[Senate Report 106-229]
[From the U.S. Government Publishing Office]
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106th Congress Rept. 106-229
2d Session SENATE Volume 2
_______________________________________________________________________
DEVELOPMENTS IN AGING: 1997 AND 1998
VOLUME 2
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A REPORT
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 54, SEC. 19(c), FEBRUARY 13, 1997
Resolution Authorizing a Study of the Problems of the Aged and Aging
February 7, 2000.--Ordered to be printed
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106th Congress Rept. 106-229
2d Session SENATE Volume 2
_______________________________________________________________________
DEVELOPMENTS IN AGING: 1997 AND 1998
VOLUME 2
__________
A REPORT
of the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
pursuant to
S. RES. 54, SEC. 19(c), FEBRUARY 13, 1997
Resolution Authorizing a Study of the Problems of the Aged and Aging
February 7, 2000.--Ordered to be printed
-------
U.S. GOVERNMENT PRINTING OFFICE
56-466 WASHINGTON : 2000
SPECIAL COMMITTEE ON AGING
CHARLES E. GRASSLEY, Iowa, Chairman
JAMES M. JEFFORDS, Vermont JOHN B. BREAUX, Louisiana
LARRY CRAIG, Idaho HARRY REID, Nevada
CONRAD BURNS, Montana HERB KOHL, Wisconsin
RICHARD SHELBY, Alabama RUSSELL D. FEINGOLD, Wisconsin
RICK SANTORUM, Pennsylvania RON WYDEN, Oregon
CHUCK HAGEL, Nebraska JACK REED, Rhode Island
SUSAN COLLINS, Maine RICHARD H. BRYAN, Nevada
MIKE ENZI, Wyoming EVAN BAYH, Indiana
TIM HUTCHINSON, Arkansas BLANCHE L. LINCOLN, Arkansas
JIM BUNNING, Kentucky
Theodore L. Totman, Staff Director
Michelle Prejean, Minority Staff Director
LETTER OF TRANSMITTAL
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U.S. Senate,
Special Committee on Aging
Washington, DC, 2000.
Hon. Albert A. Gore, Jr.,
President, U.S. Senate,
Washington, DC.
Dear Mr. President: Under authority of Senate Resolution 54
agreed to February 13, 1997, I am submitting to you the annual
report of the U.S. Senate Special Committee on Aging,
Developments in Aging: 1997 and 1998, volume 2.
Senate Resolution 4, the Committee Systems Reorganization
Amendments of 1977, authorizes the Special Committee on Aging
``to conduct a continuing study of any and all matters
pertaining to problems and opportunities of older people,
including but not limited to, problems and opportunities of
maintaining health, of assuring adequate income, of finding
employment, of engaging in productive and rewarding activity,
of securing proper housing and, when necessary, of obtaining
care and assistance.'' Senate Resolution 4 also requires that
the results of these studies and recommendations be reported to
the Senate annually.
This report describes actions taken during 1997 and 1998 by
the Congress, the administration, and the U.S. Senate Special
Committee on Aging, which are significant to our Nation's older
citizens. It also summarizes and analyzes the Federal policies
and programs that are of the most continuing importance for
older persons and their families.
On behalf of the members of the committee and its staff, I
am pleased to transmit this report to you.
Sincerely,
Charles E. Grassley, Chairman.
C O N T E N T S
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Page
Letter of Transmittal............................................ III
Item 1. Department of Agriculture............................ 1
Agricultural Research Service............................ 1
Cooperative Extension System............................. 8
Economic Research Service................................ 16
Food and Nutrition Service............................... 16
Food Safety and Inspection Service....................... 19
Marketing and Regulatory Programs........................ 19
Item 2. Department of Commerce............................... 20
Item 3. Department of Defense................................ 26
Item 4. Department of Education.............................. 28
Item 5. Department of Energy................................. 60
Item 6. Department of Health and Human Services.............. 66
Administration on Aging.................................. 66
Administration for Children and Families................. 458
Office of the Assistant Secretary for Planning and
Evaluation............................................. 465
Centers for Disease Control and Prevention............... 473
Food and Drug Administration............................. 491
Health Care Financing Administration..................... 519
Health Resources and Services Administration............. 538
Office of Inspector General.............................. 548
National Institutes of Health............................ 551
Item 7. Department of Housing and Urban Development......... 912
Item 8. Department of the Interior.......................... 922
Item 9. Department of Justice............................... 934
Item 10. Department of Labor................................. 945
Item 11. Department of State................................. 954
Item 12. Department of Transportation........................ 955
Item 13. Department of the Treasury.......................... 965
Item 14. Commission on Civil Rights.......................... 980
Item 15. Consumer Product Safety Commission.................. 997
Item 16. Corporation for National Service.................... 1002
Item 17. Environmental Protection Agency..................... 1017
Item 18. Equal Employment Opportunity Commission............. 1106
Item 19. Federal Communications Commission................... 1147
Item 20. Federal Trade Commission............................ 1154
Item 21. General Accounting Office........................... 1189
Item 22. Legal Services Corporation.......................... 1269
Item 23. National Endowment for the Arts..................... 1270
Item 24. National Endowment for the Humanities............... 1278
Item 25. National Science Foundation......................... 1279
Item 26. Pension Benefit Guaranty Corporation................ 1282
Item 27. Postal Service...................................... 1315
Item 28. Railroad Retirement Board........................... 1322
Item 29. Small Business Administration....................... 1328
Item 30. Social Security Administration...................... 1329
Item 31. Veterans' Affairs................................... 1343
106th Congress Rept. 106-229
SENATE
2d Session Volume 2
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DEVELOPMENTS IN AGING: 1997 AND 1998 VOLUME 2
_______
February 7, 2000.--Ordered to be printed
_______
Mr. Grassley, from the Special Committee on Aging, submitted the
following
R E P O R T
Report from Federal Departments and Agencies
ITEM 1--DEPARTMENT OF AGRICULTURE
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AGRICULTURAL RESEARCH SERVICE (ARS)
Title and purpose statement of each program or activity which affects
older Americans
The Jean Mayer USDA Human Nutrition Research Center on
Aging (HNRCA) at Tufts University was established by Congress
through the Food and Agricultural Act of 1977 as one of five
mission-oriented research centers designed to study the effect
of human nutrition on health. HNRCA's creation was a major
response of the federal government to the growing awareness of
the need for improved nutrition recommendations for the
American public throughout the life cycle. The overall mission
of the HNRCA is to explore the relationship between nutrition
and good health and to determine the nutritional and dietary
requirements of the maturing and elderly population. The
interaction between nutrition and the onset and progression of
aging and associated degenerative conditions is of special
concern. HNRCA scientists conduct cell and molecular biology,
animal model, and human metabolic and field studies to further
their understanding of the processes of nutrient utilization
and metabolism to determine ways by which diet in combination
with genetic and environmental factors may promote health and
vigor over the lifespan.
Antioxidants Research Laboratory. The mission of the
Antioxidants Research Laboratory is (1) to understand the role
of antioxidant nutrients and other environmental factors on
free radical reactions and lipid peroxidation events during the
aging process and (2) to elucidate the impact of these
phenomenon age-related changes in nutrient requirements and
chronic degenerative conditions. The lab pursues its mission by
exploring the effects of specific nutrients, especially
vitamins E and C, carotenoids, glutathione and polyunsaturated
fatty acids as well as factors such as exercise and xenobiotics
on free radical-mediated oxidative damage. Animal models, cell
cultures, and human volunteers are employed in this research
program.
Body Composition Laboratory. The Body Composition
Laboratory's mission is to evaluate the effect of nutrition on
the dynamic interactions between the body's protein, water,
fat, and bone and to study the relationship of these changes to
the process of aging. The laboratory includes four principal
facilities: Whole Body Counter; Partial Body and Small Animal
Counter; Neutron Activation Facility; and Neutron Generator
Facility for the in vivo measurement of fat.
Calcium and Bone Metabolism Laboratory. The mission of the
Calcium and Bone Metabolism Laboratory is to examine ways in
which diet and nutritional status in combination with exercise
and hormones, particularly estrogen and parathyroid hormone,
influence age-related loss of bone density. To determine the
extent to which increased calcium and vitamin D intake can
mitigate bone loss and prevent the development of osteoporosis
and spontaneous fractures in the elderly. This mission is
pursued through clinical studies in which the effects of
modifying the diet and/or activity level on calcium absorption
and bone density are measured in healthy, elderly volunteers.
In addition, the process of intestinal adaptation to altered
calcium intake is being examined and compared in black and
white women.
Energy Metabolism Laboratory. The mission of the Energy
Metabolism Laboratory is to examine how body weight is normally
regulated and why many people tend to gain weight as they grow
older. The importance of genetic and environmental factors in
determining body composition and energy regulation, and
quantifying optimal dietary energy requirements are under
investigation. Research involves studies at the level of whole-
body physiology such as examining the importance of energy
expenditure and energy intake in determining body fat gain
during adult life. In addition, hormonal and cellular
investigations are underway to identify the underlying
metabolic cause of differences in body composition and energy
regulation between people.
Gastrointestinal Nutrition Laboratory. The Gastrointestinal
Nutrition Laboratory's mission is to determine how aging and
associated factors such as medication use affect the intestinal
absorption and metabolism of micronutrients, including
carotenoids. Experimental animal and cell culture models, and
human volunteers are employed in studies to investigate whether
changes in the Recommended Dietary Allowances (RDA) for niacin,
vitamin A, vitamin B2, vitamin B6, vitamin B12 are warranted
for the elderly. The chemopreventive effects of carotenoids
against cancer are explored. In addition, research is conducted
in elderly subjects with atrophic gastritis or hypochlorhydria,
a significant sub-population of elderly at risk for impaired
nutrient absorption and gastric cancer. Perfused intestinal
segments and mesenteric lymph cannulae are also used in animal
models characterizing the kinetics, energy requirements and
age-associated changes in micronutrient uptake and clearance.
Genetics Laboratory. The mission of the Genetics Laboratory
is to examine the molecular mechanisms by which diet and
development regulate metabolic pathways at the genetic level.
The major focus is the absorption, storage and utilization of
nutrient energy. This process constitutes a complex homeostatic
system in mammals, balancing energy intake and expenditure
while maintaining energy stores. Consequently, the nutrient
regulation of gene expression is highly complex, involving
numerous positive and negative stimuli. In vitro and in vivo
molecular techniques are used to determine how individual
nutrients activate and suppress transcription. Little is known
about the genetic control of the process of lipogenesis which
underlies the accumulation of body fat and synthesis of
circulating fats. Molecular techniques are used to study the
dietary and hormonal control of lipogenesis in the liver. The
focus is to determine the DNA sequence elements that regulate
lipogenic gene transcription in response to diet and hormones;
to identify the critical transacting factors that interact with
these elements and how they transduce dietary and hormonal
signals; and to determine how altered transcription of
lipogenic genes in diabetes and obesity affect lipogenesis and
the response to nutritional stimuli.
Laboratory or Nutrition and Vision Research. The Laboratory
for Nutrition and Vision Research's mission is to determine the
primary causes of eye lens cataract and degeneration of the
macula and to apply that knowledge to extend the useful life of
these organs. Current approaches involve defining adequate
levels of nutrients during various life stages which will
result in delayed accumulation of damaged proteins in lens and
retina, as well as delayed lens opacification and age-related
maculopathy. The laboratory pursues this mission principally
using clinical/epidemiologic studies and laboratory tests,
human and other mammalian lens tissue, animal models, whole
lenses and lens epithelial cells in culture. Since the lens is
primarily composed of protein, a significant effort is made to
understand interrelationships between aging, regulation of lens
protein metabolism, protease function and expression, and
nutrition.
Lipid Metabolism Laboratory. The Lipid Metabolism
Laboratory's mission is to define the interrelationships
between lipoprotein metabolism, nutrition and the aging process
and to develop recommendations for older adults regarding
dietary fat and cholesterol in an effort to minimize
cardiovascular risk factors and atherosclerosis. Research
focuses on defining the biochemical parameters which identify
individuals at risk for premature coronary artery disease and
optimal diets which minimize plasma lipoprotein abnormalities
in the elderly; the short- and long-term regulation of plasma
lipoproteins by diet; the nutritional regulation of lipoprotein
synthesis and apolipoprotein gene expression in vitro and in
vivo; the nutritional requirements for essential fatty acids
with aging; and prevention of diet induced atherosclerosis.
Methodologies established in the laboratory include lipoprotein
isolation by ultracentrifugation, automated standardized
enzymatic lipid analysis, gradient gel electrophoretic analysis
of plasma lipoproteins, apolipoprotein isoelectric focusing,
apolipoprotein quantitation by enzyme linked immunoassays,
stable isotope kinetic studies, fatty acid analysis by gas
liquid chromatography, cell culture studies, DNA isolation and
genomic blotting analysis, specific mRNA quantitation, DNA
amplification and gene cloning and sequencing.
Mineral Bioavailability Laboratory. The Mineral
Bioavailability Laboratory's mission is to examine the
biochemical and physiologic basis for changes in absorption and
utilization of minerals with aging and to determine the effects
of aging on mineral requirements in the elderly. Research
focuses specifically on calcium, magnesium and zinc metabolism,
and the effects of nutrient and hormonal changes on the
expression of genes which modulate mineral metabolism.
Nutrition, Exercise Physiology and Sarcopenia Laboratory.
The mission of the Nutrition, Exercise Physiology and
Sarcopenia Laboratory is to explore the interaction between
nutrition, exercise and aging and to understand how physical
activity affects nutrient requirements and functional capacity
in the elderly. The extent to which aging alters the adaptive
responses to increased physical activity is largely unknown,
particularly its effects on protein metabolism. The laboratory
is focusing its activities on the metabolism and requirements
of several macronutrients and how they change with age and
activity. The laboratory makes use of stable isotope probes and
the euglycemic glucose clamp technique to establish how energy
expenditure, body composition and the turnover of whole body
nitrogen and glucose vary in the population with increasing
age, particularly with regard to changes in amount of physical
activity. Through the use of these techniques, it can be
established how these changes affect substrate requirements.
Nutritional Immunology Laboratory. The Nutritional
Immunology Laboratory investigates the role of dietary
components and their interactions with other environmental
factors in age-associated changes of the immune and
inflammatory responses. Research looks to reverse and/or delay
the onset of these immunologic and age-related changes by
appropriate dietary modifications and to determine the
molecular mechanisms by which antioxidant and prooxidant
nutrients modulate immune cell functions. Methods are being
developed to use the immune response as a biologically
meaningful index in determining specific dietary requirements.
Nutritional Epidemiology Program. The mission of the
Nutritional Epidemiology Program is to identify the
determinants of nutrition status in the elderly, to relate
nutrition status to health and well-being, to define groups at
special risk of nutritional problems, and to evaluate nutrition
programs which service the elderly. Research addresses age-
associated changes in energy and nutrient intake;
constitutional, psychosocial and environmental determinants of
food choices; nutritional determinants of neurobehavioral
function, and of age-related changes, such as lens
opacification.
Vitamin K Research Program. The mission of this program is
to determine dietary needs for vitamin K, and the contribution
that various forms of vitamin K make to general health and
well-being during the aging process. Vitamin K is responsible
for introducing unique calcium-binding sites (gamma-
carboxyglutamic acid residues) into vitamin K-dependent
proteins. Prior to 1976, the only known proteins (prothrombin,
Factors VII, IX, & X) thought to be vitamin K-dependent were
involved in blood coagulation. Today other vitamin K-dependent
proteins (Proteins C & S) involved as anticoagulants are known.
Protein S, osteocalcin and matrix gla protein are vitamin K-
dependent proteins involved in bone biology. As new vitamin K-
dependent proteins continue to be discovered, it is apparent
that vitamin K has roles outside of its well-established role
in regulation of blood clotting. The goals of the program are
to develop new methods for the biochemical, functional, and
dietary assessment of vitamin K nutritional status, and to
determine the nutritional sources, bioavailability and
requirements of vitamin K in humans at different stages of the
aging process. Epidemiologic studies are being undertaken to
examine the relationship between vitamin K status and chronic
diseases, such as cardiovascular disease and osteoporosis.
Vitamin Metabolism Laboratory. The mission of the Vitamin
Metabolism Laboratory is multifaceted. The Lab studies the
bioavailability of water soluble vitamins in the aging
population and determines the effect of aging on vitamin
requirements; examines the basis for the absorption,
utilization, and excretion of water soluble vitamins from food
in the maturing and elderly population; assesses vitamin status
and its relationships to drug intake and chronic diseases;
studies the impact of subclinical vitamin deficiencies on the
integrity and function of body physiology; studies the
pathogenesis and pathophysiology of homocysteinemia; determines
the relationship of vitamin status to chronic diseases; and,
determines the relationship between folate status and
dysplasia.
Brief description of accomplishments
Elevated levels of blood vitamin C is associated with
protection against eye disease. Scientists have determined the
minimal vitamin C intake needed to provide maximum protection
for eye tissue. Results indicate that in humans, elevated
vitamin C intake is associated with markedly reduced risk for
cataracts of the eye.
Age associated changes in behavior may result from
increased sensitivity to oxidative stress. Evidence indicates
that abilities to mitigate the effects of oxidative stress and
repair tissue damage due to oxidative stress show a decline as
people grow older. Data indicate that one of the major sites of
action of oxidative stress are the membrane of neurological
cells. It is suggested that attempts to increase protection
through diets rich in total antioxidant capacity from fruits
and vegetables might prevent or reverse the deleterious
oxidative-stress effects of neurological functions.
Older people might reduce their risk of gaining weight by
eating smaller, more frequent meals. These findings are from a
study that was the first to measure fat oxidation after eating.
It was aimed at revealing underlying causes behind an age-
related increase in body fat, which typically doubles between
the ages of 20 and 50 to 60 years.
Scientists conducted the first population-based study of
vitamin D with 759 free-living volunteers. Findings suggest
that inadequate vitamin D is an important public health problem
in older Americans. Vitamin D is essential for healthy bones
and teeth and helps prevent osteoporosis. Studies show that
Vitamin D status is better for elderly men and women in the
general population than for elderly hospital patients,
confirming the importance of eating foods rich in vitamin D and
exposing skin to sunlight.
Findings have identified an instigator behind the age-
related decline in T cell function, which coordinates the
body's response to an infectious agent or a would-be tumor.
What's more, they were able to reduce the effects of this
instigator in cultured cells. The finding brings science a
little closer to defining how people can maintain a healthy
immune system well into old age.
Researchers have identified a negative role of high dietary
calcium intakes on zinc homeostasis in the elderly.
Specifically, a high calcium intake reduced zinc retention, a
finding of substantial relevance to consumers who self-
prescribe calcium supplements and may thereby put them at risk
of zinc deficiency.
Human Nutrition Research Center on Aging--Research Projects Related to
Nutrition and the Elderly
Funding level
fiscal year
dollars
Functional Capacity and Nutrient Needs of Aging--1/11/95-1/10/
00. Objective: To examine the effects of increased
physical activity, body composition and diet on the
following: (1) peripheral insulin sensitivity and glucose
metabolism; (2) functional capacity and nutrition status
of the frail elderly; (3) whole body and skeletal muscle
protein metabolism; and (4) total energy expenditure and
its relationship to physical activity level and body
composition............................................... 940,560
Function and Metabolism of Vitamin K and Vitamin K Dependent
Proteins During Aging--1/11/95-1/10/00. Objective:
Molecular, biochemical and functional assays of vitamin K
nutritional status and dietary tools for the assessment of
vitamin K intakes will be developed and validated. In vivo
studies with rats will determine dietary sources of
vitamin K and requirements related to the synthesis of
matrix gla protein (MGP). The effects of aging and gender
on the expression of MGP will be studied in relationship
to dietary sources of vitamin K (phylloquinone and
menadione) and vitamin K antagonists...................... 904,769
Absorption & Metabolism of Phytochemicals: Enhancement of
Antioxidant Defense Mechanisms in Aging--10/01/96-09/30/
99. Objective: Determine (1) extent of absorption and
metabolism of flavonoids in fruits and vegetables high in
antioxidant activity, (2) usefulness of Oxygen Radical
Absorbing Capacity (ORAC) assay as an indicator of
antioxidant capacity of fruits and vegetables and status
in animal models exposed to increased oxidative stress,
and (3) possible health related outcomes.................. 370,184
Dietary Antioxidants, Aging, and Oxidative Stress Status--11/
01/94-10/31/99. Objective: To determine the effect of
enhancing antioxidant status, on oxidative status, immune
responsiveness, and other physiologic functions,
interactions between vitamin E, other dietary antioxidants
and/or polysaturated fatty acids, the effect of dietary
antioxidants on the generation of eicosanoid and cytokine
products and oxidated lipid, protein and nucleic acid
targets, the value of measures of antioxidants and
oxidative stress status as biomarkers of aging and health. 670,700
Gastrointestinal Function and Metabolism in Aging--11/01/94-
10/31/99. Objective: To delineate the pathways of
intestinal carotene metabolism, and to determine if any
metabolic intermediate can transactivate nuclear
receptors; to determine if beta-carotene or cryptoxanthin
can prevent gastric cancer in the feffet/model; to
determine relative bioavailabilities of different
carotenoid compounds in the human. To determine niacin
requirements in elderly humans. To study the effect of
antioxidants in gut immunity in young and elderly adults.. 1,684,467
Nutrition, Aging and Immune Response--11/01/94-10/31/99.
Objective: Investigate the role of nutrients and their
interactions with other environmental factors in age-
associated changes of the immune response, to reverse and/
or delay the onset of these immunological changes by
dietary modification and to use the immune response as an
index in determining the specific dietary requirements for
older..................................................... 1,033,933
The Role of Aging in Energy and Substrate Regulation and Body
Composition--1/11/95-1/10/00. Objective: To examine the
extent and causes of changes in energy metabolism, energy
regulation and body composition with agin, and to
investigate optimal values for dietary energy intake and
expenditure in the aging population. In particular to
determine the (1) roles of genetic inheritance and
environment factors in determining fat content, (2) extent
to which changes in body fat and protein with aging are
inevitable, and (3) molecular regulation of proteins
involved in fat metabolism in adipocytes.................. 1,879,726
Regulation of Gene Expression in Nutrient Metabolism--01/11/
95-01/10/00. Objective: The major areas being explored are
aimed at defining the molecular mechanisms which
contribute to metabolic dysfunction in diabetes and
obesity. Specifically, the role of oxidants in nutrient
and hormonal signal transduction and gene expression will
be examined. Secondly, how aging influences nutrient and
hormonal signaling and gene expression will be explored... 432,679
Mineral Bioavailability in the Elderly--01/11/95-01/10/00.
Objective: To define the dietary factors that influence
the Bioavailability, requirements, and status of minerals
especially, Ca, Mg, Fe and Zn in humans. To define the
relationship between restriction fragment length
polymorphisms in the vitamin D receptor gene and calcium
metabolism in humans. To define the mechanism of age-
associated intestinal calcium malabsorption............... 610,334
Bioavailability of Nutrition in the Elderly--01/11/95-01/10/
00. Objective: To study the bioavailability of water
soluble vitamins in the aging population and determine the
effect of aging on vitamin requirements. To examine the
basis for the absorption utilization and excretion of
water soluble vitamins from food in the maturing and
elderly population. To assess vitamin status and its
relationships to drug intake and chronic diseases. To
study the impact of subclinical vitamin deficiencies on
the integrity and function of body physiology............. 901,017
Dietary Assessment of Rural Older Persons--02/01/96-12/31/00.
Objective: (1) Test dietary assessment methodologies (24-
hr phone recalls and written food records) in a rural
population of older persons. (2) Seek confirmation of
dietary findings using doubly-labeled water and indirect
calorimetric procedures. (3) Correlate dietary findings
with biomarkers of nutritional status (i.e., measures of
visceral protein, folate, B 12, pyridoxine, homocysteine
and iron). (4) Investigate nutrition knowledge and
practices (use of dietary supplements and reduced calorie
foods) of rural older persons............................. 186,857
Maintaining Bone Health in the Elderly--11/01/94-10/31/99.
Objective: Define the intake of calcium and vitamin D
above which skeletal mineral is maximally spared. This
requires an understanding of how hereditary, demographic,
endocrine, and physical factors (i.e., race, sex, age,
years since menopause, weight, and activity level) affect
the absorption and utilization of these nutrients. Race
differences in bone metabolism will be sought in an effort
to understand why blacks have less osteoporosis........... 1,100,401
Dietary Effects on Neurological Function--10/01/96-09/30/99.
Objective: Identify selected food components that affect
neurological function and determine their mechanism of
action.................................................... 633,579
Lipoproteins, Nutrition and Aging--01/11/95-01/10/00.
Objective: To develop optimal diets in terms of fat and
cholesterol content which are effective in reducing LDL
cholesterol, as well as favorably affecting other heart
disease risk factors, to study nutritional regulation of
plasma lipoproteins in animals, and to study the
interrelationships between aging, nutrition, genetics, and
to examine ways to prevent diet-induced atherosclerosis,
lipoproteins, and heart disease risk in populations....... 1,285,299
Effect of Nutrition and Aging on Eye Lens--01/11/95-01/10/00.
Objective: One-half of the eye lens cataract operations
and savings of over $1 billion would be realized if
formation could be delayed by only 10 years. Enhancement
of dietary antioxidants, such as vitamin C, and other
nutrients, such as carotenoids or tocopherol, will be used
to delay damage to lens proteins and proteases and to
maintain visual function in elderly populations. This
should delay, cataract-like lesions in eye lens
preparations, cataracts in vivo, and age-related
maculopathy............................................... 958,286
Epidemiology Applied to Problems of Aging and Nutrition--01/
11/95-01/10/00. Objective: To define diet and nutrition
needs of older Americans. To advance methods in
nutritional epidemiology. To develop indices which reflect
nutrient intake and which predict health or disease
outcomes in aging populations............................. 1,250,359
COOPERATIVE STATE RESEARCH, EDUCATION, & EXTENSION SERVICE, (CSREES)
Programs and Accomplishments
Title and purpose statement of each program or activity which affects
older Americans
The Cooperative State Research, Education, and Extension
Service (CSREES) in its mission advances research, extension,
and higher education in the agricultural, environmental, and
human sciences to benefit people, communities, and the Nation.
As a major research and education arm of USDA, CSREES through
its Land-Grant institution network has conducted educational
and research programs that have benefited older persons, their
adult children, and caregivers. The vision is for older persons
to maintain and continue a quality lifestyle while aging; have
a greater opportunity to be financially secure; experience
positive human relations; and to have the knowledge necessary
to access health care options.
CSREES and its state partner institutions collaborate with
a variety of national, state, and local organizations and
agencies such as the American Association of Retired Persons
(AARP) including the AARP Grandparent Information Center, the
National Association for Family and Community Education, the
Hospice Foundation of America, the Administration on Aging, the
Area Agencies on Aging, American Society on Aging, American
Gerontological Society, the Brookdale Foundation Group,
Grandparents United for Children's Rights, Family Support
Education Program, Generations United, Health Care Financing
Administration, and Federal/State/local departments of human/
family services and health. This collaboration provides more
well-coordinated programs for consumers and extends the
resources of each collaborator to better serve the clientele.
As a component of the CSREES National Initiative on
Children, Youth, and Families at Risk, human and electronic
networks are addressing targeted issues identified by
professionals and stakeholders throughout the system. One of
those networks, the National Network for Family Resiliency
(NNFR), provides leadership for acquisition, development, and
analysis of resources that foster family resiliency. Family
resiliency is defined as the family's ability to cultivate
strengths to positively meet the challenges of life. The NNFR
brings together educators, researchers, agency personnel,
families, advocates for families, and practitioners who share
an interest in strengthening families that face multiple risks
to their resiliency. Collaborators from CSREES and more than 40
Land-Grant institutions share leadership for maximizing
expertise, bringing research to bear on significant family
issues, and guiding research based on evaluation of programs
and practices. The network provides access to resources through
multiple avenues including electronic media, training and
education, and community development. Within the network, a
special interest group has formed to address intergenerational
issues. The work group is composed of more than 35 multi-state
and multi-institutional members. Currently their focus is on
``grandparents raising grandchildren'' and ``relationships
between generations.''
An Internet web site was developed that highlights
resources for grandparents/relatives as primary caregivers and
promotion of positive intergenerational relationships for
educators and the general public. A variety of topics are
included in the web information. For example, information on
elder abuse, family support, and families with special needs
are included. An extensive collection of curriculum, research
abstracts, and educational resources/materials can be found on
the web site. The Internet address is .
The Intergenerational Special Interest Work Group has
planned a national video conference entitled, ``Grandparents
Raising Grandchildren: Implications for Professionals and
Agencies. The video conference will be held January 12, 1999.
The University of Wisconsin-Extension Cooperative Extension
Service and Purdue University Cooperative Extension Service are
the lead institutions for this project.
The video conference will provide training for
professionals from a broad spectrum of family-serving
organizations and agencies. Participants will explore the
issues facing grandparents raising their grandchildren, examine
the latest research, and learn about resources for clientele.
The ultimate goal is more educational programs for the nearly 4
million grandparents serving as primary caregivers for their
grandchildren. This is a rapidly emerging social and
educational concern and most professionals need more training
to better serve this growing clientele group.
A number of land-grant institutions have active programs
designed to help relatives be more capable caregivers. For
example, the University of Kentucky Extension Service teaches
parenting techniques, use and access of community agencies,
computer literacy, and mutual support techniques for caregiving
grandparents. Grandparents participate in monthly support group
meetings and receive a newsletter. In New Hampshire, the
Cooperative Extension Service offers a series of classes
through a community resource center to grandparents parenting
their grandchildren. Cornell Cooperative Extension, North
Carolina State University Cooperative Extension Service, and
Purdue University Cooperative Extension provide similar
programs to grandparents facing parenting again.
A national program funded by the Brookdale Foundation Group
of New York City provides supportive services for programs
focusing on grandparents and other relatives who have assumed
the responsibility of surrogate parenting. The initiative calls
attention to state and local needs by supporting the
establishment of statewide networks of local organizations and
statewide task forces, relative support groups, and community-
based services to grandparents and other relatives raising
grandchildren. The University of Wisconsin-Extension and
Cornell University Extension Service received seed grants from
the Foundation during 1998 to allow Cooperative Extension
System personnel to expand their programming to address this
growing societal issue.
CSREES and the Cooperative Extension System launched
another national initiative, Healthy People * * * Healthy
Communities in June 1998. The goals of the initiative are to
(1) Educate and empower individuals and families to adopt
healthy behaviors and lifestyles, (2) Educate consumers to make
informed health and health care decisions, and (3) Build
community capacity to improve health. Target audiences include
older citizens.
Partnerships are being formed with the Centers for Disease
Control and private corporations to address life cycle
immunization education. Older citizens need to be able to make
informed decisions about vaccinations.
With enormous change taking place in the health care arena,
the land-grant university system will be able to help consumers
make informed decisions regarding health care choices. The
initiative will marshal the extension, teaching, and research
system and its stakeholders to address these and other health
care issues of interest to older Americans.
Through the Cooperative Extension System at Land-Grant
institutions, administrators and specialists in such fields as
aging/gerontology, housing, financial management, nutrition,
health, human development, family life, community development,
and the agricultural sciences; plus the county extension
educators serving 3,150 counties have designed, implemented,
and evaluated numerous programs in the field of aging/
gerontology. Below are highlights of these programs.
Brief description of accomplishments
GEORGIA
The University of Georgia Cooperative Extension Service
produces a quarterly newsletter entitled, ``Senior Sense
Putting Knowledge to Work for Older Georgians.'' The newsletter
is distributed to 2,700 persons and is also available on the
College of Family and Consumer Sciences web page, where it is
accessed and read worldwide. Topics covered in the newsletters
include health issues, financial management, and care giving
tips.
IDAHO
In Idaho, the rapid growth in the numbers of elderly
citizens has produced the need for more people trained with an
understanding of aging development and a wide variety of
approaches to serving the elderly. An Idaho extension/research
specialist joined forces with a teaching/research colleague to
develop an interdisciplinary minor in aging in the School of
Family and Consumer Sciences at the University of Idaho. A team
of professionals from academic programs in psychology,
sociology, architecture, family and consumer sciences,
communications, and a representative from the library developed
a proposal and submitted it to the Idaho Board of Education.
The program has been approved. A minor in Aging will be an
important career compliment to majors as the student develops
expertise in a subject matter support area like aging.
The University of Idaho Cooperative Extension Service (CES)
and vocational education staff identified a need for additional
trained home health aides by the year 2005. They discovered
that 890 people were employed as aides in 1994 but by the year
2005, 1244 would be needed to meet the demand. The CES and the
Idaho Department of Vocational Education collaborated to plan a
secondary and post-secondary program for Geriatric Home Care
Aides. They compiled a curriculum to be used to train home care
aides, piloted the program, established sites for student
clinical experience and internships, and established a system
for graduate placement. Upon completion of the program
including the internship, the student will be eligible to take
the examination for Certified Nurse Assistant certification. In
Idaho, these positions command approximately $8.00 per hour and
prepare people for a wide variety of career paths.
In October 1998, the University of Idaho Cooperative
Extension Service hosted their annual conference focused on
issues of aging and health. The conference provided
professional update and continuing education units for 175
agency personnel who provide health care and services for the
elderly.
MICHIGAN
Michigan State University Cooperative Extension Service is
in a partnership with Blue Cross and Blue Shield of Michigan,
Kirtland Community College, Michigan Rural Aging Institute,
Office of Services to the Aging, Michigan Department of
Community Health, and the Michigan Family Independence Agency
to provide caregiver training that will prepare caregivers to
improve the care provided to older persons. Annually 4,000
caregivers of older adults are trained on such topics as
financial and legal issues of older adults, dementia,
understanding difficult behaviors, working with the frail
elderly, and financial abuse of the elderly. The training is
provided statewide using distance learning technology.
Caregivers obtain certification for completion of the training.
MINNESOTA
A program for transferring non-titled property among family
members after a death was created by the University of
Minnesota Extension Service. ``Who Gets Grandma's Yellow Pie
Plate?'' is an estate planning process through which
individuals can plan to share with their family members their
possessions and record the meanings associated with the
property while they are living. This program has been widely
replicated throughout the country.
In preparation for the ``Minnesota Celebration of
Community'' effort during the year 2000, school children listen
to oral histories of elders; create songs, recitations, and art
based on the personal stories of their elders. The program
culminates in a community-wide celebration honoring older
citizens.
MISSOURI
The Center on Aging Without Walls is a unique way to bring
information on age-related issues to the University Outreach
and Extension network, to the older adults of the State of
Missouri, and the many caregivers who provide care for older
citizens. The Center is a web site made possible through a
partnership between the Center on Aging Studies at the
University of Missouri--Kansas City and the University of
Missouri Outreach and Extension. Care giving issues have been
addressed in this initial phase of the web site. Topics covered
include burdens and rewards, care giver resources, ethics,
health concerns, family relationships, and mental health. The
web address is .
``Building Bridges'' is a collaborative program which
provides opportunities for children and seniors to interact.
The program targets the frail and home-bound elderly. Through
the three components of the program--education, friendship, and
caring--children learn from and develop positive images of the
elderly and help older adults achieve a sense of fulfillment.
In consideration of the needs of the elderly and the children,
a variety of appropriate activities occur such as visits to
nursing homes, tutorial assistance for children, interviewing,
story telling, reading, and dancing.
NEW YORK
A Cornell University program that has young people and
senior citizens interacting in ongoing activities has become a
national model. A detailed handbook for group leaders who want
to replicate the program is available nationally. Geared for
children ages 9 to 13, but easily adaptable for other ages,
Project EASE--Exploring Aging through Shared Experiences--is
ideal for groups of scouts, 4-H groups, religious youth groups,
after-school programs and other youth organizations. It can
also be utilized in the classroom. The project is based on
current research on the effectiveness of intergenerational
programs to develop activities and projects that youth and
senior citizens can share for mutually satisfying, meaningful
and goal oriented interaction. Three years in development,
Project EASE has been field tested and evaluated by more than
70 4-H clubs in New York, involving about 600 participants. The
youth and seniors may plan a joint community service project in
which children and elders work together on an activity that the
community will value; shared group activity projects that both
groups enjoy but are not community service; and one-on-one
programs, in which each youth is paired with a senior in
activities such as arts and crafts, sharing oral histories,
grooming pets, playing board games, etc. This project is
supported in part with grants from the Charles Stewart Mott
Foundation, the Public Welfare Foundation, and the College of
Human Ecology at Cornell.
In another innovative program, Cornell University
researchers, Coperative Extension Service faculty, and State/
local volunteers, and community agencies are addressing housing
options for senior citizens. Twenty counties in New York have
provided multi-faceted educational programs about community-
based housing options for the elderly for both professionals
and the public. Professionals, housing and human service agency
staff, municipal officials, and residents have new capacity to
respond the population. As a result of this project, they are
knowledgeable about low-cost community-based housing options
such as shared housing, accessory apartments, and elder
cottages. As a result of Cornell's research and extension
outreach, state legislation was passed to provide capital
funding for the creation of these new types of housing units.
Municipal land-use and zoning regulations have been changed to
permit the development of this housing in approximately 25
communities. Technical assistance is provided to attorneys and
community planners about zoning and land-use regulations. There
are now 12 shared living residences in communities throughout
the State. A not-for-profit organization has received $375,000
from the State to develop and operate an elder cottage lease
program for low-income elderly.
NORTH CAROLINA
The North Carolina Aging with Gusto program has been
adopted in more than half of the housing needs of an increasing
older North Carolina's 100 counties. This program is believed
to be unique nationally because it focuses on the positive
aspects of aging in how to achieve optimum financial, physical,
and mental well-being in later years. Older adults learn how to
prepare for and cope with problems related to finances, legal
issues, health, care giving, housing and self-care. Recent
figures suggest that the program has reached more than 35,000
people directly.
North Carolina Cooperative Extension Service (CES) and the
North Carolina Division of Aging have collaborated to pilot a
new approach by distributing nutrition education materials with
the Meals on Wheels food deliveries. This is one way to reach
home-bound elderly that are especially difficult to reach and
who are at greater risk of malnutrition and chronic disease.
Sixteen different learn-at-home lessons have resulted in
positive changes in the stages of change for fruit and
vegetable consumption as evidenced in the pre- and post-test
from 177 participants in five counties.
To address another important issue for seniors, North
Carolina CES and the North Carolina State Attorney General's
Office worked together to educate older adults about consumer
scams. In one county, 785 seniors were reached with 80 percent
reporting they would be more cautious about telephone and mail
solicitations and 77 percent stated that the program motivated
them to change some of their consumer practices such as: avoid
sharing credit card information on the telephone, making
financial donations to known charities and organizations, and
checking on offers that are ``too good to be true.''
OREGON
Oregon State University Cooperative Extension Service (CES)
has a grant to study Behavioral Changes in Dementia Patients:
Relationships to Caregiver Well-Being. Currently data is being
collected on caregivers to Alzheimer's patients. The goal of
the research is to expand the understanding of later life care
giving to dementia patients and its consequences on caregivers'
mental and physical health. Extension curricula will be
developed as a result of this research.
Dissemination of research-based information is the hallmark
of the Cooperative Extension System. A network of professional
educators provide such information in community-based settings.
For example, Oregon State University is in a four university
consortium to provide geriatric education with a special
emphasis on reaching rural areas. A grant from the Geriatric
Education Center Training Grant, Department of Health and Human
Services, Public Health Services makes this program possible. A
special focus is on reaching rural health care professionals to
update and expand their knowledge of geriatric health issues.
Oregon CES has disseminated 13 health guidelines for consumers
relevant to older populations to 2,700 English and over 625
Spanish consumers. In addition, Extension sponsored four
teleconferences on a variety of women's health issues in later
life with satellite downlinks in 27 sites throughout the State.
PENNSYLVANIA
Pennsylvania State University Cooperative Extension Service
(CES) has a preventive health program for people over age 75
and their family caregivers. The program provides independent
living through lifestyle changes, nutrition, and regular
exercise. Developed in rural Pennsylvania in Tioga, Bradford,
Sullivan, and Susquehanna counties, this program reaches an
extremely high-risk population. Ninety percent of the
participants had annual household incomes below $20,000, and 84
percent had only a high school or less education. High
percentages had nutrition risk, low levels of physical
activity, and losses in daily living activities. This program
will be expanded statewide.
Pennsylvania CES has also provided a program entitled
``Medicare Managed Care: What Does It Mean For You?'' More than
190 senior citizens and health care professionals in Centre
County, Pennsylvania, participated. The six sessions were
organized by Penn State's College of Agricultural Sciences and
the Pennsylvania Office of Rural Health, in collaboration with
Centre County CES, American Association of Retired Persons,
Centre County Office of Aging Apprise Program, and the
Brookline Village.
In Allegheny County the Extension Service assisted
residents of Carnegie Towers public housing in Pittsburgh to
organize and take leadership for a fledgling community.
Originally built for low income elderly citizens, a
predominantly young population now occupies the project. Most
of the households are headed by single, low-income females.
Intergenerational conflicts existed between elderly residents
and children, partly because the housing area did not include
recreational facilities for youth. After Extension leader
training workshops were completed, residents organized and
elected a tenant council of eight adults and one youth. Since
organizing, the council has sponsored a Community Day
Celebration, supported by various fund raising activities. They
have established a computer room with computer training
classes, an outdoor play area, Extension educational programs
related to 4-H youth development and nutrition, and a program
highlighting guest speakers who provide useful and practical
information.
``Generation Celebration'' is designed to help students
develop communication skills and to foster positive attitudes
about older persons. This awareness program uses a variety of
activities including family history, shared recreation, and
visits to long-term care settings. In some communities, high
school youth have adapted the program to include networking
with the Area Agency on Aging to provide regular telephone
reassurance to a vulnerable older person and in some instances
developing communication skills that improve the functioning of
dementia patients and family members in institutional care
facilities.
SOUTH CAROLINA
Clemson University Cooperative Extension Service (CES)
specialist Katherine Carson has developed a program entitled,
Learning, Innovation, Networking, and Celebration (LINC)
nutrition program. LINC focuses on the elderly and preschool
children, as well as pregnant and parenting adolescents.
Changes in attitude, skills, knowledge, and behavior are
documented. LINC has reached 2,407 elderly South Carolinians.
LINC is a collaborative effort between the Clemson University
CES, the South Carolina Department of Social Services, and the
State Department of Health and Environmental Control Center for
Health Promotion. South Carolina Governor David Beasley has
recognized Carson for developing a nutrition program that
reaches senior citizens by presenting her with the Governor's
Health Promotion for Older South Carolinians Award. This
program will be expanded with the assistance of a $759,000
grant from USDA Food and Consumer Services. One phase of the
expansion will include a Nutrition Education and Resource
Center on the Internet for people who want information rapidly.
TEXAS
Project Y.E.S. promotes positive intergenerational
relationships between youth and seniors by training 4-H and
FHA-HERO youth to provide assisted-living services that enhance
independent lifestyles for the elderly in rural communities.
Youth provide housekeeping, personal services, lawn care, and
home/auto repair for the elderly. In return, the elder
recipients of the services share their time and talent with the
youth. Youth learn more about the aging process, communicating
among generations, and potential career options. The program
sponsor, the Texas Agricultural Extension Service has developed
a curriculum manual, a youth-service provider workbook, videos
and recognition materials to support this program.
WISCONSIN
University of Wisconsin-Extension has formed a statewide
network to facilitate, link, inform, and advocate for
intergenerational understanding and interdependence by making
the best use of the skills of persons of all ages.
ECONOMIC RESEARCH SERVICE (ERS)
The ERS analyzes data collected from the USDA's Continuing
Surveys of Food Intakes by Individuals (CSFII) to understand
food choices made by American elderly age 60 and above. The
American elderly population represents 18 percent of the
population and accounts for about 30 percent of all health care
expenditures. Improved diets could prevent a significant
proportion of the incidences of heart disease, stroke, cancer,
diabetes, and osteoporosis-related hip fractures in this
population. Therefore, a better understanding of food choice
and nutrient intake by the elderly can improve their health and
well-being and hence reduce both present and societal medical
outlays.
Brief description of accomplishments:
The following publications on the elderly have been
prepared by our staff in 1998:
Weimer, J. ``Factors Affecting Nutrient Intake of the
Elderly.'' ERS AER No. 769, Oct. 1998.
Lin, B.H. and E. Frazao. ``A Nutritional Quality of Foods
At and Away from Home.'' Food Review, Vol. 20: 33-40. May-Aug.
1997.
Barefield, E. ``Osteoporosis-Related Hip Fractures Cost $13
Billion to $18 Billion Yearly.'' Food Review, Vol. 19: 31-36.
January-April 1996.
FOOD AND NUTRITION SERVICE (FNS)
Title and purpose statement of each program or activity which affects
older Americans
The Food Stamp Program provides monthly benefits to help
low-income families and individuals purchase a more nutritious
diet. In fiscal year 1997, $20 billion in food stamps were
provided to a monthly average of 23 million persons.
Households with elderly members accounted for approximately
18 percent of the total food stamp caseload. However, since
these households were smaller on average and had relatively
higher net income, they received only 7 percent of all benefits
issued.
Brief description of accomplishments
FNS continues to work closely with the Social Security
Administration (SSA) in order to meet the legislative
objectives of simplified application processing for
Supplemental Security Income (SSI) households.
In response to recommendations for joint processing
improvements, FNS and SSA have stepped up efforts to ensure
that SSI applicants are counseled on their potential
eligibility to receive food stamps. Additionally, a joint
Supplemental Security Income/Food Stamp processing
demonstration--the South Carolina Combined Application Project
(SCCAP)--was begun in the fall of 1995. Approximately 22,000
SSI households in South Carolina receive food stamp benefits
through this project. An independent evaluation of SCCAP is
underway and is scheduled to be completed in 1999.
Title and purpose statement of each program or activity which affects
older Americans
The Commodity Supplemental Food Program provides
supplemental foods, in the form of commodities, and nutrition
education to infants and children up to age 6, pregnant,
postpartum or breastfeeding women, and the elderly (at least 60
years of age) who have low incomes and reside in approved
project areas.
Service to the elderly began in 1982 with pilot projects.
In 1985, legislation allowed the participation of older
Americans outside the pilot sites if available resources exceed
those needed to serve women, infants, and children. In fiscal
year 1997, approximately $45 million was spent on the elderly
component.
Brief description of accomplishments
About 61 percent of total program spending provides
supplemental food to approximately 243,000 elderly participants
a month. Older Americans are served by 20 of the 20 eligible
State agencies.
Title and purpose statement of each program or activity which affects
older Americans
The Food Distribution Program on Indian Reservations
(FDPIR) provides commodity packages to eligible households,
including households with elderly persons, living on or near
Indian reservations. Under this program, commodity assistance
is provided in lieu of food stamps.
Approximately $26 million of total costs went to households
with at least one elderly person. (This figure was estimated
using a 1990 study that found that approximately 39 percent of
FDPIR households had at least one elderly individual.)
Brief description of accomplishments
This program serves approximately 48,000 households with
elderly participants per month.
Title and purpose statement of each program or activity which affects
older Americans
The Child and Adult Care Food Program (CACFP) provides
Federal funds to initiate and maintain nonprofit food service
for children, the elderly, or impaired adults in nonresidential
institutions which provide child or adult care as well as
children in emergency shelters. The program enables child and
adult care institutions to integrate a nutritious food service
with organized care services.
The adult day care component permits adult day care centers
to receive reimbursement of meals and supplements served to
functionally impaired adults and to persons 60 years or older.
An adult day care center is any public or private nonprofit
organization or any proprietary Title XIX or Title XX center
licensed or approved by Federal, State, or local authorities to
provide nonresidential adult day care services to functionally
impaired adults and persons 60 years or older. In fiscal year
1997, $29 million was spent on the adult day care component.
Brief discussion of accomplishments
The adult day care component of CACFP served approximately
26 million meals and supplements to over 50,000 participants a
day in fiscal year 1997.
In 1993, the National Study of the Adult Component of CACFP
was completed. Some of the major findings of the study include:
overall, about 31 percent of all adult day care centers
participate in CACFP; about 43 percent of centers eligible for
the program participate. CACFP adult day care clients have low
incomes; 84 percent have incomes of less than 130 percent of
poverty. Many participants consume more than one reimbursable
meal daily; CACFP meals contribute just under 50 percent of a
typical participant's total daily intake of most nutrients.
Title and purpose statement of each program or activity which affects
older Americans
The Emergency Food Assistance Program (TEFAP) provides
nutrition assistance in the form of commodities to emergency
feeding organizations for distribution to low-income households
for household consumption or for use in soup kitchens.
Approximately $17 million in commodities were distributed
to households including an elderly person. (This figure is
estimated using a 1986 survey indicating that about 38 percent
of TEFAP households have members 60 years of age or older.)
Brief description of accomplishments
About 38 percent of the households receiving commodities
under this program had at least one elderly individual.
Title and purpose statement of each program or activity which affects
older Americans
The Nutrition Program for the Elderly provides cash and
commodities to States for distribution to local organizations
that prepare meals served to elderly persons in congregate
settings or delivered to their homes. The program addresses
dietary inadequacy and social isolation among older
individuals. USDA currently supplements the Department of
Health and Human Services' Administration on Aging with
approximately $145 million worth of cash and commodities.
Brief description of accomplishments
In fiscal year 1997, over 247 million meals were reimbursed
at a cost of almost $150 million. On a average day,
approximately 932,000 meals were provided.
FOOD SAFETY AND INSPECTION SERVICE (FSIS)
Title and purpose statement of each program or activity which affects
older Americans
FSIS provides older Americans with information about safe
food handling through consumer education campaigns. Older
Americans are an important audience for the agency's consumer
education program because they face increased risks from
foodborne illness. They are more likely to become ill from
pathogens in food and, once ill, the health consequences can be
more serious. The elderly, with more than 35 million people in
their ranks, are the largest group facing increased risks from
foodborne disease.
Brief description of accomplishments
FSIS has developed several publications designed to address
the special needs and interests of older Americans. ``Seniors
Need Wisdom on Food Safety'' is a feature issued from the USDA
Meat and Poultry Hotline and distributed to callers to the
Hotline. The publication explains why older Americans face
special risks from foodborne illness and how to handle food
safely. Another publication, a large-print chart, provides
information seniors frequently request about how long food can
safely be stored in the refrigerator.
Finally, the FSIS food safety education staff is developing
a video called ``Healthy Choices, Healthy Lives: Food Safety
for Seniors.'' When completed, this video will be distributed
to 800 local area offices on aging and be used at senior
centers throughout the country. The video project has been
developed with cooperation and input from the Administration on
Aging, the American Association of Retired Persons and the
National Institutes on Aging.
MARKETING AND REGULATORY PROGRAMS
The Agricultural Marketing Service purchases commodities
for several federal feeding programs, with the school lunch
program being by far the largest. However, a very small amount
of our purchases goes to the Nutrition Program for the Elderly,
which is administered by the Department of Health and Human
Services. The Nutrition Program for the Elderly provides cash
or commodity support to social centers for the elderly.
ITEM 2--DEPARTMENT OF COMMERCE
----------
UPDATES TO THE DEVELOPMENTS IN AGING REPORT FOR 1997 AND 1998
This report provides short descriptions and listings of
products that contain demographic and socioeconomic information
on the elderly population, 65 years of age and older, here and
abroad. All of the items included in this report were released
by the Census Bureau during calendar years 1997 and 1998.
The items listed are available to the public in a variety
of formats including print, electronic data bases,
microcomputer diskettes, and CD-ROM. Many of these products can
be found on the Internet at the Census Bureau's Web site at:
.
1. Population, Housing, and International Reports.--Three
of the Census Bureau's major report series (Current Population
Reports, Current Housing Reports, and International Population
Reports) are important sources of demographic information on a
wide variety of population-related topics. This includes
information on the United States' elderly population, ranging
from their numbers in the total population to socioeconomic
characteristics, such as income, health insurance coverage,
need for assistance with activities of daily living, and
housing situation. Additionally, data on the elderly around the
world also are found in this series of reports.
Much of the data used in Current Population Reports are
derived from the Current Population Survey (CPS) and the Survey
of Income and Program Participation (SIPP). The Current Housing
Report series presents housing data primarily from the American
Housing Survey, a biennial national survey of approximately
55,000 housing units. The International Population Report
series includes demographic and socioeconomic data reported by
various national statistical offices, such as the National
Institute on Aging, agencies of the United Nations, and the
Organization for Economic Cooperation and Development.
Additionally, the Census Bureau's population projection
program and Special Studies Report series also contain
information about the future estimated size of the elderly
population and information pertaining to statistical methods,
concepts, and specialized data.
2. Decennial Products.--A large number of printed reports,
computer tape files, CD-ROMs, and summary tape files are
produced after each decennial census. Included in these is
information and data on the numbers and characteristics of
persons 65 years of age and over.
3. Data Base on Aging/National Institute on Aging
Products.--The data base provides a summary of analytical
studies and other ongoing international aging projects. Reports
are based on compilations of data obtained from individual
country statistical offices, various international
organizations, and estimates and projections prepared at the
Census Bureau. This work is funded by the National Institute on
Aging.
4. Federal Interagency Forum on Aging-Related Statistics
Summary.--The Forum, for which the Census Bureau is one of the
lead agencies, encourages cooperation, analysis, and
dissemination of data pertaining to the older population. A
summary of the activities of the Forum lists a number of aging-
related statistics.
5. Other Products.--In addition to the major products
listed separately, we include a list of other data products
that contain demographic and socioeconomic information on the
elderly population.
1. POPULATION, HOUSING, AND INTERNATIONAL REPORTS
Population
Report Number
Series P-20 (Population Characteristics):
Regularly recurring reports in this series contain data from
the Current Population Survey. Topics include geographical
mobility, fertility, school enrollment, educational
attainment, marital status and living arrangements,
households and families, the Black and Asian and Pacific
Islander populations, persons of Hispanic origin, voter
registration and participation, and various other topics for
the general population, as well as the elderly population 65
years and older.
Educational Attainment in the United States: March 1997....... 505
Marital Status and Living Arrangements: March 1997............ 506
The Foreign-Born Population: 1997............................. 507
The Black Population in the United States: March 1997......... 508
Household and Family Characteristics: March 1997.............. 509
Geographical Mobility: March 1996 to March 1997............... 510
The Hispanic Population in the United States: March 1997...... 511
The Asian and Pacific Islander Population in the United
States: March 1997.......................................... 512
Series P-23 (Special Studies):
Information pertaining to methods, concepts, or specialized
data is furnished in these publications. Reports in this
series contain data on mobility rates, home ownership rates,
and the Hispanic population for both the general and older
populations.
How We're Changing: Demographic State of the Nation: 1997..... 193
Population Profile of the United States: 1997................. 194
Series PPL (Population Paper Listings):
This series of reports contains estimates of population and
projections of the population by age, sex, race, and origin.
Other topics appear as well some of which address issues
related to aging.
Who is Minding Our Preschoolers: Fall 1994.................... 81
U.S. Population Estimates by Age, Sex, Race, and Hispanic
origin: 1990 to 1997........................................ 91
The Foreign-Born Population: 1997............................. 92
Educational Attainment in the United States: March 1998....... 99
Marital Status and Living Arrangements: March 1998............ 100
Household and Family Characteristics: March 1998.............. 101
The Hispanic Population in the United States: 1998............ 105
The Black Population in the United States: March 1997......... 106
The Asian and Pacific Islander Population: March 1997......... 108
Estimates of the Population of States by Age and Sex: 1990 and
1997........................................................ 109
Estimates of the Population of Counties by Broad Age Group:
July 1, 1990 to July 1, 1997................................ 112
Technical Working Papers Series:
This series contains papers of a technical nature on various
topics, which have been written by staff of the Population
Division of the Census Bureau. Evaluation of population
projections, estimates and 1990 Census results, examination
of immigration issues, race and ethnic considerations, and
fertility patterns are some of those topics.
``Trends in Marital Status of U.S. Women at First Birth: 1930
to 1994.'' Amara Bachu...................................... 20
``How Well Does the Current Population Survey Measure the
Foreign-Born Population in the United States'' Diane
Schmidley and J. Gregory Robinson........................... 22
``Timing of First Births: 1930-34, 1990-94.'' Amara Bachu..... 25
``Co-Resident Grandparents and Grandchildren: Grandparent
Maintained Households'' Lynne Casper and Ken Bryson......... 26
Series SB/CENBR (Statistical Briefs):
These are succinct reports that are issued occasionally and
provide timely data on specific issues of public policy.
Presented in narrative style with charts, the reports
summarize data from economic and demographic censuses and
surveys. In December 1996, the Statistical Brief series
format was revised and became known as Census Briefs.
Disabilities Affect One-Fifth of All Americans................ 97-5
Series PE (Population Electronic):
This series comprises microcomputer diskettes or computer
tapes covering a variety of topics in the population field.
The majority of the information on diskette is available in
printed format.
The Foreign-Born Population: March 1996....................... 54
Estimates of Population for Counties and Components of Change:
1990 to 1996................................................ 55
Population of States by Single Years of Age and Sex for
States: 1990 to 1996........................................ 56
Estimates of the Population of States by Age, Sex, Race, and
Hispanic Origin: 1990 to 1996............................... 57
Estimates of the Population of Counties by Age, Sex, Race, and
Hispanic Origin: 1990-1996.................................. 58
Estimates of Population of States, Counties, Places, and Minor
Civil Divisions: Annual Time Series, July 1, 1991 to July 1,
1996........................................................ 59
Estimates of the Population of Metropolitan Areas: April 1,
1990 to July 1, 1996........................................ 60
U.S. Population Estimates by Age, Sex, Race, and Hispanic
Origin: 1990 to 1997........................................ 61
Estimates of Population for Counties and Components of
Population Change: Annual Time Series, July 1, 1990 to July
1, 1997..................................................... 62
Estimates of the Population of Counties by Age, Sex, Race, and
Hispanic Origin: 1990-1997.................................. 64
Estimates of the Population of States by Age, Sex, Race, and
Hispanic Origin: 1990-1997.................................. 65
Series P-60 (Consumer Income):
This series of reports presents data on the income, poverty
and health insurance status of households, families, and
persons in the United States.
Money Income in the United States: 1996....................... 197
Poverty in the United States: 1996............................ 198
Health Insurance Coverage: 1996............................... 199
Money Income in the United States: 1997....................... 200
Poverty in the United States: 1997............................ 201
Health Insurance Coverage: 1997............................... 202
Measuring 50 Years of Economic Change-Using the March Current
Population Survey........................................... 203
Series P-70 (Household Economic Studies):
These data are from the Survey of Income and Program
Participation (SIPP), a national survey conducted by the
Census Bureau. Its principal purpose is to provide better
estimates of the economic situation of families and
individuals. These reports include data on the elderly
population 65 years and older.
Who's Minding Our Preschoolers? Fall 1994 Update.............. 62
Poverty, 1993-1994: Trap Door? Revolving Door? Or Both?....... 63
Health Insurance, 1993 to 1995. Who Loses Coverage and for How
Long........................................................ 64
Income, 1993 to 1994, Moving Up and Down the Income Ladder.... 65
Seasonality of Moves and Duration of Residence................ 66
Housing
These reports present data from the American Housing Survey.
Some characteristics shown in these reports include
socioeconomic status of household, physical condition of
the housing unit, and affordability of housing in relation
to income.
Survey of Income and Program Participation, Who Can Afford to
Buy a House in 1993?........................................ 97-1
Current Population Survey, Moving to America-Moving to Home
Ownership................................................... 97-2
Series H-150 (Housing Vacancy):
This book presents data on apartments; single-family homes;
mobile homes; vacant housing units; age, sex, and race of
householders; income; housing and neighborhood quality;
housing costs; equipment and fuels; and size of housing
units. The book also presents data on homeowner's repairs
and mortgages, rent control, rent subsidies, previous unit
of recent mover, and reasons for moving. A wall chart
accompanies this product.
American Housing Survey for the United States in 1995......... 95RV
Series H-170 (American Housing Survey, Selected Metro Areas):
This book presents data for selected metropolitan statistical
areas for the same characteristics shown above in Series H-
150. Eleven metro areas per year are produced on a 4-year
rotation for a total of 44 metro areas.
American Housing Survey for Selected Metropolitan Statistical
Areas in 1994, 1995 and 1996................................ 94-95
International
Series P-95 (International Population Reports):
The reports in this series contain demographic and
socioeconomic data on the world's older population as
estimated or projected by the Census Bureau or published by
various national statistical offices, agencies of the United
Nations, and/or other international agencies such as the
Organization for Economic Cooperation and Development. In
1998, the Census Bureau's International Programs Center
began work on an update of its 1993 report entitled An Aging
World II. This report will examine demographic and
socioeconomic characteristics of the world's elderly and
will highlight projected trends into the 21st century.
Graphical and tabular presentations of comparable national
statistics are included. This work is supported by the
Office of the Demography on Aging, National Institute on
Aging.
An Aging World 1999 Forthcoming Summer 1999
Series B (International Briefs):
This series of short reports (4-8 pp.) covers a variety of
topics, some of which relate to aging. The reports may
present basic demographic and socioeconomic data on a single
country or take a cross national view of a particular topic.
Population Trends: India 1997................................. 97-1
Aging Trends: South Africa 1997............................... 97-2
Gender and Aging: Demographic Dimensions 1997................. 97-3
Population Trends: Bolivia 1998............................... 98-1
Gender and Aging: Mortality and Health 1998................... 98-2
Gender and Aging: Caregiving 1998............................. 98-3
Series WP (World Profiles):
This series provides comprehensive demographic information for
all countries and regions of the world. The information is
maintained in a data base and is regularly updated. In
addition, each edition of the series focuses on a specific
topic of interest related to the world's population.
World Population Profile: 1998. Forthcoming January 1999
Series WID (Women of the World):
This series contains information on the world's women,
including elderly women. Demographic, educational,
employment, and political participation data are included.
Women's Education in India 1998............................... 98-1
2. DECENNIAL PRODUCTS
No new products were released in this area in 1997 or 1998.
A report on the population aged 100 and over in 1990, entitled
Centenarians in the United States, is forthcoming.
3. DATA BASE ON AGING/NATIONAL INSTITUTE ON AGING PRODUCTS
The following reports, articles, wall charts, and book
chapters are based on information contained in the
International Data Base on Aging and other related holdings of
the International Programs Center, Population Division, Bureau
of the Census. This work is carried out with the support of the
National Institute on Aging and is intended to highlight the
present and future worldwide dimensions of aging and portray
the diversity among nations.
``Gender Stereotypes: Data Needs for Aging Research.''
Victoria Velkoff and Kevin Kinsella. Aging International,
forthcoming, 1999.
Aging in the Americas into the XXI Century. [Wall chart]
U.S. Bureau of the Census, Pan American Health Organization and
U.S. National Institute on Aging, 1998.
Pension Management and Reform in Asia: An Overview. Loraine
A. West and Kevin Kinsella. Executive Insight No. 11. National
Bureau of Asian Research. May 1998.
``Aging Populations Signal a Demographic Sea Change.''
Kevin Kinsella and Victoria Velkoff. Common Health. Spring
1998.
Aging in the United States--Past, Present, and Future.
[Wall chart] U.S. Bureau of the Census, 1997.
``The Demography of An Aging World.'' Kevin Kinsella. In
The Cultural Context of Aging, Jay Sokolovsky, ed. Greenwood
Press. 1997.
4. THE FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS SUMMARY
The Census Bureau is one of the convening agencies in the
Federal Interagency Forum on Aging-Related Statistics. The
Forum, begun in the mid-1980s, was the first-of-its-kind effort
to coordinate data and efforts of different government
agencies. The Forum currently is being managed by staff of the
National Center for Health Statistics, with the support of the
National Institute on Aging.
The Forum encourages cooperation among federal agencies in
the development, collection, analysis, and dissemination of
data pertaining to the older population. Through coordinated
approaches, the Forum extends the use of limited resources
among agencies through joint problem-solving, identification of
data gaps, and improvement of statistical information bases on
the older population that are used to set project priorities of
individual agencies.
The Forum goals include widening access to information on
the older population, promoting communication between data
producers and public policymakers, coordinating the development
and use of statistical data bases among relevant federal
agencies, identifying information gaps/data inconsistencies,
and evaluating data quality. The work of the Forum facilitates
the exchange of information about needs at the time new data
are being developed or changes are being made in existing data
systems. It also promotes communication between data producers
and policymakers.
As part of the Forum's work to improve access to data on
the older population, the Census Bureau published in 1997 a
report entitled Data Base News in Aging, which includes
developments in data bases of interest to researchers and
others in the field of aging. Much of the information comes
from government-sponsored surveys and products. All federal
agencies are invited to contribute to the report, which is
produced in hard copy and is available on the Census Bureau's
Internet site. A new edition is planned for release in 1999.
5. OTHER PRODUCTS
American Housing Survey
Computer data tapes and CD-ROM are available for the 1997
survey efforts. The survey is designed to provide information
on the housing situation in the United States. Information is
available by age.
CPS and SIPP Surveys
Data for both surveys are available in electronic media.
Statistical Abstract of the United States: 1997 and 1998
As the National Data Book, these annually released products
contain an enormous collection of statistics on social and
economic conditions in the United States. Selected
international data also are included. The abstract appears in
both print and CD-ROM versions.
International Data Base
The International Data Base (IDB) is a computerized data
bank containing statistical tables of demographic and
socioeconomic data for all countries of the world. Most
demographic information comes from country-specific estimates
and projections made by the Census Bureau's International
Programs Center. Country-specific data on social and economic
characteristics are obtained from censuses and surveys or from
administrative records. Country files are regularly updated as
new information becomes available. Selected information from
the IDB is highlighted in the Census Bureau's various
international reports and publications mentioned previously.
ITEM 3--DEPARTMENT OF DEFENSE
----------
The Department of Defense has several ongoing initiatives
in support of older Americans. They are detailed below.
Eldercare Support
The Department's Family Centers reports that there is an
increasing demand for information about eldercare. The Centers
providing information workshops on eldercare issues describe
them as well-attended and very useful. In addition to workshops
and seminars on eldercare, the Centers access the national 1-
800 eldercare locator to assist family members with eldercare
support services in other parts of the country. The Centers
also have a number of useful pamphlets and handouts on
eldercare that they provide to military family members seeking
assistance for a particular eldercare issue.
The Family Centers often work with the local Retired
Affairs Offices across the country in sponsoring Retired
Affairs Seminars that draw thousands of military retirees and
their families. For these seminars, the staff brings in experts
to discuss eldercare topics such as long-term care insurance,
respite care, medical information, Social Security benefits,
and eldercare legal issues. These seminars are an important
vehicle to update the military retiree community on current
eldercare issues.
The Department of Defense recognizes that eldercare is a
growing issue for military personnel and their family members
and will continue to be responsive to the needs of the active
duty and retired community in this regard.
Health Care
The Department of Defense has implemented TRICARE, a
regionally managed care program for members of the uniformed
services and their families and survivors, and retired members
and their families.
TRICARE gives beneficiaries three choices for their health
care delivery: TRICARE PRIME, TRICARE Extra, and TRICARE
Standard. All active duty members will be enrolled in TRICARE
Prime. Those CHAMPUS eligible beneficiaries whom elect not to
enroll in TRICARE Prime and Medicare-eligible DoD beneficiaries
will remain eligible for care in military medical facilities on
a space-available basis.
TRICARE Prime is a voluntary enrollment option that offers
patients the advantage of managed health care, such as primary
care management, and assistance in making specialty
appointment. The PRIME option offers the coverage of CHAMPUS
plus additional preventive and primary care services. Retirees
who are eligible for CHAMPUS, i.e., those retirees under age
65, may enroll in PRIME and are charged an enrollment fee.
Enrollees in TRICARE Prime obtain most of their care within the
integrated military and civilian network of TRICARE providers.
TRICARE Extra allows CHAMPUS-eligible beneficiaries to
receive an out-of-pocket discount when using preferred network
providers. CHAMPUS beneficiaries who do not enroll in TRICARE
Extra may participate in Extra on a case-by-case basis just by
using network providers.
TRICARE Standard: This option is the same as the standard
CHAMPUS program.
Under current law, military retirees and their families up
to age 65 are eligible for CHAMPUS. Military retirees and their
dependents over the age of 65 are not covered by CHAMPUS, but
are eligible for care in military treatment facilities on a
``space available'' basis. Military beneficiaries over the age
of 65 have traditionally relied on a combination of ``space
available'' care at military treatment facilities, Medicare
coverage; and other benefits gained through non-military
employment. With the post-Cold War drawdown in the military and
the growing number of retired beneficiaries, space available
care has been shrinking. The Department of Defense is seeking
ways to enhance its services to its over-65 beneficiaries.
Specifically, the Department is conducting demonstration
programs to test alternatives to expand health care coverage to
Medicare-eligible beneficiaries. These demonstrations include a
program offering ``TRICARE Senior Prime'' at six demonstration
sites. Under this program, the Department enrolls military
Medicare-eligible beneficiaries and receives capitated payments
from the Medicare TRUST Fund. The program operates similar to a
Medicare at-risk health maintenance organization, through which
enrollees in TRICARE Senior Prime agree to receive all their
health care from designated primary care managers at the
military treatment facilities. The TRICARE Senior Prime
enrollees receive all their Medicare-covered services through
the MTF and civilian provider network, and also receive
benefits such as prescription drugs. This demonstration runs
for three years, and the Department of Defense will report to
the Congress on the results of the test program. The purpose of
the program is to leverage Medicare dollars flowing into the
military treatment facilities to expand access to Medicare-
eligible retirees.
The Department is also conducting a demonstration program
offering Medicare-eligible retirees enrollment in the Federal
Employees Health Benefit Program, a program offering TRICARE
benefits as a ``wraparound'' benefit to supplement Medicare
coverage, and a pilot program to expand the national mail order
pharmacy benefit to military retirees over the age of 65.
ITEM 4--DEPARTMENT OF EDUCATION
----------
Enforcement of the Age Discrimination Act of 1975
Calendar Years 1997-1998
i. status of the department of education's implementing regulation
The Department of Education's final regulation implementing
the Age Discrimination Act of 1975 was published on July 27,
1993. The effective date of implementation was August 26, 1993.
The Department's regulation prohibiting age discrimination
applies to all elementary and secondary schools, colleges and
universities, public libraries, and vocational rehabilitation
services. It covers age discrimination at these institutions
except age discrimination in employment.
The regulation describes the standards for determining age
discrimination; the responsibilities of recipients; and
procedures for enforcing the statute and regulation.
ii. age discrimination act implementation
The Department of Education's (ED) Office for Civil Rights
(OCR) is responsible for enforcement of the Age Discrimination
Act of 1975 (the Age Act), as it relates to discrimination on
the basis of age in federally funded education programs or
activities. The Age Act applies to discrimination at all age
levels. The Age Act contains certain exceptions that permit,
under limited circumstances, continued use of age distinctions
or factors other than age that may have a disproportionate
effect on the basis of age.
The Age Act excludes from its coverage most employment
practices, except in federally funded public service employment
programs under the Workforce Investment Act of 1998 ( formerly
the Job Training Partnership Act). The Equal Employment
Opportunity Commission (EEOC) has jurisdiction under the Age
Discrimination in Employment Act of 1967 to investigate
complaints of employment discrimination on the basis of age.
OCR generally refers employment complaints alleging age
discrimination to the appropriate EEOC regional office.
However, the EEOC does not have jurisdiction over cases
alleging age discrimination against persons under 40 years of
age. Rather than referring such a case to the EEOC, OCR closes
the complaint and informs the complainant that neither OCR nor
the EEOC has jurisdiction.
The Department of Health and Human Services (HHS) published
a general government-wide regulation on age discrimination.
Each agency that provides Federal financial assistance must
publish a final agency-specific regulation. On July 27, 1993,
ED published in the Federal Register its final regulation
implementing the Age Act.
Under ED's final regulation, OCR forwards complaints
alleging age discrimination to the Federal Mediation and
Conciliation Service (FMCS) for attempted resolution through
mediation. FMCS has 60 days after a complaint is filed with OCR
in which to mediate the age-only complaints or the age portion
of multiple-based complaints. ED's regulation provides that
mediation ends if: (1) 60 days elapse from the time the
complaint is received; (2) prior to the end of the 60-day
period, an agreement is reached; or (3) prior to the end of the
60-day period, the mediator determines that agreement cannot be
reached.
If FMCS is successful in mediating an age-only complaint or
the age portion of a multiple-based complaint within 60 days,
OCR closes the case or the age portion of the complaint. If
mediation is unsuccessful, the mediator returns the unresolved
complaint to ED for further case processing.
OCR helps its working relationship with FMCS by designating
enforcement office contact persons who coordinate directly with
FMCS. OCR also accepts verbal or facsimile referrals from FMCS
after unsuccessful attempts at mediation, and may grant FMCS
extensions of up to 10 days beyond the 60 day mediation period
on a case-by-case basis when mediated agreements appear to be
forthcoming.
The other statutes which OCR enforces are Title VI of the
Civil Rights Act of 1964, which prohibits discrimination on the
basis of race, color, and national origin; Title IX of the
Education Amendments of 1972, which prohibits discrimination on
the basis of sex; and Section 504 of the Rehabilitation Act of
1973 and Title II of the Americans with Disabilities Act of
1990, which prohibit discrimination on the basis of disability.
iii. complaints
(a) Receipts
OCR received 391 age complaints in Calendar Years 1997-
1998. Of these, 124 were age-only complaints and 267 were
multiple bases complaints. As shown on Table 1, 270 of the 391
receipts were processed in OCR and 121 were referred to other
Federal agencies for processing. The most frequently cited
issues in complaint receipts involving students were
``harassment,'' ``retaliation,'' ``student rights,''
``selection for enrollment,'' ``discipline,'' ``academic
evaluation/grading,'' and ``admission to education program.''
The most frequently cited issues in complaint receipts
involving employees were ``demotion/dismissal/disciplinary
action'' and ``retaliation.''
TABLE 1.--CALENDAR YEARS 1997-1998 AGE-BASED COMPLAINT RECEIPTS
Processed by OCR........................................... 270
Referred to FMCS........................................... 59
Referred to EEOC........................................... 54
Referred to Other Federal Agencies......................... 8
------------
Total Receipts....................................... 391
(b) Resolutions
During Calendar Years 1997-1998, OCR resolved 402 age-based
complaints, including 127 age-only complaints and 275 multiple-
based age complaints. The resolution of the complaints are
shown in Table 2.
TABLE 2.--CALENDAR YEARS 1997-1998 AGE-BASED COMPLAINT RESOLUTIONS
Inappropriate for OCR Action............................... 285
OCR Facilitated Change..................................... 33
No Changed Required........................................ 84
------------
Total Resolutions.................................... 402
Inappropriate for OCR Action
Of the 402 complaint resolutions, 285 were resolved because
they were ``Inappropriate for OCR Action.'' These would include
a resolution achieved by (1) referral of a complaint to another
federal agency; (2) lack of jurisdiction over recipient or
allegation contained in a complaint; (3) complaint was not
filed in a timely manner; (4) complaint did not contain
sufficient information necessary to proceed; (5) complaint
contained similar allegations repeatedly determined by OCR to
be factually or legally insubstantial or were addressed in a
recently closed OCR complaint or compliance review; (6) subject
of a complaint was foreclosed by previous decisions by federal
courts, Secretary of Education, Civil Rights Reviewing
Authority, or OCR; (7) there was pending litigation raising the
same allegations contained in a complaint; (8) allegations were
being investigated by another federal or state agency or
through a recipient's internal grievance procedures; (9) OCR
treated the complaint as a compliance review; (10)
allegation(s) was moot and there were no class implications;
(11) complaint could not be investigated because of death of
the complainant or injured party or their refusal to cooperate;
and (12) complaint was investigated by another agency and the
resolution met OCR standards.
OCR Facilitated Change
There were 33 complaints resolved because ``OCR Facilitated
Change.'' These would include a resolution achieved by (1) a
recipient resolving the allegations contained in the complaint;
(2) OCR facilitating resolution between the recipient and
complainant through Resolution between the Parties; (3) OCR
negotiating a corrective agreement resolving a complainant's
allegations; and (4) settlement achieved after OCR issued a
letter of findings.
No Change Required
In 84 complaints, there was ``No Change Required.'' These
would include a resolution achieved by (1) complainant
withdrawing his or her complaint without benefit to the
complainant; (2) OCR determining insufficient factual basis in
support of complainant's allegations; (3) OCR determining
insufficient evidence to support a finding of a violation; and
(4) OCR issuing a no violation letter of findings.
Postsecondary Education
The Office of Postsecondary Education administers programs
designed to encourage participation in higher education by
providing support services and financial assistance to
students.
In fiscal year 1998, $46 billion was made available to an
estimated 8.2 million students through the student financial
assistance programs authorized by Title IV of the Higher
Education Act of 1965, as amended. There are no age
restrictions for participation in the Title IV programs. An
estimated 6.1 percent, or nearly 500,000 recipients, were over
age 40.
The Federal TRIO programs fund postsecondary education
outreach and student support services that encourage
individuals from disadvantaged backgrounds to enter and
complete postsecondary education. Because age is not an
eligibility criterion under most of these programs, data on the
age of participants are not available.
In addition to these programs, the Fund for the Improvement
of Postsecondary Education supports innovative projects,
including some designed to meet the needs of older Americans.
In fiscal year 1998, FIPSE funded a program at the University
of Findlay in Findlay, OH to develop an intergenerational,
cross-disciplinary, two-year degree program to train students
to work in multi-generational care settings.
Because jobs in today's workplace require an increasingly
higher level of knowledge and skills, it is essential that all
Americans have the opportunity for further education. The
Administration was successful in obtaining an authorization for
the Learning Anytime Anywhere Partnership program in the Higher
Education Amendments of 1998 that has great promise for
assisting working Americans gain the knowledge and skills they
need to remain competitive through lifelong learning.
The Learning Anytime Anywhere Partnerships (LAAP) program
authorizes a new grant competition to promote student access to
high quality technology-mediated learning opportunities that
are not limited by the constraints of time and place. For
fiscal year 1999, the Congress has appropriated $10 million to
fund partnerships among colleges, industry, community
organizations, and others, whose projects will have a national
or regional impact and will encourage innovative solutions to
the biggest challenges facing technology-mediated learning. The
LAAP program will expand access to all learners who seek
undergraduate education, career-oriented lifelong learning, or
who can benefit from the removal of time and place constraints.
Adult Education
As America prepares for the 21st Century and a tremendous
increase in the aging population, greater emphases have been
placed on addressing issues that involve literacy skills for
adults, 60 years old and older. A report from the 1990 Census
data shows that, of the 41,399,000 adults 60 years of age and
over in the United States, 8,900,000 have had 8 years of
schooling or less.
The U.S. Department of Education is authorized under the
Adult Education Act (AEA), Public Law 100-297, as amended by
the National Literacy Act of 1991 (P.L. 102-73), to provide
funds to the States and outlying areas for educational programs
and related support services benefiting all segments of the
eligible adult population. The Division of Adult Education and
Literacy (DAEL), in the Office of Vocational and Adult
Education (OVAE), administers the Adult Education Act. The
State-administered Basic Grant Program is the central program
established by the AEA and is the major source of Federal
support for basic skills programs. Basic Grants to States are
allocated by a formula based on the number of adults, over age
16, who have not completed high school in each State. States
distribute funds to local providers through a competitive
process based upon State-established funding criteria. Eligible
providers of basic skills and literacy programs include: local
educational agencies, community based organizations,
correctional education agencies, postsecondary educational
institutions, public or private nonprofit agencies,
institutions or organizations which are part of a consortium
that includes a public or private agency, organization or
institution. This program will:
Enable adults to acquire the basic educational
skills necessary for literate functioning;
Provide sufficient basic education to enable
these adults to benefit from job training and
retraining and to obtain productive employment; and
Enable adults to continue their education to
at least high school completion.
In addition, amendments to the AEA State-administered Basic
Grant Program include, in part:
A requirement for States to develop a system
of indicators of program quality to be used to judge
the quality of State and local programs;
A requirement in allocating Federal funds to
local programs, that each State consider: past program
effectiveness (especially with respect to recruitment,
retention and learning gains of program participants),
the degree of coordination with other community
literacy and social services, and the commitment to
serving those most in needs of literacy services;
A requirement that each State Educational
agency receiving financial assistance under this
program provide assurance that local educational
agencies, public or private nonprofit agencies,
community-based organization, correctional education
agencies, postsecondary education institutions,
institutions which serve educationally disadvantaged
adults and any other institution that has the ability
to provide literacy services to adults and families
will be provided direct and equitable access to all
Federal funds provided under this program; and
A requirement that States evaluate 20 percent
of grant recipients each year.
In program year 1996-1997, over 4 million adult learners
were served through the AEA program nationwide. Of these
learners, approximately 209,486 were 60 years of age or older.
Many of the emerging workforce participants, including a large
number of older adults and nonnative speakers of English, lack
the basic literacy skills necessary to meet the increased
demands of rapid change and new technology. Therefore,
employers are revisiting their workforce strategies in training
and retraining to meet the demanding needs of older workers.
The adult education program addresses the needs of older
adults by emphasizing functional competency and grade level
progression, from the lowest literacy level, to providing
English as a second language instruction, through attaining the
General Education Developmental Certificate. States operate
special projects to expand programs and services for older
adults through individualized instruction, use of print and
audio-visual media, home-based instruction, and curricula
relating basic educational skills to coping with daily problems
in maintaining health, managing money, using community
resources, understanding government, and participating in civic
activities.
Equally significant is the expanding delivery system,
increased public awareness, as well as clearinghouses and
satellite centers designed to overcome barriers to
participation. Where needed, supportive services such as
transportation are provided as are outreach activities adapting
programs to the life situations and experiences of older
persons. Individual learning preferences are recognized and
assisted through the provision of information, guidance and
study materials. To reach more people in the targeted age
range, adult education programs often operate in conjunction
with senior citizen centers, nutrition programs, nursing homes,
and retirement and day care centers.
Cooperation and collaboration among organizations,
institutions and community groups are strongly encouraged at
the national, State and local levels to meet the demanding
needs of older adults.
Note: After 30 years, the Adult Education Act has been
repealed and the Federal investment in adult education and
literacy has been authorized as part of the new comprehensive
Workforce Investment Act of 1998, (Title II--Adult Education
and Family Literacy Act). The Act incorporates a number of
current federal statutes governing job training, adult
education and literacy, and vocational rehabilitative services.
This new Act emphasizes State and local flexibility, shared
accountability, customer choice, and stronger coordination
among service providers. This Act will take effect July 1,
1999. Data will be available in the Winter of 2000.
National Institute on Disability and Rehabilitation Research Projects
That Relate to Aging--1998
(Prepared by S. Sweeney)
The National Institute on Disability and Rehabilitation
Research (NIDRR) authorized by Title II of the Rehabilitation
Act, has specific responsibilities for promoting and
coordinating research that relates directly to the
rehabilitation of disabled persons.
Grants and contracts are made to public and private
agencies and organizations, including institutions of higher
education, Indian Tribes and tribal organizations, for the
purpose of planning and conducting research, demonstrations,
and related activities which focus directly on the development
of methods, procedures and devices which assist in the
provision of rehabilitation services.
The Institute is also responsible for facilitating the
dissemination of information concerning developments in
rehabilitation procedures, methods, and devices to
rehabilitation professionals and to disabled persons to assist
them in leading more independent lives.
The Institute accomplishes its mission through the
following programs:
--Rehabilitation Research and Training Centers
--Rehabilitation Engineering and Research Centers
--Research and Demonstration Projects
--Field-Initiated Projects
--Utilization Projects
--Career Development Projects which include:
-- Fellowships
-- Research Training
--ADA Technical Assistance Programs
--State Technology Assistance
--Small Business Innovative Research
REHABILITATION RESEARCH AND TRAINING CENTERS
The primary goals of these centers are: (1) To conduct
research targeted toward the production of new knowledge which
will improve rehabilitation methodology and service delivery
systems, alleviate or stabilize disabling conditions, and
promote maximum social and economic independence; (2) To
institute related teaching and training programs to disseminate
and promote the utilization of research findings, thereby
reducing the usual long intervening delay between the discovery
of new knowledge and its wide application in practice.
The three major activities, research, training, and service
expected to be mutually supportive. Specifically, this synergy
calls for research ideas to derive from service delivery
problems, for research findings to be disseminated via
training, and for new professionals to be attracted to research
and service via training.
1. Rehabilitation Research and Training Center on Aging with a
Disability, Rancho Los Amigos Medical Center, Downey, CA
(Principal Investigator: Bryan J. Kemp, PhD)
Abstract: This project helps people who are aging with a
disability by conducting a series of studies, using a sample of
1,000 people, with a variety of disabilities represented.
Studies include: (1) the natural course of aging with a
disability, which investigates physical, function, and
psychosocial aging with a disability over time; (2) a cross-
ethnic-group study focusing on assisting family caregivers of
people aging with a disability, and comparing stress, support,
coping preferences, and appraisals of caregiving for people
aging with a disability and evaluating the effectiveness of a
structured group intervention; (3) improving community
integration and adjustment, focusing on depression and how it
affects community integration and demonstrates effective
treatment; (4) secondary complications such as diabetes and
thyroid disorders, determining if providing feedback to
patients' primary physicians regarding these illnesses results
in appropriate treatment, and if functional impairment is
related to these illnesses; (5) bone mass, focusing on whether
a regimen of exercise and vitamins improves bone density; and
(6) the effectiveness of assistive technology (A1) and
environmental interventions (EI) in maintaining functional
independence, evaluating differences between those receiving
intensive AT and EI services and those receiving standard care.
Training, dissemination, and technical assistance activities
focus on students and professionals in the health care fields,
researchers, community service providers, and people with
disabilities and their families.
2. Rehabilitation Research and Training Center on Aging With Mental
Retardation, The University of Illinois at Chicago University
of Illinois UAP, 1640 West Roosevelt Road Chicago, IL
(Principal Investigator: Tamar Heller, PhD; David Braddock, PhD)
Abstract: This project promotes the independence,
productivity, community inclusion, full citizenship, and self-
determination of older adults with mental retardation through a
coordinated program of research, training, technical
assistance, and dissemination activities. The research program
is aimed at increasing knowledge about the changing needs of
older adults with mental retardation and their families as they
age and the effectiveness of innovative approaches, public
policies, and program interventions that provide needed
supports and that promote the successful aging of these adults
and their families. It examines how age-related changes in
physical and psychological health affect the ability to
function in the community, including home, work, and leisure
settings. The research program also identifies best practices
and current public policies that seek to support these adults
and their families. The primary goal is to translate the
knowledge gained into practice through boardbased training,
technical assistance, and dissemination to people with mental
retardation, their families, service providers, administrators
and policy makers, advocacy groups, and the general community.
Dissemination vehicles include the Center's Clearinghouse, Web
page, and newsletters.
3. Rehabilitation Research and Training Center on Enhancing Quality of
Life of Stroke Survivors, Rehabilitation Institute Research
Corporation, 345 East Superior, Chicago, IL
(Principal Investigator: Elliot J. Roth, MD)
Abstract: This project tests the effectiveness of several
stroke rehabilitation strategies and tactics, trains stroke
survivors and professionals, and disseminates knowledge
relevant to stroke care. In order to extend the knowledge base
of stroke rehabilitation, produce changes in clinical practice,
and enhance the quality of life of stroke survivors and their
families, the Center: (1) identifies, develops, and evaluates
rehabilitation techniques in order to address coexisting and
secondary conditions and improve outcomes for all stroke
patients; (2) develops and evaluates standard aerobic exercise
protocols; (3) identifies and evaluates methods to identify and
treat depression and other psychological problems associated
with stroke; (4) determines the effectiveness of stroke
prevention education provided in a medical rehabilitation
setting; (5) evaluates the impact of changes in diagnosis and
medical treatment of stroke on rehabilitation needs; (6)
evaluates long-range outcomes for stroke rehabilitation across
different treatment settings; (7) evaluates the impact of
stroke practice guidelines on delivery and outcomes of
rehabilitation services; (8) provides training on new
approaches, innovations, and the specialized principles and
practices of rehabilitation care of individuals with stoke; (9)
provides applied research experience and training in research
principles and methods; (10) disseminates information of new
developments in the area of stroke care and research to people
with stroke and their families, rehabilitation professionals,
and service providers; and (11) conducts a state-of-the-science
conference. The Center has a large database of information
regarding stroke rehabilitation patients and continues ongoing
systems and activities to collect and analyze data concerning
stroke impairment, disability, and social functioning.
4. Rehabilitation Research and Training Center Aging with Spinal Cord
Injury and Aging, Rancho Los Amigos Medical Center, Downey, CA
(Principal Investigator: Bryan J. Kemp, PhD; Robert Waters, MD)
Abstract: The Rehabilitation Research and Training Center
(RRTC) on Aging with Spinal Cord Injury (SCI) is devoted to
understanding the unique problems people with spinal cord
injury experience as they age. Topics of research include: the
course of aging with SCI, cardiovascular and pulmonary aspects
of aging with SCI, bone loss across ethnic groups, activities
of daily living, employment, depression, and formal and
informal care systems for people aging with SCI. The RRTC has
several goals for education, training, dissemination, and
utilization: to train current and future health, allied health,
and rehabilitation professionals about aging with SCI; to train
and develop rehabilitation research professionals in the area
of aging with SCI; to improve adoption and use of RRTC-
developed knowledge and treatment regimens by health and
rehabilitation professionals; to disseminate information about
aging with SCI to people with SCI and their families; and to
train graduate students and medical students in advanced
knowledge and techniques from studies about aging with SCI.
Training and dissemination occurs through advanced and
continuing education courses, local and national conferences,
workshops, and the Internet.
5. Disability Statistics Rehabilitation Research and Training Center,
University of California, San Francisco, Institute for Health
and Aging, Box 0646, Laurel Heights, San Francisco, CA
(Principal Investigator: Mitchell P. LaPlante, PhD)
Abstract: The Center conducts research in the demography
and epidemiology fields of disability and disability policy,
including costs, employment statistics, health and long-term
care statistics, statistical indicators, and congregate living
statistics. Statistical information is disseminated through
published statistical reports and abstracts, journals,
professional presentations, and a publications mailing list.
Training activities and resources (such as a predoctoral
program) disseminate scientific methods, procedures, and
results to both new and established researchers, policymakers,
and other consumers, and assist them in interpreting
statistical information. A National Disability Statistics and
Policy Forum is conducted periodically to foster dialogue
between people with disabilities and representative
organizations, researchers, and policymakers.
6. Rehabilitation Research and Training Center in Secondary
Complications in Spinal Cord Injury, University of Alabama/
Birmingham, Department of Physical Medicine and Rehabilitation,
Birmingham, AL
(Principal Investigator: Amie B. Jackson, MD)
The primary goal of this RRTC is to conduct high-quality
basic and applied research that improves existing methods of
care for people with spinal cord injury (SCI). Current RRTC
research areas include urology, pressure ulcer healing,
spasticity, psychosocial adjustment, obstetric/gynecologic
complications, costs of rehospitalization, and pulmonary
complications. The Center's training component disseminates
RRTC research results to rehabilitation professionals and
consumers with SCI in useable formats such as videotapes,
audiotapes, written materials, journal articles, and short-term
training programs.
7. Rehabilitation Research and Training Center in Neuromuscular
Diseases, University of California/Davis, MED: Physical
Medicine and Rehabilitation TB 191, Davis, CA
(Principal Investigator: Craig McDonald, MD)
Abstract: This project enhances the quality of life for
people with neuromuscular diseases through multidisciplinary
research and a comprehensive program of training and
information services. The Center serves consumers, physicians,
and health care workers. Program areas include: Interventions
to preserve functional capacity including management of
weakness and respiratory insufficiency due to muscle wasting,
exercise interventions, treatment of exercise related fatigue,
pain interventions, lower limb orthotic interventions, and
dietary interventions; interventions to enhance community
integration, including incorporating goal-based approaches to
community integration, facilitation of healthy adaptation
through development of stress management and coping skills, and
resource training for acquisition of disability-related
information through the Internet; genetic testing, information,
and research; and training and information services. The
centerpiece of the information services program is the National
Clearinghouse Information on Neuromuscular Diseases, which
provides access to findings on basic and applied research.
8. Research and Training Center on Personal Assistance Services (PAS),
World Institute on Disability, Oakland, CA
(Principal Investigator: Deborah Kaplan, JD)
Abstract: This project furthers the understanding that
Personal Assistance Service (PAS) systems design can better
promote the economic self-sufficiency, independent living, and
full integration of people of all ages and disabilities into
society. The project explores the models, policies, access to,
and outcomes of, personal assistance services, through: (1)
gathering perspectives of consumers, program administrators,
policy makers, and personal assistants using a State of the
States survey and database development; (2) a policy study on
the impact of devolution; (3) a cost-effectiveness study; (4) a
study of workplace PAS; and (5) a study on the supply of
qualified PAS.
9. Managed Health Care for Individuals with Disabilities, Medlantic
Research Institute, National Rehabilitation Hospital Research
Center, 102 Irving Street Northwest, Washington, DC
(Principal Investigator: Gerben DeJong)
Abstract: This project provides national leadership on the
major health service and health policy issues facing consumers
with disabilities in managed health care arrangements. It: (1)
conducts research; (2) prepares special policy analyses; (3)
hosts forums for discussion; (4) presents expert testimony to
Congress and governmental agencies; (5) publishes in the health
policy, consumer, and trade literature; (6) trains graduate
students with disabilities in health service research; and (7)
disseminates findings to diverse consumer, provider, payer,
academic, and policy-making audiences. On the state and
national levels the project seeks to make managed care and the
larger health care system more responsive to the needs of
people with disabilities by acting as a catalyst for the
development of new ideas. Program partners are the National
Rehabilitation Hospital Research Center (NRH-RC) in Washington
DC and the Independent Living Research Utilization (IL RU)
center in Houston Texas.
10. Rehabilitation Research and Training Center on Blindness and Low
Vision, Mississippi State University,
(Principal Investigator: J. Elton Moore, EdD)
Abstract: The Center is conducting a series of research,
training, and dissemination projects using a multidisciplinary
strategy. The project works to investigate and document
employment status, identify barriers to employment and
techniques and reasonable accommodations to overcome these
barriers, identify training needs in the Business Enterprise
Program, and develop and deliver training programs. Training
and dissemination activities include an information and
referral center, national conferences, in-service training and
technical assistance, advanced training for practitioners,
advanced training in research, and publication and distribution
of a variety of materials in accessible media.
11. Missouri Arthritis Rehabilitation Research and Training Center,
University of Missouri/Columbia, Multipurpose Arthritis Center,
DC 330.00, Columbia, MO
(Principal Investigator: Jerry C. Parker, PhD)
Abstract: MARRTC helps to prevent and manage disability in
people with arthritis and related musculoskeletal disease by
providing leadership at the national level, through three
strategies: (1) MARRTC conducts state-of-the-art rehabilitation
and health services research that addresses the needs of people
with arthritis and related musculoskeletal diseases in the
following areas: exercise and fitness, interventions for
psychological well-being and pain, job accommodations and
employment, and health and wellness, using participatory action
research (PAR) strategies to emphasize the inclusion of
consumers in all phases of the research process; (2) MARRTC
provides training for physicians and other health care
professionals in the rehabilitative aspects of rheumatologic
practice, including university-based programs, national
presentations, research capacity-building, and publications
aimed at improving clinical skills; (3) MARRTC disseminates
rehabilitation research and technology transfer for the
empowerment of people with arthritis to help them to minimize
disability, maintain employment, and improve functional status.
12. Rehabilitation Research and Training Center on Rural Rehabilitation
Services, University of Montana, Missoula, MT
(Principal Investigator: Tom Seekins, PhD)
Abstract: This RRTC has the following objectives for
improving rural rehabilitation services: (1) identify the
employment and vocational rehabilitation service needs of
people with disabilities in rural areas; (2) develop
interventions to improve employment outcomes; (3) demonstrate
rural entrepreneurial models; (4) identify issues in rural
independent living and develop interventions to improve
transportation, health care, housing, and accessibility; (5)
coordinate with rural independent living centers to identify or
design and test alternative models of delivery of rural
rehabilitation services; (6) provide training in rural
rehabilitation research and practice; (7) conduct an annual
interactive conference on disability issues in rural America;
and (8) disseminate research findings to rehabilitation
service-delivery personnel.
13. Rehabilitation Research and Training Center on Drugs and
Disability, Wright State University School of Medicine,
Substance Abuse Resources and Disability Issues, Dayton, OH
(Principal Investigator: Dennis C. Moore, EdD)
Abstract: This project conducts epidemiological and
evaluative studies of substance abuse and substance abuse
services for consumers of state vocational rehabilitation (VR)
programs. Activities address substance abuse as it co-exists
with other disabilities; all components of the RRTC are
designed to interrelate and synergistically build on each
other. The research components include longitudinal and
multisite studies to address more advanced research questions,
and quantitative/qualitative methods or secondary analysis to
investigate vocational rehabilitation issues for people with
HIV and the relationship of social benefits on VR outcomes. The
training components use a variety of materials, venues, and
trainers in order to address needs within pre- and inservice
populations. Training and dissemination components also include
extensive use of distance learning media, especially use of the
Internet to provide professionals and consumers with timely and
relevant information. Stakeholder concerns and interests are
addressed by several mechanisms, including a formal subcontract
with the National Association on Alcohol, Drugs, and
Disability. Multiple collaborations are delineated with federal
agencies, including the Substance Abuse and Mental Health
Services Administration, as well as professional and consumer
organizations, national clearinghouses, other RRTCs, and
institutions of higher education.
14. Multiple Sclerosis Research and Training Center, University of
Washington, Department of Rehabilitation Medicine, Box 356490,
Seattle, WA
(Principal Investigator: George H. Kraft, MD, MS)
Abstract: This Center promotes health and wellness of
people with Multiple Sclerosis (MS) and improves their
functioning and employment status. Fundamental to the project
is a health survey administered to people with MS throughout
the Northwest region. Information from the survey is fed into
six project components: (1) promoting wellness among people
with MS through brief counseling methods; (2) improving the
functioning of people with MS through three studies: improving
psychological distress using pharmacological intervention,
evaluating the combined effect of cooling and exercise on
performance, and improving function through cognitive
rehabilitation interventions; (3) exploring the employment
status of people with MS; (4) designing practical interventions
and workplace modifications; (5) studying the interaction
between aging and MS; and (6) exploring the effects of gender,
culture, stsocio-economic status, ethnicity, place of
residence, and insurance coverage on people with MS, in regard
to symptomology and response to treatments. Researchers develop
and apply interventions and conduct follow-up surveys to
evaluate the effectiveness of the intervention strategies. This
Center collaborates with the RRTC on Substance Abuse, the
Consortium of MS Centers, the National MS Society, and the MS
Association of America.
REHABILITATION ENGINEERING AND RESEARCH CENTERS
This program provides support for the Rehabilitation
Engineering Research Centers to conduct programs of advanced
research of an engineering or technical nature in order to
develop and test new engineering solutions to problems of
disability. Each center is affiliated with a rehabilitation
setting, which provides an environment for cooperative research
and the transfer of rehabilitation technologies into
rehabilitation practice. The centers' additional
responsibilities include developing systems for the exchange of
technical and engineering information and improving the
distribution of technological devices and equipment to
individuals with disabilities.
1. Rehabilitation Engineering Center: Assistive Technology and
Environmental Interventions for Older Persons with
Disabilities, New York University at Buffalo, Buffalo, NY
(Principal Investigator: William C. Mann, PhD)
Activities of the RERC focus on research, assistive device
development, education, and information relating to assistive
technology for older people in the home and beyond the home.
The projects of the RERC fall into four major areas: (1)
research: ten projects address assessments in the home and
community, issues for minority elders, highly problematic
device categories, clinical trials of effectiveness, and
managed care work issues; (2) device development: six projects,
including devices addressing automobiles, obesity, mobility,
balance, stairs, and public seating; (3) education: four
projects addressing professional students, graduate students,
and rehabilitation and aging service professionals; and (4)
information: ten project areas, including a ``Helpful
Products'' series of videos and booklets, training manuals,
resources for hotel and motel guests, product information,
national conferences, newsletter inserts, a World Wide Web
site, monograph series, resource sourcebook, and a resource
phone line.
2. Smith-Kettlewell Rehabilitation Engineering Research Center, Smith-
Kettlewell Eye Research Institute, 2232 Webster Street, San
Francisco, CA
(Principal Investigator: John A. Brabyn, PhD)
Abstract: This RERC develops and evaluates new technology
and methods for infant vision screening, orientation and
navigation, described video, access to products, displays and
electronic information, deaf-blind communication, and other
problems faced by people who are blind, have visual
impairments, or have multisensory loss.
3. Rehabilitation Robotics to Enhance the Functioning of individuals
with Disabilities, Applied Science and Engineering
Laboratories, University of Delaware, Wilmington, DE
(Principal Investigator: Richard A. Foulds, PhD)
Abstract: This project focuses on interfaces, design and
application, and motor control of rehabilitation robotics, as
well as related information and dissemination. Within its
research focus, the RERC conducts many interdisciplinary
research and information projects. Research and information
activities are constituent-oriented and include implementation
of a Consumer Innovation Laboratory. This lab includes
consumers in the engineering design and fabrication of robotic
devices to aid people with disabilities.
4. Rehabilitation Engineering Research Center on Telerehabilitation,
Catholic University of America, Department of Biomedical
Engineering, Angborn Hall, Cardinal Station, Washington, DC
20064
(Principal Investigator: Jack Winters, PhD)
Abstract: This project experiments with various models of
telerehabilitation for strategic populations, engages in
development activities that exploit promising technologies, and
focuses on all aspects of the human-technology interface in a
broad range of activities that benefit people with
disabilities. Structured to include national resources with a
strong focus on outreach and dissemination activities and a
broad-based set of research activities, the Center focuses on:
(1) Tele-homecare: telesupport for stroke caregivers; (2)
Telecoaching: enhancing job options; (3) Telemonitoring:
passive sensing of functional performance and health parameters
at home using unobtrusive instrumentation; (4) Teleassessment:
remote evaluation of skin health and decubiti for people with
SCI at rural hospitals and clinics using innovative
technologies; (5) Telerehab Consumer Toolkit: outreach and
development activities and products; (6) Home Telerehab:
interactive systems for remote delivery of therapy, assessment,
teaching and demonstration at home; (7) Telecounseling and
Teleevaluation: remote psychological counseling and
neuropsychological evaluation at rural clinics and homes; (8)
Behavioral Virtual Reality: investigation and training of
social and attending behaviors using virtual environment
technology; (9) Teleplay: therapeutic play, including embedded
teleassessment for children with disabilities; (10) Integrating
Telerehabilitation in Today's Health Care Marketplace. The
Center also establishes National Resources activities: (1)
Homecare and Telerehabilitation Technology Center; (2) Homecare
and Telerehab Education/Training Center; (3) Virtual Library
and Dissemination Center; (4) Standards, Codes and Electronic
Patient Records (EPR); (5) Telerehab Policy Information Center.
The Center comprises three institutions: The Catholic
University of America (CUA), the National Rehabilitation
Hospital (NRH); and the Sister Kenny Institute (SKI).
5. Rehabilitation Engineering Research Center on Universal
Telecommunications Access, Gallaudet University, Washington, DC
(Principal Investigator: Judith Harkins, PhD (Gallaudet/UTA); Gregg C.
Vanderheiden, PhD (Trace/UTA); Betsy Bayha (WID/UTA))
Abstract: This RERC conducts research and engineering
activities with the overall goal of improving the accessibility
of emerging telecommunications systems and products. The Center
moves forward the available telecommunications knowledge base
for access issues confronting people with all types of
disabilities. The program areas of the RERC are: (1) systems
engineering analyses; (2) telecommunications access research,
focusing on needs assessment and development of design
solutions; (3) universal design specification and review, aimed
at developers of products and services; (4) telecommunications
standards that include accessible features; (5)
telecommunications applications for increased independence; and
(6) knowledge utilization and dissemination. The RERC combines
expertise from Gallaudet University, the Trace Research and
Development Center at the University of Wisconsin, and the
World Institute on Disability (WID) with the expertise of the
telecommunications industry through the active involvement of
two noted telecommunications consultants, Richard P. Brandt and
Robert Mercer.
6. Rehabilitation Engineering Research Center on Prosthetics and
Orthotics,Northwestern University, Rehabilitation Engineering
Research Program and Prosthetics Research Laboratory, Chicago,
IL
(Principal Investigator: Dudley S. Childress, PhD)
Abstract: Activities of the Center include material science
studies and applications in limb prosthesis and orthoses,
biomechanical characterizations and functional design of
prostheses and orthoses, state-of-the-art studies that
delineate the status of the field and help organize and plan
for the advancement of prosthetics and orthotic.s, and an
information and education resource service.
7. Rehabilitation Engineering Research Center on Hearing Enhancement
and Assistive Devices,The Lexington Center for the Deaf
Research Division, 30th Avenue and 75th Street, Jackson
Heights, NY
(Principal Investigator: Harry Levitt, PhD; Matt Bakke, PhD)
Abstract: This RERC harnesses emerging technology to
accommodate the needs of people with hearing loss, and
disseminates related information in a form that is
understandable to consumers, service providers, employers, and
community leaders. These goals are accomplished by: (1)
developing and evaluating improved, cost-effective
technological aids for each of the target populations
identified; (2) developing and evaluating instrumentation for
detecting hearing loss at an early age; (3) providing improved
access to modern telecommunications; (4) developing and
evaluating specialized technology for community, home, and work
environments; and (5) pursuing an active program of
dissemination and training to ensure effective utilization of
these technological aids.
8. Rehabilitation Engineering Research Center on Communication
Enhancement in the New Millennium, Duke University, Department
of Surgery, Division of Speech Pathology and Audiology, Durham,
NC
(Principal Investigator: Frank DeRuyter, PhD)
Abstract: This project uses innovative communications
technologies to benefit researchers, engineers, rehabilitation
service providers, developers, and users of AAC technologies.
The project: (1) investigates attitudinal barriers toward
technology use by elderly people with communication disorders,
their listeners, and service providers; (2) studies the
organizational strategies of adult AAC users to determine if
preferences are predictive of performance using AAC; (3)
studies how to improve AAC technologies for young children with
significant communication disorders by evaluating learning
demands and functional performance (also involves development
of design specifications); (4) evaluates and enhances
communication rate efficiency and effectiveness through the
development of procedures and software technology that
simulates and measures the performance of AAC technologies; (5)
identifies barriers to employment, describes strategies to
overcome them, documents design specifications for AAC
technologies, and describes action plans to achieve successful
employment outcomes; (6) increases employment opportunities for
graduates of an employment and AAC program; and (7) develops a
coordinated program that monitors and seeks out technology
developments in both commercial form and prerelease development
stages that affect the engineering and clinical AAC field.
9. Rehabilitation Engineering Research Center on Accessible and
Universal Design in Housing, North Carolina State University
School of Design, Raleigh, NC
(Principal Investigator: Lawrence H. Trachtman)
The RERC's mission is to: (1) conduct research in
documenting problems in housing for people with disabilities;
(2) identify or generate and test solutions to documented
problems; (3) demonstrate the general utility of solutions to
documented problems; and (4) conduct training to address skill
acquisition, knowledge diffusion, and general awareness of
issues related to housing for people with disabilities. The
Center also provides information and referral services to
address identified needs through development and dissemination
of publications and other information materials and referral to
other organizations and agencies who can assist with specific
information requests. The Center's audience includes designers,
contractors, developers, financial providers, consumer
advocates, and users of residential environments.
10. Vermont Rehabilitation Engineering Research Center for Low Back
Pain, University of Vermont, Vermont Back Research Center,
Burlington, VT
(Principal Investigator: Martin H. Krag, MD)
The Vermont RERC improves the employability of people with
back disorders and back disability by developing and testing
assistive technology. Engineering projects include studies of
lifting, posture, seating, vibration, and materials handling in
connection with back pain and disability. Applied research
projects include the testing of rehabilitation engineering
products, evaluation of exercise programs, and the development
of a statewide model program to hasten return to work of people
with back injuries. The Center's Information Services Division
provides toll-free assistance in locating research and
rehabilitation programs, as well as bibliographic searching and
fact finding. The Center also maintains an Electronic
Discussion Group: BACKS-L (Send subscription request to
[email protected]; body of message should read: subscribe
backs-1 your name).
11. Rehabilitation Engineering Research Center on Information
Technology Access, University of Wisconsin/Madison, Trace
Research and Development Center, 5901 Research Park Boulevard,
Madison WI
(Principal Investigator: Gregg C. Vanderheiden, PhD)
Abstract: This RERC improves access by individuals with all
types, degrees, and combinations of disabilities to a wide
range of technologies, including computers, ATMs, kiosks,
point-of-sale devices and smartcards, home and pocket
information appliances, Internet technologies (XML, XSL, CSS,
SMIL, etc.), intranets, and 3-D and immersive environments. As
one component in a larger system of consumers, researchers,
industry, and policy and public agencies, the Trace Center's
program is designed to work within the existing structure,
supporting other components and coordinating its efforts to
address the functioning of the whole. The program identifies
strategies that can be used by industry to broaden the user
base for their standard products, so individuals with as broad
a range of abilities as possible are able to use standard
products directly. Further, the Center targets specific
compatibility and interconnection standards work to ensure that
people who cannot use products directly are able to operate
them using assistive technologies. The Center focuses on the
use of targeted projects and collaboration, both national and
international, to carry out the research, development,
information dissemination, training, and standard-setting
activities required. The approach is intended to be flexible,
forward-looking, and broad in scope, yet focused on key access
issues as defined by its consumer constituency and its research
programs.
FIELD INITIATED RESEARCH PROGRAM
This program is designed to encourage eligible applicants
to originate valuable ideas for research and demonstrations,
development, or knowledge dissemination activities in areas
which represent their own interests, yet are directly related
to the rehabilitation of people with disabilities.
1. Aging and Adjustment after Spinal Cord Injury: A 20-Year
Longitudinal Study, Shepherd Center for Spinal Injuries, Inc.,
2020 Peachtree Road, NW, Atlanta, GA
(Principal Investigator: J. Stuart Krause, PhD)
This fourth study phase will be the most extensive follow-
up yet performed and will use an expanded version of the same
questionnaire that was used in each of the three previous
followups (1973, 1984, 1988). Three types of research designs
will be used for data analysis including: (1) traditional
longitudinal analysis of 1973 to 1992 data from the original
participant sample; (2) cross-sequential analysis of the
repeated measures data from 1984 to 1992 for samples one and
two; and (3) timesequential analysis of time-lagged data
comparing the 1984 data for sample two with that of the new
third sample.
2. Remote Signage Development to Address Current and Emerging Access
Problems for Blind Individuals, Smith-Kettlewell Eye Research
Institute, 2232 Webster Street, San Francisco, CA
(Principal Investigator: John A. Brabyn, PhD; William F. Crandall, PhD)
Abstract: This project is developing new, practical
enhancements of remote signage technology to solve a range of
specific current and emerging accessibility problems faced by
people who are blind and who have other print-reading
disabilities. For users who are blind, access to any place or
facility begins with the problem of knowing it exists; then the
problem of finding it must be addressed. Specific solutions are
being developed for safe usage of light-controlled pedestrian
crossings, identification and onboard announcements of stops
for buses, identifying route number and destination of oncoming
buses, locating and accessing automated teller machines and
other vending information terminals, and access to signage by
people with cognitive impairments. These innovative solutions
are being developed from the infrared Talking Signs(R) system
of remotely readable signs for people who are blind, which was
developed by Smith-Kettlewell. This system is gaining
acceptance as an aid to orientation and navigation for those
who cannot read the print signage that fully sighted people
take for granted in navigating and accessing the world.
3. Spatial Hearing with Laboratory-Based Hearing Aids, Smith-Kettlewell
Eye Research Institute, 2232 Webster Street, San Francisco, CA
94115
(Principal Investigator: Helen J. Simon, PhD)
Abstract: Since conventional binaural hearing aids do not
satisfactorily solve the problem of speech perception in noise,
a long-term goal of the Smith-Kettlewell Eye Research Institute
is to develop a better binaural hearing aid (HA). This
project's hypothesis suggests that a binaural perceptual
balance of Interaural Intensity Difference (IID) and Interaural
Time Delay (ITD) across frequencies is required to restore
optimum localization and speech intelligibility by eliminating
or lessening exaggerated dominance consequent to asymmetric
hearing loss. Aberrations of either or both IID and ITD at
different frequencies would impair directional localization
and, therefore, speech intelligibility in noise. Hearing Aids
4. Marketing Health Promotion, Wellness, and Risk Information to Spinal
Cord Injury Survivors in the Community, Craig Hospital, 3425
South Clarkson Street, Englewood, CO
(Principal Investigator: Gale Whiteneck, PhD)
Abstract: Building on experience gained from the RRTC in
Aging with Spinal Cord Injury (SCI) at Craig Hospital, this
project offers health promotion, wellness, and risk information
to SCI survivors. Recent reports from survivors caregivers, and
researchers are demonstrating that SCI is not the unchanging
disability it was once thought to be; over time many survivors
face medical complications, psychosocial concerns, and
diminishing quality of life. Al-
though many of these adverse outcomes could be averted or
lessened with active health maintenance and wellness
strategies, SCI survivors in the community face a dearth of the
information they need to make such positive lifestyle choices.
This project creates: (1) a Wellness and Risk Assessment
Profile that provides individualized SCI-specific health risk
appraisals via the Internet; (2) regular health information
columns in three widely-read consumer journals; (3) custom
brochures targeting the prevention and health promotion needs
of SCI survivors in the community; (4) a handbook offering
information about making wise health and lifestyle choices for
recently injured SCI survivors; (5) a handbook targeting
caregivers of SCI survivors; and (6) a curriculum for people
who teach and provide support to caregivers.
5. Toward a Risk Adjustment Methodology for People with Disabilities,
Medlantic Research Institute, National Rehabilitation Hospital
Research Center, Washington, DC
(Principal Investigator: Gerben DeJong, PhD)
The principle goal of this knowledge dissemination project
is to provide its primary audiences, health care policy-makers
and payers, with key information to advance the development of
a risk adjustment system for working- and retirement-age people
with disabilities. Risk adjustment reduces the incentive for
risk selection and promotes access to needed health services.
To achieve this goal, the project assembles a panel of leading
experts on risk adjustment and disability to guide the
development of a consensus report that: (1) details the state
of science in risk adjustment, (2) evaluates the
appropriateness of health care outcome indicators for people
with physical and mental disabilities, and (3) provides a set
of recommendations for modifying and implementing risk
adjustment methodologies that enhance access to health services
for people with disabilities enrolled in public and private
sector health plans.
6. Relation of Rehabilitation Intervention to Functional Outcome in
Acute and Subacute Settings, Rehabilitation Institute Research
Corporation, Rehabilitation Services Evaluation Unit, 345 East
Superior Street, Chicago, IL
(Principal Investigator: Allen Heinemann, PhD)
Abstract: Seven rehabilitation facilities that provide
acute medical rehabilitation are assessing rehabilitation
outcomes and predictors of outcomes, using a method for
assessing rehabilitation therapy goals, activities, and
barriers to goal attainment. This project is extending that
study. It uses the same methodology used by five sites that
provide subacute rehabilitation. Being assessed are: (1)
patient attributes at admission, such as impairment severity,
comorbid conditions and complications, functional deficits, and
demographic characteristics; (2) therapeutic interventions
(type, quantity, duration, modality, and intensity) provided in
acute and subacute settings; and (3) outcomes achieved
(functional status, discharge destination, and patient
satisfaction). The lead project, the NIDRR-funded RRTC on
Functional Assessment and Evaluation of Rehabilitation
Outcomes, was awarded to the State University of New York.
7. Enhancement of Upper Limb Functional Recovery in Stroke, Using a
Computer-Assisted Training Paradigm, Rehabilitation Institute
Research Corporation, Sensory Motor Performance Laboratory,
#1406, 345 East Superior Street, Chicago, IL
Principal Investigator: Julius Dewald
Abstract: This study investigates use of a novel computer-
assisted isometric training regime to overcome abnormal
movement synergies following hemiparetic stroke. These deficits
in coordination are expressed in the form of abnormal muscle
synergies and result in limited and stereotypic movement
patterns that are functionally disabling and often
debilitating, but that are not understood. Current
neurotherapeutic approaches to the amelioration of these
abnormal synergies have produced, at best, limited functional
recovery. The effect of two training regimes on functional
movement are being investigated in 40 hemiparetic stroke
subjects. The first training regime uses a general, classical
strengthening protocol to increase torque production in
specific directions. The second, novel regime strengthens
subjects using torque combinations that require the subject to
deviate progressively from their abnormal torque synergies.
Assessment of the effectiveness of these two regimes is based
on quantitative comparisons of voluntary upper limb movements
performed pre- and post-training.
8. Knowledge Dissemination for Vision Screeners, University of Kansas
Institute for Life Span Studies, Parsons, KS
(Principal Investigator: Charles R. Spellman, EdD)
This project is disseminating a CD-ROM to providers of
vision screening and evaluation services, in order to increase
the quantity and quality of vision services available
nationally to infants, toddlers, preschoolers, and older people
with disabilities. These populations are sometimes considered
difficult to test, and as a consequence, often do not receive
traditional vision screening services. The project addresses
the training needs of a variety of personnel by providing an
interactive CD-ROM program, modeled after the ``knowledge on
demand'' technology used in industry, that can be readily
delivered in a variety of settings. The program is providing a
model for using CD-ROM to disseminate ``knowledge on demand.''
9. Development and Commercial Transfer of a Tactile Image Printer
(TIP), International Braille Research Center, 4424 Brookhaven
Avenue, Louisville, KY
(Principal Investigator: T.V. Cranmer, PhD)
Abstract: The project designs a product that allows
students, educators, and other professionals who are blind to
access a variety of graphic material such as computer screens,
maps, schematics, geometry tables, organizational charts, flow
charts, and line drawings. Researchers develop a device that
produces sharper, better-defined tactile images and includes
lines and filled-in areas of varying dimensions and textures.
Colors can also be produced as needed or as appropriate.
Developers include the inventor, engineers, educators,
publishers, and grassroots advocacy organizations, with support
from three Rehabilitation Research Engineering Centers, those
on Information Access (Trace), Blindness and Visual Impairment
(Smith-Kettlewell), and Technology Transfer (SUNY/Buffalo). The
device should help people who are blind or who have visual
impairments to become active participants in the new global
economy. Phases of the project include firmware development,
experimentation and testing, creation and testing of graphic
material, and product and information dissemination.
10. Measuring Functional Communication: Multicultural and International
Applications, American Speech-Language-Hearinq Association,
10801 Rockville Pike, Rockville, MD
(Principal Investigator: Diane Paul-Brown)
Abstract: The long-term objective of this project is to
improve the quality of life for adults with communication
disabilities by expanding and validating an assessment tool for
multicultural and international populations. Assessments can
then be made regarding communication functions and needs, and
rehabilitation can be individualized to optimize the person's
ability to communicate in their natural environments. Reliable
communication skills are a requisite for individuals to achieve
their social, educational, and vocational potentials, and for
patients to understand and participate in their care and
recovery. Activities of this project include: (1) development
of a supplemental measure of quality of communicative life; (2)
validation of the extended American Speech-Language-Hearing
Association Functional Assessment of Communication Skills for
Adults with multicultural groups including African Americans,
Asian Americans, Caucasian, Hispanic, and Native Americans; (3)
validation with various populations with communication
disorders such as those caused by brain injury, stroke,
Alzheimer's disease and related dementias, and acquired
neurological disorders; and (4) validation in other English-
speaking countries.
11. Closed Captioning and Audio Description: Development and Testing
for Access to Digital Television, WGBH Educational Foundation,
125 Western Avenue, Boston, MA
(Principal Investigator: Larry Goldberg)
Abstract: This project addresses the urgent, time-sensitive
need to improve the effectiveness of Advanced Television (ATV)
to deliver high-quality captioning and description services to
people who are deaf, hard of hearing, who are blind, or who
have visual impairments. Advanced Television (ATV) incorporates
the technologies known as High-Definition Television (HDTV) and
Standard Definition Television (SDTV), and is a complete
redesign of North America's television service, featuring a
digital signal, a sharper picture, an aspect ratio resembling
that of a wide-screen movie, multiple CD-quality audio
channels, and ancillary data services. This project uses
knowledge and understanding gained from research and
development previously undertaken by the WGBH Educational
Foundation (among others) to design and develop prototype ATV
captioning and description processes. Project objectives are:
(1) to develop and disseminate a standard data file that tests
ATV systems for quality and accuracy in handling ATV captions
and descriptions as they are encoded, transmitted, and decoded
in accordance with accepted standards and official minimum
requirements; (2) to develop and disseminate an advanced-
features data file that tests ATV systems for quality and
accuracy in handling ATV captions and descriptions as they are
encoded, transmitted, and decoded in accordance with accepted
standards and with a full range of advanced features; (3) to
evaluate the effectiveness of ATV receivers in decoding ATV
captions and descriptions and to measure implementation of
advanced features.
12. Secondary Conditions, Assistance, and Health-Related Access Among
Independently Living Adults with Major Disabling Conditions,
Massachusetts Health Research Institute, Boston, MA
(Principal Investigator: Nancy Wilber)
Participants in this study are affiliated with six
Massachusetts independent living centers (ILCs). The cross-
disability sample includes people with a range of significant
physical, mental, sensory, and developmental disabilities who
require assistance with activities of daily living. Primary
outcomes of interest are: (1) the frequency and severity of
secondary conditions, including skin problems, seizures,
chronic pain, spasms, falls, fatigue, respiratory tract
infections, and urinary tract infections; and (2) reactions to
medication, depression, anxiety, and injuries related to
medical equipment. Mediating variables include: adequacy of
personal assistance, assistive technology, access to health
promotion and health care services, environmental barriers,
transportation, employment, education, socioeconomic status,
smoking, use of substances, and compliance with prescribed
health care routines. The research study includes two annual
cross-sectional surveys, each of 300 randomly-selected ILC
consumers, to determine prevalence, distribution, frequency,
and severity of secondary conditions. Focus groups of ILC
consumers and others help interpret the data.
13. The Impact of Managed Care on Rehabilitation Services and Outcomes
for Persons With Spinal Cord Injury, Rehabilitation Institute
of Michigan, Research Department, 261 Mack Boulevard, Room 520,
Detroit, MI
(Principal Investigator: Marcel Dijkers, PhD)
Abstract: This project examines the impact of managed care
on rehabilitation services and outcomes for people with SCI.
The study analyzes demographic, medical, functional, community
integration, life satisfaction, and service delivery data
collected from Model Systems projects to determine how managed
care is altering the acute and rehabilitative management of SCI
and how it affects short- and long-term outcomes, such as
functional status and community integration. Objectives
include: (1) describing the pathways of newly injured people
with SCI through the health care system, from injury to stable
community residence: acute care, rehabilitation care (including
inpatient-acute, subacute, day hospital and outpatient), home
care, and readmissions for complications; (2) assessing the
impact of managed care on these pathways: determining whether
managed care patients differ from those with more traditional
health insurance in terms of services received (providers,
services, durations); and (3) assessing the effect of various
pathways on the outcomes for this patient population at one and
two years after injury in functional, medical, psychological,
and health services utilization. The project team disseminates
findings to consumers, managed care and other payer
organizations, policy makers, and SCI professionals using a
variety of mechanisms. Findings are expected to contribute to
the redesign of the SCI Model Systems National Database to make
it correspond optimally to the organization of health and
rehabilitative services in the 21st century.
14. Effect of Motor Learning Procedures on Brain Reorganization in
Subjects With Stroke, University of Minnesota, Program in
Physical Therapy, Box 388 Mayo, Minneapolis, MN
(Principal Investigator: James Carey)
Abstract: This project determines whether elements of motor
learning can promote brain reorganization and recovery of
function in individuals with stroke. Two interventions have
been shown to be effective in helping people recover from
stroke, ``forced use'' of the weak side and electrical
stimulation. Investigators have hypothesized that these
treatments may unmask dormant motor centers or improve synaptic
effectiveness, but no evidence has been forthcoming. The
project involves two experiments: (1) subjects with stroke
receive 20 training sessions at a finger movement tracking task
in which they are forced to process the perceptual motor
information mentally and learn to respond accurately, and (2)
different subjects with stroke receive 20 days of electrical
stimulation to the weak forearm muscles. For both experiments,
changes in finger function are measured with tracking and
manual dexterity tests. Neuroplastic changes in the brain are
measured with functional magnetic resonance imaging. This
project may show for the first time that physical
rehabilitation procedures may stimulate beneficial
reorganization of the brain following stroke and invite further
experiments to optimize treatments.
15. The Universal Bathroom, Research Foundation of State University of
New York, State University of New York (SUNY)/Buffalo, Amherst,
NY
(Principal Investigator: Abir Mullick, Project Director)
While the greatest potential benefactors of a universal
bathroom are non-institutionalized people with disabilities who
are living independently, the new bathroom's design will be
created to be safe, accessible and usable by all people
regardless of their age, sex, and disabling conditions. Its
assumed modular, interchangeable components will include three
primary units, for bathing/showering, toileting, and grooming.
Since the bathroom of the user's choice can be custom built
from a large range of component units, this will be a
marketable, culturally responsive one with accepted layouts and
levels of privacy. Additionally, the ``lifespan perspective''
of the bathroom's design will allow able-bodied care-providers
such as parents of young children and those assisting older
individuals to make layout changes and product alterations
based on their current needs. Thus the bathroom's assistive
qualities will reduce temporary dependence on others and
increase safety by preventing accidents that lead to
disability. It will empower independent users, dependent users,
and care-providers equally--the young, the old, married
couples, people with children, and families with ``live-in''
grandparents.
16. Promoting the Practice of Universal Design, North Carolina State
University School of Design, Center for Universal Design, 219
Oberlin Road, Raleigh, NC
(Principal Investigator: Molly Story)
Abstract: This project promotes the practice of univeral
design by developing and implementing a self-supporting product
design evaluation and marketing program that responds to
consumer and industry needs. Universal design is the design of
products and environments that are usable, to the greatest
extent possible, by everyone regardless of their age or
ability. The critical next step toward increasing the practice
of universal design is adoption and application of its
principles both by consumers and by industry. The three
objectives of this project are to improve consumers' ability to
recognize universal design, to improve designers' ability to
meet the needs of a diverse consumer base, and to recognize and
support industry efforts to market universal design
successfully. Ways these objectives are achieved through this
project include: (1) developing a set of performance measures
that reflect the Principles of Universal Design, (2) confirming
the reliability of these measures and pilot testing the
evaluation program, (3) developing a plan of self-support for
the universal design evaluation program, and (4) disseminating
the results to appropriate audiences. The project develops a
sound universal design program based on information gathered
directly from future users--consumers, designers, and
marketers--as well as the universal design research community.
17. Women's Personal Assistance Services (PAS) Abuse Research Project,
Oregon Health Sciences University/Portland, Child Development
and Rehabilitation Center, P.O. Box 574, Portland, OR
(Principal Investigator: Laurie Powers, PhD)
Abstract: This project increases the identification,
assessment, and response to abuse by formal and informal
personal assistance service (PAS) providers of women with
physical and physical and cognitive disabilities living
independently in the community. The aims of the project: (1)
develop culturally sensitive screening approaches to identify
PAS abuse, (2) develop a culturally appropriate PAS abuse
assessment protocol, and (3) develop culturally appropriate
response strategies to prevent and manage PAS abuse. Culturally
diverse participants assist in the development of these three
aims. The study includes three phases, beginning with a focus
group study of culturally diverse women with physical and
cognitive disabilities. Phase II involves the use of findings
from Phase I to develop and disseminate a survey of 260
culturally diverse females with disabilities drawn from four
national organizations. Phase III involves the development and
field testing of the effectiveness of the screening,
assessment, and support protocols, the final product being a
comprehensive package of PAS abuse prevention materials. The
project plans to disseminate these materials on a national
basis.
18. A Pilot Study for the Clinical Evaluation of Pressure-Relieving
Seat Cushions for Elderly Stroke Patients, University of
Pittsburgh, Pittsburgh, PA
(Principal Investigator: David Brienza)
This project designs and tests the feasibility of a
randomized clinical trial to determine the efficacy of
pressure-relieving seat cushions for immobile, elderly stroke
patients. Older people with disabilities who are immobile and,
thus, spend their time either in bed or seated, are at risk for
developing pressure ulcers. Commercial seat cushions intended
to reduce the risk of sitting-induced pressure ulcers are
available. The elderly population, however, is not customarily
evaluated for seating and positioning needs or provided with
the benefits of this technology. Reimbursement is not
available, due in part to the fact that the effectiveness of
this intervention has not been sufficiently demonstrated for
this high-risk population, and these services and technology
are not available. If these cushions are a successful
intervention for increased comfort, improved quality of life,
and pressure ulcer incidence rate reduction, the project plans
to disseminate the findings and provide justification for third
party funding. If successful, project plans to increase the
availability of seating and positioning services and products
to this deserving population.
Disability and Rehabilitation Research Projects (formerly Research and
Demonstration Projects)
These projects address rehabilitation priorities identified
by NIDRR and published in the Federal Register. These
priorities address a variety of problems encountered by people
with disabilities. Projects are funded for up to 36 months.
1. Exercise and Recreation for Individuals with a Disability:
Assessment and Intervention, Rehabilitation Institute of
Chicago, Center for Health and Fitness, Chicago, IL
(Principal Investigator: Jeffery Jones)
This project demonstrates that participation in exercise
and physical activities improves function, facilitates
community reintegration, and enhances the quality of life of
people with disabilities. The project: (1) investigates the
long-term effects of an exercise fitness program on the
physiology, metabolic performance, and quality of life of
people with spinal cord injury, stroke, and cerebral palsy; (2)
examines the role of self-efficacy in maintaining participation
in an exercise fitness program; (3) describes the types and
frequency of recreation and fitness activities among people who
have had a stroke, people with spinal cord injury, and people
with cerebral palsy; (4) examines the relationships between
participation in recreation and exercise programs and the
health status, life satisfaction, and depression in the above
populations; and (5) delineates barriers and deterrents to
participation in recreation and exercise programs that exist
for a variety of disability groups.
2. The Center on Emergent Disability, University of Illinois/Chicago,
Institute on Disability and Human Development, 1640 West
Roosevelt Road, Chicago, IL
(Principal Investigator: Glenn T. Fujiura, PhD)
Abstract: This Center focuses on characterizing the impact
of major health, social, and economic trends on the
manifestation of disability in America, through a broadly
conceived nationwide research effort across multiple
disciplines and constituencies. Core activities include
secondary analyses of major data sets, evaluation of public
health surveillance systems, local needs assessment, policy
analysis, and dissemination. This project is headquartered at
the University of Illinois at Chicago with collaborating
research groups at the University of Southern California
Children's Hospital, Rancho Los Amigos Medical Center,
Georgetown University Medical Center, Baylor College of
Medicine, University of Minnesota, Northern Arizona University,
and Vanderbilt University.
3. Reducing Risk Factors for Abuse Among Low-Income Minority Women with
Disabilities, Baylor College of Medicine, Department of
Physical Medicine and Rehabilitation, 3440 Richmond Avenue,
Suite B, Houston, TX
(Principal Investigator: Margaret A. Nosek, PhD)
Abstract: This project pursues strategies to reach women
with disabilities at all stages of resolving abusive
situations. To accomplish this purpose, the project has the
following objectives: (1) identify risk factors for emotional,
physical, and sexual abuse faced by women with disabilities;
(2) assess the ability of rehabilitation and independent living
counselors to identify women in abusive situations and refer
them to appropriate community resources; (3) develop and test
models for programs that reduce the risk of abuse for women
with disabilities, particularly among women with disabilities
from low-income, minority backgrounds where the incidence of
abuse is highest; and (4) establish an agenda for future
research on women with disabilities using a national advisory
panel. The project works not only with programs that help
battered women, but also with those in contact with women with
disabilities in various community contexts.
4. Understanding and Increasing the Adoption of Universal Design in
Product Design, University of Wisconsin/Madison, Trace Research
and Development Center, Madison, WI
(Principal Investigator: Gregg C. Vanderheiden, PhD)
This project: (1) identifies the factors that cause
industry to practice, or not to practice, universal design of
products; and (2) identifies ways that people outside companies
can encourage and facilitate the practice of universal design
of products on a more widespread basis. The project brings
together experts who have been active in universal design from
across the technology spectrum to work with industry in
addressing these questions. Areas of expertise include housing
and architecture, computers and electronic products, media and
materials, telecommunications, and educational software.
UTILIZATION PROJECTS
This program supports activities that will ensure that
rehabilitation knowledge generated from projects and centers
funded by the Institute and other sources is fully utilized to
improve the lives of individuals with disabilities.
1. Improving Access to Disability Data, InfoUse, Berkeley, CA
(Principal Investigator: Susan Stoddard, PhD, AICP)
InfoUse's Center on Access to Disability Data is the
central source for disability statistics data and related
technical reports in accessible, easy-to-understand, user-
friendly formats. The Center provides this information to
businesses, the media, urban planners and policymakers, and the
disability community. The first major product, the Chartbook on
Disability in the United States, 1996, provided updated
statistical information on a range of disability topics.
Material for the Chartbook series and related fact sheets are
available to the public in a variety of published and
electronic formats, including print and electronic media. The
Center's Web site serves as a source for electronic documents,
includes guidelines for accessible Web publishing, and provides
links to major national data sources including data sites
developed by other NIDRR grantees and by major national
disability data suppliers.
2. National Rehabilitation Information Center (NARIC), KRA Corporation,
Silver Spring, MD
(Principal Investigator: Mark X. Odum)
The National Rehabilitation Information Center (NARIC)
maintains a research library of more than 51,000 documents and
responds to a wide range of information requests, providing
facts and referral, database searches, and document delivery.
Through telephone information referral and the Internet, NARIC
disseminates information gathered from NIDRR-funded projects,
other federal programs, and from journals, periodicals,
newsletters, films, and videotapes, NARIC maintains REHABDATA,
a bibliographic database on rehabilitation and disability
issues, both in-house and on the Internet. Users are served by
telephone, mail, electronic communications, or in person.
3. ABLEDATA Database Program, Macro International, Inc., Silver spring,
MD
(Principal Investigator: Lynn Halverson)
The project maintains and expands the ABLEDATA database,
develops information and referral services that are responsive
to the special technology product needs of consumers and
professionals, and provides the data to major dissemination
points to ensure wide distribution and availability of the
information to all who need it. The ABLEDATA database contains
information on more than 23,000 assistive devices, both
commercially produced and custom made. Requests for information
are answered via telephone, mail, electronic communications, or
in person.
4. National Center for the Dissemination Of Disability Research
(NCDDR), Southwest Educational Development Laboratory, Austin,
TX
(Principal Investigator: John D. Westbrook, PhD)
This project provides information and technical assistance
to NIDRR grantees in identifying and improving dissemination
strategies designed to meet the needs of their target audience.
The project also analyzes and reports on dissemination trends
relevant to disability research. Task force and material
development activities address multicultural factors that
influence dissemination and utilization. This project conducts
ongoing International networking through a variety of
approaches, including an interactive world Wide Web site
highlighting events and other information about specific NIDRR
grantees, the production of quarterly issues of The Research
Exchange, and in-person and online technical assistance
support.
research training grants
The purpose of this program is to expand capability in the
field of rehabilitation research by supporting projects that
provide advanced training in rehabilitation research. These
projects provide research training and experience at an
advanced level to individuals with doctoral or similar advanced
degrees who have clinical or other relevant experience,
including experience in management or basic science research,
in fields pertinent to rehabilitation, in order to qualify
those individuals to conduct independent research on problems
related to disability and rehabilitation.
1. Advanced Rehabilitation Research Training Project in Rehabilitation
Services Research, Northwestern University, Rehabilitation
Institute Research Corporation, Rehabilitation Services
Evaluation Unit, Chicago, IL
(Principal Investigator: Allen W. Heinemann, PhD)
Abstract: This project develops a five-year fellowship
program in rehabilitation service research at Northwestern
University's Department of Physical Medicine and
Rehabilitation. It uses available expertise and collaborators
to train postdoctoral fellows in rehabilitation health services
research. Over two years the program includes course work, a
practicum, original research, and grant writing. Fellows new to
health services research have six core courses, as well as the
four-to-five additional courses for all fellows. The first year
concentrates on beginning Masters in Public Health (MPH)
courses. The second year includes intermediary MPH course work
plus electives. Each fellow is expected to develop an
individual research project by the end of the first training
year and a publishable article by the end of the second year in
addition to submitting at least one grant application related
to the research activity.
small business innovative research
New ideas and products useful to people with disabilities
and the rehabilitation field are encouraged with small business
innovative research grants. This three-phase program takes an
idea from development to market readiness.
1. Webwise: A Specialized Web Browser Providing Independent Access to
the Internet to Individuals with Mental Retardation, Ablelink
Technologies, 2501 North Chelton Rd, Colorado Springs
(Principal Investigator: Daniel K. Davies)
Abstract: This project investigates the issues surrounding
World Wide Web access for people with mental retardation and
other cognitive disabilities, and builds a prototype browser
called WebWise that improves their Web access. Researchers test
the prototype to assess its effectiveness compared to existing
Web browsers, and data is collected regarding educational and
recreational benefits of the WebWise browser.
2. Automated PC-based Speech-to-Sign-Language Interpreter, Seamless
Solutions, Inc., 3504 Lake Lynda Drive, Suite 390, Orlando, FL
(Principal Investigator: Edward M. Sims, PhD)
Abstract: This project demonstrates the feasibility of
real-time, PC-based, speech-to-sign-language interpretation, by
integrating commercially available speech recognition and
language modeling software with Seamless Solutions, Inc.'s PC-
based Signing Avatars(tm) 3D character animations of sign
language communication. For example, a teacher could speak into
a headmounted microphone, and the sentences would be translated
into 3D sign language communication on the student's desktop
PC; such a system could also facilitate sign language learning
for hearing people.
(3. Visual Light Audio Information Transfer System (VLAITS), Talking
Lights Company, 28 Constitution Road, Boston, MA
(Principal Investigator: George Hovorka)
Abstract: This project develops an inexpensive
communication system that uses currently installed visible
lighting, such as fluo-
rescent or mercury vapor lighting, as a carrier medium for
data. The system modulates light output from the lighting
fixture and transmits the data fast enough that no visual
flicker is perceptible. The data is received by a personal
audio receiver (PAR) and is converted into audio information
for the PAR wearer, who may be hard of hearing, have a visual
impairment, or may not have a disability. The system is
developed, evaluated, and tested with people with visual
impairments and people who are hard of hearing to maximize user
friendliness and value.
4. Development of a Tactile Graphical User Interface Touch Graphics,
140 Jackson Street, Brooklyn, NY
(Principal Investigator: Steven Landau)
Abstract: This project develops a standardized tactile
graphical user interface (TGUI) that allows fuller access to
interactive educational tools and forms of entertainment to
millions of children, adults, and senior citizens who are blind
or who have visual impairments. Goals include: (1) a fully
realized tactile ``screen'' layout that incorporates tools,
icons, data entry functions, working space, and calibration and
identification features; (2) a sample application based on the
TGUI; (3) a full regime of user tests carried out by the
American Foundation for the Blind; (4) instructional materials
for using the TGUI and the sample application; (5) a final
report documenting the findings of the project and the
feasibility for future development. The resulting device and
accessories are marketed to schools, libraries, and
individuals.
5. Trails Web Site with Universal Access Information, Beneficial
Designs, Inc., 5858 Empire Grade, Santa Cruz, CA
(Principal Investigator: Peter W. Axelson; Denise A. Chesney)
Abstract: This project develops the Trails Web site to
provide universal access information for trails throughout the
United States, making the site useful to all hikers, regardless
of their ability. The Universal Trails Assessment Process
enables trail managers to assess specific trails objectively
with regard to grade, cross slope, width, surface
characteristics, and obstacles. The collected trail data is
processed to create Trail Access Information in a format
similar to a Nutrition Facts food label. The Trails Web site
contains Trail Access Information on numerous hiking trails and
allows users to search for trails that meet their specific
access needs.
6. Broadcast Radio for Individuals who are Deaf: Gaining Equity
(BRIDGE), TeleSonic Division of Associated Enterprises, Inc.,
31 Old Solomons Island Road, Annapolis, MD 21041
(Principal Investigator: Leonard A. Blackshear)
Abstract: Phase I of this project proved it is feasible to
transmit multimedia signals over commercial radio and to
receive them with special decoder devices. Phase II develops
working models of radio transmitter and receiver devices that
allow simultaneous radio broadcasting of both audio and visual
information. Users of TTYs, for example, could receive ``closed
captioned'' broadcasts of radio programs. Research and
development tasks include: (1) conducting ongoing technical
research, (2) examining future directions in radio
broadcasting, (3) finalizing synchronization schemes, (4)
updating system specifications, (5) developing models, (6)
conducting tests with radio stations, (7) identifying modes of
sustaining further development, and (8) reporting results.
Anticipated future results include development of a commercial
broadcast system.
state technology assistance programs
This program, funded under The Technology-Related
Assistance for Individuals with Disabilities Act of 1988, as
amended, supports consumer-driven, statewide, technology-
related assistance for individuals of all ages with
disabilities.
States and territories are eligible to apply for one 3-year
development grant, a first-extension grant for years 4 and 5,
and a second-extension grant for years 6-10. The purpose of
these grants is to establish a program of statewide,
comprehensive, technology-related assistance for individuals
with disabilities of all ages.
independent living services for older individuals who are blind,
chapter 2 of title vii
Section 752 of the Rehabilitation Act of 1973, as amended,
authorizes discretionary grants to State vocational
rehabilitation (VR) agencies for projects that provide
independent living services for persons who have severe visual
impairments and who are aged 55 and older. Each designated
State unit that is authorized to provide rehabilitation
services to blind individuals may either directly provide
independent living services or it may make subgrants to other
public agencies or private non-profit organizations to provide
these services.
The services most commonly provided are: (1) training for
activities of daily living, (2) the provision of adaptive aids
and appliances, (3) low vision services, (4) orientation and
mobility services, (5) training in communication skills, (6)
family and peer counseling, and (7) community integration,
which includes outreach and information and referral.
During FY 1966, the most recent year for which we have
analyzed data, 26,846 older individuals with significant visual
impairment or blindness received services. of these consumers,
64.4 percent were at age 76 or older and 45 percent were age 81
or older. The individuals served by this program represent
approximately one-half of the individuals with significant
visual impairments or blindness who receive rehabilitation and
independent living services through public and private
rehabilitation programs as estimated by the Mississippi State
University and the New York Lighthouse for the Blind.
ITEM 5--DEPARTMENT OF ENERGY
----------
Introduction
The Department of Energy is a leading science and
technology agency whose research supports our Nation's energy
security, national security, environmental quality, and
contributes to a better quality of life for all Americans. The
Department's missions include the largest environmental cleanup
in history, as well as research and development that support
the Nation's defense, energy, and economic security. DOE
employs approximately 10,000 federal workers and 100,000
contract employees. The Department owns and manages more than
50 major installations located in 35 States.
At the center of the Department's work is science,
performed at DOE's 27 laboratories and other scientific user
facilities and in the Nation's universities. The Department
supports breakthrough research in energy sciences and
technology, high energy physics, global climate change, genome
mapping and the bio-sciences, superconducting materials,
accelerator technologies, environmental sciences, and super-
computing. DOE also supports science and mathematics education
in our schools from the K-12 level through post-doctoral work.
In support of the Nation's energy security, the Department
promotes development of secure, clean, and sustainable energy
resources, works to increase the diversity of energy sources
and fuel choices, and maintains the Strategic Petroleum
Reserve.
In fulfilling its national security mission, the Department
assures the safety and reliability of the U.S. nuclear weapons
stockpile without underground testing, in compliance with the
Comprehensive Test Ban Treaty, and supports U.S.
nonproliferation, arms control, and nuclear safety objectives
in the states of the former Soviet Union and world-wide.
In meeting its environmental quality mission, the
Department is responsible for cleaning up the environmental
legacy left at the sites where, for some 50 years, the Nation's
nuclear weapons were designed and manufactured.
Energy Efficiency Programs
Weatherization Assistance Program--The program's mission is
to make energy more affordable and improve health and safety in
homes occupied by low-income families, particularly those with
elderly residents, children, or persons with disabilities.
Elderly residents make up approximately 40 percent of the low-
income households served by this program. As of September 30,
1998 about 4.7 million homes had been weatherized with Federal,
State, and utility funds; of these, an estimated 1.9 million
were occupied by elderly persons.
Low-income households spend an average 15 percent of income
for residential energy--more than four times the proportion
spent by higher income households. The weatherization program
allows low-income citizens to benefit from energy efficiency
technologies that are otherwise inaccessible to them.
Alleviating the high energy cost burden faced by low-income
Americans helps them increase their financial independence and
their flexibility to spend household income on other needs.
The program has become increasingly effective due to
improvements in air-leakage control, insulation, water heater
systems, windows and doors, and space heating systems. A low-
income household now saves approximately $193 per year, about
one-third of its space heating costs. Program benefits are
further described in Progress Report of the National
Weatherization Assistance Program that features 90 photo
illustrations of specific benefits. The report is available
through the National Technical Information Service, 703/487-
4650, 5285 Port Royal Rd., Springfield, VA 22161.
The program is implemented by states through community-
based organizations. The Department of Energy and its State and
community partners weatherize approximately 70,000 single- and
multi-family dwellings each year. The program awarded $120.8
million in Fiscal Year 1997 and $124.8 million in Fiscal Year
1998 for grants to the 50 States, the District of Columbia and
six Native American tribal organizations. In addition to DOE
appropriations, State and local programs receive funding from
the Department of Health and Human Services Low Income Home
Energy Assistance Program, from utilities, and from States.
State Energy Program--The program provides grants to State
energy offices to encourage the use of energy efficiency and
renewable energy technologies and practices in states and
communities through technical and financial assistance. In FY
1997 $29 million was appropriated and $30.25 million was
appropriated in FY 1998. States have broad discretion in
designing their projects. Typical project activities include:
public education to promote energy efficiency; transportation
efficiency and accelerated use of alternative transportation
fuels for vehicles; financial incentives for energy
conservation/renewable projects including loans, rebates and
grants; energy audits of buildings and industrial processes;
development and adoption of integrated energy plans; promotion
of energy efficient residences; and deployment of newly
developed energy efficiency and renewable energy technologies.
There have been some projects that specifically target the
elderly such as Louisiana's low-income/handicapped/elderly/
Native American outreach program that provided energy-related
assistance through a joint venture with utilities. The elderly
also benefit from programs that provide energy audits, hands-on
energy conservation workshops, and low-interest loans for
homeowners that can result in significant energy savings.
Energy efficiency improvements in local and state buildings and
services also benefit the elderly by freeing up state and local
government tax revenues for non-energy expenses. Energy
efficient schools can be less of a burden on property taxes.
An emerging issue is the restructuring of the electric
utility industry. The State Energy Program has supported
workshops with States and local communities to ensure that
homeowners and disadvantaged groups are not overlooked or
denied the economic benefits of lower-cost sources of energy
after deregulation. Utility deregulation workshops for public
officials have emphasized techniques and negotiating
strategies, e.g. franchising, to ensure that vulnerable
populations such as the elderly are not excluded from energy
pricing competition.
