideas that allow our senior citizens the option of
remaining in their communities and living out vigorous and
productive lives ought to be a goal of this committee.
Again, I would like to thank the witnesses for sharing
their expertise, and I would particularly like to thank Melinda
Adams, from my great State of Idaho, who made a detour, I
understand, to Washington today from her commitment with her
daughter, who is visiting colleges.
Our ranking member, Senator John Breaux of Louisiana, is
off on a phone call at the moment, but he will be back, so let
me turn to my colleague from Montana, Senator Conrad Burns, for
any opening comments he may have.
Senator Burns.
OPENING STATEMENT OF SENATOR CONRAD BURNS
Senator Burns. Thank you, Mr. Chairman, and thank you for
holding this hearing, and I want to thank the witnesses.
I will put a statement in the record, but I will say that
in the State of Montana, we are getting older, as all States
are, to be quite honest with you. The percentage of older
people is becoming a bigger part of our population and our
demographics.
We started a center in Billings, MT, at Deaconess Medical
Center, using telemedicine and new technologies, because we are
going to manage our older populations in rural areas in a
different way. I have 13 counties that have no doctors.
I can remember my father, who died at the age of 86 back in
1992, telling me just a week before he died--we were a farm
family, a very close family--but my father said, ``You know, I
was never afraid to grow old, but I was always afraid to get
too old.''
And that Monday night I flew back to Washington, and I
said, ``I will see you this weekend''--I would go back through
Missouri on my way to Montana--and he said, ``I will not be
here, because I am not going to get too old.'' And by gosh, he
wasn't there the next weekend.
We are going to use new technologies. We have a doctor in
geriatrics at Deaconess now who designed these programs for
rural Montana using telemedicine and broad band services for
interacting visibly with the patient and via computers and
telephones and a lot of things, and we use that same system in
our distance learning. We also use it in the ways of rural
doctors, because as soon as they graduate from college--I have
a daughter who is a doctor--her education stops, and she wants
to practice in a rural setting, in that venue. That is her only
way of continuing education.
So we have to start thinking about this. Instead of moving
people, we have got to find those technologies that move us
closer to them from a major medical center so that we can
manage our aging and our health care for our aging in a
different way.
So we thank you for coming today, and I look forward to
your testimony. But I will tell you as chairman of the
Communications Subcommittee over in Commerce, new and exciting
technologies are coming out, and we should be setting the
environment where these new technologies can be used, and then
get out of the way and let the people who really have the
imagination to put them into use.
So thank you all for coming today, and I thank you, Mr.
Chairman.
[The prepared statement of Senator Burns follows:]
PREPARED STATEMENT OF SENATOR CONRAD BURNS
Mr. Chairman, thank you. I'm excited to get the hearings of the
Special Committee on Aging kicked off today. I look forward to working
with you and the great staff you have assembled for the betterment of
senior citizens across America.
I'd like to start off by thanking today's witnesses for taking time
out of their schedules to share their knowledge and experiences with
the Committee today. The Chairman and we have brought you here to learn
from you so that we may better legislate.
By the year 2025, Montana will have the third highest concentration
of senior citizens in America, behind Florida and your State, Ms.
Heady, West Virginia. At the present time, Montana is not ready for
this demographic shift. Montana's health care system is not merely
challenged by rural areas, it is DEFINED by rural and frontier
settings. Difficulties in transportation are exacerbated by tremendous
distances and Montana's own version of inclement weather. This hearing
is especially pertinent, therefore, to the concerns of my constituents.
As I mentioned earlier, we up here are here to learn from you, so I
will keep this short. But I am certain, however, that I will have some
questions for you after your testimony.
The Chairman. Conrad, thank you.
Senator Breaux is not back yet, and we have a vote at 9:45,
so we are going to start taking testimony, and Senator Breaux
can make his opening comments when he returns. We understand
that our first witness is time-sensitive--he is going to talk
about transportation, but he needs to catch some
transportation, which makes him time-sensitive.
With that, let the committee turn to Jon E. Burkhardt, who
is Senior Study Director at WESTAT, who will be talking to us
about transportation.
Jon, welcome before the committee. Please proceed, and I
will ask the committee to stay at the 5-minute limit, if you
would, please.
STATEMENT OF JON BURKHARDT, SENIOR STUDY DIRECTOR, WESTAT,
ROCKVILLE, MD
Mr. Burkhardt. Thank you very much. It is a pleasure to be
here. I have prepared written testimony that I would like to
submit for the record.
I am here to tell you that rural transportation is one of
the best investments that this country can make. It keeps
people off of welfare; it keeps them out of nursing homes; it
breaks down isolation; it allows volunteers to volunteer; it
connects people to health care, commerce, and to each other;
and it is especially important for healthy aging in rural
America.
I would like to point out four items today. One is that
transportation is a key concern to elderly persons in rural
areas. Travel demands of older persons will increase
significantly. Our current Federal programs have offered a
great deal of inspiration and assistance for both specific
riders and our society. We need some improvements, and I would
like to ask the committee's assistance in this.
The primary challenges in rural areas are the large
proportions of older persons and elderly poor who have few
transportation options and have critical needs for long-
distance transportation, particularly for treatments like
dialysis and chemotherapy.
The numbers of our elderly are growing quite rapidly--this
is true for rural areas as well as our urban and suburban
areas. Most elderly in the future will live in areas that are
now not well-served by public transportation.
In the year 2030, we need to think about driving. Most of
us drive, and we have to start talking about transportation by
talking about driving. In 2030, the number of drivers 65 and
older is going to double. The proportion of older drivers on
the roads will triple, and one of the possibilities is that the
number of fatalities involving older drivers will go up by
three to four times what it is now. That will make it greater
than the current level of alcohol-related fatalities, and we
know that that is unacceptable.
In my grandparents' era, few people expected to retire from
working; in today's era, not many of us think that we are going
to retire from driving. I would bet that a lot of people in
this room think that they will drive to their own funerals.
This is not going to happen.
A recent letter to Ann Landers said, ``I have had two
bypass surgeries, a hip replacement, new knees, fought breast
cancer and diabetes. I am half-blind and cannot hear anything
quieter than a jet engine. I take 10 different medications that
make me dizzy, windy, and subject to blackouts. I have had
bouts of dementia, poor circulation, I can hardly feel my hands
and feet anymore. I am 85 or 87, but I do not know, and no one
can tell me--all my friends are dead. But thank God I still
have my Florida driver's license.''
People do not want to give up driving. Driving is
important. We have had people tell us: ``Driving is my life. If
I lose my driver's license, I will curl up and die.''
We need better options. We need better programs. In rural
areas, we have the Federal Transit Administration's Section
5311 program; we have the Administration on Aging's Title III
Program, and we have Medicaid. Those are the three big
programs. They work best when they work together.
In particular, the FTA's 5311 program is a program that has
had great success in recent years in attracting many more
riders and doing this actually at a lower cost per ride, which
is wonderful.
We did some studies of the economic benefits of rural
public transportation. It is a factor of three to one, and that
is not even counting all that we really could count.
The people who get this transportation tell us things like:
``It is a blessing to have the bus. ``Thank God, you have
helped us out.'' ``This is what keeps me out of that nursing
home.'' It feels like letting a bird out of a cage.'' These are
very powerful testimonials from older people.
We have many transportation services around the country
that serve as sparkling examples of what can be done to assist
older persons. In particular I would encourage people to look
at the Independent Transportation Network in Portland, Maine,
as a highly customer-friendly and service-oriented operation.
I am running out of time, but I would like to say that we
very much appreciate the committee highlighting these issues,
and we look forward to the committee's support for full and
enhanced funding for current programs, activities like the
Coordinating Council on Access and Mobility. And I would like
to ask that you look into some changes in the current Medicare
transportation provisions. This is perhaps a $2 billion
expenditure this year. It is not being done as cost-effectively
as it might be, and this is an area where the committee could
be of great assistance.
We need new kinds of vehicles, new forms of transportation
services, and if we do that, we do not have to look at the
isolation of our older citizens and risks and avoidable traffic
fatalities.
Thank you very much.
[The prepared statement of Mr. Burkhardt follows:]
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The Chairman. Jon, thank you very much.
We are going to allow questioning of Jon now, so that he
can have the flexibility of leaving before we go on with our
panelists. But first, another one of our committee members has
joined us, Senator Carnahan, so let me turn to her at this
moment for any opening comments she would like to make before
we start the questioning of Jon.
Thank you.
STATEMENT OF SENATOR JEAN CARNAHAN
Senator Carnahan. Thank you, Mr. Chairman.
I am pleased to be here as a new member of this committee
and look forward to working with the committee to address
issues that affect seniors in Missouri and across the country.
From personal experience, I am happy to say that of all my
committee assignments, aging is the subject I know the most
about.
Mr. Chairman, the demographics of the United States are
changing. We are an aging population. My home State of Missouri
has the 14th-largest population of senior citizens. We are
experiencing the effects of this change. The growth of
Missouri's 60-and-over population now outpaces all other age
categories. This group is expected to exceed 20 percent of
Missouri's total population by the end of the decade. Even more
rapid growth is expected in the 85-and-over age group. By the
year 2020, this group will comprise more than 2 percent of the
State's population.
