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care facilities for the purpose of enabling such organization to provide service to older people and their families, with regard to any abuses, violations, and/or complaints of alleged mistreatment or neglect by duly licensed facilities and their staff, including the power to provide legal representation in such matters and issues.
Mr. Chairman, there are many other parts of the Act upon which I would like to comment. However, I am sure you will hear from many other informed witnesses who will articulate several other matters of personal interest to me in such areas as research and training, multipurpose senior centers, the role of the foster grandparent and RSVP programs.
I will be glad to answer any questions about the points that I have made in my comments today or in my formal testimony.
I again want to express my most sincere appreciation in having received the invitation to appear today.
[The prepared statement of Mr. Bechill follows:]
PREPARED STATEMENT OF WILLIAM D. BECHILL, UNIVERSITY OF MARYLAND SCHOOL
OF SOCIAL WORK AND COMMUNITY PLANNING, BALTIMORE, MD.
I. INTRODUCTION Jr. Chairman and members of the subcommittee, thank you for this opportunity to appear before your subcommittee to discuss any possible changes or modifications that may be required in the current content and implementation of the Older Americans Act.
As you know, this year will mark the tenth anniversary of the Older Americans Act legislation. Over the last decade, the Older Americans Act has become one of the basic legislative cornerstones of our national social policy in the field of aging. During that period of time, the Congress has, on several occasions, enacted amendments to the original law that have resulted in an increased role and responsibility for the federal agency primarily responsible for the overall administration of the Act's various programs, the Administration on Aging. Also, it has provided an expanded base of federal financial support for state and community programs for the elderly, for training and research in the field of aging, for a national nutrition program, and, under the auspices of the Secretary of Labor, a permanent community service employment program for low income older persons. In addition, the Act's present language authorizes a program of Federal financial support for the development of multipurpose senior centers and their initial staffing. And, in 1969 and 1972, the Act was amended to provide permanent authorization for the excellent Foster Grandparent Program, the R.S.V.P. program, and related community service programs featuring the utilization of the skills and talents of older people in “person-to-person" supportive services.
I believe that the national Nutrition Program for the Elderly Act of 1972 and the Older Americans Comprehensive Services Amendments of 1973, both of which originated in this subcommittee, were the key turning points in the history of the Older Americans Act. These were major breakthroughs in public policy in the area of aging. Both gave large-scale responsibilities to the Administration on Aging and to their counterpart agencies at the State and community levels, particularly in the area of social and other community services. The 1973 legislation clarified and strengthened the role of the Administration on Aging as the major focal point within the Federal Government for overall planning, coordination, evaluate, and stimulation of more effective programs and services for older people.
In my view, the Older Americans Act now ranks as a major piece of social legislation. Together with the Social Security, Medicare, and the new Supplemental Security Income Program. The Act is a basic part of a national commitment to sustain and improve the well-being of older people in the United States.
However, Mr. Chairman, this is not to suggest that the Older Americans Act, or the other major laws that the Congress has enacted in behalf of the elderly in recent years, are complete and perfected, or being implemented in the manner and the spirit in which the Congress may have intended. The Social Security program, despite the many improvements made in it by the Congress in recent years, still does not provide an adequate retirement income for many older people, especially in this period of high inflation and ever-rising food, housing, clothing, and energy cost.
The Medicare program still has many gaps in the coverage it offers to older people in helping meet many of their medical care expenses, especially if longterm nursing home care is required. The new Supplemental Security Income, which contains the important principle of a national minimum income for the needy aged, blind, and disabled, has gone through a tortorous period of initial implementation. It still has not reached many of those who are potentially eligible and ought to be beneficiaries of that program. And, in the case of the Older Americans Act, there also have been problems of implementation, especially of the 1973 Amendments, that need to be carefully examined and evaluated by the Congress as it considers further extensions of the law.
In my testimony today, I wish to discuss these four areas of interest in particular:
1. The need for an extension and improvements in the Title III provisions of the Act.
2. The need for formal linkage and coordination between the Title III and Title VII provisions of the Act and the new Title XX public social services program of the Social Security Act.