Information Collection and Distribution
The Energy Information Administration collects and
publishes comprehensive data on energy consumption through the
Residential Energy Consumption Survey (RECS). The RECS is
conducted in households quadrennially and collects data from
individual households throughout the country, including those
headed by elderly individuals. Along with household and housing
unit characteristics data, the RECS also collects the actual
billing data from the households' fuel suppliers for a 12-month
period.
The results of the RECS are analyzed and published by the
Energy Information Administration. The most recent household
survey data are from the 1997 RECS and are published on the
Internet at http:www.eia.doe.gov/emeu/consumption. The
consumption and expenditures data from the 1997 RECS will be
published on the same Internet site in the spring of 1999. At
that time, the RECS data files will also be made available to
the public. These files will include demographic
characteristics of the elderly such as age, marital status and
household income, as well as estimates of consumption and
expenditures for electricity, natural gas, fuel oil, kerosene,
and liquefied petroleum gas used in elderly households.
In the 1997 RECS, 28.6 million, or 28 percent of all U.S.
households, were headed by a person 60 years of age or older.
Of these elderly households, 44 percent were one-member
households (12.4 million people living alone) and 43 percent
contained two people. In 19 percent of the two-member elderly
households both members were under the age of 65; in 21 percent
of these households, only one member was younger than 65; and
in 60 percent, both members were over the age of 65.
Comparisons of elderly versus non-elderly households reveal
that:
The 1997 household income of elderly
households was generally lower than that of non-elderly
households. Nearly a quarter, 23 percent, of elderly
households had incomes of less than $10,000, compared
to 9 percent of the non-elderly households. Only 12
percent of the elderly households had incomes of
$50,000 or more, compared to 33 percent of the non-
elderly households. Of the 14.7 million U.S. households
whose income was below the poverty line, 37 percent
were headed by a person 60 years of age or older.
Despite having lower household incomes, the
elderly households were more likely to own their
housing unit, 80 percent, than were non-elderly
households, 63 percent. The elderly were also more
likely to live in a single-family house, 76 percent,
than were non-elderly households, 71 percent.
Elderly households are less likely to have a
personal computer or a modem connecting that computer
to the Internet or e-mail networks than are households
headed by persons less than 60 years of age. Among
elderly households, 14 percent have a personal computer
compared to 43 percent of the non-elderly households.
Only 7 percent of elderly households have a modem
connection compared to 26 percent of the non-elderly
households.
Elderly households are only marginally less
likely to have a microwave oven, 79 percent, than are
non-elderly households, 85 percent.
Analysis of the 1993 RECS data shows that consumption
patterns differed between the elderly and non-elderly for some
uses of energy. The elderly used more energy to heat their
homes but used less energy for air conditioning, water heating,
and appliances. Expenditures followed the same pattern.
Specifically,
The average expenditures per household
member in elderly households in 1993 was $68. This
amount was higher than the comparable amount for all
other households, due to the fact that households
headed by persons 60 years or more of age tend to be
smaller than those headed by persons under 60 years of
age.
About 61 percent of total energy consumption
and about 38 percent of total energy expenditures in
elderly households were for space heating. On the other
hand, appliances accounted for 16 percent of
consumption and 31 percent of total expenditures in
elderly households. Energy costs for appliances are
much higher relative to consumption than are energy
costs for space heating because virtually all
appliances are powered by electricity, the most
expensive energy source, whereas space heating is
largely provided by other, less expensive, energy
sources.
Research Related to Aging
In 1997 and 1998, the Office of Environment, Safety and
Health (EH) sponsored research to further an understanding of
the human health effects of radiation. As part of this research
program, the Department of Energy (DOE) sponsored epidemiologic
studies concerned with understanding health changes over time.
Lifetime studies of humans constitute a significant part of
EH's research, and because the risks of various health effects
vary with age, these studies take age into consideration. EH
supports research to characterize late-appearing effects
induced by chronic exposure to low levels of physical agents
and some basic research concerning certain diseases that occur
more frequently with increasing age.
Because health effects resulting from chronic low-level
exposure to energy-related toxic agents may develop over a
lifetime, they must be distinguished from normal aging
processes. To distinguish between induced and spontaneous
changes, information is collected from both exposed and
nonexposed groups on changes that occur throughout the life
span. These data help characterize normal aging processes and
distinguish them from the toxicity of energy-related agents.
Summarized below are specific research projects that the
Department sponsored in 1997-1998.
Long Term Studies of Human Populations--Through EH, DOE
supports epidemiologic studies of health effects in humans who
may have been exposed to chemicals and radiation associated
with energy production or national defense activities.
Information on life span in human populations is obtained as
part of these studies. Because long-term studies of human
populations are difficult and expensive, they are initiated on
a highly selective basis.
The Radiation Effects Research Foundation, sponsored
jointly by the United States and Japan, continues to work on a
lifetime followup of survivors of atomic bombings that were
carried out in Hiroshima and Nagasaki in 1945. Over 100,000
persons are under observation in this study. An important
feature of this study is the acquisition of valuable
quantitative data on dose-response relationships. Studies
specifically concerned with age-related changes are also
conducted. No evidence of radiation-induced premature aging has
been observed.
Multiple epidemiologic studies involving about 400,000
contractor employees at DOE facilities are being managed by the
Department of Health and Human Services through a Memorandum of
Understanding between the two agencies. These studies include
assessments of health effects at older ages due to ionizing
radiation and other industrial toxicants. Several of the
studies will look closely at workers who were first exposed at
age 45 or older, assessing the impact of these late exposures
in relation to the burden of chronic diseases that are common
among older people. The average age of workers included in
these studies is greater than 50 years.
The United States Uranium/Transuranium Registry, currently
operated by Washington State University, collects occupational
data including work, medical, and radiation exposure histories
and information on mortality among workers exposed internally
to plutonium or other transuranic elements. Most of the workers
participating ating in this voluntary program are retirees.
In response to the Defense Authorization Act of 1993, EH
has established a program involving a number of ongoing
projects across the DOE weapons complex to identify former
workers whose health may have been placed at risk as a result
of occupational exposures that occurred from the 1940's through
the 1960's. These projects provide medical screening and
monitoring for former workers to identify those at high risk
for occupationally related diseases and to identify workers
with diseases that may be reduced in severity by timely
interventions.
In addition to its epidemiologic research and health
monitoring programs, EH has established the Comprehensive
Epidemiologic Data Resource, a growing archive of data sets
from the many epidemiologic studies sponsored by DOE. This
public archive provides the research community with data that
continue to be used to gain additional insights into the
relationships between occupational exposures and a variety of
health outcomes including diseases of aging, such as cancer.
Other DOE-Funded Research Related to Aging
Since the inception of the Atomic Energy Commission, the
Department and its predecessor agencies have carried out a
broad range of research and technology development activities
which have impacted health care and medical research. The
Medical Sciences Division within the Office of Biological and
Environmental Research carries out a Congressional mandate to
develop beneficial applications of nuclear and other energy
related technologies including research in aging affecting
older Americans. The aging research involves study of a brain
chemical, dopamine (DA), and its function in humans as they
age. A significant decline in the function of the brain DA
system with age has long been a recognized fact, but the
functional significance of this loss is not known. Medical
imaging studies, using radiotracers; and positron emission
tomography, are designed to investigate the consequences of the
age-related losses in brain DA activity in cerebral function
and to investigate mechanisms involved with the loss of DA
function with normal aging. The results of these studies have
already shown that in healthy volunteers with no evidence of
neurological dysfunction there is a decline in parameters of DA
function, which are associated with decline in performance of
motor and cognitive functions. The results of these studies
also indicate that changes in life style, such as exercise, may
be beneficial in promoting the health of the dopamine system in
the elderly.
Additional research has resulted in the creation of a new
scientific discipline known as biodemography, a melding of
biology and demography. This research is searching for
biological information, at all levels of biological
organization, that predicts and explains patterns of age-
related mortality observed in populations. In the long term,
biodemography provides a conceptual framework that helps policy
makers assess the impact that specific biomedical interventions
such as heart bypass surgery, renal dialysis, chemotherapy, or
gene therapy will have on population aging and, as a result, on
the fiscal solvency of government entitlement programs for
aging citizens.
The programmatic costs for aging research are estimated at
approximately $400K annually.
ITEM 6--DEPARTMENT OF HEATH AND HUMAN SERVICES
----------
THE ADMINISTRATION ON AGING AND THE OLDER AMERICANS ACT
introduction
Today, one in every six Americans, or 44 million people, is
60 years of age or older. While most older Americans are active
members of their families and communities, others are at risk
of losing their independence. These include four million
Americans aged 85 and older and persons living alone without a
caregiver. The Administration on Aging (AoA) in the Department
of Health and Human Services is dedicated exclusively to
planning and delivering services to our nation's diverse
population of older Americans and their caregivers. AoA
provides critical information, assistance, and home and
community-based support services and programs that protect the
rights of vulnerable, at-risk older persons.
Working in close partnership with its sister agencies in
the Department and throughout the Executive Branch, AoA
provides leadership, technical assistance and support to the
national network on aging. This network includes AoA's central
and regional offices, 57 state units on aging (SUA's), 655 area
agencies on aging (AAA's), 223 Indian Tribal Organizations
(ITO's); and thousands of service providers, senior centers,
caregivers and volunteers. Appendix I includes an
organizational chart of the National Network on Aging.
consumer information and protection
Educating older persons and their families about issues of
concern is a critical component of AoA's consumer information
and protection role. AoA funds programs that link people to
available services, protects the rights of vulnerable and at-
risk older persons, educates them and their communities about
the dangers of elder abuse and consumer fraud, and offers
opportunities for older persons to enhance their health. Two
important examples include the Eldercare Locator and Insurance,
Benefits and Pension Counseling Programs.
AoA's elder rights protection programs also include the
Long-Term Care Ombudsman Program, that investigates and
resolves complaints that are made by or on behalf of residents
of nursing, board and care and similar adult care homes.
Through the AoA, thousands of paid and volunteer long-term care
ombudsmen, insurance counselors and other professionals have
been trained to recognize and report fraud and abuse in nursing
homes and other settings. The AoA also recruits and trains
retired professionals, such as doctors, nurses, attorneys,
accountants, and others to serve as health care ``fraud
busters.'' These recruits work with other older persons in
their communities to review their health care benefits
statements and to identify and report potential waste, fraud
and abuse.
supportive services and home and community-based care
AoA provides funds for home and community-based care
services, research and demonstrations These services include:
Access Services--information and assistance;
outreach; transportation; and case management.
In-home Services--home-delivered meals;
chores; home repair, modifications and rehabilitation;
homemaker/home health aides; and personal care.
Community Services--congregate meals; senior
center activities; nursing home ombudsman services;
elder abuse prevention; legal services; employment and
pension counseling; health promotion and fitness
programs.
Caregiver Services--respite; adult day care;
counseling and education; and support for caregivers of
persons with Alzheimer's disease by improving
coordination between the health care and social service
systems.
Long-Term Care Resource Centers--researching
best practices and innovative models of providing home
and community-based care.
native american programs
AoA awards funds to 223 ITO's, representing more than 300
tribes in the United States, to assist older American Indians,
Alaskan Natives and Native Hawaiians. Native Americans in
general--and older Native Americans in particular--are among
the most disadvantaged groups in the country. AoA's support
provides home and community-based services in keeping with the
cultural heritage and specific needs of each person receiving
assistance.
capacity building through discretionary grants
The discretionary grant programs authorized by Title IV of
the Older Americans Act constitute the major research,
demonstration, training, and information dissemination effort
of the AoA. Title IV program outcomes include:
an expanded understanding of older persons'
wants, needs and desires;
the development of innovative model
programs; and
the provision of technical assistance and
information to the aging network and to others who work
with older persons.
The Title IV program supports a number of projects,
including the continuation of the Eldercare Locator; Family
Friends; Senior Legal Hotlines, a national legal assistance
support, and related elder rights projects such as the National
Resource Centers on Long Term Care Ombudsman Programs and Elder
Abuse. New Title IV project areas, as earmarked by the
Congress, include the prevention of health care fraud, waste,
and abuse; pension information and counseling; minority aging;
and research on caregiving for Alzheimer's Disease patients. A
compendium of projects supported by Tile IV in FY 1997 and FY
1998 can be found in Appendix II.
preparing for the future
Through consumer advocacy and education targeted at present
and future generations of older Americans, AoA raises public
awareness about the importance of preparing now for living a
long life. AoA is providing leadership in addressing longevity
issues by focusing attention on attitudes and lifestyles,
interventions which contribute to good health, quality of life,
and financial security in the future.
This report is organized and divided into two sections
summarizing AoA's major activities in FY 1997-1998. Section I
discusses the activities focused on ``Improving Services for
Seniors and Their Families.'' Section II discusses the
activities related to ``Enhancing the Cap of the Network.''
Section I: Improving Services for Seniors and Their Families
preserving and strengthening the older americans act
The AoA, in consultation with key partners in the aging
network, continued work for the reauthorization of the Older
Americans Act (the ACT). A summary of the activities in the
Congress related to reauthorization of the Act follows:
Reauthorization in the 105th Congress
Senator Barbara Mikulski (D-MD) introduced the
Administration's proposed bill, S. 390, on March 4, 1997. It
contained one change from the Administration bill from the
104th Congress in that it did not transfer the USDA cash in
lieu of commodities program to AoA. This was consistent with
the Administration's position for the 105th Congress.
Representative Matthew G. Martinez (D-CA) introduced H.R.
1671 with co-sponsors Reps. Green (D-TX), J. Kennedy (D-MA),
Filner (D-CA) and Reps. Farr, (D-CA), Rep Frank (D-MA), Rep.
Nancy Pelosi (D-CA), Sanchez (D-CA), Lofgren (D-CA), Kucinich
(D-OH), Smith, Adam (D-WA), and Stabenow (D-Mich). Mr.
Martinez's statement which accompanied the bill indicated that
the bill contained the majority of the principles in the
Administration's bill from the 104th Congress. Inconsistent
with the Administration's initial position, Mr. Martinez's bill
did not transfer the Title V, Senior Community Service
Employment Program, to AoA.
On June 19, 1998, Rep. Frank Riggs (R-CA), Chair of the
House Subcommittee on Early Childhood, Youth and Families,
introduced H.R. 4099, a bill to reauthorize the Older Americans
Act.
On July 13, 1998, Senator John McCain (R-AZ), along with 25
bipartisan cosponsors, introduced S. 2295, a bill to
reauthorize the Older Americans Act until the year 2001. S.
2295 made no changes to current law, last authorized in 1992.
On July 29, 1998, Rep. Peter A. DeFazio (D-OR) and Rep.
Frank A. LoBiondo (D-NJ) introduced H.R. 4344 a bill which
mirrored the McCain bill to reauthorize the Older Americans
Act, S. 2295. H.R. 4344 was introduced with 151 bipartisan
cosponsors.
The House Subcommittee on Early Childhood, Youth and
Families (Frank Riggs, (R-CA), Chair; Matthew G. Martinez, (D-
CA), (Ranking Democrat), held two hearings (7/9/97 and 7/16/97)
on the reauthorization of the Older Americans Act. At the first
hearing held on July 9, 1997. William F. Benson, Acting
Principal Deputy Assistant Secretary for Aging, provided
testimony for the Administration. Others who testified at the
hearing included Judith Brachman, President of the National
Association of State Units on Aging and Cindy Farson, Past
President of the National Association of Area Agencies on
Aging.
Background and Status at Close of 105th Congress
The most recent reauthorization of the OAA expired on
September 30, 1995 during the 104th Congress. The 104th and
105th Congresses adjourned without taking final action on
reauthorization of the Older Americans Act. During the 105th
Congress, the Senate and House Majority Committee members
indicated that they would use their previous proposals (from
the 104th Congress) as the starting point for their legislative
proposals.
The 105th Congress adjourned on October 21, 1998 following
final passage on the FY 1999 Omnibus Consolidated
Appropriations bill which contained funding for the Older
Americans Act and the Administration on Aging for FY 1999.
Congress did not reauthorize the Older Americans Act because of
unresolved differences between the Majority and the Minority
together with the Administration. These differences included
efforts to alter parts of the Act that target services to low
income minority elders, that allow for older persons to receive
nutrition services without being required to pay, and that
provide employment to low income older persons through Title V
of the Act, administered by the Department of Labor. Near the
end of the 105th Congress, much discussion occurred around two
bills (S. 2295, McCain, R-AZ) and (H.R. 4344, DeFazio, D-OR)
which would have extended the current authorization, but no
final action occurred.
The Administration plans to introduce a bill to reauthorize
the Older Americans Act early in the 106th Congress.
protecting elders' rights
For close to three decades, state ombudsman programs have
investigated complaints and protected the rights of nursing
home and board and care facilities residents as well as brought
to the attention of the public, policymakers and regulatory
agencies a host of conditions that required change to improve
the health, safety, rights and welfare of these residents. In
FY 1996, ombudsman program funding from all sources totaled
$41,519,334, almost one million above the previous fiscal year.
In addition to attempting to improve the quality of care, paid
and volunteer ombudsman provide support for the
Administration's initiative to combat fraud, abuse and waste in
the Medicare and Medicaid Programs.
According to the Annual Long Term Care Ombudsman Report to
Congress for Fiscal Year 1996, over seventy-two percent of all
complaints by nursing home or board and care residents were
resolved or partially resolved by the national cadre of state
and local paid and volunteer ombudsmen working throughout the
nation. This report provides the first-ever compilation of data
for all state ombudsman programs on the types of problems
reported by those who seek assistance from the ombudsman
program. The data collected through this report helps to point
this nation in the right direction to better care for the
growing numbers of older persons expected in this country in
the next several decades.
Ombudsman opened 126,606 new cases and closed 116,242
cases, involving 179,111 complaints. Most complaints were filed
by residents of facilities or friends or relatives of
residents. Eighty-one percent of the cases closed involved
nursing home residents. The five most frequent nursing home
complaints were:
accidents, improper handling;
unheeded requests for assistance;
personal hygiene neglect;
lack of respect for residents; and
lack of adequate care plan, resident
assessment.
Seventeen percent of the cases closed involved board and
care homes, including assisted living, adult day care, and
similar levels of care facilities. The five most frequent
complaints in these settings involved:
menu--quality, quantity, variation, and
choice;
physical abuse;
administration and organization of
medications;
lack of respect for residents, poor staff
attitudes; and
equipment/building disrepair, hazard,
lighting, safety issues.
A copy of the Executive Summary of the Annual Long Term
Care Ombudsman Report can be found in Appendix III. Copies of
the report are also available through the National Aging
Information Center and the AoA website.
preventing crime and violence
According to the National Elder Abuse Incidence Study
released by the Assistant Secretaries for Aging and Children
and Families on October 5, 1998, at least one-half million
older persons in domestic settings were abused and or/
neglected, or experienced self neglect during 1996.
Additionally, the study estimated that for every reported
incident of elder abuse, neglect or self neglect, approximately
five go unreported. In cases where a perpetrator of abuse and
neglect is known, the perpetrator is found to be a family
member in 90 percent of the cases, and two-thirds of these
perpetrators are adult children or spouses. The report covered
all major categories of abuse and neglect in domestic settings.
Domestic elder abuse refers to maltreatment of an older
person residing in his/her own home or the home of a caregiver.
The four common kinds of elder abuse are:
physical abuse, the infliction of physical
pain or injury, e.g., slapping, bruising, sexually
molesting, restraining;
psychological abuse, the infliction of
mental anguish, e.g., humiliating, intimidating,
threatening;
financial abuse, the improper or illegal
use of the resources of an older person, without his/
her consent, for someone else's benefit; and
neglect, failure to fulfill a caretaking
obligation to provide goods or services, e.g.,
abandonment, denial of food or health-related services.
Self-neglect refers to the conduct of an older person
living alone which threatens his/her own health or safety. A
copy of the report is included in Appendix IV, and is available
from the National Aging Information Center and the AoA website.
On September 30, 1998, a new three-year cooperative
agreement was awarded to the National Association of State
Units on Aging (NASUA) to establish a new National Center on
Elder Abuse (NCEA). The NASUA operates the NCEA in partnership
with the National Committee for the Prevention on Elder Abuse
(NCPEA), National Association of Adult Protective Services
Administrators (NAAPSA), American Bar Association's Commission
on Legal Problems of the Elderly, University of Delaware's
Department of Consumer Studies, and the Goldman Institute on
Aging. The new NCEA will facilitate training and technical
assistance among state and local service providers working to
prevent elder abuse.
cracking down on fraud
Since 1995, the Administration on Aging (AoA) has been a
partner in a government-led effort to fight fraud, waste, and
abuse in the Medicare and Medicaid programs. The AoA, and its
national aging network, focused its initial anti-fraud and
abuse efforts on training state and local ombudsmen, insurance
counselors, and other professionals to recognize and report
suspected cases of fraud abuse in nursing facilities, home
health care agencies, and providers of durable medical
equipment. The effort was later expanded to train staff and
volunteers of state and area agencies on aging, senior centers,
and other aging service personnel.
Beginning in 1997, the AoA has administered two programs
designed to combat and prevent health care waste fraud and
abuse. The first program, funded under the Health Insurance
Portability and Accountability Act, expanded the training of
aging network personnel to 15 states. In early 1998, three
states were added, for a total of 18 states which focus on
training aging service professionals, and providing outreach,
counseling, and assistance through community-based provider
agencies.
The second program, funded through the enactment of P.
L.104-209, the Omnibus Consolidated Appropriations Act of 1997,
recruits and trains retired professionals, such as doctors,
nurses, teachers, lawyers, accountants, and others to work with
Medicare and Medicaid beneficiaries to review their health care
benefits statements and to identify and report potential waste,
fraud and abuse. In May, 1997, the AoA awarded funds to 12
state and community-based agencies and organizations for this
purpose.
During fiscal year 1998, both projects produced the
following outcomes:
held more than 1,600 training sessions;
trained over 8,000 professionals and
retired volunteers who are now working in their
communities on anti-fraud, waste, and abuse activities;
convened more than 3,000 community education forums
which directly informed more than 300,000 beneficiaries
in their communities about Medicare waste, fraud, and
abuse;
developed and disseminated more than 250
types of products, educational materials and training
guides--distributing tens of thousands of materials to
beneficiaries;
reached an estimated 44 million people
through public service announcements, community
education events, and other activities;
referred more than 700 calls to the Office
of the Inspector General's (OIG) hotline; and
contributed to the OIG's recovery of
millions of dollars in errors, overpayments, civil
penalties and monetary awards.
Based on information gathered from AoA's partners and
stakeholders, a number of new ORT-related technical assistance
resources were developed in 1998, including:
a report of ``best practice''
recommendations developed by the grantees;
a limited access internet communication
link which permits the AoA and its grantees and project
officers to ask questions, raise issues, and exchange
information with one another simultaneously;
an AoA anti-fraud web page for posting and
downloading manuals, brochures, fact sheets, and other
materials;
a bi-monthly newsletter, which includes
updates, volunteer spotlights, and other information;
the convening of a national technical
assistance and resource-exchange conference where
grantees exchanged best practice strategies; and
the drafting of two national brochures
designed to recruit volunteers--one targeted to retired
professionals and the other targeted to aging network
personnel.
increasing visibility of nutrition as a key component of health
State Nutritionist's Meeting
On November 14-15, 1997, the Administration on Aging (AoA)
held the second state nutritionists/administrators meeting,
``Preparing the Elderly Nutrition Program for the 21st
Century,'' in Dallas, Texas. Fifty-five state unit on aging
representatives from 45 states attended.
The program included presentations by the AoA, the Food and
Drug Administration, and Food and Nutrition Services of the
United States Department of Agriculture, state units on aging
from across the country, and personnel from the National Policy
and Resource Center on Nutrition and Aging. Individual speakers
and panels addressed the following topics: managing uncertainty
and change in Older Americans Act Nutrition Programs; strategic
planning for nutrition services at federal, state and local
levels; implementing the National Aging Program Information
System (NAPIS); using data to reduce risk; maintaining food
safety; and nutrition challenges including dietary reference
intakes, the relationship between nutrition and chronic
disease, and the delivery of nutrition services in home-care
and managed care.
Program outcomes included:
increased understanding of the relationship
between nutrition and chronic disease;
increased understanding of the components
necessary to implement the Elderly Nutrition Program
(ENP) and willingness to test innovative approaches;
increased understanding of the challenges
facing the ENP and the solutions states are using to
meet these challenges; and
improved partnerships between and among AoA
and state units on aging.
An evaluation of the comments from the meeting indicated
that states viewed the meeting as a success because it:
showed national leadership of the AoA
regarding the ENP;
ensured quality networking and information
sharing among state staff who often work in isolation
from other nutrition professionals or do not
communicate often with nutrition professionals;
integrated the nutrition program into the
larger view of home and community based care by
encouraging the participation of both nutrition staff
and social service and other state staff;
ensured a learning environment for AoA and
state staff in response to identified needs;
provided visibility for state solutions to
issues faced in many states; and
utilized state staff as partners in
developing the nutrition program nationally.
Morning Meals on Wheels
The AoA and the General Mills Foodservice (GMFS) entered
into a public-private partnership to expand meal service for
home bound older adults by adding a breakfast meal. The Morning
Meals on Wheels Breakfast Program (MMOW) partnership also
included the National Policy and Resource Center on Nutrition
and Aging at Florida International University (Center).
As a result of this public-private partnership, the AoA and
GMFS, with the assistance of the Center, conducted a six-month
feasibility study of expanding meal service from a single meal
at noon, to both breakfast and lunch meals for high risk
participants in home-delivered meal programs. Based on a
competitive request for applications, 20 nutrition service
providers were selected. These nutrition service providers were
representative of the network to ensure replicability for AoA
and GMFS. The programs were geographically dispersed; urban and
rural; large and small; served ethnically diverse populations;
utilized different methods for meal production; consisted of
independent non-profit nutrition service providers as well as
nutrition services directly provided by area agencies on aging;
targeted different groups of high risk individuals; and
represented both Title III and Title VI programs.
Successful applicants received:
$500 program setup grant from GMFS;
on-going product discounts; continuing
education funding;
written manual and newsletters;
technical assistance via conference calls,
individual telephone calls and in person visits;
publicity materials; and
volunteer materials.
Nutrition service providers began implementation in
September, 1997. Selected nutrition service providers agreed to
participate in an evaluation of the program by the Center which
would document both strengths and weakness of program
implementation and recommendations for replication.
Outcomes included:
service expansion to high risk homebound
older adults at minimal costs;
successful test of an innovative service
model;
development of individual outcome measures
for nutrition services, such as decreased nutritional
risk, improved nutrient intake, improved perceived
health, improved functionality, and increased caregiver
support;
development of program outcome measures for
nutrition services such as improved targeting of high
risk participants, improved customer satisfaction,
minimized costs for two meal a day service and improved
service delivery; and
independent evaluation of the Morning Meals
on Wheels Breakfast Program by the Center.
Based on an evaluation of the program, the AoA and GMFS
will consider the national expansion of the program to the
aging network of state and area agencies on aging, tribes and
nutrition service providers.
providing caregiver support
AoA continues to support a nationwide, toll free
information and assistance directory called the Eldercare
Locator, which can locate the appropriate AAA to help an
individual needing assistance. Older persons and caregivers can
contact the Eldercare Locator by calling 1-800-677-1116, Monday
through Friday, 9:00 a.m. to 8:00 p.m., Eastern Standard Time.
When contacting the Locator, callers should know the address,
zip code and county of residence of the person needing
assistance.
During FY 1997 and FY 1998 over 144,000 inquiries. Some of
the most frequently requested information included questions
about:
general information and assistance;
legal services;
transportation;
state general information;
insurance;
Alzheimer hotline;
nursing homes; and
prescriptions.
older americans month
The ``kick-off'' event for Older Americans Month (OAM) was
the AoA Caregivers Fair on May 1, 1998. The purpose of this
event was to provide federal employees with information on a
variety of services and resources available to assist older
persons and their caregivers. Approximately 40 local and
national organizations exhibited materials and provided
consultation and printed information to assist caregivers in
their efforts to care for a older family member, neighbor or
friend. The information provided included ``how-to''
information for long-distance caregiving, and assistance in
juggling the many demands of jobs and caregiving
responsibilities.
On May 1, 1997, the AoA launched OAM with a caregivers
resource fair for federal employees working in the southwest
area of the District of Columbia. The theme for the 1997 OAM
was ``Caregiving: Compassion in Action.'' State and Area
Agencies nationwide used the theme in the many events and
activities they sponsored in celebration of OAM. The caregiver
fair was designed to assist federal employees access a range of
care and services in the community to help older loved ones
maintain their independence and remain in their own homes and
communities. Forty-five exhibitors provided consultation and
information about in-home assistance, home-delivered meals,
home health care, transportation, legal assistance, respite/day
care, long-distance caregiving and long term care ombudsmen.
Section II: Enhancing the Capacity of the Network
improving service delivery to american indians, alaskan natives, and
native hawaiians
In 1998, grants totaling $18,457,000 were awarded to 223
Indian Tribal Organizations(ITOs) and one Native Hawaiian
organization for providing nutrition and supportive services to
Native American elders. In 1996, over 70,000 elders received
nearly two million congregate meals, 46,000 elders received 2.2
million home delivered meals, and nearly 110,000 elders
received supportive services, including outreach,
transportation, in-home services, and family support.
The University of Colorado at Denver and the University of
North Dakota at Grand Forks were awarded cooperative agreements
by the AoA totaling $700,000 to continue as National Resource
Centers for Older Indians, Alaskan Natives and Native
Hawaiians. The Centers continue to focus on health, community-
based long-term care and related issues. The Resource Centers
are the focal points for the development and sharing of
technical information and expertise to ITOs, Title VI grantees,
Native American communities, educational institutions, and
professionals and paraprofessionals in the field. In 1998, the
Resource Centers produced two culturally appropriate training
modules, entitled ``Diabetes Mellitus in American Indian/Alaska
Native Elders: Cultural Aspects of Care'' and ``Cancer among
Elder Native Americans.'' Additionally, they arranged to have
mammography screening available for elderly women attending the
National Indian Council on Aging national conference.
enhancing information and assistance activities
Over the past year the AoA has worked on several fronts to
support the enhancement of the Older Americans Act information
and assistance programs at the state and local levels. The
Balanced Budget Action of 1997 established the Medicare+Choice
Program, which authorizes new Medicare health plan options for
beneficiaries. The AoA has been working in partnership with the
Health Care Financing Administration (HCFA) to support
Medicare+Choice and initiated three steps to enhance
information and assistance activities.
First, AoA provided funds to State Units on Aging (SUAs) to
strengthen the capacity of information and referral providers
at the State, Area Agency and local levels to respond to
inquiries regarding Medicare+Choice. Second, AoA awarded grants
to six states to gather more detailed information on the type
and number of M+C inquiries made to information and referral
providers and to develop revised protocols for handling such
inquiries which will be widely disseminated to other SUAs.
Third, AoA worked in collaboration with the National
Information and Referral Support Center and HCFA to develop the
Medicare+Choice Training Manual for Older Americans Act
Information Referral & Assistance Programs. The manual was
provided to SUAs and Area Agencies on Aging to assist them in
developing Medicare+Choice training and outreach activities.
breast cancer awareness and education grants
On October 30, 1997, AoA awarded three grants totaling
approximately $300,000 designed to focus on outreach to older
under-served women, including Native Americans, to increase
their awareness of breast cancer, and encourage them to get
mammograms. The three grants to national aging organizations
were made available through the Federal Coordinating Committee
on Breast Cancer and the DHHS Office of Women's Health, and
were awarded during October, proclaimed by President Clinton as
National Breast Cancer Awareness Month. These grants were part
of the Administration's overall efforts to respond to the
significant threat posed by breast cancer. In 1995, First Lady
Hillary Rodham Clinton launched a campaign, highlighted at the
White House Conference on Aging, urging older women to obtain
mammograms, and to promote the use of Medicare coverage for
mammography. In 1997, President Clinton proposed, and Congress
adopted, the expansion of Medicare coverage which will help pay
for annual mammograms for all Medicare beneficiaries age 40 and
over.
Breast cancer is the most commonly diagnosed cancer and the
second leading cause of cancer deaths among American women.
There is no proven way to prevent breast cancer, so early
detection through mammography and clinical breast exams is
essential. For women aged 50-69, having regular mammograms can
reduce the chance of death from breast cancer by one third or
more. The AoA projects were designed to emphasize the national
aging network's capacity to reach out to older women, in
particular those who are most at risk, and urge them to become
more actively aware of the need to get a mammogram and become
more involved in their own self-care.
The grantees were:
The Long Term Care Resource Center of the
National Association of State Units on Aging,
Washington, D.C. This project was designed to work with
state and territorial agencies on aging which
administer home and community based care systems to
introduce breast cancer outreach and education into
several key aging services programs, including
information and assistance, congregate and home-
delivered meals, adult day care; case management and
homemaker/chore services. The project also coordinated
with the multi-city pilot outreach projects on
mammography being conducted by the Health Care
Financing Administration.
The Native Elder Health Resource Center at
the University of Colorado Health Sciences Center,
Denver, Colorado. This project included the
implementation of a coordinated education and
dissemination plan to address the root causes of the
differential in breast cancer morbidity and mortality
that affects older American Indian and Alaskan Native
women. The Center augmented its widely used Internet-
based telecommunications effort to more specifically
and effectively disseminate relevant educational
materials to key providers, planners, administrators
and policy makers in urban, rural and reservation
Native communities.
The National Resource Center on Native
American Aging at the University of North Dakota, Grand
Forks, North Dakota. This project also implemented a
coordinated education plan and pursued a nationwide
program of ``train the trainer'' instruction. It
disseminated culturally appropriate materials in
collaboration with the National Indian Council on
Aging, the National Title VI Directors organization,
the Recruitment and Retention of American Indians into
Nursing Programs (RAIN), the Indian Health Service, and
various other direct service programs serving urban and
reservation locations. An additional component of this
effort was four demonstration projects carried out by
RAIN to determine the most effective methods of
developing awareness.
adult immunization information
The AoA worked with the aging network to draw attention to
the importance of adult immunization with particular attention
to vaccination against influenza and pneumonia before the start
of the fall season. Every year, in the United States, between
50,000 to 70,000 adults die of influenza, pneumococcal
infections and hepatitis B. It is estimated that the cost to
society for these and other vaccine-preventable diseases of
adults exceeds 10 billion dollars per year. As a part of the
Department of Health and Human Services' effort to improve
health care provider and public awareness of the value of
immunization in promoting health and preventing disease, the
AoA encouraged aging network involvement and support of adult
immunization efforts. The Centers for Disease Control (CDC),
the National Institutes of Health (NIH), the Food and Drug
Administration (FDA), the Health Care Financing Administration
(HCFA) and the AoA, along with other agencies, have joined
together, over the years, in an effort, to reduce vaccine-
preventable illnesses.
Congress declared October 12-18, 1997, as National Adult
Immunization Awareness Week. This special observance
highlighted the importance of timely adult immunizations. The
AoA effort emphasized that adults, particularly those
individuals over age 65, should receive the flu vaccine
annually before early November. Individuals age 65 and over, or
others with chronic respiratory disease or a weakened immune
system, should also receive a once-in-a-lifetime immunization
against pneumonia. Adult immunization does not receive as much
public attention as childhood vaccination, partly because there
are no statutory requirements and partly because many adults do
not understand the importance of these preventive measures.
Adults also need immunization for the prevention of hepatitis A
and B, measles, mumps, rubella, tetanus, diphtheria, and
chickenpox.
managed care principles
The AoA conveyed a set of principles to assist and help
guide state and area agencies on aging, tribal organizations
and service providers in interactions and activities related to
managed health care. These principles reinforced the essential
role which state and area agencies on aging and other aging
organizations play with regard to consumer education,
protection, and representing the interest of the elderly.
Following the successful AoA Managed Care Conference in
February, 1996, many members of the aging network requested
additional assistance and guidance. The issuance of a set of
principles seemed to be the best approach for assisting the
aging network. This approach included receiving input about
draft documents from other federal agencies, various state and
area agencies on aging, national aging organizations,
universities and groups representing consumer concerns.
The question of the appropriate roles of state and area
agencies on aging in managed care has been widely discussed. In
an effort to respond to the issues and questions which have
been raised, AoA has worked to reinforce the public mission of
state and area agencies funded under the Older Americans Act in
the rapidly changing era of health and long-term care reform.
Our goal was to provide guidance for responding to new issues
facing the elderly as they encounter changes in health and LTC
delivery systems. This information was designed to assist the
aging network in its decision making as its representatives
worked with managed care organizations and policy makers in
addressing managed care issues. The guidance alerted the aging
network to some of the potential benefits and possible pitfalls
of managed health care plans.
The principles were developed because of the activity
related to managed care at the time. As of March 1, 1997,
approximately 5 million Medicare beneficiaries were enrolled in
managed care plans, accounting for approximately 14 percent of
the total Medicare population. Of the total 369 prepaid
contracts, 285 were risk contracts, 37 were cost contracts, 19
were demonstrations and 48 were health care prepaid plans.
There was a 1.6 percent increase in managed care enrollment
during February, 1997. Enrollment in Medicaid managed care
plans is also increasing. As of June 30, 1996, approximately
40.1 percent of the Medicaid population was enrolled in managed
care. This figure was an increase from 29.37 percent enrolled
in 1996.
documenting value of aging network in human terms
The value of the aging network is readily apparent at the
local level because of the tangible nature of the assistance
provided to older individuals. At the national level, the
network's activities are reflected through the state program
performance report under the National Aging Program Information
System (NAPIS). State Agencies on Aging provided a profile of
who was served with their submission of state program
performance data for Fiscal Year 1996. This information
represented the second step toward more client-centered
reporting by the aging network. The new reporting requirements
introduced by the AoA for Titles III and VII in 1995, required
both national and state data on persons served, services
provided, services expenditures, providers used, state and area
agency staffing, and the use of senior centers. Program
performance summaries and profiles of individual state programs
can be found in Appendix V.
celebrating the international year of older persons
The United Nations General Assembly designated 1999 as the
International Year of Older Persons (IYOP) to highlight the
challenges and opportunities of a rapidly aging global
population. President Clinton officially launched IYOP in the
United States on October 1, 1998, with its theme, ``Toward a
Society for all Ages''. Over 30 federal government departments
and agencies, coordinated by the AoA, have worked together to
plan government-wide activities through December 1999 to review
common issues that will affect aging populations of this
country in the next century and to share best practices among
other nations of the world. Many events in process at the
federal, state and local level are to highlight the importance
of an international demographic shift in aging populations and
the U.S. has assumed a leadership role in developing a
blueprint for the societal changes resulting from greater
longevity.
ADMINISTRATION FOR CHILDREN AND FAMILIES
Title XX--Social Service Block Grant Program
The major source of Federal funding for social services
programs in the States is Title XX of the Social Security Act,
the Social Services Block Grant (SSBG) program. The Omnibus
Budget Reconciliation Act of 1981 (Public Law 97-35) amended
Title XX to establish the SSBG program under which formula
grants are made directly to the 50 States, the District of
Columbia, and the eligible jurisdictions (Puerto Rico, Guam,
the Virgin Islands, American Samoa, and the Commonwealth of the
Northern Mariana Islands) for use in funding a variety of
social services best suited to the needs of individuals and
families residing within the State. Public Law 97-35 also
permits States to transfer up to ten (10) percent of their
block grant funds to other block grant programs for support of
health services, health promotions and disease prevention
activities, and low-income home energy assistance.
Under the SSBG, Federal funds are available without a
matching requirement. In fiscal year 1997, a total of $2.5
billion was allotted to States. $2.299 billion was appropriated
for these activities in fiscal year 1998. Within the specific
limitations in the law, each State has the flexibility to
determine what services will be provided, who is eligible to
receive services, and how funds are distributed among the
various services within the State. State and/or local Title XX
agencies (i.e., county, city, regional offices) may provide
these services directly or purchase them from qualified
agencies and individuals.
A variety of social services directed at assisting aged
persons to obtain or maintain a maximum level of self-care and
independence may be provided under the SSBG. Such services
include, but are not limited to adult day care, adult foster
care, protective services, health-related services, homemaker
services, housing and home maintenance services,
transportation, preparation and delivery of meals, senior
centers, and other services that assist elderly persons to
remain in their own homes or in community living situations.
Services may also be offered which facilitate admission for
institutional care when other forms of care are not
appropriate. Under the SSBG, States are not required to submit
data that indicate the number of elderly recipients or the
amount of expenditures provided to support specific services
for the elderly. States are required, prior to the expenditures
of funds under the SSBG, to prepare a report on the intended
use of the funds including information on the type of
activities to be supported and the categories or
characteristics of individuals to be served. States also are
required to report annually on activities carried out under the
SSBG. Beginning with fiscal year 1989, the annual report must
include specific information on the numbers of children and
adults receiving services, the amount spent in providing each
service, the method by which services were provided, i.e.,
public or private agencies, and the criteria used in
determining eligibility for each service.
Based on an analysis of post-expenditure reports submitted
by the States for fiscal year 1997, the list below indicates
the number of States providing certain types of services to the
aged under the SSBG.
Services: Number of States \1\
Home-Based Services \2\............................. 33
Adult Protective Services........................... 27
Transportation Services............................. 16
Adult Day Care...................................... 22
Health Related Services............................. 13
Information and Referral............................ 14
Home Delivered/Congregate Meals..................... 13
Adult Foster Care................................... 13
Housing............................................. 7
\1\ Includes 50 States, the District of Columbia, and the five eligible
territories and insular areas.
\2\ Includes homemaker, chore, home health, companionship, and home
maintenance services.
In enabling the elderly to maintain independent living,
most States provide Home-Based Services which frequently
includes homemaker services, companion and/or chore services.
Homemaker services may include assisting with food shopping,
light housekeeping, and personal laundry. Companion services
can be personal aid to, and/or supervision of aged persons who
are unable to care for themselves without assistance. Chore
services frequently involve performing home maintenance tasks
and heavy housecleaning for the aged person who cannot perform
these tasks. Based on the FY 97 data, 27 States provided Adult
Protective Services to persons generally sixty years of age and
over. These services may consist of the identification,
receipt, and investigation of complaints and reports of adult
abuse. In addition, this service may involve providing
counseling and assistance to stabilize a living arrangement. If
appropriate, Adult Protective Services also may include the
provision of, or arranging for, home based care, day care, meal
service, legal assistance, and other activities to protect the
elderly.
Low Income Home Energy Assistance Program
The Low Income Home Energy Assistance Program (LIHEAP) is
one of six block grant programs administered within the
Department of Health and Human Services (HHS). LIHEAP is
administered by the Office of Community Services (OCS) in the
Administration for Children and Families.
LIHEAP helps low income households meet the cost of home
energy. The program is authorized by the Omnibus Budget
Reconciliation Act of 198 1, as amended most recently by the
Community Opportunities, Accountability, and Training and
Educational Services Act of 1998, the NIH Revitalization Act of
1993 (P.L. 103-43), and the Human Services Amendments of 1994
(P.L. 103-252). In fiscal year 1997, all 50 states, the
District of Columbia, five territories, and 124 tribes and
tribal organizations received grants amounting to approximately
$1.215 billion, including $215 million in emergency contingency
funds.
In FY 1998, $1.0 billion is available. In addition, $300
million in emergency contingency funds are available, if the
President decides to release some or all of the funds because
of weather, supply shortages, or other energy emergencies.
Federally-recognized and state-recognized Indian tribes,
including Alaska native villages, may apply for direct LIHEAP
funding. The amount to be reserved from a state's allotment for
a direct grant to a tribe will be based on the ratio of
eligible tribal households to total eligible households in the
state, or a larger allotment amount agreed on by the tribe and
state. Of the $ 1.0 billion appropriated for FY 1998, $25
million is earmarked for leveraging incentive awards, to reward
grantees that add non-Federal resources to help low income
households meet their home heating and cooling needs. Up to 25%
of the leveraging incentive awards, or $6,250,000, will be used
to fund grants to LIHEAP grantees under the Residential Energy
Assistance Challenge Option Program (REACH) to develop
innovative programs to reduce the energy vulnerability of
LIHEAP-eligible households.
For FY 1994, Congress appropriated $1,437,408,000, of which
$141,950,240 could be used by grantees to reimburse themselves
for FY 1993 expenses. In addition, Congress rescinded some
funds and appropriated energy emergency contingency funds of
$300,000,000, which were released when the President declared
an emergency and requested the funds from Congress, thus
providing a total of $1,737,392,360 for FY 1994. The FY 1994
appropriations act provided advance FY 1995 funds of $1.475
billion. The FY 1995 HHS appropriations act rescinded part of
the advance FY 1995 appropriations included in the FY 1994
appropriations law, leaving funding of $1,319,202,479 for FY
1995. In addition, Congress appropriated energy emergency
contingency funds of $300,000,000, of which $100 million were
released when the President declared an emergency and requested
the funds from Congress, thus providing a total of
$1,419,202,479 for FY 1995. The FY 1995 HHS appropriations law
also provided for advance FY 1996 funding of $1,319,204,000.
Congress rescinded part of the advance funding for FY 1996 in
the FY 1995 supplemental appropriations law and in the FY 1996
appropriations law, leaving funding of $899,997,500. In
addition, Congress appropriated energy emergency contingency
funds of $300,000,000, of which $180 million were released when
the President declared an emergency and requested the funds
from Congress, thus providing a total of $1,079,997,500 for FY
1996. Congress did not appropriate in advance for FY 1997.
Block grants are made to States, territories, and eligible
applicant Indian Tribes. Grantees may provide heating
assistance, cooling assistance, energy crisis interventions,
and low-cost residential weatherization or other energy-related
home repair to eligible households. Grantees can make payments
to households with incomes not exceeding the greater of 150
percent of the poverty level or 60 percent of the State's
median income.\3\ Most households in which one or more persons
are receiving benefits from the Temporary Assistance to Needy
Families (TANF) block grant, Supplemental Security Income, Food
Stamps or need-tested veterans' benefits, may be regarded as
categorically eligible for LIHEAP.
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\3\ Beginning with fiscal year 1986, States are prohibited from
setting income eligibility levels lower than 110 percent of the poverty
level.
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Low-income elderly households are a major target group for
energy assistance. They spend, on average, a greater portion of
their income for heating costs than other low-income
households. Grantees are required to target outreach activities
to elderly or handicapped households eligible for energy
assistance. In their crisis intervention programs, grantees
must provide physically infirm individuals the means to apply
for assistance without leaving their homes, or the means to
travel to sites where applications are accepted.
In fiscal year 1998, about 34 percent of households
receiving assistance with heating costs included at least one
person age 60 or over, as estimated by the March 1998 Current
Population Survey.
OCS is a member of the National Energy and Aging
Consortium, which focuses on helping older Americans cope with
the impact of high energy costs and related energy concerns.
The 1998 reauthorization retains legislation from the 1994
reauthorization that specifically allows grantees to target
funds to vulnerable populations, mentioning by name ``frail
older individuals'' and ``individual with disabilities''. No
new initiatives commenced in 1997 or 1998 that impacted on the
status of older Americans.
The Community Services Block Grant (CSBG) and the Elderly
I. Community Service Block Grant--The Community Service
Block Grant Act (Title VI, Subtitle B, Public Law 97-35 as
amended; and the Coats Human Services Reauthorization Act of
1998 105-285) is authorized through fiscal year 2003. The Act
authorizes the Secretary, through the Office of Community
Services (OCS), an office within the Administration for
Children and Families in the Department of Health and Human
Services, to make grants to States and Indian tribes or tribal
organizations. States and tribes have the authority and the
flexibility to make decisions about the kinds of local projects
to be supported by the State or tribe, using CSBG funds. The
purposes of the CSBG program are:
(A) to provide a range of services and activities
having a measurable and potentially major impact on
causes of poverty in the community or those areas of
the community where poverty is a particularly acute
problem.
(B) to provide activities designed to assist low-
income participants including the elderly poor--
(i) to secure and retain meaningful
employment,
(ii) to attain an adequate education;
(iii) to make better use of available income;
(iv) to obtain and maintain adequate housing
and a suitable living environment;
(v) to obtain emergency assistance through
loans or grants to meet immediate and urgent
individual and family needs, including the need
for health services, nutritious food, housing,
and employment-related assistance;
(vi) to remove obstacles and solve problems
which block the achievement of self-
sufficiency;
(vii) to achieve greater participation in the
affairs of the community; and
(viii) to make more effective use of other
programs related to the purposes of the
subtitle,
(C) to provide on an emergency basis for the
provision of such supplies and services,
nutritious foodstuffs and related services, as
may be necessary to counteract conditions of
starvation and malnutrition among the poor;
(D) to coordinate and establish linkages
between governmental and other social services
programs to assure the effective delivery of
such services to low income individuals; and
(E) to encourage the use of entities in the
private sector of the community in efforts to
ameliorate poverty in the community; (Reference
Section 675(c)(1) of Public Law 97-35, as
amended).
It should be noted that although there is a specific
reference to ``elderly poor'' in (B) above, there is no
requirement that the States or tribes place emphasis on the
elderly or set aside funds to be specifically targeted on the
elderly. Neither the statute nor implementing regulations
include a requirement that grant recipients report on the kinds
of activities paid for from CSBG funds or the types of indigent
clients served. Hence, it is not possible for OCS to provide
complete information on the amount of CSBG funds spent on the
elderly, or the number elderly, or the numbers of elderly
persons served.
II. Major Activities or Research Projects Related to Older
Citizens in 1997 and 1998--The Human Services Reauthorization
Act of 1986 contained the following language: ``each such
evaluation shall include identifying the impact that assistance
. . . has on . . . the elderly poor.'' The reauthorization act
of 1998 requires that states assure a portion of the grant
funds will be used to support activities for elderly low-income
individuals as part of their State Application and Plan
submitted to OCS. Following the 1994 reauthorization, local
community action agencies began to include a description of how
linkages will be developed to fill identified gaps in services
through information, referral, case management, and followup
consultations as well as a description of outcome measures to
be used to monitor success in promoting self sufficiency,
family stability and community revitalization. As a result, the
CSBG Task Force on Monitoring and Assessment, a representative
body of eligible entities, established a goal which states,
``Low income people, especially vulnerable populations, achieve
their potential by strengthening family and other support
systems''. This goal assists local, state and federal agencies
to focus jointly on vulnerable populations, particularly the
frail elderly.
III. Funding Levels--Funding levels under the CSBG program
for States and Indian Tribes or tribal organizations amounted
to $480.8 million in fiscal year 1997. For fiscal year 1998,
$485.3 million was appropriated.
Aging and Developmental Disabilities Program
CRITICAL AUDIENCES PROJECT
Grantee: Institute for the Study of Developmental
Disabilities, Indiana University
Project Director: Barbara Hawkins, Ph.D., (812) 855-6506;
Fax (812) 855-9630
Project Period: 7/97-6/30/2002; FY '97--$82,680
The project provides training in a late-life functional-
developmental model for audiences that are critical to
effective planning and care of older persons. Activities
include developing training modules and instructional videos
for interdisciplinary university credit courses, and
illustrating the model by demonstration projects in community
retirement settings.
CENTER ON AGING AND DEVELOPMENTAL DISABILITIES/CADD
Grantee: University of Miami/CADD, Miami, FL
Project Director: John Stokesberry, Ph.D., (305) 325-1043
Project Period: 7/97-6/30/2002; FY '9--$82,680
CADD is providing education and training to service
providers, parents and families; advocacy and outreach for
consumers, information to the public on aging and developmental
disabilities; networking, policy direction and community-based
research. Materials will include a manual for parents/
caregivers, a resource guide and a handbook on developing a
peer companion project.
INTERDISCIPLINARY TRAINING CENTER
Grantee: UAP--Institute for Human Development, University
of Missouri-Kansas City
Project Director: Gerald J. Cohen, J.D., M.P.A., (816) 235-
1770; Fax (816) 235-1762
Project Period: 7/97-6/30/2002; FY '97--$82,680
The Center addresses personnel preparation needs with a
focus on administration, interdisciplinary training, exemplary
services, information/technical assistance/research; and
evaluation. Materials include training guide for aging,
infusion models, inservice fellowship curriculum, resource
bibliography, guide for training volunteers, and course
syllabus.
CONSORTIUM OF EDUCATIONAL RESOURCES
Grantee: UAP--University of Rochester Medical Center,
Rochester, NY
Project Director: Jenny C. Overeynder, ACSW, (716) 275-
2986; Fax (716) 256-2009
Project Period: 7/97-6/30/2002; FY '97--$82,680
An inter-university interdisciplinary consortium of
educational resources in gerontology and developmental
disabilities is being established in western New York, to be
linked to local and state networks. The project will develop
and implement preservice and inservice education curriculum for
direct care and nursing home staff
COMMUNITY MEMBERSHIP THROUGH PERSON--CENTERED PLANNING
Grantee: Eunice Kennedy Shriver Center, Inc. Shriver,
Center UAP
Project Director: Karen E. Gould, Ph.D., (617) 642-0238
Project Period: 7/92-6/30/1999; FY '97--$82,680
The Center has two primary goals which are: 1) to implement
a service delivery model that creates a new vision for
individuals who are labeled ``old'' and ``developmentally
disabled'' in Massachusetts, one in which entry into valued
adult roles is expected and capacities and interests form the
basis for structuring support; and 2) to provide training to
persons with developmental disabilities, family members and
friends, graduate students, professionals and community members
so that they can develop the skills necessary to support
community entry and inclusion in valued roles and relationships
for older adults with developmental disabilities, and learn to
use these skills in other settings.
NORTH DAKOTA PROJECT FOR OLDER PERSONS WITH DEVELOPMENTAL DISABILITIES
Grantee: North Dakota Center for Disabilities, Minot State
University
Project Director: Dr. Rita Curl and Dr. Demetrios
Vassiliou, (701) 857-3580
Project Period: 7/97-6/30/2002; FY '97--$82,680
The project seeks to upgrade the training opportunities
available to North Dakotans; 1) project staff works with pre-
service geriatric programs to develop strong DD components; 2)
project staff expands on an existing inservice training program
to provide information on aging DD service provision; and 3)
the project supports the development of training opportunities
for secondary consumers and advocates.
INTERDISCIPLINARY TRAINING INITIATIVE ON AGING AND DEVELOPMENTAL
DISABILITIES
Grantee: Graduate School of Public Health, University of
Puerto Rico--Medical Sciences
Project Director: Dr. Margarita Miranda, (809) 758-2525,
ext. 1453, (809) 754-4377
Project Period: 7/97-6/30/2002; FY '97--$82,680
The project provides pre-service training including
practical experience on best practices in serving the older
population with developmental disabilities to three (3)
graduate and to three (3) undergraduate students from different
disciplines per year (from the second funding year on);
provides culturally adapted in-service training to the Catano
Family Health Center's interdisciplinary team and to at least
40 professionals in the aging service per year through the
Graduate School and implementation of five regional Seminars on
Aging and Developmental Disabilities throughout Puerto Rico.
CREATIVE CHOICES FOR HEALTHY LIVING
Grantee: University-Affiliated Program Department of
Pediatrics, Univ. of Arkansas for Medical Sciences
Project Director: Judith Holt, Ph.D (501) 682-9900
Project Period: 7/97-6/30/2002, FY '97--$82,680
The UAP of Arkansas' Training Initiative Project, Creative
Choices for Healthy Living, will focus on persons who are aging
with developmental disabilities, their access to appropriate
services and supports within the community. Specifically, it
will enhance the health and well-being of older persons with
developmental disabilities and other members of the aging
community; enhance the skill and competencies of community
trainers to provide the training identified by the community
action plan; expand the project into new communities; develop
and disseminate preserve training modules for undergraduate and
graduate courses; disseminate project training modules for use
in other settings state- and nation-wide; and evaluate the
project's effects.
MEETING THE NEEDS OF A CULTURALLY-DIVERSE POPULATION
Grantee: Department of Pediatrics, Children's Hospital Los
Angeles
Project Director: Irma Castaneda, Ph.D (213) 669-2300-9900
Project Period: 7/1/97-6/30/2002, FY '97--$82,680
Develop and implement an interdisciplinary training program
with a special emphasis on the multicultural aspects of aging
and developmental disabilities which is integrated into
Department's curriculum for a minimum of one primary or
secondary consumer, and two graduate students per year. Will
integrate material on multicultural aging and developmental
disabilities into existing gerontology certificate programs.
Provide training and consultation on the integration of content
related to multicultural aging and developmental disabilities
to four university departments. Provide training to a total of
100 health care providers, community support personnel, and
family members on the changing health and social needs of aging
individuals with developmental disabilities from ethnic
minority groups.
OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) serves as the principal advisor to the
Secretary on policy and management decisions for all groups
served by the Department, including the elderly. ASPE oversees
the Department's legislative development, planning, policy
analysis, and research and evaluation activities and provides
information used by senior staff to develop new policies and
modify existing programs.
ASPE is involved in a broad range of activities related to
aging policies and programs. It manages grants and contracts
which focus on the elderly and coordinates other activities
which integrate aging concerns with those of other population
groups. For example, the elderly are included in studies of
health care delivery, poverty, State-Federal relations and
public and private social service programs.
ASPE also maintains a national clearinghouse which includes
aging research and evaluation materials. The ASPE Policy
Information Center (PIC) provides a centralized source of
information about evaluative research on the Department's
programs and policies by tracking, compiling, and retrieving
data about ongoing and completed HHS evaluations. In addition,
the PIC data base includes reports on ASPE policy research
studies, the Inspector General's program inspections and
investigations done by the General Accounting Office and the
Congressional Budget Office. Copies of final reports of the
studies described in this report are available from PIC.
During 1997 and 1998, ASPE undertook or participated in the
following analytic and research activities which had a major
focus on the elderly.
1. Policy Development--Aging
Federal Interagency Forum on Aging-Related Statistic
ASPE is a member of the Federal Interagency Forum on Aging-
Related Statistics. The Forum was established to encourage the
development, collection, analysis, and dissemination of data on
the older population. The Forum seeks to extend the use of
limited resources among the agencies through joint problem-
solving, identification of data gaps, and improvement of the
statistical information bases on the older population. The
primary goals of the Federal Forum were to provide federal
agencies a venue for discussing aging-related data issues and
concerns that cut across agency boundaries, facilitate the
improvement of existing aging data bases and the development of
new sources of information, improve the dissemination of
information on aging-related research and data, and encourage
cross-national research and data collection on population
aging. The Federal Forum was instrumental in gathering support
for several important surveys of the aging U.S. population
(e.g., the Health and Retirement Survey, the survey of Assets
and Health Dynamics Among the Oldest-Old, and the Second
Longitudinal Study of Aging) and produced several stand-alone
reports including Trends in the Health of Older Americans and
65+ in the United States.
Long-Term Care Microsimulation Model
During 1997 and 1998, ASPE continued to use extensively the
Long-Term Care Financing Model developed by ICF and the
Brookings Institution. The model simulates the use and
financing of nursing home and home care services by a
nationally representative sample of elderly persons. It gives
the Department the capacity to simulate the effects of various
financing and organizational reform options on public and
private expenditures for long-term care services. An updated
version of the model, which will include projections of both
long-term care and acute care expenditures, will be completed
in 1999.
2. Research and Demonstration Projects
Panel Study of Income Dynamics
University of Michigan, Institute for Social Research
Principal Investigators: James N. Morgan, Greg J. Duncan,
Martha S. Hill
Through an interagency consortium coordinated by the
National Science Foundation, ASPE assists in the funding of the
Panel Study of Income Dynamics (PSID). This is an ongoing
nationally representative longitudinal survey that began in
1968 under the auspices of the Office of Economic Opportunity
(OEO). The PSID has gathered information on family composition,
employment, sources of income, housing, mobility, health and
functioning, and other subjects. The current sample size is
over 7,000 persons, and an increasing number of them are
elderly. The data files have been disseminated widely and are
used by hundreds of researchers in this and other countries to
get an accurate picture of changes in the well-being of
different demographic groups, including the elderly.
Funding: ASPE and HHS precursors: FY67 through FY79--
$10,559,498; FY80--$698,952; FY81--$600,000; FY82--$200,000;
FY83--$251,000; FY84--$550,000; FY85--$300,000; FY86--$225,000;
FY87--$250,000; FY88--$250,000; FY89--$250,000; FY90--$300,000;
FY93--$300,000; FY94--$800,000; FY95--$150,000; FY96--$205,000;
FY97--$100,000; FY98:--$200,000
End Date: Ongoing
Welfare Reform, the Economic and Health Status of Immigrants and the
Organizations That Serve Them
The Urban Institute
Principal Investigators: Michael Fox and Leighton Ku
The main objectives of this study are to profile immigrants
with regard to health, employment, economic hardship and
participation in government programs--with special attention to
distinguishing different categories of immigrants and to
drawing comparisons with the native population; and to explore
the impacts of welfare reform on immigrants and the
organizations that serve them--with special attention to both
individual and institutional adaptations. To accomplish these
objectives this project will supplement an examination of
existing secondary data with intensive data collection in two
cities that together account for one-fourth of the immigrant
population in the United States--Los Angeles and New York.
Investigators will conduct a survey of 1625 immigrant
households in each city, intensive interviews with public and
private community organizations that serve immigrants, and in-
depth, in person interviews with immigrants affected by the new
laws. Secondary data will be used to present national profiles
of the immigrant population and to compare them with natives.
Local administrative data will be used to capture relevant
trends in program participation and, where possible, to develop
neighborhood indicators of health and other trends. The study
is structured to gather sufficient data on elderly immigrants
to make estimates of impacts on this population. We will also
conduct a survey of community organizations that serve
immigrants, and in-depth interviews with (1) immigrants
affected by the new laws; (2) community organizations that
serve immigrants; and (3) government agencies. Immigrants of
all ages will be included in the study.
Funding: (The study is funded under a cooperative agreement
and is supported by HHS (ASPE, ACF, HCFA), Agriculture (ERS/
FNS), and INS.) ASPE funding: FY97--$500,000; FY 98--$650,000
End Date: October 2000
A Primer for States and Consumers on Medicaid Home and Community Based
Services
George Washington University Medical Center
Principal Investigator: Sara Rosenbaum, Lea Nolan
An important priority of the White House, the Secretary and
the Department of Health and Human Services is a reduction in
the over-reliance on unnecessary institutional long-term care
and an expansion of consumer responsive home and community-
based long-term care options in the Medicaid program. As a step
toward addressing this priority, ASPE proposes to develop a
``primer'' on existing long-term care options in Medicaid that
promote choices in long-term care for consumers. The primer
will be an important and useful development tool for State
Medicaid and aging policy and program staff, consumers and
their representatives, and providers interested in the
expansion of choices in long-term care, including the promotion
of home and community-based options.
Funding: FY98--$150,000
End Date: July 1999
Hebrew Rehabilitation Center for the Aged, Boston and
University of Michigan
Principal Investigators: John Morris, Boston Brant Fries,
Michigan
Characteristics of Nursing Home Residents
Reducing institutionalization is a major long-term care
policy objective. It is important to identify nursing home
residents who could be discharged to the community if
appropriate home and community-based services were available.
This project will analyze data from a new source--the Minimum
Data Set (MDS). The MDS consists of assessments which have been
conducted on all nursing home residents in selected States as
part of a HCFA demonstration (and starting the summer of 1998,
the data will be collected in all 50 States). We will learn
much more about the medical conditions, functional needs, and
specific services used by nursing home residents than was
possible with previous data sets. We will also be able to study
important subpopulations, especially the nonelderly. The policy
implications of the findings will be assessed.
Funding: FY98--$150,000
End Date: September 1999
Comparative International Data on Aging: Health and Disability
Indicators
Organization for Economic Cooperation and Development,
Paris, France
Principal Investigator: Peter Hicks
This project builds on the G8 Summit Aging Experts Meeting
held in May 1997 and seeks to encourage international
comparative data collection. A two-day conference is planned
for Fall 1999 to bring researchers in disability and aging
measurement, policy experts, and survey administrators together
to discuss disability/health status measurement and survey and
data development.
Funding: FY98--$50,000
End Date: December 1999
Synthesis and Analysis of Medicare Post-Acute Care Benefits
The Urban Institute
Principal Investigators: Korbin Liu, Barbara Gage
This project will produce a synthesis of what is known
about: (a) current coverage and payment policies for post-acute
care (PAQ; (b) predictors of PAC use and nonuse and of the
type, amount, and duration of PAC use; (c) PAC utilization
including characteristics of PAC patients, patterns of PAC
utilization, and geographic distribution of providers; (d)
Medicare expenditures during the course of PAC episodes; (e)
outcomes of patients in and across PAC settings; and (f) State
policies designed to maximize Medicare PAC coverage. Medicare
PAC services refer to a broad array of services provided in a
variety of settings ranging from PPS-exempt hospitals to the
home. ``PAC providers'' include SNFs, HHAs, and LTC and
rehabilitation hospitals. In 1994, Medicare PAC expenditures
were approximately $24 billion--up from only $3 billion in
1986. Such rapid cost increases have caused policy makers to
focus considerable attention on these benefits and question the
underlying reasons for these increases. The review and
synthesis of the literature will discuss any historical issues,
the extent to which these issues remain, and any new issues
that have emerged.
Funding: FY98--$65,000
End Date: March 1999
A National Study of Assisted Living-for-the Frail Elderly
Research Triangle Institute
Principal Investigator: Catherine Hawes
The major purpose of this project is to analyze the role of
assisted living within the current long-term care system from
the perspective of consumers, owners/operators, workers,
regulators, investors and other stakeholders, and to issue a
report on its current status and future directions. ``Assisted
living'' refers to residential settings for people with
disabilities which combine both housing and personal assistance
services within a homelike or noninstitutional environment.
Currently, the number of assisted facilities nationally is not
known; estimates range from 8,000 to 30,000. Similarly,
estimates for the number of frail elderly and other persons
residing in such facilities range from 350,000 to 1,000,000.
This study will, among other things, generate a more reliable
estimate of the number of these facilities and their residents.
As assisted living options multiply, a challenge facing the
Federal and State governments is how (or whether) to regulate
such arrangements, balancing consumer protection concerns
(especially if public funds reimburse costs) with resident
rights for self-direction, taking risks and maintaining
accustomed lifestyles. The study will address several broad
policy-relevant issues, including supply and demand trends;
barriers; how closely practice parallels philosophy; the impact
of key features on outcomes; and quality and accountability.
Funding: FY94--$200,000; FY 96--$200,000; FY98--$350,000
End Date: December 1999
Personal Assistance Services ``Cash and Counseling'': Demonstration/
Evaluation
University of Maryland
Robert Wood Johnson Foundation
Principal Investigator: Kevin Mahoney
This project, undertaken in collaboration with the Robert
Wood Johnson Foundation, employs a classical experimental
research design (i.e., random assignment of participants to
treatment and control groups) to test the effects of ``cashing
out'' Medicaid-funded personal assistance services for the
disabled. The demonstration will include elderly as well as
younger disabled consumers. Two States are expected to
participate in the demonstration. In these States, control
group members will receive ``traditional'' benefits--i.e., case
managed home and community-based services, where payments for
services are made to vendors--while treatment group members
receive a monthly cash payment in an amount roughly equal to
the cash value of the services they would have received under
the traditional program. It is hypothesized that cash payments
will foster greater client autonomy and that, as a result,
consumer satisfaction will be greater. Consumers are expected
to purchase a somewhat different mix of disability-related
services and/or assistive technologies when they make the
decisions and payments themselves than when case managers
contract with vendors on their behalf. It is also hypothesized
that States will save Medicaid monies (mostly in administrative
expenses) from cashing out benefits. The analysis will consider
the effects of the demonstration according to the varying
characteristics of the consumers including age, disability,
gender, family support, and other factors.
Funding: FY97--$350,000; FY98--$111,389
End date: January 2001
Evaluation of Practice in Care (EPIC)
University of Colorado Center for Health Policy Research
Principal Investigator: Peter Shaughnessy
PURPOSE: From 1989 to 1992, there was a 210% increase in
Medicare expenditures for home health services. This increase
in utilization has generated widespread policy interest in
appropriate measures to control expenditures without
compromising quality. Medicare home health has been the subject
of considerable research, but the actual practice of home
health care has not been extensively examined. This study will
analyze ``episodes'' of care under the Medicare home health
benefit, assess the actual practice of care, the extent to
which there is variation in practice between acute and long-
term patients, and the factors that account for that variation.
This study will also examine decision-making processes between
patients, providers and physicians. What takes place during a
visit and between visits as ``actual practice'' has never been
measured. Furthermore, the function of decision-making by
various parties has not been observed in ``actual practice.''
This effort to understand issues surrounding regional and
practice variations of home health care delivery will aid the
Department and the industry in combating fraud and abuse, as
well as contribute valuable data to a future prospective
payment system.
Funding: FY97--$200,000, FY98--$0
End Date: March 2001
Imputation of Annual Family Income on the 1990-96 National Health
Interview Survey
National Center for Health Statistics
Principal Investigator: Diane Makuc
The National Health Interview Survey (NHIS) is the primary
data source for measuring the health of the
noninstitutionalized population of the United States. The
survey is conducted by the National Center for Health
Statistics (NCHS) in the Centers for Disease Control and
Prevention using a nationally representative, multistage
probability design. Approximately 50,000 households containing
roughly 115,000 persons are interviewed annually. In addition
to health information, the survey also collects demographic and
socioeconomic data (e.g., race and ethnicity, family
composition, employment status of household members, family
income and asset information, home and business ownership,
etc.). The strong relationship between socioeconomic status and
health, access to health care, and health care utilization, has
been widely documented. Annual family income is a key measure
of socioeconomic status and is used extensively in research
that measures differences in health status by racial and
economic subpopulations. These groups are frequently the focus
of federal government health initiatives and programs. Although
questions are asked on the NHIS about family income, a sizable
percentage of respondents do not have valid information. This
project supports an effort being undertaken by NCHS to impute
missing total annual family income data for the 1990-1996 NHIS.
The public use files produced from the project will provide
public policy analysts and researchers with consistent and
validated data necessary for comprehensive analyses of the
NHIS.
Funding: FY98--$25,000
End Date: December 1999
Informal Caregivers Supplement to the 1999 National Long-Term Care
Survey
Duke University
Principal Investigator: Kenneth Manton
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) has been involved in the past in designing a
modest respite benefit for Medicare beneficiaries with
Alzheimer's disease for inclusion in the President's budget. In
1998, there is renewed interest in having proposals for respite
services and other caregiver supports, on a broader scale,
incorporated into the President's long-term care budget
initiative. We are currently working with White House, OMB, and
Treasury staff to explore the use of tax incentives to help
informal caregivers be able to afford paid home care services
as a supplement to their own informal efforts. To respond to
these kinds of policy analysis requests, it is important for
ASPE to look ahead and anticipate future data needs. In this
case, the need is to have data collection mechanisms in place
to track, over time, changes in the characteristics of informal
caregivers of the disabled elderly, as we follow changes in the
population of disabled elders themselves. ASPE supported the
first and second Informal Caregiver's Supplement to the
National Long-Term Care Survey in 1982 and 1989 respectively. A
third round of data collection on informal caregivers is now
needed in order to remain up-to-date.
Family members typically initiate the process of nursing
home placement for disabled elders when they feel that the
disabled elder needs more help than can be provided in a home
setting. Often families come to such a decision when one or
more family caregivers have been providing upwards of 60 hours
per week of unpaid assistance. This project will enable in-
depth analysis of the conflicts informal caregivers experience
between employment and eldercare as well as provide information
about the health status of caregivers and measures of caregiver
stress and burden. These data can then be used in crafting
policy initiatives to support caregivers and prevent
``caregiver burnout'' which could result in premature
institutionalization. It will help determine whether and to
what extent caregivers' age, marital status, relationship to
the care recipient, household income, employment, health
status, and various measures of caregiver stress and burden are
associated with greater or lesser use of supplemental formal
care. We will also be able to measure the extent to which
caregivers as well as the disabled elders themselves experience
out-of-pocket spending for supplemental home care.
Funding: FY98--$300,000
End Date: March 2000
National Home and Hospice Care Survey (NHHCS)
National Center for Health Statistics
Principal Investigator: Thomas McLemore
Because of the difference in views as to whether or not the
homebound coverage requirement is being applied appropriately,
it would be extremely useful to have measures of the homebound
status of a nationally representative sample of Medicare
beneficiaries currently receiving services. This information
could then be used to estimate the extent to which home health
patients meet various indicators of ``homebound'' status.
The NHHCS is the only nationally representative survey that
samples and collects descriptive data on all current users of
home health services (including nonelderly as well as home
health users aged 65 and older) during the period when they are
actually in a home health episode. Because over 70% of home
health services are Medicare-financed, the sample of current
patients is predominantly comprised of Medicare beneficiaries.
The NHHCS Current Patient Survey includes descriptive
information on users of home health services, including a
number of potential indicators of ``homebound'' status.
Additional information on indicators of homebound status may be
obtained from the Outcome and Assessment Informal Set (OASIS)
instruments where these were completed and are present in
patients' files. Because HCFA has announced its intention to
mandate the use of the OASIS instrument to assess home health
patients' care needs upon admission and health status outcomes
at discharge (or every 60 days when their continued need for
home health services is recertified), many home health agencies
have already begun using the OASIS instrument on a routine
basis. It is therefore estimated that a high percentage of
patients selected for the NHHCS Current Patient Survey will
have completed OASIS instruments available. NCHS has agreed to
include in the data collection for these patients a limited set
of items from the OASIS.
Funding: FY98--$40,000
End Date: January 2001
Impact of Medicare HMO Enrollment on Health Care Costs in California
RAND
Principal Investigator: Glenn Melnick
This work is an ongoing project and an extension of
previous ASPE-funded work. The contractor performs three major
activities including: (1) updating the earlier analysis of
competition and selective contracting in California to the most
recent year available; (2) analyzing the effects of Medicare
managed care penetration on hospital Medicare Costs and
Utilization at the county level; and (3) analyzing the effects
on beneficiary utilization and costs of joining managed care
plans. In addition, the feasibility of conducting a fourth
analysis will be assessed; namely to replicate analysis number
three for beneficiaries who have withdrawn from Medicare
managed care plans in the recent past to try to see if such
beneficiaries are different from those who remain in managed
care. The contractor will put out a public use file with
documentation of the materials gathered since 1980 with ASPE
support beginning in 1987.
The project compares pre-managed care enrollment
characteristics, service utilization, and costs among
demographically-matched individuals in standard Medicare and
Medicare HMOs. In addition, the project includes comparisons
with a third group of persons who disenrolled from Medicare
HMOs. This data will then be used to build prediction models
for subsequent years.
Funding: FY94--$531,000; FY 97--$160,000; FY98--$200,000;
FY99--$173,000
End date: Fall 2000
CENTERS FOR DISEASE CONTROL AND PREVENTION
National Center for Chronic Disease Prevention and Health Promotion
CDC's National Center for Chronic Disease Prevention and
Health Promotion (NCCDPHP) is involved in a wide array of
activities on behalf of older Americans. Research and
programmatic efforts of the Aging Studies Branch of the
Division of Adult and Community Health focus on musculoskeletal
diseases (osteoarthritis, osteoporosis), Alzheimer's disease,
urinary incontinence, long-term care needs among minorities,
and surveillance. Other efforts of NCCDPHP focus on disability,
diabetes, cancer, and health information (and various other
programmatic and research areas.)
musculoskeletal diseases
Musculoskeletal diseases are prevalent and disabling
chronic diseases, affecting approximately 38 million persons in
the United States. Data indicate that 49.4 percent of persons
65 years and older have symptomatic musculoskeletal diseases
and 11.6 percent of persons in this age group have arthritis as
a major or contributing cause of activity limitation. Data are
needed to describe the natural history of disease as well as to
direct development of effective intervention efforts. To
address the burden of osteoporosis and arthritis, NCCDPHP:
developed the National Arthritis Action
Plan--A Public Health Strategy. This plan was released
in November of 1998 and was developed under the
leadership of CDC, the Arthritis Foundation, and the
Association of State and Territorial Health Officials.
The plan proposes action in three major areas:
surveillance, epidemiology, and prevention research;
communication and education; and programs, policies,
and systems. It is designed to encourage public health
organizations, arthritis organizations, and other
interested organizations to work together at the
national, state, and local levels.
analyzed the Arthritis Self-Help Course.
This analysis showed the course to be a cost-saving
intervention from both the societal and health care
system perspectives.
is studying the cost-effectiveness of
different interventions designed to prevent
osteoporosis in women who are perimenopausal or
postmenopausal.
determined the prevalence of hip and knee
osteoarthritis among whites and blacks in Johnston
County, NC, a rural, southern county. The Johnston
County Osteoarthritis Project is beginning follow-up of
3200 Caucasian and African-American residents of a
rural North Carolina county to determine factors
associated with the development and progression of hip
and knee osteoarthritis--the leading causes of
arthritis disability.
alzheimer's disease
Chronic neurological diseases, conditions common among
elderly, causes high levels of morbidity, disability, family
stress, and economic burden. For example, the costs due to
dementias were estimated at $24-$48 billion in 1985, and will
increase as the population ages. However, the epidemiology of
these conditions is poorly understood. NCCDPHP is studying the
epidemiology of Alzheimer's Disease to determine disease rates,
risk factors, and prevention factors.
long-term care needs
NCCDPHP conducted an assessment of long-term care needs
among older adults in the Indian Health Service Santa Fe
Service Unit, New Mexico. The objectives of the project were
(1) to provide estimates of the population of functionally
dependent adults age 55 and over within the Santa Fe Service
Unit (SFSU) and distinguish clinically relevant subgroups; (2)
to document the extent of informal care provided by family
members to elders with chronic care needs; (3) to analyze the
strengths and weaknesses of the current formal long-term care
service system within the SFSU to accommodate the needs of the
target population.
NCCDPHP has initiated the EnPOWER project to improve
prevention services in older women in HMO's. The project aims
to enhance and promote preventive health services for older
women in a managed care setting.
Surveillance
NCCDPHP conducts surveillance of the health status of the
elderly. Studies include:
planning a surveillance summary of the
health status and health services use among Americans
age 65 and older;
monitoring the impact of managed care
organizations' growth on the public health of the
elderly;
assessing the prevalence of
electroconvulsive therapy on older adults by age,
gender, and ethnicity;
ensuring availability of complete, timely,
and accurate cancer surveillance data at state,
regional, and national levels;
generating national and state estimates of
the prevalence and incidence of diabetes, the processes
and outcomes of care, and the costs of care in the
Medicare population;
using several health-related quality-of-life
measures in the state-based Behavioral Risk Factor
Surveillance System (BRFSS) to track quality of life in
the States;
determining the feasibility of a Medicare
claims-based surveillance system for possible adverse
effects of folic acid food fortification among persons
with vitamin B12 deficiency; and
conducting a survey of the knowledge,
attitudes, and practices of postmenopausal women
regarding hormone replacement therapy (HRT) to
determine factors associated with having heard of HRT
and initiating use of HRT.
Disability
NCCDPHP funds the Center for Health Promotion in Older
Adults at the University of Washington at Seattle, School of
Public Health to promote health among men and women aged 65
years or older. The Center evaluates the presence of social
networks and the influence of healthy eating and physical
activity on elderly residents of public housing units. The
Center also focuses on reducing disability and falls in older
adults through interventions to improve physical activity,
nutrition, and home safety.
diabetes
The burden of diabetes is heavier among elderly Americans.
More than 18% of adults over age 65 have diabetes. NCCDPHP
funds diabetes control programs (DCP) in all 50 states, the
District of Columbia, and eight U.S. affiliated island
jurisdictions to effect changes and improvements in systems
that care for and support people with diabetes. The primary
goal of the DCPs is to improve access to affordable, high-
quality diabetes care and services. Priority is on reaching
high-risk and disproportionately burdened populations which
include the aged. NCCDPHP provides resources and technical
assistance to state-based diabetes control programs to:
determine the size and nature of diabetes-
related problems and why they exist,
develop and evaluate new strategies for
diabetes prevention,
establish partnerships to prevent diabetes
problems,
increase awareness of diabetes prevention
and control opportunities among the public, the health
care and business communities, and people with
diabetes, and
improve access to quality care to prevent,
detect, and treat diabetes complications.
NCCDPHP also supports programs that try to change the way
diabetes is treated in the United States by raising awareness
among affected individuals, age 45 and older, of the importance
of lowering their blood sugar can make a huge difference in
their lives.
cancer
More than 30% of deaths from breast cancer in women over
age 50 are preventable through widespread use of mammography
screening for early detection. The National Breast and Cervical
Cancer Early Detection Program targets underserved women,
including older women with low income, and women of racial and
ethnic minority groups. NCCDPHP currently funds the 50 states,
4 U.S. territories, the District of Columbia, and 15 American
Indian/Alaska Native organizations through this program.
The WISEWOMAN (Well-Integrated Screening and Evaluation for
Women in Massachusetts, Arizona, and North Carolina) program is
funded by NCCDPHP to determine whether adding other preventive
services such as cardiovascular disease risk factor screening
and intervention to the National Breast and Cervical Cancer
Early Detection Program is effective in improving the health
status of uninsured women age 50 and older.
NCCDPHP supports a project to generate information about
attitudes towards prostate cancer screening and treatment, and
how quality of life related to early detection and treatment;
to determine whether screening for prostate cancer actually
reduces mortality; and to develop appropriate health messages
for men and their families about prostate cancer screening and
early detection.
NCCDPHP sponsors a program promoting the early detection of
colorectal cancer. The objectives of the project are to promote
awareness and use of colorectal cancer screening among health
care providers and the public, especially the older population;
to support research that promotes the inclusion of colorectal
cancer screening in quality measures applied to managed care
organizations; and to support the development of standards for
screening sigmoidoscopy.
health information
The Health Promotion and Education Database and Cancer
Prevention and Control Database contain health information that
pertains to aging. The databases include literature and
programmatic information about disease prevention, health
promotion, and health education information on nutrition,
smoking cessation, cholesterol, high blood pressure, injury
prevention, exercise, weight management, stress management,
diabetes mellitus, and breast and cervical cancer screening.
The databases are a valuable resource for health providers
working with the elderly. They are available through CDC's CDP
(Chronic Disease Prevention) File CD-ROM, the Public Health
Service's Combined Health Information Database (CHID) and CDC's
WONDER system. CDP File is available from the Superintendent of
Documents, Government Printing Office, Washington, DC 20402,
202-512-1800 (Stock No. 717-145-00000-3). CHID can be accessed
through most library and information services. CHID may be
accessed via the Internet at http://chid.nih.gov. For more
information about WONDER, contact CDC WONDER Customer Support
at 404-332-4569.
Other NCCDPHP projects are examining:
co-morbidities among older adults
hospitalized with depression
cost of excess mortality associated with
fractures in persons on Medicare
the experience of 84 Chickasaw Indian Family
care givers and their views of community-based services
and institutional care for elders
the individual and population-level
distribution of costs and resource utilization
associated with 11 types of incident fractures among
beneficiaries aged 65 and over during the 1 year period
following fracture and the excess costs of these
fractures to the Medicare program and to the health
system.
National Center for Environmental Health
CDC's National Center for Environmental Health (NCEH)
addresses the prevention of secondary conditions and promotion
of health among the 54 million Americans with disabilities.
NCEH is currently involved in two activities related to aging.
The Center is analyzing NHIS and NHIS-Supplement on Aging data
to identify the correlates of aging related to sensory
impairments and to characterize disability in the above 55 age
groups by race/ethnicity, gender, region, and activity
limitation. These analyses will be included in the disability
chapter of the upcoming MMWR Supplement on Aging. NCEH is also
collaborating with NCCDPHP in the Osteoarthritis of the Hip and
Knee in Johnston County, NC Project.
National Center for Health Statistics
CDC's National Center for Health Statistics (NCHS) is the
Federal Government's principal health statistics agency. The
NCHS data systems address the full spectrum of concerns in the
health field from birth to death, including overall health
status, morbidity and disability, risk factors, and health care
utilization.
The Center maintains over a dozen surveys and vital
statistics data files that collect health information through
personal interviews, physical examination and laboratory
testing, administrative records, and other means. These data
systems, and the analyses that result are designed to provide
information useful to a variety of policy makers and
researchers. NCHS frequently responds to requests for special
analyses of data that have already been collected and solicits
broad input from the health community in the design and
development of its surveys.
A broad range of data on the aging of the population and
the resulting impact on health status and the use of health
care are produced from these systems. For example, NCHS data
have documented the continuing rise in life expectancy and
trends in mortality that are essential to making population
projections. Data are collected on the extent and nature of
disability and impairment, limitations on functional ability,
and the use of special aids. Surveys currently examine the use
of hospitals, nursing homes, physicians' offices, home health
care and hospice, and are being expanded to cover hospital
emergency rooms and surgi-centers.
In addition to NCHS surveys of the overall population that
produce information about the health of older Americans, a
number of activities provide special emphasis on the aging.
They are described below.
Second Supplement on Aging
In 1994, the National Center for Health Statistics began
conducting the Second Supplement on Aging (SOA 11) as part of
the National Health Interview Survey. Interviews were conducted
with a nationally representative sample of 9,447 civilian
noninstitutionalized Americans 70 years of age and over. The
study, released in 1998, provides important data on the elderly
that can be compared with similar data from the 1984 SOA. In
addition, SOA 11 serves as a baseline for the Second
Longitudinal Study of Aging (LSOA 11), which will follow the
baseline cohort through one or more re-interview waves. The
first re-interview wave was conducted in 1998.
Information for the SOA II comes from several sources: the
1994 NHIS core questionnaire, Phase I of the National Health
Interview Survey on Disability (NHIS-D), and Phase 2 of the
NHIS-D, conducted approximately one year after Phase 1. The
survey questions and methodology are similar to the first LSOA,
but improvements reflect a number of methodological and
conceptual developments that have occurred in the decade
between the LSOA and LSOA II, as well as suggestions made by
users of the LSOA and others in the research community.
A primary objective of the SOA 11 is to examine changes
which may have occurred in the physical functioning and health
status of the elderly over the past decade. To this end,
questions concerning physical functioning and health status and
their correlates are repeated in the SOA 11. These include
questions on activities of daily living, instrumental
activities of daily living, and work-related activities, as
well as medical conditions and impairments, family structure
and relationships, and social and community support. In
addition to these repeated items, the SOA 11 questionnaire has
been expanded to include information on risk factors (including
tobacco and alcohol use), additional detail on both informal
and formal support services, and questions concerning the use
of prescription medications.
These data, when used in conjunction with data from the
LSOA, enable users to identify changes in functional status,
health care needs, living arrangements, social support, and
other important aspects of life across two cohorts with
different life course perspectives. This will provide
researchers and policy planners with an opportunity to examine
trends and determinants of ``healthy aging.''
Trends in Health and Aging
Objective and Description: The NCHS has launched a new data
dissemination project, Trends in Health and Aging. Funded in
part by the National Institute on Aging and located within
NCHS's Office of Analysis, Epidemiology, and Health Promotion
(OAEHP), Trends in Health and Aging draws upon the statistical
resources of NCHS and other Federal statistical agencies to
provide current, policy-relevant information on the health and
well-being of the elderly population in the United States. Work
began on the database in 1997. It will serve as an important
electronic resource for those seeking relevant national data on
a host of issues related to future access to affordable health
care and the enhancement of quality of life.
Project description
At the heart of Trends in Health and Aging will be the
routine compilation of trend data on the elderly population in
the United States organized under four general topic areas,
demography or population composition, health and well-being,
health care utilization, and health care expenditures. A set of
key indicator tables and graphics, drawn from such data systems
as Vital Statistics and the National Health Interview Survey
(NHIS) will be placed on the NCHS website and updated annually.
Summary analyses will accompany these tables as will
documentation on those administrative systems and surveys from
which data are drawn. In addition NCHS plans to provide links
to important micro-level data such as annual Cause of Death
mortality files and the Supplements on Aging for analysts who
wish to do their own analysis. Products under development
include the 1999 Health US: Chartbook on Health and Aging.
Federal Forum on Aging-Related Statistics
The Forum was initially established in 1986, with the goal
of bringing together Federal agencies with a common interest in
database development and statistical compilation on issues in
aging. The Forum has played a key role in improving aging-
related data by critically evaluating existing data resources
and limitations, stimulating new database development,
encouraging cooperation and data sharing among Federal
agencies, and preparing collaborative statistical reports.
During 1998, an organizing committee was established to
coordinate the activities and goals of the Forum for 1999 and
beyond. In addition to the Bureau of the Census, the National
Center for Health Statistics, and the National Institute on
Aging--the original core agencies--the members now include
representatives from the Administration on Aging, the Bureau of
Labor Statistics, the Health Care Financing Administration, the
Office of Management and Budget, the Office of the Assistant
Secretary for Planning and Evaluation, and the Social Security
Administration.
NHANES I Epidemiologic Follow-Up Study
The first National Health and Nutrition Examination Survey
(NHANES I) was conducted during the period 1971-75. The NHANES
I Epidemiologic Follow-up Study (NHEFS) tracks and re-
interviews the 14,407 participants who were 25-74 years of age
when first examined in NHANES I. NHEFS was designed to
investigate the relationships between clinical, nutritional,
and behavioral factors assessed at baseline (NHANES 1) and
subsequent morbidity, mortality, and hospital utilization, as
well as changes in risk factors, functional limitation, and
institutionalization.
The NHEFS cohort includes the 14,407 persons 25-74 years of
age who completed a medical examination at NHANES I. A series
of four follow-up studies have been conducted to date. The
first wave of data collection was conducted from 1982 through
1984 for all members of the NHEFS cohort. Interviews were
conducted in person and included blood pressure and weight
measurements. Continued follow-ups of the NHEFS population were
conducted by telephone in 1986 (limited to persons age 55 and
over at baseline), 1987, and 1992.
Participant tracing and data collection rates in the NHEFS
have been very high. Ninety-six percent of the study population
has been successfully traced at some point through the 1992
follow-up. While persons examined in NHANES I were all under
age 75 at baseline, by 1992 more than 4,000 of the NHEFS
subjects had reached age 75, providing a valuable group for
examining the aging process. Public use data tapes are
available from the National Technical Information Service for
all four waves of follow-up. The 1992 NHEFS public use data is
also available via the Internet. NHEFS data tapes contain
information on vital and tracing status, subject and proxy
interviews, health care facility stays in hospitals and nursing
homes, and mortality data from death certificates. All NHEFS
Public Use Data can be linked to the NHANES I Public Use Data.
NHANES IV Planning
The Fourth National Health and Nutrition Examination Survey
is in its final planning stages in preparation for the
beginning of data collection planned for January, 1999.
Although a wide range of the conditions assessed in NHANES IV
are most common among the elderly, several components are
particularly relevant to aging research:
Muscle Strength, Impairment, and Disability:
All persons age 50+ will have measurement of isokinetic
muscle strength of knee extensors and flexors and all
persons age 60+ will have an assessment of ability and
time to get up from an armless chair five times and
time to perform a twenty foot walk at the usual speed.
Both sets of measures will provide important data on
physical impairment and function in the elderly and
will be correlated to other disability related self
reported items and other objective measurements
obtained in the survey.
Lower Extremity Disease: For the first time,
the survey will include an evaluation of lower
extremity disease in persons age 40+, including Ankle-
Brachial Pressure Index measurement and assessment of
peripheral neuropathy. These data are especially
important for assessing the complications of diabetes
and the prevalence of peripheral vascular disease.
Visual and Hearing Impairment: Vision (age
12+) and hearing (age 20+) will be assessed including
assessment of visual acuity, near vision (age 50+),
pure tone audiometry thresholds, and typanometry.
Sensory impairment is an important component of
functional impairment in the elderly.
Bone Mineral Status: Bone mineral status
will be assessed including total bone mineral content
and bone mineral density by dual X-ray absorptiometry.
Osteoporosis is an important risk factor for hip
fractures in the elderly.
Cognitive Function: Cognitive function will
be assessed in persons age 60+ with the Digit Symbol
Substitution Test.
Balance and Vestibular Function: The
standard Romberg test of postural sway will be assessed
in all persons age 20+. Balance impairment is related
to the incidence of many fractures caused by falling,
especially hip fractures in the elderly.
Analysis of NHANES III Data
NCHS is engaged in a range of projects analyzing data from
NHANES III related to aging. These projects include:
Prevalence of Disability and Risk Factors
Associated with Disability. NHANES III data will be
analyzed to assess the prevalence of physical and
functional limitation. It includes self reported data
obtained in the household interview and performance-
based data obtained in the mobile examination center.
The risk factors associated with disability will be
assessed to provide a better understanding of the
etiology and treatment of disability in the elderly.
Region of Birth and Cardiovascular Risk
Factors. NHANES III data will be used to assess early-
life influences such as region of birth on the pattern
of risk factors for cardiovascular disease in later
life.
Nutritional Intake among the Elderly. The
patterns of nutrient intake among adults age 60+ in
NHANES III will be analyzed.
Vital Statistics on Aging
Information on mortality from the national vital statistics
system plays an important role in describing and monitoring the
health of both the institutionalized and non-institutionalized
elderly population. The data include measures of life
expectancy, causes of death, and age-specific death rate
trends. The basis of the data is information from death
certificates, completed by physicians, medical examiners,
coroners, and funeral directors, used in combination with
population information from the U.S. Bureau of the Census.
During 1997 and 1998, efforts were made to both assess and
improve mortality data for the elderly. NCHS is looking into
the possibility of increasing the level of age detail shown in
tabulations of mortality for the elderly, focusing on the age
group 85 years and over, often treated as an aggregated
category. Current efforts involve assessing both the
availability and quality of mortality and population data for
more detailed age groups among the elderly.
NCHS is expanding outreach to certifying physicians on
proper completion of the cause-of-death section of the death
certificate by designing material appropriate for diverse
settings including professional meetings and electronic death
certificates.
National Mortality Followback Survey: 1986 and 1993
The 1986 National Mortality Followback Survey (NMFS) was
the first such survey in 18 years. Over 100 papers and
publications have used data from the survey. The followback
survey supplements mortality information from the vital
statistics systems through inquiries of the next of kin of a
sample of decedents. Because two-thirds of all deaths in the
Nation occur at age 65 or older, the 1986 survey focused on the
study of health and social care provided to older decedents in
the last year of life. This is a period of great concern for
the individual, the family and community agencies. It is also a
period of heavy care use. Agency program planning and national
policy development on such issues as hospice care and home care
can be informed by the data from the survey. A public use data
tape from the next-of-kin questionnaire was released in 1988. A
second tape, combining data from the next-of-kin and hospitals
and other health care facilities, was available in 1990.
The 1993 National Mortality Followback Survey is comprised
of a nationally representative sample of approximately 23,000
decedents 15 years of age or older who died in 1993, with over-
sampling of black decedents, females, and centenarians. The
data were released in 1998. The survey design parallels the
earlier follow-back survey conducted in 1986, with additional
emphasis on deaths due to external causes, as well as
disability in the last year of life. Hospital records are not
included in the 1993 survey, but medical examiner/coroner
records are included.
National Health Interview (NHIS): Special Topics
The NHIS continues to collect data on a wide range of
special health topics for the civilian, non-institutionalized
population, including the older population. A recent special
health topic on disabilities was conducted in two phases. The
first phase questionnaire identified persons with disabilities.
It included questions on sensory, communication and mobility
problems; selected chronic conditions; activities and
instrumental activities of daily living (ADL/IADL); mental
health; services and benefits; self-perceived disability, and
conditions. The second phase collected detailed information
about persons identified as having a disability. It included
questions on housing and long-term care services;
transportation; social activity; work history/employment;
vocational rehabilitation; assistance with key activities;
other services; and self-direction. The first year of the Phase
1 Disability file was released in 1996. The remainder of the
Disability files were released in 1998.
The National Health Care Survey
The National Health Care Survey (NHCS) is an integrated
family of surveys conducted by the NCHS to provide annual
national data describing the Nation's use of health care
services in ambulatory, hospital and long-term care settings.
Currently, the NHCS includes six national probability sample
surveys and one inventory. These seven data collection
activities include:
the National Hospital Discharge Survey which
examines discharges from non-Federal, short-stay and
general hospitals;
the National Survey of Ambulatory Surgery
which examines visits to hospital-based and
freestanding ambulatory surgery centers;
the National Ambulatory Medical Care Survey
which examines office visits to non-Federal, office-
based physicians;
the National Hospital Ambulatory Medical
Care Survey which examines visits to emergency and
outpatient departments of non-Federal, short-stay and
general hospitals;
the National Health Provider Inventory which
is a national listing of nursing homes, hospices, home
health agencies and licensed residential care
facilities;
the National Home and Hospice Care Survey;
and
the National Nursing Home Survey.
Improving Self-Reports of Health Status by the Elderly
The National Laboratory for Collaborative Research in
Cognition and Survey Measurement of NCHS has conducted several
cognitive research projects with elderly respondents. In 1998,
Lab staff continued their investigation of recall and judgment
issues that elderly respondents may have when answering
questions regarding health status and quality of life. This
project involved both in-house and extramural research. In-
house research is conducted by recruiting subjects to the NCHS
Questionnaire Design Research Laboratory. Extramural is
conducted by the University of Maryland's Survey Research
Center using split-ballot field experiments.
National Immunization Program
The disease burden due to the occurrence of vaccine-
preventable diseases (VPDs) in adults in the U.S. is
staggering. Though surveillance of the impact of influenza and
pneumococcal disease is imprecise, it is estimated that in 7
influenza seasons since 1990, an average of 23,000 persons died
each year from complications of illness due to influenza and
over ten thousand more die from pneumococcal infections
annually. Increasing antibiotic resistance in pneumococcal
bacteria makes pneumococcal vaccination all the more important.
Hepatitis B infection still accounts for over 5,000 deaths
annually. The overall cost to society of these and other
vaccine-preventable diseases of adults exceeds 10 billion
dollars each year.
In addition to morbidity and mortality, the quality of life
for older Americans is substantially affected by vaccine-
preventable diseases. 25% of older adults in nursing homes who
survive influenza infections experienced decline in major life
functions and independence 3-4 months later, as compared to
only 16% of adults not infected.
Vaccines are effective in preventing disease, and cost-
effective. For example, CDC estimates that in 1996-97, between
8,000 and 12,000 deaths were prevented by influenza vaccination
in persons 65 years of age. In addition, using data
from CDC's Behavioral Risk Factor Surveillance System (BRFSS)
and CDC pneumococcal surveillance data for adults 65 years and
over, researchers have estimated that an almost 17% increase in
self-reported receipt of pneumococcal vaccine between 1993 and
1997 resulted in a gain of over 19,000 quality life years and a
savings of almost $27 million (1995 dollars) in hospital costs.
Recommendations from health care providers for vaccination
are critically important to improve vaccination levels, yet
adult vaccines are underutilized. Reasons for this include: (1)
limited appreciation of the impact of adult vaccine-preventable
diseases and missed opportunities to vaccinate during contacts
with health-care providers; (2) failure to organize programs in
medical settings that ensure adults are offered the vaccines
they need; (3) doubts about the safety and efficacy of adult
vaccines; (4) selective rather than universal approaches to
vaccination; and (5) inadequate reimbursement for adult
vaccination services.
Improvements in adult immunization levels will require
major changes in clinical practice, increased financial support
by public and private health insurers, and closer working
relationships among public and private health care
professionals and vaccine companies. HEDIS 3.0 reporting
measures for influenza vaccination are currently in place for
persons 65 years and over, and in the testing set for persons
under 65 years with high-risk medical conditions. CDC is
working with the American Association of Health Plans and the
National Committee on Quality Assurance to develop and
implement a pneumococcal vaccination measure.
Significant accomplishments in 1998: The Healthy People
2000 national objective for influenza vaccination in persons
65 years of age was achieved. The median influenza
vaccination level reported by CDC's 1997 BRFSS for persons
65 years of age was 65%, and also exceeded 60% in 45
States. While pneumococcal vaccination levels did not exceed
60% in any State for this population, the median level had
increased 9.8% since 1995, and levels were 50% in 18
states. Although BRFSS vaccination data do not provide national
estimates as the National Health Interview Survey, or NHIS,
does, they are usually very similar to NHIS estimates.
CDC documented continuing vaccine effectiveness. Three
health plans collaborated with CDC in assessing the
effectiveness of influenza vaccine in patients age 65 or older
in preventing hospitalizations for influenza and pneumonia from
all causes, and in preventing death from all causes for the
1996-1997 influenza season. Vaccinating elderly patients
against influenza during the fall of 1996 prevented about 22%
of the hospitalizations for pneumonia of any etiology in
vaccinated persons during influenza season. It prevented 57% of
all deaths in vaccinated older patients during this period.
These findings support the concept that not only should health
plans cover influenza vaccination, but they should actively
promote vaccination each fall.
Through partnerships, CDC implemented strategies to improve
influenza and pneumococcal vaccination. These strategies
include feedback of patient vaccination data to providers,
standing orders and provider reminder-recall strategies. Based
on work done during the 1988-92 Medicare Influenza Vaccine
Demonstration and expanded in a number of childhood
immunization programs, CDC undertook a 2-year pilot project in
collaboration with the Health Care Financing Administration in
6 New Jersey counties using the Assessment, Feedback,
Incentives, and exchange (AFIX) model, with results expected in
the Fall of 1999. The components of this project include:
Assessment: Medicare claims data for beneficiaries
with more than I visit to a provider were assessed;
Feedback: Profiles were developed for each physician
summarizing the proportion of beneficiaries vaccinated
and listing all patients' vaccination status;
Incentives: Professional recognition of providers'
efforts; and
Exchange: Newsletters publicizing aggregate baseline
data and best practices, along with presentations at a
statewide adult immunization conference.
The first national satellite video-conference on adult
immunization technical issues aired on June 4, 1998. The
satellite conference, presented three times during the day to
ensure prime time availability for participants coast-to-coast,
reached an estimated 20,000 public and private health care
professionals. CDC partners included the University of North
Carolina School of Public Health, the North Carolina Department
of Public Health, the Association of Schools of Public Health,
the Health and Sciences Television Network, and the Long Term
Care Network.
Significant accomplishments in 1997: From the 1995 National
Nursing Home Survey, CDC documented that 62% and 23% of nursing
home residents had received influenza vaccine in the previous
year and pneumococcal vaccine ever, respectively. It is
important to note that for 22% and 43% of residents, no
documentation or inadequate documentation of influenza or
pneumococcal vaccination status, respectively, existed.
The National Immunization Program (NIP), the National
Vaccine Program Office (NVPO) and the HHS Adult Immunization
Working Group developed a department-wide Adult Immunization
Action Plan. This Plan, based on recommendations of the
National Vaccine Advisory Committee (NVAC) Report on Adult
Immunization, will enhance activities to protect adults against
vaccine preventable diseases and maximize accruable health care
costs savings.
The first national video conference on successful adult
immunization strategies aired on April 24, 1997. The satellite
conference, presented 3 times during the day to ensure prime
time availability for participants coast-to-coast, reached an
estimated 20,000 public and private health care professionals.
CDC partners included the University of North Carolina School
of Public Health, the North Carolina Department of Public
Health, the Association of Schools of Public Health, the
Hospital and Sciences Television Network, and the Long Term
Care Network.
CDC continues to provide the Health Care Financing
Administration (HCFA) technical consultation and assistance to
improve influenza and pneumococcal vaccination; uses HCFA data
systems to develop new vaccination strategies; and executes
special interventions and assessment activities.
CDC collaborated with HRSA to establish projects to assess
adolescent and adult vaccination levels and provider practices
in Community/Migrant Health Centers in three States.
CDC enhanced the grant guidance for adult immunization
activities for FY 1998, requiring grantees to outline their
activities for reaching Healthy People 2000 adult immunization
objectives and to assign responsibility and accountability to
existing or new staff to ensure that adult immunization
strategies are coordinated and intensified.
CDC established projects in four States to vaccinate
persons with diabetes.
CDC supported a project with the Association of Teachers of
Preventive Medicine (ATPM) which summarized ``best practices''
to successfully vaccinate adults. Software will also be
disseminated to teach providers these strategies.
CDC co-sponsored a scientific symposium in September 1997
to review efforts to prevent disease and death among women
through immunization and develop a work plan on vaccination and
women's health. Representatives from 16 health organizations
participated.
In collaboration with the Roybal Institute of Applied
Gerontology, California State University, Los Angeles, the
Center for the Study of Latino Health at the University of
California at Los Angeles, and the California Department of
Health, CDC documented low vaccination levels against
influenza, pneumococcal disease, and tetanus in older Hispanic
persons in Los Angeles, as well as barriers to vaccination
perceived by older Hispanics. Interventions based on these
findings have been implemented to improve vaccination levels
National Center for Infectious Diseases
Infectious diseases have a disproportionate impact on older
Americans. Pneumonia and influenza remain the sixth leading
cause of death in the United States and septicemia has risen
dramatically during the past three decades to become the 13th
leading cause of death. Chronic liver disease, most due to
hepatitis C virus, is the 10th leading cause of death in the
U.S. Pneumonia and septicemia are also contributing and
precipitating factors in the deaths of many Americans with
other illnesses, especially cardiovascular diseases, cancer,
and diabetes. Quality of life declines for millions of older
Americans as a result of infectious illnesses. Prevention and
control of infectious diseases will enhance and lengthen the
lives of older Americans.
CDC emphasizes surveillance and training to prevent and
control hospital-acquired and other institutionally acquired
infections in elderly patients. CDC conducts surveillance of
elderly patients in hospitals and trains practitioners in
nursing homes. Additionally, CDC staff provides education
regarding infection control to care providers at nursing home
and patient care conferences. This education focuses on patient
care treatment and procedures associated with the highest risk
of infection. Through the National Nosocomial Infections
Surveillance (NNIS) system, special infection risks of elderly
patients have been identified. According to NNIS, over half of
the hospital-acquired infections occur in elderly patients,
although these patients represent about one-third of all
discharges from hospitals. The use of certain devices, such as
urinary catheters, central lines, and ventilators, are
associated with high risk of infection in all types of
patients. In elderly patients, the risk of infection is high
even when a device is not used, suggesting that infection
control must address other risk factors such as lack of
mobility and poor nutrition, in addition to device use.
Monitoring Influenza
Although delivering the influenza vaccine to persons at
risk is a critical step in preventing illness and death from
influenza, immunization is only part of the prevention
equation. Other CDC efforts to combat influenza in the elderly
include: (1) improving domestic surveillance through the
sentinel and state health department laboratory surveillance
networks; (2) conducting studies to better define the
immunological response of the elderly to influenza vaccines and
to natural infection; (3) conducting immunological studies
involving laboratory and clinical evaluation of inactivated and
live attenuated influenza vaccines in an effort to identify
improved vaccine candidates; (4) increasing surveillance of
influenza in the People's Republic of China and other countries
in the Pacific Basin to better monitor antigenic changes in the
virus; (5) improving methodologies for rapid viral diagnosis;
(6) using recombinant DNA techniques to develop influenza
vaccines that may protect against a wider spectrum of antigenic
variants; and (7) providing laboratory training in the People's
Republic of China, other Pacific Basin countries, and Latin
America to develop and expand capacity for the diagnosis and
detection of antigenic changes in the virus.
Preventing Pneumococcal Disease
Pneumococcal pneumonia causes an estimated 40,000 deaths
each year; about 60 percent of these are in persons 65 years
old. Prevention of pneumococcal disease in the elderly requires
widespread application of effective immunization. CDC is
currently evaluating the emergence of drug-resistant
pneumococcal strains through laboratory-based surveillance and
is actively promoting increased vaccine use in the elderly and
other groups at risk. This is critical to decrease illness and
death from pneumococcal infections in the elderly.
Other Respiratory Infections
Recent studies have suggested that noninfluenza viruses
such as respiratory syncytial virus the parainfluenza viruses
may be responsible for as much as 15 percent of serious lower
respiratory tract infections in the elderly. These infections
can cause outbreaks that may be controlled by infection control
measures and treated with antiviral drugs. Respiratory
syncytial virus vaccines are being evaluated for use by the
elderly population. Consequently, it is important to define the
role of these viruses and risk factors for these infections
among the elderly population. CDC is working to define the
disease burden associated with respiratory syncytial virus and
parainfluenza virus infections in the elderly and helping to
develop vaccination strategies for respiratory syncytial virus
in elderly populations.
Group B Streptococcus Disease
Group B streptococcus (GBS) is a major cause of invasive
bacterial disease in elderly persons in the United States. To
document the magnitude of GBS disease in the elderly and
develop preventive measures, CDC established population-based
surveillance for GBS disease and case control studies to
identify risk factors for GBS disease in the elderly. An
article published in June 1993 in The New England Journal of
Medicine documents some of the findings. The incidence of GBS
disease in nonpregnant adults increased with age and was
particularly high in older blacks. For example, the incidence
of black adults who are 70 years and older was 47 per 100,000
compared to 5 per 100,000 in black adults ages 20-29. The in-
hospital mortality rate for this particular study was 21
percent among the nonpregnant adults. This data will be
utilized to develop and evaluate vaccines and to promote the
prevention and treatment of GBS disease in the elderly
population.
Foodborne disease
Foodborne disease is of particular concern in the elderly,
who typically can have higher illness and death rates from
foodborne pathogens than younger persons. Of particular concern
are Salmonella enteritidis infections, often caused by
undercooked eggs, and Escherichia coli O157:H7 infections,
often caused by undercooked hamburger. CDC is working with USDA
and FDA to encourage use of pasteurized eggs in nursing homes
and thorough cooking of hamburger meat.
Gastrointestinal Disease
Studies using information from national data bases show
that of all age groups, the elderly (70 years) have the highest
rates of hospitalizations and deaths associated with diarrhea
in the United States. In the elderly, caliciviruses (also
called Norwalk-like viruses or Small Round Structured Viruses)
are likely to be the most common cause of both epidemics and
sporadic hospitalizations for acute gastroenteritis and studies
needed to confirm this hypothesis are now underway. These
studies should lead to a better understanding of ways to
prevent gastrointestinal disease in the elderly. The recent
identification of rotavirus as a cause of epidemic diarrhea in
the elderly suggests that one approach to control may involve
use of vaccines currently used for young children. Further
study is now needed to determine the importance of rotavirus to
gastrointestinal disease in the elderly.
Other Infectious Diseases
It is becoming increasingly evident that infections play a
major role in causing or contributing to some chronic diseases.
Some of these conditions result from infection acquired at a
younger age (including liver cancer and cirrhosis from chronic
hepatitis B and hepatitis C viruses, stomach and duodenal
ulcers or gastric cancer from Helicobacter pylori), while
others develop from exposures later in life. CDC is actively
promoting and pursuing ways to prevent initial infection and
the chronic consequences of such infections. Microbes are also
suspected but not yet proven as triggers of still other chronic
conditions. CDC is developing research activities that identify
and define these relationships. The potential to use infection
control in the prevention or treatment of infections that
produce chronic disease can improve the quality and length of
life for many elderly persons.
National Center for Injury Prevention and Control
Fall Injuries
National studies show that one-third of the people over 65
living at home will fall each year, and for people over 80,
this rate increases to 40%. Falls are the second leading cause
of injury deaths among persons aged 65-84 years and the leading
cause among persons aged 85 years and older. Of all fall
injuries, hip fractures produce the greatest morbidity and
mortality. Approximately 250,000 hip fractures occur each year
and half of those who sustain hip fractures never regain their
former level of functioning. Research shows that in order to
decrease the incidence and severity of fall-related injuries,
interventions must be multifaceted and include behavioral as
well as environmental components (e.g., exercising regularly,
reducing home hazards, and improving vision).
In 1998, CDC's National Center for Injury Prevention and
Control (NCIPC) awarded a grant to the San Diego State
University Foundation to establish a Resource Center for the
Prevention of Unintentional Injuries Among Older Americans. The
purpose of this Resource Center is to collect, organize, and
disseminate injury prevention information to health care
professionals, caretakers, and other individuals concerned
about reducing injuries among older Americans.
Since 1996, CDC has been collaborating with the National
Fire Protection Association, Consumer Product Safety
Commission, United States Fire Administration, Indian Health
Service, and Administration on Aging, on ``Remembering When'',
a fire and falls prevention program for older adults. To date,
the program has been pilot tested in the states of Mississippi,
Arkansas and Alaska, and the cities of Atlanta and Cleveland.
The program materials are now being revised and printed and
will be ready for distribution by Spring of 1999.
CDC has also worked with the Southern California Injury
Prevention Research Center (SCIPRC) at the University of
California at Los Angeles on a project to prevent falls and
fall-related injuries among elderly Hispanics living in East
Los Angeles. A fall prevention program has been developed and
is currently being field tested and evaluated among Hispanic
elderly in East L.A.
NCIPC has examined weight loss and risk of hip fracture
among women. Body weight has been shown to be an important
factor in determining hip fracture risk. In collaboration with
researchers from the National Center for Health Statistics and
the National Institute on Aging, data from the Epidemiologic
Follow-up Study of the National Health and Nutrition
Examination Survey (NHANES-I) were analyzed to determine the
association between weight loss from maximum body weight and
risk of hip fracture. The factors associated with weight loss
also were investigated.
Older Driver Activities
By the year 2020, it is estimated that there will be 51
million persons aged 65 and above eligible to drive, or 17
percent of the licensed driving population. In 1996, 178,000
older persons were injured in traffic crashes. Little is known
about how the physical changes that accompany the aging process
and diagnosed medical conditions affect driving performance.
For example, there is some evidence to suggest that Parkinson's
disease may impair driving, although the evidence is weak. More
needs to be known about the connection between specific medical
conditions and adverse driving outcomes.
NCIPC has conducted research concerning fatal motor vehicle
crashes among older people. Understanding the component risks
associated with fatal crashes may contribute to a better
understanding of the potential usefulness of certain types of
interventions to prevent them. The decomposition method is an
innovative approach to determining the relative contribution of
specific factors (such as exposure to the risk of a crash) to
the overall fatal crash involvement rate. Using this method, a
study is currently being conducted to determine how these
factors contribute to age and gender differences in fatal crash
involvement rates and their relationship to changes in the
rates over time among the US population aged 65 years or older.
NCIPC has also conducted a longitudinal study of elderly
drivers. A prospective cohort study is underway to assess the
impact of selected functional impairments and medical
conditions on the safety of older drivers. Data collection for
the study was carried out from July 1994 through December 1995
at eight North Carolina driver's license offices (Durham,
Greensboro, Asheville, Wilmington, Roanoke Rapids/Greenville/
Rocky Mount (combined site), and Hendersonville). All data were
collected by specially trained data collectors working at the
licensing office. Drivers ages 65 and above coming to renew
their license were asked to participate in the study, which
involved a series of visual and cognitive functional
assessments along with a survey to gather information on self-
reported medical conditions, use of medications, and driving
habits. The entire assessment required about 20 minutes per
subject to complete.
During the 1\1/2\ year data collection period, a total of
5,438 license renewal applicants were identified by the license
examiners as potential study participants. Of these, 3,238, or
60 percent, elected to participate in the study. Participant
and non-participant cases were linked with the North Carolina
driver history files, and initial data analyses were carried
out examining the role of various cognitive and visual
functional impairments in recent prior crash involvement and in
current driving exposure. Follow up analyses are planned in the
project's final year to examine the usefulness of the driver
functional assessments in predicting future crash involvement.
In addition to these efforts, supplemental funding was made
available by NCIPC to link North Carolina driver history data
to data collected by UNC's Sheps Center for Health Services
Research as part of an earlier study examining changes in
health status and costs associated with Medicare-reimbursed
screening and health promotion services. This add-on effort
permitted further analyses of associations between motor
vehicle crashes and injuries and a broad range of health
measures in a separate population of elderly NC residents.
NCIPC has also developed the Elderly Driver Referral
Project, which is a study attempting to ascertain relationships
between the capabilities of drivers and their safety of
operation in order to enable license administrators to initiate
licensing actions that minimize the threat from those who
cannot operate safely while preserving the mobility of those
who can. The psychophysical capabilities of the entire sample
will be assessed through a battery of test measures designed
specifically to tap capabilities shown to relate separately to
age and highway accidents. The relationships obtained in this
manner will be applied to (1) improve the methods of detecting
drivers whose abilities may be diminished by age, (2) develop
tests to validly assess drivers' ability to drive safely, and
(3) formulate licensing actions capable of achieving an optimum
balance between safety and mobility.
Finally, NCIPC is examining driving ability and car crashes
as they relate to old age and dementia. A study is underway to
objectively determine which neuropsychological and
psychophysical measures best discriminate between safe and
unsafe drivers, by comparing the performance of the Alzheimer's
Disease (AD) patients on the driving simulator and on a battery
of off-road behavioral tests. One of the ultimate goals of this
line of research is the development of fair and accurate
criteria to predict driving ability in cognitively disabled
populations.
Other Injuries
NCIPC also analyzed the performance of trauma systems for
elderly trauma patients. Hospital discharge data from 8 U.S.
trauma systems were used to evaluate the extent to which
elderly major trauma patients are triaged to a trauma center
when needed. A complimentary analysis using Maryland ambulance
trip report forms addressed the issue of compliance with pre-
hospital triage protocols for major trauma patients.
FOOD AND DRUG ADMINISTRATION
As the percentage of elderly in the Nation's population
continues to increase, the Food and Drug Administration [FDA]
has been giving increasing attention to the elderly in the
programs developed and implemented by the Agency. By the year
2000, Americans aged 75 and older will be the fastest growing
group on the United States. The elderly (those over 65) have
disproportionately high health care demands. Challenges
associated with this patient subpopulation, such as multiple
drug interactions, different physiological characterizations
and reactions to drug regimens, and the need for better medical
device design for home self-diagnostics and therapies, will
become more acute. These challenges will require greater
inclusion of the elderly in clinical testing for drugs, medical
devices, and other FDA-regulated products. Further, the
increasing educational needs of the elderly will require more
focused education programs, including specific dietary
information and foods targeted to their nutritional
requirements. The elderly population and food service workers
who prepare food for the elderly also will require special
education initiatives concerning proper food handling, because
as the population ages it becomes more susceptible to foodborne
diseases.
On October 1, 1998, the United Nations launched the
International Year of Older Persons 1999 as a worldwide
recognition of the global aging society and the need to ensure
that policies and programs are responsive to the needs of older
people. The Agency is an active participant on the Federal
Committee to Prepare for the International Year of Older
Persons, which is managed by the Administration on Aging. As a
member of this Committee, FDA is expanding its networks both
within and outside of the federal government to coordinate
program activities, exchange information, and disseminate
material. Working relationships continue with the National
Institute on Aging, the Centers for Disease Control and
Prevention, and the Administration on Aging of the Department
of Health and Human Services to further strengthen programs
that will assist the elderly now and in the future. Some of the
major initiatives that are underway are described below.
International Year of Older Persons 1999
During 1998, the FDA started several major Agency-wide
initiatives to strengthen its relationship and interactions
with the aging community. The Office of External Affairs
established a steering committee to develop and coordinate an
approach for making FDA materials not only pertinent to the
lives of older people, but also more accessible to the aging
community. Another priority for the steering committee was to
devise new approaches for informing the aging community of FDA
activities related to enriching the quality of their lives and
how to become more active in these activities.
The following are the primary initiatives undertaken by the
steering committee in 1998:
Awareness Campaign on Successful Aging,
including a specialized logo and related theme ``Active
Aging--A Lifetime of Good Health,'' standard
information packet that can be tailored for national
and grassroots audiences.
Internet Website for Older Persons to
publicize the availability of FDA materials addressing
the health interests of older people, with links to
national and international organizations within the
aging network.
Outreach and Network Building to publicize
available FDA publications through such vehicles as
Parade magazine, disseminating tailored information
packets, and building the relationships among aging
organizations to enhance the interactions between these
organizations and the Agency.
FDA Plan for Statutory Compliance
Food and Drug Administration Modernization Act of 1997
As required by the 1997 FDA Modernization Act, FDA
developed a plan outlining innovative approaches for meeting
the increasingly complex public health challenges of the 21st
century. The plan sets forth the strategic directions over the
next 5 years and the specific performance goals that will guide
FDA in accomplishing what it is required to do under the law as
well as in meeting public expectations. This plan recognizes
the International Year of Older Persons and focuses on the
significant demographic shift that, coupled with longevity,
will impact the Agency and its work.
Objective B of this FDA plan--to maximize the availability
and clarity of information for consumers and patients
concerning new products--discusses the aging population within
the context of FDA's mission and identifies specific themes
directing the Agency's efforts to fulfill this objective
including:
Tailoring product information to meet the
special needs of diverse populations, such as through
the public awareness campaigns that will be targeted
to, or involve, older people--such as Take Time To
Care, Mammography Awareness Seminars, Food Safety
Programs (Fight BAC!), Over-the-Counter Labeling
Changes Campaign, and the Partnership for Food Safety
Education.
Increasing the number of stakeholder
collaborations, such as the Pharmacist Education
Outreach Program, that will assist pharmacists in
explaining the drug approval process to consumers, many
of whom will be older consumers.
Ensuring that patients are an integral part
of the health care decisionmaking process.
Providing consumers with quick access to a
wide range of information through various methods, such
as the Internet and clinical trial registry.
The 1999 objectives established in the plan published by
FDA in November 1998 focus on two goals for over-the-counter
and prescription drugs--evaluating drug information provided to
75 percent of individuals receiving new prescriptions and
improving over-the-counter information and consumers' ability
to understand it by the year 2001.
Public Participation
As part of the Agency's long-standing tradition of
involving the public in its activities, FDA is forging new
relationships with organizations in the aging network on both
the national and grassroots levels. During 1997 and 1998, the
Agency conducted a variety of activities intended to establish
and strengthen two-way communication between FDA and its
constituencies. These activities included national and local
consumer forums, meetings with organizations, stakeholder
meetings, and public meetings. The Agency continues its efforts
to involve older people as consumer members of its advisory
committees by working with aging organizations to identify
potential candidates.
Project on Caloric Restriction
The National Center for Toxicological Research (NCTR) in
partnership with the National Institute on Aging has been
working for several years on the role caloric restriction (CR)
plays in the aging process and what effect a reduced caloric
diet has on disease etiology. Scientists working on the Project
on Caloric Restriction have concentrated on determining the
mechanisms by which caloric restriction inhibits spontaneous
disease, modulates agent toxicity and effects the normal aging
process. Studies over the last year have focused on the premise
that by using a single paradigm (caloric manipulation) and
through interdisciplinary studies a comprehensive integrated
approach can be developed to understand the effect diet has on
the initiation and development of disease. The hypotheses that
support this paradigm are mechanistically based and include the
following: CR acts through its effects on body growth, on
glucocorticoids and inflammation, on DNA damage, repair and/or
gene expression, on toxicokinetics and/or its modification of
oxidation and fat metabolism. All of these hypotheses have been
explored through interdisciplinary studies being conducted at
NCTR or at other institutions in collaboration with scientists
at NCTR.
Body Growth
Rodent studies at NCTR have found that body weight can be
used to predict tumorigenicity. For most organs, size is
directly proportional to the body weight of the animal and it
has been shown that organ weight can be used to predict
tumorigenicity. CR inhibits the induction of tumor expression
and growth and changes the state of differentiation in
replicating cells. It has also been found that CR can
specifically alter drug metabolism and reduce drug toxicity.
This could be very useful in treating and diagnosing disease.
In addition, the relevance of CR to the human population has
been strengthened by the fact that biomarkers observed in
rodents are associated with the risk of chronic disease in
humans. Plans are in place to extend the CR observation in
rodents to clinical studies in humans.
Oxidation and Fat Metabolism
A common hypothesis for tumor induction suggests that DNA,
the blue print of the cell, is damaged by oxidative chemical
species in the cell released by the metabolism of fat. CR has
been shown to reduce the impact of oxidative damage at the
organ level by increasing the oxygen scavengers in the liver
and in muscle. Similarly, it has been shown that CR reduces
high fat induced oxidative damage in cellular DNA.
Glucocorticoids and Inflammation
Glucocorticiods are used to diminish normal but undesirable
body responses to noxious stimuli and trauma, advantages are
gained by their use in counteracting stressful situations and
in decreasing pain and discomfort. Another group of normal body
protective agents are stress proteins, which are produced in
the body whenever the body undergoes a stress induced response.
CR has been shown to elevate glucocorticoid levels shortly
after inception, and has also been shown to alter stress
proteins levels in the brain.
DNA Damage, Repair and/or Gene Expression
As mentioned above DNA is the blueprint of the cell,
therefore any damage done to DNA has the potential of resulting
in a disease response. CR has been shown to inhibit genes that
are associated with tumor induction and enhances various forms
of DNA repair. One hypothesis for tumor induction suggests that
chemicals exert their damage to DNA by binding to the
components of DNA forming adducts. Animals exposed to a CR
regime and carcinogenic insult show an altered induction of
various forms of DNA adducts.
Toxicokinetics
Toxicokinetics describes the absorption, distribution,
metabolism and excretions of toxic chemicals from the body with
time. Therefore, it refers to the compartmentalization of a
toxicant within the body. Organs are complicated structures
that are made up of different kinds of cells, transport
structures and biological functioning units. CR has been shown
to alter water transport, fat deposition and waste transport,
thus complicating cellular compartmentalization, and toxic
exposure of certain cells to damaging substances.
Although the work over the last year has concentrated on
the mechanisms of toxic interaction in the body and the role CR
has on this process, studies with calorically restricted
animals have repeatedly shown that CR extends the lifetime of
animals. How this effects aging is still in question; however,
the research being conducted in this area is continuing to chip
away at the problem of how diet effects the aging process, and
what elements or lack thereof in the human diet may help to
extend human life.
Rare Diseases Affecting Primarily Older Americans
It is the intent of the Orphan Drug Act, and the Office of
Orphan Products Development [OPD], to stimulate the development
and approval of products to treat rare diseases. The OPD plays
an active role in helping sponsors meet agency requirements for
product approval. Between 1983--when the Orphan Drug Act was
passed--through the end of 1998, 181 products to treat small
populations of patients were approved by FDA.
By the end of 1998, there were 744 designated orphan
products. Two hundred and sixteen--29 percent--of these
designated orphan products represent therapies for diseases
predominately affecting older Americans. One hundred twenty-
five are for treating rare cancers in the elderly--for instance
ovarian cancer, pancreatic cancer, and metastatic melanoma.
Forty-five of the orphan products designated for treating
elderly populations are for rare neurological diseases, such a
amyotrophic lateral sclerosis [ALS], and advanced Parkinson's
disease. Twenty-six orphan-designated therapies for elderly
populations have received FDA market approval: Most noteworthy
among these is Eldepryl for treatment of idiopathic Parkinson's
disease, postencephalitic Parkinsonism, and symptomatic
Parkinsonism; riluzole for treatment of ALS; and Novantrone for
treatment of refractory prostate cancer.
FDA's orphan products grants had their beginning in 1983 as
one of the incentives of the Orphan Drug Act. This incentive of
the Act provides financial support for clinical studies
[clinical trials] to determine the safety and efficacy of
products to treat rare disorders, and to achieve marketing
approval from the FDA under the Federal Food, Drug, and
Cosmetic Act. Studies funded by the orphan products grants
program have contributed to the marketing approval of twenty-
one of these products.
Because the orphan products program is issue-specific/
indication-specific, it is typical for an approved product to
be funded under the orphan products grant program for study in
an indication unique to a distinct group of people: for
example, women, children, or a population of elderly. Under the
orphan drug program, disease populations are small; in many
instances, the firms themselves are very small. The goal of
orphan product development is to bring to market products for
rare diseases or conditions. In so doing, it is evident that
the goals of the Orphan Drug Act promote research and labeling
of drug for use by and for special populations.
The orphan products grant program has funded 42 studies
specifically aimed at treatment of diseases affecting adults
and older adults. The IV Formulations of Busulfan was approved
in 1999 for use in geriatric patients undergoing bone marrow
transplantation.
Alzheimer's Disease Research
Alzheimer's disease currently affects approximately four
million people age 65 and older, with the number projected to
increase to fourteen million by the year 2050. Development of
new drugs to diagnose, treat, and prevent this disease
represents a goal of profound importance. Alzheimer's drug
research efforts depend in part upon the availability of
patients who can participate in clinical studies of these new
drugs.
During 1996, FDA's Office of Special Health Issues [OSHI]
conducted a search and assessment of information in the public
domain regarding Alzheimer's drug development, and particularly
opportunities to participate in Alzheimer's drug research. It
was learned that little information is publicly available
regarding Alzheimer's research and opportunities to participate
in Alzheimer's drug development.
To address this problem, OSHI has undertaken an initiative
with the National Institute on Aging [NIA] to develop a
database containing information regarding opportunities to
participate in clinical trials of Alzheimer's drugs. This
database, which received some initial funds from the FDA, will
be maintained at the NIA's Alzheimer's Disease Education and
Referral [ADEAR] Center, and will be accessible by toll-free
telephone and the NIA home page on the world wide web. OSHI and
NIA developed the database and announced the initiative to
pharmaceutical manufacturers involved in domestic development
of Alzheimer's drugs. Some manufacturers have submitted
information for entry into the database, which will be
operational during Spring 1998.
Generic Drug Approvals
During 1997-1998, the Office of Generic Drugs (OGD)
approved 775 abbreviated new drug applications (ANDA's). These
drug products are often substantially less expensive, and
provide a safe and effective alternative to the brand-name
products. Many of these approvals represent the first-time a
generic drug was available for products of special interest to
older Americans such as terazosin hydrochloride capsules used
as an antihypertensive and isosorbide mononitrate tablets used
for angina. These and other recently approved generic drug
products could save the American Public and Federal Government
millions of dollars. [In July, 1998 the Congressional Budget
Office (CBO) published a report: How Increased Competition from
Generic Drugs Has Affected Prices and Returns in the
Pharmaceutical Industry. The CBO estimates that in 1994,
purchasers saved a total of $ 8 billion to $10 billion on
prescriptions at retail pharmacies by substituting generic
drugs for their brand-name counterparts.]
New Drug Approvals
In 1997 and 1998, the Center for Drug Evaluation and
Research approved more than 20 new drug products that are used
more often, although not solely, in populations 55 or older for
conditions generally associated with an aging population.
Indications for these drugs include glaucoma, osteoarthritis,
benign prostatic hypertrophy, incontinence, prostate cancer,
and hormone replacement therapy.
Geriatric Labeling Final Rule and Guidance for Industry
In a final rule published in the Federal Register on August
27, 1997, (62 FR 45313), FDA established a ``Geriatric Use''
subsection in the labeling for human prescription drug and
biological products to provide information pertinent to the use
of drugs in the elderly (persons aged 65 years and over). This
final rule recognizes the special concerns associated with the
geriatric use of prescription drugs and acknowledges the need
to communicate important information so that drugs can be used
safely and effectively in older patients. The medical community
has become increasingly aware that prescription drugs can
produce effects in elderly patients that are significantly
different from those produced in younger patients. Although
both young and old patients can exhibit a range of responses to
drug therapy, factors contributing to different responses are
comparatively more common among the elderly. For example,
elderly patients are more likely to have impaired mechanisms of
drug excretion (e.g., decreased kidney function), to be on
other medications that can interact with a newly prescribed
drug, or to have another medical condition that can affect drug
therapy.
In January 1998, the FDA published a guidance document
entitled ``Guidance for Industry-Content and Format for
Geriatric Labeling.'' This document, which is available in hard
copy, as well as on the CDER website, is intended to provide
industry with information on submitting geriatric labeling of
human prescription drugs and biological products.
Drug Labeling
On February 26, 1997, FDA proposed new labels for over-the-
counter (OTC) drug products. This proposed labeling is designed
to provide consumers with easier-to-read and understand
information about the products' benefits and risks, and how
they should be used. According to the American Pharmaceutical
Association's Handbook of Nonprescription Drugs, the elderly
comprise about 12 to 17 percent of the United States population
but consume about 30 percent of all OTC medications. The
elderly are projected to consume as much as 50 percent of all
OTC medications by the year 2000. The new bulleted format,
including minimum type size and type style, simplified
language, and uniform, standardized headings, as proposed in
this rulemaking may be particularly helpful to the elderly.
In the Federal Register dated February 11, 1998, FDA
amended its regulations pertaining to new drug applications
(NDA) to clearly define in the NDA format and content
regulations, the requirement to present effectiveness and
safety data for important demographic subgroups, specifically
gender, age and racial subgroups. The rule also amended
regulations pertaining to investigational new drug applications
to require sponsors to tabulate in their annual reports the
numbers of subjects enrolled to date in clinical studies for
drug and biological products according to age group, gender,
and race. This amendment is intended to alert sponsors as early
as possible to potential demographic deficiencies in enrollment
that could lead to avoidable deficience later in the NDA
submission.
Postmarket Drug Surveillance and Epidemiology
The Office of Post Marketing Drug Risk Assessment (OPDRA),
FDA Center for Drug Evaluation and Research [CDER], prepared an
annual report--entitled ``Annual Adverse Drug Experience [ADE]
Report''--which provides summary statistics describing some of
the activities of the postmarketing drug risk assessment
program. Each year this report contains a number of tabulations
which show the number of reports received and evaluated by such
factors as age group, sex, source of report, drug or type of
outcome. In 1997, there were 243,350 evaluable reports that
were evaluated and added to the database. In 1998, the Agency
added 232,500 reports to the evaluation database. At this time,
we have not stratified this database by age. However, we
anticipate that the percentage of reports submitted by
individuals age 60 or older will remain similar to the
percentages from previous years (23 to 26 percent).
FDA staff participated in an interagency conference
entitled ``Substance Abuse and Aging: Estimating Future
Requirements'', in which the goal of the meeting was to
identify data sources to assess the future needs of substance
abuse, drug misuse, and polypharmacy among the elderly.
Information from the current spontaneous reporting systems, as
well as previous findings from OPDRA sponsored studies were
shared. Information about the outpatient use of prescription
sedative hypnotic drugs in the U.S. from 1970 through 1989 was
described, documenting the decline in total prescriptions of
sedative hypnotic drugs, the decline in barbiturate and
increase in benzodiazepine prescriptions, the increasing use of
antidepressant drugs for insomnia, and increasing use with age.
Dialysis Access Graft
A dialysis access graft made by Possis Medical Systems,
Inc., was approved on September 25, 1998. The Perma-Seal Graft
is for use as a subcutaneous arteriovenous shunt graft to
provide immediate and subsequent chronic blood access for high-
efficiency hemodialysis in patients who have a central venous
cannulation that is deemed hazardous or is technically
unavailable or are being maintained on chronic anticoagulation
or antithrombotic therapy or are morbidly obese.
Vascular Stents (6)
Before October 1, 1996, only three vascular stents were
approved and only two of them were for coronary vessels. Six
coronary vascular stents have been approved since then and are
for use in patients with symptomatic ischemic heart disease due
to discrete de novo and restonotic native coronary artery
lesions with a reference vessel diameter ranging from 3.0 mm to
3.75 mm and is intended to improve the coronary luminal
diameter. Coronary stents have made a major impact on the
treatment of coronary artery disease (prevalence increases with
age).
Transmyocardial Revascularization
The first transmyocardial revascularization (TMR) device
The Heart Laser CO2 TMR System marketed by PLC was approved on
September 25, 1998. Transmyocardial revascularization with The
Heart Laser System is indicated for the treatment in patients
with stable angina (Canadian Cardiovascular Society class 3 or
4) refractory to medical treatment and secondary to objectively
demonstrated coronary artery atherosclerosis not amenable to
direct coronary revascularization.
Ventricular Assist Device Systems (3)
On May 21, 1998, the Thoratec Ventricular Assist Device
System was approved for an expanded indication. The original
indication was for use as a bridge to cardiac transplantation
to provide temporary circulatory support for cardiac failure in
potential transplant recipients at imminent risk of dying
before donor heart procurement. The expansion of the
indications is to include post-cardiotomy myocardial recovery.
These are patients who have had a technically successful open-
heart operation but are unable to be weaned from
cardiopulmonary bypass.
On September 29, 1998, two ventricular assist device
systems were approved. Baxter Healthcare had its first
application approved and Thermo Cardiosystems (TCI)
supplemented its previously approved application. The TCI
device is the electric version of the already approved
pneumatic device. The HeartMate electric (VE) and the pneumatic
(IP) LVASs made by TCI are approved for bridge to cardiac
transplantation. What is unique about both the Novacor LVAS and
the TCI HeartMate VE LVAS is that both are intended for use
inside and outside the hospital, thus providing the patient
with greater mobility.
Pacemakers (4)/Ablation/Implantable Defibrillators (3)/Leads (3)
Eleven applications for these devices were approved in this
time period and all are used increasingly with age.
Laser to Extract Leads
On December 9, 1997 the Spectranetics Laser Sheath was
approved for use as an adjunct to conventional lead extraction
tolls in patients suitable for transvenous removal of
chronically implanted pacing or defibrillator leads constructed
with silicone or polyurethane outer insulation. This device is
the first of its kind.
Percutaneous Vascular Surgical System
The Prostar Percutaneous Vascular Surgical System approved
on April 30, 1997, is the first of its kind and is indicated
for the percutaneous delivery of sutures for closing the common
femoral artery access site and reducing the time to hemostasis
and ambulation (time-to-standing) of patients who have
undergone interventional procedures using 8 to 11 Fr. Sheaths.
Deep Brain Stimulator To Control Tremors in Patients With Parkinson's
On July 31, 1997, the Medtronic Activa Tremor Control
System was approved. It is a unilateral thalamic stimulation
and the first device to be approved for the purpose of
suppression of tremor in the upper extremity. The system is
intended for use in patients who are diagnosed with essential
tremor or Parkinsonian tremor not adequately controlled by
medications and where the tremor constitutes a significant
functional disability. Both essential and Parkinson's
associated tremor are more frequent in the elderly.
Laser for Resurfacing and Treatment of Wrinkles
FDA, Center for Device and Radiological health has cleared
a number of laser wavelengths for the indication of skin
resurfacing and treatment of wrinkles. These devices are
capable of removing layers of facial skin in a manner that
wrinkles around the eyes, nose and mouth are partially or
completely removed and at the same time the aged skin of the
face is also removed. The result of this treatment, upon
healing, is both lack of prominent wrinkles and the appearance
of new facial skin/baby skin.
The use of lasers for this purpose potentially will affect
the older population of people as well as persons who have
experienced lengthy period of time in sunlight. The potential
use of this new procedure will therefore be seen in the older
population and in those locals of high sun exposure, that is
the southwest and west coast.
Even if the wrinkles themselves are not completely removed,
the resurfacing effect alone results in improved cosmetic
appearance of the face, since the healed skin does not have the
same appearance as older, sun exposed skin.
Intraocular Lenses
Over 1 million intraocular lenses are implanted each year
in the U.S. predominately in the senior population. These
implants have revolutionized the treatment of cataracts, which
a few decades ago were the leading cause of blindness in the
adult population. A number of flexible lens models have been
approved by FDA in the last few years and are now on the
market. These lenses permit smaller incisions which heal more
rapidly with less scarring and subsequent distortion of the
optics of the eye.
However, flexible lenses have led to a number of unexpected
post-approval consequences. Discoloration, haziness, and
glistening have all been reported. In 1996, primarily because
of FDA laboratory testing and discovery of such problems, one
company voluntarily recalled all distributed units of its
recently approved flexible IOL model. FDA verified that the
recall was effective and that monitoring was in place to access
patients implanted before the recall. FDA tasked all involved
firms with identifying the sources of these problems and
revising their quality control to prevent future occurrences.
FDA's device laboratory developed methods and tested lenses to
assess the effect of these problems on vision.
Data on intraocular lenses (IOLs) have demonstrated that a
high proportion (85-95 percent) of the patients who have
undergone cataract surgery and IOL implantation will be able to
achieve 20/40 or better corrected vision with a low risk of
significant postoperative complications. Because of the proven
safety and effectiveness of IOLs, they have become the
treatment of choice for the correction of visual loss caused by
cataracts. This has allowed elderly patients to maintain their
sight and a normal lifestyle. FDA continues to monitor some
investigational IOLs and to date has approved thousands of
models that have demonstrated safety and effectiveness.
The first IOLs were all ``monofocal,'' which were designed
to provide good vision at one distance, usually far. Patients
who receive monofocal IOLs usually need spectacles to obtain
satisfactory near vision. Typically, these patients will need
bifocal spectacles to obtain optimal distance and near vision.
On September 5, 1997, FDA approved the first ``multifocal''
IOL. The multifocal IOL is designed to provide clear distance
and near vision. The advantage of the multifocal IOL is that
there is a greater chance that the patient may have
satisfactory distance and near vision without spectacles, or
will only need ``monofocal'' (not bifocal) spectacles to
improve both distance and near vision. The disadvantages of
multifocal IOLs are : (1) distance vision may not be quite as
``sharp'' as with a monofocal IOL; (2) there is a higher chance
of difficulty with glare and halos than with a monofocal IOL;
and (3) under poor visibility conditions, vision may be worse
than with a monofocal IOL.
Throughout the time period of this update, FDA has worked
closely with industry, ophthalmologists, and researchers to
assure that the regulatory requirements for new intraocular
lens models are scientifically valid, but not overly
burdensome. This activity has occurred via work with both the
ANSI and ISO standards organizations. FDA also participates in
the Eye Care Forum, an annual meeting sponsored by the National
Eye Institute to address issues of mutual interest to the
clinical, research, and regulatory communities.
Prosthetic Heart Valves
Approximately 80,000 people in the U.S. have artificial
heart valves implanted every year, both mechanical and
bioprosthetic (pig, bovine valves). The characteristics of the
blood flow through these valves can affect the risk of thrombo-
embolism and ultimate valve failure. Turbulence, stagnation and
cavitation (bubble formation and collapse) may all cause
adverse effects. For the past few years, and currently, the FDA
has had programs in place, both research and regulatory, to
evaluate the flow characteristics of these devices and their
impact on the valves and blood components.
These programs include the development of: (1) improved
techniques to directly measure the flow patterns associated
with valves using fluorescent particle visualization and
Doppler ultrasound; (2) mathematical models to assess flow
patterns as a function of valve design and aortic geometry; (3)
guidance for manufacturers to standardize and improve their
testing; (4) techniques to acoustically detect flow induced
cavitation; (5) methods to directly assess effects on red blood
cells. Also evaluation of specific valve designs, both
currently implanted and prototype is ongoing. Finally, analysis
of a much used diagnostic tool, color Doppler, is being
undertaken to improve diagnosis or diseased or faulty valves.
On November 4, 1997, St. Jude Medical's Toronto SPV valve
was approved, which is a stentless subcoronary porcine aortic
valve comprised of the valve cusps and enough aortic tissue to
support the commissures and leaflets. On November 26, 1997, the
Medtronic FREESTYLE Aortic Root Bioprosthesis which is
comprised of a porcine aortic root with a cloth covering to add
to the strength of a proximal (inflow) suture line and to cover
any exposed porcine myocardium was approved. The design of the
FREESTYLE bioprosthesis allows the physician to trim the
prosthesis for replacement using the subcoronary, full-root or
root-inclusion technique. The need for replacement heart valves
increases with age.
Pacemakers
On October 28, 1994, the EP Technologies, Inc.'s Cardiac
Ablation System, the first radio frequency powered catheter
ablation system was approved. It is indicated for interruption
of accessory atrioventricular (AV) conduction pathways
associated with tachycardia, treatment of AV nodal re-entrant
tachycardia, and for creation to complete AV block in patients
with a rapid ventricular response to an atrial arrhythmia.
On December 20, 1995, the Thoratec Ventricular Assist
Device System was approved. It is indicated for use as a bridge
to cardiac transplantation to provide temporary circulatory
support for cardiac failure in potential transplant recipients
at imminent risk of dying before donor heart procurement. The
System may be used to support patients who have left
ventricular (LVAD), right ventricular (RVAD), or biventricular
failure (BVAD). The Thoratec VAD differs from the other two
previously approved VADs in that it can be used for right heart
and/or biventricular failure.
On May 15, 1996, a new indication for use was approved for
CPI Guidant's family of Implantable Cardioverter Defibrillators
(ICDs). The PMA supplement was received in six days and
contained clinical data in electronic format from the
Multicenter Defibrillator Implant Trial (MADIT). The new
patient population consists of patients who have a Left
Ventricular Ejection Fraction of less than 35%, and a
documented episode of non-sustained ventricular tachycardia
with inducible, non-suppressible, ventricular tachycardia.
Previously, only patients who had sustained ventricular
tachycardia were candidates for implantation. The MADIT data
provided evidence that an ICD used in high risk, asymptomatic
patients produces significantly better results than drugs in
reducing deaths.
In 1998, the FDA, Center for Device and Radiological Health
Office of Surveillance and biometrics, Epidemiology Branch
conducted and published a study of the epidemiology of cardiac
pacemakers in the elderly U.S. population. Data for the study
were obtained from the Nationwide Inpatient Sample, a massive,
nationally representative sample that includes 850 hospitals
and six million patient discharge records. The study estimated
that in a 12 month span, a total of 131,361 pacemakers were
implanted in recipients 65 years of age or older. The study
also demonstrated the outward diffusion of pacemaker
implantations from academic to community hospitals, as the
majority of pacemakers were found to be implanted outside of
academic centers.
Renal Dialysis
There were a projected 244,000 patients with kidney failure
in the United States in 1996. More than 100 individuals are
diagnosed with end stage renal disease (ESRD) each day. ESRD
patients will need to remain on either hemodialysis or
peritoneal dialysis for the rest of their lives unless they are
able to receive a successful kidney transplant. Therapy can be
delivered at dialysis facilities or in the home, depending on
various factors.
Today, more than 50 percent of the ESRD population is over
60 years of age. Through age 50, the average remaining life
span is greater than 5 years for ESRD patients. Although the
remaining lifetimes are shorter for the elderly ESRD
population, the general population also faces higher mortality
with aging. The projected expected remaining lifetime for
dialyzed patients with ESRD is approximately one-fourth to one-
sixth that for the general population through age 50, while the
ratio is often closer to one-third for older patients. These
figures are based on actuarial calculations and assumed death
rates, and are taken from the U.S. Renal Data System 1997
Annual Data Report.
Because of the nature of the underlying disease and
necessary supportive therapy, ESRD patients are at risk for a
number of potential complications during or as a result of
their therapy. Many of the potential complications can occur
from a failure to correctly maintain or use dialysis equipment,
insufficient attention to safety features of the individual
dialysis system components, or insufficient staffing or
personnel training. FDA's Center for Devices and Radiological
Health (CDRH), in conjunction with major hemodialysis
organizations, such as the Health Industries Manufacturers
Association (HIMA), the Renal Physicians Association (RPA), and
the American Nephrology Nurses Association (ANNA), developed
several educational videotapes which address human factors,
water treatment, infection control, reuse, and delivering the
prescription, as well as manuals on water treatment and quality
assurance. Complimentary videos illustrating health and safety
concerns and the use of proper techniques have been distributed
to every ESRD facility in the United States. These videos have
received a favorable acceptance from the nephrology community.