When looking at public policy, though, statistics are
helpful, but they do not tell the whole story. Behind the
statistics are real people with real concerns about the
future--seniors who suffer from chronic illnesses without
access to reliable and affordable health care; seniors on fixed
incomes who struggle with the escalating cost of prescription
drugs; adults who worry what the future holds for an aging
parent who can no longer live independently.
I believe these concerns affect us all, as they did me
during the 8 years that I cared for my father, who was
asthmatic and diabetic and lived in our home during that time.
So it is from that perspective that I will be approaching my
work on this committee.
As policymakers, we have a responsibility to ask ourselves
whether our social infrastructure is prepared to meet the
demands on the horizon. There are two fundamental questions.
First, how can people maintain quality of life as they age, and
second, how can the Federal Government most effectively help
seniors achieve that quality of life? We cannot answer the
second question without keeping the larger context of the
Federal budget in mind.
Decisions that we will make this year about taxes and the
budget could affect our ability to support our senior citizens
5 years or 10 years or even 30 years down the road.
As a member of this committee, I intend to examine these
questions closely. I have a particular interest in exploring
how we can help seniors stay in their own homes and communities
as they get older.
The challenges that seniors face with aging in place are
multiplied for those in rural areas. One critical issue in
rural areas is adequate transportation so that seniors can live
independently, be able to travel to the grocery store or to the
doctor's office or to the community center or to church.
In Missouri, we have two programs that provide door-to-door
van service. The vans are very helpful to many of our seniors.
However, some of Missouri's area agencies on aging are
reporting a decrease in the use of these vans. There is a
demand for more individualized service, particularly among
seniors in rural areas who are frail or have a disability. For
these seniors, it can be difficult to sit in a van for a long
period of time as the driver picks up other people in
neighboring small towns, towns that could be as much as an hour
away. The time that it takes a driver to pick up several
passengers, deliver them to doctors' appointments and return
them to their homes is just simply too long for some seniors.
However, individualized service is expensive. The area
agencies on aging have been relying on volunteers to assist
with the driving. But with the rising cost of gasoline, they
have lost most of the volunteers.
The transportation example illustrates just one of the
challenges for rural seniors in Missouri. It underscores the
importance of revising our understanding of the needs of
today's seniors. Once we have explored the issues, we can
adjust our public policy accordingly.
I applaud Chairman Craig for holding these hearings, and I
am optimistic that our panel today will educate us and guide us
as we develop a policy that meets the needs of our seniors in
rural Missouri and throughout the Nation.
Thank you, Mr. Chairman.
The Chairman. Senator Carnahan, thank you.
I have watched my wife's parents care for their aging
parents--and I think any of us who have done that bring a
unique perspective to this committee, and I thank you for that
contribution.
Let me turn now to our ranking member on the committee,
John Breaux of Louisiana. I think we have a vote starting in 3
or 4 minutes, John, so you can proceed with your opening
comments, and then, Senator Lincoln has joined us. The moment
the vote starts, I will step out, run and vote, so that we keep
the committee functioning.
Please proceed, John, and I will turn it over to you at
this time.
STATEMENT OF SENATOR JOHN B. BREAUX
Senator Breaux. Thank you, Mr. Chairman.
We all welcome you as our new chairman. We sort of traded
in the old chairman for a new chairman who is a little younger,
and we look forward to having you at the leadership of our
committee. I think we start with a very important panel,
talking about aging particularly in rural America.
I think all of us on this committee share the common goal
of not only helping people extend their lives and live longer
but also, an equally important goal is to allow people to live
better, not just longer. All the issues that we will be
discussing are really very important in ensuring that people
live a better quality of life and not just a longer life. So we
are delighted and look forward to working with you on a number
of other issues throughout the year that will make a major
contribution toward our aging population which is so important
to this country.
So I look forward to working with you, Mr. Chairman.
The Chairman. Thank you, Senator Breaux.
Now, let me turn to Senator Lincoln.
Blanche.
STATEMENT OF SENATOR BLANCHE L. LINCOLN
Senator Lincoln. I too, Mr. Chairman, want to congratulate
you on your new role as our committee chairman.
These are exciting and challenging times for us as we
attend to the care needs of our seniors in this Nation, and I
look forward to working with you on these matters that are very
near and dear to my heart. As many have expressed here,
caregiving is also a very real experience that I am going
through with my family as well.
Arkansas ranks fifth-highest for its population of 55-plus
seniors and first for the number of seniors living in poverty.
And although we do have the Donald W. Reynolds Center on Aging,
which has been a wonderful tool for us in Arkansas, out of 125
medical schools in this country, we only have three that offer
a residency program in geriatrics. I do not know about you, but
that tends to make me a little paranoid about how ill-prepared
we are in this Nation for the increasing number of seniors who
will come in with the baby boomers.
Although we have the center, and it has been a great
advantage to us in Arkansas, I would also be delinquent in my
duties if I did not acknowledge the tireless efforts of our
most fierce trailblazers, the State's Area Agencies on Aging.
We have a very dynamic director in the State of Arkansas. His
name is Herb Sanderson and he, along with all of the county
directors, is really clearing the way for some truly
outstanding services for the seniors of Arkansas. I have
thoroughly enjoyed my working relationship with Herb, and he
brings a great deal to this job.
Thinking out of the box is second nature for these State
directors, as they are charged with creating aging programs
that attend to the very basic needs of one of our most precious
populations. Oftentimes, in rural States like Arkansas, they
really do have to be creative.
I believe that if there were a message to take from this
hearing today, it would be that in spite of the great
challenges that face rural States, they remain our most fierce
trailblazers when it comes to the development of creative care
delivery systems. I hope that we can all talk about that; as we
look forward to the testimony.
In addition, given the magnitude and volume of challenges
that are facing Congress, I believe that a balanced approach
for Government would be to continue our support for the
creative programming that the States have initiated while the
Federal debate continues.
I really look forward to your testimony here today, and
thank you all for participating in this discussion and
certainly the opportunity to share some of Arkansas' struggles
as well as their successes. As Senator Breaux mentions we are
striving--not just to provide a longer life to our seniors, but
a quality of life for them in their own homes and in their own
communities.
Thank you, Mr. Chairman.
The Chairman. Blanche, thank you.
Now let us turn to our first witness, who has already given
his testimony in the area of transportation.
Jon, I suspect my greatest sense of freedom came the day
that I got my driver's license. And out in rural Idaho,
uniquely, that came at 12 years of age, because I lived out on
a rural ranch, and the sheriff gave a special permit to let us
kids drive--especially when you had to drive 27 miles one way
to school. That is just the way it was.
At the same time, about 10 years ago, I was forced into the
very difficult situation, because of a close relationship with
an elderly aunt, where no one wanted to tell her that she
should not drive anymore. After three or four crashes, I was
the one chosen to tell her that she should not and could not. I
can remember the look on her face and the discussion we had.
She was worried about her freedom, her access--how would she do
this, how would she do that?
So your testimony today is most appropriate, and that is
one of the greatest hurdles if our citizens want to continue to
live in rural America where they would like to live, where
oftentimes their life style is much more acceptable to them
than having to migrate toward urbanism, where they had never
lived before.
In your testimony, you have cited a variety of programs,
and you have highlighted a couple of them and mentioned one
that I believe you said was not being cost-effective in the
area of Medicare in general. Now can you be specific and give
us some examples of your concerns and your suggestions as to
how those might be improved in those program areas.
Mr. Burkhardt. Thank you, Senator Craig.
I am concerned that under Medicare provisions, the only
transportation authorized by law is by ambulance. This is for
emergency situations. We know from an Inspector General's
report from HHS that this is not exactly what is happening in
the world these days. A very large concern is rural elderly
persons who need dialysis treatment. Clearly, if you do not get
many dialysis treatments, you will die. So that is a critical
medical condition, but it generally does not fall under what is
considered emergency transportation, and it does not require
advanced life support, and it does not require basic life
support services that are provided by ambulances.
These trips to and from dialysis could be provided much
more cost-effectively by the kinds of rural public
transportation services and services from area agencies on
aging that exist now. This is not currently permitted under
Medicare legislation, but we know that it exists. I would
encourage the committee to encourage the Health Care Financing
Administration to come up with a much more comprehensive
transportation policy; for them to do that, it will require a
change in the law.
The Chairman. You had mentioned the area of planning, and
your testimony acknowledges that there seems to be a lack of
planning in the area of transportation services for the
elderly. I too am astounded by statistics in aging and where we
are going to be 20, 30, 50 years out. There was a gentleman in
my office the other day whose name I do not recall, but he is a
renowned geriatrics doctor in New York who has an aging clinic,
and he said that at the end of this century, and that seems to
be plenty of time to plan, but usually is not--we are going to
have 5 million centenarians. That is a bit mind-boggling for
all of us, and as we bring about these new health care
applications that make our lives better and extend that life,
obviously, what you are talking about is very clear. You
mentioned a few number of accidents on roads and deaths that
might be caused by elderly people less capable of driving.
