(3) FmHA does not distinguish between elderly and nonelderly in administering its programs. However, we have no objection to the definition stated by the Administration on Aging.

(4) Funds may be used to construct, enlarge, extend or improve water, sewer and solid waste disposal systems, fire stations, libraries, hospitals, nursing homes, clinics, community buildings, recreation facilities, industrial parks and other community facilities that provide essential services to rural residents.

(5) FmHA does not distinguish between elderly and nonelderly in administering its programs. However, several nursing home projects have been funded in the three States mentioned.

(6) Not applicable.

(7) FmHA does not distinguish between elderly and nonelderly in administering its programs and has no specific information regarding the needs of the elderly.

BUSINESS AND INDUSTRIAL LOANS

The official definition of a rural area under the business and industrial loan program is that "rural' and 'rural area