On October 6, 1995, CDRH completed the final draft of the
Guidance Document on Hemodialyzer Reuse Labeling for safe and
effective reprocessing for reuse manufacturers. A letter was
issued to Manufacturers and Initial Distributors of
Hemodialyzers on May 23, 1996 to inform them of the requirement
to obtain 510(k) clearance for ReUse labeling for all
hemodialyzers which were being marketed for clinics reusing
their dialyzers. They were given until February 25, 1997, to
comply with the request. A video on the methods for correct
reprocessing and reuse of hemodialyzers developed by the FDA,
RPA, and other concerned groups is available. The video
attempts to follow the standard protocols that have been
detailed in the Association for the Advancement of Medical
Instrumentation (AAMI) Recommended Practice for the Reuse of
Hemodialyzers. These practices also have been adopted by HCFA
as a condition of coverage to ESRD providers that practice
reuse.
A multistate study conducted for the FDA in 1987 indicated
that dialysis facilities appeared to have inconsistent quality
assurance (QA) techniques for many areas of dialysis treatment.
To address this problem, FDA funded a contract to develop
guidelines that could be used by all dialysis facility
personnel to establish effective QA programs. The guidelines
printed in February 1991 were mailed to every dialysis facility
in the United States free of charge.
During 1995-1996, FDA prepared a Draft Guidance Document
for the Content of Premarket Notifications for Water
Purification Components and Systems for Hemodialysis. This
document was circulated for comment by regulated industry and
other government agencies and was presented at both AAMI and
Water Quality Association Meetings. The purpose for preparing
this document was to remind the water treatment community of
the Federal requirement for submission of premarket
notifications for these types of device systems (21 CFR
876.5665). The importance of the quality of the water used for
preparation of hemodialysate solutions used during hemodialysis
was strongly emphasized in these presentations and the Guidance
Document.
In September 1996, seven patients in Alabama received
hemodialysis when the blood alarms activated on six of the
seven patients. Subsequently, the patients began to exhibit
serious central nervous (CNS) symptoms. FDA field staff, CDRH
and CDC investigated the various aspects of the incident. The
epidemiological analysis suggests a causal relationship between
the age of the dialyzer filters used (ten plus years), and the
injuries reported to the patients. As a result, CDRH and CDC
issued a joint Public Health Advisory in December 1996, with
the simple message, to ``rotate your dialysis stock using
first-in-first-out practices,'' to avoid this type of problem
in the future. FDA laboratories began a research program to
investigate the effects of aging on dialyzer filters, with the
objective of establishing safe expiration dating labeling.
Dialyzers of various ages were retrieved from the field and
tested for material changes. The results of material
characterization indicated that the cellulose acetate membranes
degraded over time. To verify the cause of the incident in
Alabama, water-soluble extracts from aged dialyzers and
chemically oxidized resin were injected IV into a rabbit model.
Symptoms similar to the case patients were observed. It was
concluded that oxidative stress, either at manufacture or
storage, can generate soluble fractions capable of adversely
affecting patients. The FDA is working with industry and
manufacturing associations to develop shelf-life criteria.
FDA has continued to work cooperatively with the nephrology
community and the ESRD patient groups to improve the quality of
dialysis delivery. These efforts appear to be yielding positive
results. CDRH has also been cooperating with CDC and HCFA in
the exchange of information to try to increase the safety of
dialysis delivery.
Fluoroscopically-Guided Interventional Procedures
An increasing number of therapeutic procedures are being
employed for a variety of conditions, such as coronary artery
disease or irregular heart rhythms, which require x-ray
fluoroscopy to provide visualization and guidance during the
procedures. Due to the time required to complete these
procedures, the potential for large radiation exposures leading
to acute skin injury exists. During the early 1990s, the FDA
received reports of such injuries, investigated the
circumstances and issued an FDA Public Health Advisory to alert
physicians and health care facilities to this concern. This
advisory was sent to hospitals and specialist physicians who
perform such procedures. During 1995 and 1996, the FDA
continued activities to increase the awareness of physicians to
this problem, including publishing supporting information for
physicians, an article in the radiology literature and numerous
presentations at medical professional meetings. These
activities brought the attention of physicians to this issue
and resulted in activities in many healthcare facilities to
assure proper attention is given to this concern. As many of
these interventional procedures are performed on older
patients, this activity contributed to improved care for older
Americans. During 1997 and 1998, the agency continued efforts
to assure that new fluoroscopic x-ray systems will be designed
in a manner that will facilitate dose reduction. This is being
done through development of an international consensus standard
for fluoroscopic systems used for interventional procedures and
development of amendments to the mandatory U.S. performance
standard. FDA staff is also contributing to the development of
a report by the international Commission on Radiation
Protection designed to inform physician users fluoroscopic
equipment regarding steps which should be observed to prevent
skin injuries.
Mammography
Since 1975, CDRH [formerly the Bureau of Radiological
Health (BRH)] has conducted a great many mammography
activities. These have been done with several goals in mind:
To reduce unnecessary radiation exposure of patients during
mammography to reduce the risk that the examination itself
might induce breast cancer; and
To improve the image quality of mammography so that early
tiny carcinoma lesions can be detected at the state when breast
cancer is most treatable with less disfiguring and more
successful treatments.
The National Strategic Plan for the Early Detection and Control of
Breast and Cervical Cancer
FDA, the National Cancer Institute, and the Centers for
Disease Control have coordinated a combined effort to cover 75
professional, citizen, and government groups to develop the
National Strategic Plan for the Early Detection and Control of
Breast and Cervical Cancer. The goal of this plan, approved by
the Secretary of Health and Human Services on October 16, 1992,
is to mount a unified effort by all interested groups to combat
these two serious cancer threats. FDA staff took the lead in
writing the Breast Cancer Quality Assurance section, one of six
components of the plan, and participated in the development of
the other components.
Mammography Quality Standards Act of 1992
On October 27, 1992, the President signed into law the
Mammography Quality Standards Act [MQSA] of 1992. This Act
requires the Secretary of Health and Human Services to develop
and enforce quality standards for all mammography of the
breast, regardless of its purpose or source of reimbursement.
Since October 1, 1994, any facility wishing to produce,
develop, or interpret mammograms has had to meet these
standards to remain in operation. The Secretary delegated the
responsibility for implementing the requirements to FDA on June
1, 1993, and Congress first appropriated funds for these
activities on June 6, 1993. Implementation of MQSA is a key
component of Secretary Shalala's National Strategic Action Plan
Against Breast Cancer.
FDA's accomplishments since the Agency was delegated
authority to implement MQSA in June 1993 include--staffing of a
new division; development of final standards; approval of four
accreditation bodies; certification of 10,000 facilities by the
statutory deadline of October 1, 1994; implementation of a
rigorous training program for inspectors; development of a
compliance and enforcement strategy [coordinated with the
Health Care Financing Administration (HCFA)]; outreach to
facility and consumer communities; and planning for program
evaluation.
On October 9, 1998, the Mammography Quality Standards
Reauthorization Act of 1998 (MQSRA) was enacted, extending the
program to 2002. On April 28, 1999, most of the final
regulations under MQSA will become effective, replacing the
interim standards, under which facilities have been operating
since October 1994. Most regulations will not change, though a
number clarify the requirements of the interim regulations.
Although there are new personnel and equipment regulations, the
most significant changes that are directly patient-related are
as follows:
Mandated by Congress in the Reauthorization
Act, all patients (not just self-referred patients)
must receive a written report of their exam results
from the facility that performs the mammography exam.
This was in response to reports, though rare, of women
receiving inaccurate exam reports or no report at all.
Because the reports must be written in terms a lay
person can easily understand, this provision will help
assure that all women have this information for
effective communication with their health care
providers, and thus are more likely to receive
appropriate medical follow-up when a breast problem is
detected.
A mammography facility must notify its
patients when FDA determines that there are significant
problems with the facility's mammography services, so
that patients involved can take appropriate follow-up
actions with respect to their healthcare.
A facility must release original mammograms,
not copies, when a patient requests the films,
regardless of whether the transfer is permanent or
temporary.
Each mammography facility must develop a
consumer complaint mechanism, to assure that all its
unresolved serious complaints, such as unqualified
personnel or an expired FDA certification, are brought
to the attention of the facility's accreditation body
or FDA for resolution.
MQSA inspections have supplanted the Health
Care Financing Administration's Medicare Screening
Mammography Inspections. Under MQSA, HCFA has agreed to
recognize FDA-certification of a mammography facility
as meeting quality standards for reimbursement
purposes.
Blood Glucose Monitoring
A proposed ISO standard [draft ISO TC 212/WG3] was proposed
for evaluating the performance of self-monitoring blood glucose
monitors by comparing monitor results to those obtained by
clinical laboratory methods. Because the draft standard did not
address how to select a clinical laboratory method, an attempt
was made, based upon telephone surveys and discussions with
CAP, the three most commonly used clinical methods for analysis
of blood glucose. A strategy was developed to evaluate the
accuracy of these methods by comparison to the recently
released Standard Reference Material from the National
Institute of Standards and Technology that has three certified
levels of glucose in human sera. Criteria were developed for
selection of high performance clinical laboratories in order to
minimize effects due to analysts.
Patient Restraints
Patient restraints are intended to limit the patient's
movement to the extent necessary for treatment, examination, or
for the protection of the patient or others.
One of the most common uses of these devices has been to
protect the elderly from falls and other injuries. Seventy-nine
documented deaths have been reported to FDA's Medical Device
Reporting System (MDR) related to patient restraint use.
Scientific literature suggests that annual deaths related to
the use of restraints may be as high as 200. These alarming
numbers of deaths, with the use of protective restraints raised
serious concerns regarding the safe use of these devices and
prompted the FDA to alert the healthcare community about these
problems.
The agency worked closely with industry in arriving at
solutions to help reduce the risk of injury and death
associated with the use of these devices. As a result, in
November 1991, FDA moved to make protective restraints
prescription devices to be used under the direction of licensed
health care practitioners. In addition, manufacturers were
required to label patient restraints as ``prescription only''
to help ensure appropriate medical intervention with the use of
these devices. In July 1992, FDA issued a Safety Alert to
healthcare providers to heighten their awareness of the
potential hazards associated with the use of these devices. FDA
identified labeling as its primary focus for intervention in
resolving this issue, and provided additional labeling
recommendations as guidance to manufacturers to ensure safer
designs. Education and training of personnel in the application
of these devices has also been emphasized.
On March 4, 1996, FDA published a final rule requiring
manufacturers of protective restraints to submit premarket
notifications (510(k)s) to the Agency. Since 1996, FDA has
reviewed approximately 150 premarket notifications for these
devices.
Today, healthcare providers are electing the restraint-free
alternative. As a result, current literature reports that
restraint use is dropping.
Hearing Aids
Several events occurred in 1995-1996 which related to FDA's
development of a guidance document that indicated criteria for
clinical hearing aid study protocols. Manufacturers met with
FDA staff to review proposed clinical studies, consultants met
with FDA to discuss interpretations of the guidance document
and how they might best interface with the regulated industry,
and FDA had meetings with the Hearing Industries Association
(HIA), representing many of the major manufacturers of hearing
aids, wherein the use of the guidance document was discussed.
In addition, members of FDA's Hearing Aid Working Group
completed its draft of the proposal to amend the 1977 hearing
aid regulation. This new regulation, if adopted, would cover
21CFR 801.420 and 801.421, Hearing Aids, Professional and
Patient Labeling and Conditions for Sale.
Orthopaedic Implant Porous Coatings
Porous coatings are widely used in both the orthopedic and
dental implant industries to fix prosthetic devices through the
process of bony in-growth without the aid of cements. However,
the coating qualities such as strength, solubility, and
abrasion resistance vary considerably depending on
manufacturing methods and have significant impact on durability
of the implants. Concern over the long-term revision rates for
plasma sprayed porous coatings prompted the FDA to require
post-market surveillance studies for these types of coatings.
In order to help industry evaluate the coatings under
surveillance, FDA developed a consensus standard based test,
qualified it using standard interlaboratory study methods and
has incorporated that method into a Federal Register Notice
that is currently out for comment. FDA also began a program to
evaluate tests to assess the durability of such coatings in
order to help in the development of longer-lived implants.
Hazards With Hospital Beds
On August 23, 1995, FDA issued a Safety Alert, Entrapment
Hazards with Hospital Bed Side Rails. The Alert noted that the
majority of deaths and injuries reported to FDA involving bed
rails were to elderly patients, and recommended a number of
actions to prevent deaths and serious injuries. This Alert was
sent to nursing homes, hospitals, hospices, home healthcare
agencies, nursing associations, and biomedical and clinical
engineers throughout the United States.
Retinal Photic Injuries
On October 16, 1995, FDA issued a Public Health Advisory,
Retinal Photic Injuries from Operating Microscopes During
Cataract Surgery. Cataract surgery is most frequently performed
on elderly patients. The Advisory discussed the types of
injuries to patients reported to FDA, and recommended actions
to reduce the risk of retinal photic injury. The Advisory was
sent to ophthalmologists and cataract centers throughout the
United States.
Electric Heating Pads
On December 12, 1995, FDA working with the CPSC, issued a
Public Health Advisory, Hazards Associated with Use of Electric
Heating Pads. At the time of the Advisory, 45% of those
reporting injuries from using heating pads, were over the age
of 65. The Advisory pointed out that patients who may be unable
to feel pain to the skin because of advanced age, diabetes,
spinal cord injury, or medication, are at high risk for injury.
This Advisory was sent to hospitals, nursing homes, hospices,
home healthcare agencies, and biomedical and clinical engineers
throughout the United States.
FDA Problem Reporting System for Medical Devices
The Office for Surveillance and Biometrics receives reports
involving medical devices through reporting from consumers,
medical professionals, manufacturers, distributors, and user
facilities. On the 191,537 reports received during the calendar
years 1995 and 1996 from all sources, 22,749 (12 percent)
reported the age of the patient. Of these, 10,855 (48 percent)
were for individuals 60 years of age or older. Prior to August
1, 1996, manufacturers of medical devices were not required to
provide age information. In many instances when manufacturers
were required to provide age information, the information was
unknown and therefore not reported.
Markers of Bone Metabolism
Osteoporosis is a major health concern. It is estimated
that 1.5 million fractures are attributable to osteoporosis in
the United States each year. One third of women older than 65
years suffer vertebral crush fractures, and the lifetime risk
of hip fracture is 15%. The mortality rate accompanying hip
fracture may be as high as 20%. Twenty-five percent of the
survivors are confined to long-term care in nursing homes. The
estimated cost of medical care for osteoporosis each year is
more than $ 10 billion.
If a woman has postmenopause-associated osteoporosis, an
assessment of bone turnover may be helpful. Because of an
increasing interest in bone disease and a greater understanding
of bone metabolism, a number of urinary markers of bone
turnover were cleared by the FDA in 1995 and 1996. The rate of
bone loss is related to an overall increase of bone turnover
which can be assessed using these biochemical indicators.
Year 2000 Health Objectives
A consortium of over 300 government and private agencies
developed a set of health objectives for the Nation which is
serving as a national framework for health agendas in the
decade leading up to the year 2000. The overall program is
called ``Healthy People 2000.'' FDA co-chairs the working group
responsible for monitoring progress on the set of 21 objectives
that focus on nutrition, dietary improvements and availability
of nutrition services and education. In the food and drug
safety area, objective 12.6 sets as a target to:
Increase to at least 75 percent the percentage of
health care providers who routinely review all
prescribed and over-the-counter medicines taken by
their patients 65 years and older each time medication
is prescribed or dispensed.
Objective 12.8 sets as a target to:
Increase to at least 75 percent the proportion of
people who receive useful information verbally and in
writing for new prescriptions from prescribers or
dispensers.
FDA's Marketing Practices and Communications Branch
conducted a number of studies that track patients' receipt of
medication information from doctors and pharmacists from 1982
to 1996. The most recent survey shows that 67% of Americans 65
and over received at least some oral information about
prescriptions from physicians and 43% from pharmacists, while
13% received written information about their prescription
medications from physicians and 62% received such information
from pharmacists. Only 2% reported asking questions at the
doctor's office, and 3% at the pharmacy. The survey is being
conducted again in 1998 to track progress toward meeting this
objective. An article outlining results of the surveys from
1982-1994 will be published in Medical Care in October 1997.
Efforts are in the final stages to prepare the Healthy
People 2010 objectives. A draft of the 2010 objectives was
published for public comment on the September 15, 1998, with
comments being accepted through December 15, 1998 on over 300
objectives in 22 focus areas. FDA would lead or co-lead the
sections on nutrition, food safety, and medical product safety.
A copy of the draft of the 2010 Healthy People objectives is
available on the worldwide web at http://www.cfsan.fda.gov--on
the Center for Food Safety and Applied Nutrition (CFSAN)
homepage, click on ``Foodborne illness'' and then go further
down the next page and click on HP2010.
Food Labeling
Food labeling is very important to the elderly. Elderly
people have a greater need for more information about their
food to facilitate preparation of special diets, maintain
adequate balance of nutrients in the face of reduced caloric
intake, and ensure adequate levels of specific nutrients which
are known to be less well absorbed as a result of the aging
process [e.g., vitamin B 12].
The food label, which is now required on most foods offers
more complete, useful, and accurate nutrition information to
help the elderly meet their nutritional needs. The food label
includes nutrition labeling for almost all foods; information
on the amount per serving of saturated fat, cholesterol,
dietary fiber, and other nutrients of major concern to today's
consumers; nutrient reference values to help consumers see how
a food fits into an overall daily diet; uniform definitions for
terms that describe a food's nutrition content [e.g., light,
low fat, and high-fiber], claims about the relationship between
specific nutrients and disease, such as sodium and
hypertension; standardized serving sizes; and voluntary
quantitative nutrition information for raw fruit, vegetables,
and fish.
To help consumers get the most from the food label,
educational materials have been widely disseminated. Among
materials now available is a large-print brochure, ``Using the
New Food Label to Choose Healthier Foods,'' which is easier to
read for senior citizens who may have vision problems.
A food label education program has been developed that
coordinates the efforts of FDA and USDA with various public and
private sector organizations to educate consumers about the
availability of new information on the food label and the
importance of using that information to maintain healthful
dietary practices. Consumer Research was used to guide the
development of educational materials and their messages. Print
and video materials were developed for diverse target
audiences, emphasizing skills and tips on how to use the food
label quickly and easily to achieve a healthier diet. The
agency has released two ``Question and Answers'' documents,
giving answers to about 400 frequently asked questions.
FDA's food labeling education program seeks to coordinate
the Government's efforts with those of the public and private
sector to insure consistent, action-oriented label education
messages. A key goal is to promote integrating label education
into new and existing nutrition education programs for diverse
target audiences (for example, through national video
teleconferences on nutrition interventions, children's games
and nutrition-oriented programs on CD ROMs, and community-based
programs for multi-cultural populations). Public information
and education materials are available from FDA's Office of
Consumer Affairs and have also been posted on CFSAN's home page
of the World Wide Web (WWW).
Dietary Supplements
The Dietary Supplement Health and Education Act of 1994
(DSHEA) was signed by the President on October 25, 1994. This
Act amended the Federal Food, Drug, and Cosmetic Act to alter
the way the Food and Drug Administration regulates dietary
supplements and requires the Agency to undertake rulemaking and
other actions to fully implement the scope of the Act.
The DSHEA established a new regulatory definition for
``dietary supplement,'' established a framework for regulating
the safety of dietary supplements that is different than that
for conventional food ingredients, defined the term ``new
dietary ingredient'' and established circumstances under which
such ingredients can be safely used in dietary supplements, and
amended the safety provisions of the Act such that FDA must
establish that a product presents a significant or unreasonable
risk of illness or injury under the label's conditions of use
before it can be removed from the marketplace.
The DSHEA allows dietary supplement manufacturers to make
certain types of claims for their products. A dietary
supplement may claim a benefit related to a classical nutrient
deficiency disease, describe the role of a nutrient or dietary
ingredient intended to affect the structure or function of the
body, describe the mechanism by which it acts to maintain
structure or function, or describe general well-being from
consumption of a nutrient or dietary ingredient. In order to
make such claims, manufacturers must have substantiation that
the claim is truthful and not misleading, the claim must
contain the mandatory disclaimer stating this statement has not
been evaluated by the FDA. This product is not intended to
diagnose, treat, cure, or prevent disease, and the firm must
notify FDA it is using the claim. However, a firm does not have
to provide FDA its substantiation for the claim nor get FDA
approval to use the claim.
The DSHEA also authorizes FDA to Issue regulations for good
manufacturing practices for dietary supplements. The Agency
published an advance notice of proposed rulemaking (ANPR) in
the February 6, 1997 Federal Register. FDA is reviewing the
comments received to the ANPR and intends to publish a proposed
rule. Good manufacturing practices would ensure that dietary
supplements are manufactured in such a manner that consumers
can be confident they contain what they purport to contain and
that they are not adulterated in any way.
FDA published final labeling regulations for dietary
supplements in the September 23, 1997 Federal Register. The
labeling regulations are effective on March 23, 1999 and will
ensure that dietary supplements are labeled in a clear and
informative manner. The new labeling requirements should assist
consumers in making informed choices on whether a particular
dietary supplement is appropriate for their particular needs.
Total Diet Studies
The Total Diet Study, as part of FDA's ongoing food
surveillance system, provides a means of identifying potential
public health problems related to the diets of the elderly and
other age groups. Through the Total Diet Study, FDA is able to
measure the levels of pesticide residues, toxic elements,
chemicals, and nutritional elements in selected foods of the
U.S. food supply. In addition, the study allows FDA to estimate
the levels of these substances in the diets of 14 age groups:
infants 6 to 11 months old; children 2, 6, and 10 years old;
14- to 16-year-old boys; 14- to 16-year-old girls; 25- to 30-
year-old men; 25- to 30-year-old women; 40- to 45-year-old men;
40- to 45-year-old women; 60- to 65-year-old men; 60- to 65-
year-old women; men 70 years and older; and women 70 years and
older. Because the Total Diet Study is conducted yearly, it
also allows for the determination of trends and changes in the
levels of substances in the food supply and in daily diets.
Postmarket Surveillance of Food Additives
FDA's Center for Food Safety and Applied Nutrition (CFSAN)
monitors complaints from consumers and health professionals
regarding food and color additives and dietary practices as
part of its Adverse Reaction Monitoring System. Currently, the
database contains 13,158 records. Of the complainants who
reported their age, approximately 21 percent were individuals
over age 60. The Special Nutritionals Adverse Event Monitoring
System (AEMS) may be accessed on the worldwide web at http://
vm/cfsan.fda.gov/-dms/.
Medicare Coverage Determinations
FDA provides representatives and scientific input to the
Health Care Financing Administrations's Technology Advisory
Committee (TAC). The TAC is a committee of government
employees, which advises HCFA on national coverage decisions
for Medicare recipients. FDA also provides input and expert
review for technology assessments produced by the Agency for
Health Care Policy and Research (AHCPR). AHCPR technology
assessments are used by HCFA and the Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) as a basis
for coverage decisions.
During the 1995-1996 reporting period, FDA and HCFA
formulated an arrangement to afford beneficiaries Medicare
coverage for investigational medical devices determined by FDA
to constitute only a minor change from an already covered
device. This arrangement allows manufacturers to validate the
safety and efficacy of improved products without denying
coverage during the period of study.
Pharmacy Initiative
During 1995 and 1996, DHHS and FDA have sought to encourage
greater pharmacy-based counseling. Through speeches, articles,
and editorials in major medical and pharmacy journals, DHHS and
FDA have encouraged the increased role of pharmacists, using
computers to print information to informing patients about the
uses, directions, risks and benefits of prescription
medications. The pharmacy profession has responded positively,
bringing many examples of their initiatives to FDA's attention.
In particular, several organizations have informed FDA of the
expanded use of new technology to provide patient instructional
materials to their customers. In August of 1996 Congress took
up this issue and developed performance goals for the private
sector to meet. In December of 1996 the private sector had
developed an Action Plan with criteria on how to determine the
usefulness of information for consumers. The Plan would then be
presented to the Secretary of HHS for concurrence. A survey by
FDA, with data collected beginning December 1996, showed 67% of
patients reporting that they received written information with
their prescription drugs. FDA will conduct studies in the
future to review the usefulness of that information and will
continue to work closely with private sector organizations in
an effort to increase the dissemination of useful information
to patients about their prescription medications.
Health Fraud
Health fraud is the deceptive promotion and distribution of
false and unproven products and therapies to diagnose, cure,
mitigate, prevent, or treat disease. These fraudulent practices
can be serious and often expensive problems for the elderly. In
addition to economic loss, health fraud can also pose direct
and indirect health hazards to those who are misled by the
promise of quick and easy cures and unrealistic physical
transformations.
The elderly, more often than the general population, are
the victims of fraudulent schemes. Almost half of the people
over 65 years of age have at least one chronic condition such
as arthritis, hypertension, or a heart condition. Because of
these chronic health problems, senior citizens provide
promoters with a large, vulnerable market.
To combat health fraud, the FDA uses a combination of
enforcement and education. In each case, the Agency's decision
on appropriate enforcement action is based on considerations
such as the health hazard potential of the violative product,
the extent of the product's distribution, the nature of any
mislabeling that has occurred, and the jurisdiction of other
agencies.
The FDA has developed a priority system of regulatory
action based on two general categories of health fraud: direct
health hazards and indirect hazards. The Agency regards a
direct health hazard to be extremely serious, and it receives
the Agency's highest priority. FDA takes immediate action to
remove such a product from the market. When the fraud does not
pose a direct health hazard, the FDA may choose from a number
of regulatory options to correct the violation, such as a
warning letter, a seizure, or an injunction.
The Agency also uses education and information to alert the
public to health fraud practices. Both education and
enforcement are enhanced by coalition-building and cooperative
efforts between government and private agencies at the
national, State, and local levels. Also, evaluation efforts
help ensure that our enforcement and education initiatives are
correctly focused.
The health fraud problem is too big and complex for any one
organization to effectively combat by itself. Therefore, FDA is
working closely with many other groups to build national and
local coalitions against health fraud. By sharing and
coordinating resources, the overall impact of our efforts to
minimize health fraud will be significantly greater.
FDA has worked with the National Association of Attorney's
General [NAGS] and other organizations to provide consumers
with information to help avoid health fraud. Since 1986, FDA
has worked with the National Association of Consumer Agency
Administrators [NCAA] to establish the ongoing project called
the NCAA Health Products and Promotions Information Exchange
Network. Information from FDA, the Federal Trade Commission
[FTC], the U.S. Postal Service [USPS], and State and local
offices is provided to NCAA periodically for inclusion in the
Information Exchange Network. This system provides information
on health products and promotions, consumer education materials
for use in print and broadcast programs, and the names of
individuals in each contributing agency to contact for
additional information.
In 1995 and 1996, FDA's Public Affairs Specialists [PASs]
continued to alert diverse and culturally specific elderly
populations throughout the United States by sponsoring
community-based education programs, information exchanges, and
outreach efforts. Dietary supplements remained a key issue. In
addition to health fraud workshops and other community-based
programs, the PASs also convey this important information
through additional networks such as radio, television shows,
and public service announcements. With respect to enforcement,
in 1997 and 1998, the Agency took actions against the
importation of Corvalolum, a Russian product containing
dangerous levels of phenobarbital. The Agency issued national
publicity to alert consumers to the dangers of this product and
worked with the U.S. Customs Service to immediately confiscate
this product upon entry into the U.S. In addition, the Agency
took actions against firms marketing various unproven products
offered for cancer, AIDS, diabetes, gonorrhea, lupus,
schizophrenia and other serious disease conditions.
Women's Health
Information about drug effects in certain populations.
Over the past decade there has been growing concern that
the drug development process does not provide sufficient
information about drug effects in certain populations,
including minorities and women of all ages. On September 8,
1995, the FDA, in an effort to collect this necessary
information, proposed to amend its regulations regarding the
format and content of investigational new drug applications
(INDs) and new drug applications (NDAs). The proposed rule
would require IND sponsors of drugs and biological products to
include in their annual reports a characterization of study
subjects by subgroups, such as age, gender, and race. Sponsors
would also be required to present safety and efficacy data by
subgroup when submitting NDAs. This rule has since gone into
effect and will assist in the determination of the optimal use
of drugs in special populations which have a variety of factors
that can lead to different responses to medical products.
Women's health research agenda
During 1995 and 1996, FDA participated with the NIH Office
of Women's Health in defining specific objectives of the
research agenda for the 21st century. The effort culminated in
plans for a workshop including experts from the federal
government and universities to be held in 1997. Some specific
age-related conditions were evaluated including cardiovascular
and pulmonary diseases, oral health, bone and musculoskeletal
disorders, kidney conditions, and cancer.
Hispanic women's health conference
On May 9-10, 1996, the Office of Women's Health sponsored
the Hispanic Women's Health Conference held in Miami, Florida.
Over 150 people attended the conference which was designed as a
grassroots effort to bring together community based
organizations, academia, federal, state and local agencies and
public/private health care providers concerned with Hispanic
women's health issues, many of which affect aging American
women. The two day meeting featured national and local speakers
who addressed key Hispanic health concerns in the areas of
diabetes, heart disease, cancer, mental health, substance
abuse, osteoporosis, and HIV/AIDS. Its purposes were to create
an ongoing network of health professionals in Southern Florida
to address this community's health needs, and to consider
priority issues on which ongoing public education should occur.
Minority women health empowerment: Workshops
The office sponsored this series of Conferences in 1995,
1996 and 1997. The purpose of the workshops was to equip
minority women, including the aging, in urban areas of the New
Jersey and Delaware Valley with information on how to take care
of themselves, how to prevent illness and disease, and what the
benefits are of early detection and treatment. This project
targeted women who were at high risk for HIV/AIDS,
cardiovascular disease, breast and other cancers, and diabetes.
The programs were conducted in community centers, Head Start
Centers, local parish halls, school auditoriums, and hospital
conference rooms. Audiotapes in English and Spanish were given
to participants at the end of the workshop.
Women's health: Take time to care
In 1996, the FDA Office of Women's Health (OWH) conceived
of a new program partnering with American women. In order to
enhance the health of women, the FDA wanted to provide mid-life
and older women, particularly in under served populations, with
the information they need to promote and protect their own
health. OWH met with 46 advocacy groups representing women, the
elderly, and disease conditions, to discuss their health
concerns. The theme, Women's Health: Take Time To Care, will be
used for a variety of health prevention messages. Women, as
represented by these organizations, told us that the first
message should be presented Use Medicines Wisely. As major
consumers of pharmaceuticals, women and their health are
significantly effected by the use of medications. In 1997,
Pilot programs using this message were conducted in Chicago, IL
and Hartford, CT. FDA provided the printed materials and
information and community organizations sponsored numerous
public awareness events. This program will be rolled out
nationally in 1998 and will be brought to 15 cities, rural
empowerment zones, and Native-American reservations across the
country.
``Before time runs out''
Breast cancer is the number one cause of cancer related
deaths among African American women. The FDA Office of Women's
Health provided funds to educate African American women in the
Houston area about the importance of screening and the impact
of breast cancer on the African American community through the
use of a locally-inspired play. This drama, which was written
and produced by an African American playwright (Thomas
Meloncon) entitled ``Before Time Runs Out'' was inspired by Mr.
Meloncon's sister who died of breast cancer. The play was
followed by a panel discussion and pertinent brochures were
distributed. This series was presented in selected churches in
under served communities in Houston in 1996 and 1997.
Public education brochures
Asian Pacific Islander women have low rates of utilization
of breast and cervical cancer screening procedures due to
language barriers and a subsequent lack of understanding of the
importance of these tests. In 1995, the Office of Women's
Health sponsored the translation of mammography and cervical
cancer screening materials into several languages to address
the needs of linguistically isolated Asian Pacific Islander
women.
Materials, Outreach, and Exhibits
The FDA Center for Food Safety and Applied Nutrition is
working with the American Association of Retired Persons (AARP)
to develop information for seniors on food safety. The project
will support the United Nation's observation of the
International Year of Older Persons 1999. AARP has developed a
program geared toward making seniors better able to manage
independently in their own homes, and food safety is an
important component of this effort.
FDA launched a public awareness campaign on the risk that
unpasteurized or untreated juices may present to vulnerable
populations, including the elderly. Educational materials
including a press kit, consumer brochure, video news release,
and a public service announcement were distributed to senior
citizen groups, as well as day care centers, elementary
schools, state PTA offices and media outlets. AARP and other
organizations also assisted in distribution of the information.
FDA issued an advisory that the elderly, children and
people with compromised immune systems should avoid eating raw
alfalfa sprouts due to the increased risk of pathogens.
The Agency routinely develops Talk Papers, Press Releases,
and FDA Consumer articles that focus on topics of high interest
to older consumers. During 1998, the Agency issued Talk Papers
and Press Releases on the FDA approval of the first ultrasound
device for diagnosing osteoporosis (Sahara Clinical Bone
Sonometer) that does not involve the use of x-rays; the launch
of a grassroots campaign, Women's Health: Take Time To Care,
which is primarily directed to women over age 45 focusing on
the management of medications for themselves and their
families; and the FDA approval of the first oral treatment for
active rheumatoid arthritis (Arava or leflunomide).
During 1997 and 1998, FDA published articles in the FDA
Consumer on a wide variety of topics of interest and concern to
older consumers. The topics of these articles included FDA's
early warning system for unforeseen medical product problems;
FDA regulation of label claims linking food with disease
prevention or better health; testing and treatments for
prostate cancer; remedies for sleeplessness; new drugs and
medical devices for treating Parkinson's Disease; new
medications and therapies for treating serious depression;
helping caregivers to learn more easily about the latest on
Alzheimer's; advances in the prevention and treatment of
stroke; treating back pain; medications and older adults; hair
replacement; new drugs and medical devices that show promise in
curbing ventricular arrhythmias; and estrogen replacement
therapy.
The Agency has established networks and communication
channels to reach the national and local aging network with
consumer-oriented information. By working with a variety of
external constituencies--consumers, patients, health
professional community, academia and scientific organizations,
industry, women's organizations, minority groups, and the
international community--FDA is able to form the collaborations
and cooperative arrangements to significantly extend its
outreach to older consumers. The Agency exhibits at major
annual meetings of national--such as the American Public Health
Association--as well as at community events and local health
fairs sponsored by grassroots organizations.
Community-Based Programs
Public Affairs Specialists, located throughout the country
in FDA field offices, conducted a variety of community-based
programs in 1997-1998 to address the health concerns and
information needs of older Americans. The topics addressed by
field programs, exhibits and outreach efforts are timely and
diverse, including such topics as food labels; food safety; the
safe use of medications; Take Time To Care; health fraud;
clinical trials; dietary supplements; prostate cancer;
osteoporosis; breast cancer; arthritis; and cataracts.
During 1995-1996, FDA Public Affairs Specialists focused on
informing older Americans about the Nutrition Labeling and
Education Act and how to use the new food label for a healthy
or special diet. These Specialists developed information kits
for older people and distributed these kits in communities
throughout the country. These kits included wallet cards on the
new food labeling law; large-print fact sheets; place mats; and
trainer guides. Senior volunteers were trained in a nutrition
program sponsored by DHHS Region V Administration on Aging in
Chicago, Illinois to disseminate information on food labeling
to senior citizens, especially older people in minority
communities.
In 1997-1998, the FDA Public Affairs Specialists used a
variety of approaches and met with wide diversity of elderly
organizations on three key issues--food safety, Take Time To
Care and safe medication use, and health fraud. Food safety
presentations and roundtable discussions provided valuable
vehicles for communicating the safe food handling message of
the ``Fight BAU campaign to senior citizens and to food service
workers. Take time To Care and the safe medication use message
were held throughout 1997-1998. This program, which is directed
primarily to older women, was held at locations throughout the
country--the programs held in San Francisco are representative
of the Take Time To Care Programs held in other locations where
the program was held from March 21-28, 1998. During this time,
approximately 50 events were held, with 100,000 brochures being
disseminated, and a wide diversity of community organizations
participating--such as American Diabetes Association, American
Indian Family Health Center, Area Agency on Aging, Center for
Elder's Independence, HealthNet Seniority Plus, National
Council of Negro Women, Older Women's League, San Francisco
General Hospital, and the YWCA. Numerous food safety
presentations to Meals-on-Wheels programs and senior centers in
the San Francisco District area were conducted. The
presentations focused on food microbiology and prevention of
foodborne illness through proper food handling techniques.
Fight BAC brochures were distributed at each location. The FDA
Public Affairs Specialists continue to work with community-
based organizations to cooperate in communicating important
information about contemporary health frauds and how to avoid
them.
HEALTH CARE FINANCING ADMINISTRATION
The mission of the Health Care Financing Administration
(HCFA) is to promote the timely delivery of appropriate,
quality health care to its beneficiaries-over 75 million aged,
disabled, and poor Americans.
Medicaid and Medicare ore the principle sources of funding
long-terrn care in the United States. The primary types of care
reimbursed by these programs of HCFA are a variety of
institutional (e.g., skilled nursing facilities (SNFs),
intermediate care facilities for the mentally retarded (ICFs/
MR), inpatient rehabilitation, and home and community-based
care services (e.g., home health, personal care).
HCFA conducts demonstration projects that demonstrate and
evaluate optional coverage, eligibility delivery system,
payment and management alternatives to the present Medicare and
Medicaid programs. HCFA also conducts research studies on a
range of issues relating to long-term care services and their
users, providers, quality and costs.
Information follows on specific HCFA demonstrations and
research:
Wisconsin partnership program
Project No.: 11-W-00123/05
Period: October 16, 1998-December 31, 2004
Funding: $0
Award: Waiver-Only
Principal Investigator: Steve Landkamer
Awardee: Wisconsin Division of Health and Family Services,
1 West Wilson Street, Madison WI 53701
HCFA Project Officer William D. Clark, Office of Strategic
Planning
Description: The State of Wisconsin submitted an
application to HCFA in February 1996 for Medicare and Medicaid
demonstration waivers to establish a ``Partnership'' model of
care for dually entitled nursing home certifiable beneficiaries
who are either under age 65 with physical disabilities or frail
elders. Waivers were approved for this demonstration on October
16, 1998. One site (Elder Care--Madison) became operational
under Medicare and Medicaid waivers on January 1, 1999;
Community Care for the Elderly--Milwaukee is expected to become
operational on March 1, 1999. Community Living Alliance--
Madison and Community Health Partnership--Eau Claire are
expected to become operational in spring, 1999.
The partnership model
The ``Partnership'' model is similar to the Program for
All-inclusive Care for the Elderly (PACE) model in the use of
multi-disciplinary care teams, prepaid capitation, and
sponsorship by community-based service providers. This model is
a variant of PACE. Rather than the physician being co-located
with the multi-disciplinary team, the ``Partnership'' program
will enable participants to use a physician of their choice in
the community who agrees to participate as a contractor with
the Partnership Plan. This model utilizes nurse practitioners
and other multi-disciplinary team members to provide continuity
and coordination with the physicians who elect to participate.
The Partnership also will rely less on adult day care centers
than do PACE sites, as the organizing focus for the provision
of care. The model is proposed as a fully voluntary enrollment
model for 1,200 beneficiaries.
Benefits
All Medicare and Medicaid covered benefits are offered
under full capitation for eligible participants who elect to
enroll.
Four demonstration sponsors
Partnership sites for the frail elderly are the existing
PACE sites in Milwaukee and Madison. The Partnership model for
people with disabilities will utilize Centers for Independent
Living in Madison and Eau Claire. The model for people with
disabilities is believed to be the first site in the nation for
fully capitated Medicare and Medicaid services for people with
physical disabilities.
Status: The project is in the early development stage.
Multi-state evaluation of dual eligibles demonstrations
Period: 9/30/1997-9/29/2002
Funding: $5,623,414
Contractor: University of Minnesota, 420 Delaware Street,
SE., Minneapolis, MN 55455-0392
Investigator: Robert L. Kane, M.D.
The Department of Health and Human Services has been
encouraging efforts to better coordinate services provided to
individuals who are eligible for both Medicare and Medicaid,
also known as dual eligibles. As a result of this policy, a
number of demonstration applications have been submitted and
the Health Care Financing Administration has approved or
expects to approve several of these demonstrations to test
various models of managed care that are specifically directed
at better coordinating care received by dual eligibles. These
include the Minnesota Senior Health Options Program, the
Wisconsin Partnership Program, Monroe County Continuing Care
Networks Demonstration (New York), and the Colorado Integrated
Care and Financing Project. While directed at different
populations and having very different operational approaches,
each is designed to use a managed care approach to better
integrate Medicare and Medicaid services to meet the needs of
dual eligibles more efficiently and effectively.
This evaluation is designed to assess the impact of dual
eligible demonstrations in the States of Minnesota, Wisconsin,
New York, and Colorado. Analyses will be conducted for each
State and across States. The quasi-experimental design will
utilize surveys, case studies, and Medicare and Medicaid data
for analysis. Major issues to be examined include the use of a
capitated payment strategy to expand services while reducing/
controlling costs, the use of case management techniques and
utilization management to coordinate care and improve outcomes
and the goal of responding to consumer preferences while
encouraging the use of noninstitutional care. A universal theme
to be developed is the difference between managing and
integration.
Beneficiary surveys and case study interviews are in
progress in the Minnesota demonstration. Preliminary
discussions have been held between the contractor and
representatives from the demonstrations in Wisconsin and New
York. Summaries and findings from completed work to date will
be included in the First Annual Report to HCFA.
Multi-State dual eligible data base and analysis development
Project No.: 500-95-0047/03
Period: September 1997-September 2000
Funding: $1,350,000
Award: Task Order
Principal Investigator: Don Lara
Awardee: Mathematica Policy Research, Inc., 101 Morgan
Lane, Plainsboro, NJ 08536
HCFA Project: William D. Clark, Officer, Office of
Strategic Planning
Description: This project will use available Medicare/
Medicaid-linked statewide data in 10-12 States to develop a
uniform database that can be used by States and the Federal
government to improve the efficiency and effectiveness of the
acute- and long-term care services to persons eligible for both
Medicare and Medicaid (dual eligibles). It will also conduct
analyses derived from these data to strengthen the ability to
develop risk-adjusted payment methods and deepen the
understanding of Medicare-Medicaid program interactions as they
relate to access, costs, and quality of service. Finally, it
will recommend longer range options that will improve the
usefulness of the database for operational and policy purposes.
Status: The project is constructing a multi-State dual
eligible database and beginning their analyses. Results from
some of the studies conducted in this contract are anticipated
in early 2000.
Continuing care networks demonstration, Monroe County, New York
The Health Care Financing Administration is reviewing a
demonstration proposal entitled: ``Continuing Care Networks
Demonstration (CCN): Monroe County, New York'' which was
submitted by the New York State Department of Health and the
Community Coalition for Long Term Care (CCLTC). The CCN
project, a 5-year demonstration, is designed to test the
efficiency and the effectiveness of financing and delivery
systems which integrate primary, acute, and long-term care
services under combined Medicare and Medicaid capitation
payments. Participants will be both Medicare only, and dually
eligible Medicare/Medicaid beneficiaries, who are 65 or older.
The State is proposing that the CCNs will enroll, over a five-
year period, at least 10,000 Medicare-only and dually eligible
Medicare/Medicaid beneficiaries in Monroe County, New York.
Enrollment will be voluntary for all participants.
The State is proposing that CCN participants be eligible
for all Medicare Part A and Part B covered services. Medicaid
participants will be eligible for the full range of Medicaid-
covered services in the New York State Plan, including long
term benefits as provided under the State's 1915 waiver
program. Medicare enrollees will be offered the same package of
chronic (long-term) care benefits as is available to the dually
eligible participants. Payment for the benefit package will be
either in the form of a capitation premium equivalent to the
Medicaid impaired-in-the-community capitation rate, or on a
private pay, fee-for-service basis from CCN providers. A
limited chronic care benefit of up to $2,600 per year (and not
to exceed a $6,000 lifetime maximum) will be available to all
who join the CCN as community-based unimpaired participants on
enrollment. The benefit is designed to prevent, or delay,
functional decline among members who are considered to be at
risk of future institutionalization.
All enrollees will complete a Health Assessment
Questionnaire at the time of enrollment. The questionnaires
will be reviewed by the care management staff to determine the
level of services needed, based on risk targeting criteria
developed for this project. Depending upon the results of the
risk targeting process, the care manager may arrange for an
assessment to be performed. The proposed assessment instrument,
the DMS-1, is currently used State-wide to assess eligibility
for both the Long Term Home Health Care Program, and, beyond a
certain score, nursing home admission. Since the DMS-1
assessment will be used for both care planning and determining
the assessed enrollee's payment cell, the tool will be
administered under the CCN demonstration, by designated project
staff from an independent assessment organization.
Medicare and Medicaid payments will be capitated. Existing
county rate book rates, established as a result of the Balanced
Budget Act of 1997, will be used for Medicare. The county rate
book rates will be multiplied by a combination of existing
AAPCC adjustors and additional adjustors which reflect three
levels of impairment (based on the DMS- I score) within the
population that could be certified for nursing home admission.
Adjustors for the ``unimpaired/non-Medicaid'' and ``unimpaired
Medicaid'' categories are lower than existing AAPCC adjustors
to balance the higher adjustors being proposed for those
enrollees who are living in the community, but could be
certified for nursing home admission. There will be three
separate categories for Medicaid rates: nursing facility
residents, beneficiaries living in the community who could be
certified for nursing home admission, and unimpaired
beneficiaries.
The State is hypothesing that combined capitated payments
from Medicare and Medicaid coupled with an integrated service
delivery system will facilitate more rational, efficient, and
cost-effective clinical approaches to providing health services
for older persons, including those who are functionally
impaired.
Evaluation of the nursing home case-mix and quality demonstration
Project: 500-94-0061
Period: 9/30/1994-9/29/1999
Funding: $2,980,219
Award: Contract
Principal Investigator: Robert J. Schmitz, Ph.D.
Awardee: Abt Associates, Inc., 55 Wheeler Street,
Cambridge, MA 02138-1168
HCFA Project Officer: Edgar A. Peden REG/DPR
Description: Using data from the Nursing Home Case-Mix and
Quality (NHCMQ) Demonstration, HCFA is evaluating the new
practice of paying skilled nursing facilities (SNFs) for
Medicare skilled nursing services on a prospective basis. Prior
to July 1, 1998, SNFs were reimbursed on a retrospective basis
for their reasonable costs. Since that date, however, following
methods used in the NHCMQ demo, a new prospective methodology
has been implemented. Under this methodology, patients are
classified into resource utilization groups which are then used
to calculate each facility's case mix. HCFA then pays
facilities for each covered day of care, according to the case
mix of patients residing there on any given day. Though some
costs will continue to be paid on a retrospective cost basis
under the demonstration, the prospective rate will eventually
include inpatient routine nursing costs and therapy costs. To
guard against the possibility that inadequate care would be
provided to patients with heavy care needs, a system of quality
indicators has been developed that will be used to monitor the
quality of care. The demonstration project which led to the
current program was implemented in six States (Kansas, Maine,
Mississippi, New York, South Dakota, and Texas) in the summer
of 1995, with Medicare-certified facilities in these States
being offered the opportunity to participate on a voluntary
basis. The evaluation of this demonstration project seeks to
estimate specific behavioral responses to the introduction of
prospective payment and to test hypotheses about certain
aspects of these responses. The principal goal of the
evaluation of the NHCMQ Demonstration is the estimation of the
effects of case-mix-adjusted prospective payment on the health
and functioning of nursing home residents, their length of
stay, and use of health care services; on the behavior of
nursing facilities; and on the level and composition of
Medicare expenditures.
Status: The evaluation design has been finalized, interim
analyses of admitting patterns and select outcomes have been
undertaken, and visits to demonstration and non-demonstration
facilities have been conducted in order to understand provider
response to the payment demonstration. Current analytic
activities center around database construction and analysis of
the third phase of the demonstration, which bundled skilled
therapy services into the prospectively paid routine rate. Of
special interest is the analysis of primary data regarding the
provision of professional therapy services from both
demonstration sites and comparison sites. This primary data
collection activity was completed in January, 1999, and will
serve to augment Medicare claims data, which may not offer
reliable information on the quantity and duration of
professional therapies. Another key issue being evaluated is
the probability of patient discharge or transfer under case-
mix-adjusted prospective payment.
Case-mix adjustment for a national home health prospective payment
system
Project: 500-96-0003/02
Period: 7/26/1996-4/30/2000
Funding: $2,966,5524
Award: Task Order
Principal Investigator: Henry Goldberg
Awardee: Abt Associates Inc., 55 Wheeler Street, Cambridge,
MA, 02138-1168
HCFA Project Officer: Ann Meadow, Sc.D. REG/DPR
Description: The primary focus of this study is to
understand existing variation in home health resource patterns
and to use this information to develop a case-mix adjustment
system for a national home health prospective payment system
(PPS). In this study, the Outcome and Assessment Information
Set (OASIS), which has been developed for outcome-based quality
assurance and improvement for Medicare home health agencies, is
being examined to see whether items included in this instrument
will be useful for case-mix adjustment. Detailed information,
including information on resource utilization and additional
items needed for case-mix adjustment not included on OASIS, is
being collected from participating agencies.
Status: Ninety agencies from eight States were recruited
and trained in the spring and summer of 1997. All agencies
began data collection on a six-month cohort of new admissions
to home care beginning in October 1997. Data collection is
scheduled to end in the spring of 1999. Analysis to date has
resulted in a viable, clinically coherent system of 80 case mix
groups that explains more than 30% of the variation in resource
use on a development sample drawn from the cohort members.
Resource use is measured for 60-day periods of care, to conform
to the planned unit of payment under the forthcoming national
PPS. Selected OASIS assessment items, collected at the start of
care, are used in the grouping system. The case mix items fall
into three major domains: clinical factors, functional-status
factors, and utilization factors. Within each domain, a
parsimonious set of items is summarized into a score for the
patient. In two of the domains, scores are partitioned into
four levels corresponding to high, moderate, low, and minimal
impact, based on the relationship of the score to resource
utilization. In the third domain, scores are partitioned into
five impact levels. A patient's combination of levels on all
the three domains identifies the group into which the patient
is classified for purposes of case-mix adjusting the
prospective payment amount. Under this system, the patient's
case mix classification is updated at the end of the payment
period to reflect the actual amount of home therapy services
received during the 60-day payment period. This information is
necessary to arrive at a final score for the utilization
domain.
Results of the study to date are described in two reports:
Case-Mix Adjustment for a National Home Health
Prospective Payment System: First Interim Report, July,
1998 (revised December, 1998)
Case-Mix Adjustment for a National Home Health
Prospective Payment System: Second Interim Report,
January 25, 1999
A third interim report is expected early in 1999.
Maximizing the cost effectiveness of home health care: The influence of
service volume and integration with other care settings on
patient outcomes
Project: 17-C-90435/8
Period: 9/1/1994-12/31/1999
Funding: $1,496,245
Award: Cooperative Agreement
Principal Investigator: Robert Schlenker, Ph.D.
Awardee: Center for Health Policy Research, 1355 South
Colorado Boulevard, Suite 706, Denver, CO 80222
HCFA Project Officer: Ann Meadow, Sc.D., REG/DPR
Description: Home health care (HHC) has been the most
rapidly growing component of the Medicare budget in recent
years. The rapid growth in home health use has occurred despite
limited evidence about the necessary volume of HHC to achieve
optimal patient outcomes and whether it substitutes for more
costly institutional care. Little is known about integrating
HHC with care in other settings to reduce overall health care
costs. The central hypotheses of this study are that volume-
outcome relationships are present in HHC for common patient
conditions; that upper and lower volume thresholds exist that
define the range of services most beneficial to patients; and
that a strengthened physician role and better integration of
HHC with other services during an episode of care can optimize
patient outcomes while controlling costs. To test these
hypotheses, a target sample size of 3,600 patient records has
been set, to be gathered from agencies in 20 States. Trained
data collectors at each agency will record patient health
status and service information between HHC admission and
discharge to assess patient outcomes and costs within the HHC
episode. Long-term, self-reported outcomes will be assessed
from telephone interview data at HHC admission and from 6-month
follow ups. These primary data concerning patient status and
outcomes will be combined with Medicare claims data over the
episode of care to assess the relationship between service
volume in HHC and both patient outcomes and costs. Analysis of
data relating to physician involvement and the sequence of use
of other providers will address issues of integration with
other services.
Status: Study Paper 1, Research Design Update, which
summarized the research design and its evolution from the
original proposal, was finalized in September, 1998. Primary
data collection ended in late 1998. An interim, descriptive
report on a subsample of 1,000 patients is scheduled for
delivery early in 1999.
Evaluation of phase 11 of the home health agency prospective payment
demonstration
Project: 500-94-0062
Period: 9/30/1994-9/29/1999
Funding: $3,732,642
Award: Contract
Principal Investigator: Valerie Cheh, Ph.D.
Awardee: Mathematica Policy Research, Inc., P.O. Box 2393,
Princeton NJ 08543-2393
HCFA Project Officer: Ann Meadow, Sc.D., REG/DPR
Description: This contract is evaluating Phase II of the
Home Health Agency Prospective Payment Demonstration, under
which home health agencies (HHAs) are paid on a prospective
basis for an episode of care reimbursed by the Medicare
program. (Phase I tested per-visit prospective payment for home
health agencies.) Ninety-one agencies from five sites--
California, Florida, Illinois, Massachusetts, and Texas--were
randomly assigned to either the treatment group (PPS payment,
48 agencies) or the control group (conventional cost-based
reimbursement, 43 agencies). The agencies phased in to the
demonstration at the beginning of their 1996 fiscal year.
Treatment-group agencies can reduce the cost of care they
provide during a 120-day payment period by reducing visits,
changing the mix of visits to make less costly visits a larger
proportion of visits, reducing per-visit costs, or some
combination of all three. The cost-reducing activities raise
the possibility that quality of care might deteriorate under
episode-based payment. Quality impacts, along with cost,
utilization, and qualitative, behavioral effects, are the focus
of the evaluation. The findings will indicate not only the
overall effects of the change in payment methodology, but also
how the effects are likely to vary with the characteristics of
agencies and patients.
Status: Interim findings from the evaluation based
primarily on the first 8 to 15 months of demonstration
operations are described in six documents:
Transition Within a Turbulent System: An Analysis of
the Initial Implementation of the Per-episode Home
Health Prospective Payment Demonstration, August 6,
1997
Preliminary Report: The Impact of Prospective Payment
on Medicare Home Health Quality of Care, January 30,
1998
Preliminary Report: The Impact of Prospective Payment
on the Cost per Episode: Striking the Balance Between
Decreasing Use and Increasing Cost, Draft Report,
February 26, 1998
Preliminary Report: The Impact of Prospective Payment
on Medicare Home Health Use--Promising Results for a
Future Program, July 22, 1998
Preliminary Quality Results from Four-Month Survey,
Memorandum, November 24, 1998
The Impact of Prospective Payment on Medicare Service
Use and Reimbursement During the First Demonstration
Year, December 1998.
Findings from the interim analysis of cost impacts suggest
that, on average, prospective payment reduced the cost of care
during the 120-day episode period by $419, or 13 percent. The
impact on cost was similar across different types of agencies,
except that small agencies (less than 30,000 visits in the year
before the demonstration) exhibited a significantly smaller
effect than large agencies. Findings from the utilization study
suggest that the per-episode group of home health agencies was
able to reduce the number of visits provided during the 120-day
episode period by 17 percent and the time from admission to
discharge by 15 percent. The proportion of patients receiving
care in each home health discipline changed little under
episode payment. The utilization findings generally applied to
agencies regardless of size, nonprofit status, affiliation
status (hospital or freestanding), or use pattern (that is,
whether the agency provided more or less than the average
number of visits during a base year, given its case mix).
The reduction in visits has not led to compensating
utilization in other parts of the health care system. An
analysis of utilization and reimbursement for Medicare-covered
services other than home health found that prospective payment
did not affect the use of, or reimbursement for, such services
during the 120-day episode period. An investigation of
spillover effects in settings not covered by Medicare similarly
found no compensating utilization. For example, prospective
payment did not affect the likelihood of receiving non-
residential services such as personal care aides and adult day
care, based on results from a patient survey. These findings
suggest that a reduction in home health utilization at the
level observed under the demonstration does not adversely
affect care quality or shift costs to services in other
settings. Other interim analyses of quality impacts found few
differences in patient outcomes between treatment and control
agencies, and when differences were found, they were small.
Analysis of claims data indicated that PPS patients have
significantly lower emergency room use. There were no
significant differences due to PPS in any other outcomes
studied from the claims data, including institutional
admissions for a diagnosis related to the home health
diagnosis, and mortality.
Results from the first patient survey on client
satisfaction suggested that both treatment and control group
clients were generally satisfied. On three specific components
of satisfaction with agency staff, treatment-group clients were
found to be somewhat less satisfied than control group clients,
although satisfaction levels were quite high in both groups.
Measures of health and functional outcomes from the survey
offered equivocal evidence for small negative effects of
prospective payment in a few of the functional outcomes. These
results are preliminary and require further study in a planned
follow up survey. Half of the treatment agencies selected for
the case study early in the demonstration reported plans for
specific initiatives to reduce per-episode costs spurred by
their participation in the demonstration project. From the case
studies, the evaluators concluded that treatment agencies were
not planning to change their behavior in ways that threatened
access or quality of care.
Subsequent evaluation reports will focus on utilization,
cost, and quality effects beyond the 120-day episode period.
There will be further case study results on agency response to
the demonstration and an extension of previous work on cost
impacts to include an analysis of agencies' financial
performance. Finally, supplementary analyses will consider the
representativeness of the demonstration sample and the patient
selection behavior of agencies.
Evaluation of the program of all-inclusive care for the elderly (PACE)
Project: 500-96-0003/04
Period: 4/23/1997-3/31/1999
Funding: $1,081,029
Award: Task Order
Principal Investigator: David Kidder, Ph.D.
Awardee: Abt Associates, Inc., 55 Wheeler Street,
Cambridge, MA 02138-1168
HCFA Project Officer: Fred Thomas, REG/DPR
Description: The Evaluation of the Program of All-inclusive
Care for the Elderly (PACE) consists of both qualitative and
quantitative components. The purpose of the qualitative
component is to examine, in detail, the structure and process
of case management as well as gain a better understanding of
the factors that drive interdisciplinary team decision-making
in the PACE model. Since enrollment in PACE has been lower than
originally expected, except for On Lok, the first part of the
quantitative part of the evaluation of PACE is examining the
decision to participate in PACE. This is particularly important
given the anomaly of under-enrollment in virtually all long-
term care alternatives, as well as the policy interest in
encouraging increased use of managed care. In the evaluation,
the process by which people come to participate in PACE is
modeled. The ``refusers'' or those who apply to PACE and pass
the initial screening eligibility criteria but do not actually
enroll in the program serve as the comparison group for the
evaluation of the impact of PACE. The impact evaluation of PACE
is addressing a broad range of questions including:
Does the government spend less on PACE clients than
it would have spent on them in the absence of PACE?
Does the PACE program spend no more on PACE clients
than the capitation amount?
Does PACE alter the mix of services provided?
Does the quality of life and satisfaction with
services increase for participants and family members?
Does PACE impact the presence and amount of formal
in-home care, formal care outside the home, informal
in-home care and informal care outside the home?
How does PACE affect the health status and functional
status of PACE participants?
Status: All of the data collection for this project has
been completed and the contractor is analyzing the impact of
PACE on Medicare costs. A final report entitled, ``The Impact
of PACE on Participant Outcomes'' has been received. Briefly,
this study found that compared to the comparison group: (1)
PACE enrollees had much lower rates of nursing home and
inpatient hospital utilization, and higher rates of ambulatory
care, (2) PACE enrollees reported better health status and
quality of life, (3) PACE participants had lower mortality
rates. The benefits of PACE appeared to be magnified for those
participants with high levels of physical impairment. Work
continues on the study of the cost effectiveness of PACE and a
final report on this issue is expected before March 31, 1999.
Project: 500-96-0010/02
Period: 9/12/1997-6/30/1999
Funding: $178,125
Award: Task Order
Principal Investigator: Steven Garfinkel
Awardee: Research Triangle Institute, PO Box 12194,
Research Triangle Park, NC 27709-2194
HCFA Project Officer: Fred Thomas REG/DPR
Description: The purpose of this task order is to: (1)
compare Medicare costs for the population that could be
certified for nursing home admission to costs for the overall
Medicare population; and (2) make recommendations regarding an
appropriate frailty adjuster for this population. Currently,
the Program of All-inclusive Care for the Elderly (PACE)
demonstration projects receive a frailty adjuster of 2.39. This
project will determine whether this is an appropriate adjuster,
using data from the National Long-term Care Survey and the
Medicare Current Beneficiary Survey.
Status: The final report was submitted on December 30,
1998. The study found that there is significant variation among
States in the manner in which they determine the population
that could be certified for nursing home admission. The
application of these various definitions to available survey
data indicates that there is a natural clustering of results,
despite the apparent difference among definition formats.
Marginal cost differences between those who could be certified
for nursing home admission and individuals who could not can be
explained in part by key variables: age, sex, functional
impairment, and the level of recent health service utilization.
With no prior risk adjustment, the data suggest that an average
frailty factor of about 200% is appropriate. However, this
factor should be adjusted for the profile of participants at
each site,
Evaluation of the District of Columbia's demonstration project, managed
care system for disabled and special needs children
Project: 500-96-0003/03
Period: 9/25/1996-3/24/2000
Funding: $1,397,452
Award: Contract
Principal Investigator: David Kidder, Ph.D.
Awardee: Abt Associates, Inc., 55 Wheeler Street,
Cambridge, MA 02138-1168
HCFA Project, Officer Fred Thomas REG/DPR
Description: The District of Columbia submitted a waiver-
only request for Medicaid waivers under section 1115(a)(1) for
a 3-year demonstration project to test the efficacy of a
managed care service delivery system designed for children and
adolescents under the age of 22 who are eligible for Medicaid
and are considered disabled according to Supplemental Security
Income (SSI) Program guidelines. This study represents a unique
opportunity to examine the experiences of a managed-care system
with voluntary enrollment of children with disabilities. The
project, which seeks to integrate acute- and long-term-care
services for children with disabilities into a single capitated
payment methodology, is the first approved demonstration of its
kind. The information gathered will be used to inform both
State and Federal policy makers who have increasingly come to
regard managed care as a mechanism to contain growing health
care expenditures. This study will provide for a special
analysis of the enrollment and disenrollment processes, as well
as of the project's implementation process (including
enrollment and participation, services/benefits, provider
participation and training, organizational and administrative
issues, contracting and risk-sharing arrangements, provider fee
schedules, community involvement, and quality assurance,
administrative and data management systems). Outcome analyses
will focus on enrollee/family outcomes (including care
management, service utilization and costs, enrollee/family
satisfaction, quality of care and health status indicators,
access to care, and family/informal care giving),
organizational outcomes (including an analysis of Health
Services for Children with Special Needs, Inc.'s (HSCSN)
financial performance, and the risk sharing arrangements
between HSCSN and the District of Columbia), and the impact
upon the provider community. Data for the evaluation will come
from surveys (primary data collection), case study interviews,
focus groups, Medicaid Management Information System and
encounter data, and SSI data.
Status: The first and second year reports have been
completed. In the first year, considerable time was spent in
planning and finalizing details of the research design.
Interviews were conducted with HSCSN providers in order to
obtain information on their incentives and how they participate
in HSCSN's care management system. The evaluators also
conducted the first set of focus groups with parents. In the
second year, additional interviews were conducted with
providers and participants. Quantitative analyses were
increased, and the survey component neared completion. The
HSCSN and the District Medicaid program both experienced major
reorganizations during the year, which may have led to
difficulties in coordination. The HSCSN reorganization was also
accompanied by changes in strategy and operations, which may
have contributed to improved financial performance. In July,
1998, the District requested and subsequently received a one-
year extension to develop a replacement waiver. There is
increasing evidence that care managers experienced an overload
of cases during the past year, and the HSCSN has both
recognized and begun to address this problem. Evidence from two
sources suggests that selection for the demonstration is
adverse. Most parents believe that their children have been
better off since joining the plan.
Evaluation of the medicare+choice risk adjustment method
Project: 440-98-40200
Period: 8/5/98-2/5/99
Funding: $24,900
Award: Purchase Order
Principal Investigator: Bill Bluhm, FSA, MAAA
Awardee: The American Academy of Actuaries, 1100 17th St,
NW, Washington, DC 20036
HCFA Project Officer: Fred Thomas, REG/DPR
Description: The Balanced Budget Act of 1997 requires
Medicare to implement a risk-adjusted payment system for its
Medicare-Choice program by January 1, 2000. The BBA requires
the Secretary to write a Report to Congress that outlines the
method of risk adjustment that will be used. An independent
actuarial evaluation of the soundness of this method must be
attached to this Report to Congress. The American Academy of
Actuaries will evaluate the risk methodology and soundness of
the proposal and will prepare a report of their findings.
Status: The American Academy of Actuaries has formed a Work
Group to review and evaluate the risk adjustor method. HCFA
provided documentation of the methodology, met with the Work
Group, and answered questions posed by the group. The final
report is expected before January 31, 1999.
Design of an integrated post acute care system
Project: 500-96-0008/04
Period: 9/30/1997-9/29/1999
Funding: $880,427
Award: Task Order
Principal Investigator: Robert L. Kane, M.D.
Awardee: University of Minnesota, 420 Delaware Street, SE.,
Minneapolis, MN 55455-0392
HCFA Project Officer: Fred Thomas, REG/DPR
Description: HCFA intends to create an infrastructure of
post-acute and long-term care delivery and payment systems that
are better integrated and more flexible in meeting the needs of
beneficiaries with chronic illnesses and disabilities. The
transition from our current benefit and provider-based system
to a beneficiary centered system requires several elements--an
assessment tool that can be used and shared across provider
types, and more flexible benefit packages. Funding based on
beneficiary health and functional needs, and case management
that involves formal and informal caregivers in care planning,
and supports and encourages, where appropriate, beneficiaries
to direct their own care. Additional work that incorporates
beneficiary preferences into outcome measures, as well as
further attempts to differentiate outcomes by post-acute care
modality for different patient conditions, is also needed. The
purpose of this project is to design several elements needed in
a more integrated system--an assessment tool, potential case
management models, appropriate payment systems, and outcome
measures that cross settings and incorporate beneficiary
preferences, with the ultimate intent of pilot testing and
refining these elements in a demonstration. A second purpose of
this project is to design an optional demonstration that tests
the feasibility and effectiveness of creating a more integrated
post-acute care system.
Status: Work has begun on developing potential case
management models as well assessment instrument.
94-074 Design and implementation of medicare home health quality
assurance demonstration
Project: 500-94-0054
Period: 9/30/1994-12/31/2000
Funding: $4,340,309
Award: Contract
Principal Investigator: Peter W. Shaughnessy, Ph.D.
Awardee: Center for Health Policy Research 1355 South
Colorado Boulevard, Suite 706 Denver, CO 80222
HCFA Project Officer: Armen Thoumaian, Ph.D., QCSQ
Description: Currently, Medicare's home health survey and
certification process is primarily focused on structural
measures of quality. Although this process provides important
information about home health care, an approach based on
patient outcome measures would substantially increase the
Medicare program's capacity to assess and improve patient well-
being. To address this need, the Medicare home health quality
demonstration will test an approach to developing outcome-
oriented quality assurance and promoting continuous quality
improvement in home health agencies.
The demonstration was implemented through a contract with
the Center for Health Policy Research (CHPR), University of
Colorado, to determine the feasibility of and establish the
methodology for national approach for outcome-based quality
improvement (OBQI). Outcome measures are computed using the
Outcomes and Assessment Information Set (OASIS), a set of
valid, reliable measures, developed through research efforts
conducted for HCFA by the Center for Health Policy Research
(CHPR) (1988-1994) to assess patient outcomes to care provided
in the home.
Under the demonstration, staff of 50 regionally dispersed
home health agencies (HHAs) complete the OASIS data collection
instrument for each patient at the start of care and at 60-day
intervals (up to and including discharge). The OASIS data is
submitted monthly to CHPR for validation and storage. There are
three rounds of data analysis and outcome report generation
each based on 12 months of data.
The general framework for OBQI is a two stage process of
continuous quality improvement. Data is collected at regular
time intervals for all adult patients. Risk adjustment is
undertaken and outcome reports are produced for specific
patient conditions (``focused reports'') and for all adult
patients (``global reports''). These reports are provided to
the participating HHAs and are used to determine which outcomes
are inferior, there by, providing a focus for agency staff to
target problematic care. Exemplary care is also investigated in
order to reinforce positive care behaviors. A plan of action
allows the agency to monitor the changes in care behavior and
through the next round of data collection, determine if
targeted outcomes have improved and if reinforcement activities
have maintained exemplary outcomes.
Status: Fifty agencies in 26 States were phased into the
demonstration beginning January, 1996. In January, 1997 the
demonstration agencies received their first outcome reports and
developed plans of actions to improve care for two patient
outcomes during 1997. Agencies received their second annual
reports in May, 1998 which contained baseline comparisons from
1997 and will receive their third and final reports in May,
1999. The original contract was modified extending it to
September, 30, 2000. In August, 1998, the contract was further
modified to provide assistance in the nationwide implementation
of OASIS collection and reporting with funding increased to a
total of $4,340,000. A final report on the evaluation of the
demonstration effort is expected by the Summer, 2000.
Research Plan ID: 2626.11
Program of All-Inclusive Care for the Elderly (PACE) Quality Assurance
Period: 9/24/1990-6/30/2000
Funding: $1,837,148
Contractor: Center for Health Policy Research, 1355 S.
Colorado Blvd, Suite 306 Denver, CO 80222
Investigator: Peter W. Shaughnessy, Ph.D.
This project will develop a core data set that will provide
the foundation for an outcome-based continuous quality
improvement system (OBCQI) for the PACE program. The OBCQI
System consists of two phases. During the first phase, the PACE
sites will complete a draft data instrument which will contain
items for outcome measurement and risk adjustment at specific
time intervals. In the second phase, the sites will take a
closer look at why and how they are achieving specific outcomes
and make recommendations for improvements in the case of poor
outcomes. This project is currently in the initial phase of
feasibility testing.
Quality Assurance for Phase 11 of the Home Health Agency Prospective
Payment Demonstration
Period: 9/22/1995-9/29/2000
Funding: $2,799,265
Contractor: Center for Health Policy Research, 1355 South
Colorado Boulevard, Suite 306 Denver, CO 80222
Investigator: Peter W. Shaughnessy, Ph.D.
This project was designed to test the effect of per-episode
prospective payment on the quality of care provided to Medicare
patients receiving home care. (HHAs receive an agency-specific
episode payment based on 120 days of care and outlier payments,
reimbursed at per-visit prospective rates, for episodes that
extend beyond 120 days). A new episode of care is identified
when there has been a gap in home health services for 45 or
more days after the initial 120 days. Agencies receiving per-
episode payments were subject to stop-loss and profit sharing
provisions as well as case-mix adjustments. Ninety volunteer
HHAs from five States (CA, FL, IL, MA, TX) were randomly
assigned to either the control group (cost-based payment) or
the treatment group (per-episode payment). All HHAs had entered
the demonstration by January 1996. As of December 31, 1998, all
participating agencies ended participation in the QA Component
of the PPS Demonstration. All data collection will be complete
by January 18, 1999. A final report is due to HCFA September,
1999.
Community nursing organization demonstration
Period: September 1992-December 1999
Contractors: See below
Section 4079 of Public Law 100-203 directs the Secretary of
the Department of Health and Human Services to conduct
demonstration projects at four or more sites to test a
capitated, nurse-managed system of care. The two fundamental
elements of the Community Nursing Organization (CNO)
demonstration are capitated payment and nurse case management.
These two elements are designed to promote timely and
appropriate use of community health services and to reduce the
use of costly acute care services. The legislation mandates a
CNO service package that includes home health care, durable
medical equipment, and certain ambulatory care services. Four
applicants were awarded site demonstration contracts on
September 30, 1992. The selected sites represent a mix of urban
and rural sites and different types of health providers,
including a home health agency, a hospital-based system, and a
large multi speciality clinic. All CNO sites have undergone a
1-year development period and began a 3-year operational period
in January 1994, which continued in 1998. The Balanced Budget
Act of 1997 extends the demonstration through December 31,
1999. Abt Associates Inc. was selected to evaluate the project
and to provide technical assistance to the sites. Abt
Associates Inc also was awarded the external quality assurance
contract.
Contractor: Care Clinic Association, 307 East Oak, Suite 3,
P.O. Box 718, Mahomet, IL 61853
Contractor: Carondelet Health Services, Inc., Carondelete
St. Mary's Hospital, 1601 West St. Mary's Road, Tucson, AZ
85745
Contractor: Living at Home/Block Nurse Program, Ivy League
Place, Suite 225, 475 Cleveland Avenue North, St. Paul, MN
55104
Contractor: Visiting Nurse Service of New York, 107 East
70th Street, New York, NY 10021-5087
Site development and technical assistance for the second generation
social health maintenance organization demonstration
Period: September 1993-December 2000.
Funding: $2,251,123.
Contractor: University of Minnesota, School of Public
Health Institute for Health Services Research, D-351 Mayo
Memorial Building, 420 Delaware Street, SE., Box 197
Minneapolis, MN 55455-0392.
Investigator: Robert L. Kane, M.D.
In January 1995, the Health Care Financing Administration
selected six organizations to participate in the Second
Generation Social Health Maintenance Organization (HMO)
Demonstration. The purpose of this project is to study the
impact of integrating acute- and long-term care services with a
capitated managed care system. It was developed to refine the
targeting and financing methodologies and the benefit design of
the current Social HMO model, which was initiated as a
demonstration in 1985.
Although similar services are provided under both of these
projects the Second Generation Social HMO Demonstration
features a greater emphasis on geriatric care and a more
inclusive case management system. Another distinguishing
characteristic of the project is its risk-adjusted payment
methodology that is based on individuals' health status and
functioning level. The primary focus of the project's
evaluation will be to compare beneficiaries enrolled in the
demonstration with beneficiaries in a section 1876 HMO program.
The University of Minnesota and its subcontractor, the
University of California, San Francisco are providing technical
assistance and support in the development, implementation, and
operation of the Second Generation Social HMO Demonstration.
The developmental phase of the Second Generation Social HMO
Demonstration began in January, 1995. Since that time, The
University of Minnesota and the University of California, San
Francisco have been providing technical assistance to the
organization participating in the project. They also have
developed a questionnaire that will be used to determine a
beneficiary's capitated payment rate, a series of geriatric
protocols to help physicians identify and treat certain health
conditions, and a care coordination assessment instrument to
assist case managers with care planning. The Health Plan of
Nevada began enrolling beneficiaries into the demonstration in
November, 1996.
Second generation of social health maintenance organization
demonstration
Period: November 1996-December 2000
Funding: Waiver-only
Grantees: See below
Description: In accordance with section 2344 of Public Law
98-369, the concept of a social health maintenance organization
(S/HMO) integrates health and social services under the direct
financial management of the provider of services. All acute-
and long-term-care services are provided by or through the S/
HMO at a fixed, annual, prepaid capitation sum. The Omnibus
Budget Reconciliation Act (BBA) of 1990 authorized the
expansion of the S/HMO demonstration. The BBA-97 extended the
demonstration through December 31, 2000. The purpose of this
second generation S/HMO (S/HMO-11) demonstration is to refine
the targeting and financing methodologies and the benefit
design of the current S/HMO model. The S/HMO model also will
provide an opportunity to test more geriatrically-oriented
models of care. Six organizations in the project will be
selected to participate. Only one plans is operational, the
Health Plan of Nevada.
Grantee: CAC Ramsey Health Plan, 75 Valencia Avenue, Coral
Gables, FL 33134.
Grantee: Contra Costa County Health Plan, 5 95 Center
Avenue, Suite 100, Martinez, CA 94553.
Grantee: Fallon Community Health Plan, Chestnut Place, 10
Chestnut Street, Worcester, MA 01608.
Grantee: Health Plan of Nevada, Inc., P.O. Box 15645, Las
Vegas, NV 89114.
Grantee: Richland Memorial Hospital, Five Richland Medical
Park, Columbia, SC 29203.
Grantee: Rocky Mountain Health Maintenance Organization,
2775 Crossroads Boulevard, Grand Junction, CO 81506 Phase 11
implementation of the Home Health Agency (HHA) Prospective
Payment Demonstration.
Period: September 1995-December 2001
Funding: $1,811,184
Contractor: Abt Associates Inc, 55 Wheeler Street,
Cambridge, MA 02138
Investigator: Henry Goldberg
Description: This contract implements and monitors Phase II
of the Home Health (HHA) Prospective Payment Demonstration.
Under phase II, a single payment per episode approach will be
tested for Medicare-covered home health care. HHA participation
is voluntary. It is expected that approximately 100 agencies in
California, Florida, Illinois, Massachusetts, and Texas will
participate in the demonstration. HHAs that agree to
participate will be randomly assigned to either the prospective
payment method or a control group that continues to be
reimbursed in accordance with the current Medicare
retrospective cost system. HHAs will participate in the
demonstration for three years.
Phase II recruitment began in Fall 1994 under a previous
contract with Abt Associates, Inc. The HHA entered into the
demonstration at the beginning of their fiscal years. Several
HHAs began receiving per-episode payments in June, 1994, with
the majority entering the demonstration in January 1996. The
episodic payment rates are prospectively set for each HHA,
reflecting their previous practice and cost experience. Rates
are to be adjusted annually. As a protection to both the HHAs
and the Medicare program, there will be retrospective
adjustments for sharing of gains or losses and for changes in
an HHA's projected case mix.
On Lok's risk-based community care organization for dependent adults:
On Lok Senior Health Services
Period: November 1983-Indefinite
Funding: Waiver only
Grantee: On Lok Senior Health Services, 1333 Bush Street,
San Francisco, CA 94109 and California Department of Health
Services, 714-744 P Street, P.O. Box 942732, San Francisco, CA
94234-7320
Description: As mandated by sections 603(c) (1) and (2) of
Public Law 98-21, the Health Care Financing Administration
granted Medicare waivers to On Lok Senior Health Services and
Medicaid waivers to the California Department of Health
Services. Together, these waivers permitted On Lok to implement
an at-risk, capitated payment demonstration in which more than
300 frail elderly persons, certified by the California
Department of Health Services for institutionalization in a
skilled nursing facility, are provided a comprehensive array of
health and health-related services in the community. The
current demonstration maintains On Lok's comprehensive
community-based program but has modified its financial base and
reimbursement mechanism. All services are paid for by a
predetermined capitated rate from both the Medicare and
Medicaid (Medi-Cal) programs. The Medicare rate is based on the
average per capita cost for the San Francisco County Medicare
population. The Medi-Cal rate is based on the State's
computation of current costs for similar Medi-Cal recipients,
using the formula for prepaid health plans. Individual
participants may be required to make copayments, spend down
income, or divest assets based on their financial status and
eligibility for either or both programs. On Lok has accepted
total risk beyond the capitated rates of both Medicare and
Medi-Cal, with the exception of the Medicare payment for end
stage renal disease. The demonstration provides service funding
only under the waivers. Research and development activities are
funded through private foundations.
Section 9220 of Public Law 99-272 has extended On Lok's
Risk-Based Community Care Organization for Dependent Adults
indefinitely, subject to the terms and conditions in effect as
of July 1, 1985, with the exception of the requirements
relating to data collection and evaluation. On Lok is
continuing to collaborative projects with other organizations
in the San Francisco Bay area. A pilot agreement with the
Institute on Aging (IOA) has been completed and the two
organizations have entered into a venture agreement in which
IOA established an adult day health center, operating it under
the rules of the program of All-Inclusive Care for the Elderly
protocol. The site is in the Richmond area of San Francisco. On
Lok provides quality assurance oversight as well as marketing
and enrollment support. IOA receives a portion of On Lok's
capitation via the HCFA demonstration and a portion is retained
by On Lok to cover administrative expenses.
Randomized controlled trail of expanded medical care in nursing homes
for acute care episodes: Monroe County Long-Term Care Program,
Inc.
Period: March 1992-December 1996
Funding: $1,054,007
Grantee: Monroe County Long-term Care Program, Inc., 349
West Commercial Street, Suite 2250, Piano Works East Rochester,
NY 14445
Investigator: Gerald Eggert, Ph.D.
Description: The objective of this demonstration is to
develop, implement, and evaluate the effectiveness of expanded
medical services to nursing home residents who are undergoing
acute illnesses that would ordinarily require hospitalization.
The intervention would here include many services that are
available in acute hospitals and are feasible and safe in
nursing homes. These include an initial physician visit, all
necessary follow up visits, diagnostic and therapeutic
services, and additional nursing care (including private duty),
if necessary. The major goals are to reduce medical
complications and dislocation trauma resulting from
hospitalization and to save the expense of homes with expanded
services. The design phase of the demonstration has been
completed. This demonstration did not enter the operational
phase because of the rapid changes in treatment patterns and
the impact of the implementation of the case mix demonstration.
Texas nursing home case-mix and quality demonstration
Period: February 1992-December 1998
Funding: $532,830
Grantee: State of Texas Department of Human Services, P.O.
Box 149030 (MC-E-601), Austin, TX 78714-9030
Investigator: Ken. C. Stedman
Texas will participate in the Multistate Nursing Home Case-
Mix and Quality (NHCMQ) Demonstration. The objective of the
demonstration is to test the feasibility and cost effectiveness
of a case-mix payment system for nursing facility services
under the Medicare and Medicaid programs that are based on a
common patient classification system. The addition of Texas
enhances the Health Care Financing Administration's ability to
project the results of the demonstration on a national basis.
Texas represents a western pattern of service using more
proprietary multistate chain providers than is the pattern used
in the East. Twenty Texas Medicare facilities were part of the
original data collection for the development of the resource
utilization group (RUG) III system. Texas has the second
largest number of hospital-based facilities in the country.
There are more than 20 metropolitan statistical areas of
varying size. In addition, the State has a large number of
rural areas. The State was traditionally a flat-rate
intermediate care facility Medicaid payment system. This RUG-
type payment system makes Texas well-suited for inclusion in
the Medicare portion of the demonstration.
During the first year of participation, the Texas
Department of Human Services worked with the Texas Department
of Health to change the resident assessment being used in the
State. In April, 1993, Texas implemented the minimum data set
plus statewide as its resident assessment instrument. Analyses
of 1990 Medicare Cost Report data, Medicare provider analysis
and review Part A skilled nursing facility stay data, and the
Texas Client Assessment and Review Evaluation (CARE) data have
been conducted for use in developing the demonstration's
Medicare case-mix payment system. Under the Medicaid
demonstration, Texas began development of the Quality
Evaluation System of Texas, a resident characteristic
information and reporting system using the CARE instrument.
During the first year, the staff continued the development and
enhancement of the system, which was codified into law by the
Texas Legislature in Summer 1993. They now are producing
facility-level reports with statewide comparisons for Texas
providers on a twice-a-year basis. The Medicare portion of the
NHCMQ demonstration was implemented July 1, 1995, in Texas.
HEALTH RESOURCES AND SERVICES ADMINISTRATION
Bureau of Primary Health Care
The Bureau of Primary Health Care (BPHC) helps assure that
primary health care services are provided to persons living in
medically underserved areas and to persons with special health
care needs. It also assists States and communities in arranging
for the placement of health professionals to provide health
care in health professional shortage areas. The Bureau provides
services to older Americans through Bureau-supported Health
Centers, including Community Health Centers, Migrant health
Centers, Health Care for the Homeless program sites, Public
Housing Primary Care program sites, the National Health Service
Corps, and the Division of Federal Occupational Health.
In 1996, the Bureau established a Geriatric Work Group,
consisting of members of the various Bureau divisions and
programs that serve elderly populations, to determine if there
was a need for the Bureau to target elderly populations for the
provision of services. In addition, the Work Group is currently
establishing partnerships with other Federally funded programs
and BPHC-supported programs at the State and local levels and
is working with Primary Care Organizations and Primary Care
Associations to expand existing program efforts to meet the
health needs of older persons.
A study was initiated during 1996 to examine service
provision to older populations, as well as to identify barriers
to services, in Bureau-supported Health Centers. The findings
of this study are now available (attached). In addition, a
project is currently underway to develop training curricula for
community-based health care providers to better serve older
patients.
Consolidated Health Centers
On October 11, 1996, the President signed the Health
Centers Consolidation Act of 1996. This Act consolidates the
Community Health Centers, Migrant Health Centers, Health Care
for the Homeless programs, and Public Housing Primary Care
programs under a single statutory umbrella that revised section
330 of the Public Health Service (PHS) Act. Health Center
programs are designed to promote the development and operation
of community based primary health care service systems in
medically underserved areas for medically underserved
populations. Legislation governing this program can be found in
section 330 of the PHS Act, as amended (42 U.S.C. 254b). The
Health Centers Consolidation Act of 1996, under section
330(a)(1) of the PHS Act, defines the term ``health center'' as
an entity that serves medically underserved population
comprised of migratory and seasonal agricultural workers, the
homeless, and residents of public housing.
The Community Health Centers (CHC) Program entered into
fiscal year 1997 with 631 grantees and a total of approximately
$633 million covering over 3,000 sites, located in medically
underserved areas throughout the United States and its
territories. The CHC program entered into fiscal year 1998 with
645 grantees and approximately $657 million.
Health Centers provide access to case-managed, family-
oriented, culturally sensitive preventive and primary health
care services for people living in rural and urban medically
underserved areas. The medical services include: preventive
health and dental services, acute and chronic services, and
appropriate hospitalization and specialty referrals. Health
Centers also provide essential ancillary services such as
laboratory tests, X-ray, environmental health and pharmacy
services. In addition, many centers provide such enabling
health and community services as transportation, health
education, nutrition, counseling, and translation. Case
management--the coordination of the center's services with
community services appropriate to the needs of the patient
(social, medical, or economic)--is emphasized.
Health Centers target medically underserved, disadvantaged
populations. These populations include: minorities, women of
child-bearing age, infants, persons with HIV infection,
substance abusers and/or homeless individuals and their
families. In fiscal year 1997, the Health Center program served
more than 8,000,000 patients annually. Of this total, 7 percent
were age 65 or older.
The BPHC has implemented clinical performance measures
related to the primary and preventive care of elderly users.
The measures include: (1) a functional assessment of activities
of daily living; (2) an inventory of prescription and
nonprescription drug use; and (3) pneumococcal and influenza
immunization administration.
EXHIBIT A.--BREAKDOWN BY PROGRAM AND AGE CLUSTER OF THE NUMBER OF
ELDERLY PERSONS WHO RECEIVED HEALTH CARE SERVICES FROM BPHC-SUPPORTED
PROGRAMS FOR THE YEAR 1997
------------------------------------------------------------------------
Program Age 65 + years Total users
------------------------------------------------------------------------
Community & migrant............. Females: 376,290.. Medical: 7,085,235
Health center................... Males: 228,691.... Dental: 1,124,576
Total: 604,981.... Total: 8,209,811
Homeless program................ Females: 3,624.... 430,000
Males: 5,767......
Total: 9,391......
Public housing.................. Females: 1,337.... 47,378
Primary care program............ Males: 598........
Total: 1,935......
---------------------------------------
Total..................... 616,307........... 8,687,189
------------------------------------------------------------------------
EXHIBIT B.--BREAKDOWN BY PROGRAM AND AGE CLUSTER OF THE NUMBER OF ELDERLY PERSONS WHO RECEIVED HEALTH CARE
SERVICES FROM BPHC FOR THE YEAR 1997
----------------------------------------------------------------------------------------------------------------
Subtotal
Program Age 65-74 Age 75-84 Age 85+ elderly Total users
----------------------------------------------------------------------------------------------------------------
1997 Cluster................................... 362,165 181,689 67,267 611,121 8,253,898
----------------------------------------------------------------------------------------------------------------
The National Health Service Corps
The National Health Service Corps (NHSC) places primary
care physicians, nurse practitioners, physician assistants,
certified nurse midwives, dental and mental health
professionals in health professional shortage areas. There are
now 2,400 clinicians serving communities and populations of
greatest need (60 percent rural/40 percent urban). Older
Americans with special health care needs benefit from the
proximity of dedicated primary care clinicians that provide
high quality health care. The NHSC works closely with Bureau-
supported Health Centers, other primary care delivery systems,
and the Indian Health Service to provide assistance in
recruiting and retaining health personnel for the poorest, the
least healthy, and the most isolated of our fellow Americans,
including the aging population.
Division of Federal Occupational Health
The Division of Federal Occupational Health (DFOH) provides
a variety of services related to health promotion and disease
prevention in the elderly to managers and employees of over
3,000 Federal agencies. Retirement planning, care of aging
parents, and prevention of osteoporosis are some examples of
generic issues that are regularly addressed in educational
seminars and employee assistance programs.
Alzheimer's Demonstration Grant to States Program
The Alzheimer's Demonstration Grant to States Program,
established under section 398 of the Public Health Service Act,
as amended by Public Law 101-157, the Home Health Care and
Alzheimer's Disease amendments of 1990, was transferred from
the Health Resources and Services Administration's Bureau of
Primary Health Care to the Administration on Aging. The
effective date was November 1, 1998. Eight of the programs
funded through this initiative continue to collaborate with
consolidated health centers and their service areas.
Bureau of Health Professions
The Bureau of Health Professions (BHPr) provides national
leadership to assure a health professions workforce that meets
the health care needs of the public. The Bureau has established
five strategic functions to guide the implementation of the
Bureau's programs to achieve its mission. These functions are:
1. Enabling access to health care through improved health
professions distribution,
2. Enabling culturally competent health care through
improved racial and ethnic diversity and cultural competence in
the health professions workforce.
3. Ensuring adequate information, analysis and planning to
strategically enable national health professions workforce
development.
4. Enabling ongoing improvement in the quality of health
professions education through demonstration, education
research, innovation and dissemination; and of health
professions practice through innovations in financing and
regulation.
5. Providing public information and technical assistance
relating to health professions.
The strategy defined by these functions will be implemented
through a variety of collaborative public and private efforts
and programs supported and operated by the Bureau. Programs
include: education and training grant programs for institutions
such as health professions schools and health professions
education and training centers; loan and scholarship programs
for individuals, particularly those from disadvantaged
backgrounds; the National Practitioner Data Bank; and the
Vaccine Injury Compensation Program. In addition, BHPr
administers several education-service network multi-
disciplinary and inter-disciplinary programs such as the Area
Health Education Centers (AHECs), the Geriatric Education
Centers (GECs), and Rural Interdisciplinary Training Programs.
The Bureau supports the Council on Graduate Medical
Education, which reports to the Secretary and the Congress on
matters related to graduate medical education, including the
supply and distribution of physicians, shortages, or excesses
in medical and surgical specialties and subspecialties, foreign
medical graduates, financing medical educational programs, and
changes in types of programs. It also supports the National
Advisory Council on Nurse Education and Practice which provides
advice and recommendations to the Secretary concerning policy
matters relating to nurse workforce, education, and practice
improvement.
The National Vaccine Injury Compensation Program is
administered by BHPr. The program which became effective
October 1, 1988, was created by the National Childhood Vaccine
Injury Compensation Act of 1986, as a no-fault system through
which families of individuals who suffer injury or death as a
result of adverse reactions to certain childhood vaccines can
be compensated without having to prove negligence on the part
of those who made or administered the vaccines.
BHPr maintains a federally sponsored health practitioner
data bank on all disciplinary action and malpractice claims.
The National Practitioner Data Bank (NPDB) was created by The
Health Care Quality Improvement Act of 1986, Title IV of P.L.
99-660, as amended November 1986. The Act authorized the
Secretary of Health and Human Services to establish a data bank
to ensure that unethical or incompetent medical and dental
practitioners do not compromise health care quality. The NPDB
is a central repository of information about: malpractice
payments made on behalf of physicians, dentists, and other
licensed health care practitioners; licensure disciplinary
actions taken by State medical boards and State boards of
dentistry against physicians and dentists; and adverse
professional review actions taken against physicians, dentists,
and certain other licensed health care practitioners by
hospitals and other health care entities, including health
maintenance organizations, group practices, and professional
societies. The NPDB opened on September 1, 1990.
The Secretary of the U.S. Department of Health and Human
Services, acting through the Office of Inspector General, was
directed by the Health Insurance Portability and Accountability
Act of 1996 to create the Healthcare Integrity and Protection
Data Bank (HIPDB). The HIPDB is a national health care fraud
and abuse data collection program for the reporting and
disclosure of certain final adverse actions taken against
health care providers, suppliers and practitioners.
The Notice of Proposed Rulemaking was published October 29,
1998. The Division of Quality Assurance is in the process of
preparing the Final Rule. The Data Bank is expected to be
operational by the end of this year.
Division of Medicine
The Division continues to support through its grant and
cooperative agreement programs significant educational and
training initiatives in geriatrics.
For FYs 1997 and 1998, 13 predoctoral grantees and 57
graduate program grantees indicated that they were actively
involved in the development, implementation, and evaluation of
their geriatrics curriculum and training. The predoctoral
grantees received funds totaling $639,643, the residency
program grantees received funds totaling $858,108. In addition,
15 faculty development programs reported that they provided
geriatrics training. One program grantee received an award
totaling $172,800 for the purpose of strengthening geriatric
training and carrying out research activities in this area.
Nine Physician Assistant Training Program grantees have
instituted training activities in geriatrics. These grantees
were awarded $398,610 specifically for their efforts in this
area.
Seven grantees receiving support for Podiatric Primary Care
Residency Training have included curricular emphasis in
geriatric health. These grantees received a total of $652,603.
Division of Nursing
The Division of Nursing continues to administer grants
awarded through four programs:
(1) Advanced Nurse Education, (2) Nurse Practitioner/Nurse
Midwifery, (3) Special Projects, and (4) Professional Nurse
Traineeships. The fourth program provides funds to schools that
allocate these funds to individual full-time master's and
doctoral students preparing to be nurse practitioners, nurse-
midwives, nurse educators, public health nurses, or other
clinical nurse specialists.
The Advance Nurse Education Program supported two programs
totaling $484,208 in FY 1997, and three programs totaling
$872,116 in FY 1998 for gerontological nursing programs leading
to a master's or doctoral degree. Graduates of these programs
are prepared broadly to meet a wide range of health needs
relative to the elderly in many settings, but are particularly
prepared to deal with the older individual with multiple health
care needs. In addition, the program prepares nurses who can
teach and offer consultation in this important field.
The Nurse Practitioner and Nurse-Midwifery Program,
supported seven master's or postmaster's geriatric nurse
practitioner (GNP) program grants totaling $1,284,115 in FY
1997, and six master's or postmaster's GNP program grants
totaling $1,255,000 in FY 1998. In addition, ten Adult Nurse
Practitioner (ANP) programs were supported in FY 1997 for a
total of $1,972,260, and seven Family Nurse Practitioner (FNP)
programs were supported in FY 1998 for a total of $7,123,120.
Both ANPs and FNPs provide primary care services to older
adults. As nurses with advanced academic and clinical
preparation, they are prepared as primary health care providers
to manage the health problems of the elderly in a variety of
settings, such as long-term care facilities, ambulatory
clinics, and homes. They provide nursing care and clinical
management of common acute and chronic health problems,
including health promotion and maintenance, disease prevention,
health assessment, and long-term management of chronic health
problems. Emphasis is placed on teaching and counseling the
elderly to actively participate in their own care and to
maintain optimal health.
The Nursing Special Projects Grant Programs supported six
Long-Term Care Fellowships for Paraprofessional projects in
four institutions totaling $321,988 in FY 1997, and five
projects in five institutions totaling $1,205,960 in FY 1998.
These fellowships supported approximately 45 individuals in FY
1997 and 73 individuals in FY 1998 employed by nursing
facilities, including long-term care facilities or home health
agencies as paraprofessionals and enrolled in approved nursing
program. The agencies assist the fellows financially to obtain
further education in nursing.
The Nursing Special Projects Grant Program supports nursing
clinics to demonstrate methods of improving access to primary
health care in medically under served communities. In FY 1997,
three nursing clinics providing services to elderly populations
received support totaling $469,709. In FY 1998, ten nursing
clinics providing services to elders in housing and other
community sites received support totaling $1,662,090. The
nursing clinic project at the University of Delaware, Newark,
Delaware, now in its fourth year of a five year grant award, is
designed to establish a community-based nurse-managed health
center to improve access to primary care for older adults. The
HEALTH (Healthy Elder Adult Living Through Holistic Healthcare)
Center provides a wide variety of health promotion, disease
prevention, and chronic disease management services through
case management by advanced practices nurses (APNs). The HEALTH
Center initially featured two extremely needed services in
Delaware: (1) comprehensive geriatric assessment and (2) mental
health services for older adults. In addition to filling health
care gaps, the HEALTH Center provides clinical experiences for
nursing students that will prepare them to provide the
specialized care needed by older adults. Project activities are
based in home and community settings in both urban and rural
areas.
Office of Rural Health Policy
The Office of Rural Health Policy (ORHP) was established in
1987 at the urging of the Senate Special Committee on Aging in
order to address severe shortages of health services in rural
areas, where one quarter of the Nation's elderly live. Aging-
related issues are of particular importance to the Office,
since rural counties have, on average, a higher percentage of
seniors over 65 years of age than urban counties; and these
residents are often poorer, sicker, and more isolated than
their urban counterparts.
To strengthen support for health services in rural areas,
the office plays a collaborative role throughout the Department
and with the States and the private sector. For example, it
apprises interest groups, such as the National Council on Aging
and the American Association of Retired Persons about its
activities and about the needs of the rural elderly. Within the
Department, the Office advises the Secretary on the effects
that Medicare and Medicaid programs have on rural health care,
on the shortage of health care providers, the viability of
rural hospitals, and the availability of primary care and also
emergency medical services to elderly and other rural
residents.
The Office supports local and States initiatives to build
rural health care services through a $32.0 million grant
program to rural communities, themselves, and a $3 million
program of matching grants to the States to support States
offices of rural health, which can recruit rural providers and
assist their rural communities in developing more local health
services.
The ORHP also promotes informed policy making by
administering a small $2.5 million program of grants for
policy-relevant studies at established rural research centers
throughout the country. These centers provide data capability
on a wide range of rural health concerns, including areas
relevant to the elderly. For example, one study currently
underway looks at the development in rural communities of
assisted living facilities to determine what challenges exist
to their growth and viability. Another is comparing mental
health treatment for residents of rural nursing homes with
treatment available to residents of urban facilities. Also
under study is the supply of health practitioners for the care
of chronically ill Medicare beneficiaries in rural areas.
The Office also administers a new $25 million grant program
to States to help them implement the Rural Hospital Flexibility
Program. Under this program, rural hospitals that convert to a
smaller Rural Critical Access Hospital can receive cost-based
payments from the Medicare. The grants help States and rural
communities plan and implement the conversion of rural
hospitals and promote the development of new local networks of
care.
In collaboration with other Federal agencies such as the
Health Care Financing Administration, the Department of
Agriculture, the Department of Transportation, and the National
Institute on Aging, ORHP sponsors workshops and seeks public
advice on a range of rural health needs. These issues may
include such issues as emergency medical services, managed care
options for Medicaid and Medicare clients, physician
recruitment, and rural economic development.
To enhance dissemination of information on strategies for
better health services to rural regions, the Office initiated a
national rural health information and referral service with
USDA that is available to rural residents throughout the Nation
with a toll-free line (1 -800-633-7701) and through an
electronic bulletin board.
The Office also channels public advice on rural issues to
the Department by staffing the Secretary's National Advisory
Committee on Rural Health, a citizen's advisory panel chartered
in 1987 to address health care crises in rural America.
Division of Associated Dental and Public Health
The Division supports the training of health professionals
through its Geriatric Education Centers (GECs). GECs use
ambulatory care centers, hospitals, long-term care facilities
and senior centers to provide appropriate educational
experiences to health professions students and providers, to
prepare them to deliver humane and dignified care and to be
responsive to older individuals whose ability to care for
themselves has been reduced by physical and/or mental
disorders.
Of the 43 Geriatric Education Centers that make up the
membership of the National Association of Geriatric Education
Centers, 30 received awards in FY 1997 and 30 received awards
in FY 1998. In FY 1997, sixteen GECs were consortia
partnerships of two or more universities with many representing
multiple schools of the health professions in their respective
States. In FY 1998, nineteen GECs were consortia. At the State
and National level the GECs comprise a comprehensive
educational system, serving as the primary coordinating body
for the preparation of faculty, health professions students,
and health care personnel to better serve the Nation's elderly
in their own homes and in long-term care institutions and
community based agencies. Over 40,000 health care professionals
received education and training through the GECs in FY 1997-
1998. Awards were made to the following institutions in FY 1997
and FY 1998:
------------------------------------------------------------------------
FY 1997 FY 1998
------------------------------------------------------------------------
Consortia:
University of California, Los Angeles, $316,665 $159,796
Univ. of California, Davis; Univ. of
California, San Francisco; UCLA School of
Medicine; California State University at
Fresno...................................
New York University; Columbia University; 161,209 263,639
Hunter College...........................
University of Pittsburgh; Pennsylvania 262,963 317,362
State University; Temple University......
University of Miami; Barry University; 322,810 161,672
Florida A&M; Florida International
University...............................
St. Louis University; U. of Missouri, 156,733 269,990
School of Optometry; Washington U.,
Occupational Therapy; St. Louis College
of Pharmacy; Kirksbille College of
Osteopathic Medicine.....................
University of Kentucky; East Tennessee 160,569 261,653
State Univ.; U. of Ohio Cincinnati.......
University of Medicine & Dentistry. of NJ; 162,000 271,823
Rutgers University School of Social Work.
University of Oregon; Portland State 288,431 159,292
University...............................
University of Iowa; University of 0 161,999
Osteopathic Medicine and Health Sciences.
Baylor College of Medicine; University of 162,000 270,000
Texas, Houston HSC; Univ. Texas, Medical
Branch; Univ. of North Texas; Univ. of
Texas-Pan AM; Texas Southern Univ.; Univ.
of Houston; Texas A&M University.........
George Washington University; Georgetown 161,283 299,201
University; Howard University............
Case Western Reserve University; Ohio 161,199 266,401
University college of Osteopathic
Medicine; Bowling Green State University;
Northeastern Ohio Universities College of
Medicine.................................
Marquette University; Univ. of Wisconsin- 306,675 0
Madison; Univ. of Wisconsin-Milwaukee;
Milwaukee Area Technical College; Medical
College of Wisconsin; Geriatrics Inst. of
Sinai Samaritan Medical Center...........
Michigan State University, Wayne State 165,359 162,000
University; Michigan Primary Care
Association; St. Lawrence Hospital.......
University of New Mexico; New Mexico State 325,426 160,648
University; New Mexico Highlands
University; National Indian Council on
Aging; Indian Health Service; Sisters of
Charity Health Care System...............
University of Pennsylvania; Geisinger 277,251 160,209
Medical Center; Lehigh Valley Hospital;
Philadelphia College of Pharmacy.........
University of Rhode Island; Rhode Island 262,681 317,126
College; Brown University; Rhode Island
Hospital.................................
Meharry Medical College; Alabama A&M 158,760 162,000
University; Tennessee State University...
Stanford University; San Jose State 302,064 162,000
University; On Lok, Senior Health
Services.................................
Single Institution:
University of Hawaii...................... 107,840 161,760
University of Oklahoma.................... 185,715 161,890
University of Puerto Rico................. 162,000 0
University of Texas San Antonio HSC....... 160,940 214,051
University of Washington.................. 215,639 107,974
University of South Florida............... 104,489 162,000
University of Nevada...................... 0 75,131
University of Rochester................... 167,832 271,970
University of Virginia Commonwealth....... 107,854 161,744
University of West Virginia............... 107,130 155,633
Harvard Medical School.................... 158,443 260,197
University of Florida..................... 100,956 95,267
University of Minnesota................... 162,000 270,000
------------------------------------------------------------------------
Awards for the 30 GECs totaled $5,851,916 for Fiscal Year
1997. Funding for FY 1998 was $6,051,428. Awards for FY 1999
are expected to be approximately $8 million. These Centers are
educational resources providing multi disciplinary and
interdisciplinary geriatric training for health professions
faculty, students, and professionals in allopathic medicine,
osteopathic medicine, dentistry, pharmacy, nursing,
occupational and physical therapy, podiatric medicine,
optometry, social work, and related allied and public or
community health disciplines. They provide comprehensive
services to the health professions education community within
designated geographic areas. Activities include faculty
training and continuing education for practitioners in the
disciplines listed above. The Centers also provide technical
assistance in the development of geriatric education programs
and serve as resources for educational materials and
consultation.
During FY 1995, a three phase Geriatric Education Futures
Project was developed to improve geriatric education in the
health professions and thereby respond to a national health
care need. The first phase was the development of eleven study
groups to develop white papers on the status of geriatric
education in medicine, nursing, dentistry, public health,
social work, allied and associated health, interdisciplinary
education, ethnogeriatrics, case management, managed care and
long-term care. Recommendations were presented to Federal, non-
Federal and response panels during the second phase. Two
reports emerged from these phases: ``A National Agenda for
Geriatric Education: White Papers and A National Agenda for
Geriatric Education: Forum Report''. Copies are available from
the Bureau of Health Professions, HRSA. The third phase of the
Futures Project is the development of innovative educational
collaborative.
Faculty Training Projects in Medicine, Dentistry, and Psychiatry
Eight joint medicine and dentistry projects were funded
under the Faculty Fellowship Program in Geriatric Medicine,
Dentistry, and Psychiatry. These interdisciplinary programs
have four learning components: longitudinal clinical
experience, teaching, research, and administration.
The following institutions received awards for both 1997
and 1998.
------------------------------------------------------------------------
FY 1997 FY 1998
------------------------------------------------------------------------
University of California, Los Angeles......... $190,812 $196,566
Boston University............................. 307,708 310,178
Harvard University............................ 348,494 353,582
University of Michigan........................ 374,178 361,499
University of Medicine and Dentistry of New 351,976 268,323
Jersey.......................................
Duke University............................... 328,631 335,705
University of North Texas..................... 314,112 247,721
University of Texas, San Antonio.............. 357,828 276,741
------------------------------------------------------------------------
Contracts Under Title VII of the PHS Act
Funding--FY1995-FY1996
Project: State University of New York at Buffalo,
``Education Performance Outcomes Measures Model,'' 8/13/96-8/
12/97--$25,000.
Project: Baylor College of Medicine, ``Tenth Workshop for
Key Staff of Geriatric Education Centers,'' 7/19/96-7/18/97--
$149.000.
Project: American Society on Aging, ``Local Implementation
of a Key Ethnogeriatrics Recommendation,'' 8/6/96-5/5/97--
$6,460.
Project: Institute for Health Care Improvement,
``Community--Based Quality Improvement Education for the health
Professions,'' 9/30/96-9/29/98--$150,228.
Project: Virginia Geriatric Education Center, ``Geriatric
Education Centers Resources Project,'' 12/30/97-3/l/98--$5,941.
Project: Stanford University, ``Ethnogeriatric Education
Collaborative,'' 7/3/97-2/28/99--$35,000.
Project: State University of New York at Buffalo,
``Education and Evaluation of an Expanding Education
Performance Outcomes Measures Model,'' 6/28/97-6/30/98--
$22,500.
Project: American Society on Aging, ``Local Implementation
of a Key Ethnogeriatric Recommendation,'' 9/5/97 & 7/22/98--
$6,460.
Project: Wisconsin Geriatric Education Center, ``Updated
Geriatric Education Centers Directories,'' 6/18/98--$5,001.
Publications
A National Agenda for Geriatric Education: Forum Report,
Volume 2. Rockville, MD: Interdisciplinary, Geriatrics and
Allied Health Branch, Division of Associated, Dental and Public
Health Professions, Bureau of Health Professions, Health
Resources and Services Administration, Public Health Service,
U.S. Department of Health & Human Services. 1996.
A National Agenda for Geriatric Education: White Papers,
Volume I--Rockville, MD: Interdisciplinary, Geriatrics and
Allied Health Branch, Division of Associated, Dental and Public
Health Professions, Bureau of Health Professions, Health
Resources and Services Administration, Public Health Service,
U.S. Department of Health & Human Services. 1995.
Geriatric Education Centers: A Resource Directory,
Rockville, MD: Interdisciplinary, Geriatrics and Allied Health
Branch, Division of Associated, Dental and Public Health
Professions, Bureau of Health Professions, Health Resources and
Services Administration, Public Health Service, U.S. Department
of Health & Human Services. 1998.
Events
Advisory Committee for the joint American Geriatric
Society/John A. Hartford Foundation initiative entitled
``Enhancing Geriatric Care Through Practicing Physician
Education, New York, NY--April 6,1997.
I0th Geriatric Education Centers Workshop for key
leadership of grantees sponsored by BHPr, Washington, DC--
February 2-9, 1997.
Gerontological Society of America's Annual Meeting.
Cincinnati, OH-- November 13-17,1997.
Association for Gerontology in Higher Education, Present
information from the Bureau--sponsored ``National Agenda for
Geriatric Education: White Paper'' Chapter on Interdisciplinary
Education at a preconference Workshop, Boston, MA--February 19-
23, 1997.
Collaborative on Ethnogeriatric Education Workgroup , San
Francisco, CA--March 26, 1998
1998 Leadership in Collaborative Practice: A cross--program
conference, Las Vegas, NV--June 8-10, 1998, for
interdisciplinary programs of the Division of Associated,
Dental and Public Health Profession, BHPr, HRSA.
National Assocaition of Medical Minority Educators
Conference (NAMME), Chicago, IL--September 27-28, 1998.
Gerontological Society of America's Annual Meeting.
Philadelphia, PA--November 20-23,1998
OFFICE OF INSPECTOR GENERAL
Introduction
The Office of Inspector General (OIG) was established by
the Inspector General Act of 1978. The OIG's mission is to
identify ways to improve effectiveness and promote economy and
efficiency in HHS programs and operations, and protect them
against fraud, waste, and abuse. This is accomplished by
conducting independent and objective audits, evaluations, and
investigations which provide timely, useful, and reliable
information and advice to Department officials, the
Administration, the Congress, and the public. In carrying out
its mission, the OIG partners with the Department and its
operating divisions, the Department of Justice (DOJ), other
Federal and State agencies, and the Congress to bring about
systemic improvements in HHS programs and operations, and
successful prosecutions and recovery of funds from those who
defraud the Government. The OIG is comprised of the following
components:
The Office of Audit Services (OAS) conducts and oversees
audits of HHS programs, operations, grantees, and contractors;
identifies systemic weaknesses that give rise to opportunities
for fraud, and abuse; and makes recommendations to prevent
their recurrence. The OAS also provides overall leadership and
direction in carrying out the responsibilities mandated under
the Chief Financial Officers Act of 1990 and the Government
Management Reform Act of 1994 relating to financial statement
audits.
The Office of Evaluation and Inspections (OEI) seeks to
improve the effectiveness and efficiency of departmental
programs by conducting program inspections that provide timely,
useful, and reliable information and advice to decision makers.
These inspections are program and management evaluations that
focus on specific issues of concern to the Department, the
Congress, and the public. The results of these inspections
generate accurate and up-to-date information on how well HHS
programs are operating and offer specific recommendations to
improve their overall efficiency and effectiveness.
The OIG's Office of Investigations (OI) conducts
investigations of fraud and misconduct to safeguard the
Department's programs and protect the beneficiaries of those
programs from individuals and activities that would deprive
them of rights and benefits. Working with Federal and State law
enforcement agencies, OIG investigators seek criminal, civil,
and exclusion actions against those who commit fraud or who
thwart the effective administration of HHS programs.
The Office Counsel to the Inspector General (OCIG)
coordinates the OIG's role in the resolution of health care
fraud and abuse cases, including the litigation and imposition
of administrative sanctions, such as program exclusions, civil
monetary penalties, and assessments; the global settlement of
cases arising under the Civil False Claims Act; and the
development of corporate agreements for providers that have
settled their False Claims Act liability with the Federal
Government. It also develops and promotes industry awareness of
models for corporate integrity and compliance programs and
monitors ongoing integrity agreements. The OCIG also provides
all administrative litigation services required by OIG, such as
patient dumping cases and all administrative exclusion cases.
In addition, OCIG issues special fraud alerts and advisory
opinions regarding the application of OIG's sanction statutes
and is responsible for developing new, and modifying existing,
safe harbor regulations under the anti-kickback statute.
Finally, OCIG counsels OIG components on personnel and
operations issues, subpoenas, audit and investigative issues,
and other legal authorities.
The Office of Management and Policy (OMP) provides support
services to the OIG, including congressional relations; public
affairs; strategic planning and budgeting; financial and
information resources management; and preparation of the OIG's
semiannual and other reports.
Accomplishments
During Fiscal Years 1997 and 1998, the OIG reported more
than $1.2 billion in fines and restitutions deposited into the
Medicare Trust Fund. More than 5,700 individuals and entities
were excluded from doing business with Medicare, Medicaid, and
other Federal and State health care programs--up from 2,846
exclusions in the previous two years. In addition, convictions
increased by nearly 20 percent in 1997, and another 16 percent
in 1998. The OIG's 1998 accomplishments included 261
convictions of individuals or entities that engaged in crimes
against departmental programs, and 927 civil actions.
The OIG reported record savings of $11.6 billion for Fiscal
Year 1998. This is comprised of $10.9 billion in implemented
legislative or regulatory recommendations and actions to put
funds to better use; $146 million in audit disallowances: and
$515 million in investigative receivables. The savings that
result from OIG recommendations that are implemented into law
or regulation represent the dollars that will not be spent.
Health Care
In recent years, Medicare has been a major focus of OIG
work. Approximately 75 percent of OIG resources in the past two
years were dedicated to Medicare audits, evaluations, and
enforcement activities. OIG work continues to show that
Medicare is not always a prudent purchaser of health care goods
and services and is inherently vulnerable to making improper
payments. In discharging its responsibilities, the OIG responds
both reactively and proactively to counteract these problems
and is pleased to report that measurable progress is being
made.
Increasingly, the OIG is working with representatives of
the health care provider community to develop reasonable and
voluntary compliance guidelines for insuring accurate billings
to the Medicare program. Medicare beneficiaries are also
enlisted for their support. For example, the OIG recently
launched a major outreach campaign with the Health Care
Financing Administration (HCFA), the Administration on Aging
(AOA), DOJ, and the American Association of Retired Persons
(AARP) to encourage senior citizens to identify improper
Medicare payments. Beneficiaries are encouraged to carefully
review their health care bills and to call their health care
provider when a possible improper item, service or good not
received is spotted. If that fails to ``clear up'' the matter,
it is suggested that the beneficiary call their Medicare
contractor and, only if necessary, to report a suspected fraud
to the OIG hotline.
Some of the significant OIG work involving the elderly,
during this reporting period, includes the following:
Outreach/Hotline: Enlisting beneficiaries as partners in
fighting fraud assists in identifying abuses at an early stage,
and preventing ongoing or widespread abuse. An OIG survey found
that Medicare beneficiaries are well-positioned to identify
fraud, with three out of four stating that they ``always'' read
their Explanation of Medicare Benefit statements. The HHS/OIG
continued to work with AOA, HCFA, and AARP to develop a
national outreach campaign designed to educate beneficiaries
and those who work with the elderly to recognize fraud and
abuse and to report it appropriately. This campaign will be
fully ``launched'' in 1999. OIG operates an HHS/OIG Hotline to
receive complaints of improprieties in the Medicare program and
other HHS programs. In FY 1997, the Hotline was expanded to
accommodate more callers and to provide more user friendly
service. In FY 1997 and 1998, the Hotline received over 134,000
calls, which resulted in more than 19,500 complaints. An
estimated $4 million in collections are associated with Hotline
complaints referred to and resolved by HCFA and its
contractors.
Beneficiary Satisfaction: OIG continued to report on
Medicare beneficiary satisfaction and understanding with the
Medicare program, including fee-for-service and managed care.
The reviews examined general satisfaction with the program as
well as beneficiary satisfaction with supplemental health
insurance and the Medicare handbook. Reviews also examined
beneficiary awareness of Medicare risk HMOs, HMO appeals and
grievance processes, and HCFA publications.
Safeguarding Long-Term Care Residents: The OIG found
shortcomings in State nurse aide registries, which are required
to record findings of abuse, neglect and misappropriation of
property involving the elderly. This work is an indication
that, among other things, HCFA and AOA should work with States
to improve the safety of long term care residents and to
strengthen safeguards against the employment of abusive workers
by elder care facilities. In addition, the OIG recommended that
HCFA consider establishing Federal requirements and criteria
for performing criminal background checks. The HCFA and AOA
generally agreed with our findings and recommendations.
NATIONAL INSTITUTES OF HEALTH, NATIONAL INSTITUTE ON AGING
There are great differences in how people age; some persons
lead healthy, independent, and productive lives well into their
70's, 80's, 90's and even beyond; other persons succumb to age-
associated diseases and disabilities in their 60's or even
earlier. The National Institute on Aging (NIA), part of the
National Institutes of Health (NIH), promotes research to
understand the mechanisms of normal aging and their
relationship to costly age-associated disease and disability.
Each day experts translate this new knowledge into strategies
to improve the health and quality of life for older Americans.
NIH is the principal biomedical research arm of the Federal
Government. NIA is the primary sponsor of aging research in the
United States.
This report highlights a number of research advances
conducted or supported by NIH during 1997 and 1998. Section 1
of this report outlines NIA's key advances for 1997. Section 2
presents NIA's key advances for 1998. Section 3 provides
selected findings from some of the other NIH institutes
involved in aging research. They are the National Eye Institute
(NEI); National Library of Medicine (NLM); Office of Research
on Women's Health (ORWH); National Heart, Lung, and Blood
Institute (NHLBI); National Institute of Nursing Research
(NINR); National Center for Research Resources (NCRR); National
Human Genome Research Institute (NHGRI); National Institute on
Deafness and Other Communication Disorders (NIDCD); National
Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS); National Institute of Mental Health (NIMH); National
Institute of Dental and Craniofacial Research (NIDCR); National
Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK); National Institute of Child Health and Human
Development (NICHD); National Institute on Neurological
Disorders and Stroke (NINDS).
Section 1.--1997 Introduction
Congress created the NIA in 1974 as part of the National
Institutes of Health. At that time, aging research was in the
early stages of developing ways to explore fundamental aspects
of the aging process. Since then, knowledge about the
fundamental processes of biology has grown as have new insights
about the processes of health and disease in later years. The
goal of NIA-supported research is to understand the basic
mechanisms of normal aging and age-associated disease,
disability, and other special problems and needs of the aged,
and to translate this knowledge into treatment and prevention
strategies.
An increasing interest in aging research is driven in part
by a projected dramatic increase in the older population.
People over age 65, who made up only four percent of the U.S.
population in 1900, constitute approximately 12 percent now and
will make up about 20 percent of the population by the year
2025. The over-85 age group, often referred to as the ``oldest
old'', is the fastest growing segment of the older population.
Population aging will become an important phenomenon of the
next half century as the presently middle-aged ``baby-boom''
generation becomes eligible for Social Security and Medicare.
Alzheimer's disease
As the baby boomers age and Americans continue to live
longer, there is an increasing concern about Alzheimer's
disease (AD), a devastating neurological disease which affects
the cognitive function of sufferers who are primarily in the 65
and older age group. AD now affects an estimated four million
Americans and is projected to reach critical proportions in the
U.S. in the near future. Unless we can develop interventions to
prevent or delay this dreaded disease, perhaps as many as 15 to
20 million older people and their families will experience the
nightmare of Alzheimer's disease early into the 21st century.
This is one reason that AD research continues to be a top
priority for NIA.
In the past five years we have made remarkable progress in
AD research. Scientists have discovered genetic mutations
linked to AD on four separate chromosomes: 1, 14, 19, and 21.
Chromosomes 1, 14, and 21 are associated with early-onset,
familial AD, an aggressive form of the disease that can cause
symptoms in people as young as 30 years of age. Scientists are
now trying to discover precisely what abnormal proteins or
processes these mutations generate and to clarify how these,
together with environmental factors, play a role in the
disease. Within the past five years, scientists discovered that
the risk of developing the more common, late onset form of AD
is linked to a gene located on chromosome 19 that codes for a
protein known as ApoE. One of the variants of this gene, ApoE4,
is associated with greatly increased susceptibility to AD and
earlier age of onset. In contrast, ApoE2 may confer a
protective effect. These important discoveries have led to
increased research activity to discover the molecular
mechanisms underlying the effects of ApoE on the development of
AD pathogenesis. If ApoE is directly involved in susceptibility
for AD, it would then become a target for interventions.
The dual goals of accurate diagnosis and early detection
have long been central to AD research. A recently reported
study that combined the use of ApoE4 typing with brain imaging
showed that it is possible to identify abnormalities in brain
function of individuals who are at high risk for Alzheimer's
disease, but who have no detectable disease symptoms, as many
as 20 years before they would be expected to develop symptoms.
This advance opens the opportunity for potential treatments
which could be started before the brain has suffered damage
from more advanced AD.
Basic biology of aging
Parallel to the discoveries in basic neurobiology, which
should eventually enable us to prevent nerve cell destruction
and onset of Alzheimer's disease symptoms, research on the
basic biology of aging will provide the foundation for
developing new or improved interventions to combat multiple
age-associated diseases and disabilities. Recent research has
advanced our understanding of the genes and biochemical
pathways involved in regulating the life span of some lower
organisms. By incorporating these ``longevity'' genes into the
chromosomes of experimental animals, NIA researchers have
actually been able to increase life span. Once researchers have
a better understanding of life span control in simple animals,
they will be able to study life span control in more complex
animals and determine the relationship of these processes to
human aging, health and disease, and longevity.
Both aging and cancer researchers share interest in one
particular field that concerns the end structures on
chromosomes known as ``telomeres,'' structures which serve to
maintain the chromosome's integrity and stability. We now know
that telomeres play a key role in determining the capacity of
individual cells to divide; after losing this capacity, cells
become senescent. Telomerase is an enzyme that works to
maintain telomere length by compensating for the shortening
which occurs each time the cell divides. Cancer cells express
relatively high levels of telomerase which enables them to
divide indefinitely. A more complete understanding of
telomerase and telomere length regulation should lead directly
to studies on the delay of cellular senescence and age-related
disease, as well as to new strategies to prevent the unlimited
replication of cancer cells.
Another important area in basic aging research is that of
oxidative damage. Damage to cells and subcellular components
from ``free radicals,'' which are naturally occurring
byproducts of normal metabolism, has long been believed to be a
factor in the degenerative processes which accompany aging in
all animal species. Recently completed research demonstrated a
strong inverse correlation between life span and the level of
free radicals produced by mitochondria, the energy-producing
powerhouses located within all cells. Thus, a promising
intervention against age-associated disease and disability
might be one which would reduce the level of free radicals by
increasing the biochemical efficiency within the cell's
mitochondria.
Applied/clinical research
The NIA also conducts research with immediate clinical
significance. NIA-supported research on treatments for AD span
a wide range of approaches, from research to develop candidate
drugs to clinical trials of drugs that show promise. In
addition to these efforts at drug development, research will
continue on the effectiveness of behavioral approaches and
services such as AD special care units, which are long-term
care settings designed to meet the needs of people with AD and
related cognitive impairments. The results of research on
special care units should inform public policy on ways to
improve care for Alzheimer's patients by determining the
effectiveness of special care units for their residents, their
families, and the unit staff members.
Physical disability is a major concern to older persons and
is associated with billions of dollars spent annually on long-
term care. For many older persons, physical disability is the
result of multiple, complex, and interacting factors.
Osteoporosis, which affects an estimated 25 million older
Americans, most of them women, is an obvious example of a major
risk factor for physical disability. Osteoporosis predisposes
older persons to serious and debilitating fractures. Each year,
thousands of older Americans, more women than men, are
hospitalized and then admitted to costly long-care facilities
because of hip fracture. Recent studies revealed that estrogen
use is associated with lower hip fracture rates, indicating the
potential for preventing bone loss and related fractures. Other
researchers, conducting a four-year longitudinal study of
women, identified hip fracture risk factors which allow
targeting of very high-risk women for preventive strategies.
There was a 25-fold difference in hip fracture rate between
those women with two or fewer risk factors and normal bone
density, and those women with five or more risk factors and low
bone density. Maintaining body weight, walking for exercise,
avoiding long-acting benzodiazepines, minimizing caffeine
intake, treating impaired vision, and taking measures to
maintain bone density are among the steps identified that may
decrease hip fracture risk. NIA will continue to fund basic
laboratory studies of the biology of osteoporosis and bone cell
function, clinical studies of age-related bone loss and
fracture epidemiology, and trials to prevent and reverse bone
loss.
Menopause is a universal phenomenon in women and until
recently has been understudied. To gather critical information
on the chronology of the biological and psychosocial factors
related to menopause and its subsequent effects on health and
age-related disease, NIA supports the Study of Women's Health
Across the Nation (SWAN). This study will generate extensive
data on menstrual cycle characteristics such as ovarian
function, nutrition, ethnicity, reproductive history, risk
factors for diabetes, hypertension and cardiovascular disease,
and physical activity.
Cardiovascular disease is another major cause of disability
and remains the leading cause of death of older Americans,
killing approximately half of those age 65 and older. Although
age is the main risk factor for cardiovascular disease, the
precise reasons are presently unknown. One potential risk
factor for cardiovascular disease in the elderly is stiffening
of the large and medium-sized arteries, leading to increased
stress on the heart. NIA is conducting research to identify
ways of preventing and reversing vascular stiffening, such as
exercise and other beneficial lifestyle changes. Other NIA
researchers are evaluating the possible roles gene therapy may
have for treatment of age-associated heart disease. These
scientists are examining whether gene therapy can be used to
enhance blood circulation in animal models of chronic heart
disease and have successfully induced the growth of new
coronary blood vessels in laboratory animals to reestablish
blood flow following heart attack. In another study, gene
therapy is being tested as a way to combat the renarrowing of
blood vessels following angioplasty, a technique used to open
narrowed coronary arteries. The potential benefit of preventing
or reducing age-associated cardiovascular disease is
considerable, both in terms of cost savings and quality of life
of older Americans.
Many of the problems of aging result from behaviors that
place individuals at greater risk for poor health, depression,
and other negative outcomes. NIA-supported research has
documented the benefits for health and longevity of adopting
healthy lifestyle practices, such as physical activity and
nutrition, and avoiding health-impairing habits, such as
smoking, even at a very old age. As one example, numerous
studies have documented the influence of exercise and physical
activity on longevity, even among the oldest old. Recent
studies also show the benefit of regular exercise in reducing
costly hospital stays and nursing home admissions. Current
research advances document the importance of the social and
behavioral context when studying physical activity and exercise
among older adults. Nevertheless, surveys report that older
people often are not motivated to make the desired changes.
Additional research is therefore being stimulated on topics
such as the social and behavioral factors involved in
initiating and maintaining health-enhancing behaviors, the role
of health care providers in identifying risk and encouraging
positive self-care practices, and the design of regimens
appropriate for older people in community and institutional
settings. Even with the hope of major advances in the treatment
and prevention of disabling conditions, the demand for long-
term care is expected to increase due to predictable
demographic trends. Research will be conducted on many aspects
of long-term care, particularly on new and evolving forms of
care with a goal of identifying the most effective and cost-
efficient approaches.
As life span and vitality in later life have increased,
more and more older people are able and willing to work
productively well into late adulthood. According to NIA's
Health and Retirement Survey, almost three-fourths of American
workers now would prefer to phase in their retirement with a
gradual shift to part-time work rather than stop working
abruptly. One major goal of this research is to understand the
productive potential represented by workers over age 60,
especially for part-time engagement in the workforce.
A vision for 21st century America drives our research
efforts. It is the prospect of an older but healthier
population of productive and independent citizens. Some of the
progress made toward this goal through the multi-faceted
research approach of the NIA is described in the following
pages.
EXTRAMURAL RESEARCH
NIA funds a broad portfolio of research grants, contracts,
and training awards encompassing many research fields and
scientific disciplines. Although not all of NIA's research
initiatives can be covered within this document due to space
limitations, many high priority research areas are described in
the following sections:
Declining cognitive function and interventions for older adults
A major concern of older adults is thinking and
remembering. A particularly exciting development is the rapid
advance of neuroimaging techniques, such as magnetic resonance
imaging (MRI) and positron emission tomography (PET), which
permit researchers to study images of the brain while cognitive
processing occurs. These and other techniques are relating
learning and memory impairments to changes in brain structure
and physiology, permitting a mapping of areas affected by
Alzheimer's disease (AD) and other neurological disorders. This
knowledge is valuable for detection, early diagnosis, and
treatment of cognitive losses due to disease. Future research
promises to identify the locations and processes of various
components of memory and to differentiate the memory loss that
can occur during normal aging to that which results from
disease. Promising work has also produced interventions that
can enhance some aspects of cognitive ability in older people.
The NIA and the National Institute of Nursing Research are now
soliciting grant applications for a trial to test such
behavioral interventions in older adults of varying racial,
ethnic, socioeconomic, and cognitive characteristics. The study
should identify means of maintaining or increasing basic
abilities critical for independence.
Alzheimer's disease: a decline in cellular communication
In AD, communication between nerve cells breaks down and
leads to nerve cell dysfunction and cell death. AD destroys
neurons in parts of the brain involved with cognition,
especially in the hippocampus (a structure deep in the brain
that plays an important role in memory encoding). As the
hippocampal nerve cells degenerate, short-term memory falters,
and eventually the ability to perform familiar tasks declines
as well. AD also attacks the cerebral cortex (the outer layer
of the brain). The greatest damage occurs in areas of the
cerebral cortex responsible for functions such as language and
reasoning. Emotional outbursts and disturbing behaviors appear
with increasing frequency as the disease progresses. In the
final stages, AD destroys the affected person's ability to
recognize close family members or communicate in any way,
leaving the person totally dependent upon others for care.
Prevalence and costs of Alzheimer's disease
An estimated 4 million Americans currently suffer from AD,
and the lives of their caregivers are affected by this
devastating illness. Families experience great emotional,
physical, and financial stress. As the disease progresses and
abilities steadily decline, family members face painful
decisions about the long-term care of their loved ones.
Moreover, AD puts a heavy economic burden on society. One
recent NIA-supported study estimated that the cost of caring
for one person with advanced AD can be more than $47,000 a
year, whether the patient lives at home or in a nursing home.
For a disease that can range in duration from two to 20 years,
the overall costs of AD to families and to society are
staggering.
Other factors in our changing society will compound the
problem of AD in the near future. Life expectancy has been
increasing since the turn of the century. Today in most
industrialized countries, the 85 plus age group is the fastest
growing segment of the older population and is also the segment
of the population most devastated by AD, with an estimated 47
percent prevalence rate. These demographics emphasize the
urgency of the need to find successful interventions that will
delay or prevent onset of AD.
Genes in early-onset Alzheimer's disease
AD can strike early and often in some families--and the
disease in families such as these is identified as early-onset
familial Alzheimer's disease (FAD). Studying the DNA of some of
these early-onset FAD families, NIA-supported researchers have
recently identified abnormalities in a gene on chromosome 21 in
a subset of people with FAD. Over the last year, other
investigators identified mutations in a gene on chromosome 1 in
a set of families from Germany and mutations in a recently
identified gene on chromosome 14 in other FAD families. The FAD
genes on chromosome I and on chromosome 14 code for highly
similar membrane proteins whose functions are not yet known.
These mutated genes are responsible for very aggressive forms
of FAD and may also play a role in the development of other
types of AD. Further research on these mutations is expected to
clarify key steps in the disease process. The FAD gene on
chromosome 21 codes for an abnormal form of the precursor for
amyloid protein, consistent with a role of amyloid protein in
some forms of AD. Interestingly, people with Down's syndrome,
who have an extra copy of chromosome 21, usually develop AD-
like pathologies as they grow older.
ApoE4 and Alzheimer's disease
In addition to the genes on chromosomes 1, 14, and 21
associated with FAD, the ApoE4 gene on chromosome 19 has been
linked to late-onset AD, the most common form of the disease.
Everyone has ApoE, a protein which helps transport cholesterol
in the blood throughout the body. The gene coding for the
production of ApoE occurs in three versions: ApoE2, ApoE3, and
ApoE4. ApoE3 is the one most commonly found in the general
population. ApoE2 may confer some protective effect against AD.
ApoE4 is associated with greatly increased susceptibility to AD
and earlier age of onset. It is found in many late-onset AD
patients and is not limited to people with a family history of
AD. On average, people with two copies of the gene for ApoE4
start showing AD symptoms before age 70 and are eight times
more likely to develop AD than those who have two copies of the
more common ApoE3 version. For those with no copies of ApoE4,
the average age of onset is over 85.
Researchers have discovered that ApoE is localized in the
two abnormal structures found in the AD brain: amyloid plaques
and neurofibrillary tangles. Located outside and around
neurons, these plaques contain dense deposits of amyloid
protein. Neurofibrillary tangles are twisted fibers inside
neurons. Progress continues to be made in determining the
makeup of these abnormal structures and in elucidating the
mechanisms that account for their buildup in AD.
The presence of ApoE4 in a blood sample does not
necessarily predict AD. A person can have ApoE4 and not get the
disease, and a person can get AD without having ApoE4. Because
screening for ApoE4 would miss a large percentage of those who
will develop AD and falsely identify others as future AD
patients, widespread screening cannot presently be advocated.
However, testing for the ApoE gene in combination with other
tests, may soon contribute to the diagnosis of AD. The
mechanism by which ApoE influences the risk of AD is currently
under study. Scientists found marked differences in the rates
at which ApoE3 and ApoE4 bind to critical nerve cell proteins
involved in receiving signals from other cells, providing a
potential basis for the influence of ApoE variants on the risk
of AD.
While still controversial and far from proven, the
hypotheses surrounding ApoE4 are driving new research. The
relatively rare protein ApoE2 may protect people against the
disease; it seems to lower risk and delay the age of onset. For
instance, people with one ApoE2 gene and one ApoE3 gene have
only one-fourth the risk of developing AD as people with two
ApoE3 genes. If ApoE2 proves to be beneficial, then substances
that mimic its effects might be candidate therapies to be
tested for the ability to slow or prevent the progress of AD.
Similarly further explanation of preliminary findings may lead
to ways to reduce the effects of ApoE4, develop drugs to treat
or prevent AD, and ultimately, decrease its occurrence.
Research on dementia special care units
Another line of AD research sponsored by the NIA concerns
the effectiveness of special care units (SCUs), which are long-
term care settings designed to meet the needs of people with AD
and related cognitive impairments. The results of these studies
may provide ways to improve care for these patients by
determining the effectiveness of SCUs for their residents, the
residents' families, and the unit staff members. This research
also assesses the impact of SCUs on residents with and without
dementia in non-specialized nursing home units. Research will
define what constitutes ``special care'' and identify effective
features of SCUs, including environment, staffing, activities,
care planning, admission policies, size, and patient
segregation. Preliminary results reveal how care in SCUs
influences behavior, cognition, and physical functioning. For
example, some of the most promising outcomes of SCUs are seen
in the residents' quality of life as measured by increases in
social behaviors and interactions.
Alzheimer's disease cooperative study: clinical trials of experimental
treatments
The Alzheimer's Disease Cooperative Study is composed of 35
research sites and was established to conduct clinical studies
of promising drugs. This important work broadly complements
other areas of AD research activity sponsored by the NIA such
as the 27 NIA-funded Alzheimer's Disease Centers and an almost
equal number of satellite centers. A study to assess the
effectiveness of Deprenyl and vitamin E in slowing the course
of AD began in October 1992. NIA-supported researchers found
that the two drugs delayed important milestones, such as entry
into nursing homes, for people with moderately severe
Alzheimer's disease, and decreased their loss of daily
activities, including bathing, dressing, and handling money, by
about 25 percent. Another study on drug and behavioral
treatment of agitation began in June 1994 and is scheduled to
end October 1996. A study of the anti-inflammatory drug
prednisone to treat AD began in January 1995 and is scheduled
to end in January 1997.
The latest trial, a pilot study investigating whether or
not estrogen can improve function in women with AD who had
previously undergone complete hysterectomy (with removal of
both ovaries), was initiated in September of 1995. Previous
reports suggested that post-menopausal women on estrogen
therapy experienced benefits including improvements in mood,
concentration, and memory. The major question addressed by this
study is whether or not women with AD who had undergone prior
complete hysterectomy show benefit from a twelvemonth period of
estrogen therapy. Study results should be available by the end
of 1997.
Aging at the cellular level: senescence, longevity genes, and telomeres
The initial discovery that isolated mammalian cells have
only a limited potential for continued cell division has
provided an important paradigm for the study of aging and of
cancer. Scientists think that this phenomenon, also known as
cellular senescence, is a tumor-suppressive mechanism as well
as an underlying cause of aging. Previously, the demonstration
of cellular senescence was limited to an analysis of cells in
culture. This year NIA-sponsored research has demonstrated that
cell senescence also occurs in cells within live organisms.
Additional efforts by NIA-funded researchers have resulted in
the identification of specific genes involved in cell
senescence.
Recent research on longevity assurance genes using
invertebrate model systems, has significantly advanced our
understanding of the genes and biochemistry involved in the
regulation of longevity. Researchers have actually extended the
life and/or health span of some lower organisms by
incorporating these genes within their chromosomes. Once
researchers gain a better understanding of lifespan control in
simple model systems, they will be in a better position to
study these processes in animals such as mammals, and to
determine the relationship of these processes to aging, health,
and disease.
Although it has long been known that cells in culture have
a limited life span before proliferation ceases, the counting
mechanism that determines this species-specific limit has been
unknown. Somewhat akin to the plastic wrap on the end of a
shoelace that prevents its unraveling and destruction,
chromosomes have end structures known as ``telomeres'', which
serve to maintain the structural integrity and stability of the
chromosome. A recent hypothesis is that telomeres shorten each
time they are replicated during cellular division, and that
continued cellular proliferation requires some minimal telomere
length, yet to be defined. However, relationships among
telomere shortening, cellular proliferative potential, and age-
related disease remain to be clarified. Telomerase is an enzyme
that functions to elongate telomeres, thus compensating for the
telomere shortening which occurs with cell division. Cancer
cells have been found to express relatively high levels of
telomerase, thus allowing the cancer cell to replicate
indefinitely. A more complete understanding of telomerase and
telomere length regulation has the potential to elucidate
approaches to delaying cell senescence as well as to prevent
the unlimited replication of cancer cells.
Oxidative damage, antioxidant defense, and aging
``Free radical'' damage has long been believed to be a risk
factor for the degenerative processes which accompany aging in
animal species ranging from insects to humans. Free radicals
are byproducts of normal metabolism that are produced as cells
turn food and oxygen into energy. To defend against these
reactive and damaging molecules, cells have a multi-layer
defense system including anti-oxidants that react with and
neutralize the radicals which otherwise will damage proteins,
membranes, and nucleic acids including DNA. Evidence continues
to accumulate about the ubiquity of free radicals and their
considerable destructive potential in living tissues. Recent
NIA-funded studies demonstrated a strong inverse correlation
between life span and production in the mitochondria (energy-
producing powerhouses located within each cell) of reactive
oxygen species, one particular form of free radicals. Thus, a
promising aging intervention might be one which can increase
the efficiency of the mitochondrial electron transport system.
Aging research in rodents has demonstrated that caloric
restriction results in substantial increases in life span.
Recent studies have shown that the extension of life span in
mice by caloric restriction is accompanied by decreases in
resting respiratory rate, mitochondrial generation of free
radicals, and one type of damage in the mouse DNA, all of which
are consistent with the hypothesis that oxidative stress is an
important factor in aging. More research is needed to establish
the critical relationships among free radical sources and the
body's protective systems. An improved understanding of free
radical processes may lead to the development of interventions
(dietary, pharmacological, or genetic) for many of the diseases
associated with aging and markedly increase healthy life span.
Nutrition in the elderly
Recently, attention has focused on the nutritional status
and nutrition-related needs of older individuals in this
country. Researchers have indicated that a substantial
proportion of Americans over the age of 50 have diets or
diseases that place them at a high risk of malnutrition.
Malnutrition can be either primary, which is defined by
deficits in dietary intake or excesses (obesity, alcohol
intoxication and various dietary imbalances) caused by the diet
alone; or secondary, which arises from other factors such as
the presence of disease, special physiological states, or
inborn errors of metabolism. In order to focus on the role of
nutritional factors in preventing age-related diseases, it is
imperative to define the alterations in nutrition and
nutritional requirements which occur during aging and determine
what interventions could be implemented to prevent or delay
malnutrition. NIA will continue to promote nutrition-related
research in order to improve our understanding of the
interrelationships between nutrition, aging, health, and
disease.
Melatonin and sleep
There has been much recent publicity in the media about the
potential effects of melatonin, including claims that this
brain hormone can slow the human aging process, improve immune
function, and scavenge DNA and protein damaging ``free-
radical'' molecules. These claims unfortunately are
unsubstantiated and controlled research is needed to confirm or
deny them. However there is a solid base of data related to
melatonin's role in the regulation of the body's circadian
(day-night) rhythms and sleep, and it is possible that
melatonin may act as an effective ``hypnotic'' agent for
humans, able to induce sleep in both young and old individuals.
Studies are underway to understand how melatonin affects the
cells within the body's circadian clock, located deep within
the brain. Melatonin appears to be a signal molecule telling
the body that night is present; how it affects other systems in
the brain and body requires further study. There is a need for
continued research to determine potential interactions between
time of administration and disruption of normal circadian
rhythms with chronic usage, as well as possible other adverse
health effects, and the delineation of what types of sleep
disorders may be treated with melatonin.
Cardiovascular disease, vascular stiffening, and control of
hypertension
Cardiovascular disease remains a main cause of disability
and the leading cause of death of older Americans, killing
approximately 50 percent of those age 65 and older. Although
age is the main risk factor for cardiovascular disease, the
precise reasons are presently unknown. Continued research in
cardiovascular and related fields is essential to ensure
progress in defining important age-associated changes in the
heart and blood vessels and in understanding the interactions
between common age-related changes and the development of
cardiovascular disease.
A potential risk factor that may underlie cardiovascular
disease in the elderly is a stiffening of the large (e.g., the
aorta) and medium-sized arteries. Age-associated vascular
stiffening is accompanied by an increase in systolic blood
pressure. In some individuals, vascular stiffening may become
severe enough to lead to the development of isolated systolic
hypertension. High blood pressure is the major risk factor for
stroke and is also an important risk factor for coronary artery
disease, heart attacks, and heart failure in older Americans.
Since vascular stiffening has been considered a part of
``normal'' aging, treatment that may decrease arterial
stiffness (e.g., lifestyle modification or pharmacologic
intervention) is rarely advocated. NIA is conducting research
to identify ways of preventing and reversing vascular
stiffening, such as exercise and other beneficial lifestyle
changes. The potential benefit of preventing or reducing age-
associated vascular stiffening is considerable, both in terms
of cost savings and quality of life of older Americans.
Control of systolic hypertension now appears to be more
important for good health than previously believed. A recent
NIA-supported epidemiologic study has shown that high blood
pressure in mid-life is a risk factor for cognition and memory
problems in late life. As systolic blood pressure goes up, so
does the risk of later cognitive difficulties. The study
compared scores on cognitive tests given in old age with blood
pressure readings taken up to 25 years before. Data from the
study strongly suggest that early control of high blood
pressure reduces the risk for cognitive impairment in old age.
Menopause, osteoporosis, and estrogen replacement therapy
Menopause, a universal phenomenon in women as they age, has
been remarkably understudied. To rectify this situation, NIA,
in collaboration with other organizations will continue to
support the recently initiated multi-site, multi-discipline
Study of Women's Health Across the Nation (SWAN). This study
will gather critical information on the chronology of the
biological and psychosocial factors related to the menopausal
transition and the effect of this transition on subsequent
health and age-related disease. SWAN will generate extensive
data on menstrual cycle characteristics such as markers of
ovarian function, nutrition, ethnicity, reproductive history,
risk factors for diabetes, hypertension and cardiovascular
disease, and physical activity.
Osteoporosis and its consequences, particularly vertebral
and hip fractures, are a significant cause of frailty,
morbidity, and mortality in old age. An estimated 25 million
older Americans are currently affected by osteoporosis. Each
year, thousands of older Americans, more women than men, are
admitted to costly long-care facilities due to hip fracture.
NIA-supported osteoporosis research includes clinical studies
of age-related bone loss and fracture epidemiology,
intervention trials to prevent or reverse bone loss, and basic
laboratory studies on the biology of osteoporosis and bone cell
function. Results of studies are encouraging as to the
potential for preventing bone loss and related fractures. For
example, newly published results further indicate the benefits
of estrogen replacement therapy. Estrogen use and bone mass
were assessed in more than 9,000 older women to determine the
association between estrogen use and fractures. Current
estrogen use was associated with a decreased risk for many
fractures when compared with no estrogen. Data from the study
indicates that for optimal protection against fractures,
estrogen should be initiated soon after menopause and continued
indefinitely; additional studies are needed to confirm these
findings.
Laboratory studies will continue to generate the knowledge
based upon which new or improved interventions can be designed
to prevent or reverse bone loss. One recently completed NIA-
supported study was designed to determine the ability of
parathyroid hormone (PTH) to restore lost bone in animals at
skeletal sites with moderate and severe bone loss. The findings
from this study indicate that: (1) PTH is much more effective
than antiresorptive
agents in restoring lost bone in the estrogen-deficient
skeleton, (2) treatments with antiresorptive agents and PTH
have no additional benefit over PTH alone, and (3) PTH fails to
restore the most severe states of bone loss. The latter finding
may provide insight into the failure of some osteoporotic
patients to respond adequately to agents such as fluoride or
PTH. Further animal studies are needed to build upon these
findings before initiating human studies.
Strategies to prevent disability in older persons
Disability among older Americans is a major contributor to
the more than $100 billion spent annually on long-term care in
the U.S. Identification and reduction of risk factors in older
people can make a critical contribution to quality of life and
help prevent the disability that leads to long-term care.
Recently completed studies typify NIA's approach to applying
relatively simple, inexpensive technologies to prevent the
complex and expensive problems brought on by disability. To
identify older individuals with pre-clinical disabilities who
may benefit from targeted interventions, NIA scientists have
been evaluating functional assessment tests for use in
screening. One such study of older non-disabled persons found
that three short tests of physical performance abilities
strongly predicted disability as much as four years in advance.
In another study, researchers conducted the first
randomized controlled trial using the multiple risk factor
approach to reduce falls in older people. The interventions
targeted risk factors for falls, such as muscle weakness,
postural hypotension, use of sedatives or multiple medications,
and impairments of motion such as balance and gait.
Participants received individualized treatment, including
medication adjustments, strength and balance training, and
instruction on safe practices to avoid lightheadedness and
environmental hazards. Over a one-year follow-up period, the
participants' rate of falls was reduced by nearly half compared
to that of the control group which had received only social
visits. The intervention was also shown to be cost-effective,
particularly among individuals at high risk for falling. Since
more than 250,000 hip fractures occur each year among persons
over age 65, a substantial national cost savings should result
from incorporating the tested strategy into the usual health
care of older persons.
A four-year longitudinal study of women identified risk
factors for hip fracture that allow targeting of very high-risk
women for preventive strategies. There was a 25-fold difference
in hip fracture rate between those women with two or fewer risk
factors and normal bone density, and those women with five or
more risk factors and low bone density. Maintaining body
weight, walking for exercise, avoiding long-acting
benzodiazepines, minimizing caffeine intake, treating impaired
vision, and taking measures to maintain bone density are among
the steps identified that may decrease hip fracture risk.