What kind of planning do you envision as it relates to
communities and to the programs?
Mr. Burkhardt. I envision planning that would focus on
access and mobility. When we interview older persons about
driving, they say two words to us--freedom and independence.
These are both very cherished American values.
I would like to believe that the automobile is not the only
way to achieve mobility and independence, but in fact in many
communities that is true today. You have the operator of a very
successful service in Iowa saying, ``I hope I never have to
depend on my own service.'' Now, he is doing well, but what he
is saying is that these services are often 9 a.m. to 5 p.m.,
Monday through Friday; they do not let you go to a movie; they
do not get you to visit your wife in the nursing home on
Christmas Day; they do not provide lots of really critical
transportation services. And then, some people who really need
these services drive when they should not. By having more
choices, I believe we could improve the safety and health and
well-being of rural Americans by a substantial amount.
The Chairman. Jon, thank you.
Let me now turn to my colleague, Senator Breaux.
Senator Breaux. Have the other panelists testified yet?
The Chairman. No, they have not, but Jon has a
transportation problem, so we are going to question him and
then move to the rest of the panel and then to questions and
follow-up.
Senator Breaux. I was just looking over the testimony, Mr.
Burkhardt, and I find it very interesting because you know, a
lot of times, we spend a great deal of effort trying to provide
better facilities, but we never follow up to find out how you
get from one place to another. I think your testimony has been
very helpful in having us look into the whole question of
transportation from one facility to the next. It is a real
challenge.
I know there will be more and more older people driving,
which creates safety problems. I am a big believer in one being
able to drive as long as he or she is capable of doing so. Let
us test them and make sure they are capable, but not have an
arbitrary cutoff date. So you raise some really interesting
points that I think will allow us to focus in on transportation
problems, which we really have not done a lot of as far as this
committee is concerned.
Senator Lincoln, do you have questions or comments?
Senator Lincoln. Yes, just briefly. We are preparing in
Arkansas for a forum that we have entitled, ``Caring Across the
Continuum,'' to look at all of the needs of seniors. We plan to
address service delivery and barriers to access. Transportation
has been a huge factor for some of our most frail seniors in
areas like the delta which is one of the highest poverty areas
in the Nation.
Can you address any creative ways that you have seen
through public-private partnerships helping with rural
transportation needs? Is there anything specific there that
comes to mind?
Mr. Burkhardt. I think there are a number of solutions that
would lend themselves to the area that you are speaking of. One
of the best approaches is to look at transportation services
that serve everybody, that serve welfare-to-work clients, that
serve older people, that serve the general public, that serve
kids getting home after basketball practice--all very, very
different kinds of clientele. The funds are put together in a
coordinated way so that no one agency is responsible for all of
the resources, and they operate cooperatively. Sometimes it is
what we call a ``brokerage,'' where there is a central
information number to call and then, perhaps, they will assign
the trip to a taxi company or perhaps to an Area Agency on
Aging or to a developmental disability program or to a public
transportation provider. A brokerage often works very, very
well.
We should include car-pooling and van-pooling, we should
include volunteer services, and we should caste as broad a net
as possible to solve these problems.
Senator Lincoln. Most of the solutions that you have
mentioned are public agencies or something under public
auspices, other than taxi services. Do you see any private
entities playing a role in that, or have you seen anything that
stands out?
Mr. Burkhardt. We have seen some wonderful efforts by
corporations like FedEx to get their employees to work, and a
number of other large corporations have also been involved. I
think we want to reach out to private enterprise, but one of
the important points about planning is to have a focal point,
and in particular one point of access, especially for older
persons, but let us say an 800 number that you can call. So it
does not really matter what color the van in which you ride is,
and it does not matter so much what it says on the side; what
matters is that you get a ride.
This is what is called the new paradigm in freight
transportation--the U.S. Postal Service buying services from
FedEx, FedEx shipping packages on UPS airplanes, and so on. We
need to look at this kind of approach for rural public
transportation.
Senator Lincoln. Thank you. I appreciate your comments.
Senator Breaux [presiding.] Senator Carnahan.
Senator Carnahan. Yes, clearly, access to transportation is
a major concern in our rural areas. In your testimony, you have
listed several ways that you think Congress could improve
transportation in the rural areas, including the sharing of
information on best practices.
Is there a clearinghouse for best practices that would be
available to people?
Mr. Burkhardt. The real focal point at the moment is the
Coordinating Council on Access and Mobility, which is jointly
staffed by the U.S. Department of Transportation and the U.S.
Department of Health and Human Services.
I will tell you that this is a voluntary effort, and it
would help that Council if its status were elevated and if it
had some more funding. At the moment, it does not have a
telephone number that you can call, and it does not have
stationery. It does have a web page.
Also, I would like to point out the Rural Transportation
Assistance Project from the Federal Transit Administration and
the Community Transportation Assistance Project from the
Department of Health and Human Services. They are both staffed
by the Community Transportation Association of America, and
they have a large amount of information available.
Senator Carnahan. Thank you.
Senator Breaux. Mr. Burkhardt, we will excuse you. If you
commuted in from Rockville this morning on 270, you understand
what transportation problems are all about. [Laughter.]
Thank you for your testimony.
Mr. Burkhardt. Thank you, Senator Breaux. I appreciate the
committee's assistance in my travel problems.
Senator Breaux. We will now take testimony from our other
distinguished panelists, and we will start with Ms. Hilda
Heady.
Ms. Heady, we are pleased to have you before the committee.
STATEMENT OF HILDA HEADY, EXECUTIVE DIRECTOR, WEST VIRGINIA
RURAL HEALTH EDUCATION PARTNERSHIPS, MORGANTOWN, WV, ON BEHALF
OF THE NATIONAL RURAL HEALTH ASSOCIATION
Ms. Heady. Thank you, Senator.
I am also pleased to be here. I appreciate the committee's
invitation to testify. I am representing the National Rural
Health Association as a member of their policy board. I am also
the Executive Director of a State-funded program in West
Virginia where we require all of our health professions
students to train in rural communities for at least 3 months
before we let them out of the State with their degree. Early on
we had some resistance to the requirement but most students
come out of it much wiser and much happier.
We have a lot of exciting opportunities and challenges, as
you know, in rural America. West Virginia achieved the
distinction last year of becoming the oldest State in the
Nation. We got older than Florida. We are using our own rural
values around collaboration and partnerships to try to deal
with some of these issues, but we expect in the next 10 years
in our own State that one out of every four people will be over
the age of 65.
The congressional fixes that have been instituted to the
Balanced Budget Act present hope for us, but one of the
greatest impacts which represents our short-term challenge, is
in the area of home health. We have had 24 agencies close and a
48 percent drop in the number of home health visits. That
presents challenges to our local communities with existing
providers and their need to collaborate and to develop other
stopgap measures.
One example that I want to use is the system of free
clinics that we have in our State. We have nine free clinics
that provide $13 million worth of free drugs to elderly who are
on Medicare and do not have a prescription benefit. So we know
that we have a number of rural elderly who could use a
prescription drug benefit in Medicare.
There are other examples of collaborations and partnerships
in our State and in others that I would like to highlight.
These are also included in my written testimony. In West
Virginia we have a program called Aging Well in Calhoun County.
There are 8,000 people in that county, and the program was
started by a group of people who wanted to volunteer to
transport elderly clients to health care facilities both in and
out of the State; but before they started that program, they
knew that they needed to be trained in how to care for the
elderly and deal with circumstances if they came up during
transportation.
Another program is the Integrated Health and Service
Council of Ritchie County, that has the senior citizens'
program, the nutrition site, and a child day care center in the
same facility with an adult day care center. I was there last
week with an Alzheimer's patient and two other seniors, playing
dominoes, and one of the elders was 101-year-old Nellie. Her
55-year-old grandson had taken her to the doctor that morning,
and she was telling me stories about living in her trailer on
her grandson's buffalo farm.
One of the exciting opportunities I have is working with
students when they are out on rural rotation, working with the
elderly and learning skills to work with this population. Our
program last year served 185,000 rural citizens. We had medical
students, nursing students, a variety of students, working with
that many people in health promotion activities.
Another program that I would like to mention is the
Partnership for Rural Elderly in Dahlonega, GA. This is a
collaborative of a number of different health and social
service agencies, and all of these programs have the objective
of trying to keep the elderly healthy and in their home
communities.
One of the prime examples that we have in the Federal
Government for the elderly that do require this type of
collaboration and use of local resources is through the Federal
Office of Rural Health Policy and their Rural Outreach Grants.
It is one of the most flexible funding streams and allows
communities to innovate as much as possible to be creative to
meet their challenges.
I would also like to bring up a topic that we rarely see
when we talk about the aging or even in rural health circles,
and that is the problems we are seeing with the aging rural
veteran. I am a member of a support group, the Significant
Others Support Group of Vietnam Wives, at our Vietnam
Readjustment Center in Morgantown, WV. That center serves 18
counties in West Virginia and Southern Pennsylvania, and more
than 50 percent of the people who come to the center come from
rural areas.