3. The authorization of a national demonstration program of home health care and nursing home care programs, including the training of personnel in such programs.
4. The reaffirmation of the importance of multipurpose senior centers in the provision and delivery of social, health, educational, and other services for older people, and the conversion of the Title V authority of the Act to a direct loan rather than a mortgage insurance program for the acquisition, alteration, or renovation of multipurpose senior centers.
II. EXTENSION AND IMPROVEMENTS IN TITLE III OF THE ACT
Under the Title III provisions of the 1973 Amendments to the Act, the Administration on Aging and the State agencies on aging were given the important mandate for the development of comprehensive and coordinated systems of social services for all persons age 60 and over in the respective States. Overall, I believe that the Amendments were an attempt to legislate a more equitable and rational system of social services for older people than had been the case in past years, and also, a major effort to give some substance to one of the basic objectives of the law, namely "efficient community services, including access to low-cost transportation, which provide social assistance in a coordinated manner and which are readily available when needed."
The 1973 Amendments, by their very nature and scope, dramatically increased the responsibility of state agencies on aging with their intent to create a rational, coordinated, and planned delivery system of social services. Also, under the regulations issued for the restructured Title III program, Commissioner Flemming broadly defined "social services" to include a very comprehensive and wide range of social, health related, educational, and legal services that were to be ultimately considered in the development of such social service systems.
But, the most significant changes in the Title III provisions of the 1973 Amendments, were those related to the establishment of area agencies and the attendant emphasis on the development of area plans. The new area agencies on aging were assigned functions under the 1973 Amendments, among them: planning, periodic evaluation of all activities carried out for older persons under the area plan, need assessment, the entering into contractual agreements with both public and private nonprofit agencies for the provision of services, and other related activities. As articulated by the Administration in testimony during the hearings held by this Committee in 1972 and 1973, and as subsequently implemented, the area agency was not viewed as an agency primarily responsible for service delivery itself, but rather seem as a planner, coordinator, evaluator, and a "service broker" acting in behalf of older people within designated planning and service areas.
There are now over 400 area agencies that have been established since the final regulations on the current Title III program were issued in October, 1973. I also understand that most of the area agencies that have been established are fully operational, although there are many that are still in a very initial phase of development.
The area agency concept and strategy, as it has been called by some, is a significant organizational change in both the Federal-State relationships that had existed under the Older Americans Act prior to 1973 and, indeed, in the usual manner in which social services have been organized and provided in the broad field of social services generally. Title III, in its present form, reflects the national Administration's overall emphasis of such approaches as increased authority to State and local governments, decentralization, and a greater reliance on regional or area-structures rather than the traditional Federal-State relationships that we have had in the fields of health, education, and rehabilitation, and services to the aging in the past.
Frankly, I think that there are many problems inherent with this approach. Its emphasis perforce first must be on structure rather than on direct services. Its implementation also must be more laborious, simply because it involves dealing with more specific organizational units than the usual Federal-State approach. And, because of its emphasis on decentralization, there are higher risks involved in meeting any standard of equal and equitable treatment of people, regardless of where they live, under a Federally authorized program.
All of these issues have surfaced to some extent in the current implementation of the Title III Older Americans Act program. In my view, at least, the emphasis has been on the development of structure rather than on the direct provision of services. This emphasis may have been inevitable, and it may have been plainly within the Congress's intent in enacting the 1973 law, but I hope that there are some questions raised concerning this during the course of these hearings.
Second, I do believe that the implementation of the Title III provisions to date have been laborious. I do not place any blame on the Administration on Aging nor the State agencies for this. In fact, they deserve great credit for the manner in which they have proceeded to carry out the Title III provisions, at a time when both also were heavily involved and committed to starting up the National Nutrition Program and in other major tasks. A long lead time is almost inherent with the approach now embodied in Title III. There is no simple way to build comprehensive and coordinated services for older people. In fact, we have even a hard time conceptualizing what that term means often, let alone trying to put it into operation.