Older people often lose their independence and require
long-term care after hospitalization for acute illnesses. In a
recent study, older persons admitted to a teaching hospital for
general medical care were randomly assigned to receive either
usual care or special care including a carefully prepared
environment, specific protocols for prevention of disability
and rehabilitation, and planning for the patient's return home.
Without increasing in-hospital or post-discharge costs, the
study showed that individuals who were helped to maintain or
achieve independence in self-care activities were significantly
more able than individuals receiving usual care to perform
basic activities of daily living and less likely to need
institutional long-term care at the time of discharge.
Elder-friendly environments
Human factors research adapts technologies and redesigns
home and community environments to accommodate the sensory,
motor, and cognitive abilities of older adults. This research
results in devices and other components of the physical
environment that better match the skill levels and abilities of
users, helping to prevent injuries such as hip fractures, and
remove physical and social barriers to independence. In
addition to modifying structures to foster community access,
this research targets design of kitchens, bathrooms, and
security systems as well as medical devices, instructions, and
labeling. Data from human factors research has already helped
improve driving safety and product ease of use. Special
emphasis is now being given to how older people use computers
and other aspects of the office environment and new information
technology as the U.S. workforce ages.
Health behaviors and behavior change over the life course
Many of the problems of aging result from behaviors that
place individuals at greater risk for poor health, depression,
and other negative outcomes. NIA-supported research has
documented the benefits for health and longevity of adopting
healthy lifestyle practices, such as physical activity and
nutrition, and terminating health-impairing habits, such as
smoking, even at a very old age. These benefits and recommended
steps for lifestyle changes have been well publicized.
Nevertheless, surveys report that older people often are not
motivated to make the desired changes. Additional research is
therefore being stimulated on topics such as the social and
behavioral factors involved in initiating and maintaining
health-enhancing behaviors, the role of health care providers
in identifying risk and encouraging positive self-care
practices, and the design of regimens appropriate for older
people in community and institutional settings.
As one example, numerous studies have documented the
influence of exercise and physical activity on longevity, even
among the oldest old. Recent studies are also showing the
benefit of regular exercise in reducing costly hospital stays
and nursing home admissions. Current research advances document
the importance of the social and behavioral context when
studying physical activity and exercise among older adults.
There is a growing consensus that exercise programs, to be
effective, must be tailored to older people's functional
status, also taking into account older people's beliefs and
readiness to adopt and maintain new exercise habits. Home-based
physical activity programs supervised by telephone contact
represent one promising strategy for reducing barriers to
regular exercise experienced by caregivers with demanding care
responsibilities.
However, more than half of older people are sedentary or
under-active. For men and women aged 55-84, the primary reason
for not exercising was ``lack of interest.'' The remaining
leading reasons given by older people for inactivity vary by
gender; women specified not having an exercise companion as a
major reason. Among the men and women older than 85, fatigue,
imbalance, and concerns about falls were the primary reasons
given for not exercising. Understanding the reasons older
people give for limiting or avoiding many moderate and vigorous
physical activities is a critical step in designing exercise
programs that will actually be incorporated into older adults'
daily routines.
Health, work, and retirement: Medicare, technology, and rising health
costs
As lifespan and vitality in later life have increased, more
and more older people are able and willing to work productively
well into late adulthood. According to NIA's Health and
Retirement Survey, almost three-fourths of American workers now
would prefer to phase in their retirement with a gradual shift
to part-time work rather than stop working abruptly. The
economic cost of workers who retire for 25 percent or more of
their lives is already creating a considerable social and
financial burden that will increase when the baby boomers
retire. One major goal of this research is to understand the
potential represented by workers over age 60, especially for
part-time engagement in the workforce.
NIA's research on the economics of health and retirement
focuses on the determinants and implications of economic well-
being and health among older households as individuals age.
Given the changing context of Medicare, pensions, and Social
Security, many demographic, sociological, and health components
of aging may be best understood in concert with economic
analyses. Recently developed data indicate that Medicare
hospital expenditure growth is not restricted to the highest-
cost beneficiaries, but occurs across the board. Similar rates
of hospital expenditure growth were found among high-cost and
low-cost users, and similar growth rates occur among different
age, race, and gender groups. Related research has found that
more use of intensive procedures, many of which are relatively
low cost has accounted for much of the growth in hospital
expenditures for Medicare beneficiaries in recent years. Thus,
more characterization of the specific technologies associated
with rising expenditures might be particularly useful to guide
strategies for cost containment. Research has made significant
progress in demonstrating how some provisions of Medicare
policy can actually result in relatively more frequent use of
certain intensive procedures.
Other work has measured the effectiveness of alternative
treatments in improving health outcomes. Results suggest that
the use of invasive procedures for heart attack patients could
be reduced by at least one-fourth with no consequences for
mortality, but with savings of over $300 million per year in
hospital costs alone. Similar studies will be carried out
examining heart arrhythmias and major cancers and will include
outcomes such as the subsequent development of medical
complications.
INTRAMURAL RESEARCH PROGRAM
In addition to the extramural research supported through
grant and contract awards, NIA directly funds and conducts
aging-related research in its own intramural laboratories
located at the Gerontology Research Center in Baltimore,
Maryland, as well as on the NIH campus in Bethesda.
Characterization of normal aging
In order to understand the biological changes found in
various disease states associated with old age, it is important
that the changes occurring in normal aging be properly defined.
At NIA laboratories, these changes are studied at the systemic,
cellular, and molecular levels. One area of study focuses on
identifying the mechanisms responsible for the progressive cell
loss observed in the aging brain. This work is complemented by
longitudinal studies assessing the general decline in total
brain mass, the increases in cerebrospinal fluid volumes, and
the difference in brain function observed in aging. Using a
variety of testing methods, researchers at the NIA have found
that blood flow to the brain during information processing
differs significantly between healthy young and old subjects.
It also has been reported that increasing age is associated
with difficulty in shifting attention from one sense (sight,
hearing, etc.) to another. These results complement other
studies showing immediate visual memory impairment in older
participants. One theory regarding the aging process and some
age-associated diseases is that such changes occur as a result
of accumulated damage to the genes and an inability to repair
damage to the genes. Recent studies by scientists at NIA have
demonstrated that gene repair declines with increasing age.
Ongoing studies are clarifying the mechanisms of genetic repair
which may lead to a better understanding of how repair
mechanisms are altered by the aging process.
Factors that alter normal aging
In an attempt to improve the longevity and quality of life,
scientist seek medical interventions that reduce the
degenerative changes associated with aging. At the NIA, several
laboratories have been successful in developing new strategies
that appear to ameliorate some of the deleterious changes
associated with aging. Scientists are examining risks
associated with heart disease, estrogen hormone deficiencies,
and dietary factors. For example, it is known that reducing
caloric intake by about 30 percent lengthens the life span of
laboratory rats and that these animals have a lower incidence
of cancer and other diseases. Parallel studies are now being
done in monkeys. These studies aim to identify the biochemical
mechanisms that are altered by caloric restriction. It is hoped
that the results from these studies will lead to development of
interventions that can promote longevity and reduce age-
associated diseases.
Novel treatment intervention strategies
Current treatment for many diseases associated with aging
relies on the use of new or improved pharmaceutical compounds.
However, other methods are also being explored including the
use of gene therapy. Experimental gene therapy is being used to
(1) replace damaged or `` bad'' genes, (2) add new (or
previously deleted) genes, or (3) increase or decrease the
production of critical proteins. NIA researchers are evaluating
the possible roles gene therapy may have for treatment of age-
associated diseases such as heart disease, central nervous
system degeneration, and cancer. Studies are underway to
investigate if gene therapy can be used to enhance blood
circulation in animal models of chronic heart disease. Using
laboratory rabbits bred for the study of heart disease, NIA
scientists have successfully induced the growth of new coronary
blood vessels to reestablish blood flow following heart attack.
In another study, gene therapy is being tested as a way to
combat the renarrowing of blood vessels following angioplasty,
a technique used to open narrowed coronary arteries. Gene
therapy is also being tested in laboratory animal studies of
Parkinson and Huntington diseases. These studies inserted a
dopamine (a neurochemical) receptor gene into cells normally
deficient in doparnine receptors. The results from these
studies were dramatic and showed that the cells with the
inserted dopamine receptor gene produce new, normally
functioning, dopamine receptors that improved motor control in
the animals.
Alzheimer's disease
Although the exact cause of Alzheimer's disease (AD) is
still unknown and therapeutic treatments remain limited, the
pace of new discoveries continues to increase. One of the
characteristic features of AD is the accumulation of amyloid in
brain plaques, a defining pathologic change associated with the
disease. NIH researchers have found a possible link between
specific mutations in the amyloid precursor protein and the
characteristic neuronal cell death that is seen in AD patients.
Early detection studies have reported that identifiable
cognitive changes are evident in patients who subsequently
progress to develop clinically apparent AD. Similarly, specific
cognitive changes have been identified with sustained attention
and immediate visual memory tasks. Although it is unclear where
the cellular and biochemical changes initially occur in the
brains of AD patients, there is a consistent decrease in the
level of acetylcholine (a key neurotransmitter). Scientists at
the NIA are researching new drug therapies for treatment of AD
which target this and other neurotransmitter systems. One such
candidate agent, phenserine, dramatically improved the ability
of laboratory rats that had memory-affecting brain lesions, to
navigate a maze. This drug is now in preclinical toxicology
testing.
Cancer
NIA researchers are studying cancers that increase in
incidence with aging, including breast, prostate, and colon
cancers. It is known that through normal cellular processes,
oxygen is metabolized and forms several compounds (metabolites)
which, if not cleared, appear to be toxic to cells. The
accumulation of these metabolites appears to cause genetic
damage that if left unrepaired by the cell, can seriously
interfere with its ability to produce key proteins, and may
initiate the transformation of a normal to a cancerous cell.
One group of NIA researchers is specifically studying the role
oxidative damage plays in breast cancer. Another group is
studying the genetic programming that is thought to determine
how breast cancer cells divide and proliferate. Collectively,
these studies will advance our understanding of the genetic
changes involved in breast cancer, which may help us understand
the cause for other cancers such as colon and prostate.
Diabetes
Diabetes is a common illness among the elderly. It is the
high glucose blood levels that lead to most of its clinical
complications including blindness, vascular disease, and kidney
disease. Adult diabetes is associated with a (1) diminished
ability of the pancreatic beta cells to release insulin in
response to blood glucose, and (2) reduced sensitivity of
target tissues to insulin. Research efforts are directed at
developing methods to lower blood glucose safely by restoring
glucose sensitivity to beta cells and improving insulin action
at the target cells. The NIA's interest in finding new ways to
maintain the pancreatic beta-cell function in aged animals has
led to the cloning of the genes that control beta-cell
regeneration in mice. NIA investigators have also synthesized a
new compound that increases insulin receptor signaling when
introduced into intact cells. The development of such reagents
that act as specific modulators of insulin receptor function
may provide an effective way to treat diabetes.
Osteoporosis
Osteoporosis occurs frequently among the elderly, and is
associated with increased morbidity and mortality. NIA
researchers have discovered that there are several deficits
associated with aged bone including reduced bone formation,
reduced number of cells which make bone, and impaired
production of the compounds needed to make and maintain bone.
Researchers are investigating several interventions for
treatment of osteoporosis including enzyme regulation, cell
replacement, and growth factor supplementation. These
scientists have found that anticollagenase (an enzyme)
treatment can prevent the bone loss seen in certain laboratory
animals used to study osteoporosis. It is hoped that similar
studies in patients can be conducted to determine if such an
approach will work as a treatment for osteoporosis in humans.
Baltimore longitudinal study on aging
The NIA manages and operates the Baltimore Longitudinal
Study on Aging (BLSA) which began in 1958. To date, over 2,200
men and women research volunteers have participated. Recent
studies using BLSA participants found that women who received
estrogen hormone treatment made significantly fewer errors in
short-term visual memory tasks than women not taking estrogen.
Even women who had recently started estrogen treatment had less
memory loss compared to women who never received estrogen
therapy. These findings support a beneficial role of estrogen
replacement on cognitive functioning in aging women. In
prostate cancer, BLSA studies have altered the standard of
practice. Rather than using an absolute value of serum levels
of prostate specific antigen (PSA) to screen for prostate
cancer, data from BLSA studies have showed that the rate of
change of PSA levels over time is a more specific indicator of
disease. Restricting diagnostic biopsies to patients with PSA
increases greater than 0.75 units/yr. can significantly reduce
the number of biopsy procedures thereby reducing the total
number and cost of unnecessary surgeries. Other studies using
BLSA participants have provided equally valuable scientific
information for other medical conditions including
cardiovascular disease, and AD.
Research management and support
The research and management support (RMS) activity provides
administrative support and scientific management for the
extramural grants and contract awards, for NIA's intramural
research program, as well as for overall program direction and
policy development. The extramural initiatives supported by NIA
have been developed and are managed by the extramural program
staff funded by the RMS activity. Scientific staff members
focus their efforts on developing research initiatives,
reviewing, awarding, and administering grants/contracts on
aging research and training to universities, hospitals, medical
centers, and other organizations. The RMS mechanism also
provides funding for facility support costs, related expense
items essential to all research programs, and the mandated
Alzheimer's Disease Education and Referral (ADEAR) Center which
gathers, maintains, and disseminates information on Alzheimer's
disease research and services. The center operates a toll-free
telephone number to provide the latest information and referral
services to health professionals. Direct support is also
provided for the operation of several interagency coordinating
committees related to aging research; NIA is chair or co-chair
of these committees which include the Federal Forum on Aging,
and the DHHS Advisory Panel on Alzheimer's Disease.
Section 2.--1998 Selected Scientific Accomplishments and Opportunities
ALZHEIMER'S DISEASE
Taking estrogen after Menopause may delay the onset and reduce the risk
of Alzheimer's disease
A recently completed epidemiologic study of 1,124 women
over age 70 provides the strongest evidence to date that taking
estrogen after menopause may delay the onset and reduce the
risk of Alzheimer's disease in postmenopausal women. At the end
of the five-year study period, researchers found that 16.3
percent of the women who had not used estrogen developed
Alzheimer's disease, while only 5.8 percent of the women who
had taken estrogen developed the disorder. The age at onset of
Alzheimer's disease was significantly later in life in women
who had taken estrogen than in those who did not. Even women
who took estrogen for as little as one year were less likely to
develop the disorder. None of 23 women who were taking estrogen
at study enrollment developed the disease. African-American,
Hispanic, and Caucasian women who took estrogen benefited
equally from estrogen replacement, as did women with varying
educational and socioeconomic levels. Although researchers are
not sure how estrogen might be protective against Alzheimer's
disease, studies suggest that estrogen promotes the growth and
survival of neurons. Estrogen also may protect neurons from
being injured by toxic substances. A prospective controlled
clinical trial is planned to confirm the preventive effects of
estrogen, to assess its safety, and to establish the dose and
duration of estrogen required to provide any observed benefits
in elderly postmenopausal women.
New mouse model developed for Alzheimer's disease displays hallmarks of
disease
Researchers have genetically engineered the first animal
model that exhibits both the behavioral and neuropathological
symptoms of Alzheimer's disease (AD). The mice were produced by
insertion of a gene, found in a large Swedish family with
early-onset AD, that overproduces a protein (beta-amyloid
precursor protein) which in turn produces the toxic protein
(beta-amyloid) associated with amyloid plaques. Large numbers
of these plaques are found in the brain tissue of AD patients,
and their presence is used to diagnose the disease. While the
transgenic mice appeared normal at two to three months of age,
by 9-10 months they exhibited impaired ability in spatial
learning tasks, and their brains contained dense deposits of
amyloid plaques; both symptoms and plaques increased with age.
This model provides an important research tool for
understanding AD and for expediting means of testing potential
drug therapies.
Study suggests causes of dementia may vary between cultures
While overall dementia rates seem to be generally similar
among nations, reports of the relative frequencies vary between
the two major subtypes of dementia, AD and vascular dementia.
For some time, AD has emerged as the major subtype in most
Western nations, and vascular dementia usually has been
reported to be the dominant subtype in Japan and possibly in
other Asian nations. To determine the basis for these disparate
rates, NIA intramural investigators and others analyzed data on
3,734 participants aged 71 to 93 years, living in the community
and in institutions, from the Honolulu-Asia Aging Study (HAAS),
an epidemiologic investigation of aging and dementia being
conducted in cooperation with NHLBI's Honolulu Heart Program.
Cognitive performance was assessed using standardized methods,
instruments, and diagnostic criteria. The researchers found
that Japanese-American men living in Hawaii have a higher rate
of Alzheimer's disease when compared with levels found in
several studies of men of similar age living in Japan, but
similar to rates of AD among European-ancestry populations. In
contrast, the prevalence of vascular dementia is slightly lower
in Hawaii than in Japan, but higher than rates of vascular
dementia in European-ancestry populations. These results
suggest that environmental factors which differ for men of
Japanese ancestry living in Hawaii or in Japan influence the
risk of AD and vascular dementia. Observations from this study
will guide a search for environmental, genetic, and cultural
factors that may influence the development of both Alzheimer's
disease and vascular dementia.
BIOLOGY OF AGING
Discovery of the genetic defect that causes Werner's syndrome may
provide insights into biological aging processes
Werner's syndrome, a rare, recessive disease with clinical
symptoms resembling premature aging, results in shortened life
span and early susceptibility to a number of major age-related
diseases, including atherosclerosis, cancer, diabetes, and
osteoporosis. People with Werner's syndrome begin to have gray
hair, lose elasticity in their skin, and develop cataracts
while in their twenties, and most die before age 50. Werner's
syndrome is therefore considered a partial model of human
aging. Researchers have identified the genetic defect that
causes Werner's syndrome in a gene on chromosome 8. The gene
shows a significant similarity to those coding for enzymes that
unwind paired DNA strands to prepare for repair, replication,
or expression of genetic material. Scientists are speculating
that the consequences of this defective gene may be related to
the accumulation of DNA damage in the patient's cells, leading
to the premature development of age-related diseases.
Continuing research, including studies in transgenic mice to
determine the biological function of the mouse gene that
performs a function similar to the human Werner's syndrome
gene, is aimed at determining the role of the gene product.
Besides the importance of this finding to understanding
Werner's syndrome, this work is expected to yield important
insights into cancers, because of the array of rare tumors
associated with Werner's syndrome; into other age-related
diseases; and into the biological processes involved in aging.
Gene involved in regulating longevity in C. elegans may provide clues
to human aging
Several ``longevity genes'' have been discovered in mammals
and lower organisms. These genes have provided insight into
biologic control of life span, and appear to make the animals
less susceptible to environmental stresses. Normal development
and longevity in a primitive worm, C. elegans, are regulated by
the ``age-1'' gene. Lack of age-1 activity in adult worms, due
to mutations in the age-1 gene, results in a doubling of adult
lifespan. NIA-supported researchers determined that the normal
age-1 gene encodes the analogous gene in the worm of a key
enzyme (phosphatidyl-inositol-3-OH-kinase) in cellular
communication and signal transduction. The research team
speculates that mutations in the age-1 gene, resulting in lower
levels of this enzyme, may trigger a biochemical program in the
worm, ultimately leading to a decreased rate of aging and
senescence. Often the effect of longevity genes depends upon
the activity of other genes. Human genes that serve the same
function as age-1 have also been identified. The effect of
these genes on aging is now being investigated. Continued
research on age-1 and other longevity assurance genes is viewed
as a critical first step in the design of biologically-based
interventions to promote human longevity, extend healthy life
span, and improve the quality of life in older individuals.
Progress made in telomere genetics
Telomeres are segments of DNA that protect the ends of
chromosomes from degradation and recombination. Study of these
structures and the enzyme telomerase that causes telomeres to
lengthen has relevance to broad issues of human aging and
disease. There is a strong correlation between telomere
shortening and senescence, the loss of cells' ability to divide
and replicate. Senescence may play a central role in age-
related disease processes and loss of function. The
uncontrolled growth of malignant cells seen in cancer is in a
sense the reciprocal phenomenon to senescence. The enzyme
telomerase, which lengthens telomeres, is rarely active in
normal cells, but is highly active in nearly all malignant or
immortalized human cells that have been examined. Because of
this link to cancer, understanding the role and regulation of
telomerase activity in normal and malignant cells is of
critical importance. During the past year, significant progress
has been made toward understanding the nature of telomerase
regulation. Scientists cloned the mouse and human genes for a
portion of telomerase. The molecular cloning of the remaining
(protein) segment of telomerase is under way. Recently,
scientists reported on the expression of telomerase by normal
human cells, including those of the immune system. Parallel
initiatives are exploring whether and how telomerase governs
the function and replication of tumor and immune cells.
MUSCULOSKELETAL RESEARCH
Antibiotic shows promise in treating osteoporosis
Osteoporosis is a major public health threat, and afflicts
25 million Americans, 80 percent of whom are women. The loss of
bone mass due to osteoporosis contributes to 1.5 million
fractures annually. NIA intramural scientists showed that
minocycline, one of the tetracycline-like antibiotics, improves
bone strength and formation and slows bone resorption in aged
laboratory animals with surgically-induced menopause. While
estrogen has been shown to prevent bone loss, minocycline
appears to prevent bone loss and to increase bone formation,
possibly achieving mineral density beyond premenopausal levels.
Minocycline is inexpensive and, because it is not a hormone,
may not exert the adverse effects seen with estrogen, such as
those on the uterine lining. Researchers are now launching a
one-year clinical trial to study the effects of minocycline in
postmenopausal women with osteoporosis.
Exercise found to be safe and effective for knee osteoarthritis
The osteoarthritic diseases are the most prevalent
disorders of the joint, with radiographic evidence seen in at
least 70 percent of those over age 65. A clinical study,
conducted at one of NIA's Claude D. Pepper Older Americans
Independence Centers, suggests that people with osteoarthritis
of the knee who exercise in moderation experience a significant
improvement in physical functioning, and up to a 12 percent
reduction in knee pain, compared with individuals who received
health education only. In this 18-month study of 439 people
over age 60, aerobic training was divided into a three-month
walking program on an indoor track with a trained exercise
leader, followed by a 15-month walking program in the home
environment designed by the exercise leader. Participants
exercised for 1 hour, which included warm-up calisthenics and
stretching three times a week, during each phase. The
resistance training program, involving dumbbells and cuff
weights for strengthening both the upper and lower body, also
consisted of a three-month facility-based program followed by a
15-month home-based program. The study concluded that exercise
over a long period of time is safe as well as beneficial for
older people with knee osteoarthritis. Further research is
needed to understand how to prevent degenerative joint disease,
a problem that afflicts tens of millions of older persons.
CARDIOVASCULAR AGING
Treatment found effective in preventing major cardiovascular events
After five years of treatment of isolated systolic
hypertension with low doses of diuretic-based anti-hypertensive
medication, men and women aged 60 and older had fewer strokes,
heart attacks, and other coronary heart disease, as well as
lower overall mortality, than those given a placebo. The
reduction in the rate of major cardiovascular disease with
treatment was 34%, and the absolute risk reduction was twice as
great for diabetic as compared with nondiabetic patients,
reflecting the diabetic patients' higher risk. Increased use of
the relatively inexpensive medication to treat isolated
systolic hypertension could save substantial hospital and
medical costs.
Exercise boosts cardiac fitness in sedentary older people
Cardiovascular diseases remain a main cause of disability
and the leading cause of death of older Americans, accounting
for approximately 50 percent of deaths in persons age 65 and
older. Declines in cardiovascular reserve capacity with aging
lead to a greater prevalence and severity of cardiovascular
disease in older individuals. With age, the hearts of otherwise
healthy sedentary people gradually lessen their ability to
increase their heart rate and ejection fraction (the percentage
of blood leaving the heart during each heart beat) during acute
exercise. While it has become clear that aerobic exercise
conditioning can partially offset age-associated cardiovascular
declines, even for those who begin at age 60 or 70, scientists
questioned whether the beneficial effects of aerobic exercise
training in older individuals depend upon their prior fitness
level. A team of investigators led by NIA intramural
researchers started with two groups of men at opposite ends of
the fitness spectrum and inversely varied their training
status. A group of sedentary older men exercised for 24 to 32
weeks, and a group of endurance-trained older athletes stopped
their exercise for 12 weeks. Researchers measured the subjects'
aerobic capacity and cardiovascular performance at the
beginning and end of the study using a treadmill exercise test
and a graded bicycle exercise test of the heart's ability to
pump blood. With training, the sedentary men increased their
ejection fraction from 73 to 81 percent and their
VO2 max, a measure of a person's aerobic capacity,
by 11.3 percent; the detrained athletes had decreases in these
functions that were qualitatively and quantitatively similar in
magnitude, although directionally opposite. The results show
that even the most sedentary older men can improve cardiac
function through aerobic exercise, and that age and prior
fitness level is no barrier to achieving these gains.
Vascular stiffness contributes to cardiovascular disease
Recent findings have identified the stiffening of large and
medium-sized elastic arteries, such as the aorta, as a
potential risk factor for cardiovascular morbidity in the
elderly. This stiffening occurs in healthy older people; but
for approximately half of Americans age 65 and older, the
degree of vascular stiffening may become great enough to lead
to isolated systolic hypertension, a major risk factor for
stroke, and to other cardiovascular disorders. Research into
the biological and physiological mechanisms involved in
vascular stiffening may suggest effective treatments, and may
enable physicians to determine when the degree of vascular
stiffening passes from the normal to the pathological range,
thus helping to prevent its negative effects. NIA is promoting
research to reduce both vascular stiffening and cardiovascular
risk factors associated with lifestyle, as well as to
understand age-related changes in cardiac function, circulatory
hemodynamics, blood pressure regulation, and lipid metabolism,
all significant contributors to morbidity and mortality in the
elderly.
AGING AND CANCER
Test provides earlier prediction of prostate cancer
An estimated 81 percent of persons affected by prostate
cancer are 65 years and older. It was projected that, in 1996,
approximately 317,000 men would be diagnosed with prostate
cancer, and approximately 41,400 men would die of this disease.
African-American men experience the highest incidence of this
cancer in the world. In a recent advance, NIA intramural
investigators have found that prostate cancer may be predicted
up to ten years before it is diagnosed, by comparing, over
time, the ratios in a man's blood of free (not bound to a
protein) to total prostate specific antigen (PSA, an enzyme
produced by the prostate gland). Repeating measurements of both
free and total PSA and calculating the ratio between the two
over time may allow the physician to predict whether prostate
cancer is developing, and to distinguish it from benign
prostatic hypertrophy.
Breast cancer a major health problem in elderly women
Women age 65 and older have an incidence rate more than six
times that of women under age 65, and mortality rates show
similarly dramatic increases with age. Nevertheless, no
comprehensive guidelines for prevention, diagnosis,
pretreatment evaluation, or treatment have been formulated that
take into account the multiple health problems and special
needs of older women. There are also insufficient data from
clinical trials about the effect of breast cancer treatment on
older women, and minimal research on how to encourage older
women to increase their participation in cancer prevention
practices. With the projected increase in the aged female
population in the U.S., the need for findings relevant to
breast cancer control is becoming more critical.
AGING AND DISABILITY
Chronic disability rates continue to decline in the elderly U.S.
population
Between 1982 and 1994, the prevalence rates for chronic
disability in the U.S. elderly population, ages 65 and older,
declined 3.6 percentage points, based upon data from the 1982,
1989, and 1994 National Long Term Care Surveys. The decline is
highly significant statistically, and occurred at nearly all
levels of disability. In absolute terms, the differences in
prevalence suggest that there are approximately 1.2 million
fewer disabled persons in 1994 than would have been predicted
if the 1982 rates had remained the same; that is, 7.1 instead
of 8.3 million persons. The declines in disability rates are
linked to differences among birth cohorts, with those in the
oldest cohorts (born 1888 to 1897) having much higher rates of
disability than younger cohorts. This suggests that declines in
disability are likely to continue with new cohorts. The
findings have implications for health care costs and needs for
health care resources. Given the higher acute and long term
care service needs of the disabled elderly population,
Medicare, Medicaid, and private expenditures may be
significantly lower than if declines had not occurred. NIA
plans to analyze the dynamics underlying this apparent decline
in old-age disability in order to enhance this trend.
For people 80 years old or older, life expectancy is greater in the
United States than in Sweden, France, England, or Japan
In many developed countries, life expectancy at birth is
higher than in the United States. In contrast, once American
men and women celebrate their eightieth birthday, they are
likely to live about 1 to 2 years longer than their
counterparts in other highly developed countries. The study,
comparing life expectancy at advanced ages in the U.S., Sweden,
France, England, and Japan, shows that in 1987 American women
lived 9.1 years and American men lived 7 years, on average,
past age 80. The investigators calculated life expectancies for
people at the age of 80 as well as the probability of surviving
five years at ages 80 through 95. Counter to demographers'
expectations, regardless of how the data were analyzed, life
expectancy at age 80, and survival probabilities from 80 to
100, were significantly greater for white U.S. men and women
than for the oldest cohorts in the other countries studies. The
findings highlight U.S. success in increasing survival of the
very old and suggest that Medicare and the overall U.S. health
care system, as well as comparatively higher education among
American elderly, may play a role in extending U.S. life
expectancy in later years.
Benefits of exercising encourage a healthy lifestyle in old age
Studies such as the Institute's Baltimore Longitudinal
Study of Aging and the Claude D. Pepper Older Americans
Independence Centers have shattered stereotypes about
inevitable physical and mental decline with age, and have
demonstrated the benefits of exercise, even for people well
into their nineties. Regular physical exercise has been shown
repeatedly to improve health and functioning. A study of more
than 13,000 men and women found that, at any age, even modest
amounts of regular exercise, equivalent to walking 30 to 60
minutes a day, can significantly improve health, prevent
disease, and reduce the risk of death. A more recent study by
the same investigator of more than 9,000 men aged 20 to 82,
which compared death rates in physically unfit men who remained
unfit over five years with physically fit men who became fit
during the same period, found that unfit men aged 60 and over
who became fit had death rates 50 percent lower than those who
remained unfit. These findings have helped form the basis for
recommendations, where health permits, for older people to
adopt a more active lifestyle.
BEHAVIORAL AND SOCIAL RESEARCH
Individualized care in nursing homes produces positive effects on
residents
An intervention program consisting of interdisciplinary
care planning, family support, and activity programming for
persons with moderate dementia produced a decrease in
psychiatric and behavioral problems, as well as a decrease in
daytime levels of verbal agitation, when compared with nursing
home residents not exposed to the intervention. This study is
representative of NIA research designed to improve the long-
term care of older people in institutional and residential
settings. In addition, a recent survey of 16,876 nursing
facilities documented a doubling in the number of special care
units (such as special units for dementia, rehabilitation, and
AIDS) between 1991 and 1996. Investigators who studied this
trend suggest that special care units may be an organizational
strategy for concentrating limited resources where needs and
benefits to the resident and facility may be the greatest. NIA
is encouraging development of cross-site analyses of special
care units and outcome studies of long-term care in residential
settings.
Study identifies factors that influence compliance with medical
regimens
A significant number of persons with diabetes, arthritis,
and hypertension demonstrate misunderstanding of recommended
medical treatments. In a recently reported study, middle-aged
and elderly members of a health maintenance organization were
randomly selected on the basis of whether they had arthritis,
hypertension and/or diabetes, and then interviewed to evaluate
self-reports of treatment as compared to the treatment regimens
recorded by their physicians. Patients with arthritis
demonstrated a greater likelihood to misunderstand treatment
regimens (50%) than patients with diabetes or hypertension
(30%). The study showed that several factors influenced the
lack of patient understanding of treatments, and highlighted
the influence of doctor-patient relationships on older clients'
understanding of and compliance with treatment regimens.
Physician style (shared decision making, tolerance of non-
compliance) was related to how well individuals with arthritis
and hypertension understood prescribed treatments. Age
contributed to reported inaccuracies for diabetic patients
only, with older age groups demonstrating the least complete
understanding when compared to other diabetic patients. The
implications for health and well-being for the group who
misunderstood information, particularly the arthritis patients,
warrant continued research on best strategies to educate
patients about their recommended treatment regimens, especially
in light of the growth of managed care arrangements which
provide a new context for doctor-patient interactions.
Section 3.--Research Sponsored by Other NIH Institutes
National Eye Institute
Age-related macular degeneration
Age-related macular degeneration (AMD) is the leading cause
of new blindness in persons over age 65. Based on recent
advances, research is being directed toward the identification
of genes which, when mutated, contribute to the development of
AMD. Techniques of molecular genetics allow scientists to
examine ``candidate'' genes to determine whether mutations
occur with a higher frequency in persons affected by AMD than
in unaffected persons. While such mutations might not by
themselves be sufficient to cause AMD, they may contribute to
the occurrence of AMD in the presence of other mutant genes or
environmental insults. Scientists in the NEI intramural program
will screen approximately 1000 patients and age-matched control
individuals from the Age-Related Eye Disease Study (AREDS).
AREDS is a large, multi-center, research program designed to
improve our understanding of the predisposing factors, clinical
course, and prognostic factors of AMD and cataract. DNA samples
from the study's participants will be examined for mutations or
sequence variants in a group of well-characterized genes known
to be involved in a fundamental retinal function or to cause
retinal disease. A repository of genetic material from the
AREDS participants is being created to test candidate genes for
AMD as they are identified. Extramural investigators will have
access to this resource. Finding a genetic basis for AMD will
increase our understanding of the pathophysiology of the
disease and assist in developing new treatments or methods of
prevention.
Prevention of complications from age-related macular degeneration
Another new direction for age-related macular degeneration
research has been through NEI support for the Complications of
Age-related Macular Degeneration Prevention Trial (CAPT). This
trial will assess the safety and effectiveness of laser
treatment in preventing loss of vision among patients at high-
risk for developing age-related macular degeneration. In
addition to the primary outcome, which is visual acuity loss,
quality of life will be assessed. Twenty-five clinical centers
will conduct the study over the next five to seven years.
Low vision education program
The NEI staff, through its National Eye Health Education
Program (NEHEP), has begun the development of a new Low Vision
Education Program. The primary target audience for this program
is people age 65 and older with a visual impairment that
interferes with daily activities. Focus groups were conducted
across the country to learn more about the knowledge,
attitudes, and practices of this target audience as they relate
to how their visual impairment affects their lives and whether
they know about and access services and devices available.
Planning meetings were held with an ad hoc working group and
NEHEP Partnership members to define program messages and
strategies as well as to identify avenues to strengthen this
public-private partnership. Based on recommendations from these
groups, the following strategies will be utilized: (1) a broad-
based consumer media campaign; (2) an education kit with
resources for health care professionals, social service
organizations, and other groups to use in educating the target
audience; and (3) an outreach program, including traveling
exhibits, for both the general public and health care and
social service professionals that work with and serve older
adults. It is anticipated that the program will be launched
during FY2000.
National Library of Medicine
Seniors enter medical cyberspace
The National Library of Medicine (NLM), co-sponsored a
project to ``train trainers'' of senior citizens from around
the country in how to access health information on the
Internet. NLM coordinated the joint project with two other
components of the NIH--the National Heart, Lung, and Blood
Institute and the Office of Research on Women's Health--and the
HHS Health Care Financing Administration and the Office of
Disease Prevention and Health Promotion.
The project was administered by the SPRY (Setting
Priorities for Retirement Years) Foundation in Washington, D.C.
SPRY is a nonprofit national organization devoted to research
and education efforts on senior citizens health and retirement
issues.
The train-the-trainer project, consisted of a series of
intensive workshops for 21 trainers of senior citizens from a
dozen states (AZ, DC, FL, IA, MA, MD, MO, NC, NY, OH, PA, VA).
The program gave special emphasis to trainers from public
libraries, senior centers, and subsidized housing who work with
low income and minority seniors. After they participate in the
training in Bethesda, the trainers returned home to train a
minimum of 10 seniors per site. A multiplier effect is expected
to raise that number substantially as more and more senior
citizens find that they can retrieve valuable information about
their health.
Seniors cruise the net for health information
NLM joined the National Heart, Lung, and Blood Institute,
the Office of Research on Women's Health, and the Department of
Health and Human Service's Health Care Financing Administration
to release findings of a jointly sponsored project to ``train
trainers'' of senior citizens from around the country in how to
access health information on the Internet.
Results of the project indicate that training had a
positive impact on seniors' confidence in using computers and
the Internet, in conducting consumer health information
searches online, and in sharing health care information with
doctors, families and friends. The report also found that
seniors can learn to use the Internet and don't want to be left
behind on the information superhighway. Two-thirds of those who
searched for health information on the Internet talked about it
with their doctors, and more than half indicated they were more
satisfied with their treatment as a result of their search. The
findings suggest that the ``train the trainer'' approach may be
used successfully to enable older adults to access credible
medical information on the Internet.
The report, ``Internet Train-the-Trainer Program for Older
Adults,'' may be requested from the Library's Office of
Communications and Public Liaison.
Office of Research on Women's Health
In conjunction with the NIA, the Office of Research On
Women's Health (ORWH) supports a variety of studies through the
Research Enhancement Awards program including:
Functional decline in victimized older women
The specific aim of this research is to identify risk
factors for functional decline in an observational cohort of
urban community-dwelling older women who are followed for 12
months after experiencing violence or the threat of violence.
The long-term goal of this project is to develop intervention
strategies to prevent functional decline in victimized older
women based on identified risk factors.
Age, ethnicity and clinical trials participation
The goal of this research is to develop barrier models for
participation of older women, particularly minority older
women, in prevention clinical trials for heart disease and
breast cancer. The purpose is to improve recruitment strategies
to ensure greater participation by this under-represented group
of women in prevention clinical trials. The effects of
ethnicity will also be tested and added to the limited database
on the decision-making processes of older adults.
National Heart, Lung, and Blood Institute
Several research areas supported by the National Heart,
Lung, and Blood Institute (NHLBI) are closely entwined with
improving the health of older people. For example, heart
failure affects about 4.8 million Americans--3.4 million age 60
or older, and heart disease is a major health concern of
postmenopausal women. The following describes some recent
NHLBI-supported research results of special relevance to older
Americans.
Treatment for systolic hypertension in the elderly
Clinical trial results from the Systolic Hypertension in
the Elderly Program (SHEP) have revealed that treatment with a
low-dose diuretic antihypertensive drug cuts in half the risk
that an older person with isolated systolic hypertension will
develop heart failure. The study also found that treatment with
diuretics decreases the risk of heart failure even further--by
80 percent-- among individuals who have already had a heart
attack. Rates for both fatal and nonfatal cases of heart
failure dropped dramatically with treatment. Even patients aged
80 and older benefited from treatment. The potential public
health impact of these findings is considerable, because
millions of Americans over age 60 have isolated systolic
hypertension, and more than 3 million have blood pressure as
high as that treated in the SHEP trial.
Designer estrogens
Investigators have found that at least two independent
pathways exist by which estrogen can act on the blood vessels
in mouse models, and that a variety of estrogen-like compounds
produce different effects. Estrogen replacement therapy has
been recommended for postmenopausal women as a preventive
measure against heart disease, but it has unwanted side effects
such as a slightly increased risk of breast cancer and an
increase in deep-vein thrombosis. The research findings suggest
that it may be possible to develop specific ``designer
estrogens'' that could provide safe, acceptable protection
against heart disease while, at the same time, reducing or
eliminating unwanted and potentially costly health side
effects.
Lifestyle interventions to reduce blood pressure
The Trial of Nonpharmacologic Interventions in the Elderly
examined the extent to which weight control and reduction of
dietary sodium diminished the need for antihypertensive
medication in older patients. Researchers found that reducing
sodium intake by about 30 percent or losing an average of about
9 pounds reduced the need for drug treatment substantially; an
even greater benefit was derived from combining these two
strategies, and no adverse effects of either lifestyle
intervention were observed. These results, which indicate that
older patients can successfully change life-long habits,
provide strong impetus for programs using such approaches to
improve control of high blood pressure.
First estimate of lifetime risk for developing heart disease
The lifetime risk for developing coronary heart disease
(CHD) has been estimated for the first time by researchers at
the NHLBI Framingham Study. The risk is high at all ages: 50
percent of men and 33 percent of women aged 40 and under will
develop CHD. Even among those 70 years old, 33 percent of men
and 25 percent of women will develop CHD in their remaining
years of life. It is clear that to improve overall public
health, increased attention must be focused on this fast-
growing older segment of our population.
National Institute of Nursing Research
Americans expect to live longer than earlier generations,
but these additional years should be lived well--with health
and independence intact for as long as possible. Nursing
researchers are exploring interventions with this goal in mind
in order to preserve cognition and the ability to function, and
to maintain or improve quality of life.
The National Institute of Nursing Research (NINR) supports
studies that address these and other health issues of the older
population, including prevention of illness and disability;
health promotion strategies; management of the symptoms of
chronic diseases, including pain; interventions for family
caregivers to help them maintain their own health as well as
that of their ill relatives; and end-of-life issues to ensure
that dying patients receive compassionate and life-affirming
health care that promotes comfort and dignity.
Among the findings of FY 1997-98 are studies that help
older people recover after hospitalization for chronic
illnesses, such as heart attack and respiratory failure, and
that address end of life issues that promote comfort and
dignity throughout the dying period.
Older people with common medical and
surgical problems, who were discharged from the
hospital following treatment, realized a significant
improvement in their health at reduced costs to the
health care system. A study tested a transitional care
model using a multidisciplinary team. The model
involves comprehensive discharge planning, including
determination of patient care needs outside the
hospital, and follow-up in the home by advanced
practice nurses specializing in geriatrics. Findings
indicate that six months after discharge, only 20% had
multiple hospital readmissions versus 14.5% for
controls. Per-patient days in the hospital were fewer
for the group receiving transitional care--1.53 versus
4.09 for controls, and the costs of post-discharge
health services for the 177 patients in the group were
about $600,000 lower than for controls. When
considering the number of frail older people
hospitalized each year with similar conditions, the
potential benefits to the patient and savings to the
health care system could be substantial.
As the lead Institute to coordinate research
on end-of-life palliative care, NINR is committed to a
focus on improving interactions between the health care
system and those who are dying. Multidisciplinary
research led by an NINR scientist has explored what
patients and families want and expect in end-of-life
care. The investigator found that families in the study
whose relatives were dying in hospitals were willing to
stop aggressive treatment if the condition was terminal
and if they believed high quality comfort care would be
provided. They reported that in the last week of life,
their relatives had more pain and other physical
distress than the health care team realized. They also
expressed concern about the views of some health care
professionals that death is a medical failure. Patients
without adequate health insurance were found to lack
access to good palliative care and were likely to
require expensive hospitalization for symptoms that
could have been managed by hospice or home-health
nurses. These research results help guide current and
future NINR research directions in management of pain
and other physical stressors, caregiving training,
bioethical issues and the decision-making processes of
patients, their families, and clinicians.
National Center for Research Resources
The National Center for Research Resources (NCRR) creates,
develops, and provides a comprehensive range of human, animal,
technological, and other resources to enable biomedical
research advances in aging research. NCRR serves as a
``catalyst for discov-
ery'' for NIH-supported investigators by supporting resources
in four areas: Biomedical Technology, Clinical Research,
Comparative Medicine, and Research Infrastructure.
Conversion of electron microscope images to three-dimensional
structures
Using an intermediate high-voltage electron microscope and
a massive parallel supercomputer, investigators at an NCRR-
supported microscopy and imaging research center at the
University of California, San Diego, have devised a method to
derive three-dimensional structures from electron microscopy
images. With the electron microscope, researchers obtained
images of tissue specimens at various depths from the surface,
roughly comparable to cutting a sausage in thin slices. After
converting the stack of ``slices'' to computer-readable data,
the supercomputer used a process called electron tomography to
derive a three-dimensional image from the multilayer flat
images. Used in conjunction with other advanced tools, electron
tomography provides unprecedented details of structures inside
cells. The new method may provide fresh approaches to detect
and treat Alzheimer's and Parkinson's diseases as well as other
diseases that involve buildup of harmful structures inside
cells.
Scientists home in on gene for age-related sight loss
By studying a large family affected by macular
degeneration, NCRR-supported researchers at the Oregon Health
Science University have homed in on the location of a gene that
causes this inherited form of eye disease. Millions of
Americans suffer gradual fading of central vision known as age-
related macular degeneration and 7 percent of those older than
75 have progressed to the late stage of this disease. This
research will help develop tools for early detection and
ultimately lead to treatments than can eliminate the disease.
Estrogen replacement and blood pressure in postmenopausal women
Coronary heart disease (CHD) is the leading cause of death
for women in the United States, responsible for one-quarter
million deaths each year. One in nine women who are between 45
and 65 years old has clinical evidence of CHD, but one in three
women older than 65 years has CHD. Although there is a
significant risk reduction for CHD in postmenopausal women
receiving estrogen replacement therapy, estrogen's effect on
blood vessel stiffness--a contributing factor to hypertension--
and blood pressure sensors in blood vessels was unknown. Now
researchers at the NCRR-supported General Clinical Research
Center at Columbia University have shown that short-term
estrogen treatment decreased vascular stiffness and increased
the sensitivity of the pressure receptors, producing
significantly lower blood pressure both during rest and during
isometric exercise. These findings provide a basis for better
treatment of cardiovascular risk factors in older women.
Vitamin D deficiency
A study of 290 patients at an NCRR General Clinical
Research Center in Boston found that more than half had too
little vitamin D in their bodies. Vitamin D deficiency, common
among older people, can lead to fractures and can also
exacerbate arthritis, affect immune function, and lead to
muscle weakness and a bone condition called osteomalacia. This
study supports other scientific evidence that most people
should take vitamin D supplements.
Slowing progression of Alzheimer's disease
In a multicenter trial involving several NCRR-supported
General Clinical Research Centers, researchers studied whether
treatment to reduce accumulation of free radicals would slow
progression of Alzheimer's disease. More than 300 patients with
moderately severe Alzheimer's disease received the antioxidants
selegiline, vitamin E, a combination of the two, or a placebo
daily for two years while being monitored for disease
progression. Compared to those receiving placebo, the time to
severe disease deterioration was prolonged by 150 to 200 days
in patients receiving antioxidant treatment.
Early diagnosis of Parkinson's disease using SPECT imaging
Destruction of dopamine-producing nerve cells is a
principal cause of Parkinson's disease, which affects about one
million Americans, according to the American Parkinson Disease
Foundation. Using nonhuman primates, scientists at the NCRR-
supported New England Regional Primate Research Center have
discovered a chemical that selectively binds to dopamine
transporters and can be detected using a novel imaging
procedure--single-photon emission computer tomography. This
procedure can diagnose Parkinson's disease much earlier than
before by measuring the level of the chemical that transports
dopamine in nerve cells.
Pathology of aging in rhesus macaques
For 14 years, a researcher at the NCRR-supported Wisconsin
Regional Primate Research Center evaluated the causes of death
of 175 macaques aged 20 to 37. His research showed that while
these macaques lived in controlled and sheltered environments,
they still died of many of what are considered the most common
human geriatric diseases, including colon cancer, hardening of
the arteries, and brain plaques similar to Alzheimer's.
According to his research, the diseases appear to be brought on
by old age and predisposing genetic factors, versus
environmental or lifestyle factors.
National Human Genome Research Institute
The National Human Genome Research Institute (NHGRI) funds
a project to address the ethical and policy issues regarding
current genetic susceptibility testing for late-onset Alzheimer
disease (AD). It also addresses ethical aspects of ongoing gene
testing in families with early-onset AD. The project's
Community Advisory Board and National Study Group will take up
the following tasks: examine current testing developments in AD
genetics, their pre-symptomatic applicability, and clinical
usefulness; consider costs of testing, potential testing pool,
and justice in access to testing; address potential impact of
susceptibility testing on private long-term care insurance
industry; develop ethics guidelines for the use of
susceptibility tests that detect a form of the apolipoprotein
(ApoE) gene; develop ethics guidelines for the use of tests
that detect an alteration in the amyloid precursor protein
(APP) gene; and develop recommendations for the Alzheimer's
Association in ensuring public understanding of test
developments. In addition, a pilot questionnaire study of
population attitudes toward ApoE susceptibility testing, to be
implemented in Chicago, is included. This project is conducted
in collaboration with the national Alzheimer's Association.
NHGRI also funds efforts to create the tools and
infrastructure to locate genes contributing to human disease.
These efforts often focus on diseases that may affect people in
later life, such as Alzheimer's disease, heart disease,
diabetes, and many common cancers such as prostate and breast
cancer. The Center for Inherited Disease Research (CIDR),
located on the Bayview campus of Johns Hopkins University,
supports disease research by providing high-throughput
genotyping services, study design advice, and sophisticated
database assistance to research efforts attempting to identify
genetic loci and allelic variants. CIDR is a joint effort by
eight NIH institutes: National Cancer Institute (NCI); National
Institute of Child Health and Human Development (NICHD);
National Institute on Deafness and Other Communication
Disorders (NIDCD); National Institute on Drug Abuse (NIDA);
National Institute of Environmental Health Sciences (NIEHS);
National Institute of Mental Health (NIMH); National Institute
of Neurological Disorders and Stroke (NINDS); and the National
Human Genome Research Institute (NHGRI) serving as the lead. A
more complete description of CIDR, including application
procedures, is available at: http://www.cidr.jhmi.edu/
National Institute on Deafness and Other Communication Disorders
Hearing loss
Presbycusis, the late onset of progressive hearing loss, is
one of the most common health problems in the elderly. Hearing
loss of at least 25 decibels occurs in only 1 percent of young
adults between 18-24 years of age; however, this figure
increases to 10 percent of individuals between 55-64 years of
age and to approximately 50 percent in octogenarians.
Scientists supported by the National Institute on Deafness and
Other Communication Disorders (NIDCD) are examining the
underlying molecular and cellular events that lead to the loss
of hearing function with age. By characterizing age-related
alterations in the inner ear, scientists will foster the
development of a rationale for designing pharmacological gene-
mediated therapies for some forms of hearing impairment,
including presbycusis.
Stroke
NIDCD-supported scientists are taking a cross-linguistic
approach to language development, language processing, and
language breakdown in aphasia. Aphasia is a language disorder
that results from damage to portions of the brain that are
responsible for language; it usually occurs suddenly,
frequently the result of a stroke or head injury. The disorder
impairs both the expression and understanding of language as
well as reading and writing. For centuries, language was
believed to be a fixed, special-purpose ``organ'' that is
neatly localized in one or two well-defined parts of the left
side of the brain. Studies of patients with aphasia and other
types of disorders of language function are revealing that
language is a plastic, broadly distributed, dynamic system that
is organized in time as well as space. These studies are
valuable in developing the highest level of function and
communication for persons with aphasia.
Using functional magnetic resonance imaging (fMRI), NIDCD-
supported investigators have documented reorganization of brain
activity after treatment for acquired reading disorders
following a stroke. fMRI performed during a reading task before
and after treatment indicated a shift in brain activation from
one area of the brain to another, showing that it is possible
to alter brain activity patterns with therapy for acquired
language disorders.
Additionally, stroke or head injury may affect the
coordination of the swallowing muscles or limit sensation in
the mouth and throat. NIDCD supported-scientists are conducting
research that will improve the ability of physicians and
speech-language pathologists to evaluate and treat swallowing
disorders.
National Institute of Arthritis and Musculoskeletal and Skin Diseases
Researchers supported by the National Institute of
Arthritis and Musculoskeletal and Skin Diseases (NIAMS) use
powerful research tools to acquire and apply new knowledge to
studies on some of the most challenging diseases affecting
older Americans today. Many of these diseases have troubled
patients and their health care providers for decades, but each
year significant discoveries have brought researchers closer to
fully understanding, diagnosing, treating, and ultimately
preventing these common, crippling, costly, and chronic
diseases, which greatly compromise quality of life. These
disorders include the many different forms of arthritis and
numerous diseases of joints, muscles, bones, and skin.
Osteoarthritis
Osteoarthritis, the most prevalent disease of the joints,
is characterized by progressive degeneration of the cartilage,
primarily affecting the hip and knee joints. It is predicted
that osteoarthritis will affect at least 70 percent of the
population over 65. In a clinical trial funded by the NIAMS and
the NIA, researchers began studying the effects of the
antibiotic doxycycline on osteoarthritis. Certain antibiotics,
such as doxycycline, inhibit the enzymes that degrade
cartilage. The NIAMS also started an initiative to study the
biological responses of cartilage and bone to various
mechanical forces and how those responses affect the onset and
progression of osteoarthritis.
Rheumatoid arthritis
NIAMS researchers and their colleagues studied rats with an
autoimmune inflammatory arthritis that resembles human
rheumatoid arthritis. Through genetic analyses of rats with
different disease susceptibilities and severity, they found
that the genetic basis in the inflammatory arthritis bore a
striking similarity to what is known about the genetics of
rheumatoid arthritis. Multiple genes are involved in both
diseases making it more complicated for researchers to reveal
the causes of the disease and design effective therapies. The
researchers located several of the particular genes that affect
arthritis susceptibility and severity in rats. One of these
genetic loci has been previously linked to other autoimmune
diseases and may play a role in the phenomenon of autoimmunity.
The NIAMS began support for the North American Rheumatoid
Arthritis Consortium to comprehensively study the genetic
aspects of rheumatoid arthritis in a national project involving
800 sibling pairs affected with rheumatoid arthritis.
The Institute also issued a Request for Proposals to
encourage studies of technology and methodology of gene therapy
relating to arthritis and skin diseases. Finally, the NIAMS
took the initiative in developing a roundtable forum of major
participants interested in rheumatoid arthritis and
osteoarthritis: the NIH, the FDA, and representatives from
industry, academia, and voluntary and professional groups.
Osteoporosis
Osteoporosis, a disease characterized by low bone mass and
structural deterioration of bone tissue, is the leading cause
of bone fractures in postmenopausal women and older people in
general. The NIAMS cosponsored the NIH Postmenopausal Estrogen/
Progestin Interventions trial that reported that postmenopausal
women taking hormone replacement therapy gained significant
amounts of bone mass at the hip and spine. In other work,
investigators showed that estrogen induces ``programmed cell
death'' in the cells (osteoclasts) responsible for bone
degradation, and that supplemental calcium prevents spine
fractures in elderly women.
The NIAMS also partnered with other NIH Institutes in
issuing a Program Announcement for the study of the basic
biology, epidemiology, prevention, and treatment of
osteoporosis and osteoporosis-related fractures in men.
National Institute of Mental Health
The National Institute of Mental Health (NIMH) program of
research on aging includes studies in the basic sciences as
well as research in neurobiology and brain imaging, clinical
neuroscience, treatment assessment, psychosocial and family
studies, and service systems research. Studies involve mental
disorders with initial occurrence in late life as well as
illnesses that begin in early adulthood but continue throughout
the life course. Major areas of research focus are the
psychiatric aspects of Alzheimer's disease and related
dementias, depressive disorders, schizophrenia, anxiety
disorders, and sleep disorders.
Alzheimer's disease
An estimated 4 million Americans age 65 and older suffer
from Alzheimer's disease or other forms of dementia. An
important area of NIMH research on Alzheimer's disease focuses
on genetic factors. NIMH-supported researchers recently
identified a new gene mutation strongly associated with the
risk of developing late-onset Alzheimer's disease, the most
common form of the brain disorder. Using the NIMH Genetics
Initiative Alzheimer's disease sample (a collection of DNA
samples and clinical information from hundreds of families in
which more than one individual has Alzheimer's), and new
methodology, the researchers found that a particular gene
mutation, alpha-2 macroglobulin-2 (A2M-2), was significantly
associated with Alzheimer's. The finding, if replicated, will
offer important clues into the disease process and will help
discern the role of additional genetic and environmental
factors involved in creating vulnerability to the disease.
Depression
Nearly 5 million of the 32 million Americans age 65 and
older suffer from depression. Significantly, many late-life
depressions are amenable to treatment. Recent NIMH-supported
studies provide important information relevant to depression
treatment in the elderly. One study compared treatment response
among elderly depressed patients who had their first depressive
episode early in life and those whose first episode occurred at
age 60 or older. Although age at onset did not affect overall
efficacy of treatment, patients who had experienced their first
depressive episode early in life took 5-6 weeks longer to reach
remission. This slower treatment response, combined with the
increasing rates of suicide among the elderly, particularly
among males, indicates that elderly depressed patients with
early-onset illness need particularly careful management.
Another study found that a combination of pharmacotherapy
and psychotherapy is extremely effective in preventing
recurrence of depression among the elderly. Older adults who
received interpersonal therapy and an antidepressant medication
during a three-year period were much less likely to experience
recurrence than those who received medication only or therapy
only. Positive long-term outcome, however, was less durable in
individuals above age 70 than in those below this age.
Suicide
Older Americans are disproportionately likely to commit
suicide. Comprising only 13 percent of the population, they
account for 20 percent of all suicide deaths. The rate of
suicide is particularly striking among white males aged 85 and
older: in 1996, the most recent year for which statistics are
available, the rate in this group was 65.4 per 100,000--about
six times the national U.S. rate of 10.6 per 100,000.
Researchers interviewed families and associates of elderly
individuals who committed suicide to determine the state of
mind of such individuals just prior to their suicide. The
investigators concluded that major depression was the sole
predictor of suicide in this study population. At least 70
percent of those who committed suicide had visited primary care
providers within a month of the suicide. The findings point to
the urgency of enhancing both the detection and adequate
treatment of depression in primary care settings as a means of
reducing the risk of suicide among the elderly. NIMH is
currently funding a multi-site study in the elderly to test the
effectiveness of an intervention aimed at improving the
recognition of suicidal ideation and depression by primary care
providers.
National Institute of Dental and Craniofacial Research
The National Institute of Dental and Craniofacial Research
(NIDCR) is interested in structures and functions of the
craniofacial complex which are critical throughout the human
lifespan. This is evident in behaviors that range from the most
basic necessary to sustain life to the complex behaviors
encompassing interpersonal communication. For example, both the
cleft lip or palate that is frequently found in infants with
craniofacial birth defects and the lack of saliva that
accompanies Sjogren's syndrome in older adults, pose threats to
both normal feeding and speaking behaviors.
Oral and pharyngeal cancer
Ninety five percent of oral cancer cases are diagnosed in
individuals older than 40 years of age, with an average age at
diagnosis of 60 years. Recent NIDCR-sponsored findings have
increased knowledge of tumor suppression mechanisms for oral
cancers. Understanding the genetic basis for cancers afflicting
the head and neck provides the opportunity to develop new
diagnostics and preventive strategies.
Salivary gland dysfunction
Many older Americans are affected by salivary gland
dysfunction which can result from cancer therapy, Sjogren's
syndrome, and treatment with any of the more than 500 drugs
known to impair salivary function. Oral dryness interferes with
normal functions of talking, chewing and swallowing and,
deprived of the protective properties of saliva, puts patients
at high risk for dental and oral infections. NIDCR scientists
have developed an animal model of gene therapy to restore
salivary gland function and work on developing an artificial
salivary gland is in progress.
Bone and hard tissues
NIDCR has a long history of support for research on bone
and hard tissues. A new mouse model of osteoporosis, developed
by NIDCR scientists, provides a means to test new therapies for
prevention of osteoporosis. In addition, recent findings on
bone morphogenetic proteins (BMPs) and cartilage-derived
morphogenetic proteins (CDMPs) offer promise for therapeutic
regeneration of bone and cartilage tissue.
Pain
It is estimated that about 22 percent of adults have
experienced some form of orofacial pain within the last 6
months. Orofacial pain is a major component of Bell's palsy,
trigeminal neuralgia, fibromyalgia, and diabetic neuropathy. A
recently developed animal model of gene therapy to stimulate
production of beta-endorphins may form the basis of a future
treatment for chronic pain conditions.
Arthritis
It is projected that by the year 2020, nearly 60 million
Americans will experience some form of arthritis. Using ``naked
DNA'', NIDCR scientists have developed an animal model of gene
therapy for arthritis. They observed dramatic reductions in
inflammation and joint degeneration in arthritic rats.
National Institute of Diabetes and Digestive and Kidney Diseases
The National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK) supports basic and clinical research in
several major diseases that disproportionately afflict older
Americans. Several major research initiatives are yielding
advances in the understanding and treatment of these
debilitating disorders.
Diabetes
The risk of type 2 diabetes, the most common form of this
devastating disease, rises dramatically in middle age and takes
a major toll on older people. Of the nearly 15 million
Americans who have type 2 diabetes, 6.3 million are age 65 or
older. Among Americans age 65 and older, 18.4 percent have
diabetes, with the highest prevalence in minority groups.
The most important risk factors for type 2 diabetes are
obesity, insulin resistance, physical inactivity, impaired
glucose tolerance, and a history of gestational diabetes or a
family history of diabetes. The Diabetes Prevention Program, a
clinical trial taking place in 26 medical centers nationwide,
seeks to determine whether type 2 diabetes can be prevented
with diet and exercise or medication. The study will find out
whether lowering blood sugar levels in people with impaired
glucose tolerance (IGT) can prevent or delay development of
type 2 diabetes. People with IGT, a precursor to diabetes, have
high blood sugar but not high enough to be diagnosed as having
diabetes. The study has nearly completed its recruitment goal
of 3,000 volunteers.
NIDDK also supported a multicenter clinical trial in
patients with type 2 diabetes, the United Kingdom Prospective
Diabetes Study, that recently demonstrated the importance of
good blood sugar control in slowing the, eye, nerve, and kidney
damage caused by diabetes. These findings reinforce the results
of the nationwide Diabetes Control and Complications Trial,
which showed similar benefits in type 1 diabetes.
Type 2 diabetes is a multifactorial disease with a
significant genetic component. A genetic mutation has been
implicated in a rare form of type 2 diabetes called Maturity-
Onset Diabetes of the Young (MODY), but the vast majority of
type 2 cases follow a complex pattern of inheritance, and the
genes underlying most cases remain elusive.
Scientists supported by NIDDK are making major gains in
understanding the genetic factors that control both pancreatic
development and insulin secretion, and such research may lead
to ways of producing insulin-secreting cells that could be
transplanted into patients with diabetes. Recently, the NIDDK
issued a Request for Applications to encourage research in this
area.
Renal disease
Kidney disease of diabetes mellitus; (KDDM) is the single
most common cause of end-stage renal disease. Several avenues
of NIDDK research are approaching the problem of how KDDM
develops and how it might be arrested before serious organ
damage occurs. Results of a major NIDDK-supported clinical
trial indicate that a heart medication used to control high
blood pressure can significantly slow the progression of KDDM.
End-stage renal disease (ESRD) is a major public health
problem whose incidence has doubled in individuals aged 65-74
and more than doubled in those over 75 years of age in the last
decade. A major cause of ESRD in the elderly is hypertension.
The Institute is currently supporting a multicenter clinical
trial, ``The African American Study of Kidney Disease and
Hypertension,'' that will help determine the treatment most
likely to retard progression of hypertensive kidney disease.
In addition, a recently completed five-year study of the
U.S. Renal Data System (USRDS), the Dialysis Morbidity and
Mortality Study, will help clarify what causes excessively high
rates of illness and death among elderly ESRD patients. The
Hemodialysis Clinical Trial is addressing the effects of
increased dialysis dose as well as the effects of high-flux
dialysis in treating elderly dialysis patients.
Osteoporosis
Parathyroid hormone (PTH), an important regulator of bone
metabolism, may have potential benefits for the treatment of
osteoporosis, a major public health problem that inflicts
significant pain and disability in older people. Therapeutic
use of glucocorticoid hormones such as prednisone causes a
severe form of osteoporosis. Last year, a small-scale clinical
trial in women with osteoporosis due to long-term use of
glucocorticoids showed that treatment with PTH resulted in
increased bone mineral density in the lumbar spine, hip, and
arm. Another small trial in young women with estrogen
deficiency as a result of treatment for endometriosis showed
that PTH administered once a day for a year increased bone
mineral density in the spine, while stopping loss of bone
mineral in other bones including the hip and arm. These
preliminary findings raise the hope that PTH administration may
have therapeutic value for people with osteoporosis.
Prostate disease
Prostate diseases affect over 2 million American men. NIDDK
is studying the genes and other factors that may affect
prostate growth and prostate cancer. The Institute currently
supports five George M. O'Brien Urology Research Centers, three
of which are dedicated to studying benign and malignant
prostate cell growth and the mechanisms that regulate the
expression of prostate specific antigen (PSA) and tumor
progression. The Chronic Prostatitis Collaborative Clinical
Research Study is a large multicenter trial designed to gather
specific clinical information on prostatitis that will allow
testing and evaluation of new treatments for this problematic
disorder.
Enlarged prostate or benign prostatic hyperplasia (BPH)
affects more than 50 percent of men past age 60 and 80 to 90
percent of men past age 80. NIDDK supports basic research on
prostate cell structure and function in BPH, biomarkers of BPH,
and prostate stem cells and stem cell genes. Clinical research
focuses on a major multicenter clinical trial. The Medical
Therapy of Prostatic Symptoms (MTOPS) study is assessing the
effectiveness of two different drugs in preventing the
progression of symptomatic BPH.
National Institute of Child Health and Human Development
The National Institute of Child Health and Human
Development (NICHD) supports a broad research portfolio that
has far-reaching implications for the entire human lifespan.
Listed below are examples of the Institute's initiatives on
aging-related research highlighting major studies in a range of
important topics.
In keeping with the Institute's commitment to advancing
women's reproductive health, the NICHD is supporting research
on the effects of maternal aging on the process of meiosis in
the human oocyte. Women attempting to reproduce beyond their
prime reproductive years often experience an increased
incidence of ``nondisjunction'' (failure of chromosomes to
separate) in their oocytes. Recent advances in molecular
cytogenetics permit researchers to identify the specific
chromosomes that most frequently separate improperly. Continued
research in this area will provide information on the
mechanisms responsible for the effect of maternal aging on
reproduction. Since more women are attempting to become
pregnant later in life, studies within this area can lead to
strategies to foster healthy pregnancies in women as they age.
The transition to menopause encompasses a wide ranging set
of changes for women. In this area, NICHD-supported scientists
are conducting a range of research:
Biodemographic models of reproductive aging
in women are being developed. This work offers a unique
opportunity to explore women's transition to menopause
by linking it to their prior menstrual, reproductive,
and health-related histories. Research will yield new
insight into the patterns and causes of variation in
women's experience of the menopausal transition and
will provide a foundation for future epidemiological
studies of the health consequences of different
patterns of reproductive aging.
Uterine fibroids (leiomyomata), benign
tumors of smooth muscle cells and fibrous connective
tissues that develop within the wall of the uterus, are
responsible for approximately 200,000 hysterectomies in
the U.S. each year. When women with fibroids reach the
perimenopausal or postmenopausal periods, they face a
troubling treatment dilemma. If they wish to preserve
their uterus, they may change the risk of increasing
fibroid growth by taking hormone replacement therapy
(HRT) during this time period. Yet, the benefits of
using HRT are substantial, particularly for women at
risk for cardiovascular disease or osteoporosis. The
NICHD is supporting a randomized controlled trial to
investigate the extent to which a commonly prescribed,
low-dose, HRT regimen stimulates fibroid growth and
proliferation in both Black and White postmenopausal
women. The results of this study will be of significant
value to a growing number of fibroid patients reaching
menopause and the clinicians who treat them.
Physical disability is one of the most prevalent major
health problems in the aging population, and the associated
need to enhance our scientific understanding of medical
rehabilitation is great for all age groups, particularly the
elderly. As the home to the National Center for Medical
Rehabilitation Research, the NICHD is sponsoring research on
the following:
Researchers are trying to identify the major
risks and other factors associated with physical
disability, the use of medical services, and the
subsequent costs of care. A major goal is to assess
trends and changes in these factors as individuals
progress from young adulthood through old age.
Researchers are trying to develop treatments
that can substantially reduce the incapacitating motor
deficit of many elderly stroke patients and improve
their independence. In particular, scientists are
developing a technique to strengthen the upper limbs of
stroke patients. The goal is to find a way to improve
motor function, amount of limb use, and range of motion
shortly following and in the long term after a stroke.
Through continuing and innovative work under
a Small Business Innovation Research Grant,
investigators have developed a new approach to correct
urinary incontinence. This condition affects more than
13 million people in the U.S. and costs the health care
system over $ 10 billion per year. Using recombinant
DNA technology, scientists have developed special
polymers that, when injected around the urethra,
effectively strengthen the damaged muscles found in
patients with stress incontinence. This discovery holds
tremendous promise for restoring independence and
improving the quality of life for millions of men and
women, particularly elderly women who may experience
incontinence due to estrogen loss in menopause.
The prevention of osteoporosis, a disease that is most
prevalent in older women, is dependent upon maximizing peak
bone mass and minimizing subsequent bone loss during childhood
and adolescence. NICHD research in this area includes a number
of studies, including the following:
Scientists are investigating the influence
of calcium supplementation using dairy products and
skeletal loading on bone mineral accretion in the
preadolescent. In particular, researchers are
investigating the effect of a school-based exercise and
calcium intervention program on bone accrual at the
lumbar spine, at the proximal femur and for the total
body, in a group of elementary school children.
Researchers are conducting genetic linkage
analyses in seven families to help identify a region on
their chromosome that could account for low bone
mineral density. This study will define the importance
of two genes that effect the inheritance of bone
density, and will provide the basis for susceptibility
testing in the population.
Dementia is a condition commonly associated with aging.
Early diagnosis and improved knowledge about the etiology of
dementia are important in developing improved and appropriate
interventions. In this area, the NICHD, with its research
targeting mental retardation and developmental disabilities is
focusing on Down syndrome (DS). Although adults with DS are
believed to be at increased risk for dementia of the
Alzheimer's type, the natural history of dementia in these
individuals is not well understood. Researchers are comparing
adults with DS and with other forms of mental retardation to
better understand the differences and similarities in their
neuropsychological and behavioral function. Results from this
study will contribute to improved diagnosis, treatment and
prediction of risk for dementia.
National Institute on Neurological Disorders and Stroke
The National Institute of Neurological Disorders and Stroke
(NINDS) supports major research programs on a number of nervous
system disorders such as Parkinson's disease, Alzheimer's
disease, and stroke that occur over the course of the lifespan
but that increase in incidence with age.
Parkinson's disease
Parkinson's disease research focuses on many areas. Some
investigators are studying the functions and anatomy of the
motor system and how it regulates movement and relates to major
command centers in the brain. Scientists looking for the cause
of Parkinson's disease will continue to search for possible
environmental factors, such as toxins that may trigger the
disorder, and to study genetic factors to determine which
defective genes play a role. While genetic defects have been
identified that cause Parkinson's in some families, the search
for new genes will continue through FY 1999 in response to an
NINDS program announcement on the genetics of Parkinson's
disease. For the great majority of patients under 50 years of
age, the origins of the disease are genetic; for those over 50,
genetic factors are not significantly important. Understanding
the genetic forms of the disease will help scientists
understand the mechanisms of action in the brain which cause
Parkinson's symptoms to appear.
Another major approach focuses directly on the study of
cell biology. To capitalize on the genetic gains, whole new
areas of research techniques are being used by NINDS grantees,
including making transgenic mice that often mimic the clinical
disease, using yeast two-hybrid systems to identify interacting
proteins, and investigating pathological functions or related
proteins in simple organisms. Further work to clarify the role
of Lewy bodies, alpha-synuclein and other proteins, and to
determine their relation to the disease, has begun.
NINDS intramural scientists are studying the regulation of
brain receptors for dopamine. The ability to regulate these
receptors on cells grown in culture will allow more efficient
screening of experimental drugs for Parkinson's disease,
resulting in more effective treatments with fewer side effects.
NINDS intramural scientists are also studying several
alternative non-dopaminergic drugs that would mimic the actions
of dopamine, targeting the specific dopamine receptors involved
in Parkinson's disease, but avoiding the receptors involved in
the negative side effects now experienced by nearly half of the
patients receiving levodopa.
NINDS grantees are currently conducting five therapeutic
trials to determine the efficacy of several interventions,
including: the surgical implantation of fetal tissue:
pallidotomy for advanced Parkinson's disease; the effects of
coenzyme Q10 in early disease; and the effects of earlier or
later administration of levodopa. The NINDS Intramural Division
is also conducting several clinical studies on Parkinson's
disease. The NINDS Experimental Therapeutics Branch is
conducting follow-up clinical studies to investigate the
neuroprotective effect of a new free radical scavenger, OPC-
14117. NINDS scientists are investigating the mechanisms of
cell death in the substantia nigra and are seeking ways to
successfully interdict this process. They are also studying the
mutated form of synuclein that triggers cell death, and the
transcription factors that stimulate the premature death of
dopamine cells. NINDS is supporting both intramural and
extramural studies to evaluate the results of surgical
implantation of deep brain stimulators.
Attempts to replace doparnine cells by transplantation of
fetal tissue are also ongoing; this procedure has provided
benefits to at least some patients. Transplants of cultured
cell lines and stem cells should eventually replace fetal
tissue with further study.
With NINDS support, two new genes have been identified that
provide clues to the pathogenesis and mechanisms of Parkinson's
disease. One gene carries the blueprint for a protein called
alpha-synuclein, earlier identified as one of the components of
``amyloid plaques,'' the abnormal clumps of proteins in the
brains of Alzheimer's patients. Under NINDS and NHGRI
sponsorship, scientists are now pursuing this lead to discover
the role of synuclein in Parkinson's disease and to find other
defective genes that may contribute to Parkinson's disease in
other families.
In another follow up study, scientists demonstrated that
synuclein is found in Lewy bodies of the most common, non-
inherited form of Parkinson's disease. Lewy bodies are abnormal
clumps of material in certain parts of the brain that are a
hallmark of Parkinson's disease and are also found in certain
other diseases. This finding supports the idea that inherited
Parkinson's disease may provide insights about the more common
forms of the disease. The finding also complements a growing
body of evidence that abnormal aggregations of proteins, such
as those found in Lewy bodies of Parkinson's disease, amyloid
plaques of Alzheimer's, and the ``nuclear inclusions'' in
Huntington's disease, are not just disease markers but actively
harmful in damaging the brain. Stopping or slowing the
formation of these aggregations may present an entirely new
approach to preventing the death of brain cells in
neurodegenerative diseases.
NINDS-supported scientists and their collaborators have
shown that a growth factor derived from glial (supporting)
cells of the nervous system (GDNF) supports and protects
dopamine neurons in vivo. They have also demonstrated that
recombinant GDNF has similar effects. This growth factor
preserves cells from destructive effects and repairs cells
after damage.
Intramural NINDS scientists found that when the
experimental drug Ro 40-7592 is added to the standard drug
treatment for Parkinson's disease, levodopa-carbidopa, symptom
relief is prolonged by more than 60 percent. This promising new
drug that blocks the breakdown of dopamine and levodopa would
allow patients to take fewer doses and smaller amounts of
levodopa-carbidopa and to decrease the problems of the wearing-
off effect. Ro 40-7592 was approved by the Food and Drug
Administration and is now available for physicians to prescribe
for their Parkinson's patients.
NINDS and the NHGRI sponsored a workshop on the genetics of
Parkinson's disease in December, 1997, at Cold Spring Harbor
that has continued to spark research interest. Encouraged by
the workshop, additional work is being focused on understanding
the products and processes that are affected by the genes
involved in familial, and perhaps other, forms of Parkinson's
disease.
Stroke
The NINDS supports a large number of basic and clinical
studies on stroke. This research program includes
investigations of stroke risk factors, especially those that
are treatable; genetic causes of stroke; the biology and
pathology of certain brain cells involved in stroke; the events
that damage and kill nerve cells in the minutes and hours
following a stroke and the brain's reaction to them; and the
cellular and molecular interactions among blood, cerebral
vessel and brain cells involved in stroke. Other studies are
looking at brain imaging to improve diagnosis; the use of
targeted protective agents for compromised cells; and ways to
isolate, purify, and characterize neuropeptides that confer
tolerance to hypoxia and ischernia. Studies to identify
potential new treatments and clinical trials of surgical and
medical methods to prevent stroke are also a major part of the
NINDS stroke research program.
Additional studies to find ways to facilitate recovery of
function; determine the points at which reversible and
irreversible damage occur; identify the fundamental biochemical
processes that may lead to DNA damage and repair in the brain;
determine the role of angiogenesis in CNS cell and tissue
survival; and find growth and trophic factors that can
accelerate the repair and recovery of specific types of neurons
are also being supported.
Several major clinical trials are either ongoing or have
recently been completed. They include:
The North American Symptomatic Carotid
Endarterectomy Trial (NASCET). This trial is attempting
to determine whether surgery (carotid endarterectomy)
can prevent stroke in selected patients who have had a
stroke or experienced warning signs of stroke. In 1998,
this study determined that, for symptomatic patients
with stenosis in the 50-69% range, surgery may be
worthwhile.
Carotid Stenting. Carotid endarterectomy,
whether done in symptomatic or asymptomatic patients,
has a low but important rate of serious complications,
including stroke and death. A new method has been
developed for treating carotid stenosis through less
invasive angiographic techniques using metallic stents
to hold the vessel open after the stenosis has been
expanded from within the arterial system. A planned
trial will compare carotid angioplasty and stenting to
the standard endarterectomy, which has been shown to be
effective for many patients in the NASCET and earlier
ACAS trials.
Aspirin and Carotid Endarterectomy (ACE).
The purpose of this trial was to determine if aspirin
reduces surgical complications from carotid
endarterectomy. Patients received one of four daily
doses of aspirin, and were followed for 3 months after
surgery to record all strokes, deaths, and changes in
functional status. The results of the study indicated
that aspirin did not have a major effect on the outcome
of this form of surgery.
NINDS Stroke Trial. This trial determined
that, if tissue plasminogen activator (t-PA) is
administered within three hours of the onset of the
more common form of stroke, there is a 33 percent
increase in the number of patients that are free of
disability three months post-stroke. The trial also
showed that effective treatment can be carried out in a
variety of health care settings. The findings were so
convincing that the FDA approved t-PA in 1996 for the
emergency treatment of ischemic stroke six months after
the clinical trial results were published.
Trial of Org 10172 in Acute Stroke Treatment
(TOAST). For many years, it has been common practice to
administer anticoagulants such as heparin to patients
immediately after a stroke in an effort to limit brain
injury and to prevent recurrent strokes. However, this
study showed that, for most patients, this therapy may
not work. These results may bring about a change in the
way the medical community treats stroke.
Warfarin Antiplatelet Recurrent Stroke Study
(WARSS). This is an ongoing study to find out whether
warfarin or aspirin is more effective in preventing a
second stroke in persons who have had a prior ischemic
stroke.
Antiphospholipid antibodies and stroke study
(APASS). APASS investigators are studying the blood
levels of anti phospholipid antibody (aPL) in patients
to see if it is a cause of ischemic stroke.
Stroke Prevention in Atrial Fibrillation III
(SPAF). The initial NINDS Stroke Prevention in Atrial
Fibrillation (SPAF) study was launched to evaluate the
effectiveness of aspirin and warfarin to prevent an
initial stroke in patients with atrial fibrillation, a
common type of irregular heartbeat associated with an
increased risk of stroke. Results from the study
revealed that both drugs were so beneficial that the
risk of stroke was cut by 50 to 80 percent. The results
suggested that 20,000 to 30,000 strokes could be
prevented each year with proper treatment. The SPAF
study was continued to determine long-term effects from
treatment and to determine the relative benefits of
warfarin compared to aspirin. Results showed that a
daily adult aspirin can provide adequate stroke
prevention for many of the people with atrial
fibrillation. For most people with atrial fibrillation
under 75 years old, and for those over 75 with no
additional stroke risk factors such as high blood
pressure or heart disease, aspirin provided adequate
protection with minimal complications. This is good
news for patients with atrial fibrillation, since
warfarin is significantly more expensive and must be
monitored regularly. SPAF III studied the remaining
atrial fibrillation patients with additional risk
factors for stroke and for whom warfarin had been shown
effective. The study clearly demonstrated the benefit
of standard warfarin therapy over the combination
therapy of aspirin and fixed-dose warfarin in these
high-risk patients. An ongoing component of the SPAF
III study is assessing the reliability of the method of
identifying atrial fibrillation patients at low risk
for stroke, for whom anticoagulation therapy may be
avoided or postponed.
Women's' Estrogen for Stroke Trial (WEST).
In order to investigate the interrelationship of
estrogen and stroke, this trial has been studying the
use of estrogen to decrease the risk of stroke in post
menopausal women who have already had a stroke. When
follow-up is completed, significant new information
will be available to those treating this special
population.
Vitamin Intervention for Stroke Prevention.
This ongoing trial seeks to determine whether the
addition of a multivitamin with high dose folic acid
and B6 and B12 can reduce recurrent cerebral infarction
and coronary heart disease in patients with non-
disabling cerebral infarction: The role of homocysteine
in heart disease and stroke has received public
attention in the public news media, and NINDS supported
a study which showed high homocysteine concentrations
and low concentrations of folate and vitamin B6 are
associated with an increased risk of stenosis in the
elderly. Folate levels in the American diet have
recently been increased in an attempt to prevent birth
defects caused by abnormal brain development in the
unborn children of women with low levels of the vitamin
folate. The trial will see if even higher levels of
supplementation will reduce stroke and heart disease
without causing serious problems.
African American Antiplatelet Stroke
Prevention Study. This ongoing major clinical trial
seeks to evaluate the use of the drug ticlopidine
compared to aspirin to prevent stroke in an African
American population. Both medicines are considered
``antiplatelet'' medications, but they work by
different mechanisms. The reason for this trial is that
previous studies suggest that African-Americans may
have a more favorable response to ticlopidine than the
general population. An additional aspect of this trial
is making the community more aware of the importance of
stroke prevention and early treatment of high blood
pressure and other modifiable risk factors.
Motor Recovery in Treatment of Patients with
Recent Stroke Using Amphetamine and Rehabilitation
Medicine. NINDS intramural scientists are conducting
this clinical study to determine if the administration
of the drug dextroamphetamine linked with intense
physical therapy will accelerate motor recovery after
stroke. Additionally, the study will allow
identification of the brain regions activated in
associated with recovery.
Findings from other NINDS-supported research include
preliminary results of a study by researchers at the University
of Cincinnati Medical Center suggesting that the number of
strokes in the United States may be dramatically higher than
previously reported. According to the study, which was
published last year, approximately 700,000 first-ever and
recurrent strokes occur in the United States every year, a
figure substantially higher than the previous estimate of
500,000 strokes a year. Earlier studies counted only the number
of first-time strokes, a traditional method of epidemiological
study. Yet people who suffer strokes frequently experience more
than one stroke, and their recurrent strokes are often more
disabling and deadly than their first stroke. The Greater
Cincinnati/Northern Kentucky study included strokes in
individuals who had experienced more than one stroke. In the
new study, the incidence rate of stroke in 1993 was found to be
1.6 times greater for blacks than the overall age and sex-
adjusted incidence rate of stroke among the white population of
Rochester Minn. during 1985-1989. Blacks under the age of 65 in
the Greater Cincinnati study had a two to four times greater
incidence of first-ever stroke compared with the rates among
whites of similar age in the Rochester population; however,
age-specific stroke incidence rates were similar for elderly
blacks and whites.
At the time of a stroke, some brain cells are immediately
killed; others brain cells are at risk of dying in the days
following a stroke. One mechanism of cell death is believed to
be an overabundance of calcium ions. Now, a protective
mechanism has been discovered that may help to delay cell
death. A protein, Bcl-2, has been previously identified as a
critical regulator of the ``cell suicide'' program by which the
body can eliminate unwanted cells. A new study by an NINDS-
supported investigator now shows that Bcl-2 seems to help fight
cell death by enhancing the ability of nerve cell
mitochondria--structures found within many cells--to sequester
large amounts of calcium ions.
There is overwhelming evidence that harmful ``free
radicals'' are involved in the pathophysiology of cerebral
ischernia. Although the molecular mechanisms are not completely
understood, strong evidence supports the principle that
cerebral ischernia and the restoration of blood flow cause an
increase in oxygen free radicals and can damage cell membranes
and function. Recent evidence from and NINDS-supported study
now shows that programmed cell death is mediated via genetic
damage caused by elevated oxygen free radicals during and after
cerebral ischernia. The hydroxyl radical, a known mutagen,
causes DNA damage and induces DNA repair synthesis through the
expression of a repair enzyme.
NINDS leads the Brain Attack Coalition, an umbrella group
of national organizations dedicated to reducing the occurrence,
disabilities, and death associated with stroke. On behalf of
the Coalition, NINDS has established a web site (www.stroke-
site.org) that features an acute stroke ``toolbox'' which
consists of guidelines, protocols, and critical pathways to
guide the development of stroke teams, along with links to
other organizations with information about the treatment of
stroke.
NINDS published the Proceedings of the 1996 National
Symposium on the Rapid Identification and Treatment of Acute
Stroke, which provided guidelines on how to respond rapidly to
acute stroke. Copies have been distributed in to EMS
physicians, state EMS program directors, EMS dispatchers,
emergency departments, etc., to establish better emergency
treatment procedures.
Other public education activities include the distribution
of the booklet ``Preventing Stroke,'' along with a book mark
with risk factors and symptoms of stroke, at health fairs and
to libraries in inner cities where a high number of people are
African-American. All stroke public information materials are
now posted on the World Wide Web.
NINDS has also begun an effort to reach out to the Hispanic
community with information about stroke, its symptoms, and how
to seek medical help. ``Preventing Stroke'' and the stroke
bookmark are available in Spanish. In addition, as part of a
new NIH initiative, NINDS staff worked with Dr. Elmer Huerta,
who broadcasts health information on 49 Spanish language radio
stations in the U.S. and Puerto Rico, to prepare a message
about stroke that was broadcast on March 9, 1998.
Alzheimer's disease
NINDS supports a broad array of studies directed toward
understanding how Alzheimer's disease develops. Identifying the
causes of dementia and methods of early diagnosis are major
goals. To achieve understanding of these areas, the NINDS
focuses on the pathogenesis of Alzheimer's disease. NINDS-
funded researchers are looking at the organization of memory in
the cerebral cortex of mammals, the structure and function of
neurons in this system, the pathology of these neurons
including plaques and tangles, and genetic factors. They also
seek to develop and use animal models of the disorder.
Continued research involving neurotransmitters is also
integral to the study of diseases such as Alzheimer's disease.
As more is learned about the disorder, researchers are
discovering their role in normal brain activity as well as in
disease. Areas of research include studies to characterize
neurotransmitters and their receptors, and therapies that
modulate neurotransmitter systems.
The NINDS Intramural Laboratory of Adaptive Systems is
continuing its efforts to develop a successful laboratory test
that may be a useful as a diagnostic test for Alzheimer's
disease.
Investigators do not yet know how the various factors that
may play a role in Alzheimer's disease interrelate. Scientists
are focusing on a number of research issues, including:
Clarifying the role of presenilins. Current
challenges include identifying additional mutations;
determining how presenilins 1 and 2 are produced and
processed, how they interact with cellular systems, and
whether they play a role in the development of late-
onset Alzheimer's disease; learning the effect of
different presenilin mutations on APP metabolism; and
studying patterns of presenilin 2 expression at the
cellular level over the life span of both healthy
people and those with Alzheimer's disease.
Developing animal models. Ongoing research
to develop animal models (e.g., for presenilins and
FAD) is aiding researchers' understanding of the
pathology of the disease and helping them identify
treatments to retard disease progression. For example,
comparing behavioral and anatomical approaches,
researchers are trying to determine whether the
appearance of the plaques in transgenic mice carrying
human APP mutations comes before or after learning and
memory problems.
Determining the relationship of beta-amyloid
to Alzheimer's disease. Alzheimer's disease researchers
are extending the search for additional cellular
receptors affected by beta-amyloid; working to
understand the pathways involved in oxidative stress
and beta-amyloid production and looking for substances
that may protect against these processes; and
attempting to determine whether defects in the system
that moves electrons within cells contribute to brain
diseases.
Understanding why cells weaken and die. Much
research is under way to determine why cells stop
functioning properly and die in Alzheimer's disease.
Some researchers now believe that cells previously
thought to be dying may actually be resting. If further
research confirms this theory, scientists may be able
to find substances that will reactivate cells.
Improving diagnostic methods. Scientists are
seeking to validate and refine current diagnostic and
autopsy procedures; establish whether differences in
disease patterns in Alzheimer's disease reflect
genetic- and gender-based factors; determine how age
affects the clinical and pathological criteria; find
tests to determine which people with mild cognitive
impairment will progress to clinical Alzheimer's
disease; develop biochemical and molecular methods for
quickly diagnosing Alzheimer's disease and compare the
results to data obtained from currently recommended
methods; develop and standardize qualitative methods;
and determine the nature and significance of white
matter pathological changes in Alzheimer's disease.
Identifying pharmacological treatments.
Researchers are initiating studies of a variety of
types of pharmacological treatments for Alzheimer's
disease, including comparative, combination, and
sequential approaches. Studies are under way to
determine the effectiveness of estrogen, anti-
inflammatory agents, and other treatments.
The pace of discovery in Alzheimer's disease research has
been most impressive in genetic studies. Scientists supported
by the NIA and the NINDS found two genes linked to FAD,
presenilins 1 and 2. The two genes produce similar proteins
with unknown functions. In analyzing gene sequences, scientists
recently have shown that proteins produced by these two genes
have chemical structures that are similar to that of a protein
involved in the signaling and development of cells in a species
of worm (c. elegans). The powerful genetic techniques that can
be applied in this species may help researchers understand the
function of these proteins. Additional recent studies suggest
that these proteins are made by neurons throughout the brain
and that they play a role in the processing of other proteins
such as APP.
The NINDS Intramural Experimental Therapeutics Branch is
conducting a clinical trial of a new anti-dementia medication,
CX 516 (Ampakine), for patients with mild to moderate dementia.
Scientists are studying CX 516 for properties that improve
thinking and memory.
ITEM 7--DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
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U.S. HOUSING FOR THE ELDERLY--FISCAL YEAR 1997 AND 1998
The Department of Housing and Urban Development is
committed to providing America's elderly with decent affordable
housing appropriate to their needs. The Department's goal is to
provide a variety of approaches so that older Americans may be
able to maintain their independence, remain as part of the
community, have access to supportive services, and live their
lives with dignity and grace.
I. Housing
a. section 202--capital advances for supportive housing for the elderly
and section 811 supportive housing for persons with disabilities
The National Affordable Housing Act of 1990 authorized a
restructured Section 202 program while separating out and
creating the new Section 811 program for Housing for Persons
with Disabilities. Funding for both programs is provided by a
combination of interest-free capital advances and project
rental assistance. Project rental assistance replaces Section 8
rent subsidies. The annual project rental assistance contract
amount is based on the cost of operating the project. The 30
percent maximum tenant contribution remains unchanged.
Since the passage of the National Affordable Housing Act of
1990, there have been 49,363 units approved under the Section
202 program and 14,210 units approved under the Section 811
program. Of those amounts 6,006 Section 202 units and 1,169
Section 811 were approved in Fiscal Year 1997. In FY 1998 there
were 6,563 additional units approved under Section 202 for
$464,251,000 and 1,650 more units approved under Section 811
for $108,714,400.
b. section 231--mortgage insurance for housing for the elderly
Section 231 of the National Housing Act authorized HUD to
insure lenders against losses on mortgages used for
construction or rehabilitation of market rate rental
accommodations for persons aged 62 years or older, married or
single. Nonprofit as well as profit-motivated sponsors are
eligible under this program. The program is largely inactive
since most sponsors and lenders prefer to use the Section
221(d)(3) and 221(d)(4) programs instead.
c. section 221(d)(3) and (4)--mortgage insurance program for
multifamily housing
Sections 221(d)(3) and (4) authorized the Department to
provide insurance to finance the construction or rehabilitation
of market rate rental or cooperative projects. The programs are
available to non-profit and profit-motivated mortgagors as
alternatives to the Section 231 program. While most projects
under the programs have been developed for families, projects
insured under Section 221 may be designed for occupancy wholly
or partially for the elderly, and the mobility impaired of any
age.
d. section 232--mortgage insurance for nursing homes, intermediate care
facilities, and board and care homes, and assisted living facilities
The Section 232 program assists and promotes the
construction and rehabilitation (or purchase or refinance of
existing projects) of nursing homes, intermediate care
facilities, board and care homes, and assisted living
facilities by providing mortgage insurance to finance these
facilities. The vast majority of the residents of such
facilities are the frail elderly. In FY 1997 HUD insured 179
projects worth $1.5 billion. In FY 1998 HUD insured 155
projects worth $896 million containing 76 nursing homes, 53
assisted living facilities, and 26 board and care homes.
e. section 8--new construction
The Section 8 program sponsored the new construction of
housing for families and for the elderly by attaching subsidies
to the units being developed. That way the landlord was
guaranteed a stream of income that would facilitate finding
financing and that would guarantee the ability to make payments
and operate the developments. The new construction program was
active from 1974 until the mid-1980s. There are 1.4 million
private, project-based Section 8 units, about 47 percent of
which serve elderly households. About 193,000 of these 658,000
units were built under the Section 202 program before the
restructuring of that program in 1990. That means that about
465,000 units developed with Section 8 project-based assistance
serve elderly households. The Section 8 new construction
program is no longer in operation.
f. service coordinators in assisted housing
The National Affordable Housing Act authorized funding for
service coordinators under the Section 202 program in 1990.
Eligibility was expanded to cover Sections 8, 221(d)(3), and
236 projects in 1992. A service coordinator is a social service
staff person who is part of the project's management team. That
individual is responsible for ensuring that the residents of
the project are linked with the supportive services they need
from agencies in the community to assure that they can remain
independently in their homes and avoid premature and
institutionalization as long as possible.
In FY 1997, HUD awarded $8,885,025 to 65 projects, 55 of
which were Section 202 projects; the remainder were Section 8,
2219(d)(3) or 236.
In FY 1998, HUD funded 51 projects for $6.5 million in new
grants, 24 of which were 202s, 10 were Section 8, 3 were
Section 221(d)(3) and 14 were Section 236. An additional 34 new
grants were funded with $4,447,985 in FY 1997 carryover
dollars. Of these 1 was a Section 202 project and 33 were
Sections 8, 221(d)(3) and 236 projects.
g. the congregate housing services program
The Congregate Housing Services Program (CHSP), initially
authorized in 1978 and revised in 1990, provides direct grants
to States, Indian tribes, units of general local government and
local non-profit housing sponsors to provide case management,
meals, personal assistance, housekeeping, and other appropriate
supportive services to frail elderly and non-elderly disabled
residents of HUD public and assisted housing, and for the
residents of Section 515/8 projects under the Department of
Agriculture's Rural Housing and Community Development Service.
In FY 1998, HUD extended 10 existing grantees for an
additional year. There were no funds appropriated for new
grants in FY 1997 or FY 1998.
h. flexible subsidy and loan management set aside (lmsa) funding
The Flexible Subsidy Program (Flex) provides funding to
correct the financial and physical health of HUD subsidized
properties, including those which house the elderly. Flex
provides funds for projects insured under Section 221(d)(3),
Section 236, and funded under the 202 program (once they have
reached 15 years old). Flex has been limited to Section 202
since FY 1995. In FY 1997, HUD funded 37 projects for
$19,420,277. In FY 1998, Flex funded 30 projects for
$9,273,177.
The Loan Management Set Aside (LMSA) Program provides
Project-based Section 8 funding to HUD-insured and HUD-held
projects and projects funded under the 202 program, which need
additional financial assistance to preserve the long term
fiscal health of the project. Funding has not been available
for this program in several years.
i. manufactured home parks
The Housing and Urban-Rural Recovery Act (HURRA) of 1983
amended Section 207 of the National Housing Act to permit
mortgage insurance for manufactured home parks exclusively for
the elderly. The program has been operational since the March
1984 publication of a final rule implementing the legislation,
although HUD insures very few manufactured home parks.
j. title i property improvement loan insurance
Title I of the National Housing Act authorizes HUD to
insure lenders against loss on property improvement loans made
from their own funds to creditworthy borrowers. The loan
proceeds are to be used to make alterations and repairs that
substantially protect or improve the basic livability or
utility of the property. There are no age or income
requirements to qualify for a Title I loan. HUD funded 87,648
loans in FY 1997 and an estimated 60,065 loans in FY 1998.
k. title i manufactured home loan insurance
Title I of the National Housing Act authorizes HUD to
insure lenders against loss on manufactured home loans made
from their own funds to creditworthy borrowers. The loan
proceeds may be used to purchase or refinance a manufactured
home, a developed lot on which to place a manufactured home, or
a manufactured home and lot in combination. The home must be
used as the principal residence of the borrower. There are no
age or income requirements to qualify for a Title I loan. HUD
funded 2,303 loans in FY 1997 and 552 loans in FY 1998.
l. home equity conversion mortgage insurance program
The Department has implemented a program to insure Home
Equity Conversion Mortgages (HECM), commonly known as ``reverse
mortgages.'' The program is designed to enable persons aged 62
years or older to convert the equity in their homes to monthly
streams of income and/or lines of credit. HUD funded 5,192
loans in FY 1997 and 7,898 loans in FY 1998.
II. Public and Indian Housing
a. section 8 rental certificates and rental vouchers
Section 8 of the U.S. Housing Act of 1937 authorizes
housing assistance payments to aid low-income families in
renting decent, safe, and sanitary housing that is available in
the existing housing market.
About 17 percent of Section 8 certificate and voucher
recipients are being used by the elderly. This represents
237,800 units.
b. elderly/disabled service coordinators
Section 673 of the Housing and Community Development Act of
1992 authorized the Department to fund services coordinators in
public housing developments to assure the elderly and non-
elderly disabled residents have access to the services they
need to live independently. From FY 1994 to 1998, the
Department awarded 227 grants totaling approximately $62.8
million for public housing authorities to hire service
coordinators for their elderly and non-elderly disabled
residents to provide general case management and referral
services, connect residents with the appropriate services
providers, and educate residents on service availability.
c. tenant opportunity program
Section 20 of the U.S. Housing Act of 1937, as amended,
authorized the Tenant Opportunities Program (TOP). The program
enables resident entities to establish priorities and training
programs for their specific public housing communities that are
designed to encourage economic development, stability, and
independence. The program began in 1988 and to date has awarded
about 986 grants totaling approximately $80 million. Public
housing developments with elderly residents are eligible to
participate and perhaps 7 percent are primarily elderly
grantees.
d. public housing development program
The Public Housing Development Program was authorized by
Sections 5 and 23 of the U.S. Housing Act of 1937 to provide
adequate shelter in a decent environment for families that
cannot afford such housing in the private market.
In 1997, 267 additional units of public housing and Indian
housing for the elderly were reserved, 115 were under
construction, and 441 became available for occupancy. In 1998
no additional units were reserved, 165 were under construction,
and 324 became available for occupancy. The following
statistics are provided for the elderly low income population
of public and Indian housing:
Public and Indian Housing..................................... 371,400
Public Housing residents...................................... 360,000
Indian housing................................................ 11,400
III. Community Planning and Development
A. COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) ENTITLEMENT COMMUNITIES
PROGRAM
The CDBG Entitlement Communities program is HUD's major
source of funding to large cities and urban counties for a wide
range of community development activities. These activities
primarily help low- and moderate-income persons and households,
however, they can also be used to help eliminate slums and
blight or meet other urgent community development needs.
The Department normally does not ask grantees to report
program beneficiaries by age. The Department estimates, based
on the 1995 Grantee Performance Report (the most recent
performance report for which the Department has reliable
information) that grantees spent about 1 percent of their
program funds (about $30 million) each year for public services
that were specifically targeted to senior citizens and about
0.6 percent of their funds (about $18 million) for public
facilities for senior citizens. In addition, HUD staff are
aware that senior citizens frequently benefit from local
housing rehabilitation programs that are funded by CDBG. What
is not known is how many of those benefiting from
rehabilitation projects are elderly. It has been the experience
of the Department that the percentage of CDBG funds spent on
these activities by grantees has not varied much from year to
year.
No further information is available at this time.
B. CDBG STATE-ADMINISTERED AND HUD-ADMINISTERED SMALL CITIES PROGRAMS
The CDBG State-administered program and the HUD-
administered Small Cities program for the States of New York
and Hawaii are HUD's principal vehicles for assisting
communities with under 50,000 population that are not central
cities of metropolitan areas. States and small cities/counties
use the CDBG funds to undertake a broad range of activities and
structure their projects to give priority to eligible
activities that they wish to emphasize. As is also true with
the Entitlement Communities program, these activities must
primarily help low- and moderate income persons and households,
however they can also be used to help eliminate slums and
blight or meet other urgent community development needs.
The Department has no specific information on the extent of
benefit from these programs for the elderly, however HUD staff
are aware that elderly persons and households who live in these
small cities and counties are benefiting from CDBG-funded
activities.
No further information is available at this time.
C. HOME INVESTMENT PARTNERSHIP
The HOME Program continues to serve as a major resource for
elderly housing assistance, particularly for the rehabilitation
of deteriorating properties of low-income elderly homeowners,
allowing them to remain in their own homes and keep those homes
in standard condition. The figures below represent the number
of HOME-assisted units completed in FY 1997 and FY 1998 that
are occupied by elderly residents, and the percentage of units
in that category that this figure represents. For example, in
FY 1998 HOME funds assisted 4,883 elderly homeowners
rehabilitate their homes; this is 41.4 percent of all HOME-
assisted homeowner rehabilitations completed in that year.
----------------------------------------------------------------------------------------------------------------
Fiscal year
Tenure type ------------------------------------------------------------------------------
1998 1997 Cumulative
----------------------------------------------------------------------------------------------------------------
Homeowner Rehabilitation......... 4,883 or 41.4%........... 5,547 or 41.7%.......... 25,663 or 42.9%.
Rental Units..................... 2,902 or 16%............. 2,470 or 12.3%.......... 8,604 or 16.8%.
New Homebuyers................... 732 or 3%................ 777 or 3.4%............. 2,287 or 3.1%
------------------------------------------------------------------------------
Total elderly units........ 8,517.................... 8,794................... 36,554
----------------------------------------------------------------------------------------------------------------
To date, HOME has assisted 36,554 low-income elderly
households. This constitutes an investment of over $594,075,000
in HOME funds, which have leveraged another $891,113,000 in
private investment and other non-HOME funds to provide housing
for the elderly (estimates based on a weighted average of
$16,252/per unit HOME investment in for production, and
conservative estimate of $1.50 per $1.00 of HOME as leverage).
For data collection purposes, the HOME Program defines
elderly as 62 or older. Therefore the above numbers do not
reflect projects which are designed for seniors between 55 and
62.
D. EMERGENCY SHELTER GRANTS PROGRAM
The Emergency Shelter Grants Program provides funds to
States, metropolitan cities, urban counties, Indian tribes, and
territories to improve the quality of emergency shelters, make
available additional shelters, meet the cost of operating
shelters, provide essential social services to homeless
individuals, and help prevent homelessness.
No further information is available at this time.
E. SUPPORTIVE HOUSING DEMONSTRATION PROGRAM
The Supportive Housing Program funds may be used to
provide: (i) transitional housing designed to enable homeless
persons and families to move to permanent housing within a 24
month period, which may include up to 6 months of follow-up
services after residents move to permanent housing; (ii)
permanent housing provided in conjunction with appropriate
supportive services designed to maximize the ability of persons
with disabilities to live as independently as possible within
permanent housing; (iii) innovative supportive housing; or (iv)
supportive services for homeless persons not provided in
conjunction with supportive housing.
A sample of grantees annual reports indicates that 4.1
percent of SHP participants were over 51 years of age, the only
breakout for which data are available.
IV. Fair Housing and Equal Opportunity (FHEO)
A. THE FAIR HOUSING ACT
The Fair Housing Act prohibits discrimination in housing
based on race, color, religion, sex, national origin, handicap,
or familial status. The Act exempts from its provisions against
discrimination based on familial status ``housing for older
persons,'' which is defined as housing intended and operated
for occupancy by elderly persons. The statutory exemption of
``housing for older persons'' comprises three categories of
housing: (1) housing provided under any State or Federal
program that the Secretary of HUD determines is specifically
designated and operated to assist elderly persons; (2) housing
intended for and solely occupied by residents 62 years of age
and older; and (3) housing intended for and solely occupied by,
at least one person 55 years of age or older per unit, provided
various other criteria are met.
B. THE HOUSING FOR OLDER PERSONS ACT OF 1995
The Housing for Older Persons Act (HOPA) of 1995 amends the
``55 and older'' housing exemption to the Fair Housing Act's
prohibition against discrimination based on familial status.
HOPA eliminates the requirement that ``housing for 55 and older
persons'' have significant services and facilities and
establishes a good faith reliance defense from monetary damages
based on a legitimate belief that the housing was entitled to
an exemption. In order to qualify for the ``55 and over
housing'' exemption a housing community or facility must: (1)
have at least 80 percent of its occupied units occupied by at
least one person 55 years of age or older; (2) adhere to
policies and procedures which demonstrate an intent by the
owner or manager to provide housing for persons 55 and older;
and (3) verify the age of its residents through reliable
surveys and affidavits.
The Department published a proposed rule to implement the
Housing for Older Persons Act of 1995 on January 14, 1997, with
a 60-day public comment period. HUD received approximately 130
public comments. The final rule, ``Implementation of the
Housing for Older Persons Act of 1995,'' has been cleared
within the Department and is currently with the Office of
Management and Budget for review under the Paperwork Reduction
Act. After OMB completes its review, the final rule will be
published in the Federal Register.
C. AGE DISCRIMINATION ACT
The Department's regulations implementing the Age
Discrimination Act became effective on April 10, 1987, and are
codified at 24 CFR Part 146.
During FY 1996, the Department received five complaints
alleging age discrimination, of which were referred to the
Federal Mediation and Conciliation Services (FMCS). Two of
these complaints were successfully mediated and agreements were
reach. Three were unsuccessfully mediated, and may be
administratively closed out at a later date. Data on 1997
activity is expected in March 1999.
D. DESIGNATED HOUSING
The 1992 Housing and Community Development Act authorized
HUD to approve Public Housing Authority plans to designate
mixed population housing units (serving elderly and persons
with disabilities) for elderly families only, if the plans met
certain statutory requirements. The Housing Opportunities
Program Extension Act of 1996 simplified and streamlined those
requirements, but continued to require HUD to review and
approve or disapprove designate housing plans.
For FY 1998 25 housing authorities received approval to
designate 4,953 units for elderly families. For FY 1997 44
housing authorities designated 8,289 units.
V. Office of Policy Development and Research
A. AMERICAN HOUSING SURVEY
The American Housing Survey for the United States, Current
Housing Reports H150 for the year 1995 contains special
tabulations on the housing situations of elderly households in
the United States. (Data for 1997 will be available soon.)
Chapter 7 of the regular report provides detailed demographic
and economic characteristics of elderly households, detailed
physical and quality characteristics of their housing units and
neighborhoods and the previous housing of recent movers, and
their opinions about their house and neighborhood. The data are
displayed for the four census regions, and for central cities,
suburbs, and non-metropolitan areas, and by urban and rural
classification. The non-elderly chapters (total occupied,
owner, renter, Black, Hispanic, central cities, suburbs, and
outside MSAs) as well as the publications for the 47 largest
metropolitan areas individually surveyed over four- to six-year
cycles. Current Housing Reports H170, also contain data on the
elderly.
An elderly household is defined as one where the
householder, who may live alone or head a larger household, is
aged 65 years or more. Special information in these
publications is provided on households in physically inadequate
housing or with excessive cost burden, and on households in
poverty.
B. EVALUATION OF THE CONGREGATE HOUSING SERVICES PROGRAM (CHSP)
The New Congregate Housing Services program was authorized
under the National Affordable Housing Act of 1990 and amended
by the Housing and Community Development Act of 1992.
The CHSP combines project-based rental assistance with
community-based supportive services to help low-income frail
elderly and non-elderly persons with disabilities maintain
independence and avoid institutionalization. In addition to
rental assistance, HUD pays 40 percent of the supportive
services cost, the grantees pay 50 percent of the cost, and the
participants pay 10 percent, if they are able. To be eligible
for the program, residents must need assistance with at least
three activities of daily living (ADL) as defined by HUD or, if
they are non-elderly, they must have temporary or permanent
disabilities.
Data for the evaluation was collected over a two-year
period. The data collection phase has been completed. The final
report, which is Congressionally mandated, is being written. It
is expected that the report will be available by March 1999.
Preliminary results show that the program was implemented
in many community settings ranging from small non-metropolitan
areas to large cities and metropolitan areas. Participants were
interviewed initially to obtain a baseline and again at 12
months and 24 months. Preliminary data shows that CHSP appears
to be targeted to those at risk of being institutionalized and
who are likely to be appropriately served by community-based
options.
CHSP participants are older and much frailer (in terms of
ADL criteria) than elderly persons in the general population,
but they are somewhat similar to residents of more restrictive
environments such as board and care homes and, in some cases,
nursing homes. The average age of CHSP participants is 81
years. CHSP participants require a broad range of services,
including help with housework, meals, transportation, and other
types of personal care assistance. CHSP participants receive on
average four services from the program and outside service
providers in addition to help from family and informal sources.
Because the CHSP participants are so frail and old, many
are not able to continue to live independently, even with CHSP
services. Overall about half of the participants left CHSP. Of
those who left the program, 38 percent moved to a more
restrictive environment or died. Those who left the program are
more likely to be older, have more ADL impairments, and be
males. Those who stayed are more likely to be satisfied with
program services and have less interaction with family.
Comparison of HOPE IV and CHSP
Comparisons based on preliminary data analysis show that
both programs appear to be targeted to those at risk of being
institutionalized who are likely to be appropriately served by
community-based options.
The two populations are very similar in most respects,
except that the HOPE IV participants are frailer at a younger
age. In general, elderly participants in both programs are much
frailer (in terms of ADL criteria) than elderly persons in the
same age range in the general population. At the end of the
two-year study period (covering the initial and follow up
interviews) a little over half of the participants remain in
the respective programs. A relatively small number have died--
13 percent for HOPE IV and 15 percent for CHSP. More CHSP
participants (25 percent) than HOPE IV participants (9 percent)
moved to a higher level of care. The rate for CHSP is high
relative to national data for the frail-elderly.
Although the overwhelming majority of participants
receiving services say they are satisfied with the programs,
some of the participants in these programs say that they need
more services to remain independent. However, these programs
are not intended to serve the elderly who have aged in place
and have gotten progressively more frail in a nursing home like
setting. The need for transition to a higher level of care will
be a reality for many who are frail and elderly.
The final report is scheduled to be completed in March
1999.
C. EVALUATION OF THE HOPE FOR ELDERLY INDEPENDENCE DEMONSTRATION
PROGRAM
The program was conceived as an alternative to the
Congregate Housing Services Program (CHSP). The major
difference between the two programs is that HOPE IV is a tenant
based program implemented by the PHAs. Beyond specifying
minimum age, level of frailty and income requirements, HUD has
allowed considerable flexibility in local implementation of the
HOPE IV program. HUD expected the grantee to recruit and assess
the candidates with the help of a service coordinator, obtain
matching funds for its share of the cost of services, and serve
as a contractor for service delivery.
The evaluation has been completed and the final report is
in the process of being cleared through HUD for publication.
The evaluation shows that the HOPE IV Program was appropriately
targeted to clients at risk of being institutionalized. The
level of assistance necessary to maintain independence
corresponded to the level of frailty and impairment of the
program participant.
At the end of the of the two-year period of the study, 40
percent of the HOPE IV elderly either died, went to nursing
homes, moved to other locations, left HOPE IV but retained
their Section 8 rental assistance, or left for unspecified
reasons. The impact of the HOPE IV program was most noticeable
in the quality of life and care of the participants. Despite
increased frailty and worsening health conditions, 90 percent
of the participants were satisfied with the HOPE IV Program. In
addition, about half of those in the program said they were
satisfied with their lives, liked their neighborhoods and
living arrangements, were confident and had few worries, had
good appetites, and were in control of their lives. This
suggests that even the frailest elderly, who are also low
income, and have few or no support systems, are able to live
independently in a service rich environment that includes case-
management.
ITEM 8--DEPARTMENT OF THE INTERIOR
----------
Departmental Office for Equal Opportunity
The Department of the Interior's (DOI) age discrimination
regulation applies to its federally assisted programs and
activities other than those that are of an insurance or
guarantee nature. The rule is codified in the Code of Federal
Regulations at 43 CFR 17, Subpart C. These rules and
regulations are proactively enforced throughout all aspects of
DOI's operations.
In 1998, DOI conducted a total of 1,121 civil rights
compliance reviews under the authority of its age
discrimination regulations. These compliance reviews covered,
in part, whether or not recipients were in compliance with the
requirements of the Act. These reviews were initiated and
completed in 1998. DOI ensures compliance with the Act through
established civil rights compliance and enforcement programs in
its various bureaus and offices. To this effect, each of DOI's
bureaus and offices is responsible for ensuring compliance with
the Act in federally assisted programs and activities that they
administer. In terms of policy development, direction, and the
provision of technical assistance and training in furtherance
of the requirements of the Act, the Departmental Office for
Equal Opportunity serves as the focal point for this
responsibility. All 1,121 of DOI's civil rights compliance
reviews considered age discrimination compliance issues. These
compliance reviews were conducted of public park and recreation
programs, including fishing and hunting activities throughout
the United States.
In 1998, the Departmental Office for Equal Opportunity
developed detailed civil rights complaint processing procedures
for the benefit of DOI's bureaus and offices. The procedures
explain how to process and investigate age discrimination
complaints. They describe DOI's role and the Federal Mediation
and Conciliation Service's responsibilities in handling age
discrimination complaints. The procedures also describe time
limits for filing complaints and steps to be taken by both DOI
and its recipients in conducting ``informal'' and ``formal''
complaint investigations under the Act.
DOI's civil rights working group remains in place. The
group includes equal opportunity specialists from all bureaus
and offices including the Departmental Office for Equal
Opportunity The group meets frequently throughout the year for
civil rights training purposes. The group operates as a
``cross-bureau'' team in addressing a variety of complex civil
rights compliance issues including those faced by older
Americans.
The public is informed of how to file age discrimination
complaints through an established public notification program.
This public notification program entails nationwide
dissemination of civil rights posters which DOI requires to be
prominently posted in reasonable numbers and places throughout
all areas of the recipient's operations. The poster describes
the procedures for filing age discrimination complaints against
DOI's recipients. The public is also informed of DOI policies
regarding the Act through civil rights compliance reviews,
complaint investigations, and written correspondence to
recipients and potential and actual program beneficiaries.
Additionally, DOI developed and established an electronic
``diversity'' website that proclaims to the public DOI's
various nondiscrimination policies including requirements of
the Act. The Department's website address is as follows:
``http://www.doi.gov/diversity/.''
DOI has taken steps to develop a new civil rights assurance
form. In part, the assurance form covers the nondiscrimination
requirements of the Act. This civil rights assurance form will
be more comprehensive than DOI's current civil rights
assurance. DOI's new civil rights assurance form, for the first
time, will require DOI's applicants and recipients of Federal
assistance to collect and maintain ``age'' data on potential
and actual program beneficiaries. This information is being
sought from federally assisted entities to enhance DOI's
capabilities in more readily identifying instances of
noncompliance with the Act. A draft version of DOI's new
assurance form was submitted to the U. S. Department of Health
and Services for review and comment purposes.
The Secretary of the Interior's ``Zero Tolerance Policy''
regarding discriminatory practices throughout DOI's operations
remains in effect. The policy addresses, among other concerns,
the elimination of discrimination based on age in DOI's
federally assisted programs.
DOI had a total of three (3) age discrimination complaints
in 1998, in its complaints inventory. One of the three
complaints was received in FY 1998, the other two were carry
over complaints from previous fiscal years. To date, two of the
three age complaints that were in DOI's complaints inventory
have been closed. The complaints in question were filed against
federally assisted fish and wildlife management programs that
are carried out by State governments. DOI did not refer any of
the three complaints to the Federal Mediation and Conciliation
Service because each of them merely required an interpretation
of the requirements of the Act.
U.S. Fish and Wildlife Service
The U.S. Fish and Wildlife Service (Service) provides
opportunities for all employees regardless of their age and
ensures that older individuals participate in special programs,
volunteer programs, and employment opportunities. The following
are the Service reports on aging for 1997 and 1998.
Calendar Year 1997.--The Service employed a total of 6,987
individuals. There were 4,851 (69%) of Service employees over
the age of 40, which was an increase of 303 employees from the
previous year. Of the Service employees over the age of 40, 280
(6%) were over the age of 60; a increase of 50 employees from
the previous year.
The majority of the Service's mission related occupations,
which include biologists, was in professional positions.
Demographic information regarding Service employees over the
age of 40 is as follows:
2,228 (46%) were in professional positions,
83 (4%) of whom were over the age of 60;
974 (20%) were in administrative positions;
48 (5%) of them over the age of 60;
688 (14%) were in technical positions; 49
(7%) of them over the age of 60;
380 (8%) were in clerical positions; 38
(10%) of them over the age of 60;
22 (4%) were in other positions; none of
them over the age of 60;
559 (12%) were in wage grade positions; 62
(11%) of them over the age of 60.
In 1997, there were 38 employment related discrimination
complaints filed Servicewide. Of those, 10 were filed alleging
discrimination on the basis of age (40 and above).
Additionally, the Service had 25 federally assisted program
related complaints filed during Fiscal Year 1976. Of those,
three were filed alleging discrimination on the basis of age
(40 and above).
A total of 8,000 Golden Age Passports were issued
Servicewide in 1997. The Golden Age Passport Program provides
free entrance or lower entrance fees to most national parks,
monuments, historic sites, recreation areas and national
wildlife refuges for any individual over the age of 62.
The Service utilized numerous individuals in its volunteer
program. There were more than 30,000 volunteers Servicewide
including 4,148 individuals over the age of 61.
There were 97 Service employees over the age of 40 who were
recognized for their exceptional contributions through the
Service's Outstanding Performance Awards Program during Fiscal
Year 1997. Additional 14 Service employees over the age of 40
were recognized for their outstanding commitment to the
Service's Human Resources Program through the Director's Equal
Employment Opportunity Awards during Fiscal Year 1997.
Calendar Year 1998.--The Service employed a total of 7,390
individuals. There were 5,103 (69%) Service employees over the
age of 40, which is an increase of 252 employees from the
previous year. Of the Service employees over the age of 40,
there were 302 (6%) over the age of 60; an increase of 22
employees from the previous year.
The majority of the Service's mission related occupations,
which include biologists, continues to be professional
positions. Demographic information regarding Service employees
over the age of 40 is as follows:
2,351 (32%) were in professional positions;
84 (4%) of them over the age of 60;
1,055 (21%) were in administrative
positions; 56 (5%) of them over the age of 60;
717 (7%) were in technical positions; 55
(8%) of them over the age of 60;
372 (7%) were in clerical positions; 39
(10%) of them over the age of 60;
22 (4%) were in other positions; none of
them over the age of 60;
586 (11%) were in wage grade positions; 68
(12%) of them over the age of 60.
During Fiscal Year 1998, there were 36 employment related
discrimination complaints filed Servicewide. Of those, 22 were
filed alleging discrimination on the basis of age (40 and
above). Additionally, the Service had 32 Federally Assisted
Program related complaints filed during Fiscal Year 1998. Of
those, one was filed alleging discrimination on the basis of
age (40 and above).
A Total of 8,237 Golden Age Passports was issued
Servicewide in 1998. The Golden Age Passport Program provides
free or lower entrance fees to most national parks, monuments,
historic sites, recreation areas and national wildlife refuges
for any individual over the age of 62.
The Service utilizes numerous individuals in its volunteer
program. There were more than 321,000 volunteers Servicewide,
including 40,995 individuals over the age of 61.
The Service recognizes the numerous contributions of older
individuals through various awards programs. There were 146
Service employees over the age of 40 who were recognized for
their exceptional contributions through the Service's
Outstanding Performance Awards during Fiscal Year 1998.
Additionally, nine Service employees over the age of 40 were
recognized for their outstanding commitment to the Service's
Human Resources Program through the Director's Equal Employment
Opportunity Awards Program during Fiscal Year 1998.
Bureau of Reclamation
Human Resources.--The Bureau of Reclamation conducts many
activities throughout the year that affect and benefit aged
individuals. Personnel Offices maintain contacts and provide
services to many retirees who need advice or have questions
concerning their retirement and health benefits. In addition,
retirees and their spouses attend annual health insurance fairs
where representatives from insurance carriers are available to
discuss the provisions of, or changes to their respective
medical plans. Several of Reclamation's regional offices
continue to mail out a monthly newsletter to all retirees. The
newsletter contains information on Reclamation's, current
employees, past employees, and is highly regarded by retirees
as a way to keep in touch. Additionally, pre-retirement
briefings and seminars are held for all interested employees as
part of retirement planning.
The Bureau of Reclamation established a Work and Family
Team (WAFT) in September 1995 to implement the President's
directive on Family-Friendly Federal Work Arrangements.
Initiatives taken on behalf of older Americans and their
families are principally addressed in this arena. The
alternative work schedules in place throughout Reclamation
allow employees to construct their work schedules to
accommodate family needs. This is in addition to its
telecommuting initiative already in place and vigorous support
of the Family and Medical Leave Acts.
Employment and Job Corps Centers Opportunities.--Reemployed
annuitants are hired to perform special projects or provide
assistance in specialized technical areas of work since they
are able to offer invaluable experience and expertise to these
assignments.
Reclamation's Weber Basin Job Corps Civilian Conservation
Center in Ogden, Utah, continued its agreement with the U. S.
Forest Service, consistent with Title V of the Older Americans
Community Service Employment Act of 1973. The purpose of this
agreement is to foster and promote useful part-time work
opportunities in community service activities for unemployed
low-income persons who are 55 years of age or older. During
1997 and 1998 Weber Basin employed four older Americans under
this agreement in positions as teachers' aides, warehouse
workers, drivers, maintenance helpers, and clericals.
An established Host Agency Agreement between Green Thumb,
Inc., and the Bureau of Reclamation's Collbran Job Corps
Civilian Conservation Center, Collbran, Colorado, continued to
be utilized to employ older Americans at the Center. Green
Thumb, Inc., administers a Senior Community Service Employment
Program by virtue of a grant with the U. S. Department of
Labor. During 1997 and 1998, Collbran Job Corps Center hired
two employees to perform clerical and warehouse duties.
Accessibility.--The Architectural Barriers Act of 1968 and
section 504 of the Rehabilitation Act of 1973, as amended,
require the provision of accessible facilities, programs and
services to the persons with disabilities. This effort directly
benefits all people, including the elderly, providing improved
access to Reclamation facilities and programs.
Reclamation has actively pursued compliance with the
Architectural Barriers Act of 1968 and section 504 of the
Rehabilitation Act of 1973, as amended, since 1990 and is in
the process of evaluating all of its facilities, services and
programs. The following chart illustrates the total number of
Reclamation sites and components that were evaluated for
accessibility purposes, as of January 11, 1999.
TOTAL SITE AND COMPONENT EVALUATIONS RECLAMATION-WIDE AS OF JANUARY 11, 1999
----------------------------------------------------------------------------------------------------------------
Sites Components
Region ---------------------------------------------------------------
Inventoried Evaluated Inventoried Evaluated
----------------------------------------------------------------------------------------------------------------
Great Plains.................................... 110 28 4495 4486
Lower Colorado.................................. 56 9 326 221
Mid-Pacific..................................... 174 0 0 0
Pacific NW...................................... 224 73 2170 1400
Upper Colorado.................................. 216 31 1696 786
---------------------------------------------------------------
Totals.................................... 800 141 8685 2893
----------------------------------------------------------------------------------------------------------------
In addition, progress toward full accessibility has
resulted in modification of Reclamation offices, visitor
facilities, restrooms, campgrounds, administrative offices,
boating facilities, and picnic areas to provide access for
people with disabilities and older Americans who experience
some degree of disability.
These modifications provide structural access elements,
which include: (1) access ramps; (2) handrails; (3) alteration
of walkways and trail gradients; and (4) restroom and doorway
modifications. In addition, modifications to Reclamation
programs have resulted in captioned videos, brochures with
large point print, audio description of videos and films and
the use of graphics to identify restroom locations and
information retrieval from brochures and displays.
These changes provide the elderly easier access to
Reclamation facilities and greatly improved information about
the availability and location of Reclamation programs,
activities, facilities and services. In 1998, Reclamation
evaluated 62 of a total of 213 work sites to determine whether
or not they were readily accessible to people with
disabilities, older employees and visitors. The following chart
illustrates, by region, the total places of employment
evaluated Reclamationwide:
TOTAL PLACES OF EMPLOYMENT EVALUATED RECLAMATION-WIDE
----------------------------------------------------------------------------------------------------------------
Sites Components
Region ---------------------------------------------------------------
Inventoried Evaluated Inventoried Evaluated
----------------------------------------------------------------------------------------------------------------
Great Plains.................................... 40 10 489 105
Lower Colorado.................................. 21 6 239 145
Mid-Pacific..................................... 67 0 0 0
Pacific NW...................................... 32 11 344 177
Upper Colorado.................................. 56 10 501 285
---------------------------------------------------------------
Totals.................................... 213 62 1573 712
----------------------------------------------------------------------------------------------------------------
The Great Plains Region.--The Region continues to conduct a
program which considers the potential employment contributions
of older citizens and continues to work to make facilities
accessible to those having physical limitations, many of whom
are senior citizens. The following activities are
representative of actions taken in 1998.
1. In 1998, the Great Plains Region employed a total of 257
employees over 50 years of age. Of those employees, 15 were 62
years or older. A breakdown by age group is shown below:
Age Group Number of Employees
51-54 years....................................................... 149
55-59 years....................................................... 80
60-70 years....................................................... 15
In addition, in 1998, the Region employed one reemployed
annuitant who was still employed at the end of the fiscal year.
2. Efforts continue with regard to enhancing recreational
opportunities at many reservoirs and recreational areas which
have traditionally attracted many senior citizens and retired
individuals.
3. Many of the Bureau of Reclamation's volunteers from the
outside public are retirees who wish to enhance their skills in
various areas, and therefore, gain some experience through the
volunteer program.
4. The Region has accessibility coordinators in each area
office to assure compliance with the American Disabilities Act.
There have been few, if any, complaints concerning reasonable
accommodations.
Lower Colorado Region.--Hoover Dam has a Visitor Center
Volunteer Program with a staff of 40 to 50 volunteers, most of
whom are from the local senior population. The volunteers'
contributions include monitoring the three-way revolving
theater, helping visitors find their way around, answering
questions about Dam tours and escorting groups from the parking
area. Volunteers are given opportunities to go on tours, enjoy
a walk across the Dam, view the new exhibits, and socialize
with fellow volunteers.
During the reporting period, the Boulder Canyon Operations
Office developed ``WEB'' pages for the benefit of older
Americans including individuals with hearing impairments who
need special equipment to obtain information about Lake Mead
and the Colorado River. This information resource is used for
general information purposes and/or for determining a good time
to go fishing.
The Bolder Canyon Operations Office contracted with a
retired employee to utilize his vast knowledge about the
Colorado River which he had gained over a 30 year career.
Mid-Pacific Region.--The Mid-Pacific Region continues to
make use of the Senior Community Service Employment Program
(SCSEP). The program provides temporary work experience for
people aged 55 and older with limited financial resources. It
is sponsored by the American Association of Retired Persons.
SCSEP gives clients the opportunity to sharpen and develop
skills while searching for a permanent job.
The Mid-Pacific Region has an employee organization called
the Federal Reclamation Employees' Association (FREA). It was
formed to maintain and advance the general and social welfare
of the employees, foster unity, cooperation, and advance the
public regard and respect for the personnel activities of the
Mid-Atlantic Region. Employees who are members of FREA at the
time of retirement are granted an Honorary Lifetime Membership.
This affords the retirees the opportunity to attend all
functions held throughout the year, which hopefully give them a
sense of belonging to the Mid-Atlantic Region.
The Federal building which houses the Mid-Atlantic Region
office employees has gone through a major retrofit. These
modifications provide structural access elements, which
include: access ramps, handrails, alteration of walkways, and
restrooms and doorway modifications. These changes provide the
elderly easier access to the facilities.
Pacific Northwest Region.--The Region continues to utilize
older and retired citizens as Camp or Park Hosts each year.
An Area Office hired an elderly volunteer in one office to
help set up files in several program areas. She was eventually
hired on a temporary appointment to continue that effort.
The Memorandum of Agreement with the State of Idaho,
Department of Health and Welfare remains current, however it
was not utilized during 1998.
The Upper Colorado Region.--The Upper Colorado Region
utilized two senior volunteers from the Green Thumb, Inc.,
organization during 1997 and 1998. In addition, the Region
utilized four older Americans through SCSEP (Senior Community
Service Employment Program) to work in the Weber Basin Job
Corps (24 hours weekly).
Recreation facilities in the Upper Colorado Region continue
to be upgraded to improve accessibility to those with physical
impairments due to disabilities and aging. This past year the
following facilities have been renovated or constructed to
improve access: Crawford Reservoir, Colorado; Navajo Reservoir,
New Mexico; Deer Creek Reservoir, Utah; and Scofield Reservoir,
Utah.
Reclamation will continue its efforts to improve access for
the elderly and disabled through an ongoing program established
to provide access for all individuals.
Bureau of Indian Affairs
During the reporting period, Calendar Years 1997 and 1998,
the Bureau of Indian Affairs continued to administer
initiatives and programs to benefit older American Indian and
Alaskan Native citizens. The Bureau's Division of Social
Services has provided and financed adults with custodial and
protective care services. These services have been provided in
homes, group homes and nursing care facilities for elderly
persons who lack financial and physical and/or mental
capability to care for themselves. Other aging citizens have
received protective and counseling services without custodial
care payments. They coordinate intensive skill nursing needs
for aging residents through referrals to other Federal, State
or local agencies. The Bureau of Indian Affairs is currently
establishing standards that will upgrade custodial care
facilities making them eligible to receive Medicare/Medicaid
payments and provide better subsequent custodial care to
eligible aging American Indian and Alaskan Native citizens. The
Division administers a Housing Improvement Program that makes
existing housing repairs and renovations and some new home
constructions on Indian communities. This program is a grant
program designed to improve housing standards for citizens who
are not qualified/eligible under conventional housing
assistance activities. Program recipients are selected from
weighted variables that favor low income persons with
disabilities and elderly applicants; many program recipients
include elderly persons. Further, Tribal entities are using
``638 Contracts'' to meet specific housing needs with emphasis
on elderly residents.
The Bureau of Indian Affair's Office of Indian Education
Programs, in concert with other associations (local and
national) has developed and administers a Family and Child
Education Program, a family literacy program, that serves young
children and their parents, which often includes elderly
American Indian and Alaskan Native guardians with
responsibility for minor children. The program includes early
childhood, parent and child time, parenting skills and adult
education activities in their home and a center provided by
local schools. These services enable elderly guardians to
become more efficient in providing parenting skills to children
in their custody. The Bureau's Office for Equal Employment
Opportunity Programs continues to vigorously enforce the Age
Discrimination in Employment Act to eliminate age
discrimination throughout the Bureau of Indian Affairs. These
efforts ensure that elderly employees may continue in their
careers, uninhibited, until they decide to retire.
Mineral Management Service
The Minerals Management Service (MMS) continues to work to
support programs for older Americans. MMS's work force
statistics show that:
Eight-one percent of the MMS's work force is
comprised of employees that are age 40 and over (1,388
of 1,719).
Older employees are well represented in a
variety of occupations within the MMS, including
accountants, auditors, computer specialists, engineers,
geologists, geophysicists, and physical scientists,
The MMS has implemented and continues to
implement effective personnel management policies to
ensure that equal opportunity is provided to all
employees and applicants including the aged. Older
workers are a source of valuable knowledge and
experience and a significant factor in the success of
the MMS's mission.
The MMS continues to explore and implement initiatives to
assist employees to care for elderly parents. Examples of
recent innovations are the establishment of family support
rooms in the Herndon, Virginia, and Lakewood, Colorado offices.
Rooms are available for employees to bring their elderly
parents for short term care on an occasional basis when
necessary, in order to facilitate such events as ease in
keeping medical appointments. Other family friendly initiatives
such as leave share and the Family and Medical Leave Act, have
been implemented and used to benefit workers who have older
relatives with medical situations.
The MMS continues to perform its mission related functions
with diligence and appreciation of the importance of its
actions. A major mission responsibility affecting large numbers
of citizens is the approval of mineral royalty payments to
various landholders, including numerous older Americans who
often depend heavily on these payments to meet their basic
human needs and rely on the ability of the MMS to effectively
discharge their financial responsibilities.
The MMS offshore mission has the ultimate objective of
increasing domestic mineral (oil and gas) production through
offshore resources, thereby decreasing the dependence on
foreign imports. Such activities have a significant effect on
the economic well-being of all Americans, especially older
Americans.
Office of Surface Mining Reclamation and Enforcement
The Office of Surface Mining Reclamation and Enforcement is
committed to ensuring that all persons are provided equal
opportunity in all employment matters. During calendar years
1997 and 1998 a policy statement from the Director of the
Office of Surface Mining Reclamation and Enforcement (OSM) was
in effect which states that discrimination based on age, 40 and
older, will not be tolerated. In addition, during calendar year
1997 a Diversity Policy statement was issued committing OSM to
creating and maintaining a diverse workforce that would be
inclusive of elderly persons. Older workers are represented in
most of OSM's occupational series. In fact, over half (59.5%)
of OSM's workforce will be eligible to retire within the next
10 years.
In 1998, OSM opened a Family Support Room. This room was
designed to give parents and primary care providers options in
managing responsibilities of family and work. This room has
been very helpful in assisting persons with elderly parents who
were sick or had doctors appointments near the work site.
Awards for 25, 30, and 35 years of service were given to
many OSM employees in calendar years 1997 and 1998.
United States Geological Survey
Geological Survey (USGS) provides opportunities to all
individuals throughout its work force and ensures that the
skills of older individuals are utilized through special
programs, volunteerism, and employment opportunities.
In 1997, USGS employed a total of 10,681 individuals in
permanent and temporary jobs. There were 6,827 USGS employees
age 40 and over. Of USGS employees age 40 and over, there were
413 (7%) employees who were 60 years of age and older, and one
employee over 80 years old.
The majority of USGS' mission related occupations, which
include occupations such as hydrologists, geologists,
cartographers, and biologists are in the professional category.
Of the 6,827 USGS employees age 40 and over, there were 3,546
(52%) in professional positions, 240 (7%) of whom were age 60
and over, and one employee over 80. Other demographic
information regarding USGS employees age 40 and over was as
follows:
998 (15%) were in administrative positions
with 32 (3%) of them age 60 or over;
1,763 (26%) were in technical positions with
93 (5%) of them age 60 or over;
359 (5%) were in clerical positions with 44
(11%) of them age 60 or over;
13 (0.2%) were in other positions with none
of them 60 or over;
148 (2%) were in wage grade positions with 7
(5%) of them age 60 or over.
In 1997, there were 14 equal employment complaints filed by
USGS employees alleging discrimination based on age.
In 1998, the USGS experienced a decrease in the number of
people it employed. In, 1998, USGS employed a total of 10,486
individuals in permanent and temporary jobs. There were 6,618
(63%) USGS employees age 40 and over. Of USGS employees age 40
and over, there were 426 (6%) employees who were 60 years of
age and older, and there were two employees over the age of 80.
USGS' mission related occupations include positions such as
hydrologists, geologists, cartographers, and biologists, are in
the professional category. Of the 6,618 USGS employees age 40
and over, there were 3,515 (53%) in professional positions, 260
(7%) of whom were age 60 and over, and two employees over the
age of 80. Other demographic information regarding USGS
employees age 40 and over was as follows:
989 (15%) were in administrative positions
with 38 (4%) of them age 60 or over;
1,657 (25%) were in technical positions with
94 (6%) of them age 60 or over;
308 (5%) were in clerical positions with 31
(10%) of them age 60 or over;
21 (0.3%) were in other positions with none
of them age 60 or over;
127 (2%) were in wage grade positions with 3
(2%) of them age 60 or over.
In 1998, there were 7 equal employment complaints filed by
USGS employees based on age. In addition to the full time
employees, USGS also has many volunteers. These individuals
provide outstanding services to USGS and the public nationwide
in a variety of capacities.
The various types of volunteer opportunities and the number
of individuals involved were:
------------------------------------------------------------------------
Categories 1997 1998
------------------------------------------------------------------------
USGS Retirees........................................... 53 69
Other Retirees.......................................... 310 320
Lecturers............................................... 6 7
Scientists Emeritus..................................... 255 260
---------------
Totals............................................ 624 656
------------------------------------------------------------------------
The USGS Scientists Emeriti are welcomed back to the USGS
after retirement to continue important scientific research. The
USGS benefits immeasurably from the accumulated knowledge,
experience, and dedication of over 250 Scientists Emeriti.
The following are examples of some of the activities in
which USGS volunteers are involved:
--Two retirees from outside the Federal sector donate
their time in Reston, Virginia, to provide critical
assistance to the development and management of the
USGS Earth Science Corps, a project that utilizes
hundreds of citizens across the country to update USGS
maps. It is estimated that within the Earth Science
Corps contingent, there are over 300 volunteers aged 60
and above. These volunteers make valuable contributions
to the USGS and the nation by providing accurate, up-
to-date geographic information about their communities.
--USGS retirees serve as lecturers in the National
Center Visitors Center, leading tours and providing
information about the USGS to groups from pre-school
age to senior citizens.
--Scores of senior citizens volunteer nationwide for
the Water Resources Division collecting and analyzing
water quality data in their communities.
--Two retirees served as volunteers on a special
project in Alaska to investigate the movement and
impact of the Bering Glacier. Working under rugged
conditions, the volunteers' help made it possible for
USGS scientists to complete numerous studies and
advance USGS' understanding of this significant
glacier.
--Senior citizens and retirees with backgrounds in
mathematics and computer science volunteer to instruct
employees on software applications, enter data and
evaluate software and hardware upgrades.
Summary of Contributions Made by Older Americans.--During
the reporting period, older Americans made the following
contributions to USGS operations:
Worked on surface-water and quality-water
records;
Compiled The Water Resources Division
History, Volume VII -1966-1979, and South Dakota
History, Volume 7;
Reviewed sediment laboratories for the
Office of Surface Water, examining method consistencies
of Water Resources Division sediment laboratories, and
providing insight to the Sediment Action Laboratory
Subcommittee;
Provided assistance in making discharge
measurements and checking gauges.
Assisted USGS in accomplishing the ``Extreme
Storm Study;''
Prepared information for and attended the
International Records annual meeting in Maple Creek,
Saskatchewan, Canada;
Assisted with the collection of water
resources data and processing in the Data Unit;
Consulted on sediment transport, data
collection and interpretation of data and on improved
instrumentation projects;
Reviewed the proposal SC94K, Simulation of
Dissolved Oxygen in the Lower Catawba River;
Assisted the Water Resources Division in the
development of the personnel history of the Hawaii
District Office and the collection of field data in
Hawaii and the Western Pacific;
Performed stream flow analysis and reviewed
District and Pacific Northwest Area records; reviewed
international water records and other quality assurance
aspects pertaining to surface water;
Reviewed reports, assisted as resources in
project planning, assisted in training workshops,
attended conferences for NAWQA Puget Sound, and as
needed for the Washington District;
Helped USGS complete two reports for the
Washington District Office;
Assisted in various activities pertaining to
field studies of juvenile fall and spring chinook
salmon, e.g., Radio telemetry activities included using
boats to track radio-tagged juvenile salmon in Lower
Granite and Little Goose Reservoirs, downloading fixed
radio telemetry receivers, collecting juvenile salmon
using trawls and purse seines in Snake River
Reservoirs, and collecting velocity and temperature
data. Near shore habitat activities included collecting
fish with beach seines and electrofishing, taking part
in surveys for stranded fish in the Handford Reach of
the Columbia River, and collecting physical habitat
data such as water velocity, temperature, turbidity,
light intensity, and substrate classification. General
duties include hauling live fish, transporting
equipment to study sites, and hauling travel trailers
to study sites;
Reorganized a histology slide collection;
and
Assisted in editing the second edition of
``Fish Hatchery Management, the Encyclopedia of
Aquaculture,'' and the Second U.S.-USSR Symposium
Reproduction, Rearing and Management of Anadromous
Fish.
ITEM 9--DEPARTMENT OF JUSTICE
----------
INITIATIVES RELATED TO OLDER AMERICANS
Introduction
As the largest law firm in the nation, the Department of
Justice (DOJ) serves as counsel for its citizens. Through its
lawyers, investigators, and agents, the Department plays a key
role in protecting the nation against criminals and subversion,
ensuring healthy competition of business in our free enterprise
system, safeguarding the consumer, and enforcing drug,
immigration, and naturalization laws. The Department also plays
a significant role in protecting citizens through its efforts
to improve public safety.
In addition, the Department conducts all suits in the
Supreme Court in which the United States is concerned. It
represents the Government in legal matters generally, rendering
legal advice and opinions, upon request, to the President and
to the heads of the executive departments. The Attorney General
supervises and directs these activities, as well as those of
the U.S. Attorneys and U.S. Marshals in the judicial districts
around the country.
Within the Department, the Civil Rights Division, the Civil
Division, the Criminal Division and the Office of Justice
Programs conduct activities related to older Americans.
Civil Rights Division
The Civil Rights Division was established in 1957 to secure
effective Federal enforcement of civil rights. The Division is
the primary institution within the Federal Government
responsible for enforcing Federal statutes prohibiting
discrimination on the basis of race, sex, disability, religion,
and national origin. In 1997, the Division created a Nursing
Home Working Group to develop a coordinated approach and
concerted effort within the Division to address a variety of
civil rights violations that currently exist in the nation's
nursing homes. Staff from the Criminal, Disability Rights,
Housing, and Special Litigation Sections participate in the
Working Group to combat abuse and discrimination in nursing
homes and to raise public awareness about civil rights in these
facilities. Listed below is an overview of the authority and
recent activities of each Civil Rights Division Section to
protect the rights of nursing home residents.
Civil Rights of Institutionalized Persons Act (CRIPA)
Enforcement.--The Division's Special Litigation Section has
responsibility under CRIPA to investigate conditions in public
facilities, including nursing homes, and to file suits where
there is a pattern or practice of violation of the
constitutional or Federal statutory rights of residents. During
1997 and 1998, the Section was active in a number of CRIPA
investigations and cases involving conditions in nursing homes
across the nation, including some of the largest public nursing
homes in the United States. As a result of the Section's CRIPA
efforts, thousands of nursing home residents who were living in
dire, often life-threatening, conditions now receive adequate
care and services and are protected from harm. For example,
during August 1998, the Section settled a CRIPA case involving
unlawful conditions of confinement in a Pennsylvania nursing
home. This settlement represents the first case stemming from a
joint investigation under CRIPA and the False Claims Act. The
settlement, which was a cooperative effort by the Special
Litigation Section, the U.S. Attorney for the Eastern District
of Pennsylvania, the Civil Division, and the Office of the
Inspector General of the U.S. Department of Health and Human
Services, covers both the injunctive relief necessary to remedy
deficiencies in the nursing home, as well as monetary penalties
to reimburse the Federal Government for fraudulent Medicare
billings for inadequate care. The settlement requires
improvements in conditions at the Pennsylvania nursing home to
ensure that its elderly and disabled residents are free from
abuse and neglect and that they receive adequate care and
treatment. As a result of alleged false billing practices, the
defendants agreed to pay civil monetary penalties to the
Federal Government under the False Claims Act and restitution
to the residents by establishing a fund for a special project,
authorized by the United States, that will improve the quality
of life for residents at the nursing home. In addition, the
settlement provides for a Federal monitor who will oversee
compliance with the terms of the agreement.
During 1997, the Section settled another CRIPA case
involving a Virginia nursing home for elderly persons with
mental illness. Under the terms of the settlement, Virginia
must take adequate steps to remedy deficiencies in medical
care, psychiatric treatment, use of restraints, and protection
from harm. The Section also brought another CRIPA case to a
successful close involving a nursing home operated by the
District of Columbia that housed elderly and chronically ill
adults and physically and mentally disabled children. During
the course of the litigation, the Section obtained court orders
to remedy dire conditions at the nursing home, including
inadequate food and medical supplies, untreated pressure sores
resulting in death and amputation, and undue restraint. When
the District decided to close the nursing home, the court
required a court monitor to provide technical assistance and
oversight to assess the needs of the residents and develop
appropriate alternative placements for them. When the court
monitor certified that all residents had been transferred to
safe and appropriate alternative placements, the court
dismissed the case in May 1997.
Throughout 1997 and 1998, the Section also was active in
public awareness and education activities to provide
information about its nursing home activities. The Section
organized meetings and participated in conferences with other
Federal agencies and consumer groups to educate them about its
CRIPA authority and activities.
The Fair Housing Act.--The Housing Section is responsible
for addressing discriminatory practices on the basis of race,
color, religion, sex, national origin, familial status, or
disability in private and public nursing homes and
discriminatory practices in zoning practices that pose barriers
to creating adult foster homes, group homes, and other
community living arrangements for individuals who are
inappropriately placed in nursing homes. During 1997 and 1998,
the Housing Section brought several cases against nursing homes
that discriminated on the basis of race and disability in their
admissions policies. The Section also was active in using the
Fair Housing Act to combat zoning ordinances that discriminate
against adult foster care homes in residential areas.
Americans with Disabilities Act (ADA).--The Division's
Disability Rights Section implements and enforces the ADA. The
ADA is a comprehensive civil rights law that prohibits
discrimination on the basis of disability. The ADA affects six
million businesses and nonprofit agencies, 80,000 units of
state and local government, and 54 million people with
disabilities. Census data indicate that more than half of the
people who are over the age of 65 have disabilities. Thirty-
four percent of these individuals characterize their
disabilities as ``severe.''
The Division's responsibilities under the ADA are to
publish, implement, and enforce the regulations that prohibit
discrimination based on disability in the programs, activities,
and services of state and local governments, and in the
operations of places of public accommodation, such as hotels,
restaurants, theaters, retail sales establishments, health care
facilities, nursing homes, and social service providers.
Through lawsuits and both formal and informal settlement
agreements, the Division has achieved greater access for
individuals with disabilities in hundreds of cases. During 1997
and 1998, the Disability Rights Section investigated several
complaints about practices in nursing homes that allegedly
discriminated against residents based upon their disabilities.
In addition, the Division has established a comprehensive
technical assistance program to educate people with
disabilities about their rights under the ADA and to assist
covered entities to understand their responsibilities. The ADA
Technical Assistance Program provides up-to-date information
about the ADA and how to comply with its requirements. The
Division also undertakes outreach initiatives to increase
awareness and understanding of the ADA and operates an ADA
technical assistance grant program to develop and target
materials to reach specific audiences at the local level,
including small businesses and other small entities. Each year
more than one million people are assisted by the Division and
its grantees.
The technical assistance program includes an ADA homepage
that permits members of the public to use the Internet to gain
access to the Department's regulations, technical assistance
materials, status reports, and settlement agreements. The ADA
homepage receives 3 million ``hits'' per year. In addition, the
technical assistance program operates a toll-free ADA
information line (1-800/514-0301) that operates 24 hours-per-
day to allow members of the public to order ADA public
information and educational materials. The ADA Information Line
receives over 160,000 calls per year.
Criminal Civil Rights Violations.--The Criminal Section has
authority under criminal civil rights statutes to prosecute
public servants--persons acting ``under color of law''--from
intentionally violating the Federal constitutional or statutory
rights of the individuals they serve. In the nursing home
context, the Section can prosecute nursing home staff acting
under color of law who willfully deprive residents of their
civil rights.