One thing we do know--Vietnam was always called ``the war
that was fought from Harlem to the hollows''--so we do know
that we have a disproportionate share of aging veterans who are
poor and that a significant number of them are rural.
In preparing my testimony, I called all the veteran
outreach centers in the States of Iowa, Idaho, Louisiana, and
West Virginia, and every one of them reported that anywhere
from one-third to two-thirds of their clients come from rural
areas.
We also know that 50 percent of all veterans who get
services from the Veterans' Administration get them from these
outreach centers. They are concerned about long-term care,
particularly for the World War II veteran. Every center needs a
family therapist, because there currently is not one in the
Veterans' Administration to staff them.
Among the things that the Federal Government can do at this
point are to look seriously at the prescription benefit for all
Medicare recipients; improve home health care and community-
based services; develop more funding streams for partnerships
with States to train health professionals in rural areas that
focus on rural content for the rural elderly; fund a national
study on the aging veteran--the last time we looked at this
population was in 1988; and provide increased funding for
transportation.
Thank you so much for your time and your attention. I want
to let you know that the National Rural Health Association is
very ready to work with you.
Thank you.
The Chairman. Thank you very much.
Mr. Sykes.
[The prepared statement of Ms. Heady follows:]
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STATEMENT OF JAMES SYKES, SENIOR ADVISOR FOR AGING POLICY,
DEPARTMENT OF PREVENTIVE MEDICINE, UNIVERSITY OF WISCONSIN
MEDICAL CENTER, MADISON, WI
Mr. Sykes. Thank you, Senator. It is a real pleasure for me
to be before the committee to speak about something that has
been the heart and soul of my life for 30 years.
Where one lives is simply the most important daily fact of
one's life. When that place is supportive, familiar, navigable,
that is a good place to live, and people who have that have
high levels of life satisfaction. Those for whom their housing
situation is not good live each day with a series of problems
that housing itself, the shelter, makes more onerous.
In my brief time here, Senators, I would like to mention
three programs--one, a community program; one, a State policy;
and third, a HUD policy--that are critical to the well-being of
people living in rural America. And I would like to very
briefly mention lessons from each of these.
Let me go first to Sun Prairie, WI where, some years ago, a
group of people with some leadership from the corporate world,
local government, religious groups, decided that the elders in
their community needed some place to go, something to do, and
out of that, the corporation gave leadership to the development
of a senior center and provided the money.
With the partnership of others in the community, that
program evolved into an exciting program with a whole range of
services including, later on, adult day care as a freestanding
facility, the meals, the transportation, the counseling, and
opportunities for personal growth.
From that experience, which is sustainable through a wide
range of support, initially brought into being by a very small
Older Americans Act grant that was important, the Colonial Club
continues to make life in a relatively small community in
Northeast Dane County livable and provides a great deal of
support to the people, knowing that in their community, they
are cared for. And for the children, it provides a great deal
of confidence that their parent or parents are cared for.
Under every good local program, there needs to be a policy,
a program that sustains it, and in this respect, Wisconsin
again provided very important leadership, including support
when Senator Feingold was one of our State Senators in
Wisconsin, when we developed a Community Options Program which
simply said that everyone in the State was entitled to an
assessment of functional capacity, that they were entitled to
some effort to devise a care plan so that they could be cared
for in the least restrictive setting, in the most effective
way, and that, using Medicaid waiver moneys and State general-
purpose revenues, the State had both an obligation and an
opportunity to enable people to continue to live in the
community and in their homes.
It was not the principal goal of the program, but it
certainly has been a favorable consequence, that there has been
serious diversion from nursing home placements because of this
program, and it is in place.
So a little program like this one in Sun Prairie and many
other towns throughout rural Wisconsin has under it a
foundation of public support through the Community Options
Program, and there are some lessons to be drawn from that.
Third, in each of the programs that I have seen across this
country, something had to make it start, something had to get
it going. In many of the communities during my tenure as chair
of the State's Housing, Finance, and Economic Development
Authority, we found that what it took was somebody coming into
that town, listening to the people talk about what they wanted
to do for their citizens, but with the knowledge and the
ability to access the funds, to show how other programs have
developed and have been successful.
So in the whole area of technical assistance, including the
Rural Housing and Economic Development Assistance Program and
other HUD technical assistance moneys, there is now the
capacity within an organization like ours, the Wisconsin
Partnership for Housing Development, to in fact pay for the
technical assistance, but that it is spent and allocated to a
particular community with its own goals.
Those are three very small and very brief examples of a
community development that needs some assistance, some
catalytic agents, some partnership at the local level. The
second is that we do need a State policy that really provides
financial assistance and enables communities to build, finance,
and sustain the kind of infrastructure that is necessary for
people to live a good life and to move ahead on many fronts. We
need people who are knowledgeable, who can provide technical
assistance, and help communities move from where they are to
where they want to be.
Across this Nation, I have not seen a religious
organization, a civic group, a local government, or others that
has not had as a part of its intention to serve their elders
well. They have had lots of problems making it happen, and we
know through examples how it can happen, how it can be
successful, and how it can be sustained.
Thank you, Mr. Chairman.
The Chairman. Mr. Sykes, thank you very much.
[The prepared statement of Mr. Sykes follows:]
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The Chairman. Before I turn to the next witness, do either
of my colleagues who have joined us here have an opening
statement?
Now let me turn to Melinda Adams, who is the Older Worker
Coordinator at the Idaho Commission on Aging. She will be
talking to us about employment of our elderly.
Melinda, again, welcome to the committee.
STATEMENT OF MELINDA M. ADAMS, OLDER WORKER STATEWIDE
COORDINATOR, IDAHO COMMISSION ON AGING, BOISE, ID
Ms. Adams. Senator Craig, thank you for your kind welcome.
I appreciate this opportunity to testify.
To start, a few words about our home State's work force
initiatives. Idaho's older worker programs have been regarded
as models of coordination and have achieved excellent results.
For 7 of the past 10 years, the U.S. Department of Labor has
ranked Idaho's Senior Community Service Employment Program
first in the Nation for success in placing low-income seniors
in jobs.
I am also pleased to report that, with the able leadership
of our former State Aging Director, now Staff Director Lupe
Wissel, Governor Kempthorne's Workforce Council approved
second-year funding for our Statewide Workforce Investment Act
Project. Since the elimination of Federal set-aside money for
older workers, Idaho was the first State to designate State-
level WIA funding for older job-seekers. Other States are
finally beginning to follow. That should not be the case in an
economy where the numbers of disadvantaged older workers are
growing far faster than any other age group and where low-
income older workers constitute the most computer-illiterate
group of workers in a labor market where 70 percent of jobs
require computer literacy.
Also, the need for dislocated worker resources for older
workers is on the increase. Idaho's rural areas have an above-
average share of older people who can no longer depend on
agriculture, timber, and mining for their support. The Sunshine
Mine closures in the Silver Valley, and the impending Boise
Cascade closures, announced in recent weeks, are unfortunate
examples of the devastation caused by layoffs in our small
communities.
Idaho is not unique in this respect. These dynamics are at
play throughout rural America with the demise of the family
farm, the decline of other natural resource-based industries,
and the impact of global economics.
The data clearly show that older persons who lose their
jobs experience far more difficulty than other age groups in
becoming reemployed. At both the Federal and State levels,
rural older worker employment should be a focus in economic and
dislocated worker initiatives.
Accordingly, as Congress reconsiders reauthorization of the
Workforce Investment Act, we urge added emphasis on older
workers.
New opportunities to serve our most geographically isolated
seniors are finally presenting themselves, thanks to the new
technologies. An older worker in Salmon, Idaho can now support
herself as a medical transcriptionist, operating out of her
home, with the right training and the right equipment. Thus,
our recommendation for expanded flexibility and increased
funding to use Title V funds for self-employment and cottage-
based entrepreneurial activities.
Similarly, expanded flexibility to use these funds for
private sector work experience will allow us to better serve
our most rural seniors who reside in locales with few, if any,
eligible host sites.
Distance learning innovations also offer hopeful solutions
to the rural senior in need of training. Many rural communities
have limited public transportation systems; the more remote
areas have none at all. As a solution, we challenge our
educational system to expand lifelong and affordable distance
learning opportunities.
We also support policy changes that eliminate disincentives
to work--the removal of provisions in pension plans that
penalize individuals for working after retirement; the
encouragement of phased retirement and tailored benefit
packages to facilitate the hiring of mature workers in flexible
work arrangements.
In closing, both job-seekers and incumbent workers need a
voice. It is ironic that, at the very time that aging workforce
issues should be a focus, Federal legislation eliminated
dedicated funding for mature workers.
Strategies on how to address the physical, educational and
training needs of disadvantaged older workers should be a focus
now. For these reasons, we urge the U.S. Department of Labor to
establish a position at the assistant secretary level for
oversight of workforce issues impacting older individuals and
employers.