Despite these concerns, in my view, it would be a mistake to abondon the present thrust of Title III, including the emphasis on a rea agencies and area planning. In reality, the time of actual implementation has been very short, and, the potentials of the approach, while frought with many issues and problems, has yet to be fully tested and evaluated. For that reason, Mr. Chairman, I would respectfully urge that the authorizations for the current title be extended for at least another two years, and that the funding level now set forth in the Act, be increased to $200 million for fiscal year 1976 and $250 million for fiscal year 1977, the authorization levels originally included in the 1972 legislation enacted by both Houses but later subsequently vetoed by then President Nixon.
In addition, I would urge the subcommittee to consider other changes in the present language of Title III. To place a greater emphasis on service delivery, I would urge that section 304 be amended to mandate and require the various area agencies on aging to either directly provide, or arrange for, the provisions of ontreach services, transportation services as now defined in the Title's regulations, and counseling services. As now written, this section of the Act mandates only two services that area agencies will provide, information and referral services and legal services. I believe the addition of these three services would provide a more complete package of basic services that would be directly under the responsibility of the area agency and would lend greater uniformity to the program on an area by area basis and State by State basis than is now the case. I particularly believe that outreach services need to be a major program component of any area agency's operation, also, the provision of transportation to various services and facilities needed by older people should have a priority claim in the development of an area plan and program of comprehensive and coordinated services.
Also, I would suggest that the Act be amended to permit any city with a population of 500,000 thousand or more to automatically qualify as an area agency under the law. I think there is ample evidence that some of the most extreme problems facing the elderly today are in our nation's larger cities, and I am concerned that the emphasis on areawide planning may tend to divert attention and financial resources away from the critical needs of older people, particularly those living in the inner city areas of cities of the size mentioned.
Further, I would propose that there be some reaffirmation, either by amendments or by statements of Congressional intent, that acknowledge and give further support to the role of the State agencies on aging in carrying out the broad mandate of Title III. In my view, I do not believe that the Congress intended that the State agencies' authority would be diminished or circumscribed when they passed the 1973 legislation. I am aware, from some of my recent studies of developments and trends at the state governmental level, that there have been tensions building between the State and newly formed area agencies about their respective roles and responsibilities. I have heard questions raised about whether there is still a need for state agencies on aging. That sort of dialogue is counter-productive. If Title III is to work as intended, we need both strong and effective state and area agencies.
III. FORMAL LINKAGE AND COORDINATION WITH THE TITLE XX PROVISIONS OF THE
SOCIAL SECURITY ACT
In their 1973 report on Development in Aging, the Special Committee on Aging of the Senate reported that, and I quote, “Area agencies found great diificulty in drawing up their required area plans for a comprehensive and coordinated service delivery system because of a lack of services to coordinate". In that one sentence, and attending discusison, the Special Committee underscored some of the irony that is involved in our present scene regarding the funding and general availability of social services to older people.
The major and excellent goal of Title III, comprehensive and coordinated services for all older people, will never be reached unless there is more adequate funding of the types of social services now set forth in section 302 of the Act.
As of now, there are only three major and reliable sources of Federally assisted funding for such services. These include the funds now authorized and appropriated under Titles III and VII of the Older Americans Act and the public social services authorized under the Social Security Act, which have been recently reconstituted by the Congress as a new Title XX of the Social Security Act. The Title XX program includes an authorization of some 2.5 billion ($2,500,000,000) on an annual basis that is ot be allocated by the Secretary of HEW to the States. Frankly, this program, although in existence for several years now, has never been fully utilized to the extent possible to provide services to the elderly. Moreover, the new legislation places very little priority on the social service needs of the elderly. Notwithstanding this, it is the major resource available today for the funding of most direct services needed by the elderly. While I appreciate and realize the jurisdictional problems involved, I would hope that and urge the subcommittee to consider statutory language, amending both the Older Americans Act and the Social Security Act, that would more formally link these three programs together. It is imperative that the funds in Title XX be utilized and become more readily available for the support of social services being planned and developed under the Older Americans Act. I would hope that my friends in the American Public Welfare Association would Support this recommendation as well.