Further information about the activities of the Civil
Rights Division is available online at www.usdoj.gov/crt or by
calling the Department of Justice's Office of Public Affairs at
202/514-2008.
Civil Division--Commercial Litigation Branch
The Civil Division represents the United States, its
departments and agencies, Members of Congress, Cabinet
officers, and other Federal employees. The Division confronts
significant policy issues, which often rise to constitutional
dimensions, in defending and enforcing various Federal programs
and actions.
Through its efforts to combat health care fraud, the
Commercial Litigation Branch of the Civil Division each year
returns significant funds to the Medicare Trust Fund for the
benefit of elderly Americans. The chief legal tool used by the
Commercial Litigation Branch in this area is the civil False
Claims Act, which imposes treble damages and statutory
penalties on those who knowingly submit false claims to the
government, and provides for a private right of action for
whistle blowers who may file actions on behalf of the United
States and share in the United States' recovery.
The Federal Government's resources to address health care
fraud were considerably enhanced by the appropriations and new
legal tools made available through Congress' enactment of the
Health Insurance Portability and Accountability Act of 1996
(HIPAA). In the two fiscal years since HIPAA, the Commercial
Litigation Branch, together with the Offices of United States
Attorneys, secured settlements and judgments of over $1.26
billion in matters involving health care providers alleged to
have violated the civil False Claims Act.
Importantly, the Commercial Litigation Branch's successful
use of the False Claims Act accomplishes much more for elderly
Americans than simply restoring lost funds to the Medicare
Trust Fund: it acts as a powerful deterrent against future
financial fraud on Medicare and the provision of inadequate and
harmful health care. For example, following several years of
diligent efforts by the Department of Justice to pursue
hospitals for false claims against Medicare, the Health Care
Financing Administration in 1998 reported a first-time ever
drop in the complexity of cases billed by hospitals
participating in Medicare's prospective payment system (PPS).
1998 is the first year that this ``case-mix index'' has dropped
since the beginning of PPS in 1984, fourteen years ago,
suggesting that hospitals are now less aggressive in billing
Medicare.
The civil False Claims Act was also used during the past
year
in cases against nursing homes that defrauded Medicare by
provid-
ing grossly inadequate nutrition and care, and against
psychiatric
hospitals that arranged with nursing homes for the transfer of
pa-
tients with Alzheimer's and other organic brain disorders so
that
unnecessary psychiatric care could be billed to the Federal
Govern-
ment. The Deputy Attorney General has made it well known to the
health care industry at industry events that it is a top
priority for the Department of Justice to use the False Claims
Act to address the knowing denial of needed care by nursing
homes and managed care organizations.
Further information about the activities of the Civil
Division is available online at www.usdoj.gov/civil or by
calling the Department of Justice's Office of Public Affairs at
202/514-2008.
Criminal Division
The Criminal Division develops, enforces, and supervises
the application of all Federal criminal laws except those
specifically assigned to other divisions. The Criminal Division
and the 93 U.S. Attorneys have the responsibility for
overseeing criminal matters under the more than 900 statutes,
as well as certain civil litigation. In addition to its direct
litigation responsibilities, the Division formulates and
implements criminal enforcement policy and provides advice and
assistance.
Since 1994, the Criminal Division has been responsible for
conducting three initiatives relating to older Americans:
National Telemarketing Fraud Initiative.--Established in
1994, this initiative enabled the Criminal Division to provide
nationwide coordination for the Department on two major
undercover operations directed at telemarketing fraud. The
first operation, Operation Senior Sentinel, involved the use of
active-duty and retired Federal agents and senior volunteers,
recruited through the American Association of Retired Persons,
who tape-recorded telephone solicitations by fraudulent
telemarketers. After the FBI and other agencies took over the
telephone lines of a number of people who had been repeatedly
victimized by telemarketing schemes, the agents and volunteers
pretended to be the victims when telemarketers continued to
call the victims' telephone numbers. From its early stages in
1993 through July 1996, Operation Senior Sentinel resulted in
the conviction of 598 individuals, the execution of 104 search
warrants, and the investigation of 180 telemarketing ``boiler
rooms.'' Leaders of telemarketing schemes who were federally
prosecuted typically received multi-year prison sentences, and
some received prison sentences exceeding 10 years.
The second operation, Operation Double Barrel, built upon
this undercover technique in expanding coordination on
enforcement operations to include state attorneys general and
Federal regulatory agencies. Operation Double Barrel, which
Attorney General Janet Reno announced in December 1998,
involved close cooperation between the FBI, 35 state attorneys
general, and Federal prosecutors between July 1996 and December
1998. During that 30-month period, Federal authorities charged
795 individuals in 218 Federal criminal cases, and 14 state
attorneys general charged 194 individuals in 100 state criminal
investigations. In addition, 255 civil complaints were lodged
against 394 individuals.
International Telemarketing Fraud Initiative.--Created in
1997, this initiative established a basis for the Criminal
Division to provide nationwide coordination for the Department
in implementing recommendations of the United States-Canada
Working Group on Telemarketing Fraud. The Working Group,
created in response to a directive by President Clinton and
Canadian Prime Minister Jean Chretien, issued a report with a
number of recommendations on legal structures, public education
and prevention measures, and strategy and coordination
approaches to combat cross-border telemarketing fraud more
effectively. The initiative has also provided travel funding
for U.S. victims of Canadian-based telemarketing schemes who
are needed for testimony in Canadian criminal prosecutions of
those schemes.
Fraud Prevention Initiative.--Established by the Attorney
General in May 1998, the Fraud Prevention Initiative is
comprised of four components intended to improve the
government's ability to prevent all major types of fraud (with
the exception of health care fraud, which is already being
addressed through the Department's existing healthcare
enforcement efforts). First, the initiative has established a
system of reporting for Federal prosecutors and agents to
identify systemic weaknesses in Federal statutes, regulations,
or policies that may adversely affect the prosecution of
various types of fraud. Second, the Department will provide
Federal law enforcement authorities with reference materials on
``exemplary practices,'' such as fraud prevention and education
projects and ``reverse boiler rooms'' that law enforcement can
establish in various regions of the country to provide improved
community outreach and education on fraud issues. Third, the
Department is expanding its Website to include Webpages on all
major areas of fraud, including frauds such as telemarketing
and investment fraud that can have a major impact on older
Americans. These Webpages are intended to inform the public
about prevalent frauds and explain how they can report possible
fraud schemes or learn how to handle such schemes. Fourth, the
Department is establishing an annual award for fraud prevention
to ensure that significant fraud prevention efforts by
government and private-sector organizations can receive
suitable public recognition.
In addition to these initiatives, the Criminal Division
also provides coordination for Federal and state agencies
through interagency Working Groups that Criminal Division
representatives chair. These include the Health Care Fraud
Working Group, the Securities and Commodities Fraud Working
Group, and the Telemarketing and Internet Fraud Working Group.
Further information about the activities of the Criminal
Division is available online at www.usdoj.gov/criminal or by
calling the Department of Justice's Office of Public Affairs at
202/514-2008.
Office of Justice Programs
Since 1984, the Office of Justice Programs (OJP) has
provided Federal leadership in developing the nation's capacity
to prevent and control crime and delinquency, improve the
criminal and juvenile justice systems, increase knowledge about
crime and related issues, and assist crime victims. OJP is
comprised of five program bureaus and six program offices. The
five bureaus are:
The Bureau of Justice Assistance (BJA) provides funding,
training, and technical assistance to state and local
governments to combat violent and drug-related crime and help
improve the criminal justice system. Its programs include the
Edward Byrne Memorial State and Local Law Enforcement
Assistance formula and discretionary programs and the Local Law
Enforcement Block Grants (LLEBG) program.
The Bureau of Justice Statistics (BJS) collects and
analyzes statistical data on crime, criminal offenders, crime
victims, and the operation of justice systems at all levels of
government. It also provides financial and technical support to
state statistical agencies and administers special programs
that aid state and local governments in improving their
criminal history records and information systems.
The National Institute of Justice (NIJ) supports research
and development programs, conducts demonstrations of innovative
approaches to improve criminal justice, develops new criminal
justice technologies, and evaluates the effectiveness of OJP-
supported and other justice programs. NIJ also provides primary
support for the National Criminal Justice Reference Service, a
clearinghouse of criminal justice-related publications,
articles, videotapes, and online information.
The Office of Juvenile Justice and Delinquency Prevention
(OJJDP) provides Federal leadership in preventing and
controlling juvenile crime and improving the juvenile justice
system at state and local levels. OJJDP also provides grants
and contracts to states to help them improve their juvenile
justice systems and sponsors innovative research,
demonstration, evaluation, statistics, replication, technical
assistance, and training programs to help improve the Nation's
understanding of and response to juvenile violence and
delinquency.
The Office for Victims of Crime (OVC) provides Federal
leadership in assisting victims of crime and their families.
OVC administers two grant programs created by the Victims of
Crime Act of 1984 (VOCA). The Victims Assistance Program gives
grants to states to support programs that provide direct
assistance to crime victims. The Victims Compensation Program
provides funding to state programs that compensate crime
victims for medical and other uncompensated expenses resulting
from a violent crime. OVC also provides funding, training, and
technical assistance to victim service organizations, criminal
justice agencies, and other professionals to improve their
response to crime victims and their families. OVC's programs
are funded through the Crime Victims Fund, which is derived
from fines and penalties collected from federal criminal
offenders, not taxpayers.
OJP's program office responsible for initiatives related to
older Americans is:
The Violence Against Women Office (VAWO) administers grant
programs to help prevent, detect, and stop violence against
women, including domestic violence, sexual assault, and
stalking. VAWO is also responsible for coordinating the
Department of Justice's public outreach and other initiatives
relating to violence against women.
The other five OJP program offices are: the Corrections
Program Office (CPO), the Drug Courts Program Office (DCPO),
the Executive Office for Weed and Seed (EOWS), the Office for
State and Local Domestic Preparedness Support (OSLDPS), and the
Office of the Police Corps and Law Enforcement Education
(OPCLEE).
Also within OJP, the American Indian and Alaska Native Desk
(AI/AN) improves outreach to tribal communities. AI/AN works to
enhance OJP's response to tribes by coordinating funding,
training, and technical assistance and providing information
about available OJP resources.
The following describes OJP's major activities on behalf of
older Americans:
Focus Group on Crime Victimization of the Elderly.--In the
spring of 1998, OJP's bureaus and offices sponsored a focus
group on issues related to the crime victimization of older
persons. Participants included representatives from: the
Administration on Aging; the National Institute on Aging at the
National Institute of Health; American Association of Retired
Persons; National District Attorneys Association; National
Association of Attorneys General; the National Sheriffs'
Association; the National Association of Adult Protective
Services; the National Committee for the Prevention of Elder
Abuse; the National Indian Council on Aging; and state criminal
justice and victims assistance agencies in California,
Pennsylvania, and Florida.
Participants cited three primary areas where states and
local jurisdictions need more support: public education and
awareness; training and technical assistance related to
identifying and addressing elderly victimization for criminal
justice and social service agencies, both within and across
agencies and disciplines; and research. The recommendations of
the focus group have guided planning for FY 1999.
Telemarketing Fraud.--The goal of the Telemarketing Fraud
Prevention and Public Awareness Program is to support federal,
state, and local efforts among law enforcement, crime
prevention, victim assistance, consumer protection, adult
protective services, and senior citizen programs in
implementing public education and training efforts. In December
1997, OVC awarded four grants totaling $600,000 to the Oregon
Senior and Disabled Services Division; the Baltimore County
Department of Aging; the National Sheriffs' Association (NSA);
and the National Hispanic Council on Aging. These funds were
supported by a $600,000 transfer from BJA, as part of a
$2,000,000 Congressional earmark to address elder abuse.
Funding under this program enabled the grantees to do the
following:
The Oregon Senior and Disabled Services
Division provided training and information on fraud for
bank personnel throughout Oregon and created services
for senior fraud victims.
The Baltimore County Department of Aging
produced and distributed a booklet aimed at preventing
telemarketing and telephone fraud. The booklet was also
used as an insert in a Sunday edition of the Baltimore
Sun, at the newspaper's expense.
The National Sheriffs' Association used the
funds for ``Operation Fraudstop,'' a national,
coordinated public education and awareness and training
effort among NSA and a range of agencies and
corporations, including the American Association of
Retired Persons, the National Association of Attorneys
General, the National District Attorneys Association,
TRIAD, state sheriffs' associations, and Radio Shack. A
pilot will also be conducted in Maryland, Montana,
Virginia, and Washington, with replication planned
nationwide.
The National Hispanic Council on Aging
funded a public education campaign to combat
telemarketing fraud in the Latino community, which
included distribution of material and meetings of small
groups of seniors in South Texas and the Washington,
D.C. area to discuss telemarketing fraud issues and the
development of a senior peer counseling program to
provide victim assistance.
BJA's Telemarketing Fraud Curriculum Initiative is
supported by a Congressional earmark for ``programs to assist
law enforcement in preventing and stopping marketing scams
against senior citizens.'' Under this initiative, the National
District Attorneys Association's (NDAA) American Prosecutors
Research Institute (APRI), in cooperation with the National
Association of Attorneys General (NAAG), working with the
American Association of Retired Persons (AARP), and the
National White-Collar Crime Center (NWCCC), is developing a
training curriculum for prosecutors and investigators to help
address these crimes. With BJA funding, the AARP is working in
coordination with the NAAG, APRI, and NWCCC to provide training
and education to state and local investigators and prosecutors
and other related professionals to prevent and effectively
prosecute telemarketing fraud cases.
Publications.--In April 1998, OJJDP released ``Guidelines
for the Screening of Persons Working with Children, the
Elderly, and Individuals with Disabilities in Need of
Support.'' These guidelines, which were prepared by the
American Bar Association's Center on Children and the Law under
a grant from OJJDP, help different types of organizations
screen caregivers by focusing on variables such as the type of
contact the caregiver would have with the client, whether the
care is supervised or unsupervised, and the age and condition
of the client. The guidelines also provide recommendations for
how states can strengthen their efforts by: encouraging abuse
prevention training for all workers at service agencies,
organizations, and facilities for children and dependent
adults; allowing greater access to state criminal record and
sex offender information; and creating central abuse and
neglect registries for children and elderly or dependent
adults.
BJS is developing a statistical report on elderly
victimization using data from the National Crime Victimization
Survey for release in 1999. These statistics will include
comparisons of victimization of senior citizens with that of
other age groups, patterns of victimization that are different
among the elderly than other groups in the population, and some
statistics on violence committed against senior citizens by
relatives and others who are well-known to the victim.
In February 1999, the National Institute of Justice
released its study, Fraud Control in the Health Care Industry:
Assessing the State of the Art , which examines the policies,
procedures, and control systems concerning the unusually high
levels of criminal fraud within the health care industry. The
NIJ study revealed the extent to which certain factors make
controlling fraud and abuse in the health care industry
particularly challenging, including the acceptability of
government and insurance companies in our society as violators,
and the level of trust given to health care providers. One
factor highlighted in the study revealed that many fraud
schemes deliberately target vulnerable populations, such as the
elderly or Alzheimer's patients, who are less willing or able
to complain or alert law enforcement. This study also focused
on criminal fraud rather than abuse because fraud controls are
aimed at an entirely different audience. For instance, controls
may work well in revealing billing errors to well-intentioned
doctors, but those same control systems may not offer an
effective defense against skilled criminals. This report is
available on the Internet at http://www.ojp.usdoj.gov/nij, or
from the National Criminal Justice Reference Service (NCJRS) by
calling toll-free, 1-800/851-3420.
Criminal Justice System Responses to Senior Citizens.--BJA
included a topic area, ``Criminal Justice System Responses to
Senior Citizens,'' in its FY 1998 Open Solicitation, which
invited communities to submit proposals for strategies to
address issues presented by senior citizens as victims,
witnesses, defendants, offenders, or volunteers. BJA received a
total of 120 concept papers under this topic area and expects
to make awards to the Spokane County Prosecuting Attorney's
Office, Spokane, Washington, the City of San Juan, Puerto Rico,
Riverside County District Attorney, Riverside, California, and
the Illinois State Police, Springfield, Illinois. The grantees
will do the following under this topic area:
The Spokane County Prosecuting Attorney's
Office will develop an Elder Abuse Prosecution Team
(EAPT) to aggressively prosecute perpetrators of
physical abuse and neglect against elders; educate the
community to recognize signs and symptoms of abuse; and
increase response to reported crime with knowledgeable
investigators, who conduct intensive and professional
investigations and work in partnership with community
organizations to develop prevention strategies.
The Municipality of San Juan, Office for the
Integral Development of Women will provide regularly
scheduled visits to elderly women living in rural and
marginal areas of San Juan. The visits will include
individual counseling, crisis intervention, and legal
orientation and assistance aimed to prevent crime,
discrimination, physical and emotional abuse,
abandonment, and other situations affecting elderly
women.
The Riverside District Attorney's Office
will establish an Elder Abuse Prevention Unit (EAPU)
and participate in a multi-agency effort to
aggressively address incidents of elder abuse. The
project will serve as a national model for the role of
the district attorney in providing leadership in
addressing this issue. The EAPU will ensure the
prosecution of approximately 50 elder abuse cases and
provide supportive services to elder victims.
The Illinois State Police will develop a
Financial Exploitation of the Elderly Unit to respond
to requests for assistance and provide training in the
investigation and prosecution of statewide financial
exploitation cases against the elderly.
Home Improvement Fraud.--In 1998, BJA awarded a grant to
the American Prosecutors Research Institute (APRI) for the Home
Improvement Fraud Against Seniors Program. APRI provides
training and technical assistance to local prosecutors to
protect senior citizens from home improvement fraud through
increased prosecution, prevention, and education. APRI also
aids local prosecutors in their fight against home improvement
fraud by showing them successful and cost effective ways to
gain evidence needed, establish proof, communicate with other
prosecutors, and develop education and prevention efforts to
protect senior citizens.
Grants to Encourage Arrest Policies and the Technical
Assistance Program.--The VAWO FY 1998 applications for the
Grants to Encourage Arrest Policies and the Technical
Assistance Program included a number of special interest areas,
one of which was ``community-driven initiatives to address
violence against women among diverse, traditionally under-
served populations,'' including elderly women. Under its
Technical Assistance Program, VAWO awarded a grant to the
American Bar Association's Commission on Domestic Violence and
Legal Problems of the Elderly to provide training and technical
assistance on issues related to older battered women to current
recipients of OJP grants under the Violence Against Women Act.
TRIAD.--TRIAD is a national program cosponsored by the
National Sheriffs' Association, the International Association
of Chiefs of Police, and the American Association of Retired
Persons. TRIAD combines the efforts and resources of law
enforcement, senior citizens and organizations that represent
them, and victim assistance providers. Activities include
educating communities about elder abuse; strengthening the
criminal justice system's process of prevention, detection, and
assistance for elderly crime victims; implementing reassurance
programs for homebound and isolated elders; and providing
technical assistance for new and existing TRIADs. There are now
436 TRIAD programs in 46 states, Canada, and England.
In FY 1999, funds will be provided to adapt TRIAD for use
in Indian country. OVC will provide funding for a demonstration
program on one Indian reservation under federal criminal
jurisdiction. The purpose of this program is to provide a
coordinated response to crime against the elderly by adapting
the TRIAD program approach to Indian country.
American Bar Association.--OVC awarded two grants to the
American Bar Association (ABA) in FY 1998. Funding from the
first award went to the ABA's Commission on Domestic Violence
and Commission on Legal Problems of the Elderly to jointly
develop a curriculum for lawyers about domestic violence and
elder abuse. The second grant was awarded to the ABA's
Commission on Legal Problems of the Elderly to develop a
curriculum on elder abuse for victim assistance professionals.
For More Information about OJP programs or activities on
behalf of older Americans, contact OJP's Office of
Congressional and Public Affairs at 202/307-0703 or access the
OJP homepage at www.ojp.usdoj.gov. Funding information is
available from the Department of Justice Response Center at 1-
800/421-6770. OJP and other criminal and juvenile justice-
related publications are available from the National Criminal
Justice Reference Service by calling toll-free, 1-800/851-3420,
or online at www.ncjrs.org.
ITEM 10--DEPARTMENT OF LABOR
----------
The welfare of our Nation's older citizens is a matter of
substantial concern to the Department of Labor. The Department
of Labor is pleased to provide this summary of the programs it
administers which can provide helpful assistance to older
citizens. These include--job training and related services,
dislocated worker services, and other employment services,
under programs administered by the Department of Labor's
Employment and Training Administration; a public information
and assistance program on matters relating to certain pension
and welfare plans under programs administered by the Pension
and Welfare Benefits Administration; the Bureau of Labor
Statistics' statistical programs providing employment and
unemployment data for older persons; protection for certain
employees to take unpaid, job-protected leave to provide care
for sick, elderly parents under a program administered by the
Employment Standards Administration; and a Clearinghouse
administered by the Women's Bureau which provides information
and resources to workers and employers interested in developing
or implementing family-friendly policies such as elder care and
child care. These programs and services are addressed more
fully in the following discussion.
EMPLOYMENT AND TRAINING ADMINISTRATION
introduction
The Department of Labor's (DOL's) Employment and Training
Administration (ETA) provided a variety of training, employment
and related services for the Nation's older individuals during
Program Years 1996 (July 1, 1996-June 30, 1997) and 1997 (July
1, 1997-June 30, 1998) through the following programs and
activities: the Senior Community Service Employment Program
(SCSEP); programs authorized under the Job Training Partnership
Act (JTPA); and the Federal-State Employment Service system.
senior community service employment program
SCSEP, authorized by Title V of the Older Americans Act,
employs low-income persons age 55 or older in a wide variety of
part-time community service activities such as health care,
nutrition, home repair and weatherization, child care, and in
beautification, conservation, and restoration efforts. Program
participants work an average of 20 hours per week in schools,
hospitals, parks, community centers, and in other government
and private, non-profit facilities. Participants also receive
personal and job-related counseling, are offered annual
physical examinations, job training, and in many cases,
referral to private sector jobs.
About 80 percent of the participants are age 60 or older,
and about 60 percent are age 65 or older. Almost three-fourths
are female; about 40 percent have not completed high school.
All participants are economically disadvantaged.
Table I below shows SCSEP enrollment and participant
characteristics for the program year July 1, 1996, to June 30,
1997, in Column 1 and July 1, 1997, to June 30, 1998, in Column
2.
TABLE 1.--SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP): CURRENT
ENROLLMENT AND PARTICIPANT CHARACTERISTICS--PROGRAM YEARS JULY 1, 1996,
TO JUNE 30, 1997, (PY96) AND JULY 1, 1997, TO JUNE 30, 1998 (PY97)
------------------------------------------------------------------------
Program years
---------------------
1996 1997
------------------------------------------------------------------------
Enrollment:
Authorized positions established.............. 60,500 61,307
Unsubsidized employment rate (Percent)........ 26.1 29.7
Characteristics (Percent):
Sex:
Male...................................... 27.2 26.9
Female.................................... 72.4 73.0
Educational status:
8th grade and less........................ 18.3 17.5
9th grade through 11th grade.............. 19.1 18.6
High School graduate or equivalent........ 39.3 39.9
1-3 years of college...................... 15.9 16.4
4 years of college or more................ 7.3 7.3
Veterans...................................... 12.9 12.4
Ethnic Groups: \1\
White..................................... 59.6 58.8
Black..................................... 24.6 25.0
Hispanic.................................. 9.8 9.9
American Indian/Alaskan Native............ 1.8 1.9
Asian/Pacific Island...................... 4.1 4.2
Economically disadvantaged.................... 100.0 100.0
Poverty level or less......................... 85.7 86.0
Age groups: \1\
55-59..................................... 17.0 16.7
60-64..................................... 22.9 22.8
65-69..................................... 24.8 24.4
70-74..................................... 19.8 19.7
75 and over............................... 15.5 16.1
------------------------------------------------------------------------
\1\ Figures may not add to 100% due to rounding.
Source: U.S. Department of Labor, Employment and Training
Administration.
Job Training Partnership Act Programs
The Job Training Partnership Act (JTPA) provides job
training and related assistance to economically disadvantaged
individuals, dislocated workers, and others who face
significant employment barriers. The ultimate goal of JTPA is
to move program participants into permanent, self-sustaining
employment. Under JTPA, Governors have the approval authority
over locally developed plans and are responsible for monitoring
local program compliance with the Act. JTPA functions through a
public/private partnership which plans, designs and delivers
training and other services. Private Industry Councils (PICs),
in partnership with local governments in each Service Delivery
Area (SDA), are responsible for providing guidance for, and
oversight of, job training activities in the area.
Amendments to JTPA became effective July 1, 1993. These
amendments target program services to those with serious skill
deficiencies; and individualize and intensify the quality of
services provided. Five percent of the funds appropriated for
the adult program (Title II-A) must be used by States in
partnership with SDAs for older workers. The amendments also
require Governors to ensure that services under the adult
program are provided to older workers on an equitable basis.
Basic JTPA Grants
Title II-A of JTPA authorizes a wide range of training
activities to prepare economically disadvantaged adults for
employment. Training and training-related services available to
eligible older individuals through the basic Title II-A grant
program include vocational counseling, jobs skills training
(either in a classroom or on-the-job), literacy and basic skill
training, job search assistance, and job development and
placement. Table 2 below shows the number of persons 55 years
of age and over who terminated from the Title II-A program
during the period July 1, 1996, through June 30, 1997, and
during the period July 1, 1997, through June 30, 1998. (The
data do not include the 5 percent set-aside for older
individuals, which is discussed separately.)
TABLE 2.--JTPA DATA JULY 1, 1996--JUNE 30, 1998
[Title II-A]
------------------------------------------------------------------------
Number served
Item ---------------------- Percent
PY96 PY97
------------------------------------------------------------------------
Total Adult Terminees.................. 151,155 198,033 100
55 years and over...................... 3,054 3,067 2
------------------------------------------------------------------------
Source: U.S. Department of Labor, Employment and Training
Administration.
Section 204 Set-Aside
The 1992 JTPA amendments require 5 percent of the Title II-
A allotment of each State to be made available for the training
and placement of older individuals in private sector jobs. Only
economically disadvantaged individuals who are 55 years of age
or older are eligible for services under this State set-aside.
Governors have wide discretion regarding use of the JTPA 5
percent set-aside. Two basic patterns have evolved. One is
adding set-aside resources to Title II-A to ensure that a
specific portion of older persons participates in the basic
Title II-A program. The other is using the resources to
establish specific projects targeted to older individuals which
operate independently of the basic job training program for
disadvantaged adults. Likewise, States are required to provide
``equitable services to older individuals throughout the State,
taking into consideration the incidence of such workers in the
population.'' Some States distribute all or part of the 5
percent set-aside by formula to local SDAs; other States retain
the resources for State administration or model programs.
Governors are expected to coordinate services as much as
possible with those provided under Title V of the Older
Americans Act--Senior Community Service Employment Program.
There are two separate provisions for older individual programs
as they relate to Title V of the Older Americans Act. First,
under the Title II-A program, up to ten percent of the
participants may be individuals who are not economically
disadvantaged, but who have a serious barrier to employment.
Second, when a JTPA grantee and Title V sponsor establish joint
projects, individuals eligible under Title V of the Older
Americans Act ``shall be deemed to satisfy the requirements''
of JTPA. These joint (JTPA-SCSEP) projects may include co-
enrollment of Title V participants in Title II-A activities.
Joint programs must have a written agreement, which may be
financial on nonfinancial in nature, and may include a broad
range of activities. For Program Year 1996 (July 1, 1996,
through June 30, 1997), 14,587 participants were enrolled in
the State set-aside program for economically disadvantaged
individuals 55 years of age and older. For Program Year 1997
(July 1, 1997, through June 30, 1998), 13,204 participants were
enrolled in the State set-aside program for economically
disadvantaged individuals 55 years of age and older.
Programs for Dislocated Workers
Title III of JTPA authorizes a State and locally-
administered dislocated worker program that provides retraining
and readjustment assistance to workers who have been, or have
received notice that they are about to be, laid off due to a
permanent closing of a plant or facility; laid off workers who
are unlikely to be able to return to their previous industry or
occupation; and the long-term unemployed with little prospect
for local employment or reemployment. Those older dislocated
workers eligible for the program may receive such services as
job search assistance, retraining, pre-layoff assistance and
relocation assistance. During the period July 1, 1996, through
June 30, 1997, approximately 28,351 individuals 55 years of age
and over exited the program (10 percent of the program
terminations). During the period July 1, 1997, through June 30,
1998, approximately 26,544 individuals 55 years of age and over
left the program (8 percent of the program terminations).
The Federal-State Employment Service System
The State-operated public employment service (ES) offices
offer employment assistance to all job seekers, including
middle-aged and older persons. A full range of basic labor
exchange services are provided, including counseling, testing,
job development, job search assistance and job placement. In
addition, labor market information and referral to relevant
training and employment programs are also available.
Federal reporting requirements for State employment service
agencies (SESAs) were revised effective July 1, 1992, to
capture additional information on applicant characteristics,
including data on the age of all ES applicants and those placed
in employment. During the period July 1, 1996 through June 30,
1997 over 1,206,000 ES applicants were age 55 and over.
Approximately 84,000 of the ES applicants age 55 and over were
placed in jobs during this period. During the period July 1,
1997 through June 30, 1998 over 1,200,000 ES applicants were
age 55 and over. Approximately 83,000 of the ES applicants age
55 and over were placed in jobs during this period.
PENSION AND WELFARE BENEFITS ADMINISTRATION
Introduction
The Pension and Welfare Benefits Administration (PWBA) is
responsible for enforcing the Employee Retirement Income
Security Act (ERISA). PWBA's primary responsibilities are for
the reporting, disclosure and fiduciary provisions of the law.
Employee benefit plans maintained by employers and/or
unions generally must meet certain standards, set forth in
ERISA and the Internal Revenue Code, designed to ensure that
employees actually receive promised benefits. Employee benefit
plans exempt from ERISA include church and Government plans.
The requirements of ERISA differ depending on whether the
benefit plan is a pension or a welfare plan. Pension plans
provide retirement benefits, and welfare plans provide a
variety of benefits, such as employment-based health insurance
and disability and death benefits. Both types of plans must
comply with provisions governing reporting to the government
and disclosure to participants (Title I, Part 1) and fiduciary
responsibility (Title I, Part 4). Pension plans must comply
with additional ERISA and Internal Revenue Code standards
(contained in both Title I, Parts 2 and 3, and Title II), which
govern membership in a plan (participation); nonforfeitability
of a participant's right to a benefit (vesting); and financing
of benefits offered under the plan (funding). Welfare plans
providing medical care must comply with ERISA continuation of
coverage requirements and medical child support orders (Title
I, Part 6).
The Departments of Labor and Treasury have responsibility
for administering the provisions of Title I and Title II,
respectively, of ERISA. The Pension Benefit Guaranty
Corporation (PBGC) is responsible for administering Title IV,
which established an insurance program for certain benefits
provided by specified ERISA pension plans. On a regular basis,
PWBA meets and coordinates closely with the Internal Revenue
Service (IRS) and PBGC on matters concerning pension issues.
PWBA emphasized its commitment to customer service by
increasing the resources devoted to this area. The number of
inquiries it handled increased to over 155,000 for FY 1998.
Through these effort staff increased its recoveries to over $42
million in this year.
In FY 1996, PWBA worked to advance the Health Insurance
Portability and Accountability Act (P.L. 104-91), enacted
August 21, 1996, which amended ERISA to provide increased
access to health care benefits, to provide increased
portability of health care benefits, and to provide increased
security of health care benefits. The Newborns' and Mothers'
Health Protection Act and the Mental Health Parity Act, enacted
on September 26, 1996 (P.L. 104-204), added to ERISA mental
health parity provisions and provisions regarding minimum
mandatory hospital stays for newborns and mothers.
Implementation of these laws requires PWBA's continuing
attention.
In FY 1997, PWBA worked to advance the Taxpayer Relief Act
(P.L. 105-33), and the Savings Are Vital to Everyone's
Retirement Act (``Saver'') (P.L. 105-92). The Taxpayer Relief
Act provided incentives for and thus encouraged the
establishment and maintenance of qualified pension plans.
``Saver'' emphasized the importance of retirement planning, and
the government's role in helping to educate consumers on this
important issue.
PWBA also worked to advance the Administration's Retirement
Savings and Security Act. Many of its provisions were
incorporated in the Small Business Jobs Protection Act (P.L.
104-188) (SBJPA) enacted on August 20, 1996. The SBJPA created
a new simplified retirement plan for small businesses, and
simplified plan distribution and nondiscrimination rules.
ERISA's rules concerning how a claim for benefits must be
processed were put in place in 1977, prior to the advent of
managed care. In order to assess whether it should revisit
these rules, PWBA published a notice in the Federal Register in
September 1997, requesting information from the public
concerning whether the claims rules are still functioning
appropriately. After reviewing the many comments received, PWBA
issued a notice of proposed rulemaking regarding these rules.
Because of the risk of abuse or loss (e.g., from employer's
bankruptcy), many employees have raised questions about the
time period during which employers must transmit participant
contributions to employee benefit plans. To address their
concerns, PWBA issued a rule under Title I of ERISA which
substantially shortens the time period during which covered
private sector employers may hold employees' contributions to
pension plans, including 401(k) plans, before depositing the
funds in the plans. Under the new rule, for example, an
employer that sponsors a 401(k) plan must deposit its
employees' contributions in the plan as soon as the
contributions can reasonably be segregated from the employers'
general assets, but not later than 15 business days following
the month in which the employer withholds the money from
employees' paychecks, or receives employees' checks for the
amount of the contributions.
With the growth of participant-directed individual account
pension plans, more employees are directing the investment of
their pension plan assets and, thereby, assuming more
responsibility for ensuring the adequacy of their retirement
income. In order to help employers address the need of
participants for more investment information, PWBA issued an
interpretive bulletin providing guidance to plan sponsors,
fiduciaries, participants and beneficiaries concerning the
circumstances under which the provision of investment related
educational information, programs and materials to plan
participants and beneficiaries will not give rise to liability
under ERISA.
Another critical factor which affects the amount an
employee has at retirement are the fees charged to 401(k)
plans. In order to increase employees' awareness, and to
encourage plan sponsors to more closely examine such fees, PWBA
held a hearing on 401(k) fee practices and subsequently
published a booklet which answers commonly asked questions
regarding plan fees.
In fiscal year 1998, PWBA continued its program of research
directed toward improving the understanding of the employment-
based pension and health benefit systems. PWBA published
comprehensive statistics on private pension participation,
finances and investments in its annual ``Private Pension Plan
Bulletin.'' It published ``Health Benefits and the Workforce,
Volume 2,'' a compendium of sixteen major PWBA-funded research
studies. PWBA also completed new major research projects on
topics including 401(k) fees, small-group health insurance
markets, and health plan liability under ERISA, and funded
eight new small research projects.
Inquiries
PWBA publishes literature and audio-visual materials which,
in some depth, explain provisions of ERISA, procedures for
plans to ensure compliance with the Act and the rights and
protections afforded participants and beneficiaries under the
law. In addition, PWBA maintains a public information and
assistance program, which responds to many inquiries from older
workers and retirees seeking assistance in collecting benefits
and obtaining information about ERISA. Further, PWBA
established an 800 number to facilitate distribution of
publications, and implemented an intense outreach program which
disseminated information utilizing the various media. Among the
publications disseminated, the following are designed
exclusively to assist the public in understanding the law and
how their pension and health plans operate: Top Ten Ways to
Beat the Clock and Prepare for Retirement; Women and Pensions--
What Women Need to Know and Do; What You Should Know About Your
Pension Rights; Protect Your Pension--A Quick Reference Guide;
How to File a Claim for Your Benefits; How to Obtain ERISA Plan
Documents from the Department of Labor; Handling Inquiries on
Pension and Welfare Benefits; Guide to Summary Plan Description
Requirements; Reporting and Disclosure Guide for Employee
Benefit Plans; Trouble Shooter's Guide to Filing the ERISA
Annual Report; Exemption Procedures under Federal Pension Law;
Health Benefits under COBRA; Multiple Employer Welfare
Arrangements under ERISA (MEWAs); Customer Service Standards--
Our Commitment to Quality; How Did We Measure Up; Questions and
Answers on Recent Changes in Health Care Law; Can the Retiree
Health Benefits Provided by your Employer Be Cut; A Look at
401(k) Plan Fees; QDROs: The Division of Pensions Through
Qualified Domestic Relations Orders.
EMPLOYMENT STANDARDS ADMINISTRATION
The Family and Medical Leave Act of 1993 became effective
on August 5, 1993, for many employers. This statute provides
potential benefit to the elderly in that it empowers eligible
employees of covered employers to take up to 12 weeks of
unpaid, job-protected leave in any 12-month period to provide
care for a parent who has a serious health condition. In the
past, the employee had to make a decision in many instances of
whether or not to give up their job to provide care to a sick,
elderly parent.
BUREAU OF LABOR STATISTICS
The Department of Labor's Bureau of Labor Statistics (BLS)
regularly issues a wide variety of statistics on employment and
unemployment, prices and consumer expenditures, compensation
including wages and benefits, productivity, economic growth,
and occupational safety and health. Data on the labor force
status of the population, by age, are prepared and issued on a
monthly basis. Data on consumer expenditures, classified by age
groupings, are published annually. In 1994 BLS published the
first results of the redesigned survey of occupational injuries
and illnesses; these data are now available by age, race, and
gender, providing important new information on this aspect of
the labor market experiences of older Americans. In addition to
regularly recurring statistical series, BLS undertakes special
studies as resources permit. In May 1994 BLS published a report
on an experimental series that reweighted the official Consumer
Price Index using expenditure data for older Americans. This
report updated a portion of a study originally performed by BLS
in response to the Older Americans Act Amendments of 1987. BLS
continues to compute the reweighted index each month.
THE WOMEN'S BUREAU
The Women's Bureau National Resource and Information Center (NRIC)
(Formerly the Women's Bureau Clearinghouse)
Established by the Women's Bureau of the U.S. Department of
Labor in 1989, the Clearinghouse is a computerized database and
resource center responsive to dependent care and women's
workplace issues. Services help employers and employees make
informed decisions about which programs and services help in
balancing work and family. The NRIC offers information in five
broad option areas for child care and elder care services:
direct services, information services, financial assistance,
flexible leave policies, and public-private partnerships.
The workforce quality component of the NRIC offers
information and guidance on the rights of women workers in such
matters as age and wage discrimination, the Family and Medical
Leave Act (FMLA), pregnancy discrimination, and sexual
harassment. In addition, information is available about the
Federal agencies that enforce laws covering these topics.
Within each of these areas customers can be provided with model
programs from other companies, implementation guides, national
and State information sources and bibliographic references.
The NRIC continues to receive requests for information on
work-site elder care program options. Information provided
included flexible work schedules, adult day care, case
management, decision making, information and referral, respite
care, and transportation services.
The NRIC can be accessed through 1-800-827-5335.
Work and Elder Care Fact Sheet
Facts for Caregivers and Their Employers
Published in May 1998, this fact sheet gives an
introduction which discusses statistics on the aging
population, women workers, and elder care.
The second section discusses the types of elder care
assistance: geriatric care managers; homemakers and home health
aides; companions/friendly visitors; telephone reassurance
systems; respite care; daily money managers; home-delivered
meals; chore and repair; legal assistance or resources; family
and medical leave; and assistance with financing care.
The third section discusses ways employers/labor
organizations are helping/can help employees with elder care:
needs surveys; elder care resource and referral; seminars;
support groups; employee assistance programs; caregiver fairs;
counseling; long-term care insurance; visiting nurse services;
adult day care, including intergenerational day care; emergency
care; elder care pager programs; flexible spending or dependent
care accounts; flexible schedules and leaves of absence; case
management; and transportation.
ITEM 11--DEPARTMENT OF STATE
----------
The Department is pleased to report that we continue to
expand services for aging Americans. Not only are employees
working longer (the mandatory retirement age for Foreign
Service is 65, and there is no mandatory retirement age for
Civil Service), but employee responsibilities for caring for
aging family members have grown significantly. In recognition
of this, in 1995 the Office of Medical Services, Education and
Wellness Programs, conducted a panel discussion on a variety of
topics focused on older persons. That office hosted a health
fair and offered several medical tests aimed at identifying
diseases found primarily in older persons, such as prostate,
cholesterol, and blood pressure screenings. The Office of
Medical Services also hosted a panel of experts from the
Washington metropolitan area to describe long-term care
programs in local jurisdictions. Seminars were offered on
Alzheimer's disease, living wills, osteoporosis and menopause.
The Office of Employee Consultation Services, staffed by
licensed clinical social workers, arranged support groups and
special presentations on topics such as caring for elderly
parents and dementia.
The Office of Work and Family Programs in the Bureaus of
Personnel was established in 1995 as a focal point for work and
family programs. This office assists employees with questions
on locating elder care services and recently hosted a monthly
series of noontime sessions on family related topics, including
elder care. The Work and Family Program Coordinator represented
the Department on the Office of Personnel Management's
Interagency Working Group on Adult Dependent Care.
In support of the Foreign Service's employees based
overseas, the family Liaison Office continued to provide
Foreign Service families with oral and written information on
caring for elderly parents, medical insurance, and procedures
for taking an elderly relative to overseas posts. In addition,
they make referrals, upon request for information on payment
options for long-term care and legal issues.
In 1996, the Department's Work and Family Programs office
expanded its outreach efforts. It held seminars for
grandparents who are primary caretakers for their grandchildren
and repeated its most popular seminar topics, i.e., caring for
aging parents and the diseases most common in the elderly. In
addition, the Office of Employee Consultation Services hired an
additional clinical social worker who had a specialty in
geriatrics.
Thank you for your continuing interest in this issue. The
Department continues to identify ways to adapt or expand our
current elder care services to help employees balance their
work and family responsibilities.
ITEM 12--DEPARTMENT OF TRANSPORTATION
----------
SUMMARY OF ACTIVITIES TO IMPROVE TRANSPORTATION SERVICES FOR THE
ELDERLY \1\
---------------------------------------------------------------------------
\1\ ``Prepared for the U.S. Senate Special Committee on Aging--
February 1999.
---------------------------------------------------------------------------
Introduction
The following is a summary of significant actions taken by
the U.S. Department of Transportation during calendar years
1997 and 1998 to improve transportation for elderly persons.\2\
---------------------------------------------------------------------------
\2\ Many of the activities highlighted in this report are directed
toward the needs of persons with disabilities. However, one-third of
the elderly are persons with disabilities and thus will be major
beneficiaries of these activities.
---------------------------------------------------------------------------
Direct Assistance
federal railroad administration (fra)
The National Railroad Passenger Corporation (Amtrak)
continued throughout calendar years 1997 and 1998 to provide
discounted fares, accessible accommodations, and special
services, including assistance in arranging travel for older
citizens and passengers with disabilities. These passengers
continue to represent a substantial part of Amtrak's
ridership--in recent years, 28 percent of long-distance
passengers were 62 or older.
Discounted Fares.--Amtrak has a systemwide policy of
offering to elderly persons and persons with disabilities a 15
percent discount on one-way ticket purchases. This 15 percent
discount cannot be combined with any other discounts.
Accessible Accommodations.--Amtrak provides accommodations
that are accessible to elderly persons and passengers with
disabilities, including those using wheelchairs, on all of its
trains. Long-distance trains include accessible sleeping rooms.
Short-distance trains, including Northeast Corridor trains,
have accessible seating and bathrooms. Many existing cars are
being modified to provide more accessible accommodations and
all new cars will provide enhanced accessibility for
passengers, with mobility and other types of disabilities.
Mechanical lifts operated by train or station staff provide
passengers with access to single-level trains from stations
with low platforms and short plate ramps provide access to bi-
level equipment. An increasing number of Amtrak stations are
fully accessible, particularly key intermodal stations that
provide access to commuter trains and other forms of
transportation.
Special On-Board Services.--Amtrak continues to provide
special on-board services to elderly persons and passengers
with disabilities, including aid in boarding and deboarding,
special food service, special equipment handling, and
provisions for wheelchairs. Amtrak has also improved training
of its employees to enable them to respond better to passengers
with special needs. It is recommended that passengers advise
Amtrak of any special needs they may have in advance of their
date of departure.
Assistance in Making Travel Arrangements.--Persons may
request special services by contacting the reservations office
at 1-800-USA-Rail. This office is equipped with text telephone
(TTY) service for customers who are deaf or hard of hearing. To
ensure that passengers receive the assistance they need, Amtrak
maintains a Special Services Desk, which supports its
reservations agents seven days a week. This desk has completed
successful responses to nearly 100,000 requests for special
services. Passengers may also inform their travel agent or the
station ticket agent of their assistance requirements when
making travel reservations.
federal transit administration (fta)
Under 49 USC 5310, the FTA provides assistance to private
non-profit organizations and certain public bodies for the
provision of transportation services for the elderly and
persons with disabilities. In FY 1997, $55.3 million was used
to assist 1,250 local providers purchase 1,635 vehicles, and in
FY 1998, $62.2 million was used to assist 1,400 local providers
purchase approximately 1,850 vehicles for the provision of
transportation services for the elderly and individuals with
disabilities. Most of the agencies funded under this program
are either disability service organizations or elderly service
organizations, and service provided under the program is nearly
equally divided between the two. Those agencies serving the
elderly are, however, more dependent on funding from the
elderly and persons with disabilities program as 53 percent of
their vehicles are purchased with Section 5310 funds compared
to 42 percent of vehicles purchased by agencies serving persons
with disabilities. Vehicles purchased with these funds may also
be used for meal delivery to the homebound as long as such use
does not interfere with the primary purpose of the vehicles.
Under 49 USC 5311, the FTA obligated $115.1 million in FY
1997 and $134.1 million in FY 1998. These funds were used for
capital, operating, and administrative expenditures by state
and local agencies, nonprofit organizations, and operators of
transportation systems to provide public transportation
services in rural and small urban areas (under 50,000
population). The nonurbanized area program funds are also used
for intercity bus service to link these areas to larger urban
areas and other modes of transportation. An estimated 36
percent of the ridership in nonurbanized systems is elderly,
which represents nearly three times their proportion of the
rural population.
Under 49 USC 5307, the FTA obligated $2.5 billion in FY
1997 and $2.4 billion in FY 1998. These funds were used for
capital and operating expenditures by transit agencies to
provide public transportation services in urbanized areas.
While these services must be open to the general public, a
significant number of passengers served are elderly.
Research
department-wide aging initiative
National Agenda for the Transportation Needs of an Aging
Society.--As a follow-up to its January 1997 study of how well
the Nation's transportation system will accommodate the growing
cohort of older adults, and its proposed theme of Safe Mobility
For Life, the Department has initiated a project to structure a
National Agenda for the Transportation Needs of an Aging
Society. This will include a national dialogue on the
transportation needs of older adults, where the system is
falling short, and what remedial measures are viable. Included
in this dialogue will be practitioners and authorities as well
as older people and their advocacy groups such as the AARP, the
AAA, and the private sector. The effort is in three parts:
(1) Developing with the Transportation Research Board a
plan for necessary future research on the transportation
problems of the elderly, reflecting the research that has been
accomplished, the new safety needs that have been identified,
and the new priorities that should be established. That report
will be published in the year 2000.
(2) Conducting a series of seminars on the special needs of
older persons, with transportation professionals, planners,
social service and medical providers--followed up by focus
group sessions with older persons and their lay care-givers on
how they see their transportation needs, and
(3) Taking the results of (1) and (2) to develop a National
Agenda for the next decade and beyond for meeting the needs of
the coming surge in aging Americans. Included in this work will
be an international conference on these issues in November
1999.
federal aviation administration (faa)
The Office of Aviation Medicine's Civil Aeromedical
Institute has contributed to the following research related to
the needs and concerns of the aging population in aviation
transportation.
Cognitive Function Test.--An automated cognitive function
test (CogScreen) was developed to permit the more sensitive and
specific evaluation of pilots after brain injury and disease.
Administration of CogScreen to groups of pilots led to the
establishment of a database that could be used to assess
fitness to perform flying duties in relation to the age of the
subject being evaluated. A report describing age-related
changes in CogScreen for non-pilots has been completed.
Throughout repeated administrations of selected components of
the CogScreen test battery, the performance of older subjects
remained slower and poorer than that of subjects in the
youngest age group.
Flight Deck-Related Human Factors Research.--Two phases of
a three-phase study have been completed to assess age-related
changes in pilots' auditory thresholds compared to non-pilots
and determine the effects of those differences on the ability
to detect and respond to auditory alarms in flight simulations.
Threshold data were collected from 150 non-pilots and 150
pilots using stratified age samplings. The usual high-frequency
decrements attributable to aging and general environmental
exposure were found in both samples. Significant differences
were found between the non-pilots and pilot samples, with
greater threshold shifts between 2 and 6 kHz in evidence among
pilots. The second phase involved the detection and
identification of conventional and novel auditory warning
sounds during exposure to simulated aircraft engine noise.
Assessments of pilot responses to different types of auditory
alarms in the general aviation simulator will be assessed this
year.
Air Traffic Control.--Issues associated with the selection
and training of air traffic personnel along with the
introduction of new technologies has maintained interest in the
role of age on performance. A study was completed to develop a
systematic projection of the aging of the current air traffic
control workforce and retirement eligibility in order to model
recruitment, hiring, and training requirements for the future.
Based on these projections, the annual retirement rate is
projected to slowly rise from about 1.4 percent in FY 1999 to a
peak of about 6.1 percent in FY 2012, and then decline to about
1.7 percent in FY 2020. These data suggest that the majority of
controllers will continue to work through at least the initial
modernization of the National Air Space, represented by Free
Flight Phase I. As part of the validation of a new computerized
selection instrument for air traffic controllers, a study was
conducted to determine the relationship between age and
performance on both the selection tests and on the criterion
measures of controller performance. The two criteria measurers
used in the study were ratings (both peer and supervisor) and
score on a newly developed computer-based performance measure.
Results show a curvilinear relationship between age and both
test scores and criterion measures, with performance declining
for controllers over the age of 42. A draft report describing
outcomes for the study has been completed.
federal highway administration (fhwa)
Beginning in 1989, a High Priority Area for research was
established to address the needs of older drivers with respect
to the roadway environment. Research under this program started
as problem identification, and quickly moved to focus on the
specific areas, which cause the greatest problems for older
drivers and pedestrians. The activities described below were
ongoing during the calendar years 1997 and 1998. It should be
noted that all human factors research, including Intelligent
Transportation Systems initiatives, conducted by FHWA includes
an older driver component to ensure the system's utility for
all potential users.
A research study, titled, Synthesis of Research Findings on
Older Drivers, gathered all available research and synthesized
it into a report of major replicable findings regarding older
drivers. This research was then incorporated into an Older
Driver Highway Design Handbook (FHWA-RD-97-135) which became
available in January 1998. The handbook serves as an important
resource for traffic engineers in assuring that highways meet
the needs and capabilities of older drivers and pedestrians.
The handbook has been widely distributed and extremely well
received. A condensed version, titled Older Driver Highway
Design Handbook: Recommendations and Guidelines (FHWA-RD-99-
045), became available in December of 1998.
As a companion to the Handbook, the FHWA has initiated a
workshop for traffic engineers and highway designers. The
workshop educates practitioners about the needs and
capabilities of older road users, reviews the recommendations
of the Handbook in detail, and presents case studies as
learning exercises. Six workshops have been presented, in
Florida, Texas, Iowa, and Pennsylvania, and more are planned.
The FHWA is also currently in the process of fulfilling a
mandate issued by Congress that requires public agencies to
maintain pavement markings to minimum levels of brightness. In
the process of establishing these minimum guidelines, research
has been conducted to determine the brightness of pavement
markings necessary for older drivers to drive safely and
comfortably at night. FHWA is also investigating a new type of
automobile headlight system, which has the potential to
drastically improve the visibility of pavement markings and
pedestrians at night. Older drivers have been included in the
field experiments of the ultraviolet headlamp technology, and
results indicate a favorable response both subjectively and
objectively. Another ongoing study will identify optimum
lighting design for older drivers.
The results of these studies and other research will be
incorporated into the next generation of the Handbook, which is
under development. Besides including the most recent research
findings, this document will address a wider range of highway
design areas. It will be produced in electronic as well as
traditional paper media.
national highway traffic administration (nhtsa)
Vehicle Design for Crash Avoidance. NHTSA's crash avoidance
research program addresses the relationship between vehicle
design and driver performance and behavior. New vehicle
technologies could help reduce older driver crashes and enhance
their mobility. For example, in-vehicle navigation systems may
allow drivers to concentrate on watching for dangerous traffic
conflicts instead of being distracted while searching for road
signs. Collision avoidance systems may alert drivers to
potential crash situations. Additional research in this area
could provide useful information regarding the acceptability of
technology-based innovations designed to help older,
functionally less able people continue to drive. The focus is
to determine how the design and function of vehicle systems
need to be adapted to the unique capabilities and needs of
older drivers.
During 1998, research was completed regarding the possible
benefits and drawbacks of Head-Up Displays (HUD). HUDS are
small windshield-projected displays of information that may
provide benefits to older drivers, as well as younger drivers,
because they present information closer to the driver's line of
sight than instrument panel displays.
A pilot effort was completed that identified an
experimental test protocol to evaluate the performance of
drivers using infrared night vision enhancement systems (VES).
VES may help alleviate one of the common complaints of older
persons--night driving. The VES technology displays a high
contrast image of the forward scene on a head-up display.
Occupant Protection.--One of the most significant reasons
for elderly drivers over-involvement in fatal crashes is the
inability of their bodies to absorb crash forces. What would be
a survivable crash for a younger person is often a fatal crash
for an older person. Current occupant-protection standards do
not specifically address the frailty of older occupants. More
information is needed to establish the feasibility of improving
the protection of older people when they are in a crash. NHTSA
is collecting detailed data for research on injuries,
treatments, outcomes, and costs for the older population.
NHTSA, with the Volpe Transportation Systems Center, is
using computer simulation and experimental work to improve
belt/air bag systems for vehicle occupants. Particular
attention is being paid to possible approaches to improving
alternate restraint designs or requirements for elderly vehicle
occupants. It is expected that this work will be of particular
value to older vehicle occupants and to women, who due to their
more fragile bone structure can benefit most from improved
belt/air bag designs.
In addition, NHTSA's new side impact standard provides a
higher level of protection to older occupants in vehicles
meeting the standard. The new standard is based on a dynamic
crash test which incorporated age effects for the first time
and, thus, will provide better protection to older vehicle
occupants. It was phased in beginning with 1994 model year cars
such that all cars by the 1997 model year had to meet the
requirement. Starting with the 1999 model year, trucks, buses,
and multipurpose passenger vehicles less than or equal to 2,721
kg (6,000 lbs.) must meet the dynamic part of this standard.
NHTSA's current efforts related to advanced frontal crash
protection, which will usher in a new generation of safer air
bags, will result in systems which will provide improved safety
benefit to all age groups.
Pedestrian Safety Issues.--Older pedestrians, 65 and over,
account for a smaller proportion (7.7 percent) of all
pedestrian crashes than would be expected by their numbers in
the population (12.8 percent). However, they account for almost
one quarter (22.4 percent) of all pedestrian fatalities. In
response to this problem, NHTSA and FHWA are continuing work
aimed at preventing crashes involving older pedestrians. A
joint research initiative was conducted in Phoenix and Chicago
that involved a demonstration program of behavioral safety
information, combined with traffic engineering applications, in
selected zones of the cities that have been shown to have a
high incidence of older pedestrian crashes. An impact
evaluation of the Phoenix initiative revealed that, while both
the overall population and pedestrian crashes increased over
the study period, older adult crashes decreased 13.7 percent.
More impressive, there were fewer crashes in each of the
pedestrian zones, amounting to an overall 46.3 percent decrease
in pedestrian crashes. Crashes in comparable areas outside the
safety zones increased 9.9 percent. These changes were
statistically significant. Upon completion of this activity, a
``how to'' Zone Guide was prepared which explains how to design
and use pedestrian safety zones. A copy of the report,
Development, Implementation and Evaluation of a Pedestrian
Safety Zone for Elderly Pedestrians, is available from the
Office of Research and Traffic Records, NHTSA, NTS-31, 400
Seventh Street, S.W., Washington, D.C. 20590, or send a FAX to
(202) 366-7096.
Older Driver Safety.--The majority of older drivers do not
constitute a major safety problem. Research has indicated that
most older drivers adjust their driving practices to compensate
for declining capabilities. They reduce or stop driving after
dark or in bad weather and avoid rush hours, and unfamiliar
routes. Men appear to be somewhat more reluctant than women to
stop driving and, consequently, are at a higher risk of
crashing than women of comparable age. Conditions, such as
memory loss, glaucoma, and antidepressant use, appear to be
related to increased crash risk.
Some older persons are not aware of their changing
conditions, most notably, those with cognitive disorders, such
as Alzheimer's disease, and certain visual problems. These
drivers may not self regulate and, as a result, pose an
increased risk of crash involvement. Such individuals may
require outside intervention to remove them from traffic.
Unfortunately, research suggests that most family members,
social service agencies, and health care professionals are
either not sufficiently aware or choose not to provide
assistance in making driving related decisions to those who
need it. For a variety of reasons, many appear hesitant to get
involved with this issue. Most older drivers prefer to decide
for themselves when it is time to stop.
In 1998, NHTSA worked with the State of Maryland to develop
a consortium comprised of national, Federal, state, and local
groups to develop and implement programs to encourage safe
mobility for life.
Driver Assessment Activities.--Those elderly drivers who
remain a problem are not easily detected with standard
licensing procedures. Further, there is some doubt as to
whether most licensing staff have the skills necessary to
detect these problem drivers, even with training and state-of-
the art testing techniques. Diagnostic tests currently in use
have not been shown to be effective in identifying those older
drivers who are at increased crash risk, but some recently
developed tests of ``speed of attention'' and ``visual
perception'' may have such potential.
Several long-term efforts are now approaching conclusion.
These developmental projects include: (1) procedures to help
elderly drivers make better decisions about adapting their
driving to accommodate their changing abilities are being
developed in a joint project with the Federal Highway
Administration and the Commonwealth of Pennsylvania; (2)
procedures for family members, friends, social service
agencies, physicians, and other health care providers to
recognize when an older person needs to adjust his or her
driving to adapt to functional limitations; (3) model screening
and assessment procedures to help driver licensing agencies
deal with those who do not appropriately restrict their
driving; and (4) model programs for medical and social service
agencies to help older people to make appropriate decisions
about driving while maintaining their mobility. Current efforts
also include a survey to determine societal perceptions and
willingness to assist older drivers to better regulate their
driving.
Mobility Issues.--One factor that must be considered with
regard to interventions is the fact that elderly people who
give up driving often lose mobility. For many, the automobile
is their primary mode of transportation and acceptable
alternatives are simply not available. Decreased mobility is
frequently followed by decreased quality of life as elderly
people are cut off from the social events, family visits,
medical attention, and opportunities for worship that are
critical in maintaining their sense of well being. These issues
are being studied in a joint project with the Department of
Health and Human Services and in a separate project with the
Federal Transit Administration.
federal transit administration (fta)
Funded under a $700,000 FTA grant in 1997, the Independent
Transportation Network (ITN) in Portland, Maine, provides
convenient and affordable transportation for seniors who have
chosen to reduce or totally eliminate driving their own cars.
Service is provided by a fleet of standard size sedans driven
by four paid drivers and over 95 volunteer drivers using their
own vehicles. The service provided by ITN allows seniors to
live independently in their own homes. The project's strategy
is to: (1) develop a prototype, financially self-sufficient
operation without tax subsidy in Portland; (2) incorporate ITS
technology in dispatching, ridesharing, and fare collection;
(3) implement and operate a satellite ITN at another location
in Maine to demonstrate the integration of multiple service
units under a centralized management structure; and (4) develop
tools for national replication in other areas with high
concentrations of seniors. The project offers a number of
payment options including credits earned from trading in
seldom-used vehicles, payments debited from an individual's ITN
account, and gift certificates. In addition to assistance from
FTA, ITN has received corporate support, foundation awards, and
funding from American Association of Retired Persons among
others. The ITN has demonstrated that its type of membership-
oriented, community supported transportation service combining
volunteer drivers, merchant participation, corporate support,
and local and national fund raising can be the solution to the
isolation and lack of mobility experienced by millions of
elderly Americans who can no longer drive their own cars.
research and special programs administration (rspa)
As revised and expanded in the Transportation Equity Act
for the Twenty-First Century (TEA-21), RSPA manages the
Department's University Transportation Centers Program.
Each center focuses its research on a specific theme or
interest area. Several of these themes are linked in whole or
in part with improving mobility for elderly citizens:
University of Arkansas: Rural Transportation
University of California--Berkeley: Improving
Accessibility for All
Marshall University: Economic Growth and Productivity
in Rural Appalachia Through Transportation
Montana State University: (Western Transportation
institute): Rural Travel and Transportation
Morgan State University: Transportation--A Key to
Human and Economic Development
University of Nebraska--Lincoln: Improved Design and
Operation of Transportation Facilities and Services in
Mid-America
North Carolina A&T State University: Urban Transit
University of Southern California and California
State/Long Beach: Solutions to Transportation Issues in
Major Metropolitan Areas
University of South Florida: Urban Transit
North Dakota State University: Rural and Non-
Metropolitan Transportation
Information Dissemination
federal railroad administration (fra)
Information about Amtrak accessibility is available
to senior citizens and passengers with disabilities in
a brochure entitled ``Access Amtrak'' which can be
obtained by calling 1-800-USA-RAIL. Amtrak also works
directly with a number of organizations each year on
moving groups of passengers needing assistance and
traveling together.
national highway traffic safety administration (nhtsa)
A Pedestrian and Bicyclist Safety and Accommodations
course, funded by NHTSA and FHWA, was completed. This course
was designed to address the pedestrian and bicyclist traffic
safety needs of highway safety specialists, police, traffic
engineers, and other professionals. A resource guide was
prepared which provides information about traffic safety
problems and ways to avoid them for all pedestrians, including
older pedestrians. Also, as a countermeasure to the hazards
that older Hispanic pedestrians face, materials were prepared
for Hispanic senior citizens. These materials include a report,
slide show, a presenters guide, brochure, and a video
``novela.''
research and special programs administration (rspa)
RSPA continues to disseminate technical reports describing
the mobility needs of senior citizens, and alternative ways to
meet them. Documents are available in hard copy from the
Department at no charge, and may be ordered on the INTERNET at
the Technology Sharing Program home page: http://
www.tsp.dot.gov
RSPA provides staff support to the National Science and
Technology Council's (NSTC's) Committee on Technology,
including its subcommittee on Transportation R&D. In September
1997 the NSTC Transportation Science and Technology Strategy
was released, which included recommendations for several
government-wide strategic partnership initiatives to promote
technology application and implementation. One of these
initiatives deals specifically with ``Accessibility for Aging
and Transportation Disadvantaged Populations.'' A goal of this
initiative is to ``create seamless regional alternative
transportation systems serving the needs of the elderly and the
transportation-disadvantaged while optimizing the existing
human and capital investment in paratransit.'' Implementation
activities are defined in the NSTC Transportation Technology
Plan, which is now being prepared for release.
To facilitate communication and information-sharing on
technology issues and support the NSTC, RSPA has brought a
science and technology INTERNET home page on line. The element
deal with the accessibility partnership is located at http://
scitech.dot.gov/partech/accage/accessaging.html. It includes
background information on the need, links to selected on-line
manuals and technical reports, and announcements of upcoming
conferences and events.
The University Transportation Centers Program integrates
its products in a directory of University Research Results on
its INTERNET Home Page at http://educ.dot.gov. The directory
includes the title of each report and a contact who can provide
further information on the research and the availability of
documentation from it. In addition, program staff is exploring
making key UTC products available on-line as volumes in the
National Transportation Library at (http://www.bts.gov/NTL).
ITEM 13--DEPARTMENT OF TREASURY
----------
U.S. TREASURY ACTIVITIES IN 1997-1998 AFFECTING OLDER AMERICANS
The Treasury Department recognizes the importance and the
special concerns of older Americans.
social security trust funds
The Secretary of the Treasury is the Managing Trustee of
the Social Security trust funds. The short- and long-run
financial status of these trust funds is presented in annual
reports issued by the Trustees. The April 1998 report, covering
calendar year 1997, estimated that the combined Old Age and
Survivors Insurance and Disability Insurance (OASDI) benefits
can be paid on time for about the next 34 years. The OASDI
cost-of-living increase was 2.1 percent for 1997 and 1.3
percent for 1998. The taxable base for OASDI was increased to
$65,400 in 1997 and $68,400 in 1998. The amount a 65- to 69-
year-old beneficiary could earn before OASDI benefits were
reduced was $13,500 in 1997 and $14,500 in 1998.
medicare trust funds
The Secretary of the Treasury is also the Managing Trustee
of the Federal Hospital Insurance (HI) and Supplementary
Medical Insurance (SMI) trust funds. In their April 1998 report
covering calendar year 1997, the trustees estimated that the HI
trust fund would be exhausted in 2008. The Supplementary
Medical Insurance Program is primarily financed by transfers
from the general fund of the U.S. Treasury and by monthly
premiums paid by beneficiaries. The Balanced Budget Act of 1997
permanently established SMI premiums at 25 percent of program
expenditures. The SMI trust fund is expected to remain
adequately financed into the indefinite future because current
law provides for the establishment of program financing each
year based on an updated calculation of expected cost per SMI
beneficiary.
personal income tax
Each year, pursuant to statute, the width of the income tax
brackets and the personal exemption and standard deduction
amounts are increased to reflect the effects of inflation
during the preceding year.
The personal exemption allowed for each taxpayer and
dependent increased from $2,550 in 1996 to $2,650 in 1997 and
to $2,700 in 1998.
Taxpayers age 65 or over (and taxpayers who are blind) are
entitled to larger standard deductions than other taxpayers.
Each single taxpayer who is at least 65 years old was entitled
to an extra standard deduction of $1,000 in 1996 and 1997, and
$1,050 in 1998. Each married taxpayer age 65 or over was
entitled to an extra standard deduction of $800 in 1996 and
1997, and $850 in 1998. Thus, a married couple both of whom
were over age 65 were entitled to extra standard deduction
amounts of $1,600 in 1996 and 1997, and $1,700 in 1998.
Including the extra standard deduction amounts and the basic
standard deduction amounts, taxpayers over age 65 were entitled
to the following standard deductions for tax years 1994 through
1998:
------------------------------------------------------------------------
Filing Status 1996 1997 1998
------------------------------------------------------------------------
Single................................. $5,000 $5,150 $5,300
Unmarried Head of Household............ 6,900 7,050 7,300
Married Filing Jointly:
One spouse age 65 or older......... 7,500 7,700 7,950
Both spouses age 65 or older....... 8,300 8,500 8,800
------------------------------------------------------------------------
The tax credit for the elderly (and permanently disabled)
was retained throughout the period.
Prior to mid-1997, an individual over age 55 was generally
entitled, on a one-time basis, to exclude from income subject
to tax up to $125,000 of gain from the sale of a principal
residence. The Taxpayer Relief Act of 1997 (TRA97) replaced
that $125,000 one-time exclusion with a $250,000 exclusion
($500,000 exclusion for married taxpayers filing a joint
return) for gain realized on the sale of a principal residence.
Taxpayers, regardless of age, may use the new exclusion each
time a residence is sold, but generally not more frequently
than once every two years.
Beginning for tax year 1998, TRA97 provides that the de
minimis exception from having to pay estimated taxes is
increased from $500 to $1,000 of unpaid tax liability. (The
other exceptions, relating to prior year liability and
percentages of current year liability, were not changed.)
Effective in 1997, the 15 percent excise taxes on excess
accumulations in, and excess distributions from, qualified
retirement plans, tax-sheltered annuities, and IRAs was
eliminated. The separate limits on contributions and benefits
applicable to each type of retirement saving vehicle remain.
Two provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) are particularly relevant to
the aged. Both provisions became effective for tax year 1997.
HIPAA provides that accelerated death benefits received under a
life insurance contract or from a viatical settlement provider
are generally excluded from income subject to tax. Also,
qualified long-term care insurance premiums and the
unreimbursed expenses for the care of a chronically ill
individual may be deductible, but only as part of the itemized
deduction for medical expenses. Employer-paid long-term care
premiums are excludable from the employee's income subject to
taxation. Long-term care premiums paid by self-employed workers
are partially deductible in the calculation of adjusted gross
income, to the same extent as other health insurance premiums.
(The Taxpayer Relief Act of 1997 accelerated the increases, and
ultimately raised to 100 percent, the deductibility of health
insurance premiums for a self-employed individual and the
individual's spouse and dependents if neither the individual
nor spouse is eligible for health insurance coverage as
employees. The changes are phased in beginning in tax year 2000
.)
The Balanced Budget Act of 1997 permits Medicare-eligible
individuals to choose either the traditional Medicare program
or Medicare Plus Choice, which may include a medical savings
account (MSA). The option will be available beginning in 1999.
Under the Medicare Plus Choice MSA, limited contributions will
be made to the individual's MSA, and those contributions and
the earnings on balances in the MSA account will not be subject
to tax. Withdrawals used to pay for qualified medical expenses
will not be subject to tax. Withdrawals used for other purposes
will be included in income subject to tax, and, if they exceed
certain limits, will also be subject to penalties.
A gift tax is imposed on lifetime transfers by gift, and an
estate tax is imposed on transfers at death. A unified credit
applying to both the gift and estate taxes permits a certain
amount to be transferred before gift or estates taxes are
imposed. TRA97 increased the unified credit from an effective
exemption of $600,000 to an effective exemption of $625,000 for
1998 and to higher amounts in subsequent years. (The unlimited
exemption for transfers to spouses was retained.) TRA97 also
provides, beginning in 1998, that estates may elect special
estate tax treatment for certain qualified family-owned
business interests; the elected exclusion for family-owned
business interests together with the general effective
exemption may not exceed $1.3 million.
internal revenue service
The Internal Revenue Service (IRS) recognizes the
importance and special concerns of older Americans, a group
that will comprise an increasing proportion of the population
in the years ahead. Major programs and initiatives of the
Office of the Chief, Operations that are of interest to older
Americans and to others are described below:
The following publications, revised annually, are directed
to older Americans:
Publication 524, Credit for the Elderly or Disabled,
explains that individuals 65 and older may be able to take the
Credit for the Elderly or Disabled, reducing taxes owed. In
addition, individuals under age 65 who retire with a permanent
and total disability and receive taxable disability income from
a public or private employer because of that disability may be
eligible for the credit.
Publication 554, Older Americans' Tax Guide, explains the
income conditions under which single taxpayers aged 65 or
older, and married taxpayers filing jointly if at least one of
the spouses is 65 or older, are generally not required to file
a Federal income tax return. The publication also advises older
taxpayers about possible eligibility for the earned income
credit. The taxpayer may be eligible for a credit based on the
number of qualifying children in the home or a smaller credit
if the taxpayer has no qualifying children.
Publication 721, Tax Guide to U.S. Civil Service Retirement
Benefits, and Publication 575, Pension and Annuity Income,
provide information on the tax treatment of retirement income.
Publication 907, Tax Highlights for Persons with
Disabilities is a guide to issues of particular interest to
persons with handicaps or disabilities and to taxpayers with
disabled dependents.
Publication 915, Social Security and Equivalent Railroad
Retirement Benefits, assists taxpayers in determining the
taxability, if any, of benefits received from Social Security
and Tier I Railroad Retirement.
All publications are available free of charge. They can be
obtained by using the order forms found in the tax forms
packages or by calling 1-800-TAX-FORM (1-800-829-3676.) Many
libraries and post offices stock the most frequently requested
forms, schedules, instructions, and publications for taxpayers
to pickup. Also, many libraries stock a reference set of IRS
publications and a set of reproducible tax forms.
Most forms and some publications are on CD-ROM and are on
sale to the general public through the National Technical
Information Service. Information about ordering can be obtained
by calling 1-877-233-6767. Forms, instructions, and tax
information are available by fax by calling 703-363-9694 using
the phone attached to your fax machine.
Taxpayers may obtain most forms, instructions,
publications, and other products via the IRS's Internet Web
Site at www.ustreas.gov.
The 1990 tax year was the first year older American could
use the expanded Form 1040A to report income from pensions and
annuities, as well as other items applicable to older
Americans, such as estimated tax payments and the credit for
the elderly or the disabled. More than half the potential
filing population eligible to use this simpler, shorter form
made the switch from the much longer Form 1040.
Responding to requests from the public for such a product,
the Tax Forms and Publications Division developed large-print
versions of the Form 1040 and Form 1040A packages earmarked for
older Americans. These packages (designated as Publication 1614
and 1615, respectively) are newspaper-size and contain both the
instructions and the forms (for use only as worksheets, with
the amounts to be transferred to regular-size forms for
filing).
irs volunteer & outreach programs
The Volunteer Income Tax Assistance (VITA) Program offers
FREE tax help to people who cannot afford paid professional
assistance. Volunteers help prepare basic tax returns for
taxpayers with special needs, including persons with
disabilities, non-English speaking persons, those with low
income, and elderly taxpayers. Assistance is provided at
community and neighborhood centers, libraries, schools,
shopping malls, and other convenient locations across the
nation. Many sites provide free electronic filing of tax
returns. Volunteers generally include college students, law
students, members of professional, business and accounting
organizations, and members of retirement, religious, military
and community groups.
In 1997, more than 40,000 volunteers assisted more than 1.7
million taxpayers at nearly 8,300 sites across the nation
through the VITA Program. In 1998, more than 39,000 volunteers
assisted more than 1.8 million taxpayers at nearly 6,100 sites
across the nation through the VITA Program.
Tax Counseling for the Elderly (TCE) Program
Tax Counseling for the Elderly (TCE) Program was first
authorized by Congress in 1978 as part of the Revenue Act of
1978. The Revenue Act authorizes an appropriation of special
funds, in the form of grants, to provide free income tax
assistance to individuals 60 years of age or older. TCE
sponsors recruit volunteers trained by the Service to provide
income tax assistance to older individuals. TCE volunteer sites
can be found in retirement homes, neighborhood sites, and
shopping malls. Many sites provide free electronic filing of
income tax returns. Volunteers also travel to the private
residences of the homebound. In 1997, 31,000 volunteers
assisted 1.6 million taxpayers at nearly 10,500 sites. In 1998,
32,000 volunteers assisted 1.7 million taxpayers at nearly
10,600 sites.
Community Outreach Tax Education Program
The Community Outreach Tax Education Program provides
individuals with group Income return preparation assistance and
tax education seminars. IRS employees and trained volunteers
conduct these seminars which address a variety of topics. They
are tailored for groups and individuals with common tax
interests, such as groups of older Americans. These seminars
are conducted at convenient community locations.
In 1997, more than 800 volunteers assisted more than
470,000 taxpayers in more than 4,900 sessions across the nation
through this program. In 1998, almost 970 volunteers assisted
more than 430,000 taxpayers in more than 5,000 sessions.
Post Offices and Library (POL) Program
During 1997 and 1998, the Post Offices and Library Program
(POL) provided approximately 46,500 post offices, libraries,
and other sites with free tax preparation materials such as tax
forms and publications that can assist older Americans in
preparing forms 1040, 1040A, 1040EZ, and related schedules. IRS
provided volunteers in some libraries to answer tax questions
and direct taxpayers to the correct tax forms.
Small Business Tax Education Program (STEP)
The Small Business Tax Education Program (STEP) provides
information about business taxes and the responsibilities of
operating a small business. During 1997 and 1998, small
business owners and other self-employed persons had an
opportunity to learn what they needed to know about business
taxes through a partnership between IRS and approximately 2,000
community colleges, universities and business associations.
Assistance was offered at convenient community locations and
times. Many elderly persons, such as those beginning second
careers, availed themselves of this program.
financial management service
The Financial Management Service (FMS) makes more than 700
million payments annually, including Social Security,
Supplemental Security Income, and Veterans benefits. Working
under the mandate of the Debt Collection Improvement Act signed
by President Clinton on April 26, 1996, Federal Departments and
agencies are on the fast track to convert Federal payments to
electronic funds transfer (EFT). The law requires most payments
to be made electronically by January 2, 1999, but also gives
the Secretary of the Treasury broad authority to grant waivers.
EFT significantly improves the certainty of payments reaching
the intended recipients on a timely basis, and improves the
ability of recipients to use those payments safely and
conveniently. Payment inquiries and claims are significantly
reduced under EFT.
Payment by EFT has substantial benefits in terms of
reliability, safety, and security that are especially important
for the elderly. Recipients are twenty times more likely to
have a problem with a paper check than with an EFT transaction,
and in FY 1998 Treasury replaced more than 600,000 checks that
were lost, stolen, delayed, or damaged during delivery. Waiting
days for a replacement check is an inconvenience and a burden
on recipients, especially elderly persons living on low
incomes. EFT payments are much more convenient and secure--
misrouted EFT payments are never lost, and, if misrouted, the
payments are typically routed to the correct bank account
within 24 hours.
During the past three years, Treasury has been overseeing
government-wide implementation of the Debt Collection
Improvement Act of 1996 by working with Federal agencies to
identify and resolve the major issues confronting stakeholders.
Significant progress has been made by Federal agencies to
convert payments to EFT (EFT' 99). The percentage of Treasury-
disbursed payments made electronically has increased from 53
percent in FY 96 to 63 percent in FY 98, and as of November
1998, 71 percent of Treasury-disbursed payments were made by
EFT. More than 74 percent of Social Security payments were made
electronically as of November 1998, an increase of more than 15
percentage points since FY 96. Other Federal benefit agencies
show similar increases in EFT payments.
Four public hearings and numerous meetings with
stakeholders were held in 1997 and 1998 prior to issuance of
the final rule. On September 25, 1998, Treasury published its
final regulation, 31 Code of Federal Regulations (CFR) 208,
which prescribed policies relating to the circumstances under
which waivers are available from the EFT requirement,
requirements for sending Federal EFT payments to accounts, and
the responsibilities of Federal agencies and recipients. This
regulation reflects the many comments and input from Federal
agencies, consumer and community organizations, financial
services trade associations, and other key stakeholders
received during the public comment period.
The final rule allows recipients choices in selecting a
payment method, depending on their circumstances, and permits
individuals to continue to receive checks in situations where
electronic payment presents a hardship. Specifically, the EFT
requirement is waived if the individual determines, at his or
her sole discretion, that payment by EFT would impose a
hardship due to a physical or mental disability, or a
geographic, language or literacy barrier, or if EFT would
impose a financial hardship.
Federal payment recipients who elect to receive their
payments via Direct Deposit enjoy the benefits of this simple,
safe, and secure payment mechanism. Recipients who have not
signed up for Direct Deposit do have choices, as described in
31 CFR 208. Federal check recipients receiving salary, wage,
benefit or retirement payments can choose to: (1) receive
payment via Direct Deposit through a financial institution, (2)
wait for the low-cost Electronic Transfer Account
(ETASM) to become available or, (3) continue to
receive a paper check, if receiving payment by Direct Deposit
would cause the recipient a hardship.
In 1999 Treasury will develop a basic, low-cost account
called the ETA SM, which will be available to
individuals who receive Federal benefit, wage, salary, or
retirement payments. Federally insured financial institutions
will be encouraged to offer the ETA SM on a
voluntary basis, subject to soon-to-be published standards and
terms set forth in an agreement between Treasury and the
financial institution. These low-cost accounts are designed to
meet the statutory mandate that recipients have access to an
account at a reasonable cost and with consumer protections,
comparable to other accounts at the same financial institution.
Treasury issued a Federal Register notice for public comment on
November 23, 1998 regarding the attributes of such an account.
Treasury is now evaluating those comments and will issue the
final notice in the spring of 1999. The ETA SM is
expected to be available to individual recipients during 1999.
The Financial Management Service and Treasury have been
conducting a massive public education campaign on both a
national and regional basis, seeking involvement of national,
regional, and local consumer and community-based organizations,
financial trade associations, and Federal regulatory agencies
to distribute materials and to conduct ``in touch'' programs
with Federal recipients to educate them about their choices
under the law. Public Service Announcements for television,
radio, and print ads were produced, as well as posters,
brochures, and other educational materials.
FMS continues to support the implementation of a nationwide
program to make Electronic Benefits Transfer (EBT) a viable
electronic payment option. Geared toward those individuals
without a bank account, EBT is an electronic benefit delivery
mechanism that enables recipients to use plastic cards to
access their benefits at automated teller machines or point-of-
sale terminals. Forty-seven states have some type of EBT
program which provides electronic access to benefits for
recipients; twenty-nine of these and the District of Columbia
are full-fledged, statewide programs, and others are either in
the pilot phases, expanding statewide, or in the process of
being awarded to providers. In 1996, FMS partnered with the
Southern Alliance of States (SAS) to deliver Federal and State
benefits through EBT to recipients in an eight-state area. In
the SAS, recipients of Federal and State benefits can access
their benefits using the same EBT card. All 50 States expect to
be operating statewide EBT systems by 2002, and Treasury will
work with individual states at their request to allow both
State and Federal benefits to be accessed through the State EBT
card where feasible.
A variety of information on EFT '99 is available on the FMS
Web site describing products and services offered by the
agency. Information available includes recent FMS activities
related to EFT '99, publications, statistics, and contact
information. The EFT Web site includes topics on General
Information, Regulations and Policy, Agency Assistance, News
and Media, Education and Marketing, Vendor Information, and the
ETA SM. The site can be accessed at
www.fms.treas.gov/eft.
The Check Forgery Insurance Fund
The Check Forgery Insurance Fund (CFIF) legislation was
enacted into law on April 26, 1996 as part of the Debt
Collection Improvement Act of 1996.
The Check Forgery Insurance Fund (CFIF) is a revolving fund
established to settle payee claims of non-receipt where the
original check has been fraudulently negotiated. FMS uses the
Fund to ensure that innocent payees, whose Treasury Checks have
been fraudulently negotiated, are promptly issued replacement
checks. Reinstitution of the CFIF relieves the burden for
recipients of forged checks by providing funding for
expeditious issuance of replacement checks.
Check forgery is a concern of FMS and individuals who
receive paper check payments. FMS continues to consider and
address this concern. On March 26, 1998, various Treasury
Systems were enhanced to comply with the legislation and to
modify both internal and external operational and system
procedures required to process check forgery claims timelier
utilizing the CFIF. Reinstituting the CFIF relieves the burden
for recipients of forged checks, especially the elderly.
The CFIF is a Fund which benefits all payees of forged
checks after the forgery has been substantiated. Although
payment by electronic funds transfer (EFT) has substantial
benefits, paper checks continue to be the desired method of
payment by recipients of various Federal payments. The elderly,
who represent a large portion of this group, continue to
receive payments by check. Because of continued check issuance,
forgery of these items is highly probable. Those elderly
individuals affected by forgeries are largely low-income,
unbanked and rely on the monthly payment for their basic
subsistence. The CFIF allows for immediate relief to the
elderly and other payees after the claim of forgery has been
substantiated.
Implementation of the CFIF benefits The Federal Program
Agencies (FPAs) by relieving the FPAs of the responsibility for
issuing replacement checks out of their appropriations on
forgery claims. Typically, the FPAs would not issue a
replacement check on a forgery claim until after FMS had
recovered the forged amount from the financial institution (FI)
and credited the agency with the check amount. The FI has 60
days to respond to FMS' request for refund. The CFIF provides
for expeditious processing of these cases and does not make
issuance of the replacement check contingent on whether
recovery on the forgery is delayed or unsuccessful.
FMS is continuing to use the CFIF to facilitate the timely
issuance of replacement checks to the elderly and all check
recipients on substantiated forgery claims.
united states mint
The U.S. Mint continues to consider the needs and concerns
of older Americans in delivery of our programs.
The Exhibits and Public Affairs staff of the Philadelphia
Mint are available to help older persons and people with
special needs who wish to take the Mint self-guided tour. A
wheelchair is also available for those wishing to take the
tour. Additionally, benches are strategically placed along the
tour route to provide resting areas for visitors.
The Denver Mint continues to provide public tours conducted
by Mint personnel that are considerate of the needs and
concerns of older persons. Tour Guides request that if any
member of the public requires special assistance; ascending
stairs, etc., that requests for such assistance are made at the
beginning of the tour. Additional assistance that may be needed
during the tour can also be requested of the Tour Guides as
well.
U.S. Mint facilities at both Denver and Philadelphia will
continue to explore how such assistance can be enhanced in 1999
and 2000.
bureau of engraving and printing
The National Academy of Sciences conducted a study on ways
to assist the blind and visually impaired with currency
transactions. Based on that study, the Bureau of Engraving and
Printing (BEP) unveiled the new $20 design on May 20th 1998
with several features to assist the elderly and visually
impaired population. In addition to several counterfeit
deterrent features, the note contained a large high contrast
numeral in the back lower right of the note. The large high
contrast numeral is designed to assist the more than 23 million
mostly elderly Americans with varying degrees of vision
impairment.
In addition, based on discussions with the American Council
for the Blind, the BEP incorporated a machine-readable feature
to the new $20 bill. This feature is intended to facilitate the
development of convenient scanners for the blind and people
with low vision. The BEP intends to add this feature in all
future redesign of currency.
office of thrift supervision
During 1997 and 1998, OTS continued its Community Affairs
Program, designed to provide outreach and support to the thrift
industry's efforts to meet housing and other community credit
and financial services needs. A primary objective of the
program is to serve as a liaison between the thrift industry
and consumer and community groups on housing and community
development issues. Most of the groups with which OTS interacts
represent low- and moderate-income individuals, including older
persons.
Our Community Affairs staff, along with senior management,
participated in meetings with hundreds of thrifts and community
organizations across the country, including groups with
particular emphasis on older persons, such as those that
provide affordable housing for senior citizens. During those
meetings, information was shared on affordable housing,
financial services and economic development needs; on thrifts'
authorities and abilities to meet those needs; and on
opportunities for collaborative partnerships.
OTS continued to publish its Community Liaison newsletter
and distribute the newsletter to all thrifts and to several
hundred community and consumer organizations. The newsletter
spotlights achievements in affordable housing and community
development, many of which have benefitted older Americans.
During 1998, the newsletter included several articles
pertaining to EFT99 which can significantly affect many older
Americans.
For many years, OTS has maintained an active program for
addressing complaints that consumers may have against the
thrifts that OTS regulates. We provide a free nationwide
consumer hotline and a TDD line, and professional staff is
available to help people evaluate whether their concerns are
addressed by OTS regulations. Senior citizens are frequent
users of this service.
OTS has also issued a Customer Service Plan for consumer
complaints and urged the institutions it regulates to give high
priority to consumer relations. Of approximately 12,500
complaints filed with OTS in 1997 and 1998, 23 complaints
alleged credit discrimination based on age. OTS investigated
each of the complaints in accordance with its expanded
procedures for discrimination complaints, which call for
interviewing the complainant and reviewing the complainant's
loan file. None of the complaints led to a finding of
discrimination.
BUREAU OF THE PUBLIC DEBT
The Bureau of Public Debt continues to make improvements in
its programs to better serve all investors. The following
improvements to simplify access to Treasury securities are of
particular benefit to the elderly investor.
Marketable securities
Treasury marketable securities provide a safe investment
and interest income, features that are popular with older
Americans. The latest survey of investors using the
TreasuryDirect service indicated that 67 percent were age 65 or
older. Therefore, our recent improvements to TreasuryDirect
will benefit older Americans.
Electronic services
In 1997 and 1998 Public Debt made it more convenient for
TreasuryDirect customers to invest by introducing a variety of
electronic services. These services benefit older Americans
since they can now conduct a wide variety of transactions from
home.
Pay Direct allows existing customers to pay
for their securities by authorizing Treasury to debit
their bank account on the day the security is issued.
Prior to this, investors had to pay for their
securities when they submitted their tender. Pay Direct
eliminates a trip to the bank by a customer to obtain a
cashier's or certified check for Treasury bill
investors.
Reinvest Direct allows customers to reinvest
maturing securities by phone 24 hours a day, 365 days a
year. When investors get a reinvestment notice in the
mail from Public Debt, all they need to do is call a
toll-free number on a touch-tone phone from anywhere in
the U.S.
Sell Direct allows customers to authorize
Public Debt to sell their securities rather than first
having to transfer them to a bank or brokerage firm.
Buy Direct gives current TreasuryDirect
customers an easy way to purchase securities by using
the Internet. To purchase and authorize Public Debt to
charge their bank account for the purchase price, a
customer visits Public Debt's ``virtual lobby,'' and
indicate which security they wish to purchase.
Investors can purchase securities by calling a toll-
free number and following a simple interactive menu
authorizing Public Debt to charge their bank account on
issue day.
Other services
TreasuryDirect customers can check their account balance,
order a statement of account, or request a duplicate interest
income statement (1099-INT) on a touch-tone phone. Customers
having Internet access can go to our website
(www.publicdebt.treas.gov) and perform the same functions. The
website offers the additional features of providing detailed
account information and allows customers to change address and
phone number information in their account. The website provides
a wealth of information about Treasury marketable securities
and the TreasuryDirect service. Current or potential customers
can obtain information, order forms and publications, and send
electronic mail inquiries directly to Public Debt.
$1,000 minimums
In August 1998, the Treasury Department took steps to
demonstrate its commitment to encourage all Americans to save
and invest by reducing the minimum amounts needed to purchase
all marketable Treasury bills, notes and bonds to $1,000.
Previously, Treasury bills were available in minimum purchase
amounts of $10,000 and notes with maturities of four years or
less required a minimum purchase of $5,000. Notes with longer
maturities and 30-year bonds were already available in $1,000.
Uniform-price auction
In November 1998, Treasury decided to expand the use of
uniform-price auctions to the sale of all marketable Treasury
securities. Prior to this, and since 1992, only the 2-year and
5-year notes were sold using this technique. Most
TreasuryDirect customers buy their securities on a
noncompetitive basis. The uniform price auction assures these
investors the same yield as larger bidders.
Public Debt continues to encourage owners of registered and
bearer securities to convert these certificates to book-entry
form in TreasuryDirect. Holding securities in book-entry form
provides a much safer and more convenient method than holding
certificates.
Public Debt will continue to seek opportunities to improve
customer service for its TreasuryDirect investors through
expanded electronic information and transaction services.
Savings securities
Series I bonds
In September 1998, Series I Bonds, accrual savings bonds
indexed to inflation, were added to the line of savings
instruments we offer our customers. Along with the usual
features which attract mature, conservative investors--tax
benefits if used for education, exemption from state and local
income taxes, federal income tax deferral, replacement in the
event of loss, theft, or destruction, etc.--I Bonds ensure a
real rate of return over and above inflation.
Home banking
Many banks have expanded their home banking services, which
allows customers to conduct many transactions from their homes.
We are working with banks and software providers to include a
savings bond module in their home banking packages. The
convenience of home banking extends to all, but particularly to
senior citizens, who may be unable to visit the bank to buy
savings bonds.
Direct deposit for series HH interest payments
We are working to encourage all Series H and HH bond
holders to use Direct Deposit for their interest payments. Now,
some 85 percent of Series H and HH investors receive their
interest by Direct Deposit. They enjoy timely payment of
interest and don't have to make trips to the bank to deposit
interest checks.
EasySaver
In November 1998, we created the EasySaver Plan for
purchasing U.S. Savings Bonds. Now, millions of Americans,
particularly the elderly, who do not have access to payroll
savings plans, can buy bonds automatically for themselves or
their families. All the customer needs to do is complete an
order form authorizing Treasury to charge their bank account
for the price of the bond and choose the date to charge their
account for their savings bond purchases.
Customer service improvements
Public Debt continues to improve customer service through
increased use of information technology and streamlined
operating procedures. Since a substantial number of savings
bonds are held by older Americans, it can be expected that
these customers will be involved in a proportionate number of
the transactions handled by the Bureau. Service improvements
should be welcomed and keenly felt among the group.
In May of 1999, we will offer for sale two new I Bonds.
They are a $200 denomination featuring Chief Joseph of the Nez
Perce, one of the greatest Native American leaders, and a
$10,000 I Bond with a portrait of Spark Matsunaga, a former
U.S. Senator and Congressman and World War II hero. The new
denominations will offer investors, including the elderly, more
flexibility.
In the coming years, we intend to continue to work with
financial institutions and financial software companies in
order to promote and expand our home banking program which
allows for customers to purchase savings bonds on-line. We also
hope to conduct many more transactions related to savings bonds
via the Internet.
UNITED STATES SECRET SERVICE
Senior Citizen Employment Program (SCEP)
In 1998, the Secret Service implemented a senior citizen
employment program (SCEP) which is designed to provide older,
economically disadvantaged seniors with an opportunity to
upgrade outdated skills and develop new skills which may
enhance future employment opportunities. Seniors hired under
this program provide administrative clerical support to Secret
Service offices. The Secret Service works closely with
organizations such as the American Association of Retired
Persons and other community associations to identify eligible
seniors.
Advanced fee fraud schemes
Advanced fee fraud schemes result in reported financial
losses exceeding a hundred million dollars annually. The true
losses are much higher as many victims fail to report their
losses due to fear or embarrassment. The elderly population is
especially susceptible. The Secret Service has received scores
of reports from the elderly indicating they have lost their
life savings through this type of fraudulent scheme. In
conjunction with the local Department's of State and Commerce,
the Secret Service has reached out to organizations that are
associated with the principal targets of this scam, namely
small businesses and the elderly. The Better Business Bureau,
the American Bankers Association, and the AARP have assisted
the Secret Service in publishing articles designed to educate
the public to these schemes and hopefully prevent them from
falling prey to these frauds.
Government benefits
The Secret Service continues to protect the nation's
elderly recipients from fraud perpetrated against their
government benefits. The Secret Service is committed to
investigating all fraud related to government benefits. During
Fiscal Year 1997-1998, the Secret Service received and
investigated 18,233 cases relating to U.S. Treasury check
violations (which includes among other Social Security
benefits, Railroad Retirement, and Office of Personnel
Management). Additionally, the Secret Service received and
investigated 4,225 cases involving the illegal diversion of
funds through the Direct Deposit/Electronic Funds Transfer
process during Fiscal Year 1997-1998.
White House tours
The Secret Service gives White House tours for over one
million visitors a year. In an effort to provide better
customer service to the elderly and physically disabled, the
Secret Service now provides escorted wheelchair tours of White
House areas open to the public. Past procedures only provided
for tours of the State Floor. Additionally, upon request, sign
language tours are made available for the hearing impaired and
touch tours are provided for the visually impaired.
U.S. CUSTOMS
U.S. Customs Service's major activities affecting older
Americans include the following:
The Customs Service offers special treatment for the aging,
the handicapped, the ill, and those who are unable to wait in
line when arriving from abroad. Such travelers can speak with a
Customs supervisor upon arrival in the Customs processing area
of the airport or other Customs port of entry. The supervisor
is able to facilitate the traveler's Customs clearance.
Customs strives to treat all travelers entering and leaving
the United States with professionalism and courtesy. In
addition, Customs works to ensure that Federal inspection
facilities, such as restrooms, etc., facilitate the movement of
the elderly or handicapped who must rely on a wheelchair or
walker.
In addition, the Customs Service has a number of programs
supporting Customs employees. For example, the Employee
Assistance Program encourages elderly employees to seek
additional assistance if needed. The Customs Health Enhancement
Program offers activities and classes to Customs employees,
including the elderly, in areas such as fitness, CPR/first aid,
stress management, conflict resolution, defense tactics,
allergy and asthma inoculations, nutrition, and health
screening. In addition, special seminars and video broadcasts
are offered throughout Customs on eldercare. Topics include
long-term health care, legal issues, caregiver issues, nursing
homes, etc. and are available for the elderly as well as
younger employees who may have older relatives and friends. The
Customs Service also offers retirement seminars several times
each year to all employees who are eligible to retire within
the succeeding 5 years. These seminars cover retirement
benefits, legal matters and financial planning.
OFFICE OF COMPTROLLER OF THE CURRENCY
During 1997 and 1998 the Office of the Comptroller of the
Currency (OCC) continued to enforce fair lending laws relating
to age discrimination. Continued emphasis was also placed on
evaluating performance of national banks with respect to the
Community Reinvestment Act (CRA). During 1998, the OCC created
a new bank supervision division specifically focused on
consumer compliance, CRA, and fair lending. The new division is
to support the OCC's consistent enforcement of compliance laws
by providing a direct link between policy makers and compliance
examiners in the field.
OCC examiners are alert to the potential for discrimination
on the basis of age (as well as the other bases covered by ECOA
and Reg. B) when conducting fair lending examinations. In 1997,
the OCC found evidence of age discrimination during two fair
lending exams and referred both cases to the Department of
Justice (DOJ) for action; the OCC found evidence of age
discrimination during one exam in 1998 and forwarded that case
to DOJ. DOJ returned all three cases to the OCC for
administrative action. The three aforementioned cases bring the
total number of OCC cases involving age discrimination to nine
since 1993.
During 1997 and 1998, Comptroller Eugene A. Ludwig and
Acting Comptroller Julie A. Williams met ten times with
representatives from national community and consumer
organizations, including representatives of senior
organizations, at the OCC's Washington, DC headquarters. They
also met six times with representatives of local community and
consumer organizations from five of six OCC regional districts.
The purpose of these outreach sessions was to share information
about OCC policy and national bank examination practices with
bank customer organizations, and to learn first-hand about the
concerns these organizations had about the activities of
national banks, as well as about the OCC's supervision of the
national banking system. Topics discussed typically included
community reinvestment, fair lending, community development,
and access to financial services for the ``unbanked'',
including elderly individuals, who do not have a relationship
with a depository financial institution.
The OCC is responsible for resolving consumer complaints
against national banks, including those complaints made by
older Americans. During 1997, the OCC received 40,000 total
telephone complaints and 33,084 total written complaints.
During 1998, we received over 85,322 total telephone complaints
and 71,000 total written complaints. In a continuing effort to
improve our assistance to customers, the complaint processing
was consolidated into the OCC's Ombudsman's Office in April,
1998. The new Customer Assistance Group was formed with the
hiring of compliance professionals and state of the art
telephone equipment. The toll-free national consumer complaint
telephone number was maintained (800-613-6743).
ITEM 14--COMMISSION ON CIVIL RIGHTS
----------
During calendar years 1997 and 1998 the Commission
continued to process complaints received from individuals
alleging denials of their civil rights. Specifically, in 1997
23 complaints alleging discrimination on the basis of age were
received by the Commission and referred to the appropriate
agency for resolution. In 1998, the Commission referred 22
complaints alleging age discrimination.
ITEM 15--CONSUMER PRODUCT SAFETY COMMISSION
----------
Report on Activities To Improve Safety for Older Consumers
Each year, according to estimates by the U.S. Consumer
Product Safety Commission (CPSC), nearly one million people age
65 and older are treated in hospital emergency rooms for
injuries associated with products they live with and use every
day. The death rate for older people is almost 7 times that of
the younger population for unintentional injuries involving
consumer products. Consumer products used in and around the
home are associated with over 40 deaths per 100,000 persons 65
and older, and over 6 deaths per 100,000 persons under 65.
Fires and burns in the home
Burns from fires in the home are a significant source of
injury to older Americans. In fact, adults age 65 and over are
twice as likely to die in fires as all ages combined. There are
a number of steps older Americans can take to protect
themselves.
CPSC recommends the installation and maintenance of smoke
detectors on every floor of the home. Older consumers should
look for nightwear that will resist flames, such as heavy
weight fabric or tightly woven fabrics such as polyester,
modacrylics, or fabrics made from wool.
Cooking fires also cause injury and death to older
consumers. CPSC urges consumers to keep pot handles turned
inward, and keep cooking surfaces and surrounding areas free
from clutter and grease build-up. Also, CPSC advises consumers
to avoid wearing loose clothing with flowing sleeves while
cooking. CPSC is evaluating the feasibility of technologies to
detect a pre-fire condition and shut the burner off before a
fire occurs.
Older consumers are at greater risk of dying from fires
involving upholstered furniture, mattresses, and bedding than
the general population. To prevent such fires, CPSC cautions
consumers to never smoke in bed, while drowsy, or while under
the influence of medication or alcohol. Further, consumers are
advised to use large, deep ashtrays for smoking debris and to
let the contents cool before disposing of them. CPSC is
currently considering ways to address upholstered furniture and
mattress and bedding flammability.
Burns from hot tap water are another cause of injury to
many older Americans. CPSC recommends that consumers turn down
the temperature of their water heater to 120 degrees Fahrenheit
to help prevent scalds.
In 1997 and 1998, CPSC distributed approximately 147,000
copies of ``Safety for Older Consumers--Home Safety Checklist''
(English and Spanish). The checklist is a room-by-room check of
the home, identifying hazards and recommending ways to avoid
injury. Consumers may order a free copy by sending a postcard
to ``Home Safety Checklist,'' CPSC, Washington, D.C. 20207.
This checklist is posted on the CPSC Web site at www.cpsc.gov
under ``Consumer-Publications.''
CPSC, in partnership with the American Association of
Retired Persons (AARP) and the National Association of State
Fire Marshals, distributes another booklet to consumers, ``Fire
Safety Checklist for Older Consumers'' (English and Spanish).
In 1997 and 1998, CPSC distributed almost 21,000 copies of this
publication. Consumers may request a free copy by sending a
postcard to ``Fire Safety Checklist,'' CPSC, Washington, D.C.
20207.
CPSC also contributed to the publication ``What Smart
Shoppers Know About Nightwear Safety.'' This brochure was
developed by a group of experts in apparel flammability and
distributed by the American Association of Retired Persons
(AARP). The brochure encourages older consumers to look for
sleepwear that is flame resistant. Consumers may request a copy
by sending a postcard to AARP, 601 E Street, N.W., Washington,
D.C. 20049.
Electrical wiring in older homes
In 1994-95, CPSC conducted a study of electrical wiring
fires in older homes. This is a subject of particular
importance to senior citizens, since they frequently live in
older homes, which are especially vulnerable to electrical
wiring fires. Based on this study, CPSC produced a video
entitled ``Wired for Safety,'' emphasizing hazards with old
electrical wiring and safety measures to prevent fire and
electric shock. About 3,000 copies of the video are distributed
to electrical safety inspectors, code officials, and others
nationwide.
CPSC launched this campaign to help prevent the estimated
40,000 home electrical wiring fires each year. These fires
claim 400 lives and cost society $2.2 billion annually. Working
with fire departments, electrical safety experts, and building
code officials, CPSC encourages electrical reinspections and
upgrades to home electrical wiring.
CPSC continues to distribute copies of its publication,
``CPSC Guide to Home Wiring Hazards,'' and in 1997-98,
distributed almost 10,000 copies. Consumers may obtain a free
copy of this publication by sending a postcard to ``Home Wiring
Hazards,'' CPSC, Washington, D.C. 20207.
Grandchild safety
The role of grandparents may range from occasional
babysitting to primary caregiving. A recent U.S. Census Bureau
study states that 1.3 million children are entrusted to
grandparents every day. In the years since grandparents were
raising their own children, many safety issues have arisen or
drastically changed. As more and more grandparents have become
caregivers for American children, it became clear there was a
need to reach them with critical child development and safety
information.
In 1997, CPSC Chairman Ann Brown and noted pediatrician T.
Berry Brazelton, M.D., head of Pampers Parenting Institute,
unveiled the booklet, ``A Grandparents Guide for Family
Nurturing & Safety.'' This easy-to-read booklet contains
important child care and nurturing information for
grandparents. It also features a safety checklist with
potentially life saving tips for childproofing homes and
protecting grandchildren, from newborns to five-year-olds.
The booklet is available free of charge through the
Consumer Information Center. The toll-free number to call is 1-
888-8-PUEBLO. The booklet is posted on both the Pampers
Parenting Institute Web site at www.pampers.com and the CPSC
Web site at www.cpsc.gov. To date, over 84,000 copies have been
distributed.
Adult-friendly poison prevention packaging
Older consumers are involved in the childhood poisoning
issue because many young children are poisoned when they
swallow grandparents' medicine. In fact, about 20% of
prescription medicines ingested by children under age 5 belong
to grandparents or other relatives. Child-resistant (CR)
packaging has saved children's lives. CPSC has data estimating
that the widespread use of child-resistant closures on aspirin
and oral prescription medicines saved the lives of at least 800
children under age five since 1974 (about 35 or more children
saved annually). Net societal savings from this action are
estimated at more than $150 million annually, due to prevented
deaths. This savings is more than 3 times CPSC's 1999 budget of
$47 million.
However, CR packaging can only work if people choose it and
use it properly. Many older consumers find it difficult to open
CR packaging and may not replace the caps or use the packaging
at all. To make it easier for all adults, especially older
ones, to use child-resistant packaging, CPSC in 1995 adopted a
change in its rules for testing packaging under the Poison
Prevention Packaging Act. The new regulation requires that
packaging be tested by panels of adults 50 to 70 years of age
rather than 18 to 45 years old, as was previously the case.
This change--effective for packaging marketed after January
1998--assures that child resistant packaging is more ``adult-
friendly.'' The change has encouraged the industry to develop
innovative closures that rely on older people's ``cognitive
skills'' instead of their physical strength. CPSC expects the
new packaging to help prevent more child poisonings. In
addition, CPSC reminds all adults to keep medicines locked up
and out of reach of children.
In 1994, Chairman Ann Brown awarded commendations to two
companies for safety innovations in child-resistant packaging
that were especially useful for older consumers. Procter and
Gamble received an award for marketing a major product in
adult-friendly child-resistant packaging and Sunbeam Plastics
was recognized for developing an entire line of adult-friendly
child-resistant packaging.
Sports safety for seniors
A recent CPSC study shows a 54% increase in the number of
sports-related injuries suffered by persons 65 years of age and
older between 1990 and 1996--from 34,400 to 53,000. The report
shows that most of these increases in injuries to older persons
are in connection with more active sports, such as bicycling,
weight training and skiing. In 1998, the CPSC and the American
Academy of Orthopaedic (AAOS) Surgeons teamed up to help
reverse this trend.
In a brochure they developed jointly, CPSC and AAOS give
older Americans important tips for remaining safe while
enjoying the many benefits of exercise. Exercise is beneficial
for most people of all ages, and Americans are remaining more
physically active into their 70s, 80s, and 90s. Studies cited
by the AAOS show that exercise can result in a longer,
healthier life, while building stronger bones and reducing
joint and muscle pain. Exercise improves mobility and balance,
and reduces the risk of falls and serious injuries like hip
fractures. However, many injuries can occur while people
exercise.
The CPSC/AAOS brochure strongly recommends the use of
proper safety gear when exercising or participating in sports.
Safety gear is the best way to reduce or eliminate injuries
while exercising. For example, bicycling injuries to older
Americans increased 75% from 1990 to 1996. Most bicycling
injuries result from falls. Head injuries accounted for 21% of
the injuries. Virtually none of the fall victims was wearing a
bike helmet. The brochure recommends that bikers always wear a
helmet. Injuries associated with exercise activity (aerobics,
weight training, etc.) increased 173% between 1990 and 1996.
The most common types of injuries were falls and strains. The
brochure recommends that persons using exercise equipment
should read instructions carefully and, if needed, ask someone
qualified to help.
During 1998, CPSC distributed over 3,500 copies of this
brochure, ``Keep Active and Safe at Any Age.'' Consumers may
order a copy of the brochure by calling toll-free at (800) 824-
BONES or send a self-addressed, stamped business-size envelope
to, ``Keep Active'' brochure, American Academy of Orthopaedic
Surgeons, P.O. Box 1998, Des Plaines, IL 60017. Copies of the
brochure and the CPSC report can be accessed at the CPSC web
site at: http//www.cpsc.gov.
International Year of Older Persons 1999
The United Nations (UN) General Assembly recognized
``humanity's demographic coming of age'' by adopting 1999 as
the International Year of Older Persons (IYOP). The UN is
encouraging countries, organizations and governments at all
levels to observe the IYOP. In 1998, CPSC joined the Federal
Committee to prepare for the International Year of Older
Persons. This Committee, comprised of 12 cabinet agencies and
15 other federal agencies, commissions, and councils, will work
throughout 1999 and beyond to assure that the federal
government is prepared for the aging of our society.
The CPSC is participating on both working subcommittees of
the Federal Committee: the Media and Conference Subcommittees.
The Media Subcommittee is assembling a number of activities
that will be undertaken by members of the Federal Committee
throughout 1999 and beyond. These activities include public
awareness campaigns and media forums on aging issues. Execution
of these activities will extend from programs and activities at
the national level to grassroots community partnerships.
CPSC developed a media sheet that summarizes agency
programs and activities supporting IYOP. On October 19, 1998,
this media sheet was included in the Federal Committee's IYOP
launch event press kit. The media sheet, CPSC publications and
technical reports have been and will be used in a number of
CPSC exhibits/ displays and other CPSC supported programs
around the country as IYOP activities continue. When
appropriate, CPSC's Chairman Ann Brown will be involved in the
Federal Committee's media activities at the national level,
increasing public awareness of the many safety programs CPSC
offers older consumers.
The CPSC is contributing to the development of the Federal
Committee's conference scheduled for June 1 and 2, 1999. Top
experts in the field of gerontology will be panelists at the
conference, and federal agencies and other professionals in the
field will develop recommendations for continued initiatives.
CPSC will contribute its own safety related programs to the
conference agenda.
ITEM 16--CORPORATION FOR NATIONAL SERVICE
----------
On September 21, 1993, the President signed into law the
National and Community Service Trust Act, which created the
Corporation for National Service (Corporation). The
Corporation's mission is to engage Americans of all ages and
backgrounds in community-based service. This service addresses
the Nation's unmet education, public safety, human and
environmental need to achieve direct and demonstrable results.
This commitment to ``get things done'' is honored by the
Corporation's three national service initiatives: The National
Senior Service Corps (Senior Corps), AmeriCorps, and Learn and
Serve America.
NATIONAL SENIOR SERVICE CORPS: A THIRTY YEAR HISTORY OF LEADERSHIP IN
SENIOR VOLUNTEERISM AND SERVICE
Senior Corps is comprised of three seasoned programs
previously supported by the Federal agency ACTION and its
predecessors:
The Foster Grandparent Program enables seniors
to provide individual support to children and youth
with special and exceptional needs.
The Retired and Senior Volunteer Program
(RSVP), volunteers perform a myriad of services,
including organizing neighborhood block watches,
identifying sources of groundwater contamination,
teaching computer classes, and participating in natural
disaster recovery.
The Senior Companion Program supports older
volunteers who provide assistance that allow frail
individuals to continue living independently and with
enhanced quality of life.
In 1997, nearly half a million Senior Corps volunteers
contributed their time, skills, wisdom and experience to
addressing unmet community needs, while emphasizing the impact
on both the individuals and the communities served.
TABLE 1.--NATIONAL SNAPSHOT OF THE SENIOR CORPS PROGRAMS \1\
----------------------------------------------------------------------------------------------------------------
Number of local Number of Volunteer hours of service to
Program projects volunteers communities (million hours)
----------------------------------------------------------------------------------------------------------------
FGP........................................ 305 25,300 23.8
RSVP....................................... 751 453,300 80
SCP........................................ 191 13,900 11.8
--------------------------------------------------------------------
Totals............................... 1,247 492,500 115.6
----------------------------------------------------------------------------------------------------------------
\1\ Source for all Senior Corps program and volunteer related data: 1997 Annual Project Profile of Volunteer
Activities (PPVA), Corporation for National Service, National Senior Service Corps.
TABLE 2.--SENIOR CORPS PROGRAMS IN THE COMMUNITY
----------------------------------------------------------------------------------------------------------------
Number of local public
Number of local Number of census and nonprofit agencies
Program projects districts served with senior corps
volunteers
----------------------------------------------------------------------------------------------------------------
FGP.............................................. 305 826 8,410
RSVP............................................. 751 1,416 70,500
SCP.............................................. 191 603 3,200
--------------------------------------------------------------
Totals..................................... 1,247 2,845 82,110
----------------------------------------------------------------------------------------------------------------
FUNDING THE NATIONAL SENIOR SERVICE CORPS--A COST-EFFECTIVE FEDERAL
INVESTMENT TO BENEFIT LOCAL COMMUNITIES
The total federal funding for National Senior Service Corps
programs in fiscal year 1998 was $163,240,000, apportioned
among each of the three programs as follows:
TABLE 3.--NATIONAL SENIOR SERVICE CORPS FY '98 FEDERAL FUNDING \2\
[Dollars in millions]
------------------------------------------------------------------------
FY '98
Senior Corps Program funding
------------------------------------------------------------------------
Foster Grandparent Program................................. $87.6
Retired and Senior Volunteer Program (RSVP)................ $40.3
Senior Companion Program................................... $35.4
Total................................................ $163.3
------------------------------------------------------------------------
\2\ Source for fiscal data: FY '98 federal appropriation, Corporation
for National Service, National Senior Service Corps.
Senior Corps projects are locally sponsored and
administered. Within the broad framework of its legislation,
service activities grow out of agreements among the
participants, funded projects, and the communities served. As a
result, these activities reflect a mix of needs unique to each
community.
The community-driven focus is, in large part, a reason for
the local non-federal support enjoyed by Senior Corps programs.
TABLE 4.--SENIOR CORPS PROGRAMS AND NON-FEDERAL LOCAL CONTRIBUTIONS
----------------------------------------------------------------------------------------------------------------
FY '98 Non-federal
Senior Corps Program federal local Percentage of non-federal support for
investment contribution every federal dollar
----------------------------------------------------------------------------------------------------------------
Foster Grandparent Program.................... $87.6 $34.8 40 percent
40 cents
per dollar
Retired and Senior Volunteer Program (RSVP)... 40.3 42.4 105 percent
$1.05 per
dollar
Senior Companion Program...................... 35.4 21.8 61 percent
61 cents
per dollar
---------------------------
Total................................... 163.3 99 .....................................
----------------------------------------------------------------------------------------------------------------
Senior Corps programs allow local agencies to provide
greater levels of service within their relatively small
operating budgets and demands placed on them as community
service providers. The monetary value of the volunteer services
provided by Senior Corps volunteers exceeds one billion
dollars.\3\
---------------------------------------------------------------------------
\3\ Based on the 1996 Biannual Report, Giving and Volunteering in
the United States, Independent Sector, which assigned a comparable
value of $13.24 per hour to volunteer service.
TABLE 5.--SENIOR CORPS PROGRAMS AND RETURN ON THE FEDERAL INVESTMENT
----------------------------------------------------------------------------------------------------------------
FY '97 annual volunteer Return on federal
Senior Corps Program service hours Value of service investment
----------------------------------------------------------------------------------------------------------------
Foster Grandparent Program........... 23.8 million hours..... $315 million........... 4-fold return
Retired and Senior Volunteer Program 80 million hours....... $1.1 billion........... 31-fold return
(RSVP).
Senior Companion Program............. 11.8 million........... $156 million........... 5-fold return
--------------------------------------------------
Total.......................... 115.6 million hours.... $1.5 billion........... .......................
----------------------------------------------------------------------------------------------------------------
VOLUNTEER OPPORTUNITIES FOR OLDER ADULTS: AMERICA'S MOST ABUNDANT
NATURAL RESOURCE
Twice as many older adults live in the United States today
as 30 years ago and the number of persons over age 55 will
double again by 2025. Three factors make older persons the
nation's best increasing natural resource:
Good Health--More than 80 percent of Americans
age 65 and over report no difficulties with activities
of daily living. Less than 5 percent are
institutionalized.
More Time--Americans are now spending a third
of their lives in retirement, freeing an average of
more than 20 hours a week to engage in additional
activities.
High Interest--According to the Independent
Sector, a Washington, D.C.-based organization that
studies American volunteerism, when persons 55 and
older are asked to volunteer, over 70 percent do.
Service by seniors is changing the definition of
satisfaction and success in post-retirement, and is
increasingly regarded as an essential ingredient in productive
aging. For example, in a 2.5-year follow-up of the MacArthur
Successful Aging study, participation in volunteer activities
was predictive of improved functioning in older adults, with 32
percent lower risk of poor physical function in those so
involved, independent of the effects of being physically
active. There is preliminary evidence from the same study that
the amount of time one is involved in formal volunteering
activities is important in conferring health benefits, with
greater time involvement predictive of the level of physical
functioning two years later. Finally, there is evidence that
organized and structured roles and behavior are among the best
predictors of survival (Fried, Freedman, et al., 1997). It
follows, therefore, that public investment in volunteer service
by seniors is not only prudent, but that it has multiple
benefits.
NATIONAL SENIOR SERVICE CORPS-SIGNIFICANT ACTIVITIES, 1997-1998
Senior Corps Volunteers: Meeting Community Needs
As a new millennium approaches, the Senior Corps is at an
unprecedented juncture. On one hand, a new generation of older
Americans--more healthy, educated, and numerous than any before
it--will provide tremendous energy and resources to the senior
service movement. On the other hand, economic realities and
funding cutbacks at all levels require increased innovation in
the delivery of volunteer services.
In this new environment, it is anticipated that funding
must go to those programs that can distinguish themselves among
competitors by demonstrating value, cost-effectiveness, and
significant results in solving critical community needs. Thus,
the Senior Corps is aggressively moving beyond talking about
``how much time and how many seniors we provide'' to answering
the question ``what difference do we make?''
Senior Corps' evolution in vision requires programming
focused on outcomes. Programming for Impact is the framework
that was developed by the Senior Corps in 1996 to facilitate
this evolution. It advocates an approach to service programming
that integrates community need, accomplishment and impact into
station and volunteer assignment development, planning and
reporting. It also measures responsiveness to the community and
thereby fosters recognition of seniors as a vital, invaluable
resource.
As a vehicle to achieve accomplishment and outcome based
programming, Programming for Impact will also position Senior
Corps to meet Government Performance and Results Act (GPRA)
requirements. As a result of the 1993 Government Performance
and Results Act, appropriation decisions will now be based on
performance and results of Federal agencies. Adding an outcome
based focus, Programming for Impact is one of the Performance
Indicators for Senior Corps' GPRA goals.
Some key components of the Programming for Impact
initiative in 1997 included state impact conferences involving
key stakeholders in dialogue and consensus building, and
development and dissemination of technical assistance
guidebooks and project management tools.
demonstration programs
Senior Corps tests new models for mobilizing older persons
in service through its demonstration authority, which builds on
the effective practices and lessons learned through RSVP, the
Foster Grandparents Program, and the Senior Companion Program
and positions Senior Corps to tap the vast civic potential of
the aging baby boom generation.
In the Fall of 1997, the Corporation launched the 2-year
Seniors for Schools initiative in nine communities. This
initiative built on and refined the core elements of the
Experience Corps model, and narrowed the focus by adopting the
goals of ``America Reads'' which focuses on literacy for young
children in grades K-3. The Seniors for Schools program
effectively enlisted men and women over the age of 55 to serve
in teams and make a significant commitment to help children
learn and read.
Seniors for School completed its first full year of
operation in summer of 1998. During this first year the nine
projects developed partnerships with AmeriCorps*VISTA, RSVP and
FGP projects and 27 Title I elementary schools. They trained
and placed a total of 250 senior volunteers in these 27 schools
and served more than fifteen hundred children with
substantially below-average reading skills in kindergarten
through grade three. In year two (1998-1999 school year), the
majority of Seniors for Schools volunteers are expected to
continue in the program. Several sites will expand to new
schools and reach more children.
The Corporation for National Service and the American
Association of Retired Persons (AARP) are working together to
implement the new Experience Corps for Independent Living in
six communities.
The purpose of the Experience Corps for Independent Living,
funded in FY '98 to begin operation in FY '99, is to develop
and test innovative approaches to using the time, talents,
experience and resources of volunteers over 55 to significantly
expand the size and scope of volunteer efforts on behalf of
independent living services for frail elders and their
caregivers in specific communities.
senior corps volunteers: supporting america reads
Reading is a key to success in education and in life.
Unfortunately, many children fall behind their classmates
because they do not learn to read early and read well. The
America Reads initiative calls on all Americans to help ensure
that every child can read well and independently by the end of
third grade. The National Senior Service Corps, with its strong
track record of effective service in tutoring and literacy, is
playing an important role in this initiative.
Senior Corps devoted 100 percent of new Foster Grandparent
and Retired and Senior Volunteer Program funds available for
program expansion in FY 1998 to America Reads activities.
Nine Seniors for Schools projects recruited
and placed 243 senior volunteers who helped 1,570
children with literacy activities at 27 schools.
Through Programs of National Significance
grant augmentations to existing Senior Corps projects,
a total of $5.5 million (RSVP and FGP) was awarded to
support child literacy.
RSVP: $2.2 million was awarded to 222 RSVP
projects supporting up to 24-26 volunteers per
project (5,500 new volunteers).
FGP: $3.3 million was awarded to 87 existing
FGP projects supporting approximately 790 new
Volunteer Service Years.
Nine new RSVP projects were funded in late
FY '98, which will recruit and place approximately
1,200 RSVP volunteers to focus on America Reads
activities in the first year, beginning operation in FY
'99.
Eleven new Foster Grandparent projects were
funded, in late FY '98, which will create opportunities
for approximately 680 new Volunteer Service Years;
volunteers will focus on America Reads activities in
the first year, beginning operation in FY '99.
national organization initiative
The purpose of the National Organization Initiative is to
expand Senior Corps Programs through an approach that taps the
expertise of national nonprofit organizations and builds on
their existing networks of affiliates who operate programs at
the local level. National organizations will explore ways to
strengthen the role of senior volunteerism throughout their
organizations and will support networking among their local
affiliates selected as Senior Corps project sites.
In July 1998, the Corporation for National Service selected
the following six national organizations to receive grants to
promote senior service as a strategy within their organizations
and support networking among designated local affiliates who
will operate new Senior Corps projects:
Big Brothers Big Sisters of America
Child Welfare League of America/Generations
United
Lutheran Services in America
Points of Light Foundation
Save the Children Federation
Volunteers of America
evaluation activities
The Retired and Senior Volunteer Program
Study was conducted by Westat, Inc in 1995-96, and was
the first large-scale study of the program in over a
decade. The study helped to clarify a number of
challenges to be addressed as RSVP moves forward, of
which 8 were selected as highest priority.
To position RSVP for the future, sustain its best
features and respond to the critical issues raised in
the Westat study, the Senior Corps convened focus
groups of stakeholders in FY 98 regarding the 8
priority challenges. Focus group members explored
challenges and made recommendations. A follow up report
will be released to RSVP stakeholders that will also
include suggested next steps to address the challenges
and move forward.
The Foster Grandparent Program Study,
conducted by Westat, Inc in 1997, sought to learn about
what Foster Grandparents actually do in Head Start
centers and how their contributions benefit the
children they serve. The findings show that the
majority of Foster Grandparents engage in a wide range
of activities and interactions that contribute
positively to children, classrooms and stations.
The final report, ``Effective Practices of Foster
Grandparents in Head Start Centers: Benefits for
Children, Classrooms and Centers'' will be disseminated
to Foster Grandparent projects nationwide in the first
quarter of FY 1999.
FOSTER GRANDPARENT PROGRAM
In 1997-1998, more than 25,000 Foster Grandparents gave
care and attention to 175,500 children and youth with special
and exceptional needs.
Program Overview
The Foster Grandparent Program began in August 1965 as a
national demonstration effort. Since its inception, the Foster
Grandparent Program has provided young and old the chance to
grow together. Today, nearly 25,000 older Americans serve as
Foster Grandparents. They give care and attention every day to
175,500 children and youth with special and exceptional needs.
In improving the lives of children they serve, Foster
Grandparents also profoundly enrich their own lives.
Foster Grandparents volunteer in schools, hospitals, drug
treatment centers, correctional institutions, and Head Start
and day care centers. They offer emotional support to children
who have been abused and neglected, mentor troubled teenagers
and young mothers, care for premature infants and children with
physical disabilities or severe illnesses, including AIDS. This
special care helps young people grow, gain confidence, and
become more productive citizens. In the process, Foster
Grandparents strengthen communities by providing personalized
services to special needs children that community budgets
cannot afford and by building strong bridges across
generations.
Foster Grandparents must be at least 60 years of age and
meet certain income eligibility requirements. They serve 20
hours per week and receive pre-service orientation, training
throughout their service, and a modest stipend to offset the
cost of volunteering. They receive reimbursement for
transportation, some meals during service, an annual physical,
and accident and liability insurance while on duty.
non-federal support and return on federal investment
Foster Grandparent projects are jointly funded by federal,
state, and local governments, with significant support from the
private sector. The federal budget to support these projects
was $77.8 million in fiscal year 1997 and $87.6 million in
fiscal year 1998. The non-federal local contribution averaged
$34.8 million annually or 40 cents for every federal dollar
invested--well above the 10 percent match required by law and
attesting to the success of Foster Grandparents in the
communities they serve.
In 1997-1998, 25,000 Foster Grandparents served through 305
projects sponsored by local nonprofit agencies.
The 23.8 million hours of service provided annually by
Foster Grandparents was worth over $315 million, according to a
study by the Independent Sector. This represented more than a
four-fold return on the federal dollars invested in these
projects.
NATIONAL PROFILE OF FOSTER GRANDPARENT VOLUNTEERS
------------------------------------------------------------------------
Characteristics Percent
------------------------------------------------------------------------
Distribution by Gender:
Female................................................. 90
Male................................................... 10
Distribution by Age:
60-69 years............................................ 31
70-79 years............................................ 51
80-89 years............................................ 13
85 and over............................................ 5
Distribution by Ethnicity:
White.................................................. 48
African American....................................... 37
Hispanic/Latino........................................ 10
Asian/Pacific Islander................................. 4
American Indian/Alaskan Native......................... 2
Population Served:
Urban.................................................. 60
Rural.................................................. 40
------------------------------------------------------------------------
The federal cost of a Foster Grandparent serving 20 hours a week is
$3,670 annually.
Foster Grandparent Project Examples
Helping Teen Mothers and Their Babies--Wayne Action Group For Economic
Solvency Foster Grandparent Program, North Carolina
Foster Grandparents serving with the Wayne Action Group for
Economic Solvency (WAGES) project provide support for teenage
mothers and their children. They go to the mothers homes,
mentoring the mothers in home management and parenting skills,
while providing nutritional and nurturing support for their
babies. Last year, four Foster Grandparents served five teen
mothers who have a total of seven children.
The teen moms are making responsible decisions and getting
their lives, and those of their babies, on track, thanks to the
guidance and support of the Foster Grandparents. Four of the
mothers went back to school and three have already earned their
GED certificates. These achievements were possible because the
Foster Grandparents cared for the babies while their moms were
in school. Four of the mothers are now employed. None have
become pregnant since they were served by a Foster Grandparent.
In-home placement of Foster Grandparents has proven a
positive response to the challenges created by the growing
number of teen mothers in Goldsboro and Wayne County, North
Carolina.
Enhancing Child Literacy and Reading Skills--Southeast Foster
Grandparent Program--Monticello, Arkansas
Four elementary schools in southeast Arkansas began
utilizing Foster Grandparents as literacy and reading tutors
the fall of 1997. Teachers from each of the four schools
referred children whose total reading scores were in the bottom
of the lowest 25 percent on the Stanford 9, a national norm-
based test. The lowest scoring 64 children were assigned to 16
Foster Grandparents. All Foster Grandparents have been trained
in caregiving, reading and helping children to stay on task.
Students were pre-tested in the fall and will be post-tested at
the end of the school year to determine progress. According to
teacher evaluations collected in January 1998, all students are
reading with more confidence after just a few months with a
Foster Grandparent, and 77 percent of the teachers reported
that the children were making excellent progress.
Mentoring Juvenile Offenders Toward Rehabilitation Foster Grandparent
Program of Sacramento--Sacramento, California
The rate of juvenile offenders in Sacramento County has
grown 16.5 percent in the last six years. Most of these
offenders, according to the Probation Department and the
Sacramento County Office of Education, are reading below grade
level or have dropped out of school. Seven Foster Grandparents
were placed in units with children and youth providing one-to-
one mentoring and support, as well as in a school setting
working on reading and math skills. The Foster Grandparents
helped their assigned youth increase reading levels by 1-2
grade levels, study for and pass GED, and help develop
proficiency for post-placement college enrollment.
Helping Students Overcome Learning Disabilities--Siete del Norte Foster
Grandparent Program--Fairview, New Mexico
At the Espanola Elementary School, eight Foster
Grandparents volunteers tutored 32 students with learning
disabilities and/or attention deficit disorders. According to
school officials, Foster Grandparents presence at the Espanola
Elementary School helped to improve language and reading
skills, and increased school attendance by 50 percent among
students with special needs. It is also noted that children
assisted by Grandparents improved more rapidly than non-
assigned students in behavioral and study habits.
Academic Tutoring for Students in Need of Extra Assistance--Hall/Adams/
Buffalo Foster Grandparent Program--Grand Island, Nebraska
Foster Grandparents were placed in 16 elementary schools to
provide one-to-one tutoring with 96 second grade students who
scored lowest on Basic Skills test. Foster Grandparents spend
an average of four hours a week with each child tutoring him or
her in reading, spelling and word recognition. Midway through
the school year, the second grade students were retested using
the same test, and results substantiated that children tutored
by the Foster Grandparents recognized more words, performed
better on spelling tests and raised their reading levels higher
than the children who did not receive any extra attention or
tutoring.
SENIOR COMPANION PROGRAM
In 1997-1988, almost 13,900 Senior Companion volunteers
served 48,900 frail older persons.
Program Overview
The Senior Companion Program awarded funds to its first
projects in August 1974. This program recruits low-income
persons age 60 and over to provide assistance and friendship to
frail adults, mostly the elderly who are homebound and living
alone. The services Senior Companions provide help others to
live independently in their own homes instead of moving to
expensive institutional care. Senior Companions also provide
respite care for short periods of time to relieve live-in
caretakers.
By assisting clients with simple chores, providing
transportation to medical appointments, and offering needed
contact to the outside world, Senior Companions often provide
the supportive services that the frail need to continue to live
independently. Because Senior Companions spend significant
amounts of time with their clients, they are often a critical
part of the client's ``care team.'' Senior Companions alert
doctors and family members of potential health problems,
allowing them to provide immediate care to the client.
Senior Companions serve three to four clients in an average
week, predominately in the client's own homes. Community
organizations that address health needs of the elderly such as
home health care agencies, hospitals, or centers on aging serve
as volunteer stations. These organizations identify individuals
who need assistance and then work with Senior Companion
projects to match them with available Senior Companions.
Like Foster Grandparents, Senior Companions serve 20 hours
per week. They also receive pre-service orientation, training
throughout their service, and a modest stipend to offset the
cost of volunteering. They are provided transportation, some
meals during service, an annual physical, and accident and
liability insurance while on duty.
Compared with the average cost of nursing home care, which
exceeds $38,000 annually, the annual cost for Senior Companion
services is $4,000. This is a very cost-effective way to
provide supportive services to an average of five frail adults
per Senior Companion, who might otherwise be at risk for
premature institutionalization.
Non-Federal Support and Return on Federal Investment
In 1997-1998, almost 14,000 Senior Companions served over
49,000 frail adults annually through 191 projects sponsored by
local public and private nonprofit agencies. These projects are
jointly funded by the federal government, state and local
governments, and the private sector. The federal budget for
Senior Companions was $35.4 million in fiscal year 1998. The
non-federal local contribution to these projects was $21.8
million. This non-federal contribution represented a support of
61 percent, or 61 cents for every federal dollar invested--well
above the 10 percent match required by law.
In fiscal year 1997, the 11.8 million hours of service
provided annually by Senior Companions was estimated to be
worth $156 million, according to a study by the Independent
Sector. This represents almost a five-fold return on the
federal dollars invested in the program.
NATIONAL PROFILE OF SENIOR COMPANION VOLUNTEERS
------------------------------------------------------------------------
Characteristics Percent
------------------------------------------------------------------------
Distribution by Gender:
Female................................................. 85
Male................................................... 15
Distribution by Age:
60-69 years............................................ 35
70-79 years............................................ 51
80-89 years............................................ 10
85 and over............................................ 4
Distribution by Ethnicity:
White.................................................. 51
African American....................................... 33
Hispanic/Latino........................................ 11
Asian/Pacific Islander................................. 4
American Indian/Alaskan Native......................... 2
Population Served:
Urban.................................................. 63
Rural.................................................. 37
------------------------------------------------------------------------
The federal cost of a Senior Companion serving 20 hours a week is
$4,000 annually.
Senior Companion Project Examples
Helping Clients With Alzheimer's Disease.--Senior Companion Program of
Kankakee County--Kankakee, Illinois
Statistics provided by the Illinois Department on Aging,
based on 1990 census information, indicate that approximately
3,027 persons residing in Kankakee and Iroquois county
communities, age 65 and over, are afflicted with Alzheimers or
a related disease. The average cost of nursing home care for
one person exceeds $30,000 annually. Three Senior Companions
who received specialized training in Alzheimers care provide
respite care to 5 clients--reducing the possibility of
premature nursing home placement for conditions that limit
activities of daily living. It is anticipated that the Senior
Companions' assistance will allow 4 of the 5 clients to remain
at home for a minimum of 8 months. The cost savings of delaying
nursing home placement is anticipated at $1,690 per month. An
overall savings of $54,096 for 4 clients is projected.
Providing non-skilled medical care to adults with AIDS--New Orleans
Council on Aging Senior Companion Program--New Orleans, Louisiana
Two Senior Companions were assigned to the Shelter
Resources, Inc., a residential care facility for adults living
with AIDS. They received 20 hours of pre-service training and
20 hours of orientation from the ``House'' Personal Care
Attendant. They also attended meetings at the end of the month
with the station supervisor. The Companions provided non-
skilled medical care to selected residents needing extra care.
They prepared meals, escorted clients to the doctor or to
social activities, assisted with personal care and room
cleanliness. The Companions, each serving 20 hours per week,
are surrogate ``family'' to those without family support.
Serving Frail Tribal Seniors on Native American Reservations.--Senior
Companion Program of Minnesota--Red Lake, Minnesota
Many elders of the Red Lake Indian Reservation have no
transportation or telephone, little income, and few family
members nearby. Four Senior Companions serve 40 home bound
elders, providing them with rides to the grocery store, medical
appointments and elder nutrition sites for meals. The Senior
Companions report that their clients are now eating better and
more regularly. Companions also have been instrumental in
obtaining emergency medical care for clients when needed, in
addition to helping to link them to other community services.
Helping Older Russian Immigrants Acclimate To A New Culture--SCP of
Franklin County--Columbus, Ohio
Senior Companions are helping 57 older Russian refugees
become familiar with their new home by providing English
tutoring, translation, obtain housing, food, and other living
necessities, and accompanying clients to appointments. Twenty-
four clients gained proficiencies to allow independence; 33
improved their English skills and understanding of culture, and
4 clients passed the citizenship test to become new United
States citizens.
Providing Quality Services to Homebound Clients--Florida Department of
Elder Affairs Senior Companion Program, Tallahassee
Florida continues to lead the nation in proportion of older
persons comprising its general population. The fastest growing
segment of its older population are those ages 80 and older,
leading to a high incidence of Alzheimer's and other chronic
illnesses. In the Tallahassee area, 141 Senior Companion
volunteers provided services to 618 frail and chronically ill
seniors, of which 110 were diagnosed with Alzheimer's. Senior
Companions provide essential services to frail clients who
require extra assistance to maintain independence, including
light chore services, companionships, and transportation.
RETIRED AND SENIOR VOLUNTEER PROGRAM (RSVP)
In 1997-1998, RSVP volunteers provided over 31.9 million
hours of service to individuals needing assistance with health
and nutritional concerns. The volunteers helped individuals who
are mentally, developmentally and physically disabled;
rehabilitating from alcoholism and drugs; and those suffering
from HIV/AIDS. The volunteers also provided health education,
nutritional support, and in-home care for those needing peer
support and meal preparation.
Program Overview
The Retired and Senior Volunteer Program (RSVP) was
launched in 1971. RSVP matches the personal interests and
skills of seniors age 55 and older with opportunities to help
solve the problems in their communities and meet the needs of
their fellow citizens. RSVP volunteers choose how and where
they want to serve--from a few to over 40 hours a week in a
wide range of community organizations such as hospitals, youth
recreation centers, schools, and local police stations.
RSVP volunteers provide hundreds of community services.
They tutor at-risk youth, computerize information systems for
community health organizations, get children immunized, teach
parenting skills to teen parents, provide respite care for
caregivers of Alzheimer's victims, establish neighborhood watch
groups, plan community gardens, and a myriad of other community
services. Through such efforts, RSVP is meeting community needs
that strained local budgets cannot afford to address.
In 1997-1998, over 453,300 RSVP volunteers served through
751 projects sponsored by local public and private nonprofit
agencies. RSVP volunteers contributed over 80 million hours of
service to their communities annually in approximately 1,416
counties nationwide.
RSVP projects are jointly funded by the federal government,
state and local governments, and the private sector. RSVP's
federal budget was $40.3 million in fiscal year 1998. The non-
federal local contribution to RSVP projects was $42.4 million,
demonstrating broad support for RSVP across the country. For
every federal dollar invested, $1.05 was contributed from non-
federal sources in 1998.
Of the combined RSVP cost, federal funding provided 49
percent, while 51 percent of the costs were borne by local
funding sources.
According to the study conducted by the Independent Sector,
the over 80 million hours of service provided annually by RSVP
volunteers had an estimated worth of over $1.1 billion. This
represented approximately a 31-fold return on the federal
dollars invested in RSVP.
NATIONAL PROFILE OF RSVP VOLUNTEERS
------------------------------------------------------------------------
Characteristics Percent
------------------------------------------------------------------------
Distribution by Gender:
Female................................................. 75
Male................................................... 25
Distribution by Age:
55-59.................................................. 4
60-64 years............................................ 13
65-74 years............................................ 41
75-84 years............................................ 33
85 and over............................................ 10
Distribution by Ethnicity:
White.................................................. 86
African American....................................... 9
Hispanic/Latino........................................ 4
Asian/Pacific Islander................................. 1
American Indian/Alaskan Native......................... 1
Population Served:
Urban.................................................. 54
Rural.................................................. 46
------------------------------------------------------------------------
The federal cost of an RSVP volunteer serving is approximately 40 cents
per hour of service.
RSVP Project Examples
Helping Domestic Violence Victims--Miles City RSVP--Miles City, Montana
There were 224 new cases of domestic abuse reported in
Custer
County. Determined to rid their community of domestic violence,
the Custer Network Against Domestic Abuse (CNADA) sought
RSVP volunteers to work in public education and victim counsel-
ing. The volunteers also trained 22 school teachers on how to
help
children who either are abused themselves or who witnessed
abuse
in the home and established an awareness program at the local
high school. These education efforts have contributed to
additional arrests in their County and fewer victims being
returned to their abusers.
Creating a Safer Environment Through Recycling Efforts--North Platte
RSVP--North Platte, Nebraska
RSVP volunteers participated in a countywide goal to reduce
the tonnage of phone books entering the city's landfill. RSVP
volunteers collected and counted books from elementary schools,
then transported them to a storage facility. Wal-Mart stores
provided trucks to transport the books to a recycling facility.
A total of seven RSVP volunteers spent 74 hours collecting and
transporting 20,000 telephone books, representing 8.5 tons of
paper waste that was recycled, thus kept out of the North
Platte landfill.
Providing Tax Assistance For Low-Income Residents--City of Las Cruces
RSVP--Las Cruces, New Mexico
The Department of Human Services estimates that there are
31,770 household in Dona Ana County who live under the poverty
level, and that at least 20 percent of those households failed
to file their taxes and receive a tax refund. The goal of the
Volunteer Income Tax Assistance Program (VITAP) is to enable
senior volunteers to provide free income tax services to the
low-income and elderly population. Forty-five RSVP volunteers
assisted more than 2,400 low-income and elderly households to
prepare their taxes, and provided over 2,409 hours of income
tax service. Calculated at the average commercial filing fee of
$90 per household, the volunteers saved their clients a total
of more than $216,000 in 1997. Each household received a refund
of approximately $100 each.
Helping to Keep Communities Safe--Mandan Golden Age Club RSVP--
Bismarck, North Dakota
The Mandan Golden Age Club, Retired and Senior Volunteer
Program utilized a ``Summer of Safety'' demonstration grant to
revitalize the Bismarck Police Department's Neighborhood Watch
program. Although the police had originally estimated it would
take eight years to accomplish an effective Neighborhood Watch
program, the RSVP volunteers had organized Watch areas for
every street in the city (about 600 separate Neighborhood Watch
areas) within several months. Comparing data over the years,
Officer Dwight Offerman of the Bismarck Police Department
estimated that RSVP efforts had directly contributed to a 27
percent reduction in residential burglaries. The categories of
theft and vandalism also were reduced by 15 and 23 percent
across the same period.
Working to Build a Community Kitchen Project--Cache County Senior
Citizens Center Kitchen Project--Logan, Utah
Since 1973, the Cache County Senior Citizens Center were
providing congregate meals for senior citizens and all
delivered meals to homebound senior citizens of Cache County.
With the growth of the aging population, it was determined that
a larger kitchen and service area at the Center was needed. A
team of volunteers including Retired and Senior Volunteer
Program volunteers were recruited for the ``Kitchen Project,''
which included research and work on facility design, staffing
costs, nutritional requirements and meal planning, raw foods
vs. prepared food cost comparison, land requirements, building
permit requirements, community support, and fund-raising. Over
the past several years, more than 80 RSVP volunteers, along
with other community volunteers, raised more than $600,000
needed to build the new kitchen facility. The chairman, an RSVP
Volunteer, alone donated over 900 recorded hours to the
project. In addition to research and fund-raising, the
volunteers also contributed ``hands-on'' work in the building
and ground preparation. Relationships were developed between
local food businesses and the Community Food Pantry who offered
to provide ongoing food donations to the ``Kitchen.'' The new
state of the art kitchen facility opened for business in July
of 1997.
Helping to Rid Communities of Hazardous Waste--Area I Agency of Aging/
Volunteer Center--Eureka, California
A large freighter ran into a dock in November 1997, causing
4,500 gallons of crude oil to spill in to the bay. This
hazardous waste disaster was a threat to the wildlife and
marine life. The Volunteer Center/Retired and Senior Volunteer
Program acted as the disaster volunteer management center,
recruiting community assistance by preparing public service
announcements for radio and television. The Volunteer Center/
RSVP and the State Department of Fish and Game and the County
Office of Emergency Services worked together to ascertain
immediate cleanup needs and mobilize resources. The result of
the volunteers work shows that 200 shore birds were saved, 79
volunteers in total were successfully recruited from the
community, 40 volunteers helped at the Marine Wildlife
Facility, and 12 volunteers were recruited to join the
Volunteer Center/RSVP program to serve as disaster preparedness
volunteers.
Helping to Immunize Children--RSVP of Southeastern Wyoming--Cheyenne,
Wyoming
The required State Of Wyoming vaccinations for seventh
graders include Hepatitis B series, Measles, Mumps, Rubella and
a tetanus booster. It is estimated that 30,000 children in
Wyoming need the immunization series. To date, 4 RSVP
volunteers have contributed 288 hours of service to a school
clinic set up by the City/County Health Department. With the
help of RSVP volunteers, the school clinic immunized 1,020
students this past year. ``The City County Health Department
values the time and talent provided by the RSVP volunteers,''
states Connie Diaz, Director of City/County Health Department
in Cheyenne.
ITEM 19--FEDERAL COMMUNICATIONS COMMISSION
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Summary of 1997 and 1998 Activities Affecting Older Americans
This report summarizes the major 1997-1998 activities of
the Federal Communications Commission (``FCC'' or ``the
Commission) affecting older Americans.
A number of these actions were taken to implement statutory
requirements or Commission policies on behalf of the general
public and all telecommunications consumers, including the
millions of Americans with some kind of hearing, vision, speech
or other disability. rather than specifically on behalf of
older Americans. However, since many older Americans may be in
declining health, e.g., losing hearing or vision, or be
especially vulnerable to unscrupulous business practices in
telecommunications services, older Americans have benefited
from the various disability-related and consumer protection
activities describedbelow.
Disabilities Issues Task Force
The Disabilities Issues Task Force was formed in March 1995
to serve as the agency's main point of contact and coordination
on all disability access initiatives. The Task Force works to
ensure that the Commission promotes access to
telecommunications by individuals with disabilities, including
many older Americans.
In the past two years, the Commission has made significant
efforts to strengthen the cross-agency Disabilities Issues Task
Force in order to highlight, among other things, the importance
of making technology available to everyone. The Task Force was
central in providing advice and expertise on major rulemaking
proceedings, including proceedings that did the following:
strengthened closed captioning rules so that persons who are
deaf or hard-of-hearing will have access to more programs on
television; proposed new rules for telecommunications relay
services and proposed to require the provision of speech-to-
speech relay service; advocated that industry provide solutions
to the problem of compatibility between digital wireless phones
and TTYs; and proposed rules to make telecommunications
services and equipment accessible to persons with disabilities.
The Task Force has worked to raise the profile of the needs
of persons with disabilities in the telecommunications area
through organizing speeches, statements, and demonstrations at
the FCC of equipment and how persons with disabilities would
benefit from it. We have also sought to ensure that the voices
of people with disabilities and their advocates are heard at
the FCC.
The Disabilities Issues Task Force is also working toward
proper implementation and compliance with Section 508 of the
Rehabilitation Act, which imposes accessibility requirements on
electronic and information technology developed, maintained,
procured, or used by federal agencies. The Task Force also is
making efforts to improve the Commission's compliance with
Section 504.
Section 255 (Access to Telecommunications)
Section 255 of the Communications Act, added by the
Telecommunications Act of 199 provides that telecommunications
equipment manufacturers and service providers must make their
equipment and services accessible to those with disabilities,
to the extent that it is readily achievable to do so. The
Commission proposed rules to implement this section in 1998. We
expect final rules to be adopted in 1999.
Common Carrier Bureau (CCB)
Some of the most important policy actions of the FCC
affecting older Americans have been initiated by
theCommission's CCB. This bureau regulates wireline
communications in the telecommunications industry.
Hearing Aid Compatibility.--An example of a CCB issue that
affects senior citizens is hearing aid compatibility and volume
control (HAC/VC). This subject is of special relevance to older
Americans because many people who lose their hearing later in
life depend on HAC telephone with VC to be able to use the
telephone.
The Hearing Aid Compatibility Act of 1988 required the
Commission to establish rules that ensure reasonable access to
telephone service by persons with hearing disabilities, and to
seek to eliminate the disparity between hearing aid users and
non-users in obtaining access to the telephone network.
To resolve various compliance issues, and recommend new
rules to replace original rules suspended in 1993, the
Commission in the spring of 1995 established a 19-member
Hearing Aid Compatibility Negotiated Rulemaking Committee. Its
members represented all interested parties, including the
Commission, telephone equipment manufacturers, employers,
hospitals, nursing homes, hotels and motels and persons with
disabilities, including some older Americans.
On July 3, 1996, the Commission adopted final rules, many
of which were recommended to it by the rulemaking committee in
its report to the FCC of August, 1995. In general, the FCC's
final rules required eventually all wireline telephones in
workplaces, in confined settings (e.g., hospitals and nursing
homes) and in hotels and motels to be hearing aid compatible
according to certain timelines. In addition, telephones that
are newly acquired or are replacement telephones eventually
will have to have volume control features. Workplaces with
fewer than 15 employees were exempted, except for telephones
provided directly for employees with hearing disabilities.