Thank you for this opportunity to testify.
The Chairman. Ms. Adams, thank you very much for that
valuable testimony.
[The prepared statement of Ms. Adams follows:]
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The Chairman. Now let me turn to Jane White, President of
the American Dietetic Association, who will be talking to us
about diet and nutrition.
Jane, welcome before the committee. We are pleased to have
you.
STATEMENT OF JANE V. WHITE, PRESIDENT, AMERICAN DIETETIC
ASSOCIATION, WASHINGTON, DC
Ms. White. Thank you, Chairman Craig.
I am pleased to be here to discuss nutrition and its
importance to healthy aging in rural America. I represent the
largest association of food and nutrition professionals in this
country. Our 70,000 members serve the public through the
promotion of optimal nutritional health and well-being.
I live and work in rural East Tennessee. As a registered
dietitian, professor of family medicine, and a member of the
ADA's Nutrition Screening Initiative, I see the difference that
optimizing nutrition status makes in the lives of older
Americans.
The Institute of Medicine has observed that poor
nutritional status is a major problem among our Nation's
elderly. Inadequate intake is estimated to affect 37 to 40
percent of free-living elderly. Diet quality ratings in these
people show that about 80 percent have diets that need
improvement or that are poor. Among hospitalized and nursing
home elderly, undernutrition is especially prevalent. In
addition, 86 percent of older Americans have one or more
chronic diet-related diseases, including hypertension,
diabetes, and dyslipidemia, singly or in combination. Adverse
health outcomes are prevented or reduced with appropriate
nutrition intervention.
Healthy aging requires adequate nutrition. However, rural
America offers some unique challenges due to distance,
topography, and limited availability of health care options
that are widely present in more urban settings. Seniors who
routinely eat nutritious food and drink adequate amounts of
fluids are less likely to have complications from chronic
disease or to require care in a hospital, nursing home, or
other facility. It makes sense to emphasize routine nutrition
screening for all Americans, but especially for seniors living
in rural areas.
Isolated individuals are more susceptible to poor control
of chronic disease states due to difficulty in accessing
available nutritional care. Nutrition screening can identify
seniors at increased risk for poor nutritional status and can
facilitate intervention to improve health. The Determine Check
List and Nutrition Care Alerts developed by ADA's Nutrition
Screening Initiative were designed for this purpose.
Take the Nevada Division of Aging Services' pilot program.
It provides 120 at-risk seniors with nutrition screening and
intervention that includes medical nutrition therapy, home-
delivered meals, and dietary supplements. A homebound older
gentleman was screened after spending 2 weeks in the hospital
to treat a sore on his foot. The healing process was impaired
by poorly controlled diabetes. His doctor was concerned that if
the wound did not heal, amputation might be necessary. Medical
nutrition therapy, in this case, meal planning and food
selection and preparation education provided by a registered
dietitian, and home-delivered meals helped this man control his
diabetes, resulting in the rapid healing of his foot wound.
The total cost of this nutrition intervention was $350--far
less than the cost of even one day in the hospital, not to
mention the additional costs in health care and support
services had the man's foot been amputated.
Meals programs and other nutrition-related services offered
through the Administration on Aging are vital to maintaining
the health and well-being of our Nation's elderly. These
programs do a good job. Between 80 and 90 percent of
participants have incomes below 200 percent of poverty level.
Two-thirds of participants are either over-or underweight,
placing them at increased risk for nutrition and health
problems. Those receiving home-delivered meals have more than
twice as many physical impairments compared to the general
elderly population. But the wait time to access these services
is 2 to 3 months in many areas, and the lines are long. Funding
for these programs are at 50 percent of 1973 levels.
Seniors must be able to access dietitians who can determine
what will best meet their needs and who can teach them how to
apply that knowledge in their daily lives. Programs like the
National Health Service Corps could help bridge the gap between
need and access. ADA believes that dietetics professionals
should again be included in this program.
Recognition of telemedicine technology as the vehicle for
nutrition services delivery also could facilitate access to
dietitians when none is available in the immediate area.
HCFA requires nursing homes to have a dietitian. However,
in many States, they set a minimum of 3 hours per week for
dietetic presence in a facility. Most facilities comply with
the bare minimum. Considering the widespread nutrition-related
problems so prevalent in nursing homes, 3 hours per week is not
enough time for dietitians to oversee the paperwork that is
required, let alone to fulfill the active role of facilitator
and manager of nutrition and hydration care.
Research indicates that the more time dietitians spend in
nursing homes, the less time the nursing home residents spend
in hospitals. It is critical to have a dietitian in every
nursing home full-time.
Chairman Craig, nutritional well-being is critical in
assuring quality of life for our seniors. We hope that Congress
will pass your legislation, the Medical Nutrition Therapy
Amendment Act, so that nutrition services for cardiovascular
disease, the leading cause of death in men and women in this
country, may be covered. This will ensure access to life-
enhancing and life-saving therapy for seniors who suffer these
debilitating conditions.
To summarize, frail elderly living in rural areas face
unique and difficult challenges, not the least of which is
accessing a nutritious meal daily and accessing preventive and
curative nutrition services.
Thanks for the opportunity to testify. I would be pleased
to answer any questions.
[The prepared statement of Ms. White follows:]
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The Chairman. Thank you very much, Ms. White. We appreciate
your testimony.
I am going to adhere to a 5-minute round of questioning for
all of us, and of course, we can repeat as often as is
necessary to complete; so if staff would take care of the
lights for us, that would be appreciated.
I apologize, Ms. Heady. I did not get a chance to hear your
testimony. I will read it, and I do have some questions that I
would like to start with you on.
You mention in your testimony that several obstacles
prevent the elderly from accessing quality health care in rural
areas. What do you think is the single biggest obstacle that is
the challenge out there that we should be tackling?
Ms. Heady. I think there are two things--transportation and
providers; having the appropriate level of care and services as
close to the elderly as possible, and their transportation to
even get to it.
One thing that we see happening, particularly with some of
our primary care centers--in West Virginia, we have some of the
most per capita--we have 102 primary care centers right now in
our State. And when reimbursement to those centers becomes a
problem, and they have to close some of their satellite
operations, we see that the elderly are the ones who suffer the
most, because they are most of the population who patronize
those service centers.
The Chairman. Are you experiencing in West Virginia
something similar to what we are experiencing in Idaho--and Ms.
Adams mentioned it--that when we lose employment that is
traditional to the region that oftentimes provides the
economics that maintain the infrastructure of health care--
hospitals--the seniors who are staying there, or living there
still, oftentimes are tremendously disadvantaged because the
younger worker has lost his or her job and moves elsewhere, and
the economy changes?
Ms. Heady. Exactly. In fact, that is one reason why West
Virginia is getting as old as it is, because we have the
generation of workers who can support that population, and the
younger population is actually leaving our State to find
employment.
The other thing that is unique in rural areas is that in
many, many rural communities, the health care industry, if it
is not the first employer is the second or third-largest
employer in that particular county. Just for example, with the
24 closures of home health agencies that we have had in our
State, we lost 1,000 jobs, and those 1,000 jobs are in
predominantly rural communities. So it is a domino effect; we
not only impact the direct services to the elderly, but long
term, we impact it even greater when we impact the economy of
the health care delivery system. So it is true that we are
experiencing the same thing in our State.
The Chairman. Thank you.
Mr. Sykes, again, thank you for your testimony. You have
been working with the elderly and housing for 30-plus years.
From your own experience, what do you see as the benefit of
keeping seniors in their own homes and in their own
communities?
Mr. Sykes. I am delighted to say that as a gerontologist
over these years that we have come to the conclusion that the
benefits are so substantial that we have to use all of the
energy and policy and resources that we can find to accomplish
that goal.
First and foremost, it is where most elders want to be; it
is what gives them emotional support as well as the feeling
that they can retain their independence for as long as
possible.
It is not simply, in my judgment, a diversion from skilled
care. There comes a time in people's lives when they need that
level of care. But we have also discovered to an extraordinary
degree in Wisconsin and elsewhere that with certain kinds of
supports, timely supports at the right time in the individual's
life, with careful assessment, with a care plan that works, and
with the monitoring of the quality of the care that one is
receiving, people who just 5 and 10 years ago in our own
independent housing would have had to move out are now able to
stay in their homes.
Part of this is due to medical advances, but far more of it
is because we have made policy commitments to support those
persons who are in fact providing the care that individuals
need.
The Chairman. We have been joined by Senator Carper. He
does not have an opening statement. We are pleased, Senator,
that you could spend some time with the committee this morning.
Senator Carper. Thank you, Mr. Chairman.
Mr. Sykes, do you have an example of best practice that
highlights the type of community partnership that you described
with a combination of Federal, State, local governments,
private corporations, religious groups, hospitals--and then
again, in all of that, what are the greatest challenges of
these kinds of collaborations, and how do we overcome those
challenges?