IV. NATIONAL DEMONSTRATION PROGRAMS IN HOME HEALTH CARE AND NURSING HOME
In November of last year, one of the most significant reports and studies erer made in the field of aging was submitted to the Senate by the Subcommittee on Long-Term Care of the Special Committee on Aging. The report entitled, “Nursing Home Care in the United States: Failure in Public Policy", and the subsequent supporting pa pers that have been published since that report, documents the desperate situation that older people face in this country when long-term care in a nursing home is required. It is a haunting report to read, and the situations and conditions that are so graphically described are a disgrace and a discredit to our civilized society.
There are no easy answers or solutions to the many problems that now exist in the area of long-term care for the elderly and in how to improve and upgrade the quality of nursing homes and other types of facilities that provide care to older people. The fact is that historically we have had no coherent policy in this area. As a result, we have permitted, through official sins of both omission and commission, this area to be largely dominated by proprietary interests and to hare based much of our present public policy around a concern with the costs of care rather than the quality and level of care received. Moreover, until very recently at least, the governmental intervention that we have had in this area has usually been far more oriented to the interests of the various providers of long-term care services rather than the consumer of such services, the elderly and the disabled. I will not elaborate on that point further, except to say that I will be glad to answer any questions about it based on both my professional experiences in the field of aging and some personal experiences that I have had in dealing with nursing homes.
While a truly comprehensive and coherent policy in this area is still to emerge, I do think that some action can be taken now, and I do feel that the Older Americans Act may be the proper vehicle for at least three courses of action in this
First, I would urge the subcommittee to authorize the establishment of a national demonstration program for developing home health care programs, and for training home health care personnel. I would hope that the content of such a program could be tailored very much along the lines of the amendment offered by Senator Frank Church to the Health Revenue Sharing and Health Services Act of 1974. While vetoed by the President, it is my understanding that the Church amendment was not among the points of controversy. The aim of such a program would be to focus more attention on the importance of developing home health care services as an alternative, when socially and medically indicated, to institutional care. The present funding priorities of both Medicare and Medicaid are now heavily weighted in favor of supporting the costs of institutional rather than community based care. This step would be a small one perhaps, but it would be one that could begin to reverse this present imbalance. Also. I think that it is proper for the Commissioner on Aging to have the leadership role in an effort of this type, especially in view of his present responsibilities in the area of social services and overall program planning and coordination at the Federal level.
Second, I would urge the subcommittee to authorize the establishment of a national demonstration program of congregate care for the elderly that would be available to voluntary nonprofit and government agencies for the establishment and evaluation of model congregate care facilities that offer a complete spectrum of living arrangements for older people. ranging from protected independent living, to personal and intermediate care, to skilled and long-term care, under one unified and organized auspice. I would see such a program as a fore. runner to a more extensive governmental effort in future years to reverse the present dominance of proprietory nursing homes as the principal means by whicha the elderly receive long-term care.
Third, in view of the present weaknesses in governmental licensing and enforcement of nursing home standards and regulations, I think that the voice of the consumer, and the legal rights and entitlements of the consumer or potential consumer of nursing home care and long-term care services, ought to be given some support as a possible way to improve the overall quality of care provided in nursing homes and other types of facilities offering long-term care to the elderly.
Accordingly, I would urge you to provide for some form of financial assistance to nonprofit organizations representing older people and their families who may be living in nursing homes, homes for the aged, and other care facilities for the purpose of enabling such organizations to provide client assistance services to older people and their families with regards to any abuses, violations, and/or complaints of alleged mistreatment or neglect by duly licensed facilities and their staff, including the power to provide legal representation in such matters,
Mr. Chairman, there are many other parts of the Act upon which I would like to comment. However, I am sure that you will hear from many other informed witnesses who will articulate several other matters of personal interest to me in such areas as research and training, multipurpose senior centers, and the role of the Fostergrandparent and R.S.V.P. programs. I would be glad to answer any questions about the points that I have made in my testimony, several of which may be somewhat controversial. All were offered out of my strong and contiming interest in the programs and great potential of the Older Americans Act:i.