Finally, the date of November 1, 1998, adopted by the FCC in
July 1996 for implementation of the volume control features in
all telephones manufactured or imported for use in the United
States, was later extended on reconsideration to January 1,
2000.
Slamming and Cramming.--``Slamming'' is the practice of
switching a person's long distance telephone company without
the customer's permission. ``Cramming'' is the inclusion of
unauthorized or unexplained charges on a person's phone bill.
Older Americans are especially vulnerable to such anti-consumer
activity. In 1998, the Commission proposed new rules to ensure
that carriers do not use misleading or confusing forms that
consumers sign to change their long distance service, to ensure
that consumers do not pay any charges to a slamming company.
These rules will be effective in May, 1999. CCB has
significantly stepped up enforcement actions against slamming
and cramming. With over $8.4 million of fines assessed and
another $8 million pending.
Truth In Billing.--To further protect customers, the Common
Carrier Bureau has initiated a rulemaking to require telephone
bills to be clearer and better organized, and to highlight new
charges. This will give customers the tools they need to make
sure they have not been improperly charged.
Consumer Information. The bureau continues to produce
customer information to help all customers better understand
and make choices regarding phone service. Information is
available on how to select a carrier, how to get the best
rates, and on which companies have the worst complaint records.
Universal Services.--The Telecommunications Act of 1996
established certain principles for the Commission to follow in
revising and expanding the scope and definition of ``universal
service'' in telecommunications services for all Americans,
including older Americans. Among the explicit provisions
established by this landmark legislation were financial support
in access to advanced telecommunications services for health
care providers, including hospitals, health clinics, and
libraries, all of which serve many older Americans.
Lifeline/Link Up Services.--The Commission has made
significant changes to its Lifeline and Link Up programs. The
federal lifeline program provides between $3.50 and $7 per
month to reduce low-income consumers' monthly telephone bills.
The amount of federal support will vary depending on decisions
made by the local state commission. All eligible low-income
consumers receive at least a $3.50 reduction on their telephone
bill from the federal universal service program. The reduction
applies to a single telephone line at a qualifying consumer's
residence.
Lifeline consumers also can receive toll blocking (which
prevents the placement of any long-distance calls) or toll
control (which limits the amount of long-distance calls to a
pre-set amount selected by the consumer).
Link Up offers eligible low-income consumers a reduction in
the local telephone company's charges for starting telephone
service (the reduction is one-half of the telephone company's
charge, or $30, whichever is less); and a deferred payment plan
for the remaining charges.
Wireless Telecommunications Bureau
In 1997-98, the Wireless Telecommunications Bureau
undertook a number of activities that affected older Americans:
Wireless Enhanced 911.--In 1997, the Commission reaffirmed
its commitment to the rapid implementation of the technologies
needed to bring emergency assistance to wireless callers
throughout the United States, and modified its wireless 911
rules to require covered wireless carriers to transmit all
wireless 911 calls to public safety authorities without respect
to a carrier's call validation process. In addition, the
Commission has been working with individuals representing the
wireless industry (carriers and manufacturers), manufacturers
of Text Telephone (TTY) equipment, emergency and relay service
providers, and consumer organizations that represent
individuals who are deaf or hard-of-hearing, to develop
solutions so that digital wireless systems will be able to
comply with the Commission's requirement that wireless carriers
have thecapability of transmitting 911 calls from individuals
using TTYs.
Spectrum for Public Safety.--The Wireless Bureau authored a
number of items to promote the use of radio by public safety
entities. The primary item was a Report and Order which adopted
service rules for the new 700 MHz public safety band. The
bureau also has chartered a public safety advisory committee to
assist the Commission in working with public safety agencies at
all levels on matters of equipment upgrading and compatibility.
Universal Licensing Service.--The bureau is in the process
of adopting a universal licensing system, which will greatly
enhance the ability of the public to file applications and
access licensing data remotely.
Billing and Disabilities Access Issues.--The bureau's
Enforcement Division has resolved numerous complaints and
inquiries of interest to older Americans, including wireless
billing issues and disabilities access issues.
Cable Services Bureau
Video Accessibility.--Older Americans with hearing and
sight disabilities can now be helped by a number of
technologies related to television, especially closed
captioning and video description. These two technologies are
designed to increase ``video accessibility.'' Closed captioning
provides important benefits primarily for individuals with
hearing disabilities by displaying the audio portion of a
television signal as printed words on the television screen.
Video description benefits individuals with visual disabilities
by providing audio descriptions of a program's key visual
elements that are inserted during the natural pauses in the
program's dialogue.
In the 1996 Act, Congress directed the Commission to ensure
that closed captioning is available to persons with hearing
disabilities and to assess the appropriate method for phasing
video description in the marketplace to benefit persons with
visual disabilities. As a first Step, Congress required the
Commission to submit a report addressing these issues. The
Commission submitted its Report to Congress on July 29, 1996.
Closed Captioning.--The 1996 Act also directed the
Commission to prescribe rules and implementation schedules for
the closed captioning of video programming, regardless of the
entity that provides the programming to consumers or the
category of programming. In August 1997, the Commission
established rules to ensure that video programming is made
accessible through closed captioning. In September 1998, in
response to petitions for reconsideration, the Commission
modified and clarified the closed captioning rules to better
comply with the statutory mandate to provide accessibility to
persons with hearing disabilities. The rules establish
timetables that gradually increase the amount of closed
captioning provided on programs. For programming first
published or exhibited on or after January 1, 1998, the
effective date of the rules, the Commission established
benchmarks to be met every two years until 100% of such
programming is required to be captioned as of January 1, 2006.
For programming first published or exhibited prior to -January
1, 1998 (``pre-rule programming''), mandatory captioning is
phased-in over a ten year. As of January 1, 2008, the end of
this transition period, 75% of the pre-rule programming on each
channel must include closed captioning. The rules also require
video programming distributors (e.g., television station
operators or cable operators) to generally pass through to
consumers any captions they receive with the programming they
distribute. Video programming distributors also must continue
to provide captioned programming at substantially the same
level as the average level of captioning that they provided
during the first six months of 1997, even if that amount of
captioning exceeds the requirements under the transition
schedules.
Video Description.--The 1996 Act required the Commission to
report to Congress on appropriate methods and schedules for
phasing video description into the marketplace and other
technical and legal issues related to the widespread deployment
of video description. Video description is a method of making
video programming accessible to persons with visual
disabilities. It adds narration about actions taking place or
other aspects of a program (e.g., a description of the set),
that are not obvious from the existing dialogue. The
descriptions are inserted during pauses in the dialogue.
In the July 1996 Report to Congress, the Commission
indicated that there is a lack of experience with developing
and assessing the best means for promoting its use since it is
a newer service. Since the record on video description before
the Commission at the time of the 1996 Report was insufficient
to assess appropriate methods and schedules for phasing in
video description, the Commission sought additional information
and comment in the context of the 1997 Annual Report to
Congress on the Status of Competition in Markets for the
Delivery of Video Programming. With respect to video
description, in the 1997 Annual Competition Report, the
Commission found that the most widespread video
descriptiontechnology uses the second audio programming
(``SAP'') channel, a subcarrier that allows each video
programming distributor to transmit a second soundtrack.
Continued public funding could foster the development of video
description services to the point where widespread
implementation of video description could become feasible, and
could ultimately create a commercial market for video
description. The advances of digital technology may allow the
development and expansion of video description to occur more
quickly than occurred in the case of closed captioning.
Senior Citizen Discounts.--Senior citizen discounts benefit
older Americans who often have limited incomes. By enacting
Section 623(e)(1) into its system of rate regulation pursuant
to the 1992 Cable Act, Congress intended to encourage cable
operators to offer, and to continue to offer through existing
franchise agreements, reasonable discounts to senior citizens
or other economically disadvantaged groups. In response to a
recent Petition for Declaratory Ruling, the Commission upheld a
previously issued informal letter ruling stating that it would
not interfere with senior citizen discounts previously allowed
for in local franchise agreements.
Office of Engineering and Technology (OET)
OET has taken action to prevent radio frequency
interference to medical telemetry devices from digital
television and land mobile services. Medical telemetry devices
are typically used in health care institutions to monitor the
vital signs of critically ill patients, many of whom are
elderly. OET worked closely with the Federal Drug
Administration (FDA), the medical community and equipment
manufacturers to identify new, interference- free spectrum for
the next generation of medical telemetry devices.
OET is in the process of considering steps that may be
necessary to ensure that personal computers equipped with TV
tuners, and new digital television receivers, are capable of
displaying closed captions. If appropriate, rule making to
address these matters may be initiated in the future.
OET continues to assist other Commission offices on issues
of particular interest to the elderly. OET has, for example,
provided extensive engineering support to the Wireless
Telecommunications Bureau in the effort to ensure that wireless
radio services are compatible with TTY services. OET also has
provided engineering support for the Commission's task force
addressing implementation of Section 255 of
theTelecommunications Act of 1996, which requires that
telecommunications services are accessible to the disabled.
Office of Managing Director/Personnel
As part of the Commission's ongoing efforts to recruit from
many diverse sources, the Commission does seek out older
Americans by, for example, sending vacancy announcements to
organizations whose membership consists of older Americans.
Office of Public Affairs (OPA)
OPA continued during 1997-98 to expand its outreach to
older Americans, particularly its effort to help older
Americans participate in the expanding telecommunications
revolution, while protecting themselves against fraudulent
activity that occurs.
OPA has an aggressive campaign to distribute print
literature and videos, instructing all Americans, including
senior citizens, on how to avoid misleading schemes, and what
to do if one becomes a victim of these schemes. OPA makes
available information about the Commission's National Call
Center, and on how to file a complaint with the Commission.
This material is distributed to senior citizen organizations,
so that those organizations can, in turn, redistribute it to
their members. This information also is directly distributed to
senior citizens through the community meetings on telephone-
related topics in which OPA participates, and through the
Commission's web site.
For example, information about the Cable Consumer Bill of
Rights has been distributed by OPA to senior citizen
organizations, as has information to help seniors protect
themselves against slamming and cramming. OPA also distributes
information in multiple languages, to reach senior citizens
from various cultures that make up the American fabric.
Additional Information
Anyone who wishes more information on any of these
activities can contact the Commission through the Office of
Public Affairs at 202/418-0500, the Commission's National Call
Center at 1-888-CALL-FCC (225-5322), or the Commission's web
site on the Internet at www.fcc.gov. For more information about
this report, feel free to contact Greg Lipscomb at the
Commission's Office of Legislative and IntergovernmentalAffairs
(OLIA), 202/418-1900, fax 202/418-2806.
ITEM 20--FEDERAL TRADE COMMISSION
----------
1997-1998 REPORT
Staff summary of Federal Trade Commission activities affecting older
Americans
The Federal Trade Commission strives to protect the ability
of consumers to make informed choices from a competitive range
of goods and services. Consumers lose the ability to make fully
informed choices when they are deceived, strong-armed or given
only half of the truth about a product or service. They may
lose a competitive range of options through the interference of
things like price-fixing agreements or anticompetitive mergers.
Some of the Commission's work has involved particular practices
or industries that are of special significance to older
consumers. This report describes those aspects of our work from
calendar years 1997 and 1998. The first section of the report
describes Commission efforts to eliminate frauds that target
older consumers. The second section reports Commission
activities relating to the health concerns of senior citizens,
since older Americans often face increased health problems and
therefore may be vulnerable to injury from misleading health
claims made about products or services or from anticompetitive
conduct by companies in the health care markets. The third
section discusses Commission law enforcement activities of
particular importance to older consumers in other areas. The
final section of the report addresses the Commission's consumer
education initiatives that may be of particular benefit to
older consumers.
fraud initiatives
In 1997 and 1998, the frauds that most affected older
Americans included telemarketing fraud generally, bogus prize
promotions, investment frauds, charitable solicitations,
recovery rooms, credit fraud, cross-border fraud and internet
fraud. This Report discusses each below.
Telemarketing fraud
The ``Script'': Well, isn't that a coincidence, Mrs.
________[Name]________. My grandmother lives in
________[City]________, too! Now I'm earning money for college
by selling magazines. If you would just give me your checking
account number, then I'll send you complimentary copies of your
favorite magazines to try.
Deceptive telemarketing continues to plague the elderly.
The FTC has taken an international and collaborative approach
to attacking this problem. First, as described in more detail
later in this report, the Commission took strides toward an
ambitious goal--a telemarketing database collecting complaint
data from law enforcement and consumer protection offices in
the United States and Canada. ``Consumer Sentinel'' now
contains approximately 150,000 complaints contributed by more
than 150 law enforcement offices. The FTC and others can
identify high impact law violations, and target law enforcement
efforts accordingly. This enhances our ability to protect the
elderly, who are often the intended targets of fraudulent
telemarketers.\1\ Telemarketers find older citizens to be
attractive targets, knowing that older persons may have
significant assets from a lifetime of saving, including self-
directed retirement accounts. These telemarketers also know
that the victim may be ashamed of falling for a scam, and often
will not tell friends and family about their losses and will be
desperate to make the money back. The telemarketers then have
other con artists ``reload'' the victim with more offers until
the victim has no more to give, monetarily or psychologically.
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\1\ Consumers complaining to the FTC about telemarketing activity
often indicate that they are older consumers. Older Americans account
for 60 percent of the fraud victims who call the National Consumers
League's National Fraud Information Center. The FBI estimates that as
many as 80 percent of the victims are older consumers.
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The Telemarketing Sales Rule (TSR), 16 CFR Part 310, was
promulgated by the FTC as directed by Congress in the
Telemarketing Consumer Fraud and Abuse Prevention Act of 1994,
15 U.S.C. Sec. 6101. The TSR imposes general requirements for
all telemarketers and addresses specific fraudulent practices.
Under the TSR, telemarketers must promptly disclose certain
information in telephone calls to consumers, including their
identities, the fact that they are making a sales call, and the
nature of the goods or services they are offering. The Rule
also prohibits telemarketers from misrepresenting the services
or products they sell and from debiting a consumer's checking
account without the consumer's express authorization. The TSR
also outlaws a number of telemarketing practices such as credit
card laundering. In addition to addressing the conduct of
telemarketers, the TSR also bars third parties from providing
substantial assistance to telemarketers--specifically,
assistance such as providing consumer lists, marketing
materials, or appraisals of investment offerings--when the
person ``knows or consciously avoids knowing'' that the
telemarketer is engaged in unlawful conduct. Violations of the
TSR may result in civil penalties of as much as $11,000 per
violation, and consumers who have lost over $50,000 are able to
sue under the TSR to recoup their losses.
Using the Telemarketing Sales Rule and the data from
Consumer Sentinel, the FTC and state Attorneys General continue
to bring individual fraudulent telemarketers into federal court
to face a variety of allegations. In addition, the Commission
continues to use both the Rule and its FTC Act authority to
conduct coordinated law enforcement ``sweeps,'' working with
state Attorneys General, state securities officials, the FBI,
the U.S. Postal Service, and other agencies. The Commission
continues to forge new alliances to coordinate actions against
fraudulent telemarketers. In many cases, once the FTC concludes
its civil case against telemarketers, state and federal
criminal prosecutors bring criminal charges against the FTC
defendants.\2\ During 1997 and 1998, the Commission brought
over 110 federal court actions stopping fraudulent operations
that cost consumers almost $450 million a year and over $1.2
billion over the lives of these schemes.
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\2\ Following the Commission's civil action against a nest of
fraudulent business opportunity sellers in FTC v. Southwest
Necessities, Inc., No. 94-6848-Civ (Hurley) (SD Fla.), the U.S.
Attorney for the Southern District of Florida brought criminal charges
against the same defendants and their cohorts, including ``singers'',
paid references, who hooked victims into this scam. The same one-two
punch resulted following our case against deceptive timeshare reseller
Ernie Taft. FTC v. Gold Crown Express, 4:97-0532-12 (D. S.C.). The FTC
action resulted in a judgment of more than $3 million against the
defendant. Following the filing of our suit, the U.S. Attorneys in
South Carolina and Colorado each also obtained convictions under mail,
wire and bank fraud statutes, leading to the incarceration of Mr. Taft.
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Prize promotions
Older Americans are often the targets of prize promotions,
an egregious type of fraud usually conducted through
telemarketing or direct mail. In 1997, more than 42% of the
complaints logged into Consumer Sentinel pertained to prize
promotions, sweepstakes, and gifts. In response to numerous law
enforcement actions by the FTC and its partners against
deceptive direct mail promotions, the percentage of complaints
about prize promotions dropped in 1998 to 24% of the complaints
in Consumer Sentinel. In a typical scheme, telemarketers make
unsolicited calls or mail notification cards to consumers
stating that they have won a valuable prize, such as a
vacation, car, cash or jewelry. Consumers are told that they
should purchase some product such as vitamins, cosmetics or
magazine subscriptions and they will then receive the prize.\3\
The TSR requires that, in any prize promotion, telemarketers
must disclose that no purchase or payment is required to win a
prize, and must provide information about the odds of winning
the prize and how to participate in the promotion at no cost.
16 CFR Sec. 310.3(a)(1)(iv).
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\3\ Commission records indicate that some consumers have actually
lost tens of thousands of dollars to prize promotion telemarketers.
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In both 1997 and 1998, the FTC led a broad based coalition
of private and public sector partners in an unprecedented law
enforcement initiative cracking down on companies that used
deceptive mailpieces, e-mails, and unsolicited faxes to obtain
payment for prize promotions from duped consumers, many of whom
were senior citizens. The Commission's partners included the
U.S. Postal Inspection Service, the American Association of
Retired Persons, the National Association of Attorneys General,
the Council for Better Business Bureaus, the Yellow Pages
Publishers Association, and all 50 states. The consumer and
business education campaign featured a bandit-in-the-mailbox
logo, with the message ``Boot the Bandit From the Mailbox.''
More than one hundred law enforcement actions were brought by
the law enforcement entities as part of Project Mailbox.
Investment frauds
Telemarketer: You're investing in the latest technology for
the future of America. It's simple: you invest today and I
guarantee a 100% return in six months or you get your money
back.
Fraudulent telemarketers are eager to cheat senior citizens
out of lifetime savings or to make false promises of
exceptionally high investment returns. Older Americans who are
anxious about financing their retirement are particularly
vulnerable to these investment pitches. The stock market boom
of the mid-1990's also led many investors to seek and expect
high returns. Fraudulent telemarketers were only too happy to
respond to these desires, peddling bogus investment
opportunities ranging from gemstones, gold and silver mining,
and oil drilling investments to telecommunications,
entertainment industry and Internet related businesses. The
telemarketers invariably assured consumers that they would
realize a substantial return on their investment, usually in a
short period of time and with minimal risk. The amounts of
individual losses often were quite high, sometimes $5,000 to
$20,000 or more per person. In one case, an 83 year old widow
lost over $70,000 to a scam hawking investments in
infomercials. Older citizens taken by these scams often are not
in a position to recoup their losses.
``Field of Schemes'' Investment Fraud Sweep--In 1997, the
Commission brought coordinated actions against nine alleged
purveyors of investment and pyramid frauds who touted
everything from gold-silver mines to Internet ``virtual
shopping malls.'' In addition to the FTC actions, the North
American Securities Administration (NASAA), state securities
regulators in 21 states, the SEC and CFTC, brought over sixty
law enforcement actions. The FTC actions stopped over $150
million in fraudulent sales from these bogus offerings. Two of
the FTC cases involved supposed profits to be made through
alleged pyramid schemes. In one case, Rocky Mountain
International Silver and Gold, Inc., the alleged scheme
masqueraded as a multi-level marketing operation selling silver
and gold coins through direct mail and then the Internet. In
the other case, JewelWay, the defendants made deceptive
earnings claims inducing an estimated 150,000 consumers to
invest an average of $1,000 with a chance to earn up to $2,250
a week in an illegal multi-level marketing plan to sell fine
jewelry. In the FTC's case Intellicom Services, Inc., 12
corporate defendants and 10 individual defendants promised
enormous profits from Internet access businesses and Internet
shopping malls. The FTC alleged that the telemarketers sold
over $30 million in this scheme. In the Dayton Film matter, the
FTC alleged misrepresentations in the sale of movie production
investments with a claim of profits of 500 percent on the
films. Another case, Coastal Gaming, involved investment in a
casino gambling ship venture with expected returns of 100 to
300 percent. Other cases involved the sale of investments in
gold and silver mines (Tippecanoe), gemstones (Windsor &
White), and oil and gas drilling (Gulfstar) and rare stamps
(Equifin). The courts in eight of the cases issued injunctive
relief that included asset freezes and the appointment of
receivers. Final court orders for permanent injunctions and
consumer redress have been entered against defendants in the
Dayton Films, JewelWay, Tippecanoe, Coastal Gaming, Equifin,
and Gulfstar matters, the Windsor & White and Intellicom
matters are partially settled with permanent injunctions
against some defendants, and the Rocky Mountain matter is still
pending.
Operation Risky Business.--In August 1998, the Commission,
together with the SEC and North American Securities
Administrators Association, coordinated a federal and state
initiative aimed at entertainment and media scam promoters
peddling movie, gambling, infomercial, and Internet business as
investments. The Commission, SEC, and 20 states filed over 60
law enforcement actions against telemarketing companies. These
companies had taken in more than $100 million from consumers
touting bogus investments. As a result of Operation Risky
Business, the FTC and its partners launched an intensive
consumer education effort and received extensive nationwide
press coverage of this operation.
Miscellaneous Investment Frauds.--The Commission followed
through on cases reported in 1995 and 1996 with settlements in
several telecommunication fraud cases. In Falconcrest, the FTC
obtained a permanent injunction and over $1.2 million in
consumer redress orders. In Metropolitan Communications, the
Commission obtained a permanent injunction and over $1.7
million in redress judgments. In our Operation Roadblock cases
against purveyors of investments in Federal Communication
Commission wireless licenses, we have obtained permanent
injunctions and over $5.8 million in redress judgments against
six sets of defendants. Finally, the Commission obtained a
settlement in an earlier case against National Art Publishers,
a movie poster investment case, for a permanent injunction and
redress in the amount of $150,000.
Charitable solicitations
In April 1997, the Commission announced the most
comprehensive action ever taken against charity fraud--
``Operation False Alarm.'' In this sweep, the Commission and
officials from all 50 states conducted a law enforcement sweep
and public educational campaign targeting ``badge fraud.'' In
this type of scam, telemarketers (also known as ``telefunders''
in the nonprofit sector) call senior citizens and other
consumers to solicit donations in the name of some real or
fictitious charity. The schemers often misrepresent that they
are local police officers or fire fighters, when in fact they
are professional solicitors. Also, the telemarketers frequently
misrepresent where consumers' donations will be used and state
that donations will go toward local causes or benefits like
bullet proof vests for the local police force. Donations seldom
make it to these causes. Rather, most donations are taken by
the solicitors themselves. Overall, ``Operation False Alarm''
included 57 law-enforcement or regulatory actions against
various telefunders. The Commission itself filed five cases in
federal court and settled one administrative action.
In the fall of 1998, the Commission followed ``Operation
False Alarm'' with another comprehensive sweep, ``Operation
Missed Giving.'' This sweep targeted not only ``badge fraud,''
but also misleading solicitations made on behalf of purported
veterans groups, children's health organizations, and other
charitable causes. ``Operation Missed Giving'' involved 39 law-
enforcement or regulatory actions aimed at fraudulent
fundraising, including five federal court actions filed by the
FTC. The Commission and its partners timed the project to
precede the holiday season when many consumers receive requests
for money, and the project included a campaign to educate the
public about wise giving.
On the day that ``Operation Missed Giving'' was announced,
AARP also coordinated and conducted a ``reverse boilerroom.''
Volunteers from AARP and representatives from the FTC, the
Department of Justice, the FBI, and the National Association of
Attorneys General called previous victims of telemarketing
fraud throughout the day. Working from a prepared script, they
gave tips about how to avoid certain types of charity fraud and
what to do to make the most of charitable donations.
Participants in the ``reverse boilerroom'' made over 4500 phone
calls in the span of nine hours and reached more than 1100
telemarketing fraud victims.
Recovery rooms
In a particularly insidious type of telemarketing,
``recovery room'' con artists prey on persons who have already
been victimized by telemarketers. Telemarketers obtain the
names and addresses of these victims by purchasing, or trading
for, lists of victims from other fraudulent operations. The
recovery room salesperson then falsely promises the victims
that, for a fee, the telemarketer can help them obtain the
promised prize or money lost in a previous telemarketing scam.
Often, telemarketers represent themselves as governmental
entities or as agents hired to locate victims and distribute
money back to them. After the consumer sends in the requested
fee, the company invariably fails to deliver the refund or
prize, thereby exacerbating the victim's losses. In past
Commission recovery room cases, older consumers are frequently
specific targets. In one case, 81% of the consumers were at
least 65 years of age and 23% were at least 80 years old. In
another case, 82% were at least 65 and 32% were at least 80
years old.
In a case begun in 1995, the defendant, Meridian Capital
Management, allegedly made unsolicited telephone calls to
consumers who had been victims of various investment frauds,
often involving Federal Communications Commission wireless
telecommunications licenses. For a fee of 10% of the consumer's
previous investment, Meridian claimed it could recover all or a
substantial portion of the money invested. In 1996-1997, the
Commission obtained default judgments for $1.6 million against
Meridian and several individual defendants, and stipulated or
court-ordered permanent injunctions were entered against all
defendants. With Commission staff acting as Special Assistant
U.S. Attorneys, the U.S. Department of Justice in 1998 obtained
indictments charging 17 defendants involved in the Meridian
scam with the crimes of conspiracy, mail fraud, and wire fraud.
In addition, seven of the defendants were charged with money
laundering. Eleven of these defendants have pled guilty and are
awaiting sentencing.
Our law enforcement efforts and the deterrent effect of the
TSR have paid off with respect to the incidence of this type of
conduct. The volume of consumer complaints concerning recovery
rooms logged into Consumer Sentinel in 1998 dropped to 187,
dramatically less than the 869 complaints regarding this
conduct recorded in 1995, despite the fact that the complaint
system now contains complaints from far more law enforcement
entities.
Credit fraud
Credit-related scams also claim hard earned dollars of
older American who get taken in by bogus credit repair services
and advance fee loan schemes.
Bogus credit repair firms promise that, for a fee, they
will remove negative, though accurate, information contained in
consumers' credit reports. Since credit reporting bureaus
legally may include verifiable, negative information in
consumers' reports for a period of seven years, and
bankruptcies for ten years, credit repair companies cannot
deliver the service they promise. The TSR prohibits credit
repair companies from obtaining payment until six months after
they have, in fact, fulfilled their promise to clean up credit
histories. This year the Commission continued its efforts
against credit repair schemes, announcing a nationwide
crackdown called ``Operation Eraser.'' In this joint federal/
state effort legal action was taken against 31 different
companies. The FTC itself handled cases against 20 companies.
This law enforcement effort also served as the platform for a
consumer education program on how to avoid such scams which is
detailed at the end of this report.
In 1998, the Commission also brought complaints against two
different companies, alleging that the companies advertised low
interest rate debt consolidation loans and in return provided
minimal bill paying services in return for advance fees.
Cross-border fraud
``Cooperative and successful law enforcement activities
with our Canadian colleagues in the past few years are
encouraging. Nevertheless, cross-border scams seem to be a
growth industry.'' Commissioner Orson Swindle, November 10,
1998 speech.
In the mid-1990's, senior citizens in the U.S. began to
receive a growing number of solicitations from fraudulent
telemarketers operating out of Canada. Between 1996 and 1997,
complaints about Canadian telemarketers rose from 7% to 23% as
a proportion of the total number of telemarketing complaints
received by the FTC. In 1998, complaints about Canadian
companies rose to 30% of the total complaints in Consumer
Sentinel. In the last two years, the Commission has redoubled
its efforts to fight cross-border telemarketing fraud and raise
the profile of the problem. During high-level diplomatic
meetings, the Commission was instrumental in putting
telemarketing fraud on the agenda of Prime Minister Chretien
and President Clinton during their meeting in the spring.
Commission staff then actively participated in the U.S.-Canada
Bilateral Working Group on Cross-Border Telemarketing Fraud, a
task force formed at the direction of the two leaders.
The Bilateral Working Group met in June and September of
1997, and discussed issues ranging from extradition and mutual
legal assistance treaties, to legal reforms and information-
sharing. Over that same period, Commission staff discussed
enforcement and diplomatic goals with U.S. counterparts at the
State Department, the Justice Department, the FBI, the Federal
Communications Commission, the U.S. Postal Inspection Service,
U.S. Customs, and the National Association of Attorneys
General. During the summer of 1997 Commission staff also joined
small U.S. delegations traveling to meet federal and provincial
law enforcement officials in Canada. In November 1997, the
Bilateral Working Group issued a comprehensive report entitled
``United States-Canada Cooperation Against Cross-Border
Telemarketing Fraud.'' The report was drafted with significant
input from the FTC and outlined the scope of cross-border
telemarketing fraud, as well as a number of solutions and
policy recommendations.
Among its findings, the Bilateral Working Group emphasized
the need to share more information among U.S. and Canadian law
enforcement officials. Quickly addressing this need, the
Commission constructed Consumer Sentinel, the first electronic
fraud database available to law enforcement on both sides of
the border. Announced in December of 1997, Consumer Sentinel
allowed law enforcement officials to access consumer complaints
quickly and easily through a secure Internet connection.\4\
Complaints came from a variety of organizations including the
FTC, the National Fraud Information Center (a project of the
U.S. National Consumers League) and PhoneBusters, a Canadian
project operated by the Royal Canadian Mounted Police and the
Ontario Provincial Police.
---------------------------------------------------------------------------
\4\ Consumer Sentinel is not open to the general public. Access to
the web site is limite authorized law enforcement members who are given
unique user names, passwords, and robust encryption software.
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Throughout 1998, Consumer Sentinel expanded rapidly. The
database now contains almost 150,000 fraud complaints,
including thousands of new complaints contributed by local
Better Business Bureaus from across the country.\5\ Over 150
law enforcement offices from across the U.S. and Canada are now
members of Consumer Sentinel, including the Department of
Justice, numerous U.S. Attorney offices, the FBI, the U.S.
Postal Inspection Service, state Attorneys General and state
securities offices, local prosecutors and sheriffs, as well as
the Royal Canadian Mounted Police, and other Canadian law
enforcement. Besides complaint data, Consumer Sentinel has
expanded to include law enforcement ``Alerts,'' a library of
sample pleadings to use in fraud cases, lists of law
enforcement contacts, law enforcement publications like
``FraudBusters,'' and a database listing 12,000 undercover
tapes collected by the San Diego Boiler Room Task Force.
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\5\ To date, over 30 local Better Business Bureaus have agreed to
contribute their complaints to Consumer Sentinel, including the BBB's
from Seattle, Chicago, Dallas, and Washington, DC.
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In addition to building and maintaining Consumer Sentinel,
the Commission has taken a number of law enforcement actions
against cross-border telemarketing fraud in 1997 and 1998. The
Commission continued to attack the problem of advanced fee
loans, and in January 1998, announced actions brought by the
Commission and several state agencies against 37 more
perpetrators of this type of fraud. Later that year, the
Commission obtained a settlement against Tracker Corporation of
North America over allegations that they had operated out of
the U.S. and Canada and misrepresented their credit card
protection services.
In 1997 and 1998, the Commission also targeted the growing
problem of illegal foreign lottery solicitations. Not only did
the Commission sue peddlers of foreign lottery tickets
directly,\6\ but the Commission also targeted U.S. card
processors alleged to have provided assistance to lottery
ticket traffickers.\7\ Realizing the need for criminal as well
as civil law enforcement in this area, the Commission's Seattle
Regional Office now has a staff member prosecuting lottery
scams as an appointed Special Assistant U.S. Attorney.
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\6\ FTC v. Win USA Services Ltd., et al., C98-1614Z (W.D. WA) and
FTC v. Pacific Rim Pools International, C97-1748R (W.D. Wash. 1997).
\7\ FTC v. Woofter Investment Corporation and Patsy M. Barbour, (D.
Nevada) CV-S-97-00515-HDM (RLH)) (D. Nevada).
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Cross-border health fraud is another growing problem that
affects millions of people, especially senior citizens, in this
country and abroad. To address this type of fraud, the
Commission, in 1997, led a ``North American Health Claim Surf
Day'' and was joined by the FDA and CDC, the FCC, health and
consumer agencies from Canada and Mexico, the Attorneys General
of 18 states, and several nonprofit groups. In just a few hours
of searching the Internet, the group found over 400 sites that
promoted questionable treatments or cures for heart disease,
cancer, AIDS, diabetes, arthritis, and multiple sclerosis. The
next year the Commission focused on claims related to these six
diseases in a Surf Day conducted on a broader scale. The 1998
``International Health Claim Surf Day'' included participants
from 80 agencies and organizations from 25 countries that
``surfed'' the Internet looking for potentially false or
deceptive claims about the treatment, prevention, or cure of
the same six serious illnesses. This international team found
more than 1,200 offending sites and sent them warning messages.
The Task Force also kicked off Campana Alerta I and II, two
sweeps targeting deceptive Spanish-language ads for health care
products that included a total of seven FTC enforcement
actions, four Spanish-language radio public service
announcements, and a Spanish-language television public service
announcement jointly-released in the U.S. and Mexico. In
addition, the Task Force participated in a crackdown on Mexican
border clinics offering ``cures'' for cancer, AIDS, and
multiple sclerosis.
Building on these actions, the Commission, FDA, Health
Canada, and the Secretaria de Salud of Mexico announced the
adoption of an agreement on Joint Strategies to Combat Health
Fraud on December 10, 1998. The agreement provides a formal
framework for cooperation and states that the participating
agencies will: (1) cooperate in the detection of cross-border
health fraud; (2) inform counterpart foreign agencies as soon
as practicable of significant investigations involving
activities in their country; (3) consider counterpart agency
requests to investigate domestic activities and to coordinate
related enforcement activities; and (4) work to develop and
disseminate joint consumer and business education messages
about health fraud.
Internet fraud
Seniors are joining the Internet community at a rapid pace.
An estimated 40% of Americans over the age of 50 have personal
computers, and of these, 72% have Internet access.\8\ Senior
citizens communicate with children and grandchildren through e-
mail, peruse web sites for news and entertainment, and use the
Internet to research travel and business opportunities.\9\
Although the Internet offers new ways to communicate, invest,
and shop, unfortunately it also provides a new haven for scam
artists. To ensure that the fraud does not undermine consumer
confidence and weaken the online marketplace, the Commission
has attacked Internet fraud through both aggressive law
enforcement and public education.
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\8\ In contrast, computer ownership among people over 50 was only
29% three years ago. See statistics on ``The Graying of the Internet,''
a report published by Charles Schwab & Co., Inc. and SeniorNet.org,
reported at http://www.headcount.com/globalsource/profile/
index.htm?choice=ussenior&id=144''.
\9\ 72% of Internet users over the age of 50 regularly use e-mail
to communicate with friends and family; over 50% use the Internet to
research topics and read the news; and approximately 40% frequently use
the Internet to pursue hobbies, explore travel options, or research
investments. See ``The Graying of the Internet,'' above.
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The Commission has brought over forty federal actions
against Internet fraud, twenty-four cases in 1997 and 1998
alone. Most of these actions have targeted traditional types of
fraud that have moved online--pyramid schemes, credit repair
fraud, deceptive investments and business opportunities, etc.
However, a few actions have targeted scams that could only have
arisen from new technology, such as ``modem hijacking.''
Although many Internet schemes target the general
population, some online scams hit senior citizens especially
hard. Fraudulent online health claims are an example. The
Commission has brought several actions against marketers of
dubious health products, including a company, American
Urological Clinic and David Brady, that advertised an herbal
impotence remedy called ``Vaegra'' and a company, TrendMark
International, that made unsubstantiated weight loss claims.
Surf Days, such as those targeting fraudulent health
claims, have become part of a broader attempt by the Commission
to protect the public through education. Surf Days enable the
Commission to contact businesses that may be injuring
consumers, not out of malice, but out of ignorance over what
the law requires. In an effort to reach out and educate online
business, the Commission has led or conducted over a dozen Surf
Days in 1997 and 1998, covering topics ranging from online
privacy to coupon fraud. In addition, the Commission has
published a set of online advertising guidelines for new and
small businesses entitled, ``The Rules of the Road.''
Health-Related Activities
It is critical that all consumers have accurate information
about the costs and benefits of health care services, devices,
drugs and related products. While health care is a subject of
concern for all of our citizens, it is of disproportionate
concern to the aging. The Commission works to ensure that
consumers are not harmed by deceptive claims about the health
benefits of products or services. In addition, the Commission's
antitrust law enforcement activity targets unlawful activity
that decreases competition among providers of health care goods
and services. Older Americans (along with their younger
counterparts) benefit from lower costs and higher quality
health care services as a result of robust competition.
Consumer Protection in Health-Related Matters
Health claims for OTC drugs, devices, foods, and dietary supplements
Advertising for any product must be truthful, not
misleading, and substantiated. . . .
Accurate information about the safety and health benefits
of over-the-counter drugs, devices, foods, and dietary
supplements are particularly important to older consumers who
may have specific nutritional needs or suffer from medical
conditions associated with aging. The Commission is responsible
for making sure that advertising about the health benefits of
these products is truthful, not misleading and substantiated by
solid scientific support and coordinates closely with the Food
and Drug Administration, which has primary responsibility for
the safety and labeling of these products.\10\
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\10\ Both advertising and labeling of prescription drugs fall
within FDA's area of jurisdiction, although the FTC has provided input
to FDA on certain aspects of the advertising of these products.
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In a case currently on appeal, the Commission successfully
challenged misleading representations that Doan's Pills, a
national advertised analgesic, is more effective in relieving
back pain than other over-the-counter pain relievers.
Continuing to attack deceptive claims in the multi-million
dollar ``hair restoration'' industry, the Commission concluded
two successful actions against marketers of nationally
advertised baldness products. The Commission also took action
against the marketer of eyeglasses that misleadingly claimed to
improve users' vision when driving at night.
The Commission has also continued to pursue false or
unsubstantiated advertising claims relating to the nutrient
content and health benefits of foods. For example, the
Commission settled charges over a national advertising campaign
for Promise margarine that focused on consumers' heart health
concerns with its ``Get Heart Smart'' slogan. In that case, the
FTC challenged, as unsubstantiated, claims that Promise
margarine spreads help reduce the risk of, heart disease, as
well as false low-fat and low-saturated-fat claims. In
addition, the FTC settled charges with the nationwide Pizzeria
Uno restaurant chain regarding false claims touting a line of
thin-crust pizzas as ``low fat.'' Finally, the FTC entered a
consent agreement with Abbott Laboratories for claims relating
to their Ensure nutritional beverage. The complaint in that
case challenged claims that doctors recommend Ensure for
healthy, active people, and claims that Ensure would provide
vitamins in an amount comparable to a typical multi-vitamin
supplement.
The most dramatic growth in health-related marketing has
been in the dietary supplement industry, a category that
includes vitamins, minerals, herbs and hormones. It is
estimated that more than 100 million U.S. consumers use
supplement products for a wide variety of health-related
benefits. The elderly may be particularly vulnerable to false
or misleading claims, since supplement marketing often relates
to conditions associated with aging. The Commission has
undertaken a number of initiatives over the past two years to
ensure that consumers are presented with truthful and accurate
information about the health benefits of supplement products.
The Commission continues to maintain an active enforcement
presence in this area. Since 1996 the Commission has taken
action against several dietary supplement advertisers for
making a wide variety of health claims, including claims
relating to medical conditions and diseases that afflict the
elderly. Most recently, the Commission obtained a court order
temporarily halting the marketing operations of the American
Urological Corp. and other related parties for false claims
about the effectiveness of its impotence treatment products.
The matter is currently pending in federal district court and
involves various multiple ingredient supplement products,
including a product called ``Vaegra,'' the name of which
closely resembles the prescription drug Viagra.
Other Commission actions include a consent agreement with
MegaSystems International, Inc. and related parties settling
charges about false and unsubstantiated claims for a variety of
products concerning health and weight loss. The MegaSystems
consent required that the respondents pay a total of $1.1
million, including $500,000 into an escrow account to repay
consumers. The Commission also settled charges against Bogdana
Corp. relating to Cholestaway, a calcium carbonate supplement.
Among other things, the company claimed the supplement would
lower blood cholesterol and blood pressure and treat heart
disease. The Bogdana consent also settled charges relating to
another supplement, Florasource, which was touted to reduce the
risk of and treat chronic fatigue syndrome, AIDS and other
diseases.
Since 1996 the Commission has brought a number of actions
to curb fraudulent advertising directed at Spanish-speaking
consumers. A number of these actions involved supplement
products being promoted to treat health conditions associated
with aging. For example, a recent consent agreement settled
charges against Nutrivida, Inc. and Frank Huerta involving a
Spanish language informercial promoting Cartilet, a shark
cartilage supplement, for treatment of cancer, rheumatism,
arthritis, diabetes, fibroids, bursitis, circulatory problems,
and cysts. A consent agreement with Venegas Inc. addressed FTC
charges of unsubstantiated claims for a multiple ingredient
supplement ``Alen,'' purported to delay the aging process,
eliminate anemia, and help diabetics produce insulin. Other
actions include a settlement with Efficient Labs for the
charges relating to the marketing of ``Venoflash'' to remove
clogs in the circulatory system and treat varicose veins and
hemorrhoids, and a settlement with Mountain Springs L.L.C. for
the marketing of a cat's claw supplement to strengthen the
immune system and treat a wide variety of ailments.
Most recently, the Commission issued a business guide for
the dietary supplement industry to provide clear and detailed
guidance on how to comply with the requirement that advertising
claims relating to health and safety must be substantiated by
competent and reliable scientific evidence. The guide provides
specific examples to illustrate longstanding FTC advertising
principles on how to develop adequate scientific support for
the benefits of supplements and how to describe those benefits
fairly and accurately. As additional guidance to industry, the
Commission simultaneously released a report on the results of
an FTC staff consumer research project that examined a number
of issues relating to consumer understanding of disclosures in
food and supplement advertising. The results of this Food Copy
Test indicate, among other things, that qualifying information
about the health benefits of these products must be presented
in strong and direct language.
Other health-related services
Older consumers make up a large part of the market for a
variety of health-related services and, as a result, are
vulnerable to fraudulent practices and misleading claims from
some bad actors in this industry. The Commission in 1997-1998
took numerous law enforcement actions in the area of health-
related services.
In 1998, the Commission accepted for comment a consent
agreement that prohibits the American College for Advancement
in Medicine (ACAM) from making unsubstantiated and false
advertising claims that non-surgical, EDTA ``chelation
therapy'' is effective in treating atherosclerosis, and that
the effectiveness of the therapy has been proven by scientific
studies.
The Commission in 1998 also obtained a consent order
against Eye Care Associates and its owner, Sami El Hage, O.D.,
primary sources of an orthokeratology service called
``Controlled Kerato-Reformation'' orthokeratology (CKR). Under
the consent order, the respondents are prohibited from claiming
that CKR or any similar procedure corrects nearsightedness and
astigmatism. In addition, the final order requires Dr. El Hage
to have competent and reliable scientific evidence before
making any health benefit claims about the procedure.
In a similar case, in 1997, the Commission obtained a
consent order against Mid-South PCM Group and its owner, J.
Mason Hurt, O.D., a leading marketer of an eye care treatment
called ``recise Corneal Molding'' orthokeratology (PCM ortho-
k). PCM ortho-k uses a series of special contact lenses
purportedly to reduce or eliminate dependence on eyeglasses and
contact lenses. The service is marketed as a non-surgical
alternative to laser PRK (photorefractive keratectomy) and RK
(radial keratotomy). The consent order prohibits Dr. Hurt from
claiming that orthokeratology can cure vision deficiencies
permanently, and requires Dr. Hurt to possess competent and
reliable scientific evidence for any success or efficacy
claims.
Finally, in 1997, Commission staff provided substantial
assistance to the American Academy of Ophthalmology in
developing its industry ``Guidelines for Refractive Surgery
Advertising,'' which were issued that same year. The Guidelines
set voluntary standards for advertising claims regarding the
safety, efficacy and success of refractive surgery services,
including radial keratotomy (RK), photorefractive keratectomy
(PRK), and LASIK (laser assisted in-situ keratomileusis).
Diet and weight loss products and services
New Triple Medical Breakthrough: ``Blast'' 49 pounds off in
only 29 days . . . ``Obliterate'' 5 inches from your waistline
. . . .
The quest to lose weight, cut fat, and gain muscles
continues to lure the investment of older consumers. The
Commission in 1997-1998 has been active in this area, and has
taken numerous actions involving diet and weight-loss products,
programs, and services. As part of its continuing effort to
ensure that consumers get accurate and reliable information
about weight loss products and programs, the Commission
initiated ``Operation Waistline,'' a coordinated, long-term
consumer education and law enforcement program. The goals of
this program were to alert consumers to misleading and
deceptive weight loss claims, to steer them to accurate
information about healthy weight loss, and to continue to bring
law enforcement actions against those in the industry who
violate the law.
As part of this coordinated effort, in March 1997 the
Commission announced settlements in seven law enforcement
actions focusing on advertisements promoting quick and easy
weight loss for products ranging from fat burning dietary
supplements to skin patches and shoe insoles.
In addition, the Bureau of Consumer Protection sent letters
to more than 100 publications that ran the weight loss
advertisements challenged in the Commission's complaints. The
letters called on these publications to step up their
advertising review efforts to prevent blatantly deceptive
weight loss ads from reaching consumers.
Three additional consent settlements involving promotions
for weight loss and purported health benefits of chromium
picolinate were finalized and announced earlier in 1997:
Nutrition 21, Universal Merchants, Inc., and Victoria Bie,
doing business as Body Gold.
In a separate law enforcement action, Commission attorneys
completed the trial phase in the case against Slim America,
Inc., a seller of over $11 million in bogus weight loss
products. The defendants' ads and product literature featured
Super-Formula as a ``New Triple Medical Breakthrough''
consisting of three different ``weight loss weapons.'' The
advertisements, published in magazines such as Ladies Home
Journal, stated that Super-Formula could effectuate dramatic
weight loss and remove inches from a user's body size in a
short period of time. Ads boasted that Super-Formula could
``blast'' up to 49 pounds off user in only 29 days,
``obliterate'' 5 inches from waistlines, and ``zap'' 3 inches
from thighs, without dieting or exercising. In 1997, the
federal district court granted a temporary restraining order,
asset freeze, and appointment of receiver, pending the court's
final decision. The decision on the Commission's petition for a
permanent injunction and consumer redress is pending.
In addition to weight-loss products, many older consumers
purchase services from diet clinics. The Commission, having
obtained fourteen consent orders against such firms in 1992-
1996, continued this program in 1997 by announcing settlements
of administrative complaints, issued in 1993, against Weight
Watchers International, Inc., and Jenny Craig, Inc. Weight
Watchers International, Inc. agreed to settle a case concerning
the substantiation for advertising claims made by the company.
The proposed settlement covers future claims, including
testimonial claims, about weight loss and weight loss
maintenance. The Commission also obtained a settlement
agreement from Jenny Craig, Inc. to resolve deceptive
advertising charges relating to the program's weight loss,
weight loss maintenance, price and safety claims, as well as
its use of consumer testimonials and endorsements.
Finally, in October, 1997, the Commission's Bureau of
Consumer
Protection spearheaded a major consumer protection effort by
bringing together representatives from science, academia, the
health care professions, state and federal agencies, commercial
pro-
viders of weight loss products and services, and organizations
pro-
moting the public interest to discuss how providers could
improve
the quality and quantity of information consumers receive about
weight loss products and services. This seminal event has
resulted in agreement among a broad-based coalition on
voluntary guidelines for consumer disclosures by providers of
weight loss products and services as well as new consumer
education initiatives. The coalition, to be called the
``Partnership for Healthy Weight Management,'' looks forward to
a formal public launch in early-1999.
Antitrust Law Enforcement In The Health Care Sector
Antitrust enforcement in the health care area, while
infinitely varied in detail, tends to fall into one of four
general categories. Most of our cases involve: (1)
anticompetitive agreements among health care providers; (2)
agreements to restrict advertising of health-related services;
(3) hospital mergers; or (4) mergers among pharmaceutical
companies. All of these activities are of particular importance
to older consumers, because their health care needs tend to be
greater than those of other age groups, as is the percentage of
their income that they devote to this purpose.
Anticompetitive agreements
In January of 1998, Mylan raised the wholesale price of
clorazepate from $11.36 to approximately $377.00 per bottle of
500 tablets.
One of the core areas of antitrust enforcement is against
anticompetitive agreements. These are agreements among the
providers of a good or a service, to increase prices or to
decrease product quality, or to in some other way artificially
reduce the level of competition between them. Such agreements
may deprive consumers of the ability to obtain goods of
competitive price and quality in a free market economy.
An example is the Commission's ongoing litigation against
four pharmaceutical firms involved in the sale of anti-anxiety
drugs that are prescribed over 20 million times a year. One of
the defendants in this action is Mylan, the nation's second
largest maker of generic drugs. Mylan produces, among other
products, the drugs lorazepam and clorazepate, which are widely
prescribed to the elderly to treat anxiety and hypertension.
According to the Commission's complaint filed in federal court,
Mylan entered into exclusive agreements with the principal
manufacturer of the active ingredients used in the drugs. These
agreements meant that other, competing drug companies were
unable to obtain new supplies or to increase their rate of
production. As a result, Mylan allegedly attained monopoly
power and was able to dramatically increase its prices without
fear of competitive consequences. In January of 1998, the
company raised the wholesale price of clorazepate from $11.36
to approximately $377.00 per bottle of 500 tablets. And, in
March, Mylan raised the wholesale price of lorazeparn from
$7.30 for a bottle of 500 tablets to approximately $190.00. The
complaint alleged that as a result of the price increases, some
consumers had to stop taking these drugs or to reduce the
quantity they take.
The remedy being sought in the Mylan litigation will make
this case particularly important to consumers. The usual FTC
antitrust remedy is an injunction that brings the improper
conduct to a halt and restores competition from that point
forward. Here, however, the conduct is particularly egregious,
and the harm to consumers is particularly great. Mylan's price
increases cost consumers at least $120 million in higher
prices--prices paid in part by elderly and infirm patients who
can afford them least. Therefore, the Commission has asked the
federal district court to order disgorgement, under which
Mylan's improper profits must be repaid.
In addition to the litigated case in Mylan, the Commission
obtained at least nine consent agreements during the years
1997-1998, under which health care providers agreed to cease
using a variety of anticompetitive practices.
In RxCare of Tennessee, a consent order settled charges
that a leading provider of pharmacy network services in that
state, which was owned and operated by pharmacists, used a
``most favored nation'' clause (MFN) in order to discourage
member pharmacies from discounting, and to limit price
competition in their dealings with pharmacy benefits managers
and third-party payors. The MFN clause at issue required that
if a pharmacy in the RxCare network accepted a reimbursement
rate from any other third-party payor that is lower than the
RxCare rate, the pharmacy must accept that lower rate for all
RxCare business in which it participates. In light of RxCare's
market power (the network includes 95% of all chain and
independent pharmacies in Tennessee and accounts for a
substantial portion of business volume) the MFN clause made
pharmacies risk substantial losses in their core business if
they granted special discounts to patients covered by other
plans, and thereby tended to discourage such discounts. The
order bars RxCare from having the MFN clause in its pharmacy
participation agreements. C-3662 (consent order) 62 Fed. Reg.
4769 (January 31, 1997).
In Montana Associated Physicians, a physician association
(MAPI) and a physician-hospital organization (BPHA) in
Billings, Montana signed a consent order in which they agreed,
for a 20 year period, not to: (1) boycott or refuse to deal
with third-party payors such as insurance companies or HMOs;
(2) collectively determine the terms upon which the member
physicians would deal with such payors; or (3) fix the fees
charged for any physician services. MAPI also is prohibited
from advising physicians to raise, maintain, or adjust the fees
charged for their medical services, or creating or encouraging
adherence to any fee schedule. The order does not prevent these
associations from entering into legitimate joint ventures that
are non-exclusive (that is, that do not restrict to rights of
participants to take part in other networks as well) and
involve the sharing of substantial financial risk. Other types
of joint ventures are subject to prior approval of the
Commission. The order settles complaint charges that MAPI
blocked the entry of an HMO into Billings, obstructed a PPO
that was seeking to enter, recommended physician fee increases,
and later acted through BPHA to maintain fee levels. C-3704
(consent order) 62 Fed. Reg. 11,201 (March 11, 1997).
In Mesa County Physicians, the complaint alleged that the
Mesa County IPA, an organization whose members include 85% of
all physicians and 90% of primary care physicians in Mesa
County, Colorado, acted to restrain trade by combining to fix
prices and other competitively significant terms of dealing
with payors, and by collectively refusing to deal with some
third party payors, such as new health-care plans. This conduct
hindered the development of alternative health care financing
and delivery systems, and resulted in higher prices for
physician services. The complaint alleged that the IPA, through
its alliance with the Rocky Mountain Health Maintenance
Organization, created a substantial obstacle to the ability of
other payers to establish physician panels in Mesa County. The
complaint also alleged that the IPA's Contract Review Committee
negotiated collectively on behalf of the IPA's members with
several third party payers using a set of guidelines and fee
schedule that had been approved by the IPA Board. The consent
agreement that has been accepted subject to public comment
prohibits the Mesa County IPA from: (1) engaging in collective
negotiations on behalf of its members; (2) collectively
refusing to contract with third party payers; (3) acting as the
exclusive bargaining agent for its members; (4) restricting its
members from dealing with third party payers through an entity
other than the IPA; (5) coordinating the terms of contracts
with third-party payers with other physician groups in Mesa
County or in any county contiguous to Mesa County; (6)
exchanging information among physicians about the terms upon
which physicians are willing to deal with third-party payers;
or (7) encouraging other physicians to engage in activities
prohibited by the order. The order also requires the Mesa IPA
to notify its members and certain third parties about the
order, amend its ``Physician Manual'' to bring it into
compliance with the order, and abolish the Contract Review
Committee. The IPA is also required to publish and distribute
copies of the complaint and order to its members. The proposed
order, however, allows the respondents to engage in: (1) any
``qualified clinically integrated joint arrangement'' (with
prior notice to the Commission); and (2) conduct that is
reasonably necessary to operate any ``qualified risk-sharing
joint arrangement'' as set forth in the DOJ/FTC Statements of
Antitrust Enforcement Policy in Health Care. D-9284 (proposed
consent order) 63 Fed. Reg. 9549 (February 25, 1998).
In College of Physicians-Surgeons of Puerto Rico, the
Federal Trade Commission and the Commonwealth of Puerto Rico
filed a final order and a stipulated permanent injunction in
federal court against the College (a group of 8,000 physicians)
and three physician independent practice associations. The
complaint charged that the defendants attempted to coerce the
Puerto Rican government into recognizing the College as the
exclusive agent for bargaining with the public corporation
responsible for administering a health insurance system that
provides medical and hospital care to indigent residents. The
complaint also charged that to achieve their goals, members of
the College called for an eight day strike during which they
ceased providing non-emergency services to patients. The order
prohibits the defendants from boycotting or refusing to deal
with any third party payer, refusing to provide medical
services to patients of any third party payer, or jointly
negotiating prices or other more favorable economic terms. The
order also calls for the College to pay $300,000 to the
catastrophic fund administered by the Puerto Rico Department of
Health. The order does not prevent the defendants from
participating in joint ventures that involve financial risk-
sharing or which receive the prior approval of the Commission,
from petitioning the government, or from communicating purely
factual information about health plans. FTC File No. 97 10011,
Civil No. 97-2466-HL (District of Puerto Rico) (October 2,
1997).
In Urological Stone Surgeons, the consent order settled
charges that three companies (Urological Stone Surgeons, Inc.,
Stone Centers of America, L.L.C., and Urological Services,
Ltd.) and two doctors providing lithotripsy services at
Parkside Kidney Stone Centers illegally fixed prices for those
services. The centers were owned by a large proportion of the
urologists practicing in the Chicago metropolitan area, and the
urologists using the Parkside facility account for
approximately 65% of urologists in the area. The complaint
alleged that the proposed respondents agreed to use a common
billing agent (Urological Services, Ltd.), established a
uniform fee for lithotripsy professional services, prepared and
distributed fee schedules for services, and billed a uniform
amount either from the fee schedule or as an amount negotiated
on behalf of all urologists at Parkside. The complaint also
alleged that the billing agent contracted with third party
payors based on a uniform percentage discount off the
urologist's charge for professional services, or a uniform
global fee that included professional services, charges for the
lithotripsy machine, and anesthesiology services. According to
the complaint, the collective setting of fees for lithotripsy
services was not reasonably necessary to achieve efficiencies
from the legitimate joint ownership and operation of the
lithotripsy machines, nor were the urologists sufficiently
integrated so as to justify the agreement to fix prices for
their professional services. The final consent order prohibits
the proposed respondents from fixing prices, discounts, or
other terms of sale or contract for lithotripsy professional
services, requires the proposed respondents to terminate third-
party payer contracts that include the challenged fees at
contract-renewal time or upon written request of the payor, and
requires the respondents to notify the FTC at least 45 days
before forming or participating in an integrated joint venture
to provide future services. C-3791 (final consent order issued
April 10, 1998).
In Institutional Pharmacy Network, the complaint alleged
that five institutional pharmacies in Oregon unlawfully fixed
prices and restrained competition among themselves, leading to
higher reimbursement levels for serving Medicaid patients in
long-term care institutions. The five pharmacies are Evergreen
Pharmaceutical, Inc., NCS Healthcare of Oregon, Inc., NCS
Healthcare of Washington, Inc., United Professional Companies,
Inc., and White, Mack & Wart, Inc. They compete to provide
prescription drugs and services to patients in long term care
institutions, and provide institutional pharmacy services for
80% of the patients in Oregon receiving such services.
According to the complaint, the pharmacies formed IPN to offer
their services collectively to managed care organizations that
provide health care services to Medicaid recipients, and to
maximize their leverage in bargaining over reimbursement rates,
but did not share risk or provide new or efficient services.
The final order prohibits IPN and the institutional pharmacy
respondents from entering into similar price fixing
arrangements. The order, however, allows the respondents to
engage in: (1) any ``qualified clinically integrated joint
arrangement'' (with prior notice to the Commission); and (2)
conduct that is reasonable necessary to operate any ``qualified
risk-sharing joint arrangement'' as set forth in the DOJ/FTC
Statements of Antitrust Enforcement Policy in Health Care. File
No. 961-0005 (final order issued August 21, 1998).
In M.D. Physicians of Southwest Louisiana, the consent
order settled charges that a physician group, composed of a
majority of the physicians in the Lake Charles area of
Louisiana, fixed the prices and other terms on which it would
deal with third party payors, collectively refused to deal with
third party payors, and conspired to obstruct the entry of
managed care. According to the complaint, the group was formed
in 1987 as a vehicle for its members to deal concertedly with
the entry of managed care, and until 1994 the members of MDP
dealt with third party payors only through the group. As a
result of this conduct, the complaint alleged, MDP restrained
competition among physicians, increased the prices that
consumers paid for physician services and medical insurance
coverage, and deprived consumers of the option of managed care.
The order prohibits MDP from engaging in collective
negotiations on behalf of its members, orchestrating concerted
refusals to deal, fixing prices or terms on which its members
deal, or encouraging or pressuring others to engage in any
activities prohibited by the order. The order does allow MDP to
operate any ``qualified risk-sharing joint arrangement'' or,
upon prior notice to the Commission, any ``qualified clinically
integrated joint arrangement,'' as reflected in the 1996 FTC/
DOJ Statements of Antitrust Enforcement Policy in Health Care.
C-3824 (final consent order issued August 31, 1998).
In Dentists of Juana Diaz, a group of dentists,
constituting a majority of the practitioners in Juana Diaz,
Coamo, and Santa Isabel, Puerto Rico, signed a proposed consent
order prohibiting them from fixing prices and engaging in an
illegal boycott of a government program that provides dental
care for indigent patients. According to the complaint, the
dentists threatened a boycott of the program if they were not
reimbursed at certain prices, and then in fact boycotted the
program. After several months, the dentists' price demands were
met and they agreed to participate. The order prohibits the
dentists from jointly boycotting or refusing to deal with third
party payers, or collectively determining any terms or
conditions for dealing with third party payers. The order does
allow the dentists to operate any ``qualified risk-sharing
joint arrangement'' or, upon prior notice to the Commission,
any ``qualified clinically integrated joint arrangement,'' as
reflected in the 1996 FTC/DOJ Statements of Antitrust
Enforcement Policy in Health Care. FTC File No. 981-0154
(proposed consent order issued September 16, 1998).
In Puerto Rican Pharmacy Association, the Asociacion de
Farmacias Region de Arecibo (AFRA) and Ricardo Alvarez Class
agreed to settle Federal Trade Commission charges that they
fixed prices and engaged in an illegal boycott in order to
obtain higher reimbursement rates for pharmacy goods and
services under Puerto Rico's government managed care plan for
the indigent. AFRA is an association of approximately 125
pharmacies operating in northern Puerto Rico, and Alvarez is a
pharmacy owner in Manati, Puerto Rico, and one of AFRA's
officers. Under the settlement, AFRA's members would be
prohibited from jointly negotiating prices or other economic
terms for pharmacies and jointly boycotting, threatening to
boycott, or refusing to provide pharmacy goods and services to
any payer or provider. FTC File No. 981-0153 (provisionally
accepted December 14, 1998).
Restraints on advertising
Without the ability to advertise low prices, members of a
profession have less incentive to offer such prices in the
first place, and less ability to communicate them effectively
even if they are offered.
One particular type of anticompetitive agreement calls for
separate mention. This is the agreement among members of a
professional association that they will cease or restrict the
use of advertising. Such agreements raise particular
difficulties for antitrust enforcers, because they involve, not
only the issue of an agreement to restrict competition, but
also other issues involving consumer information and consumer
protection problems. But it is clear that a raw case of
advertising restraints can have strongly adverse effects for
consumers. Without the ability to advertise low prices, members
of a profession have less incentive to offer such prices in the
first place, and less ability to communicate them effectively
even if they are offered.
An example of this type of case is the case against the
California Dental Association (CDA), which the Commission is
currently litigating before the Supreme Court. The Commission
originally issued a complaint charging that the CDA had
unreasonably restricted its dentist members' truthful and
nondeceptive advertising of the price, quality, and
availability of their services. One part of this conduct
effectively prohibited advertising of senior-citizen discounts.
In March, 1996, the Commission issued an opinion and order
affirming an ALJ's decision finding that the California Dental
Association's rules violated Section 5 of the FTC Act. The
Commission's order required CDA, among other things, to cease
and desist from restricting truthful, nondeceptive advertising
(including truthful, nondeceptive superiority claims, quality
claims, and offers of discounts); to remove from its Code of
Ethics any provisions that include such restrictions; and to
contact dentists who have been expelled or denied membership in
the last 10 years based on their advertising practices and
invite them to re-apply. The order also requires CDA to set up
a compliance program to ensure that its constituent societies
interpret and apply CDA's rules in a manner that is consistent
with the order.
The Commission's order was upheld by the Ninth Circuit
Court of Appeals in California Dental Assn. v. FTC, 128 F.3d
720 (9th Cir. 1997), but the CDA has obtained review in the
Supreme Court. The Commission's brief there was filed on
December 11, 1998, and the case was argued on January 13, 1999.
Anticompetitive mergers
Recent changes in the structure of the health care system,
including the growth of HMOs, have resulted in increased
pressure for cost containment. These pressures have been felt
throughout the health care system, which has responded with
efforts to decrease costs and to improve efficiency. Mergers
have been one tool for reducing costs. While such efforts are
generally beneficial to consumers, they can be harmful if they
lead to an anticompetitive outcome in a particular market.
One such merger was challenged by the Commission in the
Mediq case. This case involved Mediq's proposed $100 million
acquisition of Universal Hospital Services. The transaction
would have combined the nation's two largest firms that rent
movable medical equipment--such as respiratory, infusion, and
monitoring devices--to hospitals, and would have given Mediq a
dominate share of the rental markets both nationally and in
many major metropolitan areas across the nation. Many hospitals
and their group purchasing organizations expressed concern that
the merger would have led to higher rental prices because
hospitals and hospital chains would not switch from renting to
buying expensive equipment that may sit idle for long periods,
even in the face of a significant price increase. The FTC filed
a complaint seeking a preliminary injunction to block the
merger pending an administrative trial, and the parties then
abandoned the transaction. (D. D.C., Civ. Action. No. 97-1916)
Hospital mergers
As in other industries, the Commission approaches hospital
mergers in a cautious and considered way.
Among other mergers in the health care industry, we have
seen an increasing number of hospital mergers. As in other
industries, the Commission approaches those mergers in a
cautious and considered way. The Commission has found that the
vast majority of hospital mergers pose no competitive problems;
only a relative handful of them are investigated. The agency
challenges only those specific mergers that it has reason to
believe are likely to have anticompetitive results, and it
seeks a remedy that is carefully tailored to eliminate only the
anticompetitive part of the transaction while allowing the
remainder to proceed.
Enforcement actions are taken when the circumstances
warrant, however. In Tenet Healthcare the agency secured a
preliminary injunction against the proposed merger of the only
two commercial acute care hospitals in Butler County, Missouri.
The FTC was joined by the Attorney General of Missouri in
challenging this merger. The case had particular significance.
It broke a string of five consecutive losses in government
challenges to hospital mergers. ``This shows that the antitrust
laws do apply to local hospital markets,'' agency officials
noted at the time, ``and it also shows that we and the
Department of Justice remain committed to litigating these
complex and difficult cases where the facts warrant it.'' The
case is now on appeal to the Eighth Circuit Court of Appeals.
In another case the agency was able to obtain the necessary
divestiture through a negotiated consent agreement. In OrNda
Healthcorp, the Commission reached an agreement settling
charges that the acquisition of the firm, coincidentally by
Tenet Healthcare as well, would substantially lessen
competition for general acute care services in the San Luis
Obispo, California area in violation of Section 7 of the
Clayton Act and Section 5 of the FTC Act. Tenet and OrNda were
the second and third largest chains of general acute care
hospitals in the nation, and the two leading providers of acute
care hospital services in San Luis Obispo County. Tenet owns
195-bed Sierra Vista Regional Medical Center in San Luis
Obispo, and 84-bed Twin Cities Community Hospital in Templeton;
OrNda owned 147-bed French Hospital Medical Center in San Luis
Obispo. OrNda also owned 70-bed Valley Community Hospital in
Santa Maria, about 30 miles south of the city of San Luis
Obispo and just south of San Luis Obispo County. According to
the complaint, the combination of the three largest of the five
hospitals in San Luis Obispo County would eliminate competition
between Tenet and OrNda, significantly increase the high level
of concentration for acute care hospital services, and increase
the market share of Tenet to over 71%. The consent order
required Tenet to divest French Hospital Medical Center and
other related assets in San Luis Obispo County, to an acquirer
approved by the Commission, by August 1, 1997. That divestiture
has been completed, to a small non-profit hospital system. See
Tenet Healthcare Corporation/OrNda Healthcorp, C-3743 (consent
order) (January 26, 1998).
During the past two years the Commission has also taken an
important step to ensure the integrity of its remedial orders
(whether litigated or consent) involving hospital mergers. In
Columbia/HCA Healthcare the Commission put additional teeth in
its program by obtaining a $2.5 million civil penalty to settle
charges that the firm violated a 1995 order to divest hospitals
in Utah and Florida in a timely manner. This was the second
largest penalty ever imposed for failure to divest within
contemplated time periods.
Pharmaceutical mergers
Pharmaceutical prices are particularly important to older
consumers. It has been reported that the roughly 13 percent of
our population that is over the age of 65 consumes more than
one-third of all prescription drugs dispensed, and that this
percentage is increasing. Excluding insurance premiums,
medicines account for 34% of the health-care costs paid by
older people--a larger share than goes for doctor visits (31%)
or for hospital stays (14%). Pharmaceutical costs must be
frequently paid out of pocket: about 19 million elderly people
have little or no insurance coverage for drug purchases. All
these figures confirm that antitrust enforcement in the
pharmaceutical industry will have a disproportionate benefit
for older citizens. The Commission was accordingly active
during 1997 and 1998 in the role of protecting competition in
this area, focusing on oversight of merger activity in both the
manufacturing and distribution sectors.
One of our largest cases involved distribution of drugs.
The Drug Wholesalers matter was striking for the sheer number
of consumers protected. In this case, the FTC secured a
preliminary injunction in federal district court, preventing
the proposed mergers of the nation's four largest
pharmaceutical wholesalers into two companies. The agency
challenged McKesson Corp.'s acquisition of AmeriSource Health
Corp., and Cardinal Health, Inc.'s acquisition of Bergen
Brunswig Corp. The four firms together hold approximately 80
percent of the wholesale pharmaceutical market. In court, the
agency argued, successfully, that the two mergers might
substantially reduce competition for drug wholesaling
services--a market that is important to virtually every
consumer in the country. The Commission believes that its
action in this one case has saved consumers more than $ 100
million per year.
In 1998 the FTC also announced an agreement with Merck and
Co., Inc. (Merck), a leading pharmaceutical manufacturer, and
its subsidiary, Merck-Medco Managed Care, LLC (Medco),
resolving antitrust concerns resulting from Merck's acquisition
of Medco. The Commission had alleged that Merck's acquisition
of Medco, the largest pharmacy benefits manager (PBM) in the
United States, might substantially lessen competition in the
manufacture and sale of pharmaceuticals, and in the provision
of PBM services, leading to higher prices and reduced quality.
PBMs serve as middlemen in the provision of prescription drugs
to managed care plans. The settlement required Medco to take
steps to diminish the effects of any unwarranted preference
that might be given to Merck's drugs over those of Merck's
competitors in connection with the pharmacy benefit management
services that it provides.
The agency also monitors mergers among the actual
manufacturers of pharmaceuticals. A particularly important case
of this type involved the merger of Ciba-Gigy Ltd. and Sandoz
Ltd. to form a new pharmaceutical firm called Novartis. On
reviewing the merger the Commission became concerned that it
might reduce competition in one area where the two firms had
previously been the leading forces. This involved the
development and commercialization of gene therapy products,
which are expected to begin offering significant improvements
in the treatment of cancer and other diseases and medical
conditions by the year 2000. Before approving the merger,
therefore, the Commission negotiated a consent agreement
requiring licensing of certain specified gene therapy
technology and patent rights. This was designed to restore
competition in the development and commercialization of gene
therapy treatments for cancer and graft-versus-host disease
research and treatment. That agreement was made final in April,
1997, and the required divestitures were approved in September
of the same year.
COMMISSION ACTION IN OTHER FIELDS
Funeral services: Consumer protection
This is one time when consumers are easy prey for the less
than forthright. The Funeral Rule helps you avoid overpaying. .
. .
On average, a funeral costs in excess of $4,000, and can
easily cost $10,000 or more. It is among the most expensive of
consumer purchases, and it typically comes at an emotionally
difficult time, and often is a first-time purchase. To make
informed choices under these circumstances, consumers need
ready access to accurate information about the range of funeral
goods and services offered and the prices charged. The
Commission's Funeral Industry Practices Rule, 16 CFR Part 453,
is designed to ensure that the need for this kind of
straightforward information is met, by requiring providers of
funeral goods and services to provide itemized price
information and other material disclosures to consumers
initiating discussions about funeral arrangements. This Rule is
of considerable importance to older Americans and their
families.
In the first decade after the Rule became effective, the
Commission pursued a conventional enforcement approach,
investigating complaints from consumers and competitors, and,
where violations were found, bringing law enforcement actions
for civil penalties. From 1984 through 1994, this approach
resulted in 43 enforcement actions against funeral homes for
failing to comply with the Rule. These enforcement efforts,
however, were not effective to bring the industry into
compliance with the Rule. Surveys showed that about two-thirds
of industry members failed to comply with the ``core'' Rule
requirements--i.e., failed to provide itemized price lists of
available goods and services to consumers seeking to arrange a
funeral.
Realizing that a new strategy was needed to improve this
situation, the Commission staff implemented a more proactive
``sweeps'' approach based upon test shopping large numbers of
funeral homes in selected regions. A key element in planning
and executing the sweeps was to partner with the Commission's
consumer protection law enforcement counterparts at the state
and local level. After an initial pilot sweep by FTC staff
alone in Florida, FTC staff joined with the Attorneys General
of Tennessee, Mississippi, and Delaware, conducting four sweeps
in 1995 and 1996. Investigators posing as consumers test
shopped funeral homes in those states for Rule compliance.
Eighty-nine funeral homes were test shopped in the course of
those sweeps, and 20 homes were found not to be in compliance;
enforcement actions were brought against each of those 20
homes. Thus, in a little more than a year the Commission
brought nearly half as many enforcement actions as had been
filed in the entire first decade of Rule enforcement.
The Commission's initiation of the sweeps enforcement
approach produced a strong impact upon the funeral industry,
prompting the National Funeral Directors Association (NFDA), in
September 1995, to submit a proposal to the Commission for
bolstering the level of industry compliance through a self-
certification and training program. The Commission agreed to
this proposal in January 1996. The first component of this
innovative program is the Funeral Rule Offenders Program
(FROP), which offers a non-litigation alternative to bring
homes found to be in violation rapidly into compliance with
``core'' Rule requirements violations of the Rule. Under FROP,
if a funeral home is identified by investigators as having
failed to provide the required price lists, the home may, at
the Commission's discretion, be offered the choice of a
conventional investigation and potential law enforcement action
resulting in a federal court order and civil penalties as high
as $11,000 per violation, or participation in FROP. Violators
choosing to enroll in FROP make voluntary payments to the U.S.
Treasury or state Attorney General, but those payments
generally are less than the amount the Commission would seek as
a civil penalty. NFDA attorneys then review the home's
practices, revise them so they are in compliance with the
Funeral Rule, and then conduct on-site training and testing.
The Commission, in cooperation with state Attorneys
General,
continued to conduct Funeral Rule sweeps, providing non-comply-
ing homes with the choice of enrollment in FROP or a
conventional
law enforcement proceeding. The first round of sweeps conducted
after initiation of FROP were conducted in Massachusetts,
Oklahoma, Ohio, Colorado, and Illinois. The results of those
sweeps indicated that compliance among funeral homes had
improved significantly since 1994. Specifically, nearly 90
percent of funeral homes subjected to test shopping in 1996
were found to be in compliance with the core Rule requirements.
In 1997 and 1998, the Commission and its state partners
conducted sweeps in New Jersey, Arkansas, California,
Washington, Pennsylvania, Georgia, Texas, Iowa, Florida,
Minnesota, Michigan, Louisiana, and Utah, among others. These
enforcement activities resulted in test shopping of over 600
funeral homes across the country, and 72 violators have been
offered an opportunity to enroll in FROP in lieu of litigation.
The integrated approach of massive sweeps combined with the
FROP option for identified violators appears to be effective in
sharply raising and maintaining the level of industry
compliance. Continuing to pursue this approach is a high
priority for the Commission. In addition, the Commission will
shortly initiate a periodic regulatory review of the Funeral
Rule to assess whether the continuing need for the Rule, and
whether it could be modified to increase its effectiveness in
protecting consumers or reducing industry compliance costs.
Competition activities involving funeral homes and cemeteries
We review mergers to ensure that every local market retains
enough funeral providers to give consumers a competitive range
of alternatives. The Commission is also active in watching for
antitrust problems in the funeral and cemetery industries.
Where mergers take place between two chains providing such
services, examine them for overlaps in particular local
markets, in order to ensure that every local market retains
enough providers to give consumers a competitive range of
alternatives.
As part of this program, the Commission recently
investigated a large proposed acquisition. This acquisition
would have involved possibly significant consolidations of
funeral homes in at least 42 communities, and possibly
significant consolidations of perpetual care cemetery services
in at least seven communities. The proposed acquisition was
eventually abandoned, in part, according to the companies
involved, because of the pending investigation.
Living trusts
In 1997, cease and desist orders were made final against
two companies, The Administrative Company and Pre-Paid Legal
Services, who misled elderly consumers regarding the benefits
and appropriateness of living trusts and the specific living
trusts that the companies sold. In the order settling the
allegations with the FTC, the companies are prohibited from
making misrepresentations about living trusts, required to make
certain disclosures and one company was required to make a
partial reimbursement to consumers.
Mail or telephone order merchandise
The Commission's Mail or Telephone Order Merchandise Rule,
16 CFR Part 435, requires a seller of merchandise ordered by
mail, telephone or computer to ship goods within the time
promised or within 30 days, notify consumers of delays, and
give consumers the option to cancel an order and receive a
refund. In issuing the original Mail Order Rule in 1975, the
Commission noted that consumers with mobility problems,
including older consumers, frequently order by mail and may
also find it difficult to return merchandise. On March 1, 1994,
the Commission amended the Rule to include telephone sales.
Supporting this amendment was evidence submitted by the AARP
indicating that a significant percentage of persons age 65 and
older order products by telephone.
The Commission staff works closely with industry members
and trade associations to obtain compliance with the Rule, and
it initiates law enforcement actions where appropriate. During
1997 and 1998, the FTC obtained eight consent decrees resolving
alleged Rule violations, resulting in judgments for civil
penalties totaling $1,894,186, and consumer redress totaling
$440,643. Two of these civil penalty judgments, against Dell
Computer Corporation for $800,000 and Iomega Corporation for
$900,000, are the largest non-fraud penalties ever imposed
under the Rule.
``Made in USA'' claims
Many Americans prefer to purchase products made in the
United States and are interested in the country of origin of
the products they buy. According to recent survey data, older
Americans are especially interested in this information. In
December 1997, the Commission concluded a comprehensive review
of ``Made in USA'' and other U.S. origin claims in product
advertising and labeling, and determined to continue to hold
``Made in USA'' advertising and labeling claims to the ``all or
virtually all'' standard that the Commission has traditionally
applied. As part of the review, the Commission received more
than one thousand written comments, the majority of which
strongly supported the Commission's traditional standard.
The Commission also issued an Enforcement Policy Statement
outlining the factors the Commission will consider in
determining whether a U.S. origin claim is ``deceptive.'' Under
the Commission's standard, voluntary, unqualified U.S. origin
claims must be supported by evidence that a product is ``all or
virtually all'' made in the United States. The policy further
states that a ``product that is all or virtually all made in
the United States will ordinarily be one in which all
significant parts and processing that go into the product are
of U.S. origin. In other words, where a product is labeled with
an unqualified `Made in USA' claim, it should contain only a de
minimis, or negligible, amount of foreign content.''
Door-to-door sales
The Cooling-Off Rule, 16 CFR Part 429, requires that
consumers be given a three-day right to cancel certain sales
occurring away from the seller's place of business (often known
as ``door-to-door sales''). In addition, the Commission, in
some administrative cease and desist orders against companies
engaged in door-to-door sales, has required companies to allow
consumers the right to cancel purchases not covered under the
Rule. The Rule and these orders can particularly benefit older
Americans who are retired and at home, and who may be exposed
more frequently to high pressure sales tactics by door-to-door
or other sellers.
In 1998, the Commission, with the National Association of
Consumer Agency Administrators and the National Association of
Home Builders Remodelers Council, announced a joint consumer
education campaign to provide consumers with a tool kit to
protect themselves from home improvement fraud. The kit, ``Home
Improvement: Tools You Can Use,'' offers tips consumers can use
to head off problems in advance. It is described in more detail
in the Consumer Education section of this report. In the
materials, consumers are advised to make sure the three-day
right to cancel is included in home improvement contracts
signed in the consumer's home or at a location other than the
contractor's permanent place of business. This right to cancel
can help older Americans, who AARP has noted are most
vulnerable to unscrupulous door-to-door sellers, cancel ill-
considered financial commitments that would otherwise result in
financial liens against their homes.
Credit and other financial issues
Whether consumers are in the red or in the black, they must
be alert to the possibility of credit fraud. . . . It's
hazardous to financial health and well-being . . . .
The Commission responds to numerous credit and related
financial issues affecting virtually every consumer. The impact
of being harassed about a debt, denied for a loan or subject to
credit fraud can be particularly devastating to seniors who may
have limited choices for credit and limited resources to
informed and objective financial advice.
Debt Collection Practices.--Each year, the Commission
receives thousands of consumer complaints regarding harassing
and abusive behavior by debt collectors. Many of these letters
and telephone calls come from senior citizens. In 1997 and
1998, the Commission brought a number of actions and resolved
several actions initiated in prior years, against debt
collectors for violations of the Fair Debt Collection Practices
Act (FDCPA), 15 U.S.C. Sec. Sec. 1692-1692o.
In October 1998, one of the largest collection agencies in
the country, Nationwide Credit, Inc., agreed to pay a $1
million civil penalty to settle allegations that the company
had violated the FDCPA by harassing consumers, making false and
misleading representations to consumers, impermissibly
contacting third parties about consumers' debts, failing to
send required validation notices, and failing to verify debts
when requested to do so by consumers. Other actions in 1997 and
1998 against National Financial Services, Lundgren &
Associates, P.C., Trans-Continental Affiliates, and United
Compucred Collections yielded similar settlements of alleged
harrassment, abuse and misrepresentation against debtors.
Equal Credit Opportunity Act.--Among other things, the
Equal Credit Opportunity Act (ECOA), 15 U.S.C. Sec. 1691 et
seq., prohibits creditors from discriminating based on age in
determining whether or not to extend credit. The ECOA's
implementing Regulation B prohibits creditors from discounting
or refusing to consider an applicant's income from a pension or
other retirement benefit or from denying credit because an
applicant, on the basis of age, does not qualify for credit-
related insurance. The ECOA also prohibits discrimination based
on the fact that an applicant's income is derived from a public
assistance source, including Social Security, which is more
likely to be received by the elderly. To help detect
discrimination in mortgage credit based on age or other
prohibited factors (such as sex or race), Regulation B requires
mortgage lenders to take written applications for credit and to
record the race/national origin, sex, marital status, and age
of applicants. The ECOA also requires written notice to
consumers of the reasons for a denial of credit. The Truth in
Lending Act (TILA), a related statute, requires that all
borrowers receive accurate disclosure of the cost of credit.
In 1997, the Commission entered into two separate but
related settlement agreements with The Money Tree, Inc. (Money
Tree), a Georgia-based lender and its president. The complaint
in the first action charged that Money Tree violated the ECOA
by discriminating against elderly consumers and those who
received income from public assistance. The complaint alleged
that Money Tree discriminated against elderly applicants by
discouraging them from applying for credit, denying their
applications if they did apply, or offering them credit on less
favorable terms than younger applicants because credit-related
insurance was not available due to the applicants' age. The
complaint alleged that Money Tree discriminated against
applicants who received income from public assistance,
including Social Security, by imposing stricter loan terms on
those applicants than on employed applicants, regardless of
income level, and by collecting, or trying to collect, loan
payments from public assistance customers before they were due.
Further, the complaint alleged that Money Tree required, as a
condition of the extension of credit, that applicants who
received public assistance participate in a program in which
their public assistance payments were deposited into a bank
designated by Money Tree while employed applicants were not
required to participate in such a program. Under the agreement
to settle the ECOA charges, Money Tree paid $75,000 in civil
penalties and was barred from discrimination in the future
against elderly applicants and applicants who receive public
assistance.
The second agreement involving Money Tree settled charges
that Money Tree violated the TILA by requiring applicants to
purchase some combination of credit-related insurance or auto
club membership in order to obtain a loan. These ``extras''
cost consumers who borrowed $150 to $400 an estimated
additional $80, plus interest. The TILA and its implementing
Regulation Z require that such mandatory charges be included in
the finance charge and annual percentage rate (APR) disclosed
to the consumer. According to the complaint, Money Tree failed
to do this, and instead, wrongfully included the extras in the
amount financed in violation of the TILA and Regulation Z. The
complaint also alleged that Money Tree engaged in unfair
practices in violation of the FTC Act by inducing consumers to
sign statements asserting that they had voluntarily purchased
the extras, when in fact, they were required to pay for the
extras as a condition of receiving the loan. The redress plan
under the second agreement required Money Tree to offer all of
its current customers the opportunity to cancel the credit-
related insurance and to obtain cash refunds or credits.
In 1998, the Commission filed suit against a Washington,
D.C. area mortgage lender for violations of the ECOA and
Regulation B, among other charges. The complaint against
Capital City Mortgage Corporation (Capital City) states that,
``[i]n many instances, defendants's borrowers are minority and/
or elderly persons living on fixed or low incomes in
Washington, D.C., Maryland, and Virginia, who borrow primarily
for personal, family, or household purposes.'' The complaint
alleges that Capital City makes high interest rate (20 to 24
percent) loans to those borrowers and that the loans are often
interest-only balloon loans in which a borrower, after making
payments for the term of the loan, still owes the entire amount
of the loan principal. These loans are often secured by the
borrowers' homes and typically are made based on the worth of
the home rather than on the borrower's creditworthiness or
income.
The Commission complaint alleged that this company and its
president violated the ECOA and Regulation B by failing to take
written applications for mortgage loans; failing to collect
required information about the race/national origin, sex,
marital status, and age of applicants; failing to provide
written notice of adverse action; or when providing notice of
adverse action, failing to provide the applicant with: (1) the
correct principal reason for the action taken or (2) the
correct name and address of the Federal Trade Commission, the
federal agency that administers compliance with the ECOA with
respect to Capital City. The Commission is seeking civil
penalties and injunctive relief for violations of the ECOA.
Home Equity Lending Abuses.--The Commission is taking a
variety of steps to address reported abuses in the subprime
home equity market, which may disproportionately affect elderly
borrowers who are more likely to have equity in their homes.
First, the Commission is increasing its enforcement activities
to halt subprime lenders who are engaged in abusive lending
practices. At the same time, the Commission has been working
with states to increase and coordinate enforcement efforts. The
Commission also is educating consumers in order to help them
avoid potential home equity lending abuses.
The Commission's complaint against Capital City alleged
numerous violations of a number of federal laws resulting in
serious injury to borrowers, including the loss of their homes.
The Commission's complaint alleges that the defendants engaged
in deceptive and unfair practices against borrowers at the
beginning, during, and at the end of the lending relationship,
in violation of Section 5 of the FTC Act. The complaint alleges
that the defendants deceived borrowers about various loan
terms; for example, by making representations that a loan was
an amortizing loan that would be paid off by making payments
each month. In fact, the loan was an interest-only balloon loan
with the entire loan principal amount due after all of the
monthly payments were made. The complaint also alleges that the
defendants deceived borrowers during the loan period with phony
charges of inflated monthly payment amounts, overdue balances,
arrears, service fees, and advances. In addition, the complaint
alleges that the defendants deceived borrowers regarding
amounts owed to pay off the loans. Further, the complaint
alleges that the defendants violated the FTC Act by:
withholding some loan proceeds while requiring a borrower to
make monthly payments for the entire loan amount; foreclosing
on borrowers who were in compliance with their loan terms; and
failing to release the company's liens on title to borrowers'
homes even after the loans were paid off. The complaint states
that, after foreclosing, Capital City would buy the properties
at auction for prices much lower than the appraised value of
the properties. In addition to the Commission's allegations of
violations of the FTC Act, ECOA, and FDCPA discussed above, the
Commission also charged Capital City with violations of the
TILA.
In addition to its casework and ongoing investigations of
alleged home equity abuses by other lenders, the Commission is
sharing its knowledge and experience with other enforcement
agencies and with consumers. During 1997, the Bureau of
Consumer Protection's Division of Credit Practices (now the
Division of Financial Practices) held joint law enforcement
sessions on home equity lending abuses with state regulators
and law enforcers in six cities around the country. These
training sessions were conducted to assist states in exercising
their relatively new enforcement authority under the Home
Ownership and Equity Protection Act (HOEPA) amendment to the
TILA, a law intended to curb abuses in high rate, high fee
mortgage lending, and to share information about recent trends.
Jodie Bernstein, Director of the Commission's Bureau of
Consumer Protection, testified before the Senate Special
Committee on Aging on home equity abuses in the subprime
lending market on March 16, 1998. The Commission recognizes
that abuses in the home equity lending market are a serious
national problem. Due to sharp growth in the subprime mortgage
industry, it appears that the abuses by subprime lenders are on
the rise. As a result of unfair and deceptive practices, and
other federal law violations by certain lenders, vulnerable
borrowers--including the elderly--are facing the possibility of
paying significant and unnecessary fees and, in some cases,
losing their homes. Using its enforcement authority, the
Commission continues to work to protect consumers from these
abuses.
CONSUMER EDUCATION ACTIVITIES AFFECTING OLDER CONSUMERS
In addition to its law enforcement activities, the
Commission, through its Office of Consumer and Business
Education (OCBE), is involved in preparing, promoting and
distributing a variety of consumer publications and broadcast
materials in print and on the Web. Many of the subjects are of
significant interest to older consumers. In addition, in the
past two years, staff members of the Commission and the
Commission have spoken to news reporters \11\ and local groups
such as the Pueblo Advisory Council on Aging and the Colorado
Coalition for Elder Rights and Adult Protection on issues of
particular interest to older adults.
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\11\ For example, staff in the Denver regional office participated
with other law enforcement and the AARP in a television show on
telemarketing fraud, which evoked more than 2,000 calls to the station.
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Summary of 1997-1998 consumer education activities
During calendar years 1997-1998, the Commission published
more than 150 education materials covering a broad range of
consumer protection topics. More than 45 are of special
interest to older Americans. Most FTC consumer publications are
not age-specific. However, publications on certain topics, such
as telemarketing scams, health care, funeral services,
investments, credit issues, and the Internet, highlight many of
the needs and concerns of older citizens. In order to reach
consumers, the message gets delivered through brochures, one-
page alerts, bookmarks, postcards, and public service
announcements on the Web and in the classified ad sections of
newspapers.
Elder care issues
An estimated 22.4 million U.S. households--nearly one in
four--now are providing care to a relative or friend aged 50 or
older or have provided care during the previous 12 months,
according to a recent survey by the National Alliance for
Caregiving and the American Association of Retired Persons
(AARP). Other surveys suggest that today's Baby Boomers--adults
born between 1946 and 1965--likely will spend more years caring
for a parent than for their children. A/PACT (``Aging Parents
Adult Children Together'') is a series of 10 articles produced
by the Federal Trade Commission in partnership with AARP that
introduce elder care issues to aging parents and their adult
children. The articles provide information and encourage
families to explore options and make careful decisions that can
help maximize independence, comfort and quality of life. The
series begins with an article about protecting elders against
fraud. Subsequent articles introduce care needs like daily
money management services, making homes safe for elders,
alternative living arrangements, and long-term care insurance.
The articles are written by medical, legal, financial and
gerontology experts, as well as caregiver support
organizations. Each article includes a list of resources for
more information. The series was distributed by the FTC, AARP,
and a number of other private-sector partners.
Informing consumers about common frauds
The FTC produced education pieces that focus on a variety
of fraudulent enterprises and offer tips on how to recognize
and avoid these scams. One offensive scheme involves fraudulent
charitable fundraising. As part of Operations False Alarm and
Missed Giving, the Commission published the following consumer
materials with the National Association of Attorneys General
(NAAG): Make Your Donations Count, Charitable Donations: Give
or Take, and Dialing for Dollars: When Fund-raisers Call. The
publications identify deceptive fundraising schemes and suggest
ways to avoid becoming a victim.
In connection with its efforts to inform consumers about
fraudulent prize promotions, the Commission published materials
with NAAG and the U.S. Postal Inspection Service: Is There a
Bandit in Your Mailbox? Wanted: The Bandit in Your Mailbox, The
Mailbox Bandit and How to Spot the Bandit in Your Mailbox. The
materials tell consumers how to recognize and avoid mass mail
scam artists who use direct mail, e-mail and illegal,
unsolicited faxes to hype bogus sweepstakes, travel scams,
chain letters, illegal foreign lotteries and sham prize offers.
Additional telemarketing brochures issued during 1997-98
include: Telemarketing Travel Fraud with the American Society
of Travel Agents, Reloading Scams: Double Trouble for
Consumers, Putting Cold Calls on Ice and Magazine Subscription
Scams.
At the local level, the elderly in many cultures and
communities seek advice on business transactions from their
religious leaders, particularly where they may not have adult
children, lawyers, or accountants to consult. Commission staff
continued the partnership, that began in 1995, with the Harlem
Consumer Education Council and the Harlem Branch Office of the
New York State Attorney General. Workshops were conducted at a
Harlem church for ministers, priests, and rabbis on a wide
range of consumer issues, including the continued victimization
of older Americans via telemarketing fraud and door-to-door
sales.
Commission staff also continue to reach out to seniors
through conferences, presentations and participation with
various partner-led education efforts. For example, in Denver,
Colorado, Commission staff continued to team with the Colorado
Attorney General, the Denver District Attorney, the Better
Business Bureau, and the American Association of Retired
Persons (AARP) to sponsor a conference to educate seniors about
all types of fraud, including telemarketing fraud, under the
group name Seniors Against Fraud and Exploitation (SAFE). In
the Seattle area, commission staff also continued to train
student and senior volunteers to give presentations on
telemarketing fraud to senior centers.
Finally, Commission staff participated in two ``reverse
boilerrooms'' coordinated by AARP: one in Illinois the other in
Denver. The reverse boilerroom is a means of providing consumer
education to persons whose names appear on lead, or ``mooch,''
lists and therefore are particularly likely to be contacted by
fraudulent telemarketers. The volunteers in a reverse
boilerroom call consumers on the lists, talk with them about
the risks of telemarketing fraud, and inform them that their
names and telephone numbers are circulating among real
boilerroom scam artists.
Health
Recent advances in treating impotence have opened the
floodgates for bogus remedies for this condition. The
Commission produced The Truth About Impotence Treatment Claims
to help consumers evaluate claims that many want to believe but
shouldn't.
As part of Project Workout with the American College of
Sports Medicine, the American Council on Exercise, the American
Orthopaedic Society of Sports Medicine and Shape Up America!,
the Commission published a series of materials on buying
exercise equipment: Pump Fiction: Tips for Buying Exercise
Equipment, The Muscle Hustle: Test Your Exercise I.Q. and
Avoiding the Muscle Hustle.
Other health-related publications produced during this
period include: Sound Advice on Hearing Aids and Generic Drugs:
Saving Money at the Pharmacy.
Funerals
Consumers continue to request copies of Caskets and Burial
Vaults and Funerals: A Consumer Guide which explain their
rights under the FTC's Funeral Rule. During this period OCBE
distributed more than 320,000 copies of the brochures and
received nearly 14,000 hits on the FTC web site.
Credit and financial matters
Credit and financial issues that have a direct impact on
older consumers were among the topics of several publications
distributed by the FTC in 1997-98. Getting Credit When You're
Over 62, How to Dispute Credit Report Errors, Credit and ATM
Cards: What To Do If They're Lost or Stolen, Fair Credit
Reporting and Avoiding Credit and Charge Card Fraud emphasize
and explain consumer rights under the law.
OCBE also participated in the Financial Services Education
Coalition (FSEC) to produce Helping People In Your Community
Understand Basic Financial Services: A Community Educators
Guide. The Guide, which also contains a series of consumer fact
sheets, is intended for use with a variety of audiences who do
not have accounts with financial institutions or who need basic
information about how to use accounts. The precipitating factor
for the formation of the Coalition was the Department of the
Treasury's EFT 99 initiative requiring Direct Deposit for most
federal payments by January 2, 1999.
On the ``homefront'' during 1997, OCBE worked with the D.C.
Office of the Corporation Counsel and the D.C. Department of
Consumer and Regulatory Affairs to produce, promote and
distribute the Consumer Alert Thinking About a Home
Improvement? Don't Get Nailed. This successful effort was
expanded and taken nationwide in 1998 with the National
Association of Home Builders RemodelerTM Council and
the National Association of Consumer Agency Administrators. The
consumer education kit, Home Improvement: Tools You Can Use,
contains just about everything an organization needs to execute
a community education campaign to help consumers learn about
home improvements and how to avoid becoming a victim of
fraudulent contractors. The kit includes: campaign
backgrounder; instructions and content list; Home Sweet Home .
. . Improvement--Facts for Consumers; two consumer quizzes:
Test Your Skills at Hiring a Home Improvement Contractor; Test
Your Skills at Avoiding a Home Repair Nightmare; bookmark--Home
Improvement. Tips for Hiring a Contractor; two scripts for
radio PSAs; a community forum script/presentation--Seven Key
Words to Hammer Home the Message; sample proclamation; glossary
of home improvement terms; sample press release--Local
Officials on Home Improvement. Don't Get Nailed; newsletter
article--Hiring a Home Improvement Contractor. Don It Get
Nailed; sample editorial; and two sets of ``ads'' for the
appropriate sections of the classifieds or phone directories--
home improvement and home repair and maintenance.
The Commission also published High-Rate, High-Fee Loans
(Section 32 Mortgages) to alert homeowners to their rights
under the Home Ownership and Equity Protection Act (HOEPA). In
conjunction with the filing of the Capital City complaint, the
Commission put out two publications to help consumers recognize
and avoid home equity scams and abuses: Avoiding Home Equity
Scams and Home Equity Loans: Borrowers Beware.
Additional housing-related brochures include: After a
Disaster. Hiring a Contractor, Avoiding Home Equity Scams, Home
Equity Loans: Borrowers Beware, Reverse Mortgages: Cashing in
on Home Ownership and Home Equity Loans: The Three Day
Cancellation Rule.
Internet
The Commission has worked hard to bring consumers up to
speed about the Internet. The Commission recently posted the
privacy information page, a one-stop site for consumers to find
out how to protect their personal information. In cooperation
with NAAG, the Commission issued Site-Seeing on the Internet: A
Consumer's Guide to Travel in Cyberspace, highlighting the
kinds of services available in cyberspace and offering tips on
protecting personal information. Other Interned-related
consumer publications include: Net-Based Business
Opportunities: Are Some Flop-portunities?, Cybersmarts: Tips
for Protecting Yourself When Shopping Online with American
Express Company, Call For Action, and the Direct Marketing
Association, Online Auctions: Going, Going, Gone and How to Be
Web Ready.
The Commission is also attempting to use new technologies
such as the internet to reach consumers who might get taken by
the slick appeal of con artists on the internet. The FTC has
posted eleven ``teaser'' sites. These are fake scam sites that
contain solicitations and phrases like those found on
fraudulent web pages. As a consumer clicks through a ``teaser''
site, he or she eventually arrives at a warning that states,
``If you responded to an ad like this one, You Could Have Been
Scammed!'' The consumer then receives some helpful tips and may
link back to FTC.GOV for more information about how to avoid
online fraud.
Access to FTC publications
In addition to disseminating print versions of its
materials through a well-developed distribution mechanism, all
consumer publications produced by the agency are available
online through FTC ConsumerLine at www.ftc.gov.
In December 1997, the FTC debuted the U.S. Consumer Gateway
at www.consumer.gov the first Internet site to provide ``one-
stop'' access to federal consumer information. The Gateway
offers information from federal agencies arranged by subject.
Each of the site's 10 major subject areas, including Food,
Health, Money, Product Safety, and Technology, has
subcategories allowing consumers to locate and link to
appropriate and late-breaking information quickly and easily.
The web site is a cooperative effort among federal agencies,
including the Food and Drug Administration, National Highway
Traffic Safety Administration, Securities and Exchange
Commission, Department of Agriculture, Federal Deposit
Insurance Corporation, Environmental Protection Agency, Federal
Communications Commission, Treasury, Federal Reserve Board,
Centers for Disease Control and Prevention, and the State
Department Bureau of Consular Affairs. The initiative to
develop consumer.gov was led by the FTC's Bureau of Consumer
Protection. As the ``host'' agency, the FTC maintains the site
server and provides technical support.
Conclusion
This report summarizes Commission programs from 1997 and
1998 that may be of particular interest or usefulness to older
Americans. Through its law enforcement and consumer education
efforts, the Commission strives to provide a fair and
competitive marketplace where older consumers, and their
younger counterparts, can make decisions and choose their
purchases from a competitive range of options and on the basis
of complete and truthful information.
ITEM 21--GENERAL ACCOUNTING OFFICE
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CALENDAR YEARS 1997 AND 1998 REPORTS AND CORRESPONDENCE ON ISSUES
AFFECTING OLDER AMERICANS
During calendar years 1997 and 1998, GAO issued 132 reports
on issues affecting older Americans. Of these, 70 were on
health, 3 on housing, 35 on income security, and 24 on the
Department of Defense (DOD) and veterans.
Health Issues
Alzheimer's disease: Estimates of prevalence in the United States (GAO/
HEHS-98-16, 01/28/98)
At least 1.9 million Americans age 65 years or older
suffered from Alzheimer's Disease in 1995, more than half of
whom experienced moderate to severe cases of the illness. The
prevalence of Alzheimer's increases sharply with age: Most of
the estimated 1.9 million cases were among persons aged 75 to
89. Projecting the number of persons with Alzheimer's Disease
gives some indication of the long-term care and research
challenges facing the United States as people grow older. On
the basis of projections of longevity, GAO estimates that more
than 2.9 million Americans will suffer from the disease by the
year 2015; of these, more than 1.7 million will need active
assistance in personal care. Because of the uncertainty
surrounding current estimates of Alzheimer's Disease, several
studies are now underway, supported by the National Institute
on Aging, that should provide better estimates of the
prevalence of Alzheimer's Disease among African-Americans,
Hispanics, and other subpopulations.
California nursing homes: care problems persist despite Federal and
State oversight (GAO/HEHS-98-202, 07/27/98)
Overall, despite federal and state oversight, some
California nursing homes are not being monitored closely enough
to guarantee the safety and welfare of their residents.
Unacceptable care continues to be a problem in many nursing
homes. GAO found that nearly one in three California nursing
homes was cited by state surveyors for serious or potentially
life-threatening care problems. Moreover, GAO believes that the
extent of serious care problems portrayed in federal and state
data is likely to be understated. Nursing homes generally could
predict when their annual on-site reviews would occur and, if
inclined, could take steps to mask problems. GAO also found
irregularities in homes' documentation of the care provided to
their residents, such as missing pages of clinical notes needed
to explain a resident's injury later observed by a physician.
Finally, GAO found many cases in which California Department of
Health Services surveyors did not identify serious care
problems, including dramatic weight loss, failure to prevent
bed sores, and poor management of incontinence. Even when the
state identified serious shortcomings, the Health Care Finance
Administration's (HCFA) enforcement policies have not ensured
that the deficiencies are corrected and stay that way. For
example, California state surveyors cited about one in 11
nursing homes in GAO's analysis--accounting for more than
17,000 resident beds--for violations in both of their last two
surveys that resulted in harm to residents. Yet HCFA generally
took a lenient stance toward many of these facilities. GAO
recommends a less predictable schedule of inspections for all
nursing homes and prompt imposition of sanctions when
violations are found. GAO summarized this report in testimony
before Congress; see: California nursing homes: Federal and
State oversight inadequate to protect residents in homes with
serious care violations (GAO/T-HEHS-98-219, July 28, 1998)
Cancer clinical trials: Medicare reimbursement denials (GAO/HEHS-98-
15R, 10/14/97).
Pursuant to a congressional request, GAO determined the
potential effect of the proposed Medical Cancer Clinical Trial
Coverage Act by estimating the current rate at which Medicare
carriers deny reimbursements for routine patient care costs
when beneficiaries are enrolled in cancer clinical trials.
GAO noted that: (1) its survey method did not allow it to
give a precise national estimate of the rate at which
reimbursement is denied for Medicare beneficiaries enrolled in
cancer clinical trials; and (2) the results suggest that denial
of reimbursement is relatively rare, given the populations and
time period of its review.
Comments on H.R. 4229: A Proposal for a home health prospective payment
system (GAO/HEHS-97-144R, 05/28/97).
Pursuant to a congressional request, GAO reviewed H.R.
4229, introduced in the 104th Congress, which would require the
Health Care Financing Administration (HCFA) to establish, after
congressional approval, a prospective payment system (PPS) for
Medicare home health care 4 years after enactment that would
pay fixed rates for episodes of care.
GAO noted that: (1) home health agencies (HHA) would be
paid on a per visit basis with rates for each type of visit
equal to the national average Medicare payment in 1994,
adjusted for geographic wage differences and updated for
inflation using the Medicare home health market basket index;
(2) the transitional payment methods would give HHA incentives
to reduce costs per visit, but would provide little if any
incentive for many agencies to control the number of visits
furnished; (3) Medicare's increased costs for home health have
been driven much more by increased numbers of visits per
beneficiary and more beneficiaries being served than by growth
in cost per visit; (4) basing the limits on episodes in phase
II would at best provide weak incentives to control the number
of visits; (5) as GAO reported in 1996, the average number of
visits is skewed by a substantial portion of patients who
receive extraordinarily high numbers of visits and by the
significant variation in the average number of visits supplied
by different HHAs; (6) thus, while over time such a payment
method might provide incentives to hold down the growth in
visits per episode, the short-term effects are not likely to be
significant; (7) a potential problem with an episode payment
system with stronger cost control incentives is that HHAs might
respond by reducing the number of visits during the episode,
potentially lowering the quality of care; (8) another problem
with the phase II proposal is that it uses the 18 case mix
categories for HCFA's PPS demonstration project, which HCFA has
stated are not sufficiently developed for general use and
explain less than 10 percent of the variation in cost across
patients; (9) efforts to identify fraud and abuse indicate that
substantial amounts of noncovered care are likely to be
reflected in HCFA's home health care utilization data; (10)
similar concerns exist regarding the home health cost data
base; (11) the percentage of HHAs subjected to field audits has
generally decreased over the years, as has the extent of
auditing done at the facilities that are audited; (12) for
these reasons, there is little assurance that HCFA's cost data
reflect only reasonable costs that are related to patient care,
and using these data to set payment rates and determine extra
payments to HHAs could result in windfall profits for them;
(13) GAO believes that it is questionable whether savings would
be realized by Medicare if H.R. 4229 was adopted; and (14)
moreover, mechanisms do not exist to protect beneficiaries from
potential quality of care problems that could arise from the
incentives to shorten visit times and decrease the number of
visits in an episode of care.
Federal health programs: Comparison of Medicare, the Federal Employees
Health Benefits Program, Medicaid, Veterans' Health Services,
Department of Defense Health Services, and Indian Health
Services (GAO/HEHS-98-231R, 08/07/98)
GAO compared the Medicare program with five other federal
health programs: the Federal Employees Health Benefits Program
(FEHBP); the Medicaid and Department of Veterans' Affairs (VA)
health programs; the Department of Defense's (DOD) TRICARE
health program; and the Indian Health Service (IHS). GAO also
compared key features of these programs, including: (1)
administrative structures, including the number of pages of
legislation and regulation; (2) benefit design, including
benefits covered and out-of-pocket costs to beneficiaries; (3)
costs, including per capita costs and growth rates; and (4)
patient and provider satisfaction.
GAO noted that: (1) the programs' approaches to financing
health care for their eligible populations differ markedly; (2)
these differences are generally attributable to the programs'
serving different eligible populations and the programs'
evolving relatively independently; (3) FEHBP serves as an
insurance purchaser by contracting with several hundred private
health plans to offer health benefits to nearly 9 million
federal employees, retirees, spouses, and dependents; (4) FEHBP
administrators negotiate premiums and benefits with
participating health plans, but the program does not directly
reimburse claims or directly provide health care services; (5)
the largest federal health programs, Medicare and Medicaid,
have traditionally acted as insurers for their beneficiaries by
reimbursing private health care providers for a defined set of
health care services; (6) thus, Medicare and Medicaid
administrators directly perform or contract for many of the
claims handling and health care provider relations
responsibilities that private health plans provide for FEHBP;
(7) both Medicare and Medicaid, however, have increasingly
allowed or required their enrollees to choose alternative
benefit packages offered by health maintenance organizations
and other private managed care plans more closely resembling
FEHBP by serving as insurance purchasers for at least a portion
of their enrollees; (8) VA's and IHS' health programs are
mainly direct health care providers that own hospitals and
other health care facilities and employ or contract directly
with physicians and other health care professionals to provide
services to eligible beneficiaries; (9) DOD's TRICARE also
mainly provides direct health care services but integrates its
direct delivery system with private health plans and providers,
thereby also serving as an insurance purchaser; (10) these
direct care programs' approach involves the federal
government's owning and operating a network of health care
facilities and managing health care professionals as employees,
a distinctly different approach to financing health care than
that used by FEHBP, Medicare, or Medicaid; (11) in addition,
several federal health programs perform a public role beyond
financing health care services for their eligible populations;
and (12) these roles include funding or conducting health care
research or graduate medical education; providing additional
funds to hospitals that serve large populations of low-income
people; establishing physician and hospital payment systems
that are adapted by other federal health programs and private
health plans; and providing public health services.
Health care services: How continuing care retirement communities manage
services for the elderly (GAO/HEHS-97-36, 01/23/97)
Continuing care retirement communities provide their
residents with various services--from housing to long-term care
to recreation--in an effort to bring the benefits of managed
care to the elderly. About 350,000 residents live in 1,200 of
these communities nationwide, most of which are private,
nonprofit agencies, often with religious affiliations. The
communities GAO report examined managed to meet the needs of
both healthy residents and those with chronic conditions. They
use active strategies to promote health, prevent disease, and
detect health problems early by encouraging exercise, proper
nutrition, social contacts, immunizations, and periodic medical
exams. Many of these communities also have teams of nurses,
social workers, rehabilitation specialists, doctors, and
dieticians to plan and manage residents' care. Active
monitoring of residents with chronic diseases, such as
arthritis, hypertension, and heart disease, is an integral part
of this coordinated, multidisciplinary approach to managing
care. Although the health benefits of these practices are
generally recognized, little evidence exists to demonstrate
health care cost savings.
HCFA: Inpatient hospital deductible and hospital and extended care
services coinsurance amounts for 1999 (GAO/OGC-99-9, 11/05/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
inpatient hospital deductible and hospital extended care
services coinsurance amounts for 1999. GAO noted that: (1) the
new rule would announce coinsurance amounts for services
furnished in calendar year 1999 under Medicare's hospital
insurance program; and (2) HCFA complied with applicable
requirements in promulgating the rule.
HCFA: Medicaid Program--Coverage of personal care services (GAO/OGC-97-
64, 09/30/97)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
Medicaid coverage of personal care services. GAO noted that:
(1) the rule would revise the requirements for Medicaid
coverage of personal care services furnished in a home or other
location as an optional benefit, effective for services
furnished on or after October 1, 1994; and (2) HCFA complied
with applicable requirements in promulgating the rule.
HCFA: Medicaid Program--State allotments for payment of Medicare part B
premiums for qualifying individuals in Federal fiscal year 1998
(GAO/OGC-98-28, 02/09/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on the
Medicaid program. GAO noted that: (1) the rule would announce
the federal fiscal year 1998 state allotments that are
available to pay Medicare Part B premiums for two new
eligibility groups and describe the methodology used to
determine each state's allotment; and (2) HCFA complied with
applicable requirements in promulgating the rule.
HCFA: Medicare and Medicaid programs; hospital conditions of
participation; identification of potential organ, and eye
donors and transplant hospitals' provision of transplant-
related data (GAO/OGC-98-58, 07/07/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
Medicare and Medicaid programs' hospital conditions on
participation, identification of potential organ, tissue, and
eye donors, and transplant hospitals' provision of transplant-
related data. GAO noted that: (1) the rule would: (a) revise
current hospital conditions of participation relating to organ
procurement by modifying the relationship between hospitals and
organ procurement organizations (OPOs) in order to increase the
number of organs available for donation and transplantation;
(b) require that a hospital have an agreement with an OPO,
under which it will contact the OPO in a timely manner about
individuals who die or whose death is imminent in the hospital;
(c) require hospitals to have an agreement with at least one
tissue bank and eye bank for referrals; (d) require hospitals
to collaborate with the OPO in notifying families of potential
donors of their donation options and work cooperatively with
OPOs, tissue, and eye banks, in educating hospital staff on
donation issues, reviewing death records to improve
identification of potential donors, and maintaining potential
donors while testing and placement of organs occurs; and (e)
require transplant hospitals to provide organ-transplant-
related data as requested by the Organ Procurement and
Transplantation Network, the Scientific Registry, and OPOs; and
(2) HCFA complied with applicable requirements in promulgating
the rule.
HCFA: Medicare and Medicaid programs--Salary equivalency guidelines for
physical therapy, respiratory therapy, speech language
pathology, and occupational therapy services (GAO/OGC-98-30,
02/23/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
salary equivalency guidelines. GAO noted that: (1) the rule
would revise the salary equivalency guidelines for Medicare
payments for the reasonable costs of physical therapy,
respiratory therapy, speech language pathology and occupational
therapy services furnished under arrangements by an outside
contractor; and (2) HCFA complied with applicable requirements
in promulgating the rule.
HCFA: Medicare--Physician fee schedule for calendar year 1998 and
payment policies and relative value unit adjustments and
clinical psychologist fee schedule (GAO/OGC-98-10, 11/12/97)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
changes affecting Medicare Part B payment. GAO noted that the
rule: (1) implements changes relating to physician services,
including geographic practice cost index changes, clinical
psychologist services, physician supervision of diagnostic
tests, establishment of independent diagnostic testing
facilities, the methodology used to develop reasonable
compensation equivalent limits, payment to participating and
nonparticipating suppliers, global surgical services, caloric
vestibular testing, and clinical consultations; (2) implements
provisions in the Balanced Budget Act of 1997 relating to
practice expense relative value units, screening mammography,
colorectal cancer screening, screening pelvic examinations, and
EKG transportation; and (3) finalizes the 1997 interim work
relative value units and issues interim work relative value
units for new and revised codes for 1998. GAO noted that HCFA
complied with applicable requirements in promulgating the rule.
HCFA: Medicare Program: Changes to the hospital inpatient prospective
payment systems and fiscal year 1999 rates (GAO/OGC-98-70, 08/
14/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
changes to the hospital inpatient prospective payment systems
and fiscal year 1999 rates. GAO noted that: (1) the final rule
would revise the Medicare hospital inpatient prospective
payment systems for operating costs and capital-related costs
to implement applicable statutory requirements; (2) the final
rule would implement applicable statutory requirements
concerning the payment for the direct costs of graduate medical
education; and (3) HCFA complied with the applicable
requirements in promulgating the rule.
HCFA: Medicare Program--Establishment of the Medicare+Choice Program
(GAO/OGC-98-60, 07/13/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on the
establishment of the Medicare Plus Choice program. GAO noted
that: (1) the rule would implement provisions of the Balanced
Budget Act of 1997 which established a new Medicare Plus Choice
program that significantly expands the health care options
available to Medicare beneficiaries; (2) under the program,
eligible individuals may elect to receive Medicare benefits
through enrollment in one of an array of private health plan
choices beyond the original Medicare program or the plans now
available through managed care organizations; and (3) HCFA
complied with applicable requirements in promulgating the rule
with the exception of the 60-day delay in the effective date
required by the Small Business Regulatory Enforcement Fairness
Act of 1996.
HCFA: Medicare Program--Limited additional opportunity to request
certain hospital wage data revisions for FY 1999 (GAO/OGC-99-
20, 12/08/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
providing hospitals with a limited additional opportunity to
request certain hospital wage data revisions for fiscal year
(FY) 1999. GAO noted that: (1) the final rule would provide
hospitals with a limited additional opportunity to request
certain revisions to their wage data used to calculate the FY
1999 hospital wage index; and (2) HCFA complied with applicable
requirements in promulgating the rule.
HCFA: Medicare Program--Medicare coverage of and payment for bone mass
measurements (GAO/OGC-98-59, 07/09/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
Medicare coverage and payment for bone mass measurements. GAO
noted that: (1) the final rule with comment period would
provide for uniform coverage of, and payment for, bone mass
measurements for certain Medicare beneficiaries for services
finished on or after July 1, 1998; (2) the rule would implement
section 4106(a) of the Balanced Budget Act of 1997; and (3)
HCFA complied with applicable requirements in promulgating the
rule.
HCFA: Medicare Program--Prospective payment system and consolidated
billing for skilled nursing facilities (GAO/OGC-98-50, 05/27/
98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
Medicare's prospective payment system and consolidated billing
for skilled nursing facilities. GAO noted that: (1) the rule
would implement provisions of the Balanced Budget Act of 1997
related to Medicare payment for skilled nursing facility
services; (2) these provisions would include the implementation
of a Medicare prospective payment system for skilled nursing
facilities, consolidated billing, and a number of related
changes; (3) the retrospective payment system described in the
rule replaces the retrospective reasonable cost-based system
currently utilized by Medicare for payment of skilled nursing
facility services under Part A of the program; and (4) HCFA
complied with applicable requirements in promulgating the rule.
HCFA: Medicare Program--Revisions to payment policies and adjustments
to the relative value units under the physician fee schedule
for calendar year 1999 (GAO/OGC-99-15, 11/17/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on
payment policies and adjustments to the relative value units
under the physician fee schedule for calendar year 1999. GAO
noted that: (1) the rule would make several policy changes
affecting Medicare Part B payments; (2) the changes that relate
to physicians' services include: (a) resource-based practice
expense relative value units; (b) medical direction rules for
anesthesia services; and (c) payment for abnormal Pap smears;
(3) the rule would also revise HCFA's payment policy for
nonphysician practitioners, for outpatient rehabilitation
services, and for some drugs and biologicals; (4) it further
allows physicians, under certain circumstances, to opt out of
Medicare and to provide covered services through private
contractors and permits payment for professional consultations
via interactive telecommunications systems; and (5) HCFA
complied with applicable requirements in promulgating the rule.
HCFA: Medicare Program--Schedule of limits on home health agency costs
per visit for cost reporting periods beginning on or after
October 1, 1997 (GAO/OGC-98-25, 01/27/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on the
Medicare Program's schedule of limits on home health agency
(HHA) costs per visit for cost reporting periods beginning on
or after October 1, 1997. GAO noted that: (1) the notice sets
forth a revised schedule of limits on HHA costs that may be
paid under the Medicare Program for cost reporting periods
beginning on or after October 1, 1997; (2) in addition, the
notice provides, in accordance with the Balanced Budget Act of
1997, that: (a) there be no changes in the home health per
visit limits for cost reporting periods beginning on or after
July 1, 1997, and before October 1, 1997; (b) the establishment
of the cost per visit limitations for cost reporting periods
beginning on or after October 1, 1997, be based on 105 percent
of the median of the labor-related and nonlabor per visit costs
for freestanding HHAs; (c) there be no updates in the home
health costs limits for cost reporting periods beginning on or
after July 1, 1994, and before July 1, 1996; and (d) the wage
index value that is applied to the labor portion of the per
visit limitations be based on the geographical area in which
the home health service is located; and (3) HCFA complied with
applicable requirements in promulgating the rule.
HCFA: Medicare Program--Schedule of per-beneficiary limitations on home
health agency costs for cost reporting periods (GAO/OGC-98-44,
04/24/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Adminstration's (HCFA) new rule on the
schedule of per-beneficiary limitations on home health agency
costs for cost reporting periods. GAO noted that: (1) the new
rule would set forth a new schedule of limitations on home
health agency costs under the Medicare program; and (2) HCFA
complied with the applicable requirements in promulgating the
rule.
HCFA: Medicare Program--Scope of Medicare benefits and application of
the outpatient mental health treatment limitation to clinical
psychologist and clinical social worker services (GAO/OGC-98-
47, 05/08/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) final rule on the
scope of Medicare benefits and application of the outpatient
mental health treatment limitation to clinical psychologist and
clinical social worker services. GAO noted that: (1) the final
rule would conform the requirements for Medicare coverage of
services furnished by a clinical psychologist or as an incident
to the services of a clinical psychologist and for services
furnished by a clinical social worker with section 6113 of the
Omnibus Budget Reconciliation Act of 1989, section 4157 of the
Omnibus Budget Reconciliation Act of 1990, and section 147(b)
of the Social Security Act Amendments of 1994 (SSA '94); (2)
the rule would also address the outpatient mental health
treatment limitation as it applies to clinical psychologist and
clinical social worker services; (3) the final rule would also
conform the Medicare program to section 104 of the SSA '94,
which provides that a Medicare patient in a Medicare-
participating hospital who is receiving qualified psychologist
services may be under the care of a clinical psychologist with
respect to those services, to the extent permitted by state
law; and (4) HCFA complied with applicable requirements in
promulgating the rule.
HCFA: Monthly actuarial rates and monthly supplementary medical
insurance premium rate beginning January 1, 1999 (GAO/OGC-99-
10, 11/05/98)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on the
Medicare Program monthly actuarial rates and monthly
supplementary medical insurance premium rates. GAO noted that:
(1) the rule would announce the monthly actuarial rates for
aged (age 65 or over) and disabled (under age 65) enrollees in
the Medicare Supplementary Medical Insurance (SMI) program; (2)
it would also announce the monthly SMI premium rate to be paid
by all enrollees during 1999; (3) the monthly actuarial rates
for 1999 are $92.30 for aged enrollees and $103.00 for disabled
enrollees; (4) the monthly SMI premium rate is $45.50; and (5)
HCFA complied with the applicable requirements in promulgating
the rule.
Health Care Financing Administration: Medicare Program--Changes to the
hospital inpatient prospective payment systems and fiscal year
1998 rates (GAO/OGC-97-62, 09/17/97)
Pursuant to a legislative requirement, GAO reviewed the
Health Care Financing Administration's (HCFA) new rule on the
changes to Medicare hospital inpatient prospective payment
systems. GAO noted that: (1) the rule would revise the Medicare
hospital inpatient prospective payment systems for operating
costs and capital-related costs to implement necessary changes
resulting from the Balanced Budget Act of 1997, P.L. 105-33,
and changes arising from HCFA's continuing experience with the
system; (2) because of the recent enactment of the Balanced
Budget Act of 1997 on August 5, 1997, the changes mandated by
the act were not included in the notice of proposed rulemaking
and, therefore, were not available for public comment; (3) HCFA
has issued this final rule with a comment period on those
changes so the public may submit comments until October 28,
1997; and (4) HCFA complied with applicable requirements in
promulgating the rule.
High-risk program: Information on selected high-risk areas (GAO/HR-97-
30, 05/16/97)
This report contains additional information on 12 areas
included in GAO's list of government programs at high risk for
waste, fraud, abuse, and mismanagement: defense inventory
management, Medicare, supplemental security income, information
security, contract management at the Department of Energy,
student financial aid, air traffic control modernization, NASA
contract management, Customs Service financial management, farm
loan programs, National Weather Service modernization, and
asset forfeiture programs. It includes descriptions of key open
GAO recommendations relevant to each area, the implementation
status of those recommendations, and remaining challenges to
addressing these high-risk problems. Where possible, GAO has
identified the federal dollars involved with each program and
discusses federal dollars at risk from abusive or wasteful
practices.
High-risk series: Medicare (GAO/HR-97-10, 02/97)
In 1990, GAO began a special effort to identify federal
programs at high risk for waste, fraud, abuse, and
mismanagement. GAO issued a series of reports in December 1992
on the fundamental causes of the problems in the high-risk
areas; it followed up on the status of these areas in February
1995. This, GAO's third series of high-risk reports, revisits
these troubled government programs and designates five
additional areas as high-risk (defense infrastructure,
information security, the year 2000 problem, supplemental
security income, and the 2000 decennial census), bringing to 25
the number of high-risk programs on GAO's list. The high-risk
series includes an overview, a quick reference guide, and 12
individual reports. The high-risk series may be ordered as a
full set, a two-volume package including the overview and the
quick reference guide, or as 12 separate reports describing in
detail these vulnerable government programs. GAO summarized the
high-risk series in testimony before Congress (GAO/T-HR-97-22).
Information on the challenges that the federal government faces
in safeguarding Medicare is included in this high-risk report.
High-risk series: An overview (GAO/HR-97-1, 02/97)
In 1990, GAO began a special effort to identify federal
programs at high risk for waste, fraud, abuse, and
mismanagement. GAO issued a series of reports in December 1992
on the fundamental causes of the problems in the high-risk
areas; it followed up on the status of these areas in February
1995. This, GAO's third series of high-risk reports, revisits
these troubled government programs and designates five
additional areas as high-risk (defense infrastructure,
information security, the year 2000 problem, supplemental
security income, and the 2000 decennial census), bringing to 25
the number of high-risk programs on GAO's list. The high-risk
series includes an overview, a quick reference guide, and 12
individual reports. The high-risk series may be ordered as a
full set, a two-volume package including the overview and the
quick reference guide, or as 12 separate reports describing in
detail these vulnerable government programs. GAO summarized the
high-risk series in testimony before Congress (GAO/T-HR-97-22,
2/13/97). A separate high-risk report on Medicare issues (GAO/
HR-97-10) provides expanded information from the Medicare
summary included in this overview report.
Long-term care: Consumer protection and quality-of-care issues in
assisted living (GAO/HEHS-97-93, 05/15/97)
Several federal agencies have jurisdiction over consumer
protection and quality of care in assisted living facilities.
However, states have the primary responsibility for developing
standards and monitoring care. State approaches to oversight
vary: some states regulate these facilities under standards
developed for the board and care industry, others have
developed standards and licensing requirements specifically for
assisted living facilities, and some are in the process of
developing them. But little is known about the effectiveness of
these state approaches or about the extent of problems that
assisted living residents may be experiencing. Moreover,
concerns have been raised that the rapid growth in the assisted
living industry may be outpacing many states' ability to
monitor and regulate care. According to some experts, consumers
can find themselves in a facility unable to meet their needs.
To determine whether an assisted living facility is appropriate
for them, prospective residents rely on information supplied by
the facility, including contracts that set forth residents'
rights and provider responsibilities. However, one recent study
found that contracts varied in detail and, in some cases, were
vague and confusing. Overall, little is known about the
accuracy and adequacy of information furnished to individuals
and their families who are considering assisted living. GAO
believes that further research may be needed on these consumer
protection and quality-of-care issues.
Medicaid: Divestiture of assets to qualify for long-term care services
(GAO/HEHS-97-185R, 07/28/97)
Pursuant to a congressional request, GAO reviewed the
prevalence of asset transfers to qualify for Medicaid benefits.
GAO also responded to specific questions regarding the new
criminal provision of the Health Insurance Portability and
Accountability Act.
GAO noted that: (1) it is difficult to determine from
available studies the prevalence of divestitures that are made
with the purpose of becoming eligible for Medicaid; (2) several
limited-scope studies, however, have shown that some
individuals do shelter their assets--through transfers,
conversions, and other divestitures--despite legislative
efforts to discourage this type of activity; (3) for example,
studies based on case file reviews in two states showed that
from 13 to 22 percent of people who applied for nursing home
and other long-term care benefits through Medicaid have
transferred their assets; (4) however, the studies also found
that divested assets often are not sufficient to pay for even 1
year of nursing home coverage--in some cases, the assets that
were transferred could not pay for a single month of such care;
and (5) the law's implications for individuals who transfer
assets with the purpose of becoming eligible for Medicaid--the
only type of divestiture that is subject to criminal penalty--
are not clear in several respects.
Medicaid fraud and abuse: Stronger action needed to remove excluded
providers from Federal health programs (GAO/HEHS-97-63, 03/31/
97)
The Office of Inspector General (OIG) at the Department of
Health and Human Services has excluded thousands of providers
from participating in federal health care programs because of
health care fraud, abuse, or quality-of-care problems.
Weaknesses in the exclusion process, however, allow many
unacceptable providers to remain on the rolls of federal health
programs. These shortcomings include a lack of controls at OIG
field offices to ensure that all state referrals are reviewed
and acted on promptly, inconsistencies among OIG field offices
as to the criteria for excluding providers, lack of oversight
to ensure that states make appropriate exclusion referrals to
the OIG, and problems that states experience in trying to
identify and remove from their programs providers that appear
on the OIG's exclusion list. These weaknesses place the health
and safety of beneficiaries at risk and compromise the
financial integrity of Medicaid, Medicare, and other federal
health programs. OIG officials attribute many of these problems
to repeated cutbacks in resources during the past several
years. Recent legislation, however, addresses this concern by
providing the OIG with extra funding, specifically for dealing
with health care fraud. Officials said that some of this
funding will be used to hire additional staff to process
exclusion referrals. The legislation also includes tools and
resources to facilitate the identification of unacceptable
providers. These tools include a system of unique billing
numbers for health care providers and an adverse action data
bank, which will record information on any action taken against
a health care provider.
Medicare: Application of the False Claims Act to hospital billing
practices (GAO/HEHS-98-195, 07/10/98)
The Justice Department is using the False Claims Act,
originally enacted during the Civil War to combat contract
fraud, to deal with cases in which hospitals improperly bill
Medicare. Justice's use of the False Claims Act includes two
major multistate initiatives involving hospitals: the 72-Hour
Window Project and the Lab Unbundling Project. The 72-Hour
Window Project investigates whether hospitals have separately
billed Medicare for outpatient services covered by the Medicare
inpatient payment, such as preadmission tests done within 72
hours of admission. Hospitals that do so are, in effect,
double-billing Medicare. The Lab Unbundling Project
investigates whether hospitals have billed Medicare separately
for each blood test done concurrently on automated equipment or
billed Medicare for medically unnecessary tests. Under the 72-
Hour Window Project, about 3,000 hospitals received demand
letters for recovery of overpayments, and about $58 million had
been recovered as of April 1998.
Medicare: Clarification of provisions regarding private contracts
between physicians and beneficiaries (GAO/HEHS-98-98R, 02/23/
98)
GAO reviewed information about section 4507 of the Balanced
Budget Act of 1997 (BBA) and issues regarding beneficiaries'
access to physicians and their options for private contracting.
GAO noted that: (1) available information indicates that
Medicare beneficiaries have ready access to physicians; (2)
overall, about 96 percent of physicians accept and treat
Medicare patients; (3) while 4 percent of beneficiaries report
difficulty obtaining physician care, the amount that Medicare
reimburses physicians does not appear to be the cause of this
difficulty; (4) Medicare beneficiaries continue to be able to
pay out of pocket whenever they do not want a claim submitted
on their behalf or when they want to obtain services Medicare
does not cover; (5) in addition, section 4507 of the BBA offers
beneficiaries a new option for obtaining services from
physicians willing to enter into private contracts; (6)
however, much of the information that GAO reviewed on this
topic contained inaccurate statements or omitted important
details; and (7) for example, several documents falsely claimed
that the private contracting provisions of the BBA limit,
rather than expand, beneficiaries' options for seeking care
from physicians.
Medicare: Comparison of Medicare and VA payment rates for home oxygen
(GAO/HEHS-97-120R, 05/15/97)
Pursuant to a congressional request, GAO compared the rates
paid for home oxygen by Medicare and the Department of Veterans
Affairs (VA). GAO noted that: (1) Medicare's fee schedule
allowances for home oxygen are significantly higher than the
rates by VA, which uses competitive contracting arrangements;
(2) Medicare's monthly rate, including allowances for portable
units, was about $320 for each home oxygen patient for the
first quarter of fiscal year (FY) 1996; (3) during that same
period, VA paid about $155 per month for each patient,
according to GAO's analysis of all oxygen supplies, services,
and portable units provided to a nationwide sample of 5,000 VA
patients; (4) GAO analyzed differences between the Medicare and
VA oxygen programs that could make servicing a Medicare patient
more costly than servicing a VA patient; (5) GAO's analysis
included consideration of the administrative burden associated
with filing Medicare claims; (6) on the basis of this analysis,
GAO concluded that adding a 30-percent adjustment to VA's
payment rates adequately reflects the higher costs suppliers
incur when servicing Medicare beneficiaries; (7) the VA payment
rate, after the 30-percent adjustment, was about $200 per
month, or $120 less than Medicare; and (8) if Medicare had paid
oxygen suppliers at the adjusted VA rates, the Medicare program
would have saved over $500 million in FY 1996.
Medicare: Concerns with physicians at teaching hospitals (PATH) audits
(GAO/HEHS-98-174, 07/23/98)
About 1,200 hospitals in the United States have graduate
medical education programs to train doctors in medical
specialties after they have completed medical school. In
December 1995, the University of Pennsylvania, without
admitting wrongdoing, entered into a voluntary settlement with
the Justice Department, agreeing to pay about $30 million in
disputed billings and damages for Medicare billings by teaching
physicians. This settlement resulted from an audit done by the
Department of Health and Human Services' Office of Inspector
General (OIG). Concerned that such problems might be
widespread, the OIG, in cooperation with the Justice
Department, launched a nationwide initiative--now commonly
known as Physicians at Teaching Hospitals (PATH) audits--to
review teaching physician compliance with Medicare billing
rules. As of April 1998, five additional PATH audits had been
resolved, resulting in settlements, in three of these cases,
totaling more than $37 million. The PATH initiative has
generated considerable controversy. The academic medical
community disagrees with the OIG about the billing and
documentation standards that were in effect during the periods
under review. The medical community also contends that the
Justice Department is coercing settlements from teaching
institutions through threats of federal lawsuits. This report
determines (1) whether the Department of Health and Human
Services' OIG has a legal basis for conducting PATH audits, (2)
whether the OIG has followed an acceptable approach and
methodology in conducting the audits, and (3) the significance
of the billing problems cited in selected audits.
Medicare: Coverage of pumps used to administer intravenous drugs (GAO/
HEHS-99-16R, 11/16/98)
Pursuant to a congressional request, GAO reviewed the
advantages and disadvantages of providing Medicare coverage for
disposable infusion pumps, focusing on: (1) the clinical
benefits and limitations of disposable infusion pumps; (2) the
factors that affect whether a durable or disposable infusion
pump is less expensive to use for home infusion; (3) some
Medicaid and private insurance plans' home infusion therapy
coverage policies; and (4) issues raised by Medicare's policy
that links coverage of intravenous (IV) drugs to the use of
durable infusion pumps.
GAO noted that: (1) views on benefits and limitations of
disposable infusion pumps vary across providers and by type of
IV drug; (2) for example, most clinicians and pharmacists GAO
interviewed said that disposable infusion pumps can be used to
administer IV antibiotics and IV antivirals; (3) they also
agreed that disposable pumps were not appropriate for IV pain
medications; (4) however, there was no clear consensus on the
use of disposable infusion pumps with other infusion drugs,
such as certain chemotherapy drugs; (5) factors affecting the
relative cost of disposable versus durable infusion pumps are
the type of IV drug being administered and the frequency and
duration of the patient's infusion therapy regimen; (6) private
health insurers GAO contacted pay suppliers a per diem rate for
home infusion therapy regardless of the type of pump used; (7)
the per diem rate allows suppliers to choose the type of pump
they believe will appropriately deliver the IV drugs at the
lowest cost; (8) the IV drugs used with infusion pumps are paid
for separately; (9) Medicare, on the other hand, generally does
not cover self-administered drugs; (10) however, the Health
Care Financing Administration's (HCFA) policy is to pay for IV
drugs that must be administered with a durable infusion pump;
(11) this raises several issues; (12) under current Medicare
policy, if disposable infusion pumps become appropriate for a
broader range of IV drugs, Medicare coverage of some IV drugs
could be eliminated; and (13) if legislation expands Medicare
coverage to include disposable infusion pumps, HCFA may need to
reconsider its policy for determining which IV drugs to cover.
Medicare: Data limitations impede measuring quality of care in Medicare
ESRD Program (GAO/HEHS-97-137R, 07/11/97)
GAO reviewed the quality of care provided to Medicare end-
stage renal disease (ESRD) patients, focusing on: (1) accepted
performance standards for measuring quality of care provided to
ESRD patients; and (2) the quality of care furnished to ESRD
patients between providers such as chain-affiliated and
unaffiliated dialysis facilities, and between health
maintenance organizations (HMO) and providers paid through the
standard Medicare ESRD program.
GAO noted that: (1) most experts GAO interviewed and
applica-
ble literature GAO reviewed agree that clinical indicators
measur-
ing dialysis effectiveness, anemia, and nutritional status--
urea re-
duction ratio, hematocrit levels, and serum albumin levels,
respec-
tively--are valid performance indicators for measuring the
quality
of care ESRD patients receive; (2) these indicators are
currently
used by the Health Care Financing Administration (HCFA) to
evaluate the care furnished to Medicare beneficiaries with
ESRD;
(3) almost all experts GAO interviewed and applicable
literature
GAO reviewed also agreed that these indicators were correlated
with morbidity and mortality, the ultimate outcome measures;
(4)
GAO was unable, however, to evaluate the differences between
the
quality of ESRD care furnished in chain-affiliated and
unaffiliated
dialysis facilities or the care provided by HMOs and providers
in
the standard Medicare ESRD program because of limitations with
data availability; (5) existing HCFA data about chain
affiliation of
dialysis facilities is unreliable; (6) when GAO matched ESRD
bene
ficiaries in HCFA's Core Indicators files with HCFA data on
ESRD
beneficiaries who belong to HMOs, GAO found too few
beneficiaries
belonging to HMOs in each annual sample to give GAO confidence
in the results; (7) even after GAO combined the three annual
files,
the sample size was too small to permit GAO to make reliable
in-
ferences about differences in quality of care between the HMO
and
non-HMO ESRD populations when comparing beneficiaries with
similar characteristics such as age, gender, race,
socioeconomic status, and health conditions; (8) if HCFA
maintained up-to-date information about the chain affiliations
of dialysis facilities and included a larger sample of HMO
enrollees in its Core Indicators Project, a comparison could be
made of different types of providers and delivery systems that
would give GAO confidence in the results; and (9) HCFA program
officials agreed and said they would consider collecting data
to perform these analyses.
Medicare: Effective implementation of new legislation is key to
reducing fraud and abuse (GAO/HEHS-98-59R, 12/03/97)
Pursuant to a congressional request, GAO reviewed Medicare
fraud and abuse in both fee-for-service and managed care
programs, focusing on: (1) the impact of inadequate payment
safeguard funding on efforts to combat abusive billing; (2)
ineffective oversight of fee-for-service payments and
operations and Medicare managed care plans; and (3) challenges
that lie ahead for the effective implementation of recent
legislation that addresses fraud and abuse.
GAO noted that: (1) Medicare's size, complexity, and rapid
growth make it an attractive target for fraud and abuse; (2)
efforts
by the Health Care Financing Administration (HCFA), the agency
responsible for administering the program, to improve the
program
safeguards have not been adequate to prevent substantial
losses, in
part because the resources available to avoid inappropriate
pay-
ments have been underutilized or not deployed as effectively as
possible; (3) because of budget constraints, reviews of claims
and
related medical documentation and site audits of providers'
records
have become inadequate to keep up with the dramatic increases
in
Medicare activity; (4) in addition, Medicare's information
systems
and claims monitoring processes have not been uniformly
effective
at spotting indicators of potential fraud, such as suspiciously
large
increases in reimbursements, improbable quantities of services
claimed, or duplicate bills submitted to different contractors
for the
same service or supply; (5) insufficient oversight has also
resulted
in little meaningful action taken against Medicare health
mainte-
nance organizations (HMO) found to be out of compliance with
fed-
eral law and regulations; (6) although HCFA has required these
HMOs to prepare corrective action plans, it has not employed
other
available remedies; (7) accumulated evidence of in-home sales
abuses coupled with high rates of rapid disenrollment for
certain
HMOs also indicates that some beneficiaries are confused or are
being misled during the enrollment process and are dissatisfied
once they become plan members; (8) in addition, consumer
informa-
tion that could help beneficiaries distinguish the good plans
from
the poor performers has not been made publicly available,
limiting
the ability of beneficiaries to make informed choices about
compet-
ing plans; (9) this in turn limits the use of competition to
drive out
poor quality; (10) recent legislation--the Health Insurance
Port-
ability and Accountability Act of 1996 and the Balanced Budget
Act
of 1997--refocuses attention on various aspects of Medicare
fraud
and abuse through new program safeguard funding, new civil and
criminal penalties, and new program authorities; and (11)
however,
while the implementation of these provisions offers the
potential to
reduce Medicare losses attributable to unwarranted payments,
HCFA's history of lengthy delays in implementing legislation
gives
rise to concern about whether the authorities granted will be
de-
ployed promptly and effectively.
Medicare: Fraud and abuse control pose a continuing challenge (GAO/
HEHS-98-215R, 07/15/98)
Pursuant to a congressional request, GAO reviewed fraud and
abuse in both Medicare's fee-for-service and managed care
programs, focusing on: (1) the impact of inadequate program
safeguard funding on efforts to combat improper Medicare
payments; (2) ineffective management and oversight of fee-for-
service payments and operations; and (3) ineffective oversight
of Medicare managed care plans.
GAO noted that: (1) although the majority of health care
providers participating in Medicare provide quality services
and bill the program properly, its size, complexity, and rapid
growth make it an attractive target for fraud and abuse; (2)
more specifically, the Health Care Financing Administration's
(HCFA) past program safeguard efforts have been hindered
because budgetary constraints have reduced resources for these
efforts as the number of claims has grown; (3) although the
Health Insurance Portability and Accountability Act of 1996
(HIPAA) provided HCFA an ensured and increasing funding source
for program safeguard efforts, shortcomings in HCFA's
management of these efforts have contributed to Medicare
losses; (4) for example, HCFA has been slow to employ the funds
Congress provided under HIPAA; (5) HCFA has agreed to set
contractor program safeguard budgets in a more timely manner in
the next fiscal year; (6) in addition, HCFA has not adequately
screened providers before admitting them to the Medicare
program but is beginning to take steps to tighten admission
standards for home health agencies, a well-known problem area;
(7) Medicare's managed care program is vulnerable to other
forms of fraud and abuse that could be reduced through
competition among health maintenance organizations (HMO); (8)
HCFA's oversight of the Medicare HMOs has often been
ineffective; and (9) furthermore, HCFA's efforts to comply with
the Balanced Budget Act of 1997 and provide information about
HMO performance to beneficiaries, so that they can make
informed choices when selecting an HMO, have been slower than
necessary.
Medicare: HCFA can improve methods for revising physician practice
expense payments (GAO/HEHS-98-79, 02/27/98)
Medicare physician fee schedule sets forth payments to
doctors for more than 7,000 services and procedures, ranging
from routine office visits to surgery. Medicare's physician fee
schedule payments, which totaled $43 billion in 1997, also
influence physicians' non-Medicare income because many other
insurers base their payments on Medicare's. The fee schedule
was instituted in 1992 to link payments to the resources
physicians use to provide a service, rather than to physicians'
charges for a service. In June 1997, the Health Care Financing
Administration (HCFA) published a notice of proposed rulemaking
in the Federal Register describing proposed revisions to the
fee schedule. HCFA estimated that the revision would generally
increase Medicare payments to physician specialties that
provide more office-based services. Some physician groups
argued that HCFA based its proposed revisions on invalid data
and that the reallocations of Medicare payments would be too
severe. This report evaluates HCFA's proposed practice expense
revisions and presents information on HCFA's ongoing efforts to
refine its data and methodologies. GAO discusses (1) HCFA's
approach to estimating the practice expenses directly
associated with each medical service or procedure, (2) two
methodologies HCFA used to adjust the direct expense estimates,
(3) practice expenses excluded or limited by HCFA, (4) HCFA's
method for assigning indirect practice expenses to each medical
service or procedure, and (5) the potential impact of the new
fee schedule allowances on beneficiary access to care.
Medicare: HCFA's use of anti-fraud-and-abuse funding and authorities
(GAO/HEHS-98-160, 06/01/98)
Medicare, because of its size and mission, is an attractive
target for exploitation. GAO included Medicare in its list of
government programs at high risk for waste, fraud, and abuse.
(See GAO/HR-97-10, Feb. 1997.) In addition, the Department of
Health and Human Services (HHS) Office of Inspector General
(OIG) recently estimated that in 1997, 11 percent, or $20
billion, of Medicare fee-for-service payments were
inappropriate. The Health Insurance Portability and
Accountability Act of 1996 provides important new resources and
tools to fight health care fraud, abuse, and inappropriate
payments. These new resources include increased funding for
anti-fraud-and-abuse activities for the HHS OIG, as well as for
the Justice Department and the FBI. The act also established
the Medicare Integrity Program, which ensures increasing
funding for Medicare program safeguard efforts and authorizes
the hiring of specialized anti-fraud contractors. This report
assesses the Health Care Financing Administration's (HCFA)
progress in implementing the Medicare Integrity Program. GAO
provides information on (1) what additional resources and
authorities Congress provided to HCFA through the program, (2)
how HCFA has made use of these resources and authorities to
better protect Medicare funds, and (3) how HCFA plans to use
these authorities and resources in the future.
Medicare: Health Care Fraud and Abuse Control Program financial report
for fiscal year 1997 (GAO/AIMD-98-157, 06/01/98)
The Health Care Fraud and Abuse Control (HCFAC) Program,
which is administered by the Department of Health and Human
Services' (HHS) Office of the Inspector General and the
Department of Justice, established a national framework to
coordinate federal, state, and local law enforcement efforts to
detect, prevent, and successfully prosecute health care fraud
and abuse. HHS and Justice are required to issue a joint annual
report to Congress on the (1) amounts appropriated to the
Federal Hospital Insurance Trust Fund and the source of such
amounts and (2) amounts appropriated from the trust fund for
the HCFAC Program and the justification for the expenditure of
such amounts. The first report, issued in January 1998, covered
fiscal year 1997 deposits to the trust fund and the allocation
of the HCFAC appropriation. GAO must submit a report that
identifies (1) the amounts deposited to the trust fund and the
sources of such amounts, (2) the amounts appropriated from the
trust fund for the HCFAC program and the justification for the
expenditure of such amounts, (3) the expenditures from the
trust fund for HCFAC activities not related to Medicare, and
(4) any savings to the trust fund, as well as any other
savings, resulting from expenditures from the trust fund for
the HCFAC program.
Medicare: Home health agencies with high visit rates skew averages
(GAO/HEHS-97-139R, 06/02/97)
Pursuant to a congressional request, GAO reviewed
Medicare's reimbursement of home health agencies (HHA),
focusing on whether: (1) there are reasons why proprietary HHAs
provide more visits than voluntary and governmental agencies;
(2) there is any justification for the extra visits; and (3)
the skewing effect of the high visit rates by proprietary
agencies could be removed when calculating the number of visits
for purposes of devising a prospective payment system (PPS) for
home health.
GAO noted that: (1) its work and the work of others has
consistently shown that proprietary agencies provide more
visits per beneficiary than agencies of other types; (2)
however, while an agency could provide more visits on average
than other agencies for legitimate reasons, none of the factors
GAO and others explored provided an explanation related to
patient need for the differences in utilization among agency
types; (3) in developing a PPS, one way to lessen the influence
on visit rates of HHAs that consistently furnish more visits is
to use the median number of visits, the point at which half of
patient cases (or episodes of care) have fewer visits and half
have more, rather than using the average number of visits to
determine payment rates for episodes of care; (4) using the
median could be combined with an ``outlier'' payment system for
exceptional cases that justifiably have high numbers of visits
so that HHAs are not financially disadvantaged by patients who
need extraordinary care; (5) GAO also has concerns about the
adequacy of the Health Care Financing Administration's (HCFA)
current data on home health visit rates and costs for setting
PPS rates; (6) GAO's concern stems from the low levels of
medical reviews and cost report audits conducted by Medicare's
intermediaries during the 1990s; and (7) thorough reviews and
audits should be performed on a projectable sample of HHAs and
the results used to adjust HCFA's data bases before PPS rates
are set.