Mr. Sykes. I am pleased to say that in many parts of our
State and country, we have found ways to bring together the
kinds of resources that we are talking about. I am thinking of
a low-income housing tax credit project where the private
sector is putting up the funds necessary to do the construction
of the project; I am looking at some of the community
development block grant moneys that become available for
programs that are serving people in transition of one kind or
another, another channel of resources. There is private
fundraising, either with or around the United Way; efforts to
bring those programs.
Your question had to do with best practices. I cannot look
at a project across the State of Wisconsin that I have had some
role in in my State Housing Finance chairmanship that does not
reflect the kind of partnership of a variety of sources.
Frequently, it is the donation of a piece of land that gets it
started in the right place at the right time, and then come,
with some careful planning, the resources to sustain it.
Terribly important to most of the lowest-income people in
both rural and other parts of America is the Section 8 subsidy,
a sufficient subsidy to enable somebody to pay whomever owns or
manages that property a fair market rate so that that property,
that program, can be sustained.
It takes all of the above to make a good project, and we
have lots of wonderful examples, whether they were begun by
churches or a trade union or a rural hospital or a corporation,
as in the case of the Sun Prairie story.
The Chairman. Thank you.
Let me turn now to Senator Kohl.
Herb.
Senator Kohl. Thank you very much, Senator Craig.
Mr. Sykes, you have highlighted several examples of
Wisconsin businesses and hospitals that took the initiative to
address the needs of the elderly in their communities. Ideally,
we would like to see more businesses take a more active role in
this area. Is there anything that the Congress or the
Government can do to encourage this?
Mr. Sykes. That is a tough one, and speaking as a corporate
officer myself for many years, I realize that there was not a
particular program that induced us to start building elderly
housing.
I think that what is needed is a public awareness campaign
that says that to be successful, a corporation--especially a
large company in a small town--the responsibility goes beyond
adequate pay to the workers, adequate retirement benefits to
the workers, but to help create within that community the kinds
of conditions and environment in which people can grow old, can
live comfortably, can have a high level of satisfaction.
Most of the successful corporations in the country have
either a foundation or have reasonable pots of resources that
they can make available within their community.
So I do not see, other than programs that generally
encourage--obviously, the 5 percent write-off that we get as a
cost of doing business is an initial kind of incentive--but I
think it is going to take a good effort at public information.
HUD's Best Practices Program highlights a lot of successful
projects. I think that when we show other corporations that
they can do what we have done in a community, that is the
single best thing. I am sorry, I do not have a good answer for
what the Government's role should be to help the private sector
take the initiatives that my company did.
Senator Kohl. Mr. Sykes, as you know, the Senate will take
up the budget next week. In your opinion, which programs
affecting housing for the elderly in rural areas should we
continue to make a priority in this year's budget?
Mr. Sykes. Thank you. That is a really important question.
First, let me say that working with the Elderly Housing
Coalition here in Washington and the National Council on Aging
in that group, we clearly came to the conclusion that right
now, with approximately 1.5 million elders in subsidized
housing, and with that population growing old very rapidly and
becoming increasingly frail, the most cost-effective and humane
policy for the Government is to support such initiatives as I
will mention one quick moment that will enable those people to
stay where they are and not to move.
The first is the whole idea of service coordinators within
subsidized housing. That has shown that we can connect people
who are frail with resources extant in the community to enable
them to stay in their homes. That is an important program; it
is in the budget at $50 million. It should be expanded. It
should be available to every housing project, even some of the
small ones that do not seem to support that level of
responsibility.
Second, I think we need to use the resources of both HHS
and HUD to be certain that people who are in or need to be in
subsidized housing have those benefits brought together. That
requires some level of flexibility; it has required funds from
more than one place. But when they come together--and my
example would be the HUD Congregate Housing Services Program
that has been funded and revised, but it has always been so
marginal that it is a token program, very much as the Title V
program is a token program--we know how many people could
benefit from this. If we could just move it ahead another $50
million for service coordinators, another $50 million for the
Congregate Housing Services Program, we will be making
important steps toward enabling people to remain in their
homes.
And third, we have a lot of projects that need
retrofitting. Where there are already 24 people living in a
rural area or community, by just some modifications in that
facility itself, we can provide the community spaces, we can
collocate community service providers in that facility that
will enable those people to continue to live in their homes
longer.
Those are important initiatives. They are not new. We
certainly need substantially more resources to make them
effective across the country.
Senator Kohl. Thank you.
My last question is for all the members of the panel. What
are the most critical programs for our rural elderly that need
additional Government support? What are one or two of the most
critical programs, in your opinion, that we need to focus on
this year in terms of supplying resources?
Ms. Heady.
Ms. Heady. I would say any of the Federal programs, and
particularly the rural health outreach grants, should fund
groups to do partnership services in other words, to go into an
area where you have low density numbers who are participating
in the program--and require those groups to come together to
make available their unduplicated services. This approach is
probably the smartest thing that we can do with what money we
have available for rural communities.
Programs that provides for existing health care providers
to be much more innovative, to go out of their dependency on
their reimbursement stream and to really innovate and try to do
``push the envelope'' for rural seniors should be supported.
Senator Kohl. Thank you.
Ms. Adams.
Ms. Adams. I would have to say that the recent wave of
layoffs and business closures both in Idaho and throughout many
other States is something that we really need to take a hard
look at now.
We need to look at the past and take some preventive action
based on that. About 14 years ago, when the bottom fell out of
silver, smelters and mines shut down in Northern Idaho; there
were widespread layoffs. The incidence of suicide among older
males in the Silver Valley section of our State skyrocketed.
We cannot let unemployment do that to our seniors again.
Reemployment can be a very, very difficult problem in rural
America. You cannot just pick up and leave when your life
savings are tied up in your house, and homes are not selling.
Even though you have a lifetime of very substantive experience,
let us say in refrigeration systems for mining, how can you
transfer that when the industry is so very depressed?
On top of that, many of our older people are very
entrenched in their rural communities--they are third- and
fourth-generation families.
Dr. Barbara McIntosh at the University of Vermont is a
business professor who is looking into the whole issue of older
workers being dislocated from their jobs, and what she is
finding is that those older people who succeed in getting
reemployed are those who get connected with the dislocated
worker initiatives that are triggered now, when there are
massive layoffs.
That is a long answer to your question, but what we need to
do is make sure that there is legislative emphasis on older
worker service within the dislocated worker section of the
Workforce Investment Act. That is sorely missing right now.
Unfortunately, when this new legislation was passed in
1998, it even removed as an eligibility criterion long-term
unemployed, and that is how, in previous legislation, we made
many of our older individuals eligible for those very services.
So I would encourage legislative emphasis in the Workforce
Investment Act.
Senator Kohl. Thank you.
Ms. White.
Ms. White. I think it is critical that we fund elderly
nutrition programs at an appropriate level. Many of the
communities--for example, the one in Knoxville--have doubled
the number of people they serve with home-delivered meals over
the last 4 years, with no increasing in funding, and funding is
at 50 percent of 1973 levels.
I also think it is critical that elders have access to
nutrition services through Medicare, particularly for
cardiovascular disease, hypertension, congestive heart failure,
and the dyslipidemias, which are major contributors to poor
health and limited functional status in our elderly.
Senator Kohl. Thank you.
Thank you, Senator Craig.
The Chairman. Thank you.
Senator Ensign.
Senator Ensign. Thank you, Mr. Chairman.
I have a few questions, first for Mr. Sykes. I have dealt a
lot in the past with the low-income housing tax credit, and one
of my first experiences with it was when I was on the Ways and
Means Committee in the House, and we were trying to eliminate
the low-income housing tax credit because there had been a lot
of problems with it in the past.
After doing a lot of research, I actually became a big
supporter of the low-income housing tax credit because I
realized what an efficient use of Government tax dollars it is
versus normal public housing.
It was an experience with senior housing with the low-
income housing tax credit that really turned me around. At the
opening of one of these projects, in Las Vegas there were a lot
more people there who wanted to get into the place than there
were available units.
This brings me to the point that I would like you to
comment on. We talked about Section 8 and some of the other
types of things that the elderly utilize, and some of our
public housing things with the elderly do seem to me to be the
most successful parts of our public housing. Additionally, the
tax credits seem to be the most efficient use of the money.
In rural and in fast-growing areas, however, the tax credit
seems to be totally inadequate. That is why I have sponsored
legislation in the past and will continue to do so. To expand
the tax credit and to look for other ways to make more
affordable housing for people, especially our senior
population, who need it the most, and for those in rural areas
where it is going to be critical.
I would just like your comments on that.
Mr. Sykes. First, in candor, I must say that any effort to
meet a substantial major national problem by using tax
expenditures as opposed to budget outlays is not efficient. As
one who has used tax credits and as one who is part of a
profitable corporation, to be able to make a community
investment, if you will, and also pay in effect less taxes by
doing good within the local community is a very attractive
alternative. Certainly all the housing bonds that I signed
during my years on the State Housing Finance Agency, it was
always with a little bit of difficulty in my hand, because it
just seemed to me like a less direct way to bring the resources
of our Nation to bear on a very large problem.