Medicare: Home oxygen program warrants continued HCFA attention (GAO/
HEHS-98-17, 11/07/97)
In fiscal year 1996, nearly 480,000 Medicare beneficiaries
received supplemental oxygen at home at a cost of about $1.7
billion. GAO found that Medicare pays about 38 percent more for
home oxygen supplies than the competitive marketplace rates
paid by the Department of Veterans Affairs (VA). In some cases,
Medicare obtains even fewer oxygen benefits despite paying
higher prices. The Balanced Budget Act of 1997 includes
provisions that should bring Medicare's reimbursement rates
more in line with the competitive marketplace rates paid by VA.
The act also requires developing service standards for home
oxygen suppliers that serve Medicare patients, as well as
monitoring patient access to home oxygen equipment. However,
concerns have been raised that these rate reductions could
reduce Medicare beneficiaries' access to portable units, which
do not offer suppliers the attractive profit margins associated
with lower-cost oxygen concentrators.
Medicare: Impact of changing transportation policy for portable
equipment is uncertain (GAO/HEHS-98-82, 05/18/98)
The Health Care Financing Administration (HCFA) has reduced
payments to some providers who perform electrocardiogram (EKG)
and ultrasound examinations in nursing homes and in
beneficiaries' residences. In the past, Medicare had allowed
these providers of portable diagnostic tests to receive, in
addition to the fee for doing the test, a separate payment for
transporting the necessary equipment. Effective January 1,
1996, HCFA eliminated separate transportation payments for
ultrasound services. HCFA also eliminated separate payments for
EKG services effective January 1, 1997, but these payments were
temporarily restored by the Balanced Budget Act of 1997. Some
claim that eliminating separate transportation payments could
ultimately increase Medicare outlays and adversely affect
beneficiaries. They argue that providers will be less willing
to provide EKG and ultrasound services without a separate
transportation payment, forcing Medicare to pay for ambulances
to transport homebound patients or nursing home residents to
hospitals for these diagnostic tests. This report studies how
changes to HCFA's payment policies would affect Medicare
beneficiaries. GAO identifies and analyzes (1) the Medicare
recipients, places of service, and providers who might be
affected the most; (2) the numbers of services that would be
affected by the change in policy; and (3) the effect on
Medicare's program costs.
Medicare: Improper activities by Mid-Delta Home Health (GAO/OSI-98-5,
03/12/98)
Mid-Delta Home Health is one of the largest home health
care providers in Mississippi, employing more than 600 people
who deliver home health care through 16 offices throughout the
state. Medicare reimbursement to Mid-Delta for home health care
and rural health clinic services from 1993 through 1996 totaled
nearly $78 million. During this period, Medicare reimbursed
Mid-Delta for payroll costs that, in GAO's opinion, were
improperly claimed because they did not represent actual costs
to the provider. The company's owner regularly asked employees
to return to the company the cash value of unused leave and 20
percent or more of bonuses received. The owner also maintained
a list of ``special employees'' to whom she gave larger bonuses
if they agreed in advance to return a portion of them to the
company. Mid-Delta then billed Medicare for these costs. GAO
also questions other costs submitted by Mid-Delta Home Health
for Medicare reimbursement. For example, the owner's daughter
was paid a salary as an executive even though she was attending
school full-time. GAO also questions the reasonableness of the
daughter's $65,000 bonus in 1996. Medicare also reimbursed Mid-
Delta for the payroll costs of some employees whose jobs
involved marketing activities--a nonreimbursable expense under
Medicare rules. In addition, nurses working for Mid-Delta Home
Health have alleged that staff visited Medicare beneficiaries
whose eligibility or need for visits was doubtful. GAO's review
of 41 patient files found that 34 percent of the individuals'
eligibility for Medicare-reimbursed services was questionable.
GAO summarized this report in testimony before Congress; see:
Medicare: Improper Activities by Mid-Delta Home Health (GAO/T-
OSI-98-6, Mar. 19, 1998).
Medicare: Many HMOs experience high rates of beneficiary disenrollment
(GAO/HEHS-98-142, 04/30/98)
Included in the Balanced Budget Act of 1997 is a mandate
that the Health Care Financing Administration (HCFA) make
comparative information available to Medicare beneficiaries,
including data on health plan disenrollment rates, so that they
can make informed choices about health maintenance
organizations (HMO). The disenrollment data will be required by
the fall of 1999, but it is unclear whether HCFA must publish
disenrollment data for HMOs in business less than two years.
GAO evaluated the feasibility of computing voluntary
disenrollment rates for HMOs from readily available data, and
analyzed the extent to which these rates vary among plans.
Disenrollment rates varied substantially; in many markets, the
highest disenrollment rates exceeded the lowest by more than
fourfold. Although the data indicates that competing plans vary
widely in their ability to retain members, they do not reveal
why.
Medicare: Most beneficiaries with diabetes do not receive recommended
monitoring services (GAO/HEHS-97-48, 03/28/97)
At least 10 percent of Medicare beneficiaries are diagnosed
with diabetes. Although experts agree that close medical and
patient monitoring is important to slow or prevent
complications of the disease, Medicare beneficiaries are not
receiving recommended levels of physicals, eye exams, blood
tests, and other screening services. Several factors may
contribute to low use of monitoring services, including
doctors' lack of awareness of the latest recommendations and
patients' lack of motivation to maintain adequate self-
management care. Efforts by Medicare health maintenance
organizations (HMO) to improve diabetes care have been varied
but generally limited. The Health Care Financing Administration
(HCFA) also has begun to test preventive care initiatives for
diabetes and has targeted this area for special emphasis. But
like the efforts of Medicare HMOs, HCFA's initiatives are quite
recent, and the agency does not yet have results that would
allow it to evaluate their effectiveness. GAO summarized this
report in testimony before Congress; see: Medicare: Provision
of Key Preventive Diabetes Services Falls Short of Recommended
Levels (GAO/T-HEHS-97-113, Apr. 11, 1997).
Medicare: Need to hold home health agencies more accountable for
inappropriate billings (GAO/HEHS-97-108, 06/13/97)
Despite many studies documenting inflated billings for home
health care benefits, Medicare reviews of home health care
claims have decreased in recent years. GAO tested 80 high-
dollar claims that had been processed without review and found
that in 46 of the claims, 43 percent of the total charges--or
more than $135,000--were later denied after being reviewed by a
Medicare claims-processing contractor. The reasons for the
denials included failure to substantiate medical necessity,
noncoverage of services or supplies, and inadequate
documentation, including the absence of physician orders.
Private insurers use controls that, although not readily
adaptable to Medicare's coverage terms or billing rules, are
instructive regarding claims monitoring. For example, the
insurers employ professional staff, such as nurses, to
determine in advance the legitimacy of requests for home health
services. Reduced funding for payment safeguards in recent
years helps explain the marked absence of adequate claims
reviews by Medicare contractors. Ten years ago more than 60
percent of home health claims were reviewed. In 1996, Medicare
reviewed only two percent of all claims. GAO suggests a plan
that would identify habitual abusers of the system and make
them bear the financial burden of investigative reviews.
Medicare: Need to overhaul costly payment system for medical equipment
and supplies (GAO/HEHS-98-102, 05/12/98)
In 1996, Medicare part B (which generally covers non-
hospital-based care) paid over $4.6 billion for medical
equipment, supplies, prosthetics, and orthotics--in other
words, durable medical equipment (DME). Congress included
provisions in the Balanced Budget Act of 1997 authorizing the
Health Care Financing Administration (HCFA) to more quickly
adjust Medicare's fee schedule allowances by up to 15 percent
per year. This report reviews two problems that HCFA must
overcome to use its new authority effectively. First, HCFA must
better identify products billed to Medicare. The only product
identifiers on the claims are HCFA billing codes that cover
broad ranges of products, quality, and prices. For example, a
single billing code is used for more than 200 different
urological catheters, whose wholesale prices range from $1 to
$18 each. The claim allowance is set at $11 for all catheters
in this group; without better product identification, HCFA
cannot know what it is paying for. The second problem with
Medicare's DME payment system is that the fee schedule
allowances are often out of line with current market prices.
HCFA's new price-adjusting authority should help, but HCFA and
its contractors do not have sufficient current product and
price information for the thousands of DMEs covered. Another
issue is that the fee schedule applies to individuals and to
large institutional claimants, even though large institutions
buy at significant discounts.
Medicare: Problems affecting HCFA's ability to set appropriate
reimbursement rates for medical equipment and supplies (GAO/
HEHS-97-157R, 06/17/97)
Pursuant to a congressional request, GAO reviewed the
problems associated with setting appropriate Medicare
reimbursement rates for medical equipment and supplies.
GAO noted that: (1) the Health Care Financing
Administration (HCFA) does not know specifically what products
it is paying for when it pays Medicare claims for medical
equipment and supplies, according to GAO's work to date; (2)
HCFA does not require suppliers to identify specific products
on their Medicare claims; (3) instead, suppliers use HCFA
billing codes, some of which cover a broad range of products of
various types, qualities, and market prices; (4) because
Medicare pays suppliers the same amount for all the products
covered by a billing code, the reimbursement system gives
suppliers a financial incentive to provide Medicare patients
with the least costly products covered by a billing code; (5)
in addition, because Medicare claims do not identify the
specific product provided, HCFA lacks the information it needs
to ensure that each billing code is used for comparable
products; (6) to identify specific medical equipment and
supplies, the Department of Defense and some other major
purchasers are beginning to require suppliers to use a
universal product numbering system; (7) this system, which can
also be used for bar coding the products, enables purchasers
and insurers to identify specific products being used and track
reimbursements for each product and groups of similar products
as well as the market prices of specific products; (8) HCFA
officials, on the other hand, have not begun exploring the
possibility of using the universal product numbering system in
the Medicare program; (9) Medicare reimburses large suppliers
and individual beneficiaries the same amounts for medical
equipment and supplies, even though large suppliers negotiate
substantial discounts with manufacturers and wholesalers, while
individual beneficiaries pay retail prices; (10) large
suppliers provide some products, such as urological catheters
and drainage bags, to nursing homes and home health agencies,
which then provide them to individual Medicare beneficiaries;
(11) in turn, the large suppliers can bill Medicare directly
and get reimbursed at fee-schedule rates based on historical
charges and catalog prices; and (12) HCFA has not considered
establishing a separate fee schedule for products provided to
nursing home and home health patients that accounts for their
suppliers' substantially lower acquisition costs compared with
the cost of products beneficiaries purchase directly.
Medicare billing: Commercial system could save hundreds of millions
annually (GAO/AIMD-98-91, 04/15/98)
More than three years after GAO recommended that Medicare
acquire commercial software to detect inappropriate billings--
which could save hundreds of millions of dollars each year--the
Health Care Financing Administration (HCFA) has tested the
software and plans to install it. Incorrect codings, fraudulent
and otherwise, cost Medicare about $1.7 billion in improper
payments in 1997. This report analyzes HCFA's progress in
testing and acquiring a commercial system for identifying
inappropriate Medicare bills, the consequences of HCFA's
initial management decisions, and its current plans for
immediate implementation. GAO summarized this report in
testimony before Congress; see: Medicare Billing: Commercial
System Will Allow HCFA to Save Money (GAO/T-AIMD-98-166, May
19, 1998).
Medicare computer systems: Year 2000 challenges put benefits and
services in jeopardy (GAO/AIMD-98-284, 09/28/98)
The Health Care Financing Administration (HCFA) and its
contractors are severely behind schedule in repairing, testing,
and implementing the mission-critical computer systems
supporting Medicare. HCFA has recently begun to improve its
management of Year 2000 issues, including establishing a Year
2000 organization and hiring independent contractors to assist
in overseeing the work. However, because of the complexity and
magnitude of the problem and HCFA's late start, the repairs lag
far behind schedule. Less than one-third of Medicare's 98
mission-critical systems had been fully renovated as of June
30, 1998, and none had been validated or implemented, according
to HCFA. Compounding this difficult task is the absence of key
management practices HCFA needs to adequately direct and
monitor its Year 2000 project. HCFA also has not effectively
managed the identification and correction of its electronic
data exchanges. Because of the magnitude of the tasks ahead and
the limited time remaining, it is unlikely that all of the
Medicare systems will be compliant in time to guarantee
uninterrupted benefits and services into the year 2000.
Medicare dialysis patients: Widely varying lab test rates suggest need
for greater HCFA scrutiny (GAO/HEHS-97-202, 09/26/97)
Medicare is the leading payer for dialysis and other
medical treatments for end-stage renal disease. Medicare
enrollment by kidney patients more than doubled between 1984
and 1994, while expenditures more than trebled--to $8.4
billion. Medicare does not scrutinize the level of laboratory
tests for patients on dialysis, and GAO found that similar
patients received laboratory tests at widely different rates.
At one extreme, Medicare may be paying for excessive tests,
while at the other, patients may not be receiving the tests
needed to monitor their condition. Fee-for-service
reimbursement does not give physicians adequate incentives to
order tests judiciously, and neither Medicare nor its claims
processing contractors routinely analyze the kind of claims
data that GAO reviewed when it found anomalies. GAO recommends
that Medicare profile doctors ordering laboratory tests for
Medicare dialysis patients and notify contractors of unusual
test rates. In addition, Congress should consider holding
physicians liable when they order excessive tests.
Medicare fraud and abuse: Summary and analysis of reforms in the Health
Insurance Portability and Accountability Act of 1996 and the
Balanced Budget Act of 1997 (GAO/HEHS-98-18R, 10/09/97)
Pursuant to a congressional request, GAO: (1) summarized
the anti-fraud and abuse reforms enacted in the Health
Insurance Portability and Accountability Act (HIPAA) and
Balanced Budget Act (BBA); and (2) determined whether and how
the legislation responds to GAO recommendations and those of
the Department of Health and Human Services' (HHS) Inspector
General.
GAO noted that: (1) the provisions in HIPAA and BBA offer
the potential to improve program management significantly; (2)
together they address Medicare's enforcement tools, payment
safeguards, and pricing and payment method problems; (3) in
addressing several aspects of waste, fraud, and abuse, the acts
incorporate a substantial proportion of recommendations to the
Congress and matters for congressional consideration; and (4)
in many instances, the acts also address recommendations that
GAO and the HHS Inspector General have made directly to the
Department, by either emphasizing priorities or dispelling
ambiguities about authority.
Medicare HMO enrollment: Area differences affected by factors other
than payment rates (GAO/HEHS-97-37, 05/02/97)
Enrollment nationwide in the Medicare managed care program
has more than tripled during the past decade--from about 1
million enrollees in 1987 to 3.8 million in 1996--but
differences in enrollment by state and by market area are
striking. In such cities as Portland, Oregon, and Tucson,
Arizona, health maintenance organizations (HMO) have enrolled
more than 40 percent of the Medicare beneficiaries. By
contrast, HMO enrollment in most rural areas is negligible.
Although the linkage of payment rates to risk HMO enrollment
may be important in some areas, dramatic differences in
enrollment are often associated with other factors. The
presence of HMOs, population density, and the number of
Medicare beneficiaries, especially those familiar with managed
health care, all spur enrollment growth--and their absence
hinders it. In addition, the health care benefits provided by
employers in a market area can affect beneficiaries'
willingness to enroll in risk HMOs. The rapid growth in risk
HMO enrollment is likely to continue as employers encourage
retirees to join HMOs and as HMOs pursue various strategies for
expanding their Medicare business.
Medicare HMO institutional payments: Improved HCFA oversight, more
recent cost data could reduce overpayments (GAO/HEHS-98-153,
09/09/98)
A growing number of seniors--about 5 million out of 38
million Medicare beneficiaries--receive care through health
maintenance organizations (HMO) that participate in Medicare's
risk contract program. Unlike fee-for-service providers, which
are paid on a per-claim basis, these HMOs receive from Medicare
a monthly fixed sum per enrolled beneficiary--a capitation
rate--and assume the risk of providing beneficiary health care,
regardless of the actual costs involved. The estimated 2.6
million beneficiaries in nursing homes and other long-term care
facilities often incur greater-than-average Medicare-covered
expenses. Consequently, the ``institutional'' risk adjuster
generally raises capitation payments for Medicare HMO enrollees
in such facilities. However, some of the facilities GAO visited
that HMOs had classified as institutional residences provided
no medical care but rather offered recreational activities for
seniors capable of living independently. The Health Care
Financing Administration (HCFA) acted on this finding by
narrowing the definition of eligible institutions, effective
January 1, 1998. Even with more stringent criteria, however,
HCFA relies on the HMOs to determine which beneficiaries
qualify for institutional status. HCFA conducts only limited
reviews, about every two years, to confirm the accuracy of HMO
records. The task of ensuring accurate data may be further
complicated by HCFA's policy allowing HMOs three years to
retroactively change institutional status data in beneficiary
records. HCFA generally waits two years to verify that HMOs
have corrected inaccurate record-keeping systems, even when
serious errors have been identified. Moreover, HCFA continues
to use 20-year-old cost data to determine payment rates for
institutionalized enrollees. As a result, HCFA overcompensates
HMOs for their enrolled, institutionalized beneficiaries.
Although HCFA has revised its definition of eligible
institutions, concerns remain that HCFA's oversight of payments
for institutional status is inadequate.
Medicare HMOs: HCFA can promptly eliminate hundreds of millions in
excess payments (GAO/HEHS-97-16, 04/25/97)
Medicare's method for paying risk contract health
maintenance organizations (HMO)--Medicare's primary managed
care option--was designed to save the program five percent of
the costs for beneficiaries who enrolled in HMOs. Contrary to
expectations, however, these HMOs have not produced savings for
Medicare. Research sponsored by Medicare and others have found
that the program has actually spent more for HMO enrollees than
if they had stayed in fee-for-service plans. Researchers
attribute this outcome to ``favorable selection,'' or the
tendency for healthier persons to enroll in HMOs. To reduce
excess Medicare payments to HMOs by several hundred million
dollars a year, the current Medicare HMO rate-setting formula
should be modified to include cost data on HMO enrollees, who
tend to be healthier as a group than other Medicare
beneficiaries. The current formula relies on costs of fee-for-
service beneficiaries only.
Medicare HMOs: Potential effects of a limited enrollment period policy
(GAO/HEHS-97-50, 02/28/97)
Congress has recently considered making Medicare's policies
more consistent with those of other large health care
purchasing organizations by establishing a limited time each
year when Medicare beneficiaries could enroll in a particular
plan and by restricting disenrollment outside that period. To
assist Congress in considering the effects of such a policy
change, this report assesses how a limited enrollment period
would affect Medicare, private health plans, beneficiaries, and
employers who provide Medicare supplemental benefits to
retirees. GAO examines the potential effects of policy changes
on (1) the growth of Medicare's managed care program, (2)
employers' attempts to administer their respective benefits
seasons, (3) taxpayer savings measured against beneficiary
protections, and (4) the resources needed by the federal agency
that runs Medicare's day-to-day operations.
Medicare HMOs: Setting payment rates through competitive bidding (GAO/
HEHS-97-154R, 06/12/97)
GAO reviewed the Health Care Financing Administration's
(HCFA) proposed use of competitive bidding as an alternative
method for setting Medicare health maintenance organization
(HMO) payment rates, focusing on: (1) the potential advantages
of competitive bidding in the Medicare HMO program; (2) the
main features of HCFA's planned competitive bidding
demonstration in Denver; and (3) HMO's key objections to it.
GAO noted that: (1) Medicare's current system for setting
HMO payment rates, which is based on local fee-for-service
spending, generates excess payments to some health plans; (2)
these excess payments are substantial, perhaps $2 billion
annually, and are likely to grow as the managed care program
grows; (3) alternative payment mechanisms could reduce excess
HMO payments and help Medicare, and taxpayers, realize the
savings potential of managed care; (4) competitive bidding is
one such alternative mechanism that might be successfully
employed in certain markets; (5) to succeed, a competitive
bidding system must provide health plans an incentive to submit
bids that reflect no more than the plans' expected costs and a
reasonable profit; (6) allowing plans to choose to remain
outside of the competitive bidding process and collect the
adjusted average per capita cost-based rate, while other area
plans submit competitive bids, would unravel the fundamental
incentives of competitive bidding; (7) similarly, the plans
that bid, but bid high relative to their competitors must face
some consequence; (8) the mechanism proposed by HCFA for the
Denver demonstration, and recommended by the Physician Payment
Review Commission, is to require high bidders to charge
beneficiaries a premium, making it harder for high bidders to
gain market share; (9) this is a much weaker consequence than
excluding high bidders from the marketplace, as is done in the
Arizona Medicaid program; (10) however, HCFA's mechanism has
the advantage of preserving the widest possible choice of plans
for Medicare beneficiaries; (11) GAO recognizes that HCFA's
legislative authority does not explicitly address the type of
competitive bidding demonstration planned for Denver; and (12)
HCFA may already possess the necessary authority, however, in
the interest of facilitating demonstrations that test new
methods of paying HMOs, including competitive bidding, GAO
continues to believe, as it stated in its 1995 report, that the
Congress should consider enacting legislation to give HCFA
explicit authority to mandate HMO participation in
demonstration projects.
Medicare home health: Differences in service use by HMO and fee-for-
service providers (GAO/HEHS-98-8, 10/21/97)
Health maintenance organizations (HMO) manage Medicare-
provided home health care more actively than do fee-for-service
providers, emphasizing shorter-term rehabilitation goals.
Differences between HMO and fee-for-service providers are most
apparent in the use of home health aides. In the fee-for-
service programs, the use of home health aides to provide long-
term care for patients with chronic conditions is growing,
whereas the six HMOs that GAO visited do not provide such
services on a long-term basis. Although fee-for-service
providers have less effective controls for preventing
unnecessary services, the Medicare program lacks the data
needed to determine if the chronically ill are adequately
served by HMOs.
Medicare home health agencies: Certification process ineffective in
excluding problem agencies (GAO/HEHS-98-29, 12/16/97)
Becoming a Medicare-certified home health agency is
relatively easy--probably too easy, given the large number of
problem agencies cited in various studies in recent years. If
owners of home health agencies have not been previously barred
from Medicare, they can obtain certification without having any
health care experience. Although certified home health agencies
must be periodically recertified, serious deficiencies in the
process allow problems to go undetected. Once certified, home
health agencies have little reason to fear that they will
suffer serious consequences from failing to comply with
Medicare's conditions of participation and associated
standards. Few problem home health agencies are terminated from
the program; instead, they are given repeated opportunities to
correct their shortcomings, even if the same deficiencies occur
from one survey to the next. Moreover, the Health Care
Financing Administration has not implemented a range of
penalties to sanction problem home health agencies, even though
Congress gave it the authority to do so more than 10 years ago.
Medicare home health benefit: Impact of interim payment system and
agency closures on access to services (GAO/HEHS-98-238, 09/09/
98)
Until 1996, Medicare spending for home health care had been
rising dramatically, consuming about $1 in every $11 of
Medicare outlays in 1996, compared with $1 in every $40 in
1989. To control this rapid cost growth, the Health Care
Financing Administration was required to implement a
prospective payment system that sets fixed, predetermined
payments for home health services. Until that system is
developed, home health agencies will be under an interim
payment system that imposes limits on the cost-based payments
they receive. The limits provide incentives to control per-
visit costs and the number and mix of visits for each user.
Industry representatives claim that the system's new cost
limits have caused some home health agencies to close or some
beneficiaries, particularly those with high-cost needs, to have
difficulty obtaining care. This report (1) identifies the
potential impact of the interim payment system on home health
agencies; (2) determines the number, distribution, and effect
of recent home health agency closures; and (3) assesses whether
the interim payment system could be affecting beneficiaries'
access to services, particularly beneficiaries who are
expensive to serve.
Medicare home health care benefit (GAO/HEHS-97-70R, 02/11/97)
Pursuant to a congressional request, GAO reviewed: (1) the
potential effects of shifting the Medicare home health care
benefit from the part A trust fund to the part B trust fund;
and (2) Medicare and Congressional Budget Office (CBO)
projections of home health costs and utilization and made rough
estimates of the dollar effects of the proposal.
GAO noted that: (1) it found three potential effects from
shifting most home health costs from part A to part B; (2) as
expected, the depletion date for the part A trust fund would be
extended because the majority of home health payments would no
longer come from that fund; (3) CBO estimated last year that
the shift would add about 3 years to the 2001 depletion date it
then estimated; (4) the shift would result in the need for more
general revenues to fund part B in direct proportion to the
costs shifted from part A; (5) available information indicates
about $95 billion would be needed over the fiscal year 1998
through 2002 period, assuming no other changes to the home
health benefit are made; (6) the administration and others also
propose additional changes to the home health benefit designed
to hold down its cost growth, and to the extent that such
proposals are implemented, the amount shifted from part A to
part B would be reduced; (7) the shift, however, would not
affect the reported budget deficit amount because both funds
are included in the unified budget, and the increase in general
fund expenditures would be offset by an equal decrease in part
A trust fund expenditures; and (8) Medicare beneficiaries would
not be affected except that they would have less opportunity to
appeal home health denials to administrative law judges because
the dollar threshold for such appeals is $100 under part A but
$500 under part B.
Medicare managed care appeal process for denials of care: A comparison
with recommendations from the President's Quality Commission
(GAO/HEHS-98-155R, 05/08/98)
Pursuant to a congressional request, GAO reviewed
information on Medicare managed care appeals to help Congress
consider legislation on national appeal rights for private-
sector health care consumers, focusing on: (1) comparing the
President's Advisory Commission on Consumer Protection and
Quality in the Health Care Industry's recommended appeal
process with that required by the Medicare program; and (2)
describing the appeals reviewed by Medicare's external appeals
contractor, the Center for Health Dispute Resolution (CHDR).
GAO noted that: (1) the Quality Commission recommended an
appeals process that is very similar in structure to the
process used by the Medicare managed care program in that both
require that individuals receive timely notification of appeal
rights and appeal decisions and both require an expedient
process for certain kinds of cases for internal and external
appeals; (2) virtually all internal appeals that are not
completely favorable to the beneficiary are automatically
subject to Medicare's external review process, while the
Quality Commission restricts external review to appeals that
involve experimental issues, circumstances that jeopardize the
health or life of the patient, or services that exceed a
significant financial threshold that has not been specified;
(3) the effect of these differences on the number and types of
appeals seen in the Quality Commission's appeal process would
depend on how its recommendations are implemented; (4) while
appeals from fewer than three-tenths of one percent of Medicare
managed care enrollees actually reach the external review
process, GAO's review of CHDR appeals indicates that it
provides an important protection for beneficiaries at a modest
cost to the program; (5) the majority of CHDR's decisions
uphold a managed care plan's denial of a service; (6) in about
two-thirds of the overturned cases, CHDR found that the plans
had made an inappropriate clinical decision and that the care
involved in the appeal was medically necessary and met
Medicare's clinical coverage criteria; (7) because of
differences between Medicare enrollees and the commercially
insured, Medicare's experience with external appeals may not
apply to this population; (8) while Medicare enrollees can
disenroll in any given month and therefore may choose to
disenroll rather than appeal a dispute with their plan, many
commercially insured managed care enrollees may not have this
option; (9) the commercially insured population may also have
fewer appeals per capita; and (10) these differences make it
difficult to predict the volume or type of appeals that would
be seen in the external appeals process for the commercially
insured based on Medicare's experience.
Medicare managed care: Payment rates, local fee-for-service spending,
and other factors affect plans' benefit packages (GAO/HEHS-99-
9R, 10/09/98)
Pursuant to a congressional request, GAO provided
information on Medicare's health maintenance organizations
(HMO), focusing on: (1) the key differences between Medicare's
traditional fee-for-service (FFS) and managed care programs;
(2) how Medicare historically set the monthly capitation rates
paid to managed care plans and why these rates varied among
counties; (3) how the Balanced Budget Act of 1997 (BBA)
affected rates and the rate-setting process; (4) how the Health
Care Financing Administration (HCFA) approves managed care
plans' benefits and premiums; and (5) what requirements HCFA
places on plans to notify beneficiaries about impending benefit
and premium changes.
GAO noted that: (1) most Medicare beneficiaries can choose
to receive health care services through a traditional FFS
arrangement or a managed care organization; (2) there are
several key differences between the two health care systems;
(3) for beneficiaries, some of these differences involve trade-
offs; (4) for example, compared to Medicare FFS, managed care
plans typically cover more services and impose lower out-of-
pocket cost; (5) however, a beneficiary in FFS can obtain care
from any provider who receives Medicare payments, while a
beneficiary in a managed care plan is typically limited to
providers authorized by that plan; (6) another difference is
how medical care is paid for; (7) in FFS, Medicare makes a
separate payment for each covered service provided, while
managed care plans receive a fixed monthly capitated payment
for each beneficiary they enroll; (8) before 1998, payments to
managed care plans were tightly linked to per capita Medicare
FFS spending in each county to reflect the dramatic variation
in health care costs and use; (9) as a result, capitation rates
varied with the demographic characteristics of the beneficiary
and his or her county of residence; (10) for example, in 1997,
a managed care plan would receive $767 per month for serving a
beneficiary in Richmond County (Staten Island), New York,
compared to $221 for serving a similar beneficiary in Arthur
County, Nebraska; (11) moreover, plans in relatively high-
payment counties tend to offer a richer benefit package
compared to plans in low-payment counties; (12) BBA will likely
gradually reduce the geographic variation in managed care
payments and benefit packages; (13) at the same time, because
the legislation was designed to slow the growth of Medicare
spending, benefit packages offered by managed care plans may
become less generous; (14) managed care plans must contract
with HCFA before they can serve Medicare beneficiaries; (15)
contracts normally begin in January and run for one year; (16)
at a minimum, plans must provide all FFS-covered benefits; (17)
if HCFA determines a plan's projected Medicare profits will
exceed its normal profit level, the plan is required to enhance
its benefit package, set aside funds for future use, or both;
(18) although plans can increase benefits or reduce the fees
they charge at any time, they do so only with HCFA approval;
and (19) in addition, Medicare requires that all plans notify
members 30 days before a change takes place.
Medicare transaction system: Success depends upon correcting critical
managerial and technical weaknesses (GAO/AIMD-97-78, 05/16/97)
By the year 2000, Medicare, the nation's largest health
insurer, expects to process more than 1 billion claims and pay
$288 billion in benefits annually. To keep up, Medicare plans
to spend $1 billion to replace nine separate automated
processing systems with the Medicare Transaction System (MTS).
MTS is intended to improve service; cut operating costs;
improve contractor oversight; better protect against waste,
fraud, and abuse; and accommodate managed care and other
alternative payment methodologies. However, since GAO issued
its first analysis in 1992, project costs have soared from $151
million to $1 billion. GAO concludes that the benefits of MTS
will not be realized unless the Health Care Financing
Administration (HCFA) overcomes serious management and
technical weaknesses in three areas. First, HCFA needs to
greatly improve management of its interim Medicare processing
environment. Second, MTS should be better managed as an
investment. HCFA has not followed practices that are essential
if management is to make informed technology investment
decisions, including preparing a valid cost-benefit analysis
and considering viable alternatives. Third, HCFA has not
adequately applied sound systems development practices
necessary to reduce risk. GAO summarized this report in
testimony before Congress; see: Medicare Transaction System:
Serious Managerial and Technical Weaknesses Threaten
Modernization (GAO/T-AIMD-97-91, 5/16/97).
Medigap insurance: Compliance with federal standards has increased
(GAO/HEHS-98-66, 03/06/98)
Millions of Medicare beneficiaries depend on private
insurance to cover Medicare's deductibles and coinsurance. From
1988 through 1995, the Medigap insurance market grew from $7
billion to more than $12 billion, with most of the growth
occurring before 1993. During this eight-year period, loss
ratios--the percentage of premiums returned to policyholders as
benefits--averaged 81 percent and ranged from a low of 76
percent in 1993 to a high of 86 percent in 1995. Loss ratio
standards are currently set at 65 percent for policies sold to
individuals and 75 percent for policies covering groups. In
1994 and 1995, more than 90 percent of the policies in effect
for three years or more met these loss ratio standards.
Although applicable law provides for refunds if loss ratio
standards are not met, no refunds were required in 1994 and
only two were required in 1995 because most of these policies'
loss experience was based on too few policyholders to be
considered credible. A primary reason for requiring refunds was
to give insurers an incentive to meet loss ratio standards, and
it appears that the incentive is working.
Private health insurance: Declining employer coverage may affect access
for 55- to 64-year-olds (GAO/HEHS-98-133, 06/01/98)
Too young to qualify for Medicare, many near elderly (55-
to 64-year-olds) are considering retirement or gradually moving
out of the workforce. These events may be related to declining
health, job displacement, or simply the desire for more leisure
time. Because health insurance for most Americans is an
employment-related benefit, retirement may necessitate looking
for another source of affordable coverage. However, insurance
bought directly in the individual market or temporary
continuation coverage purchased through an employer are
typically expensive and may not always be available.
Affordability, moreover, may be exacerbated by both declining
health and the reduction in income associated with retirement.
For some near elderly, an alternative to retiring without
insurance is simply to continue working. This report assesses
the ability of Americans aged 55 to 64 to obtain health
benefits through the private market--either employer-based or
individually purchased. GAO discusses the near elderly's (1)
health, employment, income, and health insurance status; (2)
ability to obtain employer-based health insurance if they
retire before becoming eligible for Medicare; and (3) use of
and costs associated with buying coverage through the
individual market or employer-based continuation insurance. GAO
summarized this report in testimony before Congress; see:
Private Health Insurance: Employer Coverage Trends Signal
Possible Decline in Access for 55- to 64-Year-Olds (GAO/T-HEHS-
98-199, June 25, 1998).
Retiree health insurance: Erosion in employer-based health benefits for
early retirees (GAO/HEHS-97-150, 07/11/97)
Health insurance coverage for retirees paid by former
employers is steadily declining; some employers have stopped
offering such coverage and others have raised the premiums paid
by retirees. Reductions in employer-based private insurance
afflict both early retirees and those who rely on it to fill
gaps in Medicare and looms as a major issue for baby boomers
nearing retirement. This report reviews (1) private sector and
government surveys of changes in retiree access to and
participation in employer-based health coverage; (2) the health
benefit plan in effect at the Pabst Brewing Company during 1996
(Pabst notified about 750 retirees of its Milwaukee plant that
it planned to terminate their health benefits within a month);
(3) data from health insurance carriers on the cost of
alternative sources of coverage for early retirees in
Wisconsin, where Pabst is located, and other selected states;
(4) applicable federal and state laws and legal precedents; and
(5) earlier GAO work.
Rural primary care hospitals: Experience offers suggestions for
Medicare's expanded program (GAO/HEHS-98-60, 02/23/98)
To maintain health care services in rural communities,
Congress authorized limited-service hospitals, known as rural
primary care hospitals, to operate in seven states--California,
Colorado, Kansas, New York, North Carolina, South Dakota, and
West Virginia. In October 1997, Congress replaced rural primary
care hospitals with critical access hospitals, which were
authorized to operate nationally. Existing rural primary care
hospitals were eligible to participate in Medicare as critical
access hospitals. GAO found that rural primary care hospitals
were an important source of inpatient and outpatient care for
Medicare beneficiaries in rural areas. Medicare payments to
these hospitals for inpatient stays were, however, somewhat
higher than payments would have been to full-service rural
hospitals. A chief reason for this was that about 21 percent of
the inpatient cases had lengths of stays that exceeded the 72-
hour maximum in effect at the time, and eight percent would
have exceeded the 96-hour limit for critical access hospitals.
The Health Care Financing Administration (HCFA) has not
established a way to enforce the length-of-stay limit, and GAO
believes that one is needed to give critical access hospitals
an incentive to adhere to the limit. For critical access
hospitals and peer review organizations that are authorized to
grant waivers to the 96-hour limit, HCFA also needs to define
the conditions and the circumstances under which it would be
appropriate to waive the requirement. HCFA also has not
established a way to check compliance with the requirement that
a doctor certify that patients admitted to rural primary care
hospitals--now critical access hospitals--are expected to be
discharged within the maximum allowed length-of-stay limit.
Such a mechanism should underscore the importance of
certification and its intent to ensure that only the
appropriate kinds of patients are admitted.
Specialty care: Heart attack survivors treated by cardiologists more
likely to take recommended drugs (GAO/HEHS-99-6, 12/04/98)
Pursuant to a congressional request, GAO reviewed the
potential differences in treatment patterns for health
maintenance organizations (HMO) patients treated by specialists
and those treated by generalist physicians, focusing on: (1)
the proportion of Medicare heart attack survivors enrolled in
HMOs who take cholesterol-lowering drugs, beta-blockers, and
aspirin; and (2) whether Medicare heart attack survivors in
HMOs regularly treated by a cardiologist are more likely to
take cholesterol-lowering drugs, beta-blockers, and aspirin
than those who do not have regular cardiology appointments.
GAO noted that: (1) the ongoing use of cholesterol-lowering
drugs
and beta-blockers reported by Medicare heart attack survivors
en-
rolled in HMOs generally parallels the patterns for heart
attack
survivors in the U.S. health care system overall; (2) as others
have
found for the general patient population, GAO found a much
small-
er proportion of respondents reported taking cholesterol-
lowering
drugs (36 percent) or beta-blockers (40 percent) than would be
ex-
pected if everyone who would benefit from using these drugs
were
taking them; (3) Medicare HMO heart attack survivors with regu-
lar cardiology care--40 percent of GAO's survey respondents--
were more likely to take the recommended drugs than those
without regular appointments with a cardiologist; (4) enrollees
who saw cardiologists regularly for their cardiac care were
approximately 50 percent more likely to take cholesterol-
lowering drugs and beta-blockers--a finding consistent with
other comparisons of care provided by cardiologists and
generalists; (5) although factors such as age, education, self-
reported health status, and the presence of other illnesses
also influenced who took cholesterol-lowering drugs and beta-
blockers, they did not account for the higher use levels
observed among patients who had routine cardiology
appointments; (6) still, even patients of cardiologists often
did not take one or both of these drugs; (7) by contrast, the
overall use of aspirin was much higher--71 percent--and while
regular patients of cardiologists were still more likely to
take aspirin, the difference between them and other patients
was smaller and not statistically significant (75 percent
versus 68 percent); (8) on the whole, GAO's results for heart
attack survivors treated by cardiologists and generalist
physicians in Medicare HMOs are consistent with those of other
studies of physician specialty differences in the United
States; and (9) GAO's finding that patients under the regular
care of cardiologists are more likely to take recommended
medications reinforces the findings of the small number of
other studies of physician specialty differences that are
specifically concerned with HMO members and extends those
findings to an older population and to a different medical
condition.
Housing Issues
Assisted housing: occupancy restrictions on persons with disabilities
(GAO/RCED-99-9, 11/12/98)
The Housing and Community Development Act of 1992 allows
the owners of federally assisted housing projects to establish
occupancy policies that favor elderly tenants over nonelderly
tenants with disabilities. These owners are not required to
obtain approval from the Department of Housing and Urban
Development (HUD) before imposing such a restriction, nor to
notify HUD once a restriction occurs. As a result, little
information is available on the law's effect. However, concerns
have been raised that the law may make it harder for nonelderly
persons with disabilities to obtain affordable housing. Since
fiscal year 1997, Congress has appropriated funds for new
Section 8 rental housing certificates and vouchers for the
exclusive use of nonelderly persons with disabilities. This
report discusses (1) the extent to which the occupancy policies
of eligible projects restrict occupancy to the elderly and the
portion of units in eligible projects actually occupied by
nonelderly persons with disabilities and (2) the use of Section
8 certificates and vouchers to help nonelderly persons with
disabilities affected by the act.
Housing for the elderly: Information on HUD's section 202 and HOME
Investment Partnerships programs (GAO/RCED-98-11, 11/14/97)
The Department of Housing and Urban Development (HUD)
reported in 1996 that at least 1.4 million elderly persons
needed, but were not receiving housing assistance. Most of
these individuals had extremely low incomes, were paying more
than half of their income for rent, or lived in homes that were
physically inadequate. Two HUD programs--Section 202 Supportive
Housing for the Elderly and HOME Investment Partnerships--are
receiving funds each year to make new multifamily rental
housing available to the elderly. This report compares the
Section 202 program and the HOME program in the following three
areas: (1) the amount and the types of new multifamily rental
housing that each program has provided for the elderly; (2) the
sources of each program's funding for multifamily rental
projects; and (3) the availability of support services for
elderly residents. GAO visited projects in four states with
relatively high concentrations of low-income elderly residents
and numbers of Section 202 and HOME-funded projects--
California, Florida, North Carolina, and Ohio.
Public housing: Impact of designated public housing on persons with
disabilities (GAO/RCED-98-160, 06/09/98)
The provisions of the Housing and Community Development Act
of 1992 allowing public housing authorities to designate units
as elderly-only have had little impact on the availability of
public housing for disabled people. Seventy-three of the 3,200
public housing authorities had allocation plans approved by the
Department of Housing and Urban Development as of November 1,
1997, allowing them to designate 24,902 of their units as
elderly--only about 36 percent of their total housing stock for
the elderly and the disabled. Nearly all of these designated
units had been available previously to tenants who were elderly
or who had disabilities but were younger than 62, although few
were actually occupied by younger people with disabilities.
GAO's survey found that, as of November 1, 1997, the number of
elderly residents and disabled residents in these and other
housing units for which they were eligible had not changed
substantially since the housing authorities began submitting
allocation plans. Designating public housing units as elderly-
only may have more impact in the future, depending on how many
more housing authorities opt to do so and on what the housing
alternatives are for younger people with disabilities.
Income Security Issues
Employee benefits: Status of the UMWA Combined Benefit Fund (GAO/HEHS-
99-7R, 10/02/98)
Pursuant to a congressional request, GAO provided
information on the current state of the United Mine Workers of
America (UMWA) Combined Fund, focusing on: (1) the current
population of beneficiaries; (2) the medical benefits provided
to all classes of beneficiaries; (3) the extent to which the
benefits provided by the fund represent the beneficiaries'
primary medical coverage; (4) the major components of
expenditures by the Combined Fund; and (5) how long the fund
will remain solvent and able to cover beneficiaries.
GAO noted that: (1) the Combined Fund provides benefits to
71,337 individuals; (2) because Combined Fund benefits are only
available to individuals who were eligible to receive and
receiving benefits on July 20, 1992, the number of
beneficiaries declines over time; (3) other beneficiaries
include parents of mine workers, unmarried children of mine
workers under the age of 22, unmarried dependent grandchildren
under the age of 22, dependent children of any age who are
mentally impaired or disabled before the age of 22, and
surviving dependent children of deceased miners; (4) the
Combined Fund provides beneficiaries with an array of medical
benefits; (5) of the 71,337 individuals receiving benefits
through the Combined Fund, 65,146 are also covered by Medicare;
(6) Combined Fund officials could not provide GAO with the
exact number of beneficiaries covered by private insurance; (7)
however, they estimate that the number of beneficiaries is
negligible; (8) according to the June 1998 actuarial
projections, the major expenses of the Combined Fund are
medical benefits, death benefits, and administrative costs; (9)
in 1997, medical expenses constituted approximately 90 percent
of expenditures, with death benefits and administrative costs
amounting to about 3 percent and 7 percent, respectively; (10)
these expenses vary with both the size of the beneficiary pool
and trends in the costs of medical treatment; (11) since a
finite number of beneficiaries is covered by the Combined Fund,
the beneficiary pool will likely decline as recipients die,
driving down the number of individuals claiming benefits; (12)
conversely, medical costs are expected to rise, thereby
increasing per-capita medical expenses; (13) thus, as the
beneficiary pool decreases over time, medical expenses may
become a larger component of Combined Fund expenses in the
future; (14) if the Combined Fund becomes insolvent, the cost
of borrowing to pay benefits may add to expenses; (15) it is
difficult to accurately project the future solvency of the
Combined Fund, primarily because of uncertainties created by
the recent Supreme Court decision; (16) the June 1998 Court
ruling will likely reduce the number of firms that are required
to pay into the fund; and (17) regardless of the ultimate
effect of the ruling on fund revenues, actuarial estimates made
just before the decision show that the fund will be insolvent
by 2000 and that its deficit will grow to between $107 million
and $619 million by 2007, depending on the variation in
Medicare-related expenses.
Federal pensions: Judicial survivors' annuities system costs and
benefit levels (GAO/GGD-97-87, 06/27/97)
This report reviews certain aspects of the Judicial
Survivors' Annuities System, which provides annuities to the
surviving spouses and dependent children of deceased federal
judges and other judicial officials. Legislation passed in 1992
enhanced the benefits available under the system and reduced
the amounts that participating judges and other judicial
officials were required to contribute toward the plan's costs.
GAO is required to review the system's costs every three years
and determine whether participants' contributions covered one-
half of the costs. If the contributions are less than half of
these costs, GAO must determine what adjustments would be
needed to achieve the 50-percent figure. GAO is also required
to compare the Judicial Survivor Annuities System to the
survivor benefit plans for other federal workers.
Federal pensions: Relationship between pensions and final salaries for
retired former members of Congress (GAO/GGD-97-178R, 09/26/97)
Pursuant to a congressional request, GAO responded to a
series of questions concerning the relationship between
pensions and the final salaries of retired members of Congress,
focusing on: (1) determining the number of former members, if
any, whose pensions have come to exceed the final salaries that
they earned while working; (2) explaining why these members'
pensions came to exceed their final salaries; and (3)
determining the difference, if any, in these members' pension
amounts had the current cost-of-living adjustment (COLA) policy
been in effect without interruption since 1962, and also
determining any difference in the number of retired members
whose pensions would have exceeded their final salaries.
GAO noted that: (1) seventy-six, or about 19 percent, of
the 404 former members of Congress who were living and on the
federal retirement rolls as of October 1, 1995, were receiving
pensions that had come to exceed their final salaries when
these salaries were not adjusted for inflation; (2) however,
when final salaries were adjusted for inflation--i.e.,
expressed in constant dollars--only one former member was
receiving a pension that was larger than the final salary; (3)
using constant dollars provides a more meaningful way to
compare monetary values across time; (4) three factors played
an important role in explaining why members' pensions came to
exceed their unadjusted final salaries: (a) the number and size
of COLAs that former members received; (b) a former member's
years of federal service; and (c) whether a member had chosen a
survivor annuity benefit; (5) GAO's analysis of the effects
that COLA policies have had on the pensions of retired former
members of Congress and GAO's prior analysis of general
employees suggest that these polices have played an important
role in maintaining the purchasing power of retiree pensions
since automatic COLAs began; (6) the effects COLA policies
actually have had on retiree pension amounts cannot be
summarized easily because of the numerous changes that have
been made in COLA policies over the past 35 years; (7) COLA
policy changes have affected individual retirees differently,
depending on when their retirements began; (8) if current COLA
policy--that is, the COLA policy enacted in 1984, which
established the formula and schedule used today by the Office
of Personnel Management--had been in effect without
interruption since 1962, the pensions of some former members
would have been larger than the pensions that they actually
received, and the pensions of other former members would have
been smaller; and (9) the changes that would have occurred in
the former members' pension amounts under current policy were
enough to cause about a two percentage point (2.0) increase in
the number of former members whose pensions would have come to
exceed their unadjusted final salaries.
Federal pensions: Relationship between retiree pensions and final
salaries (GAO/GGD-97-156, 08/11/97)
About 27 percent of the 1.7 million retirees who were
receiving federal pensions as of October 1995 were receiving
pensions that had come to exceed their final salaries. However,
when their salaries were adjusted for inflation and expressed
in constant dollars, no retiree was receiving a pension that
was larger than his or her final salary. Three factors helped
explain why the pensions exceeded the retirees' unadjusted
final salaries: the number and the size of cost-of-living
adjustments (COLA) that retirees had received, the number of
years that they had been retired, and the number of years that
they had worked for the federal government. COLAs have played
an important role in maintaining the purchasing power of
retiree pensions. However, the COLA policies of the late 1960s
and 1970s overcompensated for inflation and will continue to
affect the pensions of those retirees who receive them as long
as they are alive. If the current COLA policy--that is, the
policy that was enacted in 1984--had been in effect without
interruption since automatic COLAs began in 1962, the pensions
of some retirees would have been different. GAO's analysis
suggests that a majority of those who retired before 1970 would
have received smaller pensions had the current COLA policy been
continuously in effect during their retirement, and about 90
percent of those who retired after 1970 would have received
larger pensions.
Federal retirement: Comparison of high-3, 4, and 5 salary factors
(GAO)/GGD-97-84R, 04/25/97)
Pursuant to a congressional request, GAO provided
information on the effects of changing the high-3 salary factor
in the formulas that are currently used to compute Civil
Service Retirement System (CSRS) and Federal Employees
Retirement System (FERS) pension benefits.
GAO noted that: (1) employees retiring under either CSRS or
FERS would need to work longer to receive annuities under a
high 4 or high 5 that would be comparable to the annuities they
would have received under a high 3, before any change in the
annuity computation factor; (2) the amount of extra time,
however, is measured in months rather than years; (3) reasons
why include the fact that an employee's pay normally increases
when he or she works longer, thus, so does the employee's
annuity at retirement; (4) employees who work into the next
calendar year in order to earn comparable annuities can receive
general schedule pay increases early in the calendar year as
well as step increases; and (5) in addition, the extra time
employees work is added to their years of creditable service,
which also increases the value of their annuities at
retirement.
Federal retirement: Federal and private sector retirement program
benefits vary (GAO)/GGD-97-40, 04/07/97)
GAO found no clearcut answer to the question of whether the
two largest federal civilian retirement programs offer greater
or smaller benefits than those offered by private sector
retirement programs. The benefits available from the Federal
Employees Retirement System (FERS) and the Civil Service
Retirement System (CSRS) can be smaller, similar, or greater
than those offered by the private sector, depending on a range
of variables. Chief among these factors are the (1) ages at
which employees retire and at which programs provide unreduced
benefits, (2) extent to which employees and employers
contribute to the defined contribution plans that are integral
components of FERS and most private sector programs, and (3)
impact of cost-of-living adjustment practices on benefit
amounts over the long term. In fact, FERS and CSRS can provide
quite different benefit amounts because of their different
designs. As a rule, greater benefits are available from FERS
than from CSRS, but FERS employees must contribute larger
percentages of their salaries to receive the higher benefits.
Financial management: Review of the military retirement trust fund's
actuarial model and related computer controls (GAO)/AIMD-97-
128, 09/09/97)
The Defense Department's (DOD) Military Retirement Trust
Fund was created to oversee the accumulation of funds to
finance, on an actuarially sound basis, military retirement and
survivor benefit programs. With total actuarial liabilities of
$548 billion as reported in its financial statements for fiscal
year 1996, the Fund has significant implications for the
consolidated governmentwide financial statements that GAO plans
to audit beginning in fiscal year 1997. In preparation for that
audit, GAO contracted with an independent public accounting
firm, KPMG Peat Marwick LLP, to review (1) the methods and
assumptions used by the DOD Office of the Actuary to calculate
the fund's pension liability as of September 30, 1996, and (2)
the effectiveness of computer controls at the facilities that
are responsible for receiving, formatting, and processing the
actuarial information. This report presents the findings of
that review.
Improving financial condition of the Pension Benefit Guaranty
Corporation and insured pension plans (GAO)/HEHS-99-37R, 12/18/
98)
Pursuant to a congressional request, GAO provided
information on: (1) the Pension Benefit Guaranty Corporation's
(PBGC) projections of its financial condition and assumptions
used to prepare these projections; and (2) the funding status
of the plans it insures and its strategy for investing its
assets.
GAO noted that: (1) PBGC uses different methodologies to
fore-
cast the financial condition of its single-employer and multi-
em-
ployer insurance programs; (2) PBGC relies on extrapolations of
its
past claims experience and past economic conditions to develop
forecasts for the single-employer program; (3) the optimistic
and in-
termediate forecasts project surpluses at the end of fiscal
year (FY)
2007 of $8 billion and $6.9 billion, respectively, while the
pessimis-
tic forecast projects a deficit of $17.1 billion; (4) PBGC uses
plan-
specific historical data in projecting whether multiemployer
plans
will become insolvent and require its assistance; (5) PBGC
projects
that the multiemployer program should remain financially strong
and that the program's surplus, $219 million in FY 1997, should
continue to grow; (6) the funding status of many single-
employer
plans has improved; (7) between 1980 and 1995, the proportion
of
fully funded single-employer plans (plans with assets equal to
or
exceeding benefits earned by participants) increased from 58
per-
cent to 65 percent; (8) overall, funding among multiemployer
plans
has improved since 1980, and in 1995 about 60 percent of
multiem-
ployer plans were fully funded; (9) at the end of FY 1997, PBGC
reported having about $15.6 billion in assets available for
investment; and (10) in accordance with its investment policy,
these assets are invested primarily in equities and fixed
income securities.
Integrating pensions and Social Security: Trends since 1986 tax law
changes (GAO/HEHS-98-191R, 07/06/98)
Pursuant to a congressional request, GAO provided
information on the impact of the 1986 change in the tax code
integration provision, focusing on: (1) how integrated plans
were modified to conform with the new provision; and (2) trend
data relating to integrated plans.
GAO noted that: (1) the actuaries and studies GAO consulted
indicated that the Tax Reform Act of 1986 (TRA86) may not have
had an immediate impact on many integrated plans because in
1986 these plans appeared to already meet the new integration
provision; (2) in 1986, most plans using the offset method of
integration generally reduced pension benefits by no more than
50 percent, and relatively few excess plans used a formula that
withheld all benefits from the plans' lower-paid workers; (3)
for plans not already in compliance with the new TRA86
integration provision, plan sponsors' reactions to TRA86
varied; (4) TRA86 increased plan costs for those sponsors who
had to modify their plans to comply with the new integration
provision; (5) an increasing proportion of sponsors of
integrated plans are using the general test, even though
initial cost remains high, because it offers design flexibility
that can reduce the sponsors' yearly contribution costs; (6)
the Internal Revenue Service (IRS) conducted a targeted study
of integrated defined contribution plans for fiscal year 1993
to determine whether they complied with the TRA86 pension
integration provision; (7) it found that 3 of the 80 plans it
audited required changes to bring them into compliance; (8) the
IRS is now conducting a targeted study to determine the level
of compliance; (9) data from surveys conducted by private
employee benefits consultants show a decline in the proportion
of pension plans that are integrated; (10) Bureau of Labor
Statistics data show that the percentage of participants in
large and medium private firms covered by integrated defined
benefit plans declined from 62 percent in 1986 to about 51
percent in 1995; (11) it is unclear whether the TRA86
integration changes are working as intended, in part because
plan sponsors can use the general test to avoid the special
integration provision restrictions; (12) according to IRS
officials, the TRA86 changes clearly prevent plans from
eliminating employees' pension benefits through integration if
they adhere to the TRA86 integration provision; (13) however,
they acknowledged that a plan whose integration formula
exceeded the integration provision restrictions could remain
qualified by passing the general test; and (14) neither the
actuaries nor the benefit rights advocate GAO contacted were
able to provide any specific examples of benefits being
eliminated by integration, and GAO found no examples in the
literature it reviewed.
Pension Benefit Guaranty Corporation: Financial condition improving,
but long-term risks remain (GAO/HEHS-99-5, 10/16/98)
The Pension Benefit Guaranty Corporation (PBGC) insures the
pensions of about 42 million participants in 45,000 private
defined benefit pension plans. During 1997, PBGC paid $824
million to retirees in plans that had terminated with
insufficient assets to pay promised benefits. PBGC's financial
condition has improved significantly in recent years. The
agency has posted a surplus for the past two fiscal years--
after having had a deficit for more than 20 years. The
financial health of most insured, underfunded plans has also
improved, but underfunding among some large plans continues to
pose a risk to the agency. The improved financial condition of
PBGC and the plans that it insures has resulted from better
funding of underfunded plans and economic improvements, such as
the extended national economic expansion and growth in the
stock market. At this time, it is difficult to isolate the
effects of the 1994 pension reform legislation on plan funding
from other factors, such as the continued economic expansion.
However, risks to the agency's long-term financial viability
remain. PBGC is developing a new single-employer program
forecasting model to estimate the probability of bankruptcies
and terminations of underfunded plans under various economic
conditions. In addition, PBGC has already improved its
methodology for forecasting the financial status of the
multiemployer program. PBGC has also improved its techniques
for estimating its liability for plans that are likely to
require future financial assistance and is now more closely
monitoring the companies with underfunded plans that represent
its biggest risks. Moreover, PBGC is strengthening its
oversight through more audits of premium payments and audits of
fully funded terminated plans and is working closely with plan
sponsors to decrease plan regulatory and administrative
burdens. Still, PBGC needs to continue its efforts to reduce
the time it takes to assume control of terminated plans,
improve the timeliness of final determinations of participants'
benefits, and monitor the performance of contractors that
assist PBGC in administering the insurance programs.
Pension Plans: Status of labor's economically targeted investments
clearinghouse (GAO/HEHS-98-99R, 02/27/98)
Pursuant to a congressional request, GAO provided
information on the Department of Labor's contract to establish
and operate an economically targeted investments (ETI)
clearinghouse, focusing on: (1) whether the applicable federal
statutes and regulations were fully adhered to in selecting the
ETI Clearinghouse contractor; (2) how much was budgeted for and
paid to the contractor; (3) what Labor staff resources were
involved in setting up and operating the ETI Clearinghouse; (4)
work that the contractor performed; and (5) the current status
of the ETI Clearinghouse.
GAO found that Labor complied with the applicable federal
procurement law and regulation in awarding the ETI
Clearinghouse contract to Hamilton Securities. The entire
contractor selection process was competitive among three
vendors. Labor held negotiations with each vendor. Of the
$1,520,411 base period contract awarded in September 1994 for
the 2-year period, Labor's share of the approved contract
expenses was to be 55 percent, and the contractor's share was
the remaining 45 percent. For the 2-year base period, Labor
approved payments of $774,723 of the $780,000 initially
budgeted to reimburse Hamilton Securities for approved contract
expenses. Labor estimates that about 16 individuals from seven
departmental offices spent nearly 630 hours from January 1993
through December 1997 on the ETI Clearinghouse project. Labor
personnel activities included ETI Clearinghouse contract
procurement, development, analysis, policy research, and
monitoring.
Based on its analysis of material provided by Labor, GAO
believes that Hamilton Securities successfully completed each
of the eight required contract tasks by the end of the contract
base period. Among other things, the contractor developed an
ETI database and created a clearinghouse web site for use by
members of the pension community. In August 1996, Labor decided
not to exercise the option year permitted by the September 1994
contract because the contract requirements had been met by the
end of the 2-year base period. After the base period contract
ended in September 1996, Hamilton Securities continued to
operate the ETI Clearinghouse but without any further Labor
financial support. In December 1997, the firm decided to cease
clearinghouse operations. Labor cited operational difficulties
and long-term revenue concerns as the reasons for Hamilton
Securities' decision to discontinue these operations.
Private pensions: Plan features provided by employers that sponsor only
defined contribution plans (GAO/GGD-98-23, 12/01/97)
This report identifies the general features of defined
contribution plans in the private sector. Defined contribution
plans provide retirement benefits that are based on employer
and/or employee contributions to individual employee accounts
and the investment experience of those accounts. GAO describes
patterns in the plans' (1) eligibility requirements for
employee participation, (2) arrangements for employer and
participant contributions, (3) eligibility requirements for
employee rights to accrued benefits, (4) employee investment
options, (5) loan and other provisions for participant access
to plan assets while still employed, and (6) options for
withdrawal of benefits upon separation or retirement. GAO also
presents information on the six features for the Thrift Savings
Plan--the defined contribution plan component of the Federal
Employees Retirement System--for comparison. GAO also
summarizes the explanations provided in retirement literature
and by pension experts with whom GAO consulted on why employers
might decide to sponsor more than one pension plan for the same
groups of employees.
Railroad retirement: Enhancing portability would raise cost and policy
concerns (GAO/GGD-98-168, 08/10/98)
The Railroad Retirement program, established in 1937, is
among the older retirement programs for private sector
employees in the country. In 1997, the program had about
254,000 active participants and provided pension benefits to
about 742,000 retirees, spouses, and survivor and disability
annuitants. During the past 30 years, the railroad industry has
experienced extensive downsizing. Also, about 60 percent of
employees who begin railroad service leave the industry with
less service than they need to qualify for a pension under the
program. Consequently, there has been discussion of possible
legislation to enhance the portability of Railroad Retirement
benefits. This report discusses (1) which, if any, Railroad
Retirement benefits are portable; (2) what changes could be
made to the Federal Employees' Retirement System (FERS) that
might enhance the portability of Railroad Retirement benefits
into FERS for former railroad employees who secure federal jobs
and the cost and administrative implications of those changes
for FERS and whether such changes could be made cost-neutral to
FERS; and (3) what changes could be made to Railroad Retirement
that might enhance the overall portability of its retirement
benefits and what are the cost and administrative implications
of these changes for Railroad Retirement.
Retirement income: Implications of demographic trends for Social
Security and pension reform (GAO/HEHS-97-81, 07/11/97)
The U.S. elderly population has tripled since 1940 and will
more than double by 2050, according to Census Bureau
projections. The population of ``very old''--those aged 85 and
older--will increase fivefold. The elderly are expected to make
up 20 percent of the U.S. population as early as 2030 compared
with 13 percent today. These dramatic demographic trends raise
questions about the future financing, availability, and
protection of retirement income for the nation's elderly.
This report provides information on (1) demographic and
economic trends affecting retirement income, (2) the status of
Social Security's long-term financing problems and proposals to
address them, and (3) the extent of pension coverage and
retirement saving and how to ensure that Americans can count on
them throughout their retirement years.
Social Security: Better payment controls for benefit reduction
provisions could save millions (GAO/HEHS-98-76, 04/30/98).
Under the Government Pension Offset provision, enacted in
1977, the Social Security Administration (SSA) must reduce
social security benefits to persons whose entitlement to social
security benefits is based on another person's (usually their
spouse's) social security coverage. Their social security
benefits are to be reduced by two-thirds of the amount of their
government pension. Under the Windfall Elimination Provision,
enacted in 1983, SSA must use a modified formula to calculate
the social security benefits that people earn when they have
had a limited career in covered employment. The modified
formula reduces the amount of payable benefits. With regard to
the Government Pension Offset provision, spouse and survivor
benefits were intended to provide some social security
protection to spouses with limited working careers. The
Government Pension Offset reduces spouse and survivor benefits
to persons who do not meet this limited working career
criterion. With regard to the Windfall Elimination Provision,
Congress was concerned that the social security benefit formula
provided unintended windfall benefits to workers who had spent
most of their careers in noncovered employment. This report
discusses how well SSA administers the two provisions and
identifies ways to overcome administrative deficiencies.
Social Security: Different approaches for addressing program solvency
(GAO/HEHS-98-33, 07/22/98)
The aging of the baby boomers, lower fertility rates, and
increasing longevity have eroded the long-term solvency of the
Social Security program. The system's annual cash surpluses are
now projected to decline substantially beginning around 2008,
and by 2013, benefit payments are expected to exceed cash
revenues. The Social Security Trust Funds are forecast to be
depleted by 2032, at which time revenues will be able to pay no
more than 75 percent of promised benefits. With a national
debate underway on how best to resolve Social Security's long-
term financing problems, GAO reviewed the various perspectives
underlying the solvency debate, reform options within the
current program structure, and issues that might arise if
Social Security were restructured to include individual
retirement accounts.
Social Security: Implications of extending mandatory coverage to State
and local employees (GAO/HEHS-98-196, 08/18/98)
The Social Security Act of 1935 excluded state and local
government employees from coverage because of concerns about
the federal government's right to impose a tax on state
governments and because many state and local employees were
already covered by public pension plans. Over the years,
Congress has extended mandatory Social Security coverage to
workers not covered by a public pension plan and voluntary
coverage to other state and local government workers. The
Social Security Administration estimates that 5 million state
and local government workers, with annual salaries totaling
$132.5 million, are currently not covered by Social Security.
This report examines the implications of extending mandatory
coverage to all newly hired state and local employees.
Specifically, GAO discusses the implications of mandatory
coverage for the Social Security program and for public
employers, employees, and pension plans. GAO also identifies
potential legal or administrative problems associated with
mandatory coverage.
Social Security: Mass issuance of counterfeit-resistant cards
expensive, but alternatives exist (GAO/HEHS-98-170, 08/20/98)
Since legislation was enacted in 1986 requiring employers
to review documents of prospective employees to establish their
right to work in the United States, the Social Security card
has become one of the primary documents used to determine
employment eligibility. However, concerns have deepened that
the card is easily counterfeited and does not prevent
individuals from illegally working in the United States. As a
result, some Members of Congress have asked, on several
occasions, the Social Security Administration (SSA) and the
Congressional Budget Office (CBO) to estimate the cost of
issuing a counterfeit-resistant card. In 1996, the Illegal
Immigration Reform and Immigrant Responsibility Act required
SSA to develop a prototype counterfeit-resistant card made of a
durable tamper-resistant material with various security
features that could be used to establish reliable proof of
citizenship or legal noncitizenship status. That Act also
required SSA to estimate and compare the cost of producing and
disseminating several types of enhanced cards to all living
number holders over 3-, 5-, and 10-year periods. Earlier that
year, a Member of Congress asked CBO to estimate the cost of
issuing a counterfeit-resistant card, believing an earlier SSA
estimate of producing such a card was high. This report (1)
explains differences in CBO's and SSA's estimates for replacing
the Social Security card, (2) evaluates SSA's estimates for the
cost of issuing a more secure card, and (3) presents additional
issuance options.
Social Security Administration: Information on monitoring 800 number
telephone calls (GAO/HEHS-98-56R, 12/08/97)
Pursuant to a congressional request, GAO reviewed the
Social Security Administration's (SSA) teleservice monitoring
operations, focusing on: (1) requirements by laws and
regulations regarding proper telephone monitoring practices and
steps SSA has taken to gain consent for its telephone
monitoring practices; and (2) best practices in telephone
monitoring.
GAO noted that: (1) under the current law, SSA cannot
monitor telephone calls unless its monitoring practices fall
within a statutory exception; (2) one exception generally
relates to the type of telephone equipment provided to a
business and whether it is used for business purposes; (3)
another exception requires the consent of at least one party to
a conversation; (4) the SSA Office of Inspector General did not
determine whether SSA meets the first exception, but SSA
believes it does; (5) also, the agency has taken steps to gain
consent for telephone monitoring from the public and its
employees; (6) SSA has negotiated agreements with the American
Federation of Government Employees to more often notify
employees when particular calls will be monitored and has added
a recorded message to its 800 number to notify callers that
their calls may be monitored; (7) SSA is also developing a new
regulation that will formally notify its employees and the
public of its monitoring practices; (8) regarding best
practices, there are some similarities and differences between
SSA's telephone monitoring practices and those identified in a
key study of private companies considered to be the best in the
800 number business; (9) for example, the approach SSA
supervisors use to monitor broader unit-level performance is
similar to private sector best practices; (10) SSA's approach
to monitoring for quality assurance differs from private
industry's best practices; and (11) rather than immediate
supervisors' performing the quality monitoring function, SSA
maintains a separate unit to monitor for quality to ensure that
benefits are paid accurately.
Social Security Administration: More cost-effective approaches exist to
further improve 800-number service (GAO/HEHS-97-79, 06/11/97)
Every day, thousands of people contact the Social Security
Administration (SSA) to file claims for disability or
retirement benefits, check to see that their records are up to
date, obtain a Social Security card, or ask questions about the
agency's programs. To reach its goal of providing world-class
service to the public, SSA is working to improve its toll-free
800-number service. Since the 800 number became widely
available in 1989, SSA has struggled to keep pace with caller
demand. Moreover, once callers reach SSA, they are limited to
simple transactions, such as ordering Social Security card
application forms or making appointments to file benefit
claims. SSA has initiatives underway to improve caller access
to its 800 number and to expand the range of available
transactions. This report reviews (1) how well SSA's 800 number
provides service to the public and (2) the steps that SSA needs
to take to ensure that upgrades to the 800 number are cost-
effective.
Social Security Administration: Responses to subcommittee questions
about the on-line PEBES service (GAO/AIMD-97-121R, 06/20/97)
Pursuant to a congressional request, GAO provided answers
to questions relating to its May 6, 1997, testimony on the
Social Security Administration's (SSA) use of the Internet to
provide Personal Earnings and Benefits Estimate Statements
(PEBES) to individuals.
GAO noted, among other things, that (1) discussions
concerning SSA's use of the Internet to disseminate PEBES
should include a focus on systems security because there have
been recent problems in implementing currently available
commercial encryption processes, and computer systems that use
these processes have been successfully attacked; (2) in making
information readily available via the Internet, many
opportunities for serious misuse of sensitive information
exist, and these must be carefully considered and communicated
to those individuals whose information might be placed at risk;
(3) because of the sensitive information contained in the PEBES
system, effective risk management is necessary to ensure that
the most appropriate technical safeguards are identified and
implemented to protect against security threats; (4) in light
of the increasing importance of information security and the
pattern of widespread problems that has emerged, it is
essential that federal agencies implement information security
programs that proactively and systematically assess risk,
monitor the effectiveness of security controls, and respond to
identified problems; and (5) as the senior official designated
to oversee information resources management, SSA's chief
information officer should have primary responsibility for
ensuring that the on-line PEBES initiative represents a sound
information technology investment based on factors such as the
project's cost, risk, return on investment, and support for
mission-related outcomes.
Social Security Administration: Significant challenges await new
commissioner (GAO/HEHS-97-53, 02/20/97)
The Social Security Administration (SSA) is ahead of many
federal agencies in developing strategic plans; measuring its
service to the public; and producing complete, accurate, and
timely financial statements. This gives SSA a sound foundation
from which to manage significant current and future challenges.
The aging of the baby boomers, coupled with longer life
expectancy and the declining ratio of contributing workers to
beneficiaries, will place unprecedented strains on the Social
Security program in the 21st century. SSA, however, has yet to
do the research, analysis, and evaluation needed to inform the
public debate on the future financing of Social Security--the
most critical long-term issue confronting the agency. Also
challenging SSA have been disability caseloads that have grown
by nearly 70 percent during the past decade. At this critical
juncture, leadership is essential so that SSA can take the
following steps to ensure success in the years ahead: inform
the national debate on Social Security financial issues;
complete its redesign of the disability claims process and
promote return to work in its disability programs; enhance
efforts to ensure program integrity, while quickly and
effectively implementing many reforms; and make the technology
enhancements and workforce decisions needed to meet increasing
workloads with fewer resources.
Social Security Administration: Significant progress made in year 2000
effort, but key risks remain (GAO/AIMD-98-6, 10/22/97)
Unless timely corrective action is taken to address the
Year 2000 problem, the Social Security Administration (SSA),
like other federal agencies, could face critical computer
system failures at the turn of the century. If left
uncorrected, this could result in Social Security benefit
checks being issued incorrectly, or not on time, beginning in
January 2000. This report discusses the adequacy of steps taken
by SSA to ensure that computing problems arising from the year
2000 are fully addressed, including its oversight of state
Disability Determination Services' (DDS) Year 2000 program
activities.
GAO noted that while the agency deserved credit for its
leadership in addressing the Year 2000 issue, the agency
remained at risk that not all of its mission-critical systems
would be corrected before January 1, 2000. At particular risk
were systems that had not been assessed for the 54 state DDSs
that provide vital support to SSA in administering its
disability insurance programs. SSA also faced the challenge of
ensuring that its critical data exchanges with federal and
state agencies and other businesses are Year 2000 compliant.
Finally, GAO noted that SSA's risk could be magnified if the
agency does not develop contingency plans to ensure the
continuity of its critical systems and activities should
systems not be corrected in time.
In light of the importance of SSA's function to most
Americans and the risks associated with the Year 2000 program,
GAO recommended that SSA (1) expeditiously complete the
assessment of state DDS mission-critical systems; (2)
strengthen its monitoring and oversight of state DDS
activities; (3) include information on the status of DDS
activities in SSA's quarterly reports to the Office of
Management and Budget; (4) expeditiously complete the agency's
compliance coordination with all data exchange partners, and
(5) develop contingency plans for ensuring the continued
operation of core business functions if planned corrections are
not completed in time or if systems fail to operate as
intended.
Social Security Administration: Software development process
improvements started but work remains (GAO/AIMD-98-39, 01/28/
98)
The Social Security Administration (SSA) is in the process
of redesigning its work processes and modernizing its computer
systems to better serve a growing beneficiary population and
improve productivity. The agency plans to switch from
centralized, mainframe-based computer processing to a more
distributed, client/server processing environment, in which the
Intelligent Workstation/Local Area Network will serve as the
basic automation infrastructure. Software developed for the new
client/server systems will be critical to ensuring that the
modernized processes work as intended and achieve the desired
productivity outcomes. However, software development has been
cited by many experts as one of the riskiest and most costly
aspects of systems development. Moreover, SSA has recognized
weaknesses in its own software development capability and has
begun taking steps to improve its processes for developing
software.
This report discussed the status of SSA's software process
improvement efforts and noted a number of actions that SSA was
taking to improve its capability, including launching a formal
improvement program and acquiring the assistance of the
Software Engineering Institute to assess current process
weaknesses and implement improvements. However, the report also
noted that SSA's software process improvement program lacked
measurable goals and baseline data needed to measure the
progress and success of the improvement efforts. To strengthen
SSA's software process improvement program, GAO recommended
that SSA develop and implement plans that explicitly articulate
a strategy and time frames for (1) developing baseline data,
(2) identifying specific, measurable goals for the improvement
initiative, and (3) monitoring and measuring progress in
achieving these goals.
Social Security Administration: Subcommittee questions concerning
information technology challenges facing the commissioner (GAO/
AIMD-98-235R, 07/10/98)
Pursuant to a congressional request, GAO provided
information on the challenges the Social Security
Administration (SSA) faces in preparing its information systems
for the new century and in implementing technology initiatives,
such as the Intelligent Workstation/Local Area Network (IWS/
LAN) and the on-line Personal Earnings and Benefits Estimate
Statement (PEBES) system.
GAO noted that (1) SSA was making good progress in its
efforts to become Year 2000 compliant and the agency had taken
numerous actions that demonstrated a sense of urgency and
commitment to achieving readiness for the change of century;
(2) although SSA stated that 100-megahertz workstations
specified in its IWS/LAN contract met the agency's current
needs, it was uncertain whether these workstations would
adequately support all of the agency's future software needs;
(3) SSA did not include a technology refreshment clause for
IWS/LAN, but the contract did include two other clauses that
would allow the agency to replace equipment originally
specified in the contract with upgraded technology; (4) staff
in certain state Disability Determination Services offices had
expressed valid concerns about the effectiveness of SSA's
network management control over IWS/LAN, and dissatisfaction
with the service and technical support received from the
contractor following its installation; (5) weaknesses in SSA's
software development capability raised significant concerns
about the agency's ability to effectively develop the software
that will be needed to support its operations into the next
century; and (6) implementation of the on-line PEBES systems
remained suspended and the agency was continuing to evaluate
alternatives for protecting the privacy and security of
sensitive information that would be transmitted via the
Internet.
Social Security Administration: Technical and performance challenges
threaten progress of modernization (GAO/AIMD-98-136, 06/19/98)
To better serve a growing beneficiary population and
improve productivity, the Social Security Administration (SSA)
is redesigning its work processes and modernizing its computer
systems. The Intelligent Workstation/Local Area Network (IWS/
LAN) project is intended to provide the basic automation
infrastructure needed to increase SSA's processing abilities.
The first phase of the planned project is a seven-year,
approximately $1 billion effort to acquire more than 56,000
intelligent workstations and 1,700 local area networks. This
report (1) discusses the status of SSA's implementation of IWS/
LAN, (2) assesses whether SSA and state Disability
Determination Services' (DDS) operations have been disrupted by
the installation of network equipment, and (3) assesses SSA's
practices for managing its investment in IWS/LAN.
The report contains a number of recommendations aimed at
strengthening SSA's management of its IWS/LAN investment,
including (1) assessing the adequacy of the workstations
specified in the IWS/LAN contract to determine the number and
capacity of workstations required to support the initiative;
(2) working with the state Disability Determination Services to
resolve network management concerns; and (3) establishing a
formal oversight process for measuring the actual performance
of each phase of IWS/LAN.
Social Security advocacy: Organizations that mail fund-raising letters
(GAO/HEHS-97-69, 06/18/97)
As part of their fund-raising efforts, some groups mail
letters to the elderly claiming that Social Security has ``dire
financial troubles'' or that the trust funds are being
``mishandled'' and requesting financial contributions to combat
alleged threats to the program. The media have criticized some
letters for using scare tactics to solicit millions of dollars
in donations from the elderly. This report focuses on the
following seven organizations that use Social Security issues
in fund-raising letters: the American Conservative Union, the
Council for Citizens Against Government Waste, the National
Committee to Preserve Social Security and Medicare, TREA Senior
Citizens League, the Seniors Coalition, the 60/Plus
Association, and the United Seniors Association, Inc. (USA).
The report discusses (1) the bases for the groups' tax
exemption; (2) the services they provide; (3) their sources of
income, income subject to taxes, and expenses; (4) their
financial relationships with other businesses; and (5) the
characteristics of their Social Security-related fund-raising
letters.
SSA: The agency's relationship with the Office of Management and Budget
since becoming an independent agency (GAO/HEHS-98-235R, 08/26/
98)
Pursuant to a congressional request, GAO reviewed the
Social Security Administration's (SSA) dealings with the Office
of Management and Budget (OMB) since it became an independent
agency, focusing on: (1) SSA's current practices when dealing
with OMB on budget, legislative, and policy matters; and (2)
whether these current practices are in compliance with the law.
GAO noted that: (1) since becoming an independent agency,
SSA has continued to work with OMB on all budget, legislative,
and policy matters; (2) according to SSA officials, two key
differences in SSA's relationship with OMB since independence
are: (a) the agency now works directly with OMB rather than
going through the Department of Health and Human Services and
(b) the President is now required to submit the Commissioner's
budget for SSA to Congress along with the President's own
budget; (3) during the annual budget process, SSA receives
guidance from OMB to help it prepare a budget proposal; (4)
once approved by OMB, SSA's budget is transmitted to Congress
as part of the President's budget; (5) SSA continues to submit
its legislative and regulatory proposals and testimonies to OMB
for review prior to publication; (6) OMB officials told GAO
that OMB's relationship with SSA is similar to that of other
agencies within the executive branch of the government; (7)
SSA's independence gives the agency more visibility within the
executive branch and allows it to express agency concerns and
views directly to OMB and Congress; (8) SSA officials told GAO
that the budget provision in SSA's independence law, which
requires the Commissioner to identify his budget needs
separately in the President's budget, strengthens the agency's
position in budget negotiations with OMB; (9) SSA officials
believe that the agency's current relationship with OMB
complies with the law; (10) these officials believe that, even
though SSA is independent, it is still part of the executive
branch; (11) therefore, SSA still needs to obtain OMB clearance
when promulgating regulations, presenting testimony, and making
legislative recommendations; (12) GAO agrees that SSA is not
constrained by the independence legislation from submitting its
regulations, testimony, and legislative recommendations to OMB;
(13) GAO agrees with OMB and SSA officials that SSA's budget
presentation, prepared in consultation with OMB and as
submitted by the President, complies with the independence law
and the federal budget process; (14) even so, Congress has
other options should this information not satisfy its needs;
(15) the budget provision in SSA's independence law is intended
to provide information to Congress on SSA's budget needs, yet
in practice the information provides a brief summary only and
omits detail; and (16) if Congress would like more detailed or
different information on SSA than what appears in the
President's budget submission, the law authorizes Congress to
obtain this information directly from SSA.
SSA benefit estimate statement: Adding rate of return information may
not be appropriate (GAO/HEHS-98-228, 09/02/98)
Legislation was proposed that would require Social Security
to include an individual rate of return estimate on the
Personal Earnings and Benefit Estimate Statement that virtually
every worker will begin receiving in 2000. The goal would be to
enable workers to compare the current Social Security program
with other investments, including alternatives being discussed
in the congressional debate about how to restore Social
Security's long-term solvency. GAO found that substantial
disagreement exists about whether the rate of return concept
should be applied to Social Security. Supporters point out that
providing this information would educate people about the
return that they will receive on their contributions. Others
contend that it is inappropriate to use rate of return
estimates for Social Security because the program is designed
to pursue social insurance goals, such as assuring that low-
wage earners have an adequate income in their old age or
providing for dependent survivors. In addition, actual rates of
return for individuals can vary substantially from the
estimates because of various uncertainties, such as a worker's
retirement age and future earnings. To be clearly understood,
the underlying assumptions and their effect on the estimates
should be explained in any presentation of rate of return
information. Moreover, comparing rate of return estimates for
Social Security with estimates for private investments could be
difficult for several reasons. For example, the comparisons
would need to indicate whether the estimates for other
investments include the transaction and administrative costs
and the differences in risk associated with Social Security and
private investments. Finally, providing rate of return
information on the statements could further complicate and
lengthen an already complex and difficult-to-understand
document.
SSA benefit estimate statements: Additional data needed to improve
workload management (GAO/HEHS-97-101, 05/20/97)
Congress passed legislation in 1990 requiring the Social
Security Administration (SSA) to begin providing the public
with annual statements about its Social Security earnings
records and estimates of the amount of benefits persons may
receive. Starting in fiscal year 2000, SSA must mail Personal
Earnings and Benefit Estimate Statements to nearly every U.S.
worker aged 25 and older--an estimated 123 million people. SSA
projects that printing, mailing, and personnel costs associated
with this effort will total nearly $77 million in fiscal year
2000 alone. Although SSA believes that it is prepared for the
increased workload arising from this initiative, it has not
adequately assessed the added work likely to stem from
questions about and corrections to the statements. SSA lacks
reliable data on either the number of people who call or visit
SSA with questions about their statements or the number of
earnings corrections resulting from statement mailings. SSA
could better manage the potential workload if it began to
collect more complete and accurate data now on the effects of
mailing the mandated statements.
Social Security financing: Implications of Government stock investing
for the trust fund, the Federal budget, and the economy (GAO/
AIMD/HEHS-98-74, 04/22/98)
Allowing the Social Security trust fund to invest in the
stock market is a complex proposal that has potential
consequences for the trust fund, the U.S. economy, and federal
budget policy. For the Social Security trust fund, stock
investing offers the prospect of higher returns but greater
risk. Higher returns would allow the trust fund to pay benefits
longer, even without other program changes. However, if stock
investing is implemented in isolation, the trust fund would
inevitably have to liquidate its stock portfolio to pay
promised benefits, and it would be vulnerable to losses in the
event of a general stock market turndown. Although stock
investing is unlikely to solve Social Security's long-term
financial imbalance, it could reduce the size of other reforms
needed to restore the program's solvency.
For the federal budget, stock investing would have the
immediate effect of increasing the reported unified deficit or
decreasing any reported unified surplus because, under current
budget scoring rules, stock purchases would be treated as
outlays. Any money used to buy stocks would no longer be
invested in Treasury securities, reducing the Treasury's
available cash and more clearly revealing the underlying
financial condition of the rest of the government. Without
compensating changes in fiscal policy, stock investing would
not significantly alter the impact of federal finances on
national saving and the economy. GAO summarized this report in
testimony before Congress; see: Social Security Financing:
Implications of Stock Investing for the Trust Fund, the Federal
Budget, and the Economy (GAO/T-AIMD/HEHS-98-152, Apr. 22,
1998).
Social Security reform: Implications for women's retirement income
(GAO/HEHS-98-42, 12/31/97)
On average, Social Security pays lower retirement benefits
to women than to men, primarily because women tend to have
lower lifetime earnings. Social Security reforms that would
create individual private savings accounts and change the way
that benefits are distributed are most likely to affect women
and men differently. Working women earn less than men, on
average, and would have less money to invest in their
individual accounts. Also, women are often more cautious
investors than men, and may be less likely to invest in
potentially higher yielding, though riskier, assets such as
stocks, a tendency that puts them at risk of accumulating
relatively less money in their accounts at retirement.
Moreover, even if men and women enter retirement with equal
amounts in their individual accounts, women may receive a lower
monthly benefit if they buy an individual annuity because it is
adjusted for their greater longevity.
SSA: Cycling payment of Social Security benefits (GAO/OGC-97-24, 02/25/
97)
Pursuant to a legislative requirement, GAO reviewed the
Social Security Administration's (SSA) new rule on cycling
payment of Social Security benefits. GAO noted that: (1) the
rule would establish additional days throughout the month on
which Social Security benefits would be paid; and (2) SSA
complied with applicable requirements in promulgating the rule.
401(k) pension plans: Extent of plans' investments in employer
securities and real property (GAO/HEHS-98-28, 11/28/97)
Policymakers and the pension community are concerned about
401(k) plans in which decisions on how to invest plan assets,
particularly employee contributions, are made exclusively by
employers. This concern was prompted mainly by two cases in
which employers invested a large part of the 401(k) plan assets
in their companys' securities or real property. Later business
reversals then forced the employers into bankruptcy,
reorganization, or liquidation. In one case, employees lost
their jobs and almost all of their pension benefits because the
value of the employer's securities decreased significantly.
This report (1) provides information on the extent to which
401(k) plan assets are invested in employers' securities and
real property, (2) examines the protection and any possible
problems associated with recent amendments to title I of the
Employee Retirement Income Security Act of 1974 (ERISA), and
(3) identifies alternative mechanisms that might safeguard the
retirement benefits of participants in 401(k) plans in which
the employer decides how to invest assets.
401(k) pension plans: Loan provisions enhance participation but may
affect income security for some (GAO/HEHS-98-5, 10/01/97)
More employees are likely to participate in 401(k) pension
savings plans when they are allowed to borrow from those plans.
Moreover, participants in plans that allow borrowing
contribute, on average, 35 percent more to their pension
accounts than do participants in plans that do not permit
borrowing. GAO found that relatively few plan participants--
less than eight percent--have one or more loans from their
pension accounts. Blacks and Hispanics, lower-income persons,
participants who have recently been turned down for a loan, and
workers who are also covered by other pension plans are more
likely to borrow from their pension account than are other
participants. The loan provisions of many pension plans provide
for loan repayment at favorable interest rates, which may be
lower than the investment yield that could have been earned had
the money been left in the pension account. Consequently, the
borrower will have a smaller pension balance at retirement
because the interest paid to the account is less that what
could have been earned from investing in equities. On the other
hand, borrowing can help plan participants meet other financial
goals. For example, borrowing for education or training could
boost a family's lifetime income and, hence, retirement income.
Veterans and DOD Issues
Consumer-directed personal care programs: Department of Veterans
Affairs and Medicaid experience (GAO/HEHS-98-50R, 01/16/98)
Pursuant to a congressional request, GAO reviewed the
Department of Veterans Affairs' (VA) Aid and Attendance (A&A)
program as well as selected state Medicaid programs that permit
consumers to hire their own personal care attendants, focusing
on whether: (1) the government might be paying twice for
persons in nursing homes who also received A&A benefits; (2)
there are any existing public programs that could serve as a
model for Medicaid; and (3) there is sufficient knowledge about
consumer-directed personal care to recommend one of these
programs as a model.
GAO noted that: (1) while such programs exist, the
information currently available is not sufficient to determine
whether any of the existing consumer-directed personal
assistance programs that allow consumers to pay or participate
in paying attendants could serve as a model for Medicaid; (2)
in terms of the programs in place, they tend to differ both in
their mechanisms for paying attendants and in whether they
monitor the use of the payments; (3) VA does not monitor the
use of A&A allowance, taking the position that has no authority
to tell veterans how to use the benefit; (4) state programs
want to ensure that the employer taxes are paid for personal
care attendants, and this can present difficulties for the
consumer/employer, who must satisfy all Internal Revenue
Service reporting requirements, and for the state, which
generally prefers not to be the employer of record; (5) in most
cases, the state or a fiscal intermediary makes payments and
handles the taxes; and (6) although there has been no rigorous
evaluation of any of these programs to date, the four-state
Cash and Counseling Demonstration, sponsored by the Robert Wood
Johnson Foundation and the Department of Health and Human
Services, will produce important information on its cost-
effectiveness--but not until 2001.
Defense health care: Fully integrated pharmacy system would improve
service and cost-effectiveness (GAO/HEHS-98-176, 06/12/98)
The rapid rise in health care costs, the closure of
military treatment facilities, and the rising number of retired
military beneficiaries have prompted the Defense Department
(DOD) to continually reengineer its health care delivery
system. DOD's TRICARE health care system provides most of its
care at Army, Navy, and Air Force facilities, supplemented by
civilian health care services arranged by regional TRICARE
contractors. Among health care services, the pharmacy benefit
is most in demand by military beneficiaries. As in the private
sector, DOD's pharmacy costs have continued to grow relative to
total health care costs. GAO estimates that DOD's pharmacy
costs rose 13 percent between 1995 and 1997, while its overall
health care costs increased two percent during that same
period. This report discusses (1) the adequacy of the
information that DOD and its contractors use to manage the
pharmacy benefit; (2) the merits and the feasibility of DOD and
its contractors applying commercial best practices, including a
uniform formulary, in managing its pharmacy programs; (3) the
merits or limitations of recent mail-order and retail pharmacy
initiatives to secure discounted DOD drug prices; and (4) the
potential effects that military treatment facility's funding
and formulary management decisions can have on beneficiaries'
access to pharmacies and TRICARE contractors' costs.
Information systems: VA computer control weaknesses increase risk of
fraud, misuse, and improper disclosure (GAO/AIMD-98-175, 09/23/
98)
Computer control weaknesses put critical operations at the
Department of Veterans Affairs (VA), from health care delivery
to benefit payments to home mortgage loan guarantees, at risk
of misuse and disruption. In addition, sensitive information in
VA's systems, including financial transaction data and medical
records, is vulnerable to inadvertent or deliberate misuse,
even destruction. GAO found significant weaknesses in VA's
control and oversight of access to its systems. For example, VA
did not adequately limit the access of authorized users or
effectively manage user identifications and passwords. In
addition, VA did not provide adequate physical security for its
computer facilities, assign duties so that incompatible
functions were segregated, control changes to powerful
operating system software, or update and test disaster recovery
plans to prepare its computer operations to maintain or regain
critical functions in emergencies. A primary reason for VA's
computer control problems is that the agency lacks a
comprehensive computer security planning and management
program.
Military retirees' health care: Costs and other implications of options
to enhance older retirees' benefits (GAO/HEHS-97-134, 06/20/97)
Today, 4.3 million military retirees, their dependents, and
survivors are eligible for care under the military health care
system. However, because of changes during the past decade,
including the establishment of a nationwide managed care
program and the closure of many medical facilities, many
military retirees fear that they will lose access to care. This
report describes various proposals that have been made to
enhance older retirees' military health care benefits and
provides cost estimates for implementing them. These options,
each of which would require legislation to implement, include
(1) enrolling Medicare-eligible retirees in TRICARE Prime, a
health maintenance organization, and paying for their care with
Medicare funds; (2) using Defense Department (DOD) funds to pay
retirees' Medicare part B premiums and to furnish Medigap
policies; (3) providing the Civilian Health and Medical Program
of the Uniformed Services as a Medicare supplement; (4)
extending the Federal Employees Health Benefits Program to
retirees as a Medicare supplement and using DOD funds to pay
part of the premium; and (5) expanding DOD's current mail-order
prescription program to Medicare-eligibles who do not live near
military medical facilities. GAO also discusses the
uncertainties about and limitations of these options.
National cemetery system: Opportunities to expand cemeteries'
capacities (GAO/HEHS-97-192, 09/10/97)
In fiscal year 1996, the Department of Veterans Affairs
(VA) spent $73 million to provide burial benefits for 72,000
veterans and their family members in national cemeteries. These
burial grounds, however, are rapidly running out of space. As
World War II veterans age, the number of deaths and internments
in national cemeteries are rising and expected to peak sometime
early in the next century. Because of the depletion of
available gravesites, more than half of the national cemeteries
will be unable to accommodate casket burials of family members
before then. VA has several options to deal with this
situation, including establishing new national cemeteries,
developing space to hold ashes of the deceased, and acquiring
additional land adjacent to existing cemeteries. GAO found that
increased use of cremation, which is growing in acceptance
nationwide, could extend the capacity of existing cemeteries at
the lowest possible cost. For example, the cost of a
traditional cemetery would exceed $50 million, while the cost
of an above-ground columbarium, which holds cremations, would
total $21 million.
VA aid and attendance benefits: Effects of revised HCFA policy on
veterans' use of benefits (GAO/HEHS-97-72R, 03/03/97)
Pursuant to a congressional request, GAO provided
information on the: (1) historical purpose of the Department of
Veterans Affairs' (VA) aid and attendance (A&A) benefits and
the policies affecting the use of these benefits; (2) medical,
demographic, and economic characteristics of veterans who
receive these benefits; and (3) impact of the Health Care
Financing Administration's (HCFA) 1994 A&A policy decision on
state veterans nursing homes, including federal and state
expenditures for the care of veterans in these homes. GAO did
not independently verify the data received from VA or the state
veterans nursing homes.
GAO noted that: (1) A&A benefits have historically been a
means of providing additional disability benefits to veterans
requiring assistance with activities of everyday living; (2)
veterans receiving these benefits are generally among the
oldest, poorest, and most disabled veterans; (3) HCFA's current
A&A policy has increased state and federal Medicaid payments
for the care of veterans in state veterans nursing homes; (4)
while the increases potentially could be as much as $30 million
annually, GAO estimated that the current financial impact is
significantly less because of such factors as the relatively
small number of Medicaid-eligible veterans residing in state
nursing homes and the fact that many states have not yet
implemented the current HCFA policy; and (5) HCFA's policy may
also create an inequity by allowing Medicaid-eligible veterans
in state homes to keep their A&A benefits, while non-Medicaid
eligible veterans in these homes are required to use these
benefits to pay for the cost of care.
VA community clinics: Networks' efforts to improve veterans' access to
primary care vary (GAO/HEHS-98-116, 06/15/98)
In 1995, the Veterans Health Administration (VHA) announced
plans to switch from a hospital-based system of care to a
health-care system rooted in primary and ambulatory care. VHA
has restructured its facilities into 22 service delivery
networks. VHA has strengthened the process that these networks
are to use when establishing new community-based clinics,
thereby addressing several of GAO's earlier recommendations.
VHA has provided more detailed guidance and it has developed a
more structured planning process. VHA's long-range goal is to
increase the number of community-based clinics. To that end,
VHA has approved 198 clinics, and network business plans show
that 402 additional clinics are to be established by 2002. The
plans, however, do not address the percentage of current users
who have reasonable access, or what percentage of those without
reasonable access are targeted to received enhanced access
through the establishment of new clinics. As a result, VHA's
network business plans cannot be used to determine on a
systemwide basis how well networks are using clinics to
equalize veterans' access to primary care.
VA health care: Closing a Chicago hospital would save millions and
enhance access to services (GAO/HEHS-98-64, 04/16/98)
GAO's analysis found that three hospitals can meet the
health care needs of Chicago-area veterans. By reducing the
number of VA hospitals in the Chicago area from four to three,
the Veterans Health Administration (VHA) can save about $200
million during the next 10 years and possibly generate millions
of dollars more through the sale or lease of the closed
property. VHA has experienced a large supply of unused beds,
and veterans' demand for VHA hospital care is expected to
decline further as (1) treatments shift from inpatient to
outpatient settings and (2) the Chicago-area veteran population
continues to decrease. In addition, other Chicago public and
private hospitals have about 5,700 excess beds, which VHA could
use on a contract basis to meet veterans' inpatient needs
closer to their homes.
VA health care: Medicare reimbursement for services to veterans (GAO/
HEHS-98-145R, 04/28/98)
As part of its fiscal year 1998 budget submission, the
Department of Veterans Affairs (VA) requested authority to
collect, on a demonstration basis, Medicare funding for care
provided to veterans with income above a statutory threshold
(so called, high income veterans) who are eligible for both VA
care and Medicare.
GAO noted that a Medicare HMO demonstration could offer
such potential benefits as: (a) access to VA care for high-
income, Medicare-eligible veterans who would otherwise not be
served; and (b) enhanced access to or quality of care for
veterans not enrolled in VA's demonstration. GAO cautioned that
a demonstration could expose current VA users to such potential
risks as delays in receiving services, denials of care, or
reductions in quality of care. Risks for veterans could be
minimized by VA's efforts to establish safeguards, including
procedures to: (a) assess available operating capacity and link
the number of demonstration enrollees to that level; and (b)
monitor waiting times, care denials, and quality of care on an
ongoing basis for veterans who use VA health care, but are not
enrolled in VA's demonstration.
VA health care: More veterans are being served, but better oversight is
needed (GAO/HEHS-98-226, 08/28/98)
In recent years, the Department of Veterans Affairs (VA)
has launched two major initiatives to change the way it manages
its $17 billion health care system. In fiscal year 1996, VA
decentralized the management structure of its Veterans Health
Administration, forming 22 veterans integrated service networks
to coordinate the activities of hundreds of hospitals,
outpatient clinics, nursing homes, and other facilities. VA
expected the networks to improve efficiency and patient access.
In April 1997, VA began to phase in the Veterans Equitable
Resource Allocation system to allocate resources to the 22
networks. Previously, each medical center received and managed
its own budget. Concerned that some networks would be forced to
take significant cost-saving measures to manage with the
diminished resources they would receive under the Veterans
Equitable Resource Allocation system and that these networks
would, as a result, reduce veterans' access to care, Congress
asked GAO to examine changes in access to care in two
networks--one headquartered in Bronx, New York, and one
headquartered in Pittsburgh, Pennsylvania. This report
discusses (1) the changes in overall access to care, changes in
access to certain specialized services, and a comparison of
changes in these networks with VA's national data from fiscal
years 1995 to 1997; (2) the extent to which VA headquarters and
networks are working to equitably allocate resources to
facilities within the networks; and (3) the adequacy of VA's
oversight of changes in access to care.
VA health care: Resource allocation has improved, but better oversight
is needed (GAO/HEHS-97-178, 09/17/97)
The Department of Veterans Affairs (VA) provides health
care to about 2.6 million veterans each year, but veterans in
different parts of the country traditionally have not had equal
access to these services. A shift of the veteran population
from the northeast and the midwest to the south and the west
without appropriate reallocation of resources has created
inequities in access to services. In April 1997, VA launched
the Veterans Equitable Resources Allocation system as part of a
strategy to improve the equity of veterans' access to health
care. The system is designed to allocate resources to 22
regional VA health care networks, which are responsible for
allocating resources to hospitals and clinics. This report
assesses VA's (1) implementation of the Veterans Equitable
Resources Allocation system, (2) monitoring of changes in
health care delivery resulting from the system, and (3)
oversight of the network allocation process used to give
veterans equitable access to service.
VA health care: Status of efforts to improve efficiency and access
(GAO/HEHS-98-48, 02/06/98)
The Department of Veterans Affairs (VA) has taken important
steps to improve the efficiency of its health care system and
veterans' access to it. VA medical centers have increased
efficiency by expanding the use of outpatient care. Preventive
care, including health assessments and patient education, has
also increased, enabling patients to stay healthier and avoid
expensive hospital stays. VA is further increasing efficiency
by integrating services both within and among medical centers.
VA is improving access to health care in several ways. For
example, it has begun to emphasize primary care, in which
generalist physicians see patients initially and coordinate any
specialty care that patients may need. In addition, VA is
providing outpatient care at additional community-based
outpatient clinics, expanding evening and weekend hours for
clinics, and exploring other innovations. As networks and
medical centers continue to respond to incentives to improve
the efficiency of their operations, headquarters' monitoring of
the impact of such responses is necessary to help ensure that
they do not compromise the appropriateness of health care that
veterans receive.
VA health care: VA is adopting managed care practices to better manage
physician resources (GAO/HEHS-97-87, 07/17/97)
The Department of Veterans Affairs (VA) is in the midst of
making fundamental changes in its health care delivery system
because of budgetary pressures and increasing competition in
the health care industry. Many of these initiatives are
affecting the entire VA health care system; they will also
affect how VA manages physician resources, including
identifying the appropriate number and skill mix of physicians
and monitoring productivity and quality of care provided. These
initiatives involve changes in physician practice patterns and
in resource allocation to help ensure effectiveness and
efficiency. In this report, GAO discusses steps VA is taking
and the challenges it faces in managing physician resources,
including the need to balance multiple congressionally mandated
missions.
VA health care: VA's plan for the integration of medical services in
central Alabama (GAO/HEHS-98-245R, 09/23/98)
On June 11, 1998, The Department of Veterans Affairs (VA)
submitted a plan for congressional approval to integrate
services at medical facilities located in Tuskegee and
Montgomery, Alabama.
GAO noted that VA's plan contains the necessary information
to understand the proposed integration of services at the
Montgomery and Tuskegee facilities, including (1) how proposed
changes should occur, (2) how such changes could benefit
veterans and employees, and what steps will be taken to
minimize adverse effects on veterans' access to care and
employees' access to work sites. Most veterans responding to
GAO's survey believed VA's plan contains the necessary
information to understand the proposed integration of the
Montgomery and Tuskegee facilities and most supported VA's plan
because they believe that integrating the two facilities will
increase VA's capacity to provide health care.
VA Hospitals: Issues and challenges for the future (GAO/HEHS-98-32, 04/
30/98)
Use of the 173 hospitals run by the Department of Veterans
Affairs (VA) has steadily declined during the past three
decades; from 1963 through 1995, the average daily workload of
VA hospitals declined 66 percent. This report identifies major
issues and changes that Congress and the administration will
face in the next few years concerning VA hospitals. GAO
compares VA and community hospitals regarding (1) how hospital
care evolved during the 20th century, including changes in
supply and demand; (2) factors contributing to the declining
demand; (3) the extent of excess capacity; and (4) actions
taken to increase efficiency and compete for patients.
VA medical care: Increasing recoveries from private health insurers
will prove difficult (GAO/HEHS-98-4, 10/17/97)
For more than a decade, the Department of Veterans Affairs
(VA) has been authorized to recover from private health
insurers some of its expenses in providing health care to
veterans with no service-connected disabilities. VA's recovery
authority was expanded in 1990 to include care provided to
veterans with service-connected disabilities, as long as that
care was for treatment of conditions unrelated to the veterans'
service-connected disabilities. In fiscal year 1996, VA sought
to recover $1.6 billion but obtained only 31 percent of the
billed amount--or $495 million--a five-percent decline from
fiscal year 1995 recoveries. In its fiscal year 1998 budget
submission, however, VA projects that it will be able to
recover $826 million from private health insurers by fiscal
year 2002. This is important because VA sought and was recently
authorized to keep the money it recovers and to use it to
supplement future appropriations. This report (1) identifies
factors that limit VA's ability to recover more of its billed
charges, (2) evaluates VA's ability to achieve its revenue
targets by identifying factors that could decrease future
recoveries and by assessing the potential for VA initiatives to
boost medical care cost recoveries, and (3) evaluates the way
that VA applies insurance payments to veterans' copayment
liability for veterans in the discretionary care category.
The Veterans Benefits Administration: Clarifying information on
implementing the results act performance requirements (GAO/
HEHS-98-149R, 04/17/98)
Pursuant to a congressional request, GAO provided follow-up
information on the Veterans Benefits Administration's (VBA)
implementation of the Government Performance and Results Act of
1993.
GAO noted that (1) while federal agencies' planning efforts
in implementing the Results Act, as well as, GAO's assessment
of these efforts are still very much a work in progress, the
Department of Human Services is one of the agencies with
programs involving human services that had identified goals
that largely focused on outcomes; (2) moving agencies towards
result-oriented management and associated performance measures
is a significant challenge and GAO believes judging the success
or failure of the Results Act should turn on the extent to
which information produced through the act's goal-setting and
performance measurement practices helps inform policy
decisions; (3) while we have made no recommendations, we have
pointed out that the initial goals and measures for the VBA
programs, as stated in VA's June 1997 draft strategic plan,
were process-oriented and did not reflect program results and
that VBA needs to coordinate with other agencies and
effectively measure and assess its performance in meeting its
goals; and (4) VA's Office of the Inspector General (OIG)
reported that data on claims-processing times were inaccurate,
the data reliability in the claims-processing system was
questionable, and there was evidence of manipulation of data by
regional office staffs. VBA is developing safeguards and plans
for addressing the prevention of data manipulation.
Veterans benefits computer systems: Risks of VBA's year-2000 efforts
(GAO/AIMD-97-79, 05/30/97)
Unless timely, corrective action is taken, the Veterans
Benefits Administration (VBA), like other federal agencies,
could face widespread computer failures at the turn of the
century because of the ``Year 2000'' problem. In many computer
systems, the Year 2000 is undistinguishable from 1900. This
could make veterans who are due to receive benefits appear
ineligible. If this were to happen, issuance of benefits checks
could be disrupted. VBA has tried to address this problem, but
it can do more. First, the Year-2000 management office's
structure and technical capabilities are inadequate. Second,
key Year-2000 readiness assessment processes--determining the
potential severity of the Year-2000 impact on VBA operations,
inventorying its information systems, and developing
contingency plans--have not been completed. Third, VBA lacks
enough information on the costs or potential problems
associated with its approach to making systems Year-2000
compliant. As a result, it cannot make informed choices about
which systems must be funded to avoid disruptions in service
and which can be deferred. Addressing these problems requires
top management attention. Contributing to the challenges are
the loss of key computer people, difficulties in obtaining
information on whether interfaces and third-party products are
Year-2000 compliant, and delays in upgrading systems at VBA
data centers. GAO summarized this report in testimony before
Congress; see: Veterans Benefits Computer Systems:
Uninterrupted Delivery of Benefits Depends on Timely Correction
of Year-2000 Problems (GAO/T-AIMD-97-114, June 26, 1997).
Veterans benefits modernization: VBA has begun to address software
development weaknesses but work remains (GAO/AIMD-97-154, 09/
15/97)
The Veterans Benefits Administration (VBA) is modernizing
its information systems to strengthen its administrative
operations. VBA has taken steps to improve its software
development capability, including launching a software process
improvement initiative, chartering a software engineering
process group, and obtaining the services of an experienced
contractor to help with software process improvements. Despite
this progress, other software development improvements are
needed. These include (1) a defined strategy to reach the
repeatable level and a baseline to measure improvements, (2) a
process improvement training program for its software
developers, and (3) a process to ensure that VBA's software
development contractors are at the repeatable level. Unless
these deficiencies are addressed, VBA's software development
capability will remain ad hoc and chaotic, putting the agency
at risk for cost overruns, poor quality software, and schedule
delays in software development.
Veterans Health Administration facility systems: Some progress made in
ensuring year 2000 compliance, but challenges remain (GAO/AIMD-
98-31R, 11/07/97)
Pursuant to a congressional request, GAO provided
additional information on Year 2000 initiatives at the
Department of Veterans Affairs (VA), focusing on the Veterans
Health Administration's (VHA) failure to complete an inventory
of the elevator, heating, air conditioning, lighting systems,
and disaster recovery systems at its hospitals.
GAO noted that: (1) ensuring Year 2000 compliance for
facility-related systems, as well as disaster recovery or
backup systems, is a critical problem for both public and
private organizations; (2) many facilities built or renovated
within the last 20 years contain embedded computer systems that
control, monitor, or assist in operations, and many of these
systems could malfunction due to vulnerability to the Year 2000
problem; (3) addressing the facility-related systems problems
is especially critical for VHA, because it oversees 173 medical
centers, 376 outpatient clinics, 133 nursing homes, and 39
domiciliaries; (4) VHA has made some progress, including: (a)
its Year 2000 project office has established a project team to
pull together a list of facility-related systems manufacturers;
(b) its medical centers are developing an inventory and
assessing their facility systems for Year 2000 compliance; and
(c) VHA is working with the Chief Information Officer Council's
newly formed Year 2000 Building Systems Subgroup on facility-
related systems issues; and (5) VHA faces some major
challenges, including: (a) it has a very short time frame to
address the Year 2000 computing problem; (b) manufacturers may
not promptly respond to VHA and may not know whether their
products are Year 2000 compliant; (c) VHA is largely dependent
upon manufacturers to determine whether a Year 2000 problem
exists and how problems will be corrected; and (d) VHA must
implement the manufacturers' recommendations for achieving Year
2000 compliance, validate the systems, develop contingency
plans for failures and errors, and coordinate contingency plans
with disaster recovery plans.
Veterans' health care: Chicago efforts to improve system efficiency
(GAO/HEHS-98-118, 05/29/98)
In June 1996, the Department of Veterans' Affairs (VA)
announced the integration of two Chicago hospitals--Lakeside
and West Side hospitals--under one director. These hospitals
became the VA Chicago Health Care System within the Great Lakes
network, which encompasses parts of Illinois, Indiana,
Michigan, and Wisconsin. The Great Lakes network runs 8
hospitals and 12 outpatient clinics. Lakeside and Westside,
which are located about six miles apart in downtown Chicago,
provide acute inpatient medical, surgical, and psychiatric
care. Both hospitals are affiliated with medical schools. This
report examines the effect that the integration has had on
veterans, employees, and medical schools in the Chicago area.
GAO describes (1) the VA Chicago Health Care System's
integration process; (2) the integration decisions made; (3)
the impacts on veterans, employees, and medical schools; and
(4) the dollar savings resulting from these decisions.
Veterans' health care: Service delivery for veterans on Guam and the
Commonwealth of the Northern Mariana Islands (GAO/HEHS-99-14,
11/04/98)
About 9,400 veterans live on Guam and the Commonwealth of
the Northern Mariana Islands. On Guam alone, about 700 veterans
received health care from the Department of Veterans Affairs
(VA) in 1997, at a cost of $1.2 million. In addition to
providing care through its outpatient clinic, VA bought care
from the Navy and private providers on Guam, as well as from
military and private providers in Hawaii and the continental
United States. Veterans groups have raised concerns about the
health care provided on Guam and the inconvenience of traveling
to Hawaii and elsewhere when appropriate care is unavailable on
Guam. They have also raised concerns about the possibility that
the Navy may reduce or eliminate services in its hospital on
Guam. They believe that VA should establish an inpatient
facility at the U.S. Naval Hospital on Guam. This report (1)
describes how VA now meets veterans health care needs on Guam
and the Northern Mariana Islands, (2) estimates these veterans'
possible future demand for health care and assesses VA's
ability to meet this demand, and (3) estimates the cost to
establish a veterans' inpatient ward at the U.S. Naval Hospital
on Guam.
Year 2000 computing crisis: Compliance status of many biomedical
equipment items still unknown (GAO/AIMD-98-240, 09/18/98)
Biomedical equipment that relies on computers or computer
chips, from cardiac monitoring systems to electronic imaging
machines, may be adversely affected by the Year 2000 problem.
Although this situation has serious implications for the
delivery of health care to the nation's veterans, the Veterans
Health Administration (VHA) still does not know the full extent
of its Year 2000 problem or the cost to overcome it. This is
because it has yet to receive compliance information from 27
percent of the biomedical equipment manufacturers on its list
of suppliers or from the nearly 100 other manufacturers that
VHA discovered were no longer in business. According to VHA,
most manufacturers reporting noncompliant equipment cited
incorrect display of date and/or time as problems--albeit ones
that health care providers can work around. Some manufacturers,
however, cited more serious problems that could jeopardize
patient safety. For example, a miscalculation by a radiation
therapy planning computer could cause a patient to receive a
hazardous radiation dose. The Food and Administration (FDA),
which oversees and regulates medical devices, has sent letters
to biomedical equipment manufacturers asking for information on
products affected by the Year 2000 problem. The response rate
to FDA has been disappointing. It is critical that such
information be obtained and publicized. GAO summarized this
report in testimony before Congress; see: Year 2000 Computing
Crisis: Leadership Needed to Collect and Disseminate Critical
Biomedical Equipment Information (GAO/T-AIMD-98-310, Sept. 24,
1998).
Year 2000 computing crisis: Progress made in compliance of VA systems,
but concerns remain (GAO/AIMD-98-237, 08/21/98)
GAO has reported in the past that unless timely corrective
action is taken, the Department of Veterans Affairs (VA) could
face widespread computer system failures at the turn of the
century because of incorrect information processing involving
dates. (See GAO/T-AIMD-97-174, Sept. 1997; GAO/T-AIMD-97-114,
June 1997; GAO/AIMD-97-79, May 1997; and GAO/AIMD-96-103, June
1996.) In many systems, the year 2000 is indistinguishable from
the year 1900, which could make veterans who are due to receive
benefits and medical care appear ineligible. The upshot is that
benefits and health care that veterans depend on could be
delayed or interrupted. This report assesses the Year 2000
programs of the Veterans Benefits Administration and the
Veterans Health Administration.
CALENDAR YEARS 1997 AND 1998 TESTIMONIES ON ISSUES AFFECTING OLDER
AMERICANS
GAO testified 53 times before Congressional committees
during calendar years 1997 and 1998 on issues relating to older
Americans. Of these testimonies, 31 were on health, 11 on
income security, and 11 on veterans and DOD issues.
Health Issues
Balanced Budget Act: Implementation of key medicare mandates must
evolve to fulfill congressional objectives (GAO/T-HEHS-98-214,
07/16/98)
The Balanced Budget Act of 1997 (BBA) contained more than
200 mandates for Medicare. These mandates amount to what are
probably the most significant modifications to the Medicare
program since its inception 30 years ago. In summary, this
testimony found that the Health Care Financing Administration
(HCFA) is making progress in meeting the legislatively
established implementation schedules for BBA Medicare
provisions. Since the passage of BBA in August 1997, almost
three-fourths of the mandates with a July 1998 deadline have
been implemented. However, HCFA officials have acknowledged
that many remaining BBA mandates will not be implemented on
time.
California nursing homes: Care problems persist despite Federal and
State oversight (GAO/T-HEHS-98-219, 07/28/98)
This testimony summarizes a July 1998 report, California
Nursing Homes: Federal and State Oversight Inadequate to
Protect Residents in Homes With Serious Care Violations (GAO/
HEHS-98-202, 7/27/98).
High-risk areas: Benefits to be gained by continued emphasis on
addressing high-risk areas (GAO/T-AIMD-97-54, 03/04/97)
This testimony addresses solutions to the serious
management problems (discussed two weeks before in GAO/T-HR-97-
22), which cost taxpayers billions of dollars and undermine the
quality of government services. GAO outlines the steps that
need to be taken to fix these problems. (High-Risk Series, GAO/
HR-97-1 through GAO/HR-97-14, February 1997)
High-risk areas: Update on progress and remaining challenges (GAO/T-HR-
97-22, 02/13/97)
In 1990, GAO began a special effort to identify federal
programs at high risk for waste, fraud, abuse, and
mismanagement. GAO issued a series of reports in December 1992
on the fundamental causes of the problems in the high-risk
areas; it followed up on the status of these areas in February
1995. GAO's third series of high-risk reports, revisits these
troubled government programs and designates five additional
areas as high-risk (defense infrastructure, information
security, the year 2000 problem, supplemental security income,
and the 2000 decennial census), bringing to 25 the number of
high-risk programs on GAO's list. This testimony before
Congress summarized the third series of high-risk reports.
(High-Risk Series, GAO/HR--7-1 through GAO/HR-97-14, February
1997)
Long term care: Baby boom generation presents financing challenges
(GAO/T-HEHS-98-107, 03/09/98)
Long-term care presents a significant burden for many
persons and for public programs. Long-term care in a nursing
home can cost more than $40,000 per year, with many nursing
home residents paying that out of their own pockets. In
addition to this out-of-pocket spending, Medicaid and Medicare
paid out more than $51 billion in 1995 for long-term care for
the elderly. More than a million elderly persons with extensive
disabilities live at home, relying on their families for
assistance. The aging of the baby boomers, particularly as they
reach age 85 and older, will have a dramatic impact on the
numbers of persons needing long-term care and will challenge
individuals, families, and public programs to finance and
furnish that care. This testimony (1) provides an overview of
current spending for long-term care for the elderly, (2)
discusses the increased demand that the baby boomers will
likely create for long-term care, (3) describes recent shifts
in Medicaid and Medicare financing of long-term care, and (4)
discusses the potential role of private long-term care
insurance in helping to pay for this care.
Medicare automated systems: Weaknesses in managing information
technology hinder fight against fraud and abuse (GAO/T-AIMD-97-
176, 09/29/97)
GAO has included Medicare in its list of government
programs at high risk for fraud and abuse. (See GAO/HR-97-10,
Feb. 1997.) The Department of Health and Human Service's
Inspector General estimates that Medicare overpayments totaled
$23.2 billion in fiscal year 1996, or about 14 percent of total
Medicare fee-for-service payments. Ongoing Medicare initiatives
to combat fraud and abuse include (1) an arrangement with the
Energy Department's Los Alamos National Laboratory in 1995 to
research the potential identification of fraud and abuse
patterns and, more recently, (2) an assessment of the
feasibility of using commercial abuse-detection software. This
testimony focuses on the Medicare Transaction System (MTS), the
Health Care Financing Administration's (HCFA) principal
information technology initiative to detect fraud and abuse,
and recommendations GAO made to correct serious weaknesses in
MTS management. GAO also describes the two continuing HCFA
initiatives against fraud and abuse, including the agency's
response to earlier GAO recommendations on the benefits of
commercial abuse detection software. Finally, GAO frames the
discussion in broader terms, examining underlying information
technology management issues with an eye toward identifying
causes and solutions so HCFA can use automated systems to
successfully fight Medicare fraud and abuse.
Medicare billing: Commercial system will allow HCFA to save money,
combat fraud and abuse (GAO/T-AIMD-98-166, 05/19/98)
This testimony summarizes the GAO report on Medicare
Billing: Commercial System Could Save Hundreds of Millions
Annually (GAO/AIMD-98-91, 04/15/98).
Medicare: Control over fraud and abuse remains elusive (GAO/T-HEHS-97-
165, 06/26/97)
Medicare's size and mission make it an attractive target
for exploitation. That wrongdoers continue to dodge safeguards
underscores the need for increasingly sophisticated ways to
protect against system abuses. Improved oversight and
leadership at the Health Care Financing Administration (HCFA),
the mitigation of risks involved in acquiring Medicare's new
multibillion dollar automated claims processing system--the
Medicare Transaction System, and the appropriate use of new
anti-fraud-and-abuse funds should help stem substantial losses
in the future. Moreover, as Medicare's managed care enrollment
grows, HCFA needs to ensure that beneficiaries receive enough
information about health maintenance organizations (HMO) to
make informed choices and that the agency enforces HMO
compliance with federal standards. How HCFA will use the
funding and authority provided under the Health Insurance
Portability and Accountability Act of 1996 to improve its
oversight over Medicare expenditures has not yet been
determined. However, HCFA's earlier efforts to oversee fee-for-
service contractors, the acquisition of the Medicare
Transaction System, and Medicare managed care plans were
plagued by weak monitoring, poor coordination, and delays. In
GAO's view, HCFA's prospects for successfully combatting
Medicare fraud and abuse are unclear.
Medicare: HCFA can improve methods for revising physician practice
expense payments (GAO/T-HEHS-98-105, 03/03/98)
This testimony summarizes an earlier GAO report with the
same title (GAO/HEHS-98-79, Feb. 27, 1998), which evaluated the
Health Care Financing Administration's (HCFA) proposed
revisions of physician practice expense payments and presented
information on HCFA's ongoing efforts to refine its data and
methodologies.
Medicare: HCFA faces multiple challenges to prepare for the 21st
century (GAO/T-HEHS-98-85, 01/29/98)
This testimony focuses on the Health Care Financing
Administration's (HCFA) preparedness to run the Medicare
program in the 21st century. Because the $200 billion Medicare
program is critical to nearly all elderly Americans and to many
of the nation's disabled, program management, excessive
spending, and depletion of the Medicare Trust Fund have been
the subject of much congressional scrutiny in recent years. GAO
and others have frequently reported that too much is being
spent inappropriately because of the fraudulent and abusive
billing practices of health care providers. GAO discusses (1)
HCFA's new authorities under recent Medicare legislation, (2)
the view of HCFA managers on the agency's ability to carry out
various Medicare functions, and (3) the steps HCFA needs to
take to accomplish its objectives over the next several years.
Medicare: Home health cost growth and administration's proposal for
prospective payment (GAO/T-HEHS-97-92, 03/05/97)
After relatively modest cost growth during the 1980s,
Medicare expenditures for home health care have soared in
recent years. Home health care costs grew from $2.4 billion in
1989 to $17.7 billion in 1996--an average annual increase of 33
percent. Medicare's home health care costs have grown because a
larger portion of beneficiaries use this benefit than in the
past and the number of service used by each beneficiary has
more than doubled. Several factors have increased use of the
benefit. Legislation and coverage policy changes in response to
court decisions liberalized coverage criteria for the benefit.
These changes, in turn, transformed the nature of home health
care from primarily posthospital care to more long-term care
for chronic conditions. Finally, weaker administrative controls
over the benefit, resulting from resource constraints, make the
detection of inappropriate claims more unlikely. The
administration's major proposals for home health care are
designed to give providers greater incentives to operate
efficiently by immediately tightening the limits on the cost
per visit that will be paid and imposing a new cap on per-
beneficiary costs. After these changes go into effect in 1999,
home health payments would switch from a cost reimbursement to
a prospective payment system. These two proposals are estimated
to save $12.4 billion during the next five years.
Medicare: Improper activities by Mid-Delta Home Health (GAO/T-OSI-98-6,
03/19/98)
Testimony given on report entitled: Medicare: Improper
Activities by Mid-Delta Home Health (GAO/T-OSI-98-5, Mar. 12,
1998).
Medicare: Inherent program risks and management challenges require
continued federal attention (GAO/T-HEHS-97-89, 03/04/97)
Federal spending for Medicare, one of the largest
government entitlement programs, totaled $197 million in fiscal
year 1996. Because of the program's size and mission, Medicare
remains at high-risk for waste, fraud, and abuse. That
wrongdoers continue to find ways to dodge safeguards
illustrates the need for constant vigilance and increasingly
sophisticated ways to protect against gaming the system. Better
oversight and leadership by the Health Care Financing
Administration (HCFA), the appropriate application of new anti-
fraud-and-abuse funds, and the mitigation of risks involved in
acquiring the Medicare Transaction System--a major claims
processing system--should help reduce future losses. Moreover,
as Medicare's managed care enrollment grows, HCFA must ensure
that payments to health maintenance organizations (HMO) reflect
the cost of care, that beneficiaries receive enough information
about HMOs to make informed choices, and that the agency uses
its expanded authority to enforce HMO compliance with federal
standards.
Medicare: Interim payment system for home health agencies (GAO/T-HEHS-
98-234, 08/06/98)
A well-designed prospective payment system is the best way
for Medicare to rationally control home health spending. Until
such a system is implemented, however, the interim payment
system will help constrain the growth in outlays. Yet concerns
have been raised about the interim payment system.
Specifically, the industry doubts whether payments will be
adequate and whether the payment limits will adequately account
for differences in patient mix and treatment patterns across
agencies. Another concern is that inefficient providers will
have unduly high limits because the limits are based on
historic payments that reflect inappropriate practices. GAO and
the Department of Health and Human Services' Office of
Inspector General have previously reported that Medicare has
been billed for home health visits that may not have been
needed, were inconsistent with Medicare policies, or were not
even delivered. Thus, concerns about the overall adequacy of
payments under the interim system may be unwarranted because
the limits were based on historic costs, a portion of which
were unreliable. Whether the payments to individual agencies
will reflect legitimate differences across agencies is more
difficult to determine.
Medicare: Provision of key preventive diabetes services falls short of
recommended levels (GAO/T-HEHS-97-113, 04/11/97)
This testimony summarizes a report entitled Medicare: Most
Beneficiaries With Diabetes Do Not Receive Recommended
Monitoring Services (GAO/HEHS-97-48, 3/28/97).
Medicare: Recent legislation to minimize fraud and abuse requires
effective implementation (GAO/T-HEHS-98-9, 10/09/97)
With the enactment of the Health Insurance Portability and
Accountability Act of 1996 and the Balanced Budget Act of 1997,
Congress has provided significant opportunities to strengthen
areas in the Medicare program at high risk for fraud and abuse.
How Medicare will use this legislation to improve its oversight
of program expenditures remains to be seen, however. The
outcome depends largely on how promptly and effectively the
Health Care Financing Administration (HCFA) implements the
various provisions. HCFA's past efforts to implement
regulations, oversee Medicare managed care plans, and acquire a
major information system have often been slow or ineffective.
Now that many more demands have been placed on HCFA, GAO is
concerned that the promise of the new legislation to combat
health care fraud and abuse could be delayed or not realized at
all.
Medicare and Medicaid: Meeting needs of dual eligibles raises difficult
cost and care issues (GAO/T-HEHS-97-119, 04/29/97)
``Dual eligibles'' are Medicare beneficiaries who are also
eligible for some form of Medicaid support. In 1995, Medicare
and Medicaid spending for the roughly 6 million dual eligibles
totaled $106 billion, or nearly one third of these programs'
combined expenditures. The dually eligible population is
expected to grow, resulting in even greater health financing
expenditures and care challenges. The dually eligible
population consists of persons with a range of health needs--
from the young to the very old, from the healthy to the
chronically ill in nursing homes. Compared with Medicare-only
beneficiaries, however, dually eligible beneficiaries are more
likely to be in poor health and require costly care, including
long-term care. Meeting their needs under two programs that are
administered under different rules complicates matters in both
fee-for-service and managed care environments. The potential to
cover posthospital and long-term care benefits under either
program has resulted in costs being shifted between programs.
Much of the financial burden falls on the federal government.
To better coordinate acute and long-term care needs, some
states are looking into enrolling their dually eligible
populations in a single managed care plan. However, differences
in Medicare and Medicaid requirements for commercial managed
care participation could pose barriers.
Medicare HMOs: HCFA could promptly reduce excess payments by improving
accuracy of county payment rates (GAO/T-HEHS-97-78, 02/25/97)
This testimony discusses the rates that Medicare pays
health maintenance organizations (HMO) in its risk contract
program, Medicare's principal managed care option. Medicare's
method for paying risk contract HMOs was designed to save the
program five percent of the costs for beneficiaries who enroll
in HMOs. However, GAO testified that HMO rate-setting problems
have prevented Medicare from realizing this saving. The
program's rate-setting methods have resulted in excess payments
to HMOs because HMO enrollees would have cost Medicare less if
they had stayed in the fee-for-service sector. A recent
estimate placed the total excess payments to HMOs at $2 billion
annually. GAO's method of calculating the county rate would
reduce payments more for HMOs in counties with higher excess
payments and less for HMOs in counties with lower excess
payments. GAO's method represents a targeted approach to
reducing excess payments and could lower Medicare expenditures
by at least several hundred million dollars each year.
Medicare HMOs: HCFA could promptly reduce excess payments by improving
accuracy of county payment rates (GAO/T-HEHS-97-82, 02/27/97)
This testimony discusses the rates that Medicare pays
health maintenance organizations (HMO) in its risk contract
program, Medicare's principal managed care option. Medicare's
method for paying risk contract HMOs was designed to save the
program five percent of the costs for beneficiaries who enroll
in HMOs. However, GAO testified that HMO rate-setting problems
have prevented Medicare from realizing this saving. The
program's rate-setting methods have resulted in excess payments
to HMOs because HMO enrollees would have cost Medicare less if
they had stayed in the fee-for-service sector. A recent
estimate placed the total excess payments to HMOs at $2 billion
annually. GAO's method of calculating the county rate would
reduce payments more for HMOs in counties with higher excess
payments and less for HMOs in counties with lower excess
payments. GAO's method represents a targeted approach to
reducing excess payments and could lower Medicare expenditures
by at least several hundred million dollars each year.
Medicare home health: Success of balanced budget act cost controls
depends on effective and timely implementation (GAO/T-HEHS-98-
41, 10/29/97)
This testimony examines how the Balanced Budget Act of 1997
has addressed rapid cost growth in Medicare's home health
benefit. This benefit is important to many beneficiaries
recovering from illness or injury following hospitalization--
the original purpose of the benefit. Of late, however,
increasing numbers of beneficiaries have used the benefit for
custodial-type care for chronic conditions. This change has
helped to fuel growth in Medicare home health costs, which
soared from about $2 billion in 1989 to nearly $18 billion in
1996. GAO's remarks focus on the following four areas: the
reasons for the rapid growth of Medicare home health care costs
in the 1990s, the interim changes in the act to Medicare's
current payment system, establishment under the act of a
prospective payment system for home health care, and efforts by
Congress and the administration to strengthen program
safeguards to prevent fraud and abuse in home health services.
Medicare home health agencies: Certification process is ineffective in
excluding problem agencies (GAO/T-HEHS-97-180, 07/28/97)
As a result of changes to Medicare during the 1980s, more
people are receiving home health services for longer periods of
time. This has led to rapid growth in the number of certified
home health agencies--from 5,700 in 1989 to nearly 10,000 at
the beginning of 1997. During this same period, Medicare
payments for home health care jumped from $2.7 billion to about
$18 billion. These payments are projected to reach nearly $22
billion in fiscal year 1998. GAO testified that it is simply
too easy for home health agencies to become certified. The
certification of a home health agency as a Medicare provider is
based on an initial survey that takes place soon after the
agency begins operating, and there is little assurance that the
home health agency is providing quality care. And because the
requirements are minimal, Medicare certifies nearly all home
health agencies seeking certification. Although many home
health agencies are drawn to the program with the intent of
providing quality care, some are attracted by the relative ease
with which they can become certified and participate in this
lucrative, growing industry. Once certified, home health
agencies are unlikely to be terminated from the program or
otherwise penalized, even when they have been repeatedly cited
for substandard care or failure to meet Medicare's conditions
for participation.
Medicare home health benefit: Congressional and HCFA actions begin to
address chronic oversight weaknesses (GAO/T-HEHS-98-117, 03/19/
98)
Home health care is an important Medicare benefit, allowing
beneficiaries with acute-care needs, such as recovery from hip
replacement, and chronic conditions, such as congestive heart
failure, to receive care in their homes rather than in more
costly settings, such as nursing homes and hospitals. Drawing
on past GAO work on the home health care industry, this
testimony summarizes (1) the general nature of beneficiary
eligibility criteria, which opportunists exploit to provide
excessive services; (2) diminished Medicare contractor review
and audit effort, which makes it less likely that abusers will
be caught; (3) weaknesses in Medicare's home health provider
certification process; and (4) new tools that Congress has
provided to strengthen oversight of the home health benefit,
including provisions of the Health Insurance Portability and
Accountability Act of 1996 and the Balanced Budget Act of 1997.
Medicare managed care: HCFA missing opportunities to provide consumer
information (GAO/T-HEHS-97-109, 04/10/97)
Medicare beneficiaries need more and better information so
that they can make informed decisions when choosing a health
plan. Although Medicare is the nation's largest purchaser of
managed care services, it lags behind other large purchasers in
providing comparative information to beneficiaries. The need
for this information grows more urgent each month as tens of
thousands of beneficiaries join the 4 million beneficiaries who
have already opted for Medicare managed care. The Health Care
Financing Administration (HCFA) is moving in the right
direction by making information available, but GAO believes
that HCFA could, with relatively little time and effort, do
much more. Requiring that health maintenance organizations use
standard terminology and formats to describe benefits,
producing comparison charts and ensuring that interested
beneficiaries know how to get such charts, and analyzing and
publishing comparative data already available (such as
disenrollment rates) would greatly enhance the ability of
Medicare beneficiaries to be wise consumers of managed care.
Medicare managed care: HMO rates, other factors create uneven
availability of benefits (GAO/T-HEHS-97-133, 05/19/97).
Medicare risk health maintenance organization (HMO) plans
are not available nationwide, and differences in premiums
charged and benefits offered across the country have produced
inequities for Medicare beneficiaries. In addition, the risk
contract program has not realized the expected savings from
enrolling beneficiaries in capitated managed care plans.
Medicare's risk HMO payment system, which is built largely on
fee-for-service costs, accounts for some, but not all, of the
unevenness in Medicare's risk contract program. Differences in
local medical prices and service utilization explain much of
the variation in HMO capitation rates across counties. In turn,
the variation in these rates explains some of the differences
across locations in the availability of risk contract HMOs, the
level of HMO premiums charged, and the richness of benefits
offered. Other factors, however, also play an important role.
GAO proposes correcting a flaw in Medicare's rate-setting
method that contributes to excess payments to HMOs.
Medicare managed care: Information standards would help beneficiaries
make more informed health plan choices (GAO/T-HEHS-98-162, 05/
06/98)
GAO reported in 1996 that beneficiaries received little or
no comparative information on Medicare health maintenance
organizations. (See GAO/HEHS-97-23.) GAO recommended that the
Health Care Financing Administration (HCFA) produce plan
comparison charts; require plans to use standard formats and
terminology in key aspects of their marketing materials; and
publicize readily available plan performance indicators, such
as disenrollment rates. In addition, Medicare+Choice provisions
authorize new health plan options for Medicare beneficiaries
and require HCFA to provide beneficiaries with comparative
information on the Medicare+Choice options. This testimony
discusses the extent to which HCFA's Medicare+Choice
information development efforts are likely to (1) enable
beneficiaries to readily compare benefits and out-of-pocket
costs using plan brochures and (2) facilitate the agency's
approval of plans' marketing materials and other administrative
work required of both HCFA and the health plans.
Medicare post-acute care: Cost growth and proposals to manage it
through prospective payment and other controls (GAO/T-HEHS-97-
106, 04/09/97)
After relatively modest growth during the 1980s, Medicare
outlays for skilled nursing facilities and home health care
have soared during the 1990s. Expenditures for inpatient
rehabilitation facilities have grown rapidly since the mid-
1980s. Skilled nursing facility payments rose from $2.8 billion
in 1989 to $11.3 billion in 1996, while home health care costs
grew from $2.4 billion to $17.7 billion during that same
period. Rehabilitation facility payments increased from $1.4
billion in 1989 to $3.9 billion in 1994. During those periods,
annual growth averaged 22 percent for skilled nursing
facilities, 33 percent for home health care, and 23 percent for
rehabilitation facilities. This testimony focuses on the
reasons behind the cost growth and the administration's
legislative proposals for these three Medicare benefits.
Medicare post-acute care: Home health and skilled nursing facility cost
growth and proposals for prospective payment (GAO/T-HEHS-97-90,
03/04/97)
After relatively modest cost growth during the 1980s,
Medicare's outlays for skilled nursing facilities and home
health care have grown rapidly during the 1990s. Skilled
nursing facility payments rose from $2.8 billion in 1989 to
$11.3 billion in 1996, while home health care costs rose from
$2.4 billion to $17.7 billion during the same period. This
testimony discusses the reasons behind the costs growth for
skilled nursing facilities and home health care and the
administration's announced legislative proposals for these two
Medicare benefits.
Medicare transaction system: Serious managerial and technical
weaknesses threaten modernization (GAO/T-AIMD-97-91, 05/16/97)
This report summarizes the GAO report on Medicare
Transaction System: Success Depends Upon Correcting Critical
Managerial and Technical Weaknesses (GAO/AIMD-97-78, 05/16/97).
Nursing homes: Too early to assess new efforts to control fraud and
abuse (GAO/T-HEHS-97-114, 04/16/97)
Although Medicaid is the largest single payer for nursing
home care, Medicare pays a substantial portion of the health
care costs of nursing home residents. For the opportunistic
provider, a nursing home represents a vulnerable elderly
population in a single location and the opportunity for
multiple billings. Many nursing home patients are mentally
impaired, and their care is controlled by the nursing home.
Because these patients would not realize what items or services
were billed on their behalf, some providers may take advantage
of the situation by submitting fraudulent claims. GAO testified
that fraudulent billing has occurred because (1) the
complexities of the reimbursement process invite exploitation
and (2) poor control over Medicare claims has reduced the
likelihood that inappropriate claims will be denied. GAO is
encouraged by recent efforts to combat fraud and abuse--the
pending implementation of provisions in the Health Insurance
Portability and Accountability Act and a proposal made by the
administration.
Private health insurance: Employer coverage trends signal possible
decline in access for 55- to 64-year-olds (GAO/T-HEHS-98-199,
06/25/98)
This testimony summarizes the GAO report on Private Health
Insurance: Declining Employer Coverage May Affect Access for
55- to 64-Year-Olds (GAO/HEHS-98-133, 06/01/98).
Retiree health insurance: Erosion in retiree health benefits offered by
large employers (GAO/T-HEHS-98-110, 03/10/98)
Employer-provided insurance for retirees has experienced a
slow but persistent decline since the early 1990s. Rising
health care costs have spurred companies to find ways to
control their benefit expenditures, including eliminating
retiree coverage and increasing cost sharing. Moreover, a new
financial accounting standard developed in the late 1980s has
changed employers' perceptions of retiree health benefits and
may have served as a catalyst to reduce retiree coverage. The
Health Insurance Portability and Accountability Act of 1996
mandates continued access to health insurance for persons
losing group coverage. The legislation does not, however,
guarantee that the continued coverage will be affordable.
Because state laws governing the operation of the individual
market can vary, the premiums faced by early retirees vary
substantially. Moreover, considering that large companies
typically pay 70 to 80 percent of the premium, costs in the
individual market may come as a rude awakening for early
retirees. Persons who are already retired when a company
terminates coverage are not eligible to temporarily continue
that firm's health plan at their own expenses. COBRA coverage
is only available to active employees who quit or retire or are
fired or laid off. To address this potential gap in coverage
when a former employer unexpectedly terminates health
insurance, Congress and the President have proposed allowing
affected retirees to purchase continuation coverage at a cost
that reflects their higher utilization of services until they
become eligible for Medicare.
Income Security Issues
Social Security: Mandating coverage for State and local employees (GAO/
T-HEHS-98-127, 05/21/98)
This testimony preceded a GAO report on mandatory coverage
which expanded on the testimony. The report was entitled Social
Security: Implications of Extending Mandatory Coverage to State
and Local Employees (GAO/HEHS-98-196, 08/18/98).
Social Security: Restoring long-term solvency will require difficult
choices (GAO/T-HEHS-98-95, 02/10/98)
Social Security, the foundation of the nation's retirement
income system, provides 42 percent of all income for the
elderly--about twice as much as any other single source.
Because of significant demographic changes, however, Social
Security now faces a serious long-term financing shortfall.
This testimony discusses five fundamental choices that Social
Security reforms will reflect: (1) balancing income adequacy
and individual equity, (2) determining who bears risks and
responsibilities, (3) choosing among various benefit reductions
and revenue increases, (4) using pay-as-you-go or advance
funding, and (5) deciding how much to save and invest in the
nation's productive capacity.
Social Security Administration: Information technology challenges
facing the commissioner (GAO/T-AIMD-98-109, 03/12/98)
During congressional testimony, GAO discussed generally the
challenges that SSA faced in implementing its Year 2000 program
and other information technology initiatives. GAO noted SSA's
need to address three major risks in its Year 2000 program: (1)
ensuring compliance of the state Disability Determination
Services' (DDS) systems that support SSA in administering its
disability programs, (2) ensuring that SSA's data exchanges
with other federal agencies, state agencies, and private
businesses were Year 2000 compliant, and (3) developing
contingency plans to ensure business continuity in the event of
systems failure. GAO also discussed ongoing issues concerning
the implementation of IWS/LAN, including contractor concerns
regarding the availability of the workstations specified in the
IWS/LAN contract, DDS concerns regarding SSA's management of
the network, and the need for IWS/LAN performance measures. In
addition, this testimony discussed a recent GAO report on SSA's
efforts to improve its software development process (see GAO/
AIMD-98-39, Jan. 1998); it also updated testimony from last
year on SSA's experiences in making personal earnings and
benefits information available over the Internet (see GAO/T-
AIMD/HEHS-97-123, May 1997).
Social Security Administration: Internet access to personal earnings
and benefits information (GAO/T-AIMD/HEHS-97-123, 05/06/97)
This testimony updated the testimony described immediately
above. See Social Security Administration: Information
Technology Challenges Facing the Commissioner (GAO/T-AIMD-98-
109, 03/12/98).
Social Security reform: Demographic trends underlie long-term financing
shortage (GAO/T-HEHS-98-43, 11/20/97)
Increasing life expectancy and declining fertility rates
pose serious challenges not just for the Social Security system
but also for Medicare, Medicaid, the federal budget, and the
economy as a whole. The aging of the baby boomers will simply
accelerate this trend. Today, Social Security receives more
from payroll taxes than it pays out in benefits. This excess
revenue is helping to build substantial trust fund reserves
that should help pay full benefits until 2029, according to
Social Security's intermediate projections. At the same time,
this excess revenue is helping to reduce the overall federal
budget deficit, although it will begin to taper off after 2008.
In 2012, Social Security benefit payments are projected to
exceed cash revenues, and the federal budget will start to come
under considerable strain as the general fund starts to repay
funds borrowed from the trust funds.
Although Social Security's revenues now exceed its
expenditures, those revenues are expected to be about 14
percent less than total projected expenditures over the next 75
years, according to Social Security Administration estimates.
Various benefit reductions and revenue increases within the
current program structure could be combined to restore
financial balance. However, some observers believe that the
program structure should be reevaluated. Reform is necessary,
and the sooner it is addressed the less severe the adjustments
will need to be.
Social Security reform: Implications for the financial well-being of
women (GAO/T-HEHS-97-112, 04/10/97)
Proposed Social Security reforms affect the financial well-
being of beneficiaries, especially women. Elderly unmarried
women are much more likely to be living below the poverty line.
Twenty-two percent of unmarried elderly women have income below
the poverty threshold, compared with 15 percent of unmarried
elderly men and only 5 percent of elderly married couples.
Under current Social Security law, women tend to receive lower
financial benefits than do men, primarily because they usually
have lower lifetime earnings and work fewer years. Women's
experiences under pension plans also differ from men's not only
because of earning differences but also because of differences
in investment behavior and longevity. Moreover, public and
private pension plans do not offer the same social insurance
protections that Social Security does. The Social Security
Advisory Council's reform proposals aimed at resolving future
financial problems confronting the system contain elements that
may exacerbate the differences in benefits. For example,
proposals that call for individual retirement accounts will pay
benefits that are affected by investment behavior and
longevity. Expected changes in women's labor force
participation rates and increasing earnings will reduce but
probably not eliminate these differences.
Social Security reform: Raising retirement ages improves program
solvency but may cause hardship for some (GAO/T-HEHS-98-207,
07/15/98)
Many of the proposals before Congress to mitigate Social
Security's long-term financial shortfall of nearly $3 trillion
would raise either the normal retirement age, currently 65, the
early retirement age, currently 62, or both. Increasing
retirement ages is expected to help alleviate the financing
problem by increasing the amount that individuals pay into the
Social Security trust fund and reducing the benefits they draw
out. GAO found that raising the Social Security retirement ages
could improve long-term solvency for the program by increasing
revenues and reducing benefits, but it is unclear whether
employers will be willing to retain or hire older workers.
Older blue-collar workers may be adversely affected because
they are at risk for certain health problems that limit their
ability to continue working.
Social Security financing: Implications of Government stock investing
for the trust fund, the Federal budget, and the economy (GAO/T-
AIMD/HEHS-98-152, 04/22/98)
This testimony summarized GAO's report entitled Social
Security Financing: Implications of Government Stock Investing
for the Trust Fund, the Federal Budget, and the Economy, (GAO/
AIMD/HEHS-98-74, April 22, 1998). In addition, it examined ways
that government stock investing contrasts with stock investing
through Social Security reforms that would create individual
retirement savings accounts. With government stock investing,
risks and returns would be shared collectively through the
government rather than borne individually.
SSA's management challenges: Strong leadership needed to turn plans
into timely, meaningful action (GAO/T-HEHS-98-113, 03/12/98)
The Social Security Administration (SSA) has been an
independent agency since March 1995. This testimony discusses
SSA's progress in addressing several challenges identified in
earlier GAO reports. These challenges include the agency's need
to strengthen its research and policy capacity so that it can
address the solvency issue, address management and oversight
problems with its Supplemental Security Income program,
redesign its disability programs and promote beneficiaries'
return to work, and meet its future workload demands.
Year 2000 computing crisis: Continuing risks of disruption to Social
Security, Medicare, and Treasury programs (GAO/T-AIMD-98-161,
05/07/98)
The upcoming change of century poses a challenge to
virtually all major organizations, public and private,
including government programs with a high degree of interaction
with the American public such as Social Security and Medicare.
For this reason, GAO designated the Year 2000 computing problem
as a high risk area for the federal government, and published
guidance to help organizations successfully address the issue.
GAO briefly outlined what additional actions must be taken
to reduce the nation's Year 2000 risks, and what its inquiries
into Year 2000 readiness found at the Social Security
Administration (SSA), the Health Care Financing Administration
(HCFA), and the Department of Treasury.
The Year 2000 will present many difficult challenges in
information technology and in ensuring the continuity of
business operations, and has the potential to cause serious
disruption to the nation and to the government entities on
which the government depends, including the SSA, the HCFA, and
the Department of the Treasury. These risks can be mitigated
and disruptions minimized with proper attention and management.
While these agencies and programs have been working to mitigate
their Year 2000 risks, further action must be taken to ensure
continuity of mission critical business operations.
Year 2000 computing crisis: Progress made at Department of Labor, but
key systems at risk (GAO/T-AIMD-98-303, 09/17/98)
The Department of Labor has made progress in addressing the
Year 2000 computing crisis, but risks remain in several areas,
including making benefit payments to laid-off workers,
collecting labor statistics, and ensuring accurate accounting
for pension benefits. Some of the systems supporting these
business areas are at risk. It is critical that contingency
plans be developed to ensure business continuity in the event
of systems failures.
Veterans' & DOD Issues
Arlington National Cemetery: Authority, process, and criteria for
burial waivers (GAO/T-HEHS-98-81, 01/28/98)
Since 1967, 196 waivers have been granted to allow burial
at Arlington National Cemetery to persons not otherwise
qualified, and at least 144 documented requests have been
denied. Of the granted waivers, about 63 percent involved
burials of persons in the same grave as someone already
interred or expected to be interred. Although the Secretary of
the Army has no explicit statutory or regulatory authority to
grant waivers, it is legal for the Secretary to do so. GAO
found that most waiver requests have been handled through an
internal Army review process involving officials responsible
for the administration of Arlington. However, this process is
not followed in all cases. For example, in the case of
presidential waiver decisions, the Army process is generally
bypassed. Moreover, because the process is not widely
understood, persons with high-level contacts sometimes appear
to have an advantage. Finally, although those responsible for
making waiver decisions appear to apply some generally
understood criteria, these criteria, which are not formally
established, are not always consistently applied or clearly
documented.
Defense health care: Limits to older retirees' access to care and
proposals for change (GAO/T-HEHS-97-84, 02/27/97)
When space and resources are available in military medical
facilities, military retirees may receive care at little or no
cost. When resources are unavailable, retirees under age 65 can
seek medical care from the private sector, and the Defense
Department's (DOD) Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) will cover the cost. But retirees
age 65 or over lose the CHAMPUS benefit, and the only DOD-
funded care they are eligible for is the space-available care
at military facilities. In the last 10 years, one-third of
military hospitals have been closed because of military
downsizing, reducing space available for older retirees, a
group that has grown 75 percent during the last 10 years to 1.2
million. In addition, DOD's managed health care system gives
older retirees the lowest priority for access to space. GAO
examines the costs and benefits of five proposed alternatives
for addressing the issue of health care for older retirees: (1)
Medicare subvention, (2) enrollment in the Federal Employees
Health Benefit Program, (3) CHAMPUS as a secondary payer, (4)
Medigap policies, and (5) a mail order pharmacy benefit. This
testimony preceded the actual enactment and implementation of
Medicare Subvention and FEHBP for persons 65 or over on a trial
basis. See Military Retirees' Health Care: Costs and Other
Implications of Options to Enhance Older Retirees' Benefits
(GAO/HEHS-97-134, 06/20/97), which was related to this
testimony.