However, in the meantime, it does work, and one reason why
the low-income housing tax credit works efficiently is because
it does target a population that really needs support; it puts
them in a project which is not only built for the poorest of
the poor, but it provides for some market-rate rents as well.
So the result is a more habitable environment for those who
live in a low-income housing tax credit program.
Equally important to me is that in order for one of those
to go up, you have already to have achieved a very high level
of cooperation among many people within the community--not only
the Government, but also private business, with personal
contributors, to those who are supporting the programs that the
people who live in that housing need as well.
So it is an effort to really bring the community together,
and to that extent I think has worked very well. I am frankly
distressed with the amount of resources, when they are finally
added up, that go to accountants and lawyers and bankers to
comply with all the provisions of it. There is a better way to
do it, and it is called outlays. It is not a politically
achievable thing, so I am just going to wish for a better time.
Senator Ensign. Thank you.
Ms. White, I would like to address quickly--because when I
was in the House, I was very involved, as Senator Craig was
here on the Senate side--the Medical Nutrition Therapy Act.
Having a lot of experience in our family with a diabetic and
seeing the horrible things that diabetes can do to a person,
but also seeing over the years how much dietitians have helped
her, there is no question that more of these kinds of things
are going to be important. But even if we have the Medical
Nutrition Therapy Act, where Medicare is paying for some of
these diseases--and obviously, we are happy that they are now
paying for kidney and diabetes treatments, but there are a few
other diseases like heart diseases and cancer that we still
need to be paying for--what about rural Nevada? Are there
adequate supplies of registered dietitians to be able to meet
the needs, even through Medicare?
Ms. White. Again, that is why I was talking about ways to
increase access of dietitians in rural areas. An example is the
National Health Service Corps that dietitians were a part of in
earlier years and are now excluded from. I think that is one
way.
I think that distance learning modalities that are
interactive, that would allow individuals to access nutrition
services via computer or telemedicine--we are using
telemedicine in our family practice program with resident
education and the delivery of some types of health care
services--just think what we could do if we could utilize this
technology to provide nutrition education and counseling to
people in remote areas.
I also think that we have to recognize that the meals
programs through the Older Americans Act do offer medical
nutrition therapy as well as food. In urban areas, they are
required to provide five meals a week home-delivered, but in
rural areas, it may be only two or three meals a week that are
provided.
I think we have to expand the opportunities for our seniors
not only to receive home-delivered meals--and now, with the
waiting lists 2 months, 3 months, 4 months in Knox County, and
with 85 or more individuals on that list, only the most
critical are being served. We are not preventing; we are just
putting a bandaid on food needs in this population.
Senator Ensign. Thank you.
Ms. Heady.
Ms. Heady. I would like to comment on your question as
well. My mother, who lives in rural North Alabama, was just
diagnosed with diabetes, and from West Virginia, I attempted to
find a registered dietitian or a certified diabetes educator to
work with her in her home, because she is currently not
driving. The closest person I could find who would actually
make a home visit--and my mother is fortunate--she has kids who
can pay for it--was 3 hours away in Tennessee. She could get a
diabetic class, and she could receive instruction at the local
hospital, but not follow-up care. That is part of the problem
with the reimbursement that we have seen with home health
agencies that can only take the very ill, as Ms. White was
saying.
Ms. White. That is right, and there is no provision for
medical nutrition therapy services in home health. I think that
if we had that option, dietitians could go out, either with
home health agencies or even through the local health
department, and provide some of these services.
Senator Ensign. When you were talking about the
telemedicine and some of the things via computer, that might be
one thing we will have to look at utilizing in places like
senior centers. In Nevada--and I am sure that all of us on the
campaign trail learn where the senior centers are--every small
community has a senior center, and a lot of the seniors go to
those places, and that might be a place to provide some of
these services.
Ms. White. Right. And the congregate meals at the senior
centers do offer the opportunity for elders to get together and
socialize. The problem is that those areas of the elderly
nutrition program really have not been able to grow because the
demands are so high for home-delivered meals, and
transportation is so difficult in these areas.
Senator Ensign. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Breaux.
Senator Breaux. I want to thank the panel for the very
important and educational statements from each and everyone of
you. As we try to get this committee to concentrate on helping
to provide quality of life for seniors, everything that you all
are involved in is part of that equation.
Ms. White, the whole area of nutrition is so critically
important. Why is it that the Meals-on-Wheels are unable to
provide more services in rural areas than they do in urban
areas? Is it just a funding problem?
Ms. White. It is a funding issue; it is an issue of access,
transportation, volunteers needed to deliver the meals. For
example, in Knox County, we have 450 volunteers a year, 55 per
meal delivery, period. But we need 75 in order to reach the
number of people who need to be served.
Senator Breaux. So it is more expensive in rural areas.
Ms. White. Oh, yes, it is more expensive because of the
transportation costs involved. If we could bring people to the
senior centers, we have screening, and we could have dietitians
available to work with them.
Senator Breaux. I imagine that for many of the seniors who
are living alone and who depend on Meals-on-Wheels, it may be
just about the only contact they have with the outside world
and perhaps the only meal they get.
Ms. White. Absolutely. I have a number of examples from
Houma, LA, which is where I was born and where I cared for my
parents, showing that for very elderly individuals who have
lost their spouses and have no living family members, this meal
is a lifeline for them both from the standpoint of social
contact and just from the standpoint of food.
The one meal a day with the senior nutrition program
supplies two-thirds of the calories and nutrients that those
individuals need. It is an incredible boon and really allows
folks to live in their own homes.
Senator Breaux. Which is a savings in the long term by a
big margin. I wonder what it would take if we wanted to make a
commitment that the Government would ensure that we would fully
fund or help to fund a Meals-on-Wheels program for rural
America. I think it would be a good investment, because in the
long-term, if a person is not adequately fed with a Meals-on-
Wheels program, he is going to end up in a nursing home or a
hospital, and it is going to cost us a lot more per day to have
him served there than to spend another year or two in his own
home, receiving food.
Ms. White. Absolutely. Food helps to maintain function, it
helps to maintain quality of life. Appropriate food really
helps to prevent some of the complications associated with many
of the chronic diet-related diseases that are killers.
Senator Breaux. We just have to be smarter, I think, Mr.
Chairman, on how we spend money in order to be more efficient
and more effective. I am a firm believer that sometimes a
little bit of money spent up front saves us a lot of money in
the long term down the road. Adequate health care in the
beginning for children prevents us from spending a great deal
more because they do not have health care and we wait until it
becomes an emergency in the emergency room. Something as simple
as Meals-on-Wheels in a home setting could save us a lot of
money in nursing home costs and hospital costs if we do not
provide that.
So I think we need to really be looking at the budget in
that regard as an investment and as a long-term savings. I do
not think anybody on the Joint Committee on Taxation could give
us a scoring on this, but common sense would give us a scoring
that says that we save money by keeping people in their own
home settings and adequately feeding them instead of putting
them in a nursing home at $1,000 per week or more.
I thank all of you. It has been very helpful, and
everything that you have said will be very important to this
committee.
Thank you, Mr. Chairman.
The Chairman. Thank you, John.
Ms. White, you kept using the figure 50 percent of 1973
funding levels. Could you expand on that for us? That is a
fairly alarming statement.
Ms. White. Right. That figure comes directly from
information provided by the Administration on Aging regarding
funding levels for these programs.
The Chairman. Is that an aggregate figure, or is that
specific to nutrition programs?
Ms. White. That is specific to the elderly nutrition
programs.
The Chairman. OK.
Ms. White. In Knox County, I have been very involved with
the feeding program there, and we have only been able to
increase numbers served from 400 to 800 through an aggressive
community funding outreach program. And again, the waiting list
in Knox County is 4 months. We have 85 people on that list. I
work with family physicians in the area to try to get an
elderly person who is being released from the hospital on that
meals program, and it is almost impossible, even if they can
pay for the cost of the meal. We simply do not have the
resources transportation-wise and volunteer-wise to get the
meals there.
The Chairman. And as you have mentioned, any of us who
spend time in the senior centers of our communities in our
States see a phenomenal stretching of the dollar--I am
absolutely amazed--and a very large voluntary effort to do what
they get done. They have truly taken the dollar available and
stretched it probably more than they ever thought they could or
would.
Ms. Adams, let me turn to you for a couple of questions
before I come back to Ms. White. Recent data indicates that
staying active in the workplace keeps seniors healthier longer
and can contribute to a higher quality of life. Because of this
new data, I am especially interested in ways that employers can
help those seniors who still want to work. From your
experience, how does employer behavior affect seniors working,
and are there ways for this relationship to improve?
Ms. Adams. Those employers who show that they value the
experience of older workers make a huge difference in terms of
that older worker wanting to stay employed and working longer.
Those employers who will take a look at their fringe
benefit packages and structure those packages to better meet
the needs of an older employee as opposed to just a younger
employee who might have a need for child care and other kinds
of benefits, those employers who really look at the needs of an
older worker and offer flexible work arrangements that meet the
older person's need to visit their grandchildren in the summer
or work part-time or work half a year as opposed to a full
year, those are the employers, I think, who are really the
employers that older workers want to stay with.