National cemetery system: Plans for addressing projected increases in
veterans' burials (GAO/T-HEHS-98-157, 04/29/98)
This testimony summarizes a GAO report on National Cemetery
System: Opportunities to Expand Cemeteries' Capacities (GAO/
HEHS-97-192, 09/10/97).
VA health care: Lessons learned from medical facility integrations
(GAO/T-HEHS-97-184, 07/24/97)
The Department of Veterans Affairs (VA) operates 173
hospitals and more than 200 freestanding outpatient clinics
nationwide at a cost of about $17 billion a year. Two years
ago, VA created 22 networks to help improve service delivery to
the 3 million veterans who use its medical facilities each
year. So far, networks have begun facility integrations in 18
geographic areas, involving a total of 36 hospitals. This
testimony focuses on (1) the role of facility integrations in
reshaping VA's health care delivery system and (2) lessons
learned that could help enhance VA's process for planning and
implementing ongoing and future facility integrations.
VA health care: Opportunities to enhance Montgomery and Tuskegee
service integration (GAO/T-HEHS-97-191, 07/28/97)
The Department of Veterans Affairs (VA) is integrating its
medical facilities in Tuskegee and Montgomery, Alabama. The two
facilities' managerial, clinical, and patient support services
are to be restructured into a single health care delivery
system called the Central Alabama Veterans Health Care System,
which is intended to provide the same or higher quality
services at lower cost. GAO testified that VA officials have
made significant progress in planning for this integration, and
benefits have already been realized. Planning activities,
however, have yet to be completed, including (1) key decisions
on whether and how to restructure services, such as nutrition
and food services; (2) assessments of the probable impact of
clinical, administrative, and patient support service changes
on veterans and employees; and (3) determinations of how
savings will be reinvested to benefit veterans. Moreover, some
stakeholders have found it difficult, if not impossible, to
assess the reasonableness of VA's decisions and to ultimately
``buy in'' to them without the benefit of information from
completed planning activities facilitywide. VA needs to
complete its planning in sufficient detail to ensure that
benefits are maximized and adverse impacts minimized.
Veterans' Affairs: Veterans Benefits Administration's progress and
challenges in implementing GPRA (GAO/T-HEHS-97-131, 05/14/97)
In response to widespread management problems in the
government, Congress has taken steps to fundamentally change
the way that federal agencies go about their work. The
Government Performance and Results Act, passed in 1993,
requires agencies to clearly define their missions, set goals,
measure performance, and report on their accomplishments. This
testimony discusses the progress made and the challenges faced
by the Veterans Benefits Administration in implementing that
legislation.
Veterans Affairs computer systems: Action underway yet much work
remains to resolve year 2000 crisis (GAO/T-AIMD-97-174, 09/25/
97)
This testimony discusses the progress being made by the
federal government and, in particular, the Department of
Veterans Affairs (VA) in ensuring that its automated
information systems are ready for the upcoming century change.
GAO summarizes the federal government's progress in addressing
the Year 2000 problem, discusses action taken by VA as a whole,
and examines steps taken by the Veterans Benefits
Administration in response to recent GAO recommendations.
Veterans Benefits Administration: Progress and challenges in
implementing the results act (GAO/T-HEHS-98-125, 03/26/98)
The Veterans Benefits Administration (VBA) received more
than $22 billion in fiscal year 1997 to run programs that
provide veterans, their dependents, and survivors with a host
of benefits--from pensions to rehabilitation assistance to
education and home loan assistance. This testimony discusses
VBA's progress in implementing the Government Performance and
Results Act of 1993, which requires agencies to clearly define
their mission, set goals, measure performance, and report on
their accomplishments.
Veterans benefits computer systems: Uninterrupted delivery of benefits
depends on timely correction of year-2000 problems (GAO/T-AIMD-
97-114, 06/26/97)
This testimony summarizes GAO's May 1997 report, Veterans
Benefits Computer Systems: Risks of VBA's Year 2000 Efforts,
GAO/AIMD 97-79, 5/30/97.
Veterans' health care: Challenges facing VA's evolving role in serving
veterans (GAO/T-HEHS-98-194, 06/17/98)
The Department of Veterans Affairs (VA) operates one of the
nation's largest health care systems including 400 service
delivery locations, and 183,000 employees. This year, VA will
serve about 2.9 million of the nation's 26 million veterans, at
a cost of $19 billion. During the past 75 years, this health
care role has evolved from one of rehabilitating disabled
wartime veterans to also providing a health care safety net for
veterans in peacetime. Today, VA is positioning itself as a
competitive health care alternative for all veterans. More
specifically, three years ago VA began to transform its health
care system, in response to market changes and budgetary
pressures, to make it more competitive with other health care
providers. To aid in this transformation, Congress provided new
revenue sources and reformed veterans' eligibility for care and
VA's ability to purchase services from other providers. This
testimony focuses on how the transformation of VA's health care
system is progressing and what challenges VA faces as its role
evolves.
Year 2000 computing crisis: Leadership needed to collect and
disseminate critical biomedical equipment information (GAO/T-
AIMD-98-310, 09/24/98)
This testimony summarizes GAO's September 1998 report, Year
2000 Computing Crisis: Compliance Status of Many Biomedical
Equipment Items Still Unknown (GAO/AIMD-98-240, September 18,
1998).
Related GAO Products
Aging issues: Related GAO reports and activities in calendar years 1995
and 1996 (GAO/HEHS-98-101, March 27,1998)
Aging issues: Related GAO reports and activities in fiscal year 1996
(GAO/HEHS-97-41, Dec. 31, 1996)
Aging issues: Related GAO reports and activities in fiscal year 1995
(GAO/HEHS-96-82, Mar. 6, 1996)
Aging issues: Related GAO reports and activities in fiscal year 1994
(GAO/HEHS-95-44, Dec. 29, 1994)
Aging issues: Related GAO reports and activities in fiscal year 1993
(GAO/HRD-94-73, Dec. 22, 1993)
ITEM 22--LEGAL SERVICES CORPORATION
----------
Service to the Aging
The Legal Services Corporation (LSC) was created by
Congress in 1974 to provide access to civil legal aid to low-
income Americans. The corporation receives an annual
appropriation from Congress. In 1997, LSC funded some 269 local
legal aid programs across the country, serving every county and
congressional district in the nation.
Legal services clients are as diverse as our nation,
encompassing all races and ethnic groups and ages. The problems
that bring people to local legal services offices arise out of
everyday life. Usually they relate to matters of family law.
Housing, employment, government benefits, or consumer
disagreements. Frequently they represent matters of crisis for
clients and their families. The possible consequences may be as
serious as the loss of a family's only source of income,
homelessness, or the breakup of a family.
In 1997, LSC-funded programs served 193,261 Americans over
the age of 60. Older Americans represented 10 percent of the
clients served by legal services programs. Because of their
special health, income, and social needs, older people often
require legal assistance, especially in coping with the
government-administered benefits on which many depend for
income and health care.
Some local legal services programs have special elderly law
units. But every program provides services to the elderly. Most
LSC programs are listed in the blue or yellow pages of the
phone book, usually listed under Legal Aid or Legal Services.
You can also get a referral by calling LSC at (202) 336-8800;
going to the LSC web site (www.lsc.gov); or writing Public
Affairs, LSC 750 First Street NE, Washington, DC 20002.
ITEM 23--NATIONAL ENDOWMENT FOR THE ARTS
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Summary of Activities Relating to Older Americans--Fiscal Year 1998
introduction
The National Endowment for the Arts works to broaden public
access to the arts for people of all ages throughout the
country by strengthening the role of the arts in enriching
educational experiences, enhancing the vitality of communities
and promoting individual growth.
Realizing that cultural activities enrich the lives of all
citizens, we enthusiastically seek ways to involve older adults
in the arts as creators, students, volunteers, patrons,
teachers and as audience members. Through funding, leadership
initiatives and technical assistance, the Arts Endowment
assures the continued participation of older Americans in the
ever-widening kaleidoscope of arts activities.
office for access abiltity
The AccessAbility Office continues to serve as the advocacy
and technical assistance arm of the Arts Endowment for older
adults, individuals with disabilities and people living in
institutions including long-term care. This Office works with
grantees, applicants, organizations that represent the targeted
populations, and other Federal agencies to educate and assist
on the importance of making the best art more available to
older citizens.
As part of her technical assistance efforts, the
AccessAbility Coordinator organizes and conducts presentations
at conferences to better educate participants concerning the
value of and how to implement accessible programming. During
this reporting period, workshops and panels were given at eight
conferences including those of the National Council on Aging in
Washington, D.C., the National Assembly of State Arts Agencies
in Cleveland, Ohio, and the American Association of Museums in
Los Angeles, CA.
The Arts Endowment received the Universal Design Leadership
Award at the international conference, Designing for the 21st
Century, for the Endowment's ``substantial and effective
leadership in encouraging and assisting universal design.''
Convened at Hofstra University in New York City on June 18-21,
1998, this was the first-ever international conference that
focused on universal design. As documented in previous reports
to the Special Committee beginning in 1990, the Arts Endowment
has initiated and supported a variety of projects that address
this important design process--which makes spaces and products
usable by people of all abilities throughout their lifespans.
national forum on careers in the arts for people with disabilities
The Arts Endowment convened the first ``National Forum on
Careers in the Arts for People with Disabilities'' in
partnership with four other Federal agencies: the U.S. Dept. of
Education, the U.S. Dept. of Health and Human Services, the
Social Security Administration and the John F. Kennedy Center
for the Performing Arts. Convened June 14-16, 1998 at the
Kennedy Center in Washington, D.C., 300 people of all ages from
around the country discussed the myriad of issues facing people
with disabilities in pursuit of the wide variety of arts
careers. Participants included artists, arts administrators,
rehabilitation professionals, educators and staff from Federal
agencies. In addition, conference proceedings were audio and
video-streamed over the internet, making it possible for
hundreds more to participate as they provided valuable input
via listservs.
Guidance from the eighteen-member planning committee,
composed of select leadership from the arts, aging,
rehabilitation and education fields, was invaluable in setting
goals, selecting speakers and conducting the Forum. The Forum
focused on three areas: education/training, funding and jobs.
We were able to involve leaders in the arts, disability and
funding fields including: Phyllis Frelich, the first deaf actor
to receive the Tony award; Gordon Davidson, Artistic Director
of the Mark Taper Forum; Dianne Pilgrim, Director of the Cooper
Hewitt Museum of Design; Melissa Franklin, Director of Pew
Fellowships in the Arts; Robert Cogswill, Director of the Folk
Arts Program at the Tennessee Arts Commission; Jeremy Alliger,
Artistic Director of Dance Umbrella; and Jordan Thaler, Casting
Director of the Joseph Papp Theatre. The forum featured
performances by artists with disabilities on the Kennedy
Center's Millennium Stage, including the Cleveland Ballet's
Dancing Wheels and jazz musicians Valarie Capers and Lisa
Thorson.
I was pleased to address this enthusiastic body in my
second keynote as Chairman of the National Endowment. My
remarks included some of my goals for this agency:
We must advance President Clinton's goal of health
coverage for all Americans, addressing the health
concerns of artists, and disseminating relevant
information to the field. This includes the Endowment's
work with the Actor's Fund of America to develop a
national database of health insurance for artists.
We must help the arts advance the concerns of our
communities--from design and celebration to youth-at-
risk, and through arts initiatives in non-traditional
venues like long-term care facilities, correctional
facilities and hospitals. It is in these settings that
the arts can be a powerful tool to educate and enhance
the quality of life.
We must encourage and support lifelong learning in
the arts, from kindergarten through grade twelve and
through a lifetime of learning as well.
We must broaden access to the arts for all Americans.
This means geographical reach, and the use of advanced
technologies--for example audio description,
captioning, and universal design.
In panels and breakout sessions, Forum participants
discussed models for pursuing education and jobs; and the
concept of universal design, which has the potential to open up
education and cultural institutions to everyone. And in almost
every session, concerns were expressed about financial
disincentives to receiving financial remuneration due to
government program regulations (such as SSI, supplemental
income and health benefits) that restrict receiving monetary
awards for excellence in one's career field (i.e.
apprenticeships, fellowships or National Heritage awards); and
receiving irregular or infrequent compensation for art. We find
that these rules affect many older artists including
basketmakers, musicians, quilters and poets.
At the Forum's final session, participants formulated
recommendations that address barriers to arts careers. They
encouraged vigorous enforcement of government disability rights
legislation; finding ways to end financial disincentives;
working with government vocational rehabilitation to ensure
that counselors are able to assist eligible people who chose
arts careers; ensuring the definition of diversity includes
disability; and establishing more arts related scholarship/
internship programs for people with disabilities. Taking this
important guidance into consideration, the Arts Endowment is
presently working with our Federal partners to plan for the
next steps to advance arts careers for Americans of all ages
and abilities.
As the National Endowment for the Arts continues to work
towards these worthy objectives, older adults will benefit even
more from this agency's initiatives and funding.
universal design: designing for the lifespan
Through the competitive process, the Center for Universal
Design at North Carolina State University in Raleigh, N.C. was
selected to identify, describe and visually document fifty
excellent examples of universal design from the disciplines of
interior, landscape, graphic and product design, and
architecture. The purpose of this effort is to encourage and
assist the use of this valuable design process that makes the
environment usable by people from childhood into their oldest
years. The visuals and text will be produced on CD Rom and
widely disseminated to schools of design, design professionals,
city planners, as well as private and public sector leaders.
This project will be completed within the year for review by
the Special Committee in next year's report.
work in progress
Our AccessAbility Office is working with the New England
Foundation for the Arts in Boston to convene the fifth regional
symposium on making the arts fully available to older adults
and people with disabilities. These regional meetings have
enjoyed a high degree of success where arts administrators
participate in workshops and share their experiences to learn
about the latest technologies, materials and models for making
the arts fully accessible. ``Clearing the Path: Arts
Accessibility in New England'' will take place in September 22-
24, 1999 at the new Pequot Museum and Research Center in
Mashantucket, CT. The main reason that this new museum was
selected for the symposium is because it was conceived and
built with the elders of the Piquot tribe--to assure it meets
the needs of older adults and that Native Americans' traditions
and culture are authentically depicted throughout the museum.
Further, we are working with the National Assembly of State
Arts Agencies (NASAA) and the National Endowment for the
Humanities to update our 700 page ``Design for Accessibility:
An Arts Administrator's Guide'' and put it on NASAA's Website.
Produced in 1994 with NASAA, it is the most comprehensive guide
to-date for making the arts accessible to older adults and
individuals with disabilities. Through an interagency
agreement, the Humanities Endowment joined with us to add
humanities examples of accessible programming to the Guide and
disseminate 2,000 print copies to its grantees.
arts endowment funding
Endowment supported programs continue to benefit people of
all ages. Many projects specifically focus on older adults. For
example:
Des Moines Metro Opera, Inc. in Indianola, Iowa was awarded
a grant for Opera Iowa's three-state tour of
``Rumpelstiltskin,'' a world premiere opera commissioned by Des
Moines Opera and composed by Amy Tate Williams. The nine week
tour includes workshops and performances in concert halls,
retirement complexes, long-term care institutions and schools.
Grass Roots Art and Community Efforts (GRACE) in Hardwick,
VT received funding for its weekly community visual arts
workshops for older adults that culminate with an exhibition in
Greensboro, Vermont's elementary school and library.
Hunter College of CUNY in New York City received a grant
for the production of a documentary film by Menachem Daum and
Oren Rudasky, ``Trial by Fire: The Faith and Doubt of Aging
Holocaust Survivors'' that profiles the lives of five survivors
and their families, with emphasis on how their faith in God was
affected by the Holocaust.
Life Long Medical Care of Berkeley, CA received support for
a ceramic and paint installation by artists Chere Mah and Susan
Wick at the Over Sixty Health Center that is located in the
senior housing community of South Berkeley. Members of the
community donated objects that reflect personal or historical
aspects of their community which the artists integrated into
the two dimensional elements on the building's exterior and the
three-dimensional art in the interior lobbies and courtyard.
The North Dakota Council on the Arts in Bismarck was
awarded a grant for a traditional arts apprenticeship program
and a series of performances in long-term facilities by folk
artists.
Stuart Pimsler Dance and Theater of Columbus, Ohio received
support for its ``Caring for the Care Giver'' program to create
a performance work and workshops that address and provide
outlets for the healing of care givers.
Other examples of Arts Endowment supported efforts that
benefit older Americans are listed by arts discipline.
dance
Margaret Jenkins Dance Studio, Inc. of San Francisco,
California received support for the creation, presentation and
national touring of a dance-theater collaboration titled ``Time
After.'' This piece is an exploration in movement and words of
personal and public issues at the critical juncture in the life
of a choreographer, performer and older woman.
folk arts
Fellowships
Seven National Heritage Fellowships were awarded to artists
who are age sixty five and older in recognition of their
outstanding contributions to the traditional arts. They
include:
Antonio De la Rosa is an accordionist from the Texas-
Mexican ensemble in Riviera, Texas. Mr. De La Rosa was one of
twelve children in a family of field laborers. As a child, he
heard an accordion on the radio, acquired one, and learned to
pick out the chords. He imitated the recordings of accordion
pioneer Narciso Martinez and at age sixteen, went to nearby
towns and played in small taverns. De La Rosa codified the
instrumentation of the conjunto that endures to this day. In
1949, he made his first recorded disc featuring two polkas
entitled ``Sarita'' and ``Tres Rios.'' Soon his polkas made him
a household word among the Texas-Mexican working class. He was
inducted into the Conjunto Music Hall of Fame in San Antonio in
1982 and is considered ``an icon of a style whose cultural
power few musicians in the Americas can match.''
Claude Williams, an African-American jazz/swing fiddler was
born in Muskogee, Oklahoma, where, by the age of ten, he was
playing the guitar, mandolin, banjo, and cello in his brother-
in-law's string band. In 1928, Mr. Williams moved to Kansas
City where he played and toured with a variety of bands,
including Clouds of Joy led first by Terrance Holder. He worked
with the Cole Brothers, featuring pianist and singer Nat
``King'' Cole. In 1937, Claude formed his own group and has
toured with a variety of jazz bands for forty years. Further,
Mr. Williams performed in the popular Broadway show ``Black and
Blue'' and in a tour entitled ``Masters of the Folk Violin.''
Folk Arts' Grants
Documentary Arts Inc. in Dallas, Texas received a grant for
the production of ``Masters of Traditional Arts,'' an
interactive digital program showcasing the arts and cultures of
recipients of the Arts Endowment's National Heritage
Fellowships for their lifetime achievements in the arts.
Elders Share the Arts Inc. in New York city received a
grant to support a partnership with the Los Pleneros de la 21
to complete post production work and distribute the video,
``Bomba! Dancing the Drum,'' a documentary about the Cepeda
family, who are important artists in the Puerto Rico Bom.
University of Georgia in Athens received a grant for the
restoration of important folk music tapes recorded in northern
and coastal Georgia, which include performances by the McIntosh
County Shouters, the Tanners and the Eller Brothers.
media arts
Dance Pioneers of Honolulu, Hawaii received support for the
production of a video documentary intended for national
broadcast on American choreographer and dancer Donald McKale.
Produced in collaboration with Hawaii Television, ``Donald
McKale: Heartbeats of a Dancemaker'' chronicles this artist's
struggle from his Harlem roots to become a leading statesman
and ambassador of American modern dance. McKale's distinguished
career began in 1948 and has spanned choreography, direction,
writing, education, and performance in dance, theater, film and
television.
ETV Endowment of South Carolina in Spartanburg received
funding for the production of a weekly radio series ``Marian
McPartland's Piano Jazz.'' The series features host Marian
McPartland collaborating with fellow musicians to explore the
world of jazz through a mix of performance and discussion. A
part of the jazz through a mix of performance and discussion. A
part of the jazz scene since the 1940's, McPartland is a
preeminent jazz performer and thoughtful observer of music and
musicians.
Film Arts Foundation FOR Search Films in San Francisco,
California received funding for the production and post-
production of a documentary film on gospel singer Marion
Williams. The video, ``Packin' Up: Marion Williams & the
Philadelphia Gospel Women,'' is a one-hour portrait of one of
America's greatest singers, and the important influences that
her hometown, Philadelphia, had in the early development of
black gospel music. The film used extensive archival footage
and photographs, oral histories, contemporary performance
footage, and taped interviews with Ms. Williams--where she
describes her conscious decision to remain in gospel music
rather than switching to a more lucrative career in secular
blues and pop music.
New York Foundation for the Arts in New York City received
support for the completion of a documentary film by Academy
award-winning film maker Ira Wohl entitled ``Best Man: Best Boy
and All of Us Twenty Years Later.'' It is a follow-up piece to
his 1979 Oscar-winning film, ``Best Boy,'' about his 50- year-
old developmentally disabled cousin, Philly, and his transition
from life at home with his parents to a group house with other
disabled residents. The sequel features Philly's extended
family; his close relationship with his sister and his
comfortable lifestyle within the group home.
Washington D.C. International Film Festival received
support for its International festival that features films for
older citizens and other underserved people in the Washington
Metropolitan area. ``Cinema for Seniors'' offers free matinees
of movie classics for older persons. The festival presents
American independent films, cinema from around the world,
classic restored Hollywood productions and special events for
older adults.
music
Coro de Ninos de San Juan, Inc. in San Juan, Puerto Rico
received support for its 1998 Christmas Concerts that involved
a tour to five rural areas in Puerto Rico, including audiences
of older adults and people with disabilities. Musicians
presented classical, traditional and international Christmas
music with special attention to Puerto Rican Christmas
traditions and the works of Puerto Rican composers.
Dorian Woodwind Quintet Foundation, Inc. of New York City
received support for a domestic tour of the Dorian Woodwind
Quintet and associated outreach activities. The Quintet tours
domestically each year to six cities and towns that are often
in economically distressed areas. They offer master classes,
``informances'' for school children, pre-concert lecture
demonstrations, and visits to hospices, hospitals, centers for
older adults, and nursing homes.
Helena Presents of Helena, Montana received support for
``Cultural Crossings,'' a program of new work that involves
multi-cultural and multi-disciplinary collaborations by
performing artists throughout the Helena community. The
``Cultural Crossings'' concept includes intergenerational
programming and older artists as part of its diverse mix. The
overarching goals of the series are: to sensitize audiences to
the complex issues of ``difference,'' cultural diversity, and
inclusion; empower community voices in support of tolerance;
continue introducing aesthetic traditions and multi-
disciplinary work; and show the power of art in its depiction
of cultural identity and collaboration between cultures.
Artists include: The National Theatre of the Deaf; and
percussionist-rhythm dancer Keith Terry with Indonesian
choreographer Wayan Dibia in their new project, ``Perayaan: The
Celebration.''
Minnesota Orchestral Association in Minneapolis received
support for the Minnesota Orchestra's statewide educational and
outreach efforts including their Music Residency program where
two to four musicians visit rural towns in Minnesota, and a
program to reach seniors residents in convalescent and nursing
homes. The project is designed to increase access statewide,
specifically targeting needs of the older people living in
isolated circumstances, inner-city youth and those living in
rural Minnesota. Working with Minnesota Public Radio, they
created a one-hour radio program and video for older adults
living in nursing homes, convalescent centers, and hospices.
New Sounds Music, Inc. received support for a year-long
artist's residency in Philadelphia by the PRISM Quartet, the
Saxophone, MIDI Ensemble and composer Jennifer Higdon in
collaboration with the Settlement Music School, Free Library of
Philadelphia, and Kardon Institute of the Arts for People with
Disabilities. The project involves a wide variety of arts
education and outreach activities in the community for people
of all ages.
Spokane Symphony Orchestra in Washington received support
for the Symphony Ensembles for Education (SEED) program which
provides underserved populations of all ages throughout the
Inland Northwest with interactive and educational programming
by Symphony Orchestra ensembles. Through the SEED program, the
orchestra reaches audiences that traditionally have less access
to live performances, including school children, older adults,
families in rural and economically disadvantaged areas, and
people with disabilities. Each program is specifically designed
for the targeted audience with demonstrated sensitivity toward
the audiences' needs and culture.
theater
Cornerstone Theater Company of Santa Monica, California
received support to commission playwright Chay Yew to create a
theater work produced in collaboration with Cornerstone's
ensemble of older artists, guest artists, and members of Los
Angeles' Chinese American communities at the Pacific Asia
Museum. The artists involved local participants of all ages in
the creation of this new theater piece, which serves as a
source of pride, entertainment and cultural exploration for
participants and audiences from the surrounding communities.
Stagebridge of Oakland, California received support for its
``Storybridge,'' an intergenerational arts and literacy
project. Stagebridge is using its experience in theater
storytelling and training senior actors to develop
``Storybridge''. This project reaches 2,000 low-income older
adults and 12,000 at-risk children. It incorporates three
programmatic approaches: (1) Grandparents Tales uses drama to
capture children's interest in language and stories. It
involves a play about grandparents, performed in schools
throughout Oakland by a multi-cultural, professional cast of
older actors. The teachers receive twenty page curriculum
guides to continue the dialogue in their classrooms; (2) Senior
Storytellers in the Schools involves the development of ongoing
relationships between older storytellers and students that
helps to keep children interested in literature and
storytelling; and (3) Storytelling Assemblies where Stagebridge
recruits, trains, and places older adults as storytellers in
schools in Oakland, Berkeley and San Francisco where the
storytellers work once a week at schools, telling stories and
talking with students.
visual arts
Little City Foundation in Palatine, Illinois was awarded a
grant for a multi-phase exhibition of artwork, created by
student artists with developmental disabilities, in a variety
of locations in the greater Metropolitan Chicago area. The
exhibition grew out of a residency program of three guest
artists who worked with the student artists at Little City
Foundation's campus.
National Institute of Art and Disabilities (NIAD) of
Richmond, California received support for the development of a
new exhibition to promote public awareness concerning the
creative abilities of adults with developmental disabilities.
The exhibition consists of fifty of the best works on paper,
canvas, and prints, as well as ceramic and textile pieces. The
exhibition brochure includes photographs of each piece, brief
biographical information on the artists, and an overview of
NIAD.
ITEM 24--NATIONAL ENDOWMENT FOR THE HUMANITIES
----------
National Endowment for the Humanities Report on Activities Affecting
Older Americans in Fiscal Years 1997 and 1998
In 1997, an agency representative attended the Office of
Personnel Management's ``Celebrating Older Americans
Conference'' in order to gain information on resources and
services available for older Americans and to learn about the
issues that are important to them.
In 1998, the agency was again represented at the
``Celebrating Older Americans Conference.'' In addition, staff
members were informed of hyperlinks to internet sites for elder
caregivers and notified of a conference dealing heavily with
Alzheimer's disease, ``Dimensions of Dementia.''
Referral to the agency's employee assistance program COPE,
Inc. is always available to Endowment employees for assistance
in locating services or in dealing with issues and problems
related to aging.
ITEM 25--NATIONAL SCIENCE FOUNDATION
----------
National Science Foundation Report for Developments in Aging
The National Science Foundation, an independent agency of
the Executive Branch, was established in 1950 to promote
scientific progress in the United States. The Foundation
fulfills this responsibility primarily by supporting basic and
applied scientific research in the mathematical, physical,
environmental, biological, social, and engineering sciences,
and by encouraging and supporting improvements in science and
engineering education. The Foundation does not support projects
in clinical medicine, the arts and humanities, business areas,
or social work. The National Science Foundation does not
conduct laboratory research or carry out educational projects
itself, rather, it provides support or assistance to grantees,
typically associated with colleges and universities, who are
the primary performers of the research.
The National Science Foundation is organized generally
along disciplinary lines. None of its programs has a principal
focus on aging-related research; however, a substantial amount
of research bearing a relationship to aging and the concerns of
the elderly is supported across the broad spectrum of the
Foundation's research programs. Virtually all of this work
falls within the purview of the Directorate for Social,
Behavioral, and Economic Sciences and the Directorate for
Engineering.
Directorate for Social, Behavioral, and Economic Sciences (SBE)
The Directorate for Social, Behavioral, and Economic
Sciences supports research in a broad range of disciplines and
interdisciplinary areas through its Division of Social,
Behavioral, and Economic Research. For example, sociological
research is being supported which examines how the labor force
participation and earnings of older Americans have been
affected by recent economic trends; how Americans in their 50's
cope with the dual pressures of supporting aging parents and
grown children; how income distribution differs between the
``young old'' and the ``old old,'' and how the degree of
political activism of older Americans has changed overtime in
the twentieth century. Projects within anthropology are being
supported to examine how economic development affects patterns
of caring for dependent elderly, and with cognitive psychology
to examine the extent to which knowledge acquired in youth is
retained in later life.
The SBE Directorate also supports several large-scale data
gathering efforts which can be and have been used to study
issues related to aging, although that is not their sole or
even primary purpose. For example the Panel Study of Income
Dynamics, which has been tracking a sample of more than 7,000
American families since 1968, provides information on changing
household composition, labor force participation, income,
assets, and consumption patterns as individual respondents grow
older. The General Social Survey, which has carried out sample
surveys of the U.S. adult population more or less annually
since 1972, contains several attitudinal items dealing with the
status of, and care for, the elderly. These surveys enable
researchers to examine how attitudes toward the elderly have
changed over time and how age groups differ across a wide range
of opinion areas. The National Election Survey, which has
studied American elections since 1952, provides information on
how attitudes regarding candidates and issues vary across age
groups. The SBE Directorate is also supporting a project that
will make available to researchers in a consistent and readily
usable form public use microdata from the U.S. censuses from
1850 through 1990. When completed, this project will make it
possible to examine how the status and family relationships of
older Americans have changed over the course of a century and a
half.
Directorate for Engineering (ENG)
The National Science Foundation's Directorate for
Engineering seeks to enhance long-term economic strength,
security, and quality of life for the Nation by fostering
innovation, creativity, and excellence in engineering education
and research. This is done by, supporting projects across the
entire range of engineering disciplines and by identifying and
supporting special areas where results are expected to have
timely and topical applications, such as biotechnology and
materials processing.
Aging-related research is primarily supported within the
Directorate for Engineering through the Biomedical Engineering
and Research to Aid Persons with Disabilities programs.
Research funded in this program relates to issues of aging and
the elderly due to the propensity for the elderly to develop
physical disabilities. Many of the current projects are also of
interest to NASA. Several of the effects of weightlessness on
the human body are strongly similar to the effects of aging on
the human body. Projects recently supported by this program
include the following studies: Biophysical mechanisms of
cartilage repair and generation; Mechanisms of drug delivery in
the treatment of various diseases, including those associated
with aging, such as diabetes; Simple, noninvasive, quantitative
methods to assess postural instability associated with aging;
Investigation of biodegradable polymer matrices to support the
growth of bone and the generation of bone-like tissues for
application in osteoporosis; A variety of activities involving
joint replacement, including computer assisted design of
orthopedic surgery, cementing techniques, failure detection
techniques, and the pathophysiology of implant device-related
infection; An image processing system for low vision people
such as those with age related maculopathies; An artificial
retina which will restore limited vision to people who are
blind due to certain diseases; A visual speech articulation
training aid for the hearing impaired; and Imaging modalities
that allow physicians to perform a ``virtual colonoscopy'' in a
non-invasive fashion; Undergraduate projects by student
engineers to design and fabricate custom designed devices and
software for disabled individuals.
While some of these projects are not specifically directed
toward problems of aging, all of these studies have potential
for dealing with conditions prevalent among the elderly.
ITEM 26--PENSION BENEFIT GUARANTY CORPORATION
----------
Executive Director's Message (1997)
It gives me great pleasure to report that the Pension
Benefit Guaranty Corporation has concluded a very rewarding
year. Record earnings on investments enabled PBGC to record
significant net income for both insurance programs, further
strengthening the agency's financial footing.
Our highest priority now must remain PBGC's solvency. After
more than 20 years of continuous deficits, we must maintain a
reserve that will be sufficient to protect the program. The
most recent gains came in a good economic period marked by high
investment returns and low pension losses. The agency remains
vulnerable to changing economic conditions, which can
significantly affect the values of both its assets and its
liabilities. Even with a strong economy last year, PBGC assumed
responsibility for more than 160 underfunded plans, and
underfunding continues to exist among ongoing defined benefit
pension plans. We have achieved a surplus which can serve as a
cushion to protect workers and retirees in the event of future
economic downturns.
It is very important for PBGC to remain strong. With a
healthy insurance program, workers and employers can have
confidence in the defined benefit pension system. Workers can
be confident their pensions are secure and their benefits will
be there when they are ready for them. Employers can be
confident that the cost of providing insurance coverage will be
kept reasonable.
Our second priority is making PBGC a premier customer
service organization--not only for the workers and retirees
whom we protect, but also for the companies that pay our
insurance premiums and for the pension professionals who advise
them. PBGC has won many awards for its service to workers and
retirees. Our goal now is to make sure we pay the same
attention to the employers whose payments support the insurance
program and the pension professionals who rely on our agency.
Our third priority is to promote defined benefit pension
coverage for American workers. We want both workers and
employers to take a new look at defined benefit pensions and to
understand their value in providing American workers with a
predictable, guaranteed lifetime pension. It is PBGC's mandate
to promote defined benefit pensions and to bring the advantages
of workplace pensions to a greater number of working Americans.
I want PBGC to play a meaningful role in the ongoing public and
private sector efforts to meet that challenge.
The improvement in PBGC's financial condition and service
to the public is a fitting tribute to the leadership of my
predecessor, Martin Slate, who passed away unexpectedly at
midyear, and to the creativity and diligence of the agency's
staff. A significant number of people are affected by PBGC. We
want to make sure that we continue the remarkable turnaround of
the pension insurance program and serve them well.
David M. Strauss,
Executive Director.
Safeguarding Solvency
PBGC developed a five-year Strategic Plan that provides
long-term direction to the agency's activities and milestones
for measuring progress along the way. The plan resulted from
consultation with PBGC's stakeholders, including participants,
pension professionals, and premium payers.
The Strategic Plan established four goals that support the
Secretary of Labor's overall goal of enhancing retirement
security. PBGC's goals are to:
Strengthen financial programs and systems to
keep the pension insurance system solvent;
Provide high-quality services and accurate
and timely payment of benefits to participants;
Protect existing defined benefit plans and
their participants and encourage new plans; and
Improve internal management support
operations.
PBGC's financial results for 1997 showed encouraging
progress toward the agency's strategic goal of strengthening
its financial programs and systems to keep the pension
insurance system solvent. Record investment earnings enabled
PBGC to further strengthen its financial base to support the
insurance programs' long-term responsibilities. Valuable
settlements generated through the Early Warning Program, in
combination with the agency's vigorous litigation posture,
protected the insurance program and tens of thousands of
workers and retirees from pension losses.
financial management
PBGC's financial strength rests on a foundation of skilled,
professional financial management. The agency's financial
statements have received their fifth straight unqualified
opinion from the agency's auditors, attesting to the
consistency and integrity of its financial systems. The 1997
audit was again performed by Price Waterhouse LLP under the
direction and oversight of PBGC's Inspector General.
Both PBGC insurance programs recorded significant financial
gains in 1997, fueled largely by investment earnings.
Investments of the larger single-employer program produced
record income of nearly $2.7 billion. Premium income totaled
nearly $1.1 billion, down slightly from the record level
reached in 1996 because reduced underfunding led to lower
variable-rate premium payments to PBGC. Investment gains
enabled the single-employer program to record net income of
$2.6 billion. As a result, the program's net surplus grew to
nearly $3.5 billion.
The multiemployer program also continued to be financially
strong, with net income of $95 million and an end-of-year net
surplus of $219 million, based on assets of $596 million and
liabilities totaling $377 million primarily for future benefits
and nonrecoverable future financial assistance. The net income,
paced by investment gains, reversed a three-year period of
moderate losses.
The agency took several steps during the year to improve
compliance with premium obligations. Several of these
initiatives were intended to create a more cooperative climate
and forge a partnership with the employers who pay PBGC's
premiums. With the assistance of focus groups and surveys, PBGC
began to identify employers' concerns and make changes that
would improve service and still ensure the agency's ability to
safeguard workers' pensions and the pension insurance program.
In addition to restructuring and lowering its premium penalties
to encourage voluntary correction of premium payment errors,
the agency set time limits to ensure that needed information is
submitted timely for its premium audit program. PBGC also
expanded the premium audit program nationwide after
successfully testing the program in a limited geographic area.
The pilot program had proven premium audits to be a cost-
effective means of ensuring accuracy in premium payments.
investment program
The Corporation has approximately $15.6 billion of total
assets available for investment, consisting of premium receipts
accounted for in the Revolving Funds and assets from terminated
trusteed plans and their sponsors accounted for in the Trust
Funds. Under law, the Revolving Funds are required to be
invested in fixed-income securities; current policy is to
invest these funds only in Treasury securities. PBGC has more
discretion in its investment of the Trust Funds, which are
primarily invested in high-quality equities, with asset
allocation designed for sound long-term performance.
The agency's investment in equities provides overall
portfolio diversification and a higher long-term expected
return, within prudent levels of risk. PBGC uses institutional
investment management firms to invest its assets subject to
PBGC oversight. PBGC's investment portfolio is structured to
improve PBGC's financial condition in a stable manner over the
long term. PBGC continually reviews its investment strategy to
ensure that the agency maintains an investment structure that
is consistent with its long-term objectives and
responsibilities.
Investment Profile.--As of September 30, 1997, the value of
PBGC's total investments, including cash, was approximately
$15.6 billion. The Revolving Fund's value was $9.0 billion and
the Trust Fund's value was $6.6 billion.
PBGC's fund allocation further shifted toward equities
during 1997 due primarily to strong equity returns. Cash and
fixed-income securities represented 61 percent of the total
assets available for investment at the end of the year, as
compared to 63 percent at the end of 1996, while the equity
allocation stood at 38 percent of all investments compared to
36 percent one year earlier. A very small portion of the
invested portfolio remains in real estate and other financial
instruments.
INVESTMENT PROFILE
------------------------------------------------------------------------
Sept. 30--
---------------------
1997 1996
------------------------------------------------------------------------
Fixed-income assets:
Average quality............................... AAA AAA
Average maturity (years)...................... 21.0 22.6
Duration (years).............................. 10.5 10.1
Yield to maturity (%)......................... 6.4 7.2
Equity assets:
Average price/earnings ratio.................. 26.0 19.7
Dividend yield (%)............................ 1.6 2.0
Beta.......................................... 1.04 1.08
------------------------------------------------------------------------
Investment Results.--Fiscal year 1997 was a favorable year
for capital market investments and PBGC's investment program.
The broad stock market, as measured by the Wilshire 5000 Index
that most closely reflects PBGC's equity portfolio, advanced
38.0%, while PBGC's equity portfolio returned 37.6%. PBGC's
fixed-income program returned 13.5% for the year, while the
Lehman Brothers Long Treasury Index gained 13.2%. For the year,
PBGC reported income of nearly $1.1 billion from fixed-income
investments and nearly $1.7 billion from equity investments.
Other investments, including real estate and insurance
contracts, produced a small gain of $8 million, for total
investment income of almost $2.8 billion.
INVESTMENT PERFORMANCE
[Annual rates of return in percent]
----------------------------------------------------------------------------------------------------------------
Sept. 30,-- Five years
-------------------------------- ended Sept.
1997 1996 30, 1997
----------------------------------------------------------------------------------------------------------------
Total invested funds............................................ 21.9 8.5 14.4
Equities........................................................ 37.6 19.7 20.6
Fixed-income.................................................... 13.5 2.2 10.9
Trust funds..................................................... 35.6 18.6 19.1
Revolving funds................................................. 13.3 2.3 11.6
Indices:
Wilshire 5000............................................... 38.0 18.9 20.6
S&P 500 Stock Index......................................... 40.4 20.3 20.8
Lehman Brothers Long Treasury Index......................... 13.2 2.3 8.9
----------------------------------------------------------------------------------------------------------------
early warning program
The Early Warning Program, which helps PBGC prevent pension
losses, continued to play a major role in safeguarding the
solvency of the pension insurance program. Under this program,
PBGC monitors companies with pension plans underfunded by at
least $5 million to identify transactions that could jeopardize
pensions. This effort enables PBGC to find such transactions at
an early stage, when both PBGC and the company involved have
the most flexibility to structure an agreement that protects
the interests of the company, its workers and the pension
insurance program. During 1997, while monitoring more than 500
companies, PBGC negotiators reached agreements valued at about
$760 million with 17 companies, providing contributions,
security, and other protections for the pensions of about
140,000 workers and retirees. Since its inception six years
ago, the program has generated more than $15 billion in
additional protection for the pensions of more than 1.6 million
people. Specific agreements reached in 1997 included:
NCR Corporation.--NCR, a formerly wholly owned subsidiary
of AT&T Corporation, was responsible for underfunded pensions
covering more than 57,000 workers and retirees. AT&T planned to
spin off NCR at the end of 1996. Under an agreement reached in
November 1996, NCR provided security interests in various NCR
properties totaling $80 million to guarantee the future funding
of the pensions. In addition, the company agreed to continue
full minimum funding contributions without applying an existing
credit balance of more than $100 million for prior funding that
exceeded the contributions required by law. Without the
agreement, NCR could have used the credit balance to reduce or
eliminate future contributions for a number of years. The
agreement will remain in effect five years, after which it will
expire once NCR achieves a specified financial rating.
Anchor Glass Container Corporation.--Anchor planned to sell
its assets to a buyer who would also assume responsibility for
the company's three pension plans, which covered some 15,600
workers and retirees and were underfunded by about $190
million. The sale would remove Anchor from the control of its
Mexican parent, Vitro S.A., thereby relieving Vitro and its
subsidiaries from responsibility for the Anchor pensions. When
PBGC proposed to terminate the plans in order to preserve
claims against Vitro for the pension underfunding, the buyer
agreed to pay missed pension contributions totaling about $18
million at the close of the sale and to assume responsibility
for all future contributions to the plans. Vitro agreed to
guarantee payments of up to $70 million over 10 years should
PBGC have to terminate any of the plans in the future. A
separate firm acquired a smaller portion of Anchor covering
about 500 workers and assumed responsibility for about $15
million of the total underfunding.
Del Monte Corporation.--Del Monte, with three pension plans
that were underfunded about $90 million and covered more than
6,700 workers and retirees, was being purchased at part of a
leveraged buyout. In April 1997, PBGC and the company reached
an agreement to compensate the pension plans for the increased
risk resulting from the transaction. Under the agreement, Del
Monte will add $55 million in cash to its plans over the next
five years, with the funding planned for the last three years
secured by an irrevocable $20 million letter of credit. As a
result of the agreement, the plans are expected to be close to
fully funded at the end of the five-year period.
Amphenol Corporation.--Amphenol maintained eight plans that
covered 6,800 workers and retirees and were underfunded by
about $45 million. When bank financing for a planned leveraged
buyout of Amphenol threatened to add significant debt to the
company, PBGC initiated negotiations that led to a May 1997
agreement. The agreement gave PBGC a second interest for up to
$45 million in stock of Amphenol's foreign subsidiaries as
security for the pension underfunding. PBGC will get additional
collateral for the underfunding if the banks financing the
purchase later determine that they need more collateral to
secure their loans. The agreement will be in effect for at
least five years and will continue thereafter until the pension
plans are fully funded or Amphenol debt obtains an investment -
grade rating.
Lockheed Martin Corporation.--Lockheed spun off some of its
aerospace and defense communications units to a new, highly
leveraged company called L-3 Communications Corporation. As
part of the transaction, Lockheed also transferred seven
pension plans covering nearly 3,000 workers and retirees of the
divested businesses. While four of the plans were well funded,
three were underfunded by about $40 million. In May 1997, PBGC
and Lockheed negotiated a settlement under which Lockheed
agreed to reassume sponsorship of the three underfunded plans
if L-3 is unable to support the plans. The agreement will
remain in effect until L-3 achieves an investment-grade
financial rating.
Kerr Group, Inc.--A leveraged buyout of Kerr would have
been financed primarily through debt secured by Kerr assets.
Kerr maintained a pension plan covering 5,600 workers and
retirees that was underfunded by about $41 million. PBGC
determined that the proposed transaction would weaken its
position relative to other creditors, thereby putting the
insurance program at increased risk of loss, and filed a motion
in district court to terminate the plan. Subsequent
negotiations led to an agreement in August 1997 under which
Kerr will continue to be responsible for the pension plan while
accelerating funding of the plan. Kerr paid $3.5 million into
the plan at the closing of the sale and will pay an additional
$35.5 million through January 2003. PBGC obtained a second
security interest in substantially all Kerr assets and withdrew
its pending court action to terminate the plan. The agreement
will remain in effect for at least five years and until Kerr
meets other conditions.
litigation
While preferring to negotiate solutions to pension issues,
PBGC stands ready to use its independent litigation authority
when necessary to enforce its legal positions and to protect
the insurance program. At the end of the year, PBGC had 85
active cases in state and federal courts and 790 bankruptcy
cases. Major cases in 1997 included:
Pineiro, Brooks, and Beaumont v. PBGC.--In September 1996,
three former employees of Pan American World Airways filed suit
in district court asking that the court replace PBGC with an
independent trustee. PBGC had terminated and become trustee of
three Pan Am pension plans underfunded by $914 million in 1991.
The agency currently pays more than $100 million annually to
14,000 Pan Am retirees, and has issued benefit determinations
to more than half of the Pan Am participants to whom PBGC owes
benefits. It is expected that more than 95 percent of the Pan
Am participants will receive all of their pension benefits
earned under the plans.
PBGC filed a motion to dismiss the complaint and, in
November 1997, the court dismissed all but one of the
allegations in the suit as meritless. The court noted that
there were no allegations that ``estimated benefits are not
being paid or that the amounts of estimated benefits that are
being paid are incorrect.'' The only allegation the court left
open, without ruling on the merits, concerns the timeliness of
PBGC's notice of benefits to the Pan Am participants.
Despite complications caused by the deplorable condition of
company records and the company's protracted bankruptcy
proceedings, PBGC has been paying benefits to Pan Am retirees
continuously since taking over the plans while making steady
progress in completing its determination of the benefits owed
to about 35,000 former Pan Am workers and retirees.
Copperweld Steel Company.--PBGC continued to pursue
bankruptcy claims to recover amounts due PBGC and Copperweld's
three terminated pension plans, which covered about 3,000
workers and retirees. The company's liquidation trustee
contests the extent to which PBGC's claims for unpaid minimum
funding contributions are entitled to priority under the
Bankruptcy Code and whether the factors prescribed in PBGC's
regulations appropriately measure PBGC's claims for unfunded
benefit liabilities in terminated pension plans that are
trusteed by PBGC. These issues are central to PBGC's ability to
recover its losses from bankrupt employers. In December 1997,
the bankruptcy court ruled for the liquidation trustee's
positions in both issues. PBGC is determining what appropriate
future steps it should take in the litigation.
CF&I Steel Corporation.--PBGC continued to pursue its
claims against the reorganized CF&I for a CF&I plan that was
underfunded by about $221 million when terminated in March
1992. In a November 1994 ruling, a district court denied
priority to most of PBGC's claims for minimum funding
contributions owed to CF&I's plan and for the plan's
underfunding. The court also remanded the case to the
bankruptcy court for reconsideration of the amount of PBGC's
underfunding claim, ruling that the bankruptcy court erred in
``deferring'' to PBGC's interest rate assumption. The
bankruptcy court subsequently revalued PBGC's claim for
unfunded benefit liabilities from about $221 million to about
$123 million based on a ``discount rate'' that differed from
the assumptions prescribed by PBGC's regulation. The district
court affirmed this ruling in April 1997. PBGC's appeal was
pending in the Tenth Circuit Court of Appeals at yearend.
White Consolidated Industries, Inc.--White continued to
contest PBGC's claims for estimated $120 million underfunding
in pension plans that White transferred to Blaw Knox
Corporation in 1985. PBGC is alleging that a principal purpose
of White in entering into the transaction was to evade pension
liabilities. PBGC has taken over all the Blaw Knox plans either
because they ran out of money or because they would have been
abandoned after Blaw Knox ceased business and sold its assets
in 1994. Trial before the district court was completed during
April 1997, but the court's decision was still pending at
yearend.
multiemployer litigation
Although most of the significant multiemployer plan issues,
such as ``arbitrate first,'' are now well-settled principles of
law, some important questions remain.
In Board of Trustees, Bay Area Laundry and Dry Cleaning
Pension Trust Fund v. Ferbar Corp of CA, et al., the Supreme
Court was asked to decide when the statute of limitations
begins to run for an action to collect withdrawal liability
under the Multiemployer Pension Plan Amendments Act of 1980. In
December 1997, the Court affirmed the position advocated by
PBGC and the Solicitor General, who had filed a joint brief in
July 1997 as ``friends of the court.'' The Court held that the
statute of limitations begins to run when an employer fails to
make a scheduled withdrawal liability payment, and not on the
(earlier) date the employer withdrew from the plan. The lower
court's holding to the contrary could have significantly
limited the ability of multiemployer plans to collect
withdrawal liability.
Providing High-Quality Services
PBGC's second strategic goal is to provide high-quality
services and accurate and timely payment of benefits to
participants. During the year, PBGC worked to improve service
both to the people owed benefits and to the employers whose
premium payments support the pension insurance program.
single-employer program
Through its single-employer program, PBGC oversees
terminations of fully funded plans and guarantees payment of
basic pension benefits when underfunded plans must be
terminated. The single-employer program covers about 33 million
workers and retirees in about 43,000 plans. While the number of
people covered by the program has grown slightly over the past
few years, the number of plans has decreased as small companies
have terminated their plans. The decrease abated during 1997.
Standard Terminations.--An employer may end a fully funded
plan in a standard termination by purchasing annuities or
paying lump sums to participants. Standard terminations are
subject to legal requirements governing notifications to
participants and to PBGC and payment of benefits. PBGC may
disallow standard terminations that do not comply with the
requirements.
The number of standard terminations filed with PBGC
continued to decline in 1997, albeit at a slower pace, falling
by 8 percent to about 3,500. Most of these plans had 50 or
fewer participants.
PBGC audits a statistically significant number of completed
terminations to confirm compliance with the law and proper
payment of benefits. These audits generally have found few and
relatively small errors in benefit payments, which plan
administrators are required to correct. The errors primarily
are due to the use of incorrect interest-rate assumptions in
valuing lump sum distributions to plan participants. PBGC's
enforcement of its audit findings in 1997 resulted in payment
of nearly $4 million of additional benefits to about 4,900
participants, about 5 percent of all participants in audited
plans.
Shortly after the year ended, PBGC issued final rules that
extended the deadlines and simplified the procedures companies
must follow in standard terminations. The changes had been
developed after PBGC conducted focus groups with pension
professionals and also took participant concerns and PBGC's
experience into account. The final rules also provided new
model notices companies may use to inform workers and retirees
about the intended termination of their plan and the guarantees
offered by their states for annuity benefits if their annuity
provider encounters financial difficulty. The simplified
requirements provided regulatory relief for employers while
maintaining full protection for workers' pensions.
Distress and Involuntary Terminations.--Defined benefit
plans that are not able to pay all promised benefits may be
terminated either by the company responsible for the plan or by
PBGC. An employer wishing to terminate an underfunded plan
generally may do so only if the employer is being liquidated or
if the termination is necessary for the company's survival. The
employer must first prove to PBGC, or to a bankruptcy court if
appropriate, that it and each of its affiliated companies meets
one of the financial distress criteria set by law.
An underfunded plan also may be terminated involuntarily by
PBGC when necessary to protect the interests of the
participants or of the insurance program. PBGC must terminate
any plan that does not have assets available to pay current
benefits.
During 1997 the agency completed the termination of 165
underfunded plans, the vast majority of which were involuntary
terminations by PBGC. In most cases termination was necessary
because the sponsoring employer had gone out of business. Many
of these plans had been under consideration for termination for
a period of time and their actual termination dates occurred in
earlier years, when the circumstances leading to their
termination first arose.
Trusteed Plans.--PBGC typically becomes trustee of a plan
only after it has been terminated, although not necessarily in
the same year it was terminated. During the year, PBGC became
trustee of 195 single-employer plans covering 54,000 people. At
yearend, the agency was in the process of becoming trustee of
an additional 90 plans terminated in 1997 or earlier. In all,
including 10 multiemployer plans previously trusteed, a total
of 2,510 terminated plans were trusteed or were being trusteed
as of the end of the year. (This total also reflects the
elimination of three single-employer plans included in last
year's total, which no longer required PBGC to become trustee.)
Benefit Processing.--PBGC 's responsibility for benefit
payments begins immediately upon becoming trustee of a
terminated plan. Top priority is given to maintaining
uninterrupted benefit payments to existing retirees and
commencing payments to new retirees without delay.
Concurrently, PBGC staff also begin to notify plan participants
of PBGC's trusteeship and to obtain essential data and records
on each individual participant, a difficult task frequently
complicated by inadequate plan and employer records.
PBGC pays estimated benefits to retirees until it has
confirmed necessary data and valued plan assets and recoveries
from the plan's sponsor. PBGC then calculates the actual
benefit payable to each participant according to the specific
terms of that person's plan, statutory guarantee levels, and
the funds available from plan assets and employer recoveries.
Benefit calculation can be an intricate process since each
trusteed plan is different and must be separately administered.
By the end of the year, PBGC was responsible for the
current and future pension benefits of about 465,000
participants from single-employer and multiemployer plans.
These include 205,800 retirees who received benefit payments
totaling $824 million.
PBGC continued to accelerate its completion of individual
benefit determinations. In 1997, PBGC issued more than 69,000
benefit determinations, exceeding the record number issued one
year earlier. The heightened production is the direct result of
the agency's advanced automated imaging, letter generation, and
participant record management systems.
Benefit Payment Policies.--PBGC announced two important
changes in policies affecting benefit payments to people in
PBGC-trusteed plans. In one. PBGC will no longer charge for
pre-retirement survivor annuity protection for any plan
terminated on or after August 23, 1984. This insurance provides
benefits to surviving spouses of workers who die before they
retire and begin receiving benefits. The agency had been
providing this protection as an option for plan participants,
who were subject to a small fee if they accepted the insurance.
PBGC now provides this coverage without charge. Under the other
change, announced shortly after the year ended, PBGC will be
revising how it recovers benefit overpayments made after the
date of plan termination from plan participants. PBGC has been
giving participants the choice of repaying overpayments either
in a lump sum or through a permanent reduction (generally
capped at 10 percent) in their benefit payment. With the
change, which is expected to be final during 1998, the
reduction will cease when the total amount collected matches
the amount by which the person had been overpaid.
Appeals of Benefit Determinations.--PBGC's Appeals Board
reviews appeals of certain PBGC determinations. Most of the
appeals are from people disputing their benefit determinations.
Typically, about 2 percent of all benefit determinations are
appealed and that remained true this year. In 1997, the Appeals
Board received 1,300 appeals and decided 927 appeals. Of these,
the Board met to decide 122 appeals, 65 of which required
changes in benefits primarily as a result of new facts,
correction of calculation errors, or a different interpretation
of plan provisions; the other 805 appeals were resolved based
on prior Board decisions, settlements with organizations
representing the appellants, Board staff efforts that led to
new determinations, or more thorough explanations of the
original determination.
Pension Search Program.--PBGC's efforts to link people
missing from terminated pension plans with their retirement
benefits continued to meet with success throughout the year. In
addition to searching for workers and retirees missing in
terminated underfunded plans that the agency now administers,
PBGC conducts a missing participants clearinghouse to assist
employers who are terminating fully funded plans to locate all
people owed benefits. For the hardest-to-find people who have
frustrated all previous searches by either their former
employers or PBGC, the agency also maintains a listing on the
Internet, which is called the Pension Search Directory.
During 1997, the second year of operation for the missing
participants clearinghouse, 417 companies asked PBGC to find
4,734 missing people. Of these, 3,542 were due over $5.3
million in benefits and 1,192 were covered by annuity contracts
that will pay their benefits when they are found. By yearend,
PBGC had confirmed addresses for 554 of the missing people and
paid nearly $1 million in benefits to 510 of them. PBGC is
continuing its search for valid addresses for the remaining
missing people.
In 1997, the Pension Search Directory enabled PBGC to find
more than 1,000 other people who were owed over $4 million in
benefits plus interest. The total listing included about 4,600
people who had worked for some 780 companies and were owed over
$12 million in pension benefits. The Directory is a joint
public and private sector effort that is being assisted by more
than 20 organizations and unions. It may be viewed on the
Internet at http://search.pbgc.gov. The agency's Pension Search
effort, with its innovative use of an on-line self-search
listing and partnerships with private organizations, was
recognized after the year ended with a Hammer Award from Vice
President Al Gore's National Performance Review, the fifth such
award received by PBGC. With this award, PBGC has won more
Hammer Awards per employee than any other government agency.
multiemployer program
The multiemployer program, which covers about 8.8 million
workers and retirees in about 2,000 insured plans, is funded
and administered separately from the single-employer program
and differs from the single-employer program in several
significant ways. The multiemployer program covers only
collectively bargained plans involving two or more unrelated
employers. For such plans, the event triggering PBGC's
guarantee is the inability of a covered plan to pay benefits
when due at the guaranteed level, rather than plan termination
as required under the single-employer program. PBGC provides
financial assistance through loans to insolvent plans to enable
them to pay guaranteed benefits.
The significant reforms enacted in 1980 created several
safeguards for the program, including a requirement that
employers who withdraw from a plan pay a proportional share the
plan's unfunded vested benefits. These safeguards have
permitted PBGC to maintain multiemployer premiums at a
constant, reasonably low level.
Plan Underfunding.--Based on Form 5500 data at the
beginning of 1995--the most recent information available--
multiemployer plans had total assets of $202.3 billion and
liabilities of $217.0 billion. Overfunding among multiemployer
plans as of the beginning of 1995 totaled about $12.6 billion.
Underfunding among these plans totaled $27.4 billion, a
decrease of $2.6 billion from the previous year resulting
mainly from the higher interest rates that prevailed in 1994.
The average funding ratio of underfunded plans slipped slightly
from 81 percent to 80 percent because of the effect of
declining investment returns on asset values.
Future developments in multiemployer underfunding and the
financial condition of the multiemployer program depend on
future economic and demographic factors such as interest rates,
plan experience and investment performance, and the financial
health of covered industries, particularly as reflected in
industry employment levels.
Financial Assistance.--The multiemployer program has
received relatively few requests for financial assistance.
Since enactment of the reforms in 1980, PBGC has provided
assistance to only 19 of the 2,000 insured plans, with a total
value of approximately $35 million net of repaid amounts. In
1997, only 14 of these plans were still receiving assistance of
about $4 million annually.
customer service
Premier customer service is a corporate priority and was a
driving force behind a variety of PBGC initiatives during the
year. While most of the agency's activity was aimed at those
whom PBGC serves directly, two projects will also benefit the
general public.
PBGC completed and issued a new reference publication, the
``Pension Insurance Data Book 1996,'' which provides detailed
statistics on the experience of the single-employer insurance
program and on the pension plans that it protects. The ``Data
Book'' is intended to contribute to informed analyses that will
help ensure a sound pension system. PBGC also redesigned and
expanded its Home Page and web-site on the Internet to make it
more user-friendly and to highlight information of interest to
workers, retirees, employers, and pension professionals.
Service Improvements for Participants.--PBGC annually
surveys a sampling of people whose plans have been taken over
by the agency to determine their level of satisfaction with
PBGC services and identify areas for improvement. Past surveys
indicated a general desire for better and more timely
communications, leading PBGC to introduce regular newsletters,
a Customer Service Center with a toll-free telephone number,
and more understandable form letters for regular
correspondence. The most recent survey showed increased
satisfaction with PBGC, as 79 percent of the surveyed
participants rated PBGC's overall customer service as ``above
average'' or ``outstanding.'' One of PBGC's goals under its
strategic plan is to satisfy 90 percent of the participants by
the year 2002. In response to the latest survey, PBGC added a
new standard that pledges the agency to deal with routine
matters in one telephone call. The agency also expanded the
availability of its toll-free telephone number so that all
participants have a single telephone number with which to reach
PBGC on any matter.
In other areas of communication, PBGC simplified and
clarified its benefit determination letters and benefit
summaries, which are used to inform people of the amount of
their guaranteed benefit, and its two most important
explanatory pamphlets for participants in trusteed plans. In
addition, while continuing to hold informational meetings for
people in large, newly trusteed plans, PBGC developed a
videotape for participants of smaller plans when meetings with
PBGC representatives are not feasible.
Service Improvements for Employers.--In addition to easing
deadlines and simplifying rules for terminations of fully
funded pension plans, PBGC adopted several measures to improve
service and provide reporting relief for the business
community. The agency ended publication of its annual listing
of the 50 companies with the most underfunded pension plans.
PBGC determined that the list was no longer needed since full
implementation of the reporting and funding reforms enacted in
the Retirement Protection Act has provided better enforcement
tools to protect pensions.
PBGC also waived a requirement that small companies notify
the agency if they fail to make quarterly pension
contributions. According to PBGC analysis of reports received
during the year, this change will ease reporting burdens for
small companies without harm to plan participants or the
insurance program. In addition, PBGC also announced shortly
after the end of the year that it generally would ask employers
selected for the agency's premium audit program to provide only
three years of premium-related information rather than the six
years of information previously required, in order to ease the
burden and expense of these audits. Agency audits will extend
back beyond three years only if problems appear in the initial
information.
Promoting Defined Benefit Pensions
Only defined benefit pensions offer a predictable,
guaranteed, lifetime pension for America's working men and
women and their families. For a company, defined benefit plans
promote worker loyalty and retain an experienced workforce, and
in some cases are the most economical way to provide adequate
pensions for employees.
The decline in the number of defined benefit plans
continued to slow in 1997. Employers ended about 3,500 fully
funded plans during the year, compared to about 3,800 such
terminations in 1996. As a result of the continuing
terminations and mergers of ongoing plans, the number of
insured single-employer pension plans fell from a high of
112,000 in 1985 to 43,000 in 1997. The drop has been primarily
among small plans--those with fewer than 100 participants. The
number of larger plans--with 1,000 participants or more--has
remained relatively stable.
PBGC has a statutory mandate to encourage the maintenance
and continuation of defined benefit pension plans. To carry out
this mandate, PBGC focused effort in 1997 in several areas.
The agency discussed with employer groups ways for small
businesses, where fewer than 25 percent of the workers are
covered by any retirement plan, to provide federally insured
defined benefit pension coverage. As the year ended, the
Administration was developing a simplified defined benefit
plan--later called SMART (Secure Money Annuity or Retirement
Trust)--to provide small businesses with an easy- to-administer
pension option that would provide predictable, guaranteed
benefits for workers. The Administration's proposal builds on
the bipartisan SAFE proposal developed by Representatives Earl
Pomeroy of North Dakota and Nancy Johnson of Connecticut, among
others, and combines many of the best features of defined
benefit and defined contribution plans. The SMART plan
eliminates many of the complex rules that now apply to defined
benefit plans while ensuring that the tax benefits of the plan
flow primarily to low and middle-income workers. The
Administration's proposed plan would cover all eligible workers
in small businesses with 100 or fewer employees, and employers
would have predictable funding based on conservative
assumptions that would keep earned benefits fully funded at all
times. Participants would be guaranteed a minimum annual
retirement benefit that could be increased if the return on
plan investments exceeded specified conservative assumptions,
and their benefits would be protected by PBGC.
PBGC also sought to spur interest in defined benefit plans
by following one of the key principles of a customer-driven
organization--listening more effectively to the concerns of our
customers, including the employers who provide defined benefit
plans and pay insurance premiums. PBGC developed mechanisms for
two-way communication with employers and pension plan
practitioners through focus groups, surveys, and through the
Internet via e-mail. The agency sought to identify obstacles to
the creation and maintenance of defined benefit pension plans
arising from PBGC rules and procedures and to take corrective
action where appropriate.
To set up an environment conducive to defined benefit
plans, PBGC began to ease regulatory and administrative
requirements to encourage the provision of defined benefit
plans, while still carrying out its mandate to protect workers'
pensions and the pension insurance program. PBGC will continue
to build on the achievements of 1997 to ease the burdens on
providers of defined benefit pensions.
Defined benefit plans offer distinct advantages to workers:
Predictable benefits
Secure benefits
Lifetime benefits
To further encourage defined benefit pensions, PBGC has
begun to seek opportunities to reach out with information and
education strategies to communicate the value of defined
benefit pension plans to both employers and employees. Defined
benefit retirement plans offer numerous advantages. Workers can
earn a reasonable retirement benefit even if they were not
covered by a retirement plan earlier in their career, and they
can know in advance what benefits they will receive at
retirement. These retirement benefits are not dependent on the
amount of salary that workers are willing or able to
contribute, and the retirement benefit is not subject to
fluctuations of the stock market. The benefit is paid as an
annuity for the life of a worker, no matter how long the worker
lives. The defined benefit plan must also pay a lifetime
survivor annuity to the worker's surviving spouse, unless both
the worker and spouse elect otherwise.
Defined benefit plans offer distinct advantages to
employers:
Valuable retirement benefits for workers
Flexible benefit options
Investment advantages
Defined benefit plans provide more flexibility for
employers to design different types of benefits packages for
their workforces. For example, a defined benefit plan can be
used to accomplish corporate workforce goals by providing early
retirement incentives. Employers also can choose to add
valuable benefits such as extra spousal benefits, disability
benefits, or cost-of-living adjustments. There are investment
advantages as well for employers. The collective investment of
plan assets can result in higher plan investment returns, and
favorable interest rates and economic conditions can reduce an
employer's contribution. Finally, PBGC guarantees to pay most
of a worker's pension benefit if the employer cannot afford to
pay the benefits or goes out of business.
Defined benefit pensions have and will continue to play an
important role in the effort to provide American workers with a
secure retirement.
single-employer program exposure
PBGC's expected future claims are dependent on two factors:
the amount of underfunding in the pension plans it insures
(i.e., the exposure), and the likelihood that plan sponsors
encounter financial distress that results in bankruptcy and
plan termination (i.e., the probability of claims).
Expected claims over the near term are related to
underfunding in plans sponsored by firms that exhibit weakness
in their creditworthiness. PBGC assigns plan sponsors to this
category based upon factors such as whether the firm has a
below-investment-grade bond rating. PBGC calculates
underfunding for vested benefits using data from a variety of
sources, including the annual confidential filings that
companies with plans with at least $50 million in underfunding
for vested benefits are required to make under Section 4010 of
ERISA.
Underfunding by companies in this category is classified as
PBGC's ``reasonably possible'' exposure, for purposes of PBGC's
financial statements, as required under generally accepted
accounting principles. As of December 31, 1996, baseline
``reasonably possible'' exposure was $21 billion, as compared
to $22 billion one year earlier.
Expected claims in the longer term are more difficult to
quantify either in terms of a single number or a limited range.
That is, the amount of PBGC's future claims depends on many
factors, including current underfunding among insured plans,
changes in underfunding over time, and bankruptcies among plan
sponsors. These factors are influenced by future economic
conditions, most particularly those affecting interest rates,
stock returns, and the rate of business failure.
Claims also depend importantly on the financial performance
and the plan funding history of the individual insureds. If
firms that enter bankruptcy also are those that sponsor
underfunded defined benefit plans, then claims could be high
even if overall economic conditions are favorable, and vice
versa. It is not possible to predict either economic conditions
or which particular firms will enter bankruptcy in the future.
Indeed, PBGC needs to be prepared financially to handle a range
of outcomes.
In assessing the longer term, underfunding in companies
with investment-grade bond ratings also must be considered
because, over time, some of these companies will experience
deterioration of their financial condition. Although this
underfunding is referred to as ``remote'' (to distinguish it
from ``reasonably possible''), PBGC will incur claims from some
of these firms over the next ten years.
In previous years, we based our estimates of total pension
underfunding on information received from companies during the
process of creating a list of the 50 companies with the largest
underfunded pensions. With the reporting requirements in the
Retirement Protection Act of 1994 fully implemented, the agency
discontinued the Top 50 process in 1997.
Using data obtained for the last Top 50 list, PBGC reported
overall pension underfunding of $64 billion as of the end of
1995. While the agency does not have a comparable estimate for
aggregate underfunding as of the end of 1996, various other
indices used by PBGC indicate that a moderate reduction in
underfunding did take place in 1996.
Underfunding is sensitive to changes in interest rates or
stock returns, or the development of underfunding in some large
firms. There is clear volatility in underfunding over time, as
seen in the period from 1980 to 1995.
Likewise, claims vary substantially over time reflecting
overall economic conditions, the performance of some particular
industries, or the bankruptcy of a few very large companies.
Volatility and the concentration of claims in a small number of
terminations characterize PBGC expected claims. This volatility
is apparent in the agency's historical claims experience.
Methodology for considering long-term claims.--No single
underfunding number or range of numbers--even the reasonably
possible estimate--is sufficient to evaluate PBGC's exposure
and expected claims over the next ten years. There is too much
uncertainty about the future, whether the performance of the
economy or the performance of the companies that sponsor the
insured pension plans.
The proper way to assess future claims is with advanced
analytic tools such as stochastic models. The agency is now in
the final stages of peer review of its stochastic model, the
Pension Insurance Modeling System (PIMS). PIMS models future
underfunding under current funding rules as a function of a
variety of economic parameters and recognizes that all
companies have some chance of bankruptcy, and that these
probabilities can change significantly over time. The model
recognizes the uncertainty in key economic parameters
(particularly interest rates and stock returns). The model
simulates the flows of claims that could develop under
thousands of combinations of economic parameters and bankruptcy
rates.
Until PIMS is fully peer-reviewed, we will continue to use
our existing model that portrays three potential claims
scenarios and does not assign probabilities to their
occurrence.
Ten-Year Forecasts.--PBGC's current methodology for the
ten-year forecasts relies on an extrapolation of the agency's
claims experience and the economic conditions of the past two
decades.
Forecast A is based on the average annual net claims over
PBGC's entire history ($467 million per year) and assumes the
lowest level of future losses. Forecast A projects steady
improvement in PBGC's financial condition, resulting in a
surplus of $8.0 billion at the end of 2007.
Forecast B, which assumes the mid-level of future losses,
is based upon the average annual net claims over the most
recent 11 fiscal years ($545 million per year). Forecast B
projects net income levels that, while lower than Forecast A,
still lead to a surplus of $6.9 billion at the end of 2007.
Forecast C is highly pessimistic and reflects the potential
for heavy losses from the largest underfunded plans by assuming
that the plans that represent the reasonably possible exposure
will terminate uniformly over the next ten years in addition to
a modest number of lesser terminations each year. This forecast
assumes $2.1 billion of net claims each year, resulting in a
return to a deficit position and the steady growth of PBGC's
deficit throughout the ten-year period to $17.1 billion.
The 1997 forecasts share several assumptions. Average
annual net claims and projected claims are in 1997 dollars. The
present value of future benefits is valued at 6.18% and using
other actuarial assumptions that are consistent with
assumptions used to value the present value of future benefits
in the financial statements as of September 30, 1997. PBGC's
assets are projected to earn 6.18% annually. Benefits for plans
terminating in the future are assumed to grow at 4.38% annually
until termination. Plan funding ratios are assumed to increase
at 1.5% per year from historical averages and recoveries from
plan sponsors are assumed to be constant at 10% of plan
underfunding. The number of participants in insured single-
employer plans is assumed to remain constant. The flat-rate
portion of the single-employer premium is assumed to remain
constant at $19 per participant. Receipts from the variable-
rate portion of the premium are projected on the basis of a
constant 30-year U.S. Treasury bond rate of 6.5%. Assumed
administrative expenses are consistent with PBGC's 1999
President's Budget submission.
Improving Internal Management Support
With a strategic goal of improving internal management
support operations, PBGC is committed to a strong
infrastructure built on modern technology and comprehensive
employee development.
technology advances
PBGC continued to bring new automated information
management systems on-line, using commercial off-the-shelf
software as appropriate. Some of the new systems, such as a new
trust fund accounting system, converted critical applications
from outmoded mainframe computers to modern PBGC-based "client-
server" systems using networked personal and small multi-user
computers. Another system that will become operational in 1998
will account for revolving fund activities with the use of off-
site Department of Commerce computers for which PBGC has made a
special arrangement. Both of the new accounting systems will be
part of PBGC's integrated core financial system.
The agency also worked to improve existing systems while
applying finishing touches to the major new systems implemented
within the past two years. Enhanced software for the Early
Warning Program provides the program's financial analysts with
easier access to the detailed information they need for their
analyses, freeing them to handle more cases and address more
issues. PBGC expanded the availability of the new participant
information management and image processing systems that had
been developed for insurance operations so that other
departments could begin making use of the information in these
systems. The agency also established an in-house Document
Management Center to centralize and facilitate mail handling,
imaging, and limited automated letter generation, and an off-
site facility has been set up to handle large-scale production
and mailing of automated letters.
While PBGC has not yet achieved full integration of its
automated information systems, the systems it is developing do
allow easier sharing of data. In addition, the agency adopted a
corporate-wide systems development methodology that will ensure
that all future information systems and applications will be
developed consistent with existing corporate standards and
systems.
PBGC's advances in technology are beginning to demonstrate
value beyond the pension insurance program. During 1997, PBGC
received special recognition from the Smithsonian Institution
for using information technology ``for the benefit of
mankind.'' Information on the premium accounting system will be
added to the Smithsonian's Permanent Research Collection of
Information Technology at its National Museum of American
History. Separately, in support of the President's initiative
to strengthen the District of Columbia and in memory of PBGC's
late Executive Director Martin Slate, the Department of Labor
and PBGC donated 45 surplus computers to a local elementary
school, increasing the accessibility of computers from one for
every eight students to one for every four students. PBGC
volunteers subsequently donated time and materials to wire the
school for access to the Internet.
employee development
PBGC added new courses to expand its in-house employee
training program, which also was renamed the Martin Slate
Training Institute in memory of the late PBGC Executive
Director. Secretary of Labor Alexis Herman joined PBGC's then-
Acting Executive Director John Seal and Mr. Slate's widow, Dr.
Caroline Poplin, in a June 1997 ceremony dedicating the newly
named Training Institute in commemoration of Mr. Slate's
commitment to employee training and development.
By yearend the agency had completed development of ten new
technical courses and was in the process of developing six
additional courses. The new courses focus on such areas as the
agency's new information systems, pension law, and the
processing and administration of terminated plans. Other
innovations during the year included a new mentoring program
for professional staff and an expert witness-attorney trial
advocacy training program to sharpen the expert testimony
skills of PBGC analysts and actuaries and the trial skills of
PBGC attorneys.
Executive Director's Message (1998)
I am happy to report that, for the third consecutive year,
the Pension Benefit Guaranty Corporation's insurance programs
generated an accounting surplus. Because of low claims, good
investment performance, and adequate premium revenues, PBGC is
financially healthier than ever before. But I am also very
mindful that it was not so very long ago that PBGC's financial
condition was precarious. As the U.S. General Accounting Office
stated in its recent evaluation of PBGC, ``While PBGC's
financial condition has significantly improved, risks to the
long-term financial viability of the insurance programs
remain.'' We remain vigilant.
PBGC's improving financial position has allowed me to focus
my efforts on strengthening and expanding the defined benefit
system. We face an enormous challenge in helping to provide
retirement security for the baby boom generation and others
nearing retirement. If we are to achieve the goal of retirement
income security for our aging workforce, I believe the solution
must include defined benefit plans. Defined benefit plans
provide a predictable, secure pension for life, and even small
monthly benefit amounts can make a large difference in a
retiree's standard of living.
I believe that the defined benefit system is in trouble.
Both the number of plans and the number of workers whose
primary pension is a defined benefit plan have declined
dramatically. To remedy this, I asked a PBGC team to work with
pension professionals and other stakeholders to find out what
can be done to make defined benefit plans more attractive. We
have received a lot of good ideas and we are working to develop
them to strengthen and expand the defined benefit system. That
will be my primary objective in 1999. It is important that we
succeed. The retirement security of millions depends on our
efforts.
David M. Strauss,
Executive Director.
Strategic Planning
PBGC continued to follow the five-year strategic plan first
developed in 1997. The plan established four broad goals that
form the framework for PBGC to structure both its short-term
and long-term plans. PBGC's goals are to:
(1) protect existing defined benefit plans and their
participants and encourage new plans,
(2) provide high-quality services and accurate and
timely payment of benefits to participants,
(3) strengthen financial programs and systems to keep
the pension insurance system solvent, and
(4) improve internal management support operations.
The strategic plan establishes performance measures through
which PBGC assesses its progress toward each of its strategic
goals. The performance measures track specific results that are
significant to PBGC's customers and gauge PBGC's solvency and
customer service accomplishments. PBGC will periodically review
its performance measures for necessary adjustments as
circumstances change and program performance reporting
capabilities improve.
1998 PBGC Corporate Performance Measures
----------------------------------------------------------------------------------------------------------------
Measure and applicable goal 1998 milestone 1998 result Baseline (1997)
----------------------------------------------------------------------------------------------------------------
Pension Loss Prevention (total (1)...................... 100%..................... 88.5%.
value of loss prevention as
compared to total underfunded
vested benefits) (goal 1).
Achieve 90% participant 81%...................... Available in 3/99........ 79%.
satisfaction regarding
responses to inquiries (goal
2).
Provide post-audit estimated To be established in 1999 93.5%.................... 90%.
benefits to new retirees that
are within 5% of final
benefits in clear,
understandable language (goal
2).
Provide final accurate benefit
determinations to participants
within 3-5 years of plan
trusteeship (goal 2):
(a) age of pretrusteeship No more than 4 years..... 98.6% 4 years............ Not available.
inventory.
(b) timeliness of final 7-8 years................ 5.39 years............... 5.95 years.
benefit notifications.
Collect 97% of total pension 95%...................... 99%...................... 97%.
insurance premiums due (goal
3).
Approximate comparable 5-year (1)......................
investment indices for PBGC's
portfolio investment (goal 3).
----------------------------------------------------------------------------------------------------------------
1 Not projected--determined annually based on actual results.
[In percent]
------------------------------------------------------------------------
1998 Result-- Baseline (1977)
-----------------------------------
PBGC Index PBGC Index
------------------------------------------------------------------------
Equities............................ 18.1 17.6 20.6 20.6
Fixed-income........................ 9.2 9.2 10.9 8.9
------------------------------------------------------------------------
Promoting Defined Benefit Pensions
Providing retirement income security for the baby boom
generation and others nearing retirement is one of the most
compelling domestic challenges facing the country. The problem
is becoming increasingly urgent because of the huge number of
people affected and the short time left to deal with this
issue. There are 25 million people between ages 53 and 62 who
are now close to the end of their working careers, and right
behind them are 78 million ``baby boomers,'' 18 million of whom
are already at least 48 years old.
People are not saving enough, early enough in life, to meet
their retirement needs. Many low-income workers have no savings
at all, and most older workers have not saved very much either.
Half of America's households headed by people between ages 55
and 64 have wealth of less than $92,000, the bulk of which is
equity in their homes. Nor is the savings situation likely to
improve soon. Even those with a 401(k) plan are not saving
enough. An Employee Benefit Research Institute study of 6.6
million 401(k) participants shows that the average 401(k)
balance is only $37,000 and that nearly half of these
participants have less than $10,000 in their accounts. Many
low-income workers do not make enough to contribute anything to
their 401(k) accounts. President Clinton has taken an important
step to address this problem by proposing to establish
universal savings accounts to give all Americans the
opportunity to save.
Not only are workers not saving enough on their own, but
many have no pension plan. Half of the private-sector workforce
is not covered by any employer-sponsored retirement plan, and
only 20 percent of the workers in small businesses have any
retirement plan. Among lowwage workers, only 8 percent have a
plan.
Historically, the defined benefit plan has provided
adequate benefits for low-income workers who cannot afford to
save and for older workers who failed to start saving early
enough.
Yet, despite the value of defined benefit plans, the number
of plans insured by PBGC has decreased from 114,000 in 1985 to
44,000 today, with most of the decline among smaller plans. The
number of active workers in all plans has dropped from 29
million in 1985 to fewer than 25 million in 1994.
To encourage more employers to offer defined benefit plans,
the Administration proposed a simplified defined benefit plan
called SMART (Secure Money Annuity or Retirement Trust) for
small businesses with 100 or fewer employees. SMART combines
many of the best features of defined benefit and defined
contribution plans. The plan would provide coverage for all
eligible workers, and employers would have predictable funding
based on conservative assumptions that would keep earned
benefits fully funded at all times. SMART would guarantee a
minimum annual retirement benefit for participants that
employers could increase if the return on plan investments
exceeded specified conservative assumptions, and PBGC would
protect their benefits.
SMART is an important step. More could be done for
businesses of all sizes. At the request of the Executive
Director, a PBGC team is working with employer and employee
groups, pension professionals, and consultants who market
pension plans to determine the reasons defined benefit plans
are less prevalent today.
PBGC's efforts to promote defined benefit plans in 1998
laid the groundwork for future action. In 1999, PBGC will
continue to work with stakeholders to develop ideas to
strengthen and expand the defined benefit system.
Safeguarding Solvency
PBGC reported further improvement in its financial
condition, marking another year of progress toward its
strategic goal of strengthening its financial programs and
systems to keep the pension insurance system solvent. Fixed-
income investments, in particular, recorded dramatic gains. The
Early Warning Program produced numerous settlements that
protected the insurance program and hundreds of thousands of
workers and retirees from pension losses. The agency also
continued to meet legal challenges in courts across the
country.
financial management
Both PBGC insurance programs again posted significant
financial gains due mainly to investment earnings. Investments
of the larger single-employer program produced income of more
than $2.1 billion. Premium income totaled $966 million, $100
million less than in 1997 and nearly $200 million less than the
record level reached in 1996. PBGC collected 99 percent of the
premiums due, exceeding the target of 95 percent set under its
strategic plan. However, companies' premium payments continued
to decline because of reduced risk-based premium obligations.
The investment earnings enabled the single-employer program to
record net income of more than $1.5 billion, increasing the
program's net surplus to more than $5 billion.
The multiemployer program also continued to be financially
strong, with net income of $122 million almost exclusively from
investment income and an end-of-year net surplus of $341
million. As of September 30, the program had assets of $745
million and liabilities totaling $404 million primarily for
nonrecoverable future financial assistance. Both the net income
and net surplus represent record levels for the multiemployer
program.
Year 200 Readiness Disclosure
PBGC instituted a comprehensive review of its information
systems, Operations, and third-party relationships to assess
its readiness for the Year 2000. Under the leadership of the
Chief Financial Officer, PBGC formed a cross-functional team to
formulate the agency's Y2K plans.
PBGC expects new automated systems implemented during 1998
to be century-date-change ready and all systems requiring
changes to become ready and to complete independent
verification in 1999. PBGC is also working with its business
partners to address their readiness for the Year 2000, but PBGC
cannot ensure that other entities will be Y2K-compliant.
This information is PBGC's Year 2000 Readiness Disclosure
for the purpose of the Year 2000 Information and Readiness
Disclosure Act.
PBGC's financial statements have received their sixth
straight unqualified opinion from the agency's auditors. The
1998 audit was again performed by PricewaterhouseCoopers LLP
under the direction and oversight of PBGC's Inspector General.
After the year ended, the U.S. General Accounting Office
issued a report, ``Pension Benefit Guaranty Corporation:
Financial Condition Improving, But Long-Term Risks Remain,''
which cited PBGC's ``significantly'' improved financial
condition. However, GAO also noted that long-term risks to the
insurance program remain, many of which are beyond PBGC's
control. These risks include continued underfunding among some
large plans, downturns in the economy, problems in certain
sectors of the economy, a significant decline in the stock
market, and a substantial drop in interest rates. As the report
stated, ``An economic downturn and the termination of a few
plans with large unfunded liabilities could quickly reduce or
eliminate PBGC's surplus.'' The GAO report provided independent
validation that PBGC needs to be vigilant in managing its risks
and cautious about changes that could affect liabilities or
revenues.
Investment Program--The Corporation's investable assets
consist of premium revenues accounted for in the Revolving
Funds and assets from terminated plans and their sponsors
accounted for in the Trust Funds. By law, PBGC is required to
invest the Revolving Funds in fixed-income securities; current
policy is to invest these funds only in Treasury securities
agency has more discretion in its management of the Trust
Funds, which it invests primarily in high-quality equities. The
asset allocation is designed to provide sound long-term
performance.
PBGC has structured its investment portfolio to improve the
agency's financial condition in a prudent manner. The Revolving
Fund assets are invested to earn a competitive return and
partially offset changes in its benefit liabilities. The
agency's investment in equities provides overall portfolio
diversification and a higher long-term expected return, within
prudent levels of risk. PBGC uses institutional investment
management firms to invest its assets subject to PBGC
oversight. PBGC continually reviews its investment strategy to
ensure that the agency maintains an investment structure that
is consistent with its long-term objectives and
responsibilities.
As of September 30, 1998, the value of PBGC's total
investments, including cash, was approximately $18.1 billion.
The Revolving Fund's value was $11.6 billion and the Trust
Fund's value was $6.5 billion. PBGC's fund allocation shifted
toward fixed income and cash during 1998 due primarily to
strong fixed income returns. Cash and fixed-income securities
represented 66 percent of the total assets invested at the end
of the year, as compared to 61 percent at the end of 1997,
while the equity allocation stood at 33 percent of all
investments compared to 38 percent one year earlier. A very
small portion of the invested portfolio remains in real estate
and other financial instruments.
INVESTMENT PROFILE
------------------------------------------------------------------------
September 30--
---------------------
1998 1997
------------------------------------------------------------------------
Fixed-income assets:
Average quality............................... AAA AAA
Average maturity (years)...................... 21.3 21.0
Duration (years).............................. 11.3 10.5
Yield to Maturity (%)......................... 5.1 6.4
Equity assets:
Average price/earnings ratio.................. 19.7 26.0
Dividend yield (%)............................ 1.6 1.6
Beta.......................................... 1.04 1.04
------------------------------------------------------------------------
Fiscal year 1998 was positive for capital market
investments and PBGC's investment program. For the year, PBGC's
fixed-income program returned 22.8% while its equity program
advanced 2.1 %. PBGC's five-year returns equalled or exceeded
their comparable market indices, surpassing the requirements of
the agency's strategic plan. For the year, PBGC reported income
of more than $2.1 billion from fixed-income investments and
$121 million from equity investments.
INVESTMENT PERFORMANCE
(Annual rates of return on percent)
----------------------------------------------------------------------------------------------------------------
September 30-- Five years
-------------------------------- endedSept. 30,
1998 1997 1998
----------------------------------------------------------------------------------------------------------------
Total Invested Funds............................................ 14.4 21.9 11.9
Equities........................................................ 2.1 37.6 18.1
Fixed-income.................................................... 22.8 13.5 9.2
Trust funds..................................................... 2.1 35.6 16.2
Revolving funds................................................. 22.4 13.3 9.1
Indices:
Wilshire 5000............................................... 3.3 38.0 17.6
S&P 500 Stock Index......................................... 9.2 40.4 19.9
Lehman Brothers Long Treasury Index......................... 22.1 13.2 9.2
----------------------------------------------------------------------------------------------------------------
single-employer program exposure
PBGC's ``expected claims'' are dependent on two factors:
the amount of underfunding in the pension plans that PBGC
insures (i.e., exposure), and the likelihood that corporate
sponsors of these underfunded plans encounter financial
distress that results in bankruptcy and plan termination (i.e.,
the probability of claims).
Over the near term, expected claims result from
underfunding in plans sponsored by financially weak firms. PBGC
treats a plan sponsor as financially weak based upon factors
such as whether the firm has a below-investment-grade bond
rating. PBGC calculates the underfunding for plans of these
financially weak companies using the best available data,
including the annual confidential filings that companies with
large underfunded plans are required to make to PBGC under
Section 4010 of ERISA.
For purposes of its financial statements, PBGC classifies
the underfunding of financially weak companies as ``reasonably
possible'' exposure, as required under generally accepted
accounting principles. As of December 31, 1997, PBGC's
estimated ``reasonably possible'' exposure ranged from $15
billion to $17 billion.
Over the longer term, exposure and expected claims are more
difficult to quantify either in terms of a single number or a
limited range. Claims are sensitive to changes in interest
rates and stock returns, overall economic conditions, the
development of underfunding in some large plans, the
performance of some particular industries, and the bankruptcy
of a few large companies. Large claims from a small number of
terminations and volatility characterize the agency's
historical claims experience and are likely to affect PBGC's
potential future claims experience as well.
Despite the exceptional economic conditions of recent
years, it is not reasonable to assume that future experience
will be as favorable to PBGC. PBGC has had a surplus for only
three years after running a deficit for more than 20 straight
years. Furthermore, with premium changes built into the reforms
of the Retirement Protection Act of 1994, PBGC expects its
variable-rate premium revenues to decline substantially after
the year 2000.
After reviewing PBGCs financial situation, the U.S. General
Accounting Office concluded on October 16, 1998, that:
``Although PBGC's financial condition has significantly
improved over the past few years, risks remain from the
possibility of an overall economic downturn or a decline in
certain sectors of the economy, substantial drops in interest
rates, and actions by sponsors that reduce plan assets. These
risks could threaten the long-term viability of the insurance
programs. Further, PBGC has only a limited ability to protect
itself from risks to the insurance programs.''
Methodology for considering long-term claims.--No single
underfunding number or range of numbers--even the reasonably
possible estimate--is sufficient to evaluate PBGC's exposure
and expected claims over the next ten years. There is too much
uncertainty about the future, both with respect to the
performance of the economy and the performance of the companies
that sponsor the insured pension plans.
The proper way to assess future claims is with advanced
analytic tools such as stochastic models, which incorporate
random events. PBGC has developed a stochastic model to
evaluate its exposure, the Pension Insurance Modeling System
(PIMS), and, with this report, the agency is adopting this
model for its forecasts.
PIMS portrays future underfunding under current funding
rules as a function of a variety of economic parameters. The
model recognizes that all companies have some chance of
bankruptcy and that these probabilities can change
significantly over time. The model also recognizes the
uncertainty in key economic parameters (particularly interest
rates and stock returns). The model simulates the flows of
claims that could develop under thousands of combinations of
economic parameters and bankruptcy rates.
Under the model, median claims over the next ten years will
be about $600 million per year (expressed in today's dollars);
that is, half of the scenarios show claims above $600 million
per year, and half below. The mean level of claims (that is,
the average claim) is much higher, more than $900 million per
year. The mean is higher because there is a chance under some
scenarios that claims could reach very high levels. For
example, under the model, there is a ten percent chance that
claims could exceed $2.1 billion per year. Despite PBGC's
recent favorable experience, the financial condition of the
agency could seriously deteriorate.
PIMS projects PBGC's potential financial position by
combining simulated claims with simulated premiums, expenses,
and investment returns. The mean outcome is an $8.8 billion
surplus in 2008 (in present value terms). However, the model
also shows the potential for significant downside outcomes. In
particular, there is nearly a 20 percent chance that the agency
could return to a deficit in the next ten years and a ten
percent chance that the deficit could exceed $6.3 billion in
2008 (in present value terms). These outcomes are most likely
if the economy performs poorly, in which case PBGC may
experience large claims amounts and investment losses. PBGC is
continuing to analyze the best way to manage and reduce the
risk of insolvency.
Comparison to the Previous Forecast Method.--PBGC's past
methodology for the tenyear forecasts relied on an
extrapolation of the agency's claims experience and the
economic conditions of the past two decades. Although PBGC is
now using a new method for forecasting its future financial
condition, the agency also prepared forecasts using the old
methodology for comparison with PIMS.
Forecast A is based on the average annual net claims over
PBGC's entire history ($527 million per year) and assumes the
lowest level of future losses. Forecast A projects steady
improvement in PBGC's financial condition, resulting in a
surplus of $11.5 billion at the end of 2008 ($6.6 billion in
present value terms for comparison to PIMS).
Forecast B, which assumes the mid-level of future losses,
is based upon the average annual net claims over the most
recent 11 fiscal years ($611 million per year). Forecast B
projects net income levels that, while lower than Forecast A,
still lead to a surplus of $10.5 billion at the end of 2008
($6.0 billion in present value terms).
Forecast C reflects the potential for heavy losses from the
largest underfunded plans by assuming that the plans that
represent the reasonably possible exposure will terminate
uniformly over the next ten years in addition to a modest
number of lesser terminations each year. This forecast assumes
$1.5 billion of net claims each year and projects a $2.5
billion deficit in ten years ($1.4 billion in present value
terms).
Technical Notes.--Forecasts A, B, and C share several
assumptions. Average annual net claims and projected claims are
in 1998 dollars. PBGC calculated the present value of future
benefits using an interest rate of 5.71% and other actuarial
assumptions that are consistent with assumptions used to value
the present value of future benefits in the financial
statements as of September 30, 1998. PBGC's assets are
projected to earn 5.71% annually. Benefits for plans
terminating in the future are assumed to grow at 3.81% annually
until termination. Plan funding ratios are assumed to increase
at 1.5% per year from historical averages and recoveries from
plan sponsors are assumed to be constant at 10% of plan
underfunding. The number of participants in insured single-
employer plans is assumed to remain constant. The flat-rate
portion of the singleemployer premium is assumed to remain
constant at $19 per participant. Receipts from the variable-
rate portion of the premium are projected on the basis of a
constant 30-year U.S. Treasury bond rate of 5.2%. Assumed
administrative expenses are consistent with PBGC's 1999
President's Budget submission.
loss prevention
Under its Early Warning Program, PBGC continued to monitor
more than 500 companies with pension plans underfunded by at
least $5 million in order to identify transactions that could
jeopardize pensions and to arrange suitable protections for
those pensions and the pension insurance program. During 1998,
PBGC negotiators reached agreements valued at nearly $1.1
billion with 35 companies, including Pepsico, Fruit of the
Loom, Sunbeam, Pillowtex, and Inland Steel Company. These
agreements provided contributions, security, and other
protections for the pensions of about 257,000 workers and
retirees. Loss prevention is PBGC's principal performance
measure for its strategic goal of protecting existing defined
benefit plans and their participants; with regard to these
agreements, PBGC is able to report a loss prevention rate of
100 percent for 1998.
litigation
PBGC continues to face challenges in courts across the
country, a number of which threaten to impair the agency's
ability to recover its losses for underfunded plans from the
employers responsible for those plans. At the end of the year,
PBGC had 132 active cases in state and federal courts and 830
bankruptcy cases.
Several of the most significant cases concerned the
priority and value of PBGC's claims for losses from plan
terminations:
Copperweld Steel Company.--PBGC continued to pursue
bankruptcy claims to recover amounts due PBGC and Copperweld's
three terminated pension plans, which covered about 3,000
workers and retirees. The company's liquidation trustee
contests whether PBGC's claims for unpaid minimum funding
contributions in excess of $1 million are entitled to tax
priority, and whether the assumptions PBGC prescribes in its
regulations appropriately measure PBGC's claims for unfunded
benefit liabilities. These issues are central to PBGC's ability
to recover its losses from employers in bankruptcy. In December
1997, the bankruptcy court ruled for the liquidation trustee's
position on both issues. PBGC and the liquidation trustee
negotiated an agreement that will expedite PBGC's appeal of
these two programmatic issues to the district court.
CF&I Steel Corporation.--PBGC continued to pursue its
claims against the reorganized CF&I for a CF&I plan that was
underfunded by about $221 million when terminated in March
1992. In August 1998, the Tenth Circuit Court of Appeals
adversely decided PBGC's appeal regarding the treatment of its
claims in bankruptcy. The court found that PBGC valuation of
its claim for unfunded benefit liabilities conflicts with the
Bankruptcy Code and affirmed lower court decisions reducing
PBGC's claim to about $123 million. The court also found that
PBGC's claim for unpaid minimum funding contributions is not
entitled to tax priority and that only a small portion of this
claim is entitled to administrative priority. PBGC's subsequent
petition for rehearing by the full appeals court was denied in
October 1998. PBGC is considering whether to seek further
review.
PBGC v. Skeen (In re Bayly Corporation).--Just after
yearend, PBGC received an adverse ruling from the Tenth Circuit
Court of Appeals in this case of first impression. The court
rejected PBGC's argument that a portion of its unfunded
liability claim is entitled to tax priority under the
Bankruptcy Code. The appeals court therefore affirmed the
decisions of the lower courts denying priority to this claim.
Other major cases in 1998 included:
Hughes Aircraft Company v. Jacobson.--On January 25, 1999,
the U.S. Supreme Court unanimously ruled that the Hughes
pension plan was not terminated merely because it was amended.
The Court expressly stated that the provisions of Title TV of
ERISA ``constitute[ ] the sole avenues for voluntary
termination'' of a pension plan. Hughes had amended its ongoing
plan in 1991 to create a non-contributory benefit structure.
Prior to the amendment, the plan, which was reportedly
overfunded by $1 billion, had been funded by contributions from
both employees and the employer. A group of retirees filed suit
for a share of the plan's alleged surplus, claiming that the
amendment created a new pension plan and terminated the old
one. A district court dismissed the suit but was reversed on
appeal. PBGC, along with the Department of Labor and the
Internal Revenue Service, filed a ``friend-of-the-court'' brief
urging the Court to reverse the Ninth Circuit decision. On the
issue of most concern to PBGC, the government argued that the
appeals court seriously misconstrued the plan termination
requirements of Title IV in ruling that the plan amendment had
``constructively'' terminated the plan even though the plan had
not been terminated in accordance with Title IV, and the Court
agreed.
Pineiro, Brooks, and Beaumont v. PBGC.--In 1991, PBGC
became trustee of three Pan Am pension plans underfunded by
$914 million. Three former employees of Pan American World
Airways later filed suit asking a district court to replace
PBGC with an independent trustee. The court dismissed virtually
all of the allegations as meritless, leaving open only an
allegation concerning the timeliness of PBGC's notice of
benefits to the Pan Am participants. The plaintiffs filed an
amended complaint in January 1998 realleging PBGC delays in
issuing benefit determinations as well as most of the dismissed
allegations. PBGC's motion to dismiss the amended complaint was
pending action by the district court at yearend. Despite the
exceedingly poor condition of company records and the
difficulties caused by Pan Am's protracted bankruptcy
proceedings, PBGC has been paying benefits to Pan Am retirees
continuously since taking over the plans and has completed
benefit determinations for more than 44,000 of the 53,000
former Pan Am workers and retirees. The agency expected to
complete most of the remaining benefit determinations by the
end of calendar year 1998.
White Consolidated Industries, Inc.--The district court's
decision was pending at yearend on PBGC's claims for the
estimated $120 million underfunding in pension plans that White
transferred to Blaw Knox Corporation in 1985. PBGC alleges that
a principal purpose of White in entering into the transaction
was to evade pension liabilities. PBGC took over all the Blaw
Knox plans either because they ran out of money or because they
would have been abandoned after Blaw Knox ceased business in
1994.
Providing High-Quality Service
Listening to customers is an essential ingredient to
premier customer service, to which PBGC management and staff
are committed. PBGC continued its outreach to plan sponsors,
plan participants, and pension professionals as it searched for
ways to further improve its service.
single-employer program results
Through its single-employer program, PBGC oversees
terminations of fully funded plans and guarantees payment of
basic pension benefits when underfunded plans must be
terminated. The single-employer program covers about 33 million
workers and retirees in more than 42,000 plans.
Standard Terminations of Fully Funded Plans.--The number of
standard terminations continued to decline from their peak of
about 11,800 in 1990, with 2,475 submitted to PBGC in 1998.
Most of these plans had 50 or fewer participants.
PBGC audits a statistically significant number of completed
terminations to confirm compliance with the law and proper
payment of benefits. These audits generally have found few and
relatively small errors in benefit payments, which plan
administrators are required to correct. The errors arise
primarily from use of incorrect interest-rate assumptions in
valuing lump-sum distributions to plan participants. Due to
PBGC's audits, in 1998 some 5,800 participants (about 4 percent
of all participants in audited plans) received about $2.75
million of additional benefits.
Distress and Involuntary Terminations of Underfunded
Plans.--During 1998 the agency completed the termination of 160
underfunded plans, the vast majority of which were involuntary
terminations by PBGC. In most cases termination was necessary
because the sponsoring employer had gone out of business. Many
of these plans had been under consideration for termination for
a period of time and their actual termination dates occurred in
earlier years, when the circumstances leading to their
termination first arose.
Trusteed Plans.--PBGC generally becomes trustee of a plan
after the plan has been terminated, although not necessarily in
the same year the plan was terminated. During 1998, PBGC became
trustee of 187 single-employer plans covering 41,000 people. At
yearend, the agency was in the process of trusteeing an
additional 58 plans terminated in 1998 or earlier. In all,
including 10 multiemployer plans previously trusteed, a total
of 2,665 terminated plans were trusteed or were being trusteed
as of the end of the year. (This total also reflects the
elimination of five single-employer plans included in last
year's total, which no longer required PBGC to become trustee.)
When PBGC trustees a large plan, the agency organizes
informational meetings with plan participants to allay their
concerns and to explain about PBGC's insurance. In 1998, the
agency held 21 such sessions across the country that reached
about 3,000 people. Executive Director David Strauss often
attended the sessions to meet the participants and answer their
questions.
Benefit Processing.--By the end of the year, PBGC was
responsible for the current and future pension benefits of
about 472,000 participants from single-employer and
multiemployer plans. These include 209,300 retirees who
received benefit payments totaling $848 million.
In 1998, PBGC issued more than 61,100 benefit
determinations. The agency's improved automation and
adjustments to basic benefit payment policies enabled PBGC
staff to further reduce the amount of time needed to produce
final benefit determinations. On average, PBGC issued final
benefit determinations 5.39 years after the date it had
trusteed the participant's plan, compared to the 8.75 year
average of just two years earlier. In doing so, the agency
exceeded the performance goal of 7-8 years set for 1998 under
its strategic plan, which directs PBGC to issue final
determinations within 3-5 years of plan trusteeship. PBGC
routinely pays benefits in estimated amounts until final
determinations are completed.
Appeals Processing.--PBGC's Appeals Board reviews appeals
of certain PBGC determinations. Most of the appeals are from
people disputing their benefit determinations. Typically, about
2 percent of all benefit determinations are appealed. During
1998, the Appeals Board received 3,705 appeals, a greater
percentage of benefit determinations than is usual due to a
high rate of form-letter appeals relating to one large pension
plan. The Appeals Board decided 779 appeals during the year,
closing them within 349 days, on average, of the date received.
The Board also made substantial progress toward decisions on
the high number of appeals filed this year.
Pension Search Program.--During 1998, the third year of
operation for the missing participants clearinghouse, 552
companies terminating fully funded plans asked PBGC for
assistance in finding 4,855 missing people. Of these, 3,687
were due over $6.6 million in benefits and 1,168 were covered
by annuity contracts that will pay their benefits when they are
found. By yearend, PBGC had confirmed addresses for 769 of the
missing people and paid more than $1.5 million in benefits to
493 of them. PBGC is continuing its search for valid addresses
for the remaining missing people.
The agency maintains a listing on the Internet called the
Pension Search Directory as an additional means of locating
people who have frustrated all previous searches by either
their former employers or PBGC. Since its inception in December
1996, the Directory has enabled PBGC to find nearly 1,400
people who were owed more than $4 million in benefits plus
interest. By the end of 1998, the total listing included almost
7,200 people who had worked for about 1,000 companies and were
owed nearly $13 million in pension benefits. The Directory is
found on the Internet at http://search.pbgc.gov.
multiemployer program results
The multiemployer program, which covers about 8.7 million
workers and retirees in about 2,000 insured plans, is funded
and administered separately from the single-employer program
and differs from the single-employer program in several
significant ways. The multiemployer program covers only
collectively bargained plans involving two or more unrelated
employers. For such plans, the event triggering PBGC's
guarantee is the inability of a covered plan to pay benefits
when due at the guaranteed level, rather than plan termination
as required under the single-employer program. PBGC provides
financial assistance through loans to insolvent plans to enable
them to pay guaranteed benefits.
As PBGC stated in its June 1996 report on the multiemployer
program's financial condition, ``The multiemployer program is
financially strong. Since enactment of the current financial
assistance program in 1980, the program's financial condition
has improved from a deficit of $8.5 million to the current
surplus . . . The program has had a surplus since 1982 . . .
Projections show that the surplus should continue to grow under
a wide range of economic scenarios.'' During 1998, PBGC updated
the data used in preparing the report and found that the
results remained substantially the same.
Financial Assistance.--The multiemployer program has
received relatively few requests for financial assistance.
Since 1980, PBGC has provided assistance to only 22 of the
2,000 insured plans, with a total value of approximately $38
million net of repaid amounts. In 1998, 18 of these plans were
still receiving assistance of about $6 million annually.
In January, the Anthracite Health and Welfare Fund and
Pension Plan, a plan for coal miners, became the first
multiemployer plan to repay financial assistance from PBGC. The
Fund repaid PBGC $3.2 million for financial assistance provided
in the 1980's to enable the Fund to pay benefits during
temporary periods of insolvency.
Legislation.--The Administration has recommended that the
Congress more than double the current maximum guarantee from
$5,850 to $12,870. The multiemployer program's benefit
guarantee has been at the same level since 1980, and inflation
has cut the real value of the guarantee almost in half.
Currently, less than 1 percent of all workers and retirees in
insolvent multiemployer plans have all their benefits
guaranteed. With the change, at least three-quarters of all
plan participants in future insolvencies would receive their
full benefits through PBGC's insurance. The guarantee increase
would require no change in the multiemployer premium rate. The
proposed increase in the guarantee has been pending before the
Congress since 1996.
customer service
PBGC's Customer Service Center for participants in trusteed
plans continued to meet higher-than-expected demands. When the
center began operations three years ago, PBGC projected that it
would handle about 8,000 calls per month with answer times
averaging about 2 minutes. During the past year, the center
handled, on average, more than 21,000 calls each month in
slightly more than 2 minutes per call. Another 516,000 calls
were answered through automated information.
In 1998, PBGC began implementing President Clinton's plain
language initiative. The agency started developing a Plain
Language Guide for use by PBGC staff that includes, in part, a
dictionary that defines technical terms commonly used by PBGC
in more easily understandable language. The agency also began
training staff in how to write in plain language. In addition,
PBGC rewrote selected, frequently sent letters to customers
using common everyday words and short sentences. These efforts
will continue in 1999.
PBGC also completed its first ``practitioner'' survey of
plan administrators and pension professionals to determine
their level of satisfaction with the agency's services. The
results, together with those of the agency's third survey of
plan participants conducted in 1997, were heartening and
instructive. Both practitioners and participants found that
PBGC's service was improving, with 79 percent of the surveyed
participants and 54 percent of the practitioners rating PBGC's
overall customer service as ``above average'' or
``outstanding.'' Under its five-year strategic plan, one of
PBGC's goals is to satisfy 90 percent of participants by the
year 2002--the agency intends to set a satisfaction goal for
practitioners after it reviews the results of its second
practitioner survey, during the second quarter of 1999.
pbgc's customer service standards
Our customers deserve our best effort as well as our
respect and courtesy.
On the first call from you, we will say:
what we can do immediately and what will
take longer,
when it will be done, and
who will handle your request.
We will call you if anything changes from what we first
said, give you a status report and explain what will happen
next.
We will have staff available from 8:00 a.m.--5:00 p.m.
Eastern time to answer your calls. If you leave a message, we
will return the call within one workday.
We will acknowledge your letter within one week of receipt.
The practitioner survey suggested that PBGC could raise the
overall satisfaction level simply by improving the timeliness,
responsiveness, and follow-up to inquiries. Those surveyed made
it clear they want their calls returned promptly and their
questions resolved within three to five days and with only one
or two calls. Many of these issues also surfaced in the
participant surveys. As a result, PBGC revised its Customer
Service Standards to reflect the type of service requested by
its customers.
In response to the surveys, PBGC formed several cross-
departmental teams of employees late in the year to develop
recommendations for improvements in specific areas of service,
including participant communications and billings for underpaid
premium payments. The intensive effort, termed Reach for
Excellence and Customer Happiness, allowed team members to tap
each other's knowledge about different areas of the agency in
identifying and addressing barriers to good customer service.
The teams had wide discretion to propose solutions. Ultimately,
many of the teams' recommendations were accepted, including
toll-free telephone numbers for employers, plan administrators,
and pension professionals and expansion of PBGC's website to
include more information for plan participants. The agency was
beginning to implement the recommendations as the year ended.
PBGC initiated a number of changes in part to address
issues raised by the surveys and to improve customer service.
Of these, perhaps the most significant involved the extension
of the premium filing due date by one month. Plan
administrators and pension professionals have frequently
expressed concern about the requirement that plans file their
final premium payment one month earlier than the final due date
for the Form 5500 annual information report they must file with
the Internal Revenue Service. Some of the information needed to
compute the PBGC premium is reported on the plan's Form 5500.
The premium due date also coincided with the last day a company
may contribute to its plan for the prior year, leading to
problems in the calculation of a plan's funding level. The
change in due date, effective for plan years beginning on or
after January 1, 1999, will ease a substantial burden on plan
administrators.
The agency introduced an electronic version of its
reportable events forms on its Internet website. Software on
the website now allows employers and plan administrators to
complete the form and submit it to PBGC by e-mail. In addition,
PBGC issued a new publication, the ``Small Business Guide,'' to
help small businesses with PBGC-insured plans understand the
operation and requirements of the pension insurance program.
The Guide summarizes all employer administrative
responsibilities under the insurance program in a single,
nontechnical reference publication.
PBGC also began an effort to educate workers about defined
benefit plans. Through a special section on its website and the
issuance of a new publication called ``A Predictable, Secure
Pension for Life,'' PBGC is providing easy-to-understand
information about how traditional defined benefit plans operate
and the advantages they offer.
For plan participants in PBGC-trusteed plans, PBGC changed
its policy on recovery of benefit overpayments to ensure that
no one ever repays more than the actual amount of the
overpayment. Until 1998, if a participant did not wish to repay
an overpayment in a lump sum, PBGC made the recovery through a
permanent reduction (generally capped at 10 percent) in the
person's future benefit payments. Now, the reduction will cease
when the total amount collected matches the amount by which the
person had been overpaid. In addition, PBGC increased the
maximum value of a benefit it will pay in a single, lump sum
from $3,500 to $5,000. A participant still has the option of
receiving the benefit as an annuity instead if that person's
monthly benefit at normal retirement age is at least $25. PBGC
also revised its procedures for valuing its recoveries for plan
underfunding and unpaid contributions, which will help reduce
the amount of time needed to complete final benefit
determinations.
ITEM 27--POSTAL SERVICE
----------
Programs Affecting Older Americans
ballots by mail
A growing number of Americans are voting early by sending
their ballots through the mail. After election officials make
the decision to utilize this opportunity, the Postal Service
has an obligation to ensure that officials know how to optimize
use of the mail for voter registration and elections. There are
numerous examples demonstrating that mail has enabled the
achievement of greater voter participation while lowering costs
to taxpayers. This phenomenon benefits, among others, the large
population of senior citizens who otherwise might not be able
to exercise their right to vote due to infirmities or inclement
weather which may prevent them from getting to the polls.
During 1998, the Postal Service worked with election
officials from around the country to develop and distribute an
Election Officials User Guide as a special resource manual to
assist them in utilizing mail more efficiently and effectively
for sending and receiving election ballots. The Postal Service
also unveiled a new ``Official Election Mail'' logo which
clearly distinguishes official election mail--voter
registration materials, absentee ballots, and referendum
information--from partisan political mail, campaign literature,
and other mail.
carrier alert program
Carrier Alert is a voluntary community service provided by
city and rural delivery letter carriers who watch participant
mailboxes for mail accumulation which might signal illness or
injury. Accumulations of mail are reported by carriers to their
supervisors, who then notify a sponsoring agency, through
locally developed procedures, for follow-up action. The program
completed its 16th year of operation in 1998 and continues to
provide a lifeline to thousands of elderly citizens who live
alone.
delivery service policy
The Postal Service has a long-standing policy of granting
case-by-case exceptions to delivery regulations based upon
hardship or special needs. This policy accommodates the special
needs of elderly, handicapped, or infirm customers who are
unable to obtain mail from a receptacle located some distance
from their home. Information on hardship exceptions to delivery
receptacles can be obtained from local postmasters.
services available from your rural carrier
Rural carriers continue to provide their customers with
retail services they have come to expect from the rural ``post
office on wheels.'' Retail services provided include registered
and certified mail, accepting parcels for mailing, and taking
applications for money orders. Rural carriers also provide
customers with receipts for such services.
Retail services are available to all customers served by
rural carriers but are most beneficial to those individuals who
are elderly or have a physical handicap which limits their
ability to go to the post office for these important services.
Rural carriers provide their customers with almost all retail
services available from the post office 302 days per year.
parcel delivery policies
For postal customers who are unavailable to receive
parcels, but who normally are at home, our letter carriers will
automatically redeliver the article the following day. In
addition, if the mailer requests, uninsured parcels are left at
customer homes or businesses provided there is reasonable
protection from weather and theft. Both of these policies make
it easier for customers, particularly the elderly, to receive
mail and minimize the need for trips to the post office.
accessibility
The Postal Service is subject to the Architectural Barriers
Act of 1968. The resulting standards for the design,
construction, and alteration of leased and owned facilities,
are published in Postal Service Handbook RE-4, Standards for
Facility Accessibility by the Physically Handicapped.
Significant progress continues to be made to increase the
accessibility of the 36,000 Postal Service Facilities. In
Fiscal Year 1998, approximately $1.5 billion was invested in
new construction projects resulting in the completion of over
800 new facilities. These projects were built fully accessible
for elderly and disabled customers. The 1998 Building Design
Standards comply with and in some cases exceed all
accessibility standards. Our commitment to barrier-free
facilities is apparent by our continued effort toward
retrofitting historic facilities. The Postal Service values its
elderly customers and feels they will benefit from our efforts
to make facilities more accessible.
consumer education and fraud prevention
The U.S. Postal Inspection Service endeavors to alert
consumers and businesses to various types of crimes by
attracting media attention to postal crime trends, publicizing
positive law enforcement accomplishments, circulating media
releases, and hosting crime prevention presentations.
In February 1997, the Inspection Service joined with the
American Association of Retired Persons (AARP) and the Attorney
General's office for the state of New Mexico in a continuing
public education initiative aimed at preventing telemarketing
fraud. Volunteers from the Albuquerque area AARP, state and
local consumer protection agencies, the New Mexico Attorney
General's office, and the Postal Inspection Service worked
together to turn the tables on crooked boiler room operators.
Using lists of previous victims of telemarketing fraud and
names of seniors gleaned from commercial phone lists,
volunteers telephoned 1,500 New Mexico residents to warn them
of the dangers of telemarketing fraud.
At a joint press conference in September 1997, the Chief
Postal Inspector, and members of the AARP, the Federal Trade
Commission (FTC), and the offices of the Attorneys General of
Massachusetts and Arizona, via satellite, announced Operation
Mailbox. This cooperative effort focused attention on
unsolicited mailings received by seniors, including suspicious
prize offerings, sweepstakes promotions, and requests for
charitable contributions. Senior volunteers collected hundreds
of unsolicited mailings which were displayed dramatically at
the press conference.
Project Mailbox II is an on-going, multi-pronged public/
private initiative focusing on companies that use deceptive
mass mailings, e-mails, and unsolicited faxes to entice
consumers to send money through the mail, call a telemarketer,
or show up at a face-to-face sales meeting. On October 1, 1998,
the U.S. Postal Inspection Service joined with the Attorneys
General from all 50 states, the FTC, AARP, Better Business
Bureaus, Yellow Pages Publishing Association, and National
Association of Attorneys General (NAAG) in announcing Project
Mailbox II. The project is designed to remind consumers that,
while the vast majority of direct mail solicitations are sent
by legitimate mail order companies, sometimes crooks use the
mail too.
Senior victimization was the topic of a Dateline NBC story
which featured the Inspection Service's efforts to stop the
flood of illegal foreign lottery mailings entering the United
States. The story focused on the success inspectors have
achieved in identifying illegal mailings at border entry
points, with the assistance of the U.S. Customs Service. These
efforts have led to the seizure and destruction of over 4.5
million pieces of foreign lottery mail. This story also
explored the sad tales of financial ruin suffered by many
elderly victims of these schemes who seem easy prey to the
allure of promised multi-million dollar jackpots.
In January 1998, the Inspection Service, the Postal Service
General Counsel, and the FTC held a joint news conference in
Washington to announce the filing of multiple injunctions and
civil complaints against various self-styled employment
agencies. Inspectors and General Counsel attorneys sought to
focus public awareness on ``postal job'' promotions, which
misrepresent their relationship with the U.S. Postal Service
and the benefits they can provide prospective job hunters.
These promoters seek to take advantage of individuals who may
be out of work or seeking to better themselves, and who
consider Postal Service employment extremely desirable.
The Inspection Service, FBI, AARP, and Retired Service
Volunteer Program (RSVP) participants assembled in Los Angeles
in February 1998 to conduct a friendly boiler room initiative.
Volunteers used call lists seized in raids by law enforcement
officers to telephone individuals who were treated to several
telemarketing fraud prevention messages. A number of
entertainment celebrities attended the affair to help attract
media attention.
A similar friendly boiler room was conducted in Washington,
D.C., during November 1998. The AARP, FTC, and Department of
Justice (DOJ), with the assistance of the Inspection Service
and the FBI, made friendly fraud prevention calls from a
downtown hotel to consumers nationwide. Several thousand calls
were made during a 12-hour period and over two thousand
individuals were contacted, several whom dishonest
telemarketers may have victimized. These potential victims were
provided Mail Fraud Complaint forms and instructed as to proper
completion.
In New Jersey and Massachusetts, inspectors and local AARP
volunteers formed partnerships to educate senior citizens about
some of the fraudulent promotions which target the elderly
through direct mail and telemarketing schemes. Senior
volunteers were recruited to participate by collecting all
questionable or suspicious unsolicited promotional mailings
received during a specific period of time. Volunteers also kept
a log of all unsolicited telemarketing calls received.
Everything collected by the volunteers was turned over to
inspectors for examination and follow-up attention. The results
of the seniors' collection effort and the inspectors'
preliminary investigations were publicized with media
cooperation. This served to dramatically highlight the quantity
of fraudulent solicitations targeting senior citizens.
On September 1, 1998, Chief Postal Inspector Ken Hunter
testified before the Senate Subcommittee on International
Security, Proliferation, and Federal Services regarding
sweepstakes and prize award mailings representing fraud against
the consumer. Chief Hunter discussed numerous cases, which
illustrated prize award schemes, and the actions postal
inspectors took to prevent consumer losses.
One of the most significant investigations involved a
Canadian citizen who operated numerous companies that solicited
money from consumers through direct mail and telemarketing
ventures. The individual was indicted based on his involvement
in a telemarketing scheme involving foreign lotteries, which
had swindled hundreds of American consumers out of millions of
dollars. During the investigation, a questionnaire sent to 880
victims revealed the average age of the victim was 74. This
individual was sentenced to 180 days in custody and ordered to
forfeit approximately $8 million in funds seized by postal
inspectors to be paid to victims of his scheme. An article
regarding this case was published in the AARP Bulletin.
In October 1998, the U.S. Postal Inspection Service joined
with AARP, the Attorney General's office for the state of
Arizona, and Arizona State University Gerontology Program, in a
telemarketing and mail fraud conference. Over 135 people
attended the one-day seminar in Tempe, Arizona, whose theme was
New Directions: Seniors, Sweepstakes and Scams. The conference
was held to educate and protect seniors from telemarketing and
mail fraud schemes.
Postal Inspectors have taken a new tact in efforts to
combat international mail fraud schemes. From March through
November 1998, about 30 postal employees at John F. Kennedy
Airport/Air Mail Center in Queens, NY, using guidelines set by
postal inspectors, intercepted approximately 3 million letters
from Nigeria that promoted an illegal scam. The letters, often
referred to as ``419'' letters after the Nigerian statute that
makes them illegal, were found to have counterfeit Nigerian
postage and they promoted fraudulent business proposals. Most
of the intercepted letters were destroyed unopened at a
Westbury, Long Island, landfill. Nigerian postal authorities
are cooperating with the Postal Inspection Service in the
crackdown.
injunctions and other civil powers
In addition to the investigation of individuals or
corporations for possible criminal violations, the Inspection
Service can protect consumers from material misrepresentations
through the use of several statutes. In less severe cases,
operators of questionable promotions agree to a Voluntary
Discontinuance. This is an informal promise to discontinue the
operation of the promotion. Should the agreement be violated,
formal action against the promoter could be initiated. In
certain cases where a more formal action is better suited, a
Consent Agreement is obtained. Generally, a promoter signs a
Consent Agreement to discontinue the false representations or
lottery charged in a complaint. If this agreement is violated,
the Postal Service may withhold the promoter's mail pending
additional administrative proceedings.
The Postal Service (Judicial Officer) is empowered under 39
U.S.C. (b)(2) to issue a Cease and Desist (C&D) Order which
requires any person conducting a scheme in violation of Section
3005 to immediately discontinue. C&D orders are issued as part
of a False Representation order and, as a matter of course, are
agreed to as a part of a Consent Agreement. Violators of C&D
orders may be subject to civil penalties under 39 U.S.C. 3012.
When more immediate relief to protect the consumer is
warranted, the Postal Service has a number of effective
enforcement options available. Title 39 U.S.C. 3003 and 3004
enables the Postal Service, upon determining that an individual
is using a fictitious, false, or assumed name, title, or
address in conducting or assisting activity in violation of 18
U.S.C. Sections 1302 (Lottery), 1341 or 1342 (Mail Fraud), to
withhold mail until proper identification is provided and the
person's right to receive mail is established.
In those instances where a more permanent action is
necessary, 39 U.S.C. 3007 allows the Postal Service to seek a
Temporary Restraining Order detaining mail. By withholding
service to the suspected violator, the extent of victimization
is limited while an impartial judge reviews the facts and makes
a final determination. If the judge decides that all mail
pertaining to the promotion should be returned, then a False
Representation Order, authorized under 39 U.S.C. 3005 is
issued. In addition, U.S. District Judges may hold a hearing on
alleged fraudulent activity and issue a permanent injunction
regarding the operation pursuant to 18 U.S.C. 1345.
By requesting the court to withhold mail while a case is
argued, Postal Inspectors have been successful in many cases in
limiting the extent of victimization. Action under these
statutes does not preclude criminal charges against the same
target.
customer advisory councils
The Postal Service established its first Customer Advisory
Council (CAC) in October, 1998. The council concept was adopted
to foster a sense of partnership between local postal officials
and the communities they serve. Since that time, customer
participation in, and the total number of councils, have
continued to grow.
CACs provide a forum for the exchange of ideas and
suggestions and improve the quality of service provided through
an understanding of customer expectations. Membership usually
includes individuals who are representative of their community;
small business owners, local government officials, university/
college students, homemakers, and retired persons. The valuable
feedback received from councils is often used by local postal
officials to improve service and customer relationships.
national consumer protection week
The Postal Service has sponsored an annual Consumer
Protection Week since 1977. Beginning in 1980, the Postal
Service scheduled its observance to coincide with the National
Consumers Week sponsored by the U.S. Office of Consumer
Affairs. Postmasters and facility managers are urged to sponsor
special activities to educate customers about postal products
and services as well as Postal Inspection Service efforts to
protect consumers from perpetrators of fraudulent schemes and
other postal crimes. In conjunction with open houses and
special gatherings scheduled during National Consumers Week,
brochures are distributed to warn consumers about mail fraud
and misrepresentations of products and services sold by mail.
Helpful information about proper addressing of mail, packaging
parcels correctly, temporary address changes, sending valuables
through the mail, and how to report service problems are made
widely available through planned events. As medical fraud and
work-at-home schemes have traditionally ranked at the top of
the fraudulent promotions, the focus of material distributed is
frequently directed toward alerting senior citizens of these
other schemes.
Traditionally, National Consumers Week has been held in
October. In 1998 a decision was made to postpone it until the
first week of February 1999. The U.S. Postal Inspection Service
will join the U.S. Postal Service, the Federal Trade Commission
(FTC), and the American Association of Retired Persons (AARP)
to promote National Consumer Protection Week.
The Inspection Service will issue three Video News Releases
(VNRs) entitled, Conning Older Americans; How They Scam Older
Americans; and Fraud Fighters which will be sent to local
television stations via satellite for release during Consumer
Protection Week. The VNRs correspond with the purpose of
National Consumer Protection Week, which is to highlight
consumer protection and education efforts around the country.
stamps by automated teller machine (atm)
Stamps by ATM is a convenient way to purchase stamps at a
bank's automated teller machine. A specially designed sheetlet
of 18 First-Class stamps is dispensed at the touch of a button.
The cost is debited from your checking or savings account and
treated like a cash withdrawal. Because many ATMs are
accessible 24 hours a day, our customers are able to do banking
and buy postage stamps at their convenience.
stamps by mail
Stamps by Mail is a service that allows customers to
purchase stamps in booklets, sheets and coils along with other
products such as postal cards, and stamped envelopes by
ordering through the mail.
The Stamps by Mail program benefits a wide variety of
people and is particularly beneficial to elderly or shut-in
customers who cannot travel to the post office. Stamps by Mail
provides order forms incorporated in self-addressed postage-
paid envelopes to customers for their convenience in obtaining
products and services without having to visit a Postal Service
retail unit. The form is available in lobbies or from the
customer's letter carrier. Once the form is completed it can be
returned to the carrier or dropped in a collection box. Orders
are normally returned to the customer within 2 or 3 business
days.
stamps by phone
Stamps by Phone is a convenient program that is intended to
target business, professional, and household customers who are
willing to pay a service charge for the convenience of ordering
by phone and paying by credit card (VISA or Master Card) to
avoid trips to the post office. Customers utilizing this
service can call a toll-free number (1-800-STAMPS-24), 24 hours
a day, 7 days a week, and order from a menu of postal products.
There is no minimum purchase amount, and customers receive
their orders within 3 to 5 business days.
alternate postal retail sites
Alternate postal retail sites include, grocery stores and
other retail stores that offer stamps for sale through a
consignment agreement, and contract Postal Units that offer a
wider variety of services. Stamps offered through consignment
agreements are sold at no more than face value at retailer
checkstands. Contract postal units provide more convenient
locations for our customers to mail packages, purchase stamps
and postal money orders, send registered mail, and obtain
postal services.
In 1998 the Postal Service began testing a partnership with
Mail Boxes Etc. (MBE) to sell stamps and postal services at 250
MBE locations throughout the United States. By providing
services at numerous alternate locations, the Postal Service
provides greater access and flexibility for all customers to
obtain stamps and other postal services, which generally means
less wait time for them to obtain these retail services. This
enables customers to combine their mailing needs and other
errands into a single trip to the neighborhood shopping center
or grocery store. This is especially convenient for our elderly
customers who may have limited access to transportation.
ITEM 28--RAILROAD RETIREMENT BOARD
----------
Annual Report on Program Activities for the Elderly for the U.S Senate
Special Committee on Aging 1997 and 1998
The U.S. Railroad Retirement Board is an independent agency
in the executive branch of the Federal Government,
administering comprehensive retirement-survivor and
unemployment-sickness benefit programs for the nation's
railroad workers and their families under the Railroad
Retirement and Railroad Unemployment Insurance Acts. The Board
also has administrative responsibilities under the Social
Security Act for certain benefit payments and railroad workers'
Medicare coverage.
Under the Railroad Retirement Act, the Board pays
retirement and disability annuities to railroad workers with at
least 10 years of service. Annuities based on age are payable
at age 62, or at age 60 for employees with 30 years of service.
Disability annuities are payable before retirement age on the
basis of total or occupational disability. Annuities are also
payable to spouses and divorced spouses of retired workers and
to widow(er)s, divorced or remarried widow(er)s, children, and
parents of deceased railroad workers. Qualified railroad
retirement beneficiaries are covered by Medicare in the same
way as social security beneficiaries.
Under the Railroad Unemployment Insurance Act, the Board
pays unemployment benefits to railroad workers who are
unemployed but ready, willing and able to work and pays
sickness benefits to railroad workers who are unable to work
because of illness or injury.
benefits and beneficiaries
During fiscal year 1998, retirement and survivor benefit
payments under the Railroad Retirement Act amounted to some
$8.2 billion, $41 million more than the prior year. The number
of beneficiaries on the retirement-survivor rolls on September
30, 1998, totaled 718,000. The majority (86 percent) were age
65 or older.
At the end of the fiscal year, 325,000 retired employees
were being paid regular annuities averaging $1,284 a month. Of
these retirees, 149,000 were also being paid supplemental
railroad retirement annuities averaging $43 a month. In
addition, some 174,000 spouses and divorced spouses of retired
employees were receiving monthly spouse benefits averaging $502
and, of the 227,000 survivors on the rolls, 190,000 were aged
widow(er)s receiving monthly survivor benefits averaging $768.
About 9,000 retired employees were also receiving spouse or
survivor benefits based on their spouse's railroad service.
Some 659,000 individuals who were receiving or were
eligible to receive monthly benefits under the Railroad
Retirement Act were covered by hospital insurance under the
Medicare program at the end of fiscal year 1998. Of these,
645,000 (98 percent) were also enrolled for supplementary
medical insurance.
Gross unemployment and sickness benefits paid under the
Railroad Unemployment Insurance Act totaled $92.4 million
during fiscal year 1998, while net benefits totaled $59.3
million after adjustments for recoveries of benefit payments,
some of which were made in prior years. Total gross and net
payments decreased by approximately $12.0 million and $13.6
million, respectively, from fiscal year 1997. Unemployment and
sickness benefits were paid to 31,000 railroad employees during
the fiscal year. However, only about $0.2 million (less than 1
percent) of the benefits went to individuals age 65 or older.
financing
At the end of fiscal year 1998, the balance in the Railroad
Retirement Board's accounts was $16.5 billion, registering an
increase of over $1.1 billion over the previous year, and
earnings on investments totaled $1.2 billion for the year.
The Board's 1998 railroad retirement financial report to
Congress, which addressed railroad retirement financing during
the next 25 years, was generally favorable. It concluded that,
barring a sudden, unanticipated, large decrease in railroad
employment, no cash-flow problems arise during the next 20
years. Cash-flow problems arise only under the Railroad
Retirement Board's most pessimistic employment assumption and
then not until 2022. This is one year later than in the
previous year's report. Like previous reports over the last
decade, the 1998 report also indicated that the long-term
stability of the system, under its current financing structure,
is still dependent on future railroad employment levels.
The Board's 1998 railroad unemployment insurance financial
report was also favorable, indicating that even as maximum
benefit rates increase 40 percent from $43 to $60 from 1997 to
2008, experience-based contribution rates are expected to keep
the unemployment insurance system solvent, even under the
Board's most pessimistic employment assumption. The average
employer contribution rate remains well below the maximum
throughout the projection period.
The Board's reports consequently did not recommend
financing changes for the railroad retirement or unemployment
insurance systems.
legislative developments
Public Law 105-277, enacted October 21, 1998, provided for
the restoration of annuities to certain divorced spouses of
workers whose widows previously elected to receive lump-sum
payments. Public Law 105-33, enacted August 5, 1997, clarified
that non-resident aliens are eligible for benefits under the
Railroad Retirement and Railroad Unemployment Insurance Acts.
House Concurrent Resolution 52 was a non-binding resolution
which urged all parties of the railroad community, including
rail labor, rail management and railroad retiree organizations
to begin open discussions for the purpose of adequately funding
an amendment to the Railroad Retirement Act to increase
benefits for widows and widowers. A hearing on this resolution
was held on September 17, 1998, before the Subcommittee on
Railroads of the House Committee on Transportation and
Infrastructure, but no further action was taken by the House on
this resolution.
officials
On April 27, 1998, the Senate confirmed President Clinton's
appointment of Cherryl T. Thomas as Chair of the Railroad
Retirement Board for a term expiring in August 2002. Prior to
her appointment, Ms. Thomas served as Commissioner of the
Department of Buildings for the City of Chicago and in numerous
other posts including Deputy Chief of Staff to Mayor Richard M.
Daley during a 30-year career with the city.
V. M. Speakman, Jr. continues to serve as Labor Member of
the Board; prior to his appointment Mr. Speakman had been
President of the Brotherhood of Railroad Signalmen and had also
served as Vice Chairman of the Railway Labor Executives'
Association.
Jerome F. Kever continues to serve as Management Member of
the Board; before his appointment Mr. Kever had been Vice
President and Controller of the Santa Fe Pacific Corporation.
service and administrative improvements
The Railroad Retirement Board implemented various
initiatives during 1997 and 1998 to improve agency operations
and provide the best possible service to its customers.
Plans.--In its Strategic Plan prepared in accordance with
the Government Performance and Results Act of 1993, the Board
outlined its four main goals: (1) provide excellent customer
service; (2) safeguard the trust funds through prudent
stewardship; (3) align resources to effectively and efficiently
meet the agency's mission; and (4) expand the use of technology
and automation to achieve the agency's mission. The overall
mission statement in the Strategic Plan provides, in part, that
the Board ``will pay benefits to the right people, in the right
amounts, in a timely manner, and safeguard our customers' trust
funds.'' The Board will also ``treat every person who comes
into contact with the agency with courtesy and concern, and
respond to all inquiries promptly, accurately and clearly.''
The Board submitted its initial annual performance plan
with its fiscal year 1999 budget submission. The performance
plan links the goals in the Strategic Plan to day-today work,
defines the processes and resources necessary to meet the goals
and shows how the agency will measure progress toward achieving
its goals. The Board also finalized a Strategic Information
Resources Management Plan which incorporates the agency's
Information Technology Capital Plan and outlines the critical
role of information technology and automation in achieving the
goals and objectives contained in the Strategic Plan.
Consistent with those plans, the agency made technological
improvements that will improve performance and efficiency.
Y2K Compliance.--At the beginning of 1999, all of the
Board's mission-critical computer systems were Year 2000 (Y2K)-
compliant.
The Board's computer systems process benefit payments,
issue informational notices, enroll beneficiaries in Medicare,
withhold Federal income tax and perform other functions
essential to the Board's ongoing operations and service to the
railroad public. Having met the Y2K goal, the Board began a
series of comprehensive tests of its mission-critical systems
to ensure that all interfaces, connections, and links between
the various systems remain in sync and are fully functional.
The Board also plans to complete work on those systems that are
not mission-critical by September 30, 1999.
The agency's most important information exchange systems
are with the Department of the Treasury and the Social Security
Administration. The Board exchanges data with the Department of
the Treasury in order to issue benefit payments, and the
Board's staff expects a smooth transition in that area. The
Board also coordinates benefit payments with the Social
Security Administration, and these systems have already been
tested to ensure that the data exchanges will function
correctly in the year 2000.
Help Line.--In November 1997, new service options were
added to the Board's Help Line, a toll-free interactive voice
response system. Employees can now use the Help Line to obtain
statements of creditable service and compensation, and
beneficiaries on the rolls can use it to verify their current
monthly benefit rate or secure a replacement Medicare card.
Callers are also able to find the address and telephone number
of their local field office by entering their zip code, and
information on unemployment-sickness benefits continues to be
available on the Help Line, which is available 24 hours a day,
7 days a week.
Customized Notices.--In cooperation with the Department of
the Treasury's Chicago Financial Management Center which
provided printing services, the Board mailed customized notices
to over 750,000 annuitants which expanded the general
information notices issued annually following cost-of-living
adjustments. The revised notices gave annuitants a detailed
breakdown of their monthly rates by tier, and can be used as
proof of income, to verify the amount of the cost-of-living
adjustment and to calculate Federal income tax withholding
amounts.
Field Service.--As of October 30, 1997, the restructuring
of the Board's field service achieved its target configuration
of 53 service locations and 3 regional offices, as the number
of its field offices declined from 86 service locations and 5
regional offices in 1995. Most of the closed offices had been
base points or branch offices that functioned as satellites of
larger district offices. Automatic call forwarding was
established in those areas where offices were closed so that
customers could contact their new servicing office at no
additional expense. Board staff members have been able to
maintain service standards in these areas through greater use
of the telephone, mail and itinerant service as planned. Voice
mail and Internet e-mail are also now available in all field
offices. The restructuring reflected the ongoing demographic
changes in the rail industry and the budget limitations on the
Board's resources.
Occupational Disability Standards.--The Board unanimously
approved new standards for the evaluation of claims for
occupational disability benefits payable under the Railroad
Retirement Act. The standards, based on joint recommendations
negotiated by representatives of rail labor organizations and
the Association of American Railroads, call for a system based
on up-to-date medical standards to replace guidelines that had
been in effect for five decades. Effective February 13, 1998,
the new standards apply to applications filed on or after
January 1, 1998.
office of inspector general
During fiscal year 1998, the Office of Inspector General
continued its efforts to assist management in increasing the
efficiency of agency programs. Twenty-three audits and
evaluations issued during the year contained findings for
improvement in both administrative and program operations. Two
audit reports will have an estimated financial impact of $2.4
million when Board management completes necessary corrective
actions. Reviews were conducted of significant activities which
included the status of the conversion of information systems to
ensure compliance with the Year 2000, the investment of agency
trust funds, and agency progress in meeting the requirements of
the Government Performance and Results Act. Investigative
activities resulted in 100 criminal convictions, 43
indictments/informations, 73 civil judgments and almost $2
million in court-ordered restitutions, fines, recoveries and
prevention of overpayments.
public information activities
The Board maintains direct contact with railroad retirement
beneficiaries through its field offices located across the
country. Field personnel explain benefit rights and
responsibilities on an individual basis, assist railroad
employees in applying for benefits and answer any questions
related to the benefit programs. The Board also relies on
railroad labor groups and employers for assistance in keeping
railroad personnel informed about its benefit programs.
At informational conferences sponsored by the Labor
Member's Office of the Board for railroad labor union
officials, Board representatives describe and discuss the
benefits available under the railroad retirement-survivor,
unemployment-sickness and Medicare programs, and the attendees
are provided with comprehensive informational materials. During
1998, 2,210 railroad labor union officials attended 46
informational conferences held in cities throughout the United
States. In addition, railroad labor unions frequently request
that a Board representative speak before their meetings,
seminars and conventions.
At seminars for railroad executives and managers, Board
representatives review programs, financing, and administration,
with special emphasis on those areas which require cooperation
between railroads and Board offices. The Board also conducts
informational seminars on benefit programs for employees at the
request of railroad management. During 1998, the Management
Member's Office of the Board conducted 11 seminars for railroad
officials. It also conducted pre-retirement counseling seminars
attended by railroad employees and their spouses, and benefit
update presentations.
The Board's headquarters is located at 844 North Rush
Street, Chicago, Illinois 60611-2092, phone (312) 751-4500; the
agency's Web site is www.rrb.gov. In addition, the Board
maintains an Office of Legislative Affairs in Washington, DC as
a liaison for dealing with Members of Congress on matters
involving the Railroad Retirement and Unemployment Insurance
Acts and legislative issues that affect the Board. The Office
of Legislative Affairs is located at 1310 G Street, NW, Suite
500, Washington, DC 20005-3004, phone (202) 272-7742.
ITEM 29--SMALL BUSINESS ADMINISTRATION
----------
The SBA continues to create, implement and deliver
technical and financial assistance programs for the benefit of
the Nation's small business community. We currently do not have
a program that gives specific focus to older Americans.
However, the SBA is the sponsoring Federal agency for the
Service Corp of Retired Executives (SCORE) program. SCORE is an
organization of nearly 12,000 business men and women who
volunteer their time and expertise to provide management
counseling and training to small business owners and people
just starting a new business. They have extensive business
experience, either as entrepreneurs and business owners or as
former corporate executives. SCORE counseling is confidential
and free of charge and is provided at more than 700 locations
in the United States and its territories.
ITEM 30--SOCIAL SECURITY ADMINISTRATION
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Programs Administered by the Social Security Administration, Calendar
Year 1998
The Social Security Administration (SSA) administers the
Federal Old-Age, Survivors, and Disability Insurance (OASDI)
program (title II of the Social Security Act). OASDI is the
basic program in the United States that provides income to
individuals and families when workers retire, become disabled,
or die. The basic idea of the cash benefits program is that,
while they are working, employees and their employers pay
Social Security taxes; the self-employed also are taxed on
their net earnings. Then, when earnings stop or are reduced
because of retirement in old-age, death, or disability, cash
benefits are paid to partially replace the earnings that were
lost. Social Security taxes are deposited to the Social
Security trust funds and are used only to pay Social Security
benefits and administrative expenses of the program. Amounts
not currently needed for these purposes are invested in
interest bearing obligations of the United States. Thus,
current workers help to pay current benefits and, at the same
time, establish rights to future benefits.
SSA also administers the Supplemental Security Income (SSI)
program for needy aged, blind, and disabled people (title XVI
of the Social Security Act). SSI provides a federally financed
floor of income for eligible individuals with limited income
and resources. SSI benefits are financed from general revenues.
In about 46 percent of the cases, SSI is reduced due to
individuals' having countable income from other sources,
including Social Security benefits.
SSA shares responsibility for the black lung program with
the Department of Labor. SSA is responsible, under the Federal
Coal Mine Health and Safety Act, for payment of black lung
benefits to coal miners and their families who applied for
those benefits prior to July 1973 and for payment of black lung
benefits to certain survivors of miners.
Local Social Security offices process applications for
entitlement to the Medicare program and assist individuals with
questions concerning Medicare benefits. Overall Federal
administrative responsibility for the Medicare program rests
with the Health Care Financing Administration, HHS.
Following is a summary of beneficiary data and selected
administrative activities for calendar year 1998.
i. old-age, survivors, and disability insurance benefits and
beneficiaries
At the beginning of 1998, about 96 percent of all jobs were
covered under the Social Security program. The major groups of
workers not covered under Social Security are Federal workers
hired before January 1, 1984 and State and local government
employees covered under a retirement system for whom the State
has not elected Social Security coverage.
At the end of December 1998, 44.2 million people were
receiving monthly Social Security cash benefits. Of these
beneficiaries, 27.5 million were retired workers, 3.3 million
were dependents of retired workers, 6.3 million were disabled
workers and their dependents, 7.1 million were survivors of
deceased workers.
The monthly amount of benefits being paid at the end of
December 1998 was $31.3 billion. Of this amount, $22.7 billion
was payable to retired workers and their dependents, $3.8
billion was payable to disabled workers and their dependents,
and $4.8 billion was payable to survivors.
Retired workers were receiving an average benefit at the
end of December 1998 of $780, and disabled workers received an
average benefit of $733.
During the 12 months ending December 1998, $375 billion in
Social Security cash benefits were paid. Of that total, retired
workers and their dependents received $252.7 billion, disabled
workers and their dependents received $48.2 billion, and
survivors received $73.9 billion.
Monthly Social Security benefits were increased by 2.1
percent for December 1997 (payable beginning January 1998) to
reflect a corresponding increase in the Consumer Price Index
(CPI).
ii. supplemental security income benefits and beneficiaries
In January 1998, SSI payment levels (like Social Security
benefit amounts) were automatically adjusted to reflect a 2.1
percent increase in the CPI. From January through December
1998, the maximum monthly Federal SSI payment level for an
individual was $494. The maximum monthly benefit for a married
couple, both of whom were eligible for SSI, was $741.
As of December 1998, 6.6 million aged, blind, or disabled
people received Federal SSI or federally administered State
supplementary payments. Of the 6.6 million recipients on the
rolls during December 1998, about 2.0 million were aged 65 or
older. Of the recipients aged 65 or older, about 701,000 were
eligible to receive benefits based on blindness or disability.
About 4.6 million recipients were blind or disabled and under
age 65. During December 1998, Federal SSI benefits and
federally administered State supplementary payments totaling
slightly over $2.5 billion were paid.
For calendar year 1998, $29.4 billion in benefits
(consisting of $26.4 billion in Federal funds and $3.0 billion
in federally administered State supplementary payments) were
paid.
iii. black lung benefits and beneficiaries
Although responsibility for new black lung miner claims
shifted to the Department of Labor (DOL) in July 1973, SSA
continues to pay black lung benefits to a significant, but
gradually declining, number of miners and survivors. (While DOL
administers new claims taken by SSA under part C of the Federal
Coal Mine Health and Safety Act, SSA is still responsible for
administering part B of the Act.)
As of the end of March 1998, about 116,000 individuals
(106,000 age 65 or older) were receiving $47 million in black
lung benefits which were administered by the Social Security
Administration. These benefits are financed from general
revenues. Of these individuals, 18,000 miners were receiving
$10 million, 78,000 widows were receiving $35 million, and
20,000 dependents and survivors other than widows were
receiving $2 million. During fiscal year 1998 SSA paid out
black lung payments in the amount of $588 million.
Black lung benefits increased by 3.1 percent effective
January 1999. The monthly payment to a coal miner disabled by
black lung disease increased from $455.40 to $469.60. The
monthly benefit for a miner or widow with one dependent
increased from $683.10 to $704.40 and with two dependents from
$797.00 to $821.80. The maximum monthly benefit payable when
there are three or more dependents increased from $910.80 to
$939.20.
iv. communication and services
SSA's public information initiatives are aimed at more than
44 million Social Security beneficiaries, more than six million
SSI recipients and about 150 million workers currently paying
into the system. SSA seeks to ensure that current and future
beneficiaries are aware of programs, services, and their rights
and responsibilities.
In 1998, SSA planned public information outreach activities
to help educate the public about Social Security. Two public
service campaigns were conducted during 1998. The campaigns
used television, radio and print media to encourage the public
to learn more about Social Security. To date, the media has
donated more than $2.5 million in advertising space.
The Agency designed, pilot tested, and produced a kit of
information materials for employers to use in helping educate
employees about the value of Social Security. It updated its
Social Security Teachers Kit and developed a special ``kids
page'' on the Internet. It continued working with external
groups and organizations to help them better understand Social
Security and spread the word about Social Security to their
constituencies.
Additional subjects covered through public information
messages included changes in the law affecting noncitizens and
direct deposit of benefits. Messages were placed in the form of
news releases, radio and television public service
announcements and publications such as Social Security Today, a
newsletter distributed to national organizations.
SSA produces a wide range of publications on all Social
Security programs. More than 100 consumer booklets and fact
sheets keep the public informed about programs and policies
affecting them. Many publications also are available in
Spanish. Many are available through the agency's FAX Catalog,
as well as on the Internet at SSA's web site, http://
www.ssa.gov. Also, SSA's Public Information Distribution Center
provides materials directly to external groups and
organizations.
v. summary of legislation that affects ssa, 1997-98
P.L. 105-18 (H.R. 1871), emergency supplemental appropriations bill
including extension of benefits for noncitizens, signed on June
12, 1997
Provided a one-month extension of SSI
eligibility for noncitizens who were receiving benefits
on August 22, 1996, and who would not continue to be
eligible under the noncitizen restrictions in the
Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, by changing the date that
noncitizen redeterminations have to be completed from
August 22, 1997 to September 30, 1997.
P.L. 105-33 (H.R. 2015), Balanced Budget Act of 1997, signed on August
5, 1997
Noncitizens
SSI Eligibility for Aliens Receiving SSI on August 22, 1996 and
Disabled Legal Aliens in the United States on August 22, 1996