There are a number of large corporations, too, that are
beginning to actually look at their pension plans and
restructure them to make them more older-worker-friendly, to
encourage older workers to work beyond normal retirement age.
Polaroid Corporation has done some very interesting things
in terms of phased retirement, allowing an older individual to
take 6 months off and then come back and work the remainder of
the year.
There is much that employers can do to encourage a longer
work life.
The Chairman. You mentioned in your testimony that the loss
of traditional jobs in rural areas--and you have highlighted
several in Idaho in logging, agriculture, and mining--is
forcing workers out of work, or at least, certainly, older
workers. What types of programs are working in Idaho to retain
these displaced workers, and do you think these applications
would work in other States?
Ms. Adams. We do have a very effective dislocated worker
program in Idaho. Rapid response teams are put together around
plant closures and layoffs, and those response teams consist of
labor and management and worker representation as well as our
State Department of Labor. We need to make sure that older
worker staff are looped into those kinds of rapid response
teams so that they can focus on the needs of the older
dislocated worker who has a much more difficult time getting
reemployed.
We also need more Senior Community Service Employment
Program funds to help serve this need. We have been at flat
funding for years, and the current program only serves 2
percent of the eligible population. So if we had more funds, we
could focus more emphasis on these dislocated people.
The Chairman. Thank you.
Ms. White, the Senator from Nevada mentioned, and we worked
cooperatively together, both the House and Senate, last year on
legislation to provide for medical nutrition therapy and
coverage for diabetes and kidney disease. This year, I am
working to expand coverage for people with cardiovascular
disease, and I am enlisting the support of my colleagues to get
this done.
Can you briefly discuss the types of benefits that
nutrition therapy provides to seniors? You have already
highlighted some, but I am always amazed to see the role of
good nutrition in both the quality of life of the individual
senior but also the extension of life and the vibrancy of the
life that they have.
Ms. White. Absolutely. Good nutrition, particularly for
people with diabetes or the dyslipidemias, can No. 1 reduce
complications. We know that if you normalize blood sugar, if
you get lipid levels to less than 200 total, and for people
with established disease less than 100 LDL, you can
significantly reduce complications, you can reduce the need for
medications, you can reduce readmission rates to acute care
systems, you can reduce length of stay in acute care settings,
you can improve wound healing and enhance immune function.
Nutrition is integral to life, and you can just improve all
of these factors. There is a lot of evidence to show--some
people think that older people really are not motivated to
change life styles--but in fact, older people are probably more
receptive than any other age group. They would much rather
modify diet and life style than add another drug to an already
often very complicated drug system. Again, this saves money.
The Chairman. Thank you.
Senator Kohl.
Senator Kohl. Thank you, Senator Craig.
Well, you have made it very clear that there is a desperate
need for increased funding to improve the quality of life of
people who live in the rural areas of our country and who are
elderly, and that there would be a significant improvement in
their lives if we could get just 5 or 10 percent more funding.
It is not like you are suggesting that there is so much funding
out there that there is not much more we can do--it is to the
contrary--that there are enormous things that could be
accomplished if we could get just a little bit more funding.
So when we look at our Federal budget as citizens, and read
about what it is we are proposing to do, and how we are
thinking about spending the surplus, and just for example,
spending $1.6 trillion over 10 years on tax cuts--which I am
not quarreling with, and I am not being critical about--but you
wonder whether we should be able to find some additional
funding for some of these needs that you are talking about this
morning. Do you think that if you had a chance to work on that
budget, you might be able to figure out how we can use our
resources here at the Federal level to do a better job with the
rural elderly in our country, Ms. White?
Ms. White. Absolutely. Food is such a basic need, and we
have such an abundance of food in this country; it is a shame
that we cannot find the funds and the means to get this food to
the people who are in desperate need of it and to whom it would
make an enormous difference in health and in quality of life.
Senator Kohl. Ms. Adams.
Ms. Adams. I think that we probably need to do a better job
of looking at the return on investment that these programs
really provide and communicate that to lawmakers. When you look
at our older worker programs in terms of those people who get
jobs off the program, and when you look at how much money those
people are generating via paychecks that they earn, taxes that
they pay--I know that our Idaho older worker programs pay for
themselves in just 11 months.
So this is a very wise investment of tax dollars.
Furthermore, we also need to look at the value that the Senior
Community Service Employment Program brings to our communities
in the form of public service; they also provide infrastructure
support for all of the aging programs that you have heard
described today.
So maybe we need to do a better job of communicating the
value of these programs, again, to decisionmakers like
yourselves.
Senator Kohl. Thank you.
Mr. Sykes.
Mr. Sykes. I do not want to be cynical in regard to the
last point, but during the time when I was on the Federal
Council on Aging, we did a very major study of the Title V
program, and the evidence was overwhelming that the purposes
were being fulfilled, the eligibility was carefully targeted,
the results were incredible. And we barely kept from losing the
program totally, and it has been flat-funded for years despite
that reality.
So yes, Melinda, we do need to deliver those facts. I would
go to housing quickly and show the 202 program. There is none
within the housing area that has wider public support, and we
who have put 202 programs together have daily evidence of a
program that works, and it works well. It is expensive, but it
works, and it keeps people from laying out money in another
way.
We could easily and effectively double or triple the number
of units in the 202 program, and communities across this
country would be beneficiaries, and many elders would find
alternatives to either neglect, which is all too often the
situation, or institutionalization.
I would like to join the force and help to figure out some
ways not simply to divert from a tax refund, but I know in
terms of the elders of America and rural elders that there will
be a much higher return on investment, if you will, and a much
greater benefit for doing things to increase the likelihood
that that local environment will support them in their homes,
with the services they need, than any amount of money that will
pass to me or to my rich children in terms of a tax children.
Senator Kohl. Thank you, Mr. Sykes.
Ms. Heady.
Ms. Heady. Thank you.
I would like to offer something that would be a mere drop
or even less than a drop in the Federal budget, and that is to
look at studying the next generation, the rural aging veteran.
We have a window of opportunity right now to start looking at
and preventing some serious, serious problems in the future.
Right now, we have 1.5 million elderly who are in subsidized
housing, and right now, we have diagnosed 1.5 million veterans
with PTSD, and these are guys whose families are
disintegrating, they are winding up on park benches, and they
are becoming part of the rural homeless as well.
We have outreach centers, and if we can get some better
knowledge about what they need, how to survey that population--
we have not even looked at that population since 1988--we can
gear ourselves up.
One thing that I find most frustrating about this issue is
that whenever I say the word ``veteran,'' everybody immediately
sends everything to the Veterans' Administration. They think
that that is where it all belongs. But that is not true.
Particularly in rural communities, when these veterans are
spread out among the rural population--and we do know that
there are more aging Vietnam-era veterans in rural areas than
any place else in the country--it is an issue that we really do
need to look at. And unfortunately, we do not even know enough
about it to talk about it intelligently in a policy arena. Only
those of us who have been personally affected by it and have
tried to get services for either the veteran or his family
through the outreach centers can really see the tip of the
iceberg.
From what I have learned personally--and I know women who
now, for 30 years, have slept every night with a man who keeps
a loaded weapon under his bed because that is the only way he
can sleep--we really have a serious problem that we need to
look at.
Senator Kohl. Say that again, please.
Ms. Heady. I personally know women whose veteran husbands
sleep with loaded weapons. They feel that they need to have
that level of security to be able to get whatever sleep they
can get for the night--and that has been going on in their
relationships for 30 years.
Senator Kohl. Well, thank you. You have been a great panel.
The Chairman. Let me extend that thanks, too. You have all
been a great panel. There are a good many more questions that
we could ask, but time is not going to allow that to happen.
We will leave the record open for several days, and we may
extend to you some questions in writing to complete the record
and would appreciate your cooperation there.
Again, we have obviously just surfaced the tip of the
iceberg on this issue, and as it grows and as our communities
grow older, we would hope that the programs that we can make
available will be well-funded and flexible enough to adjust to
the changes occurring out there with an aging America.
I am fascinated by the sheer numbers and the length of
health. I tell this story because it is real, and I think it
well-illustrates it. My wife's parents are in their eighties
and are alive and healthy, going strong, living in a retirement
center in Tucson. We visit them as often as we can, and during
the holidays of this past winter, we were down there. They live
in a very lovely retirement center, and they are fully active,
so they can still interact well with their community.
We were sitting in the dining room having dinner, and two
fellows walked through--you are only allowed to use canes in
that dining room; you cannot access it with wheelchairs or
walkers--and they came roaring through on their canes, and as
they passed by, my father-in-law said, ``There is 100 and so
many months and another 100 and so many months.'' There were
two living, active members of that immediate community who were
100 years old or better.
It kind of washed over me--oh, my goodness--and that is
happening everywhere else in America, and it continues to
increase. So we have a job to get done.
Thank you all very much for being with us this morning. We
appreciate it.
The committee will stand adjourned.
[Whereupon, at 11:17 a.m., the committee was adjourned.]
A P P E N D I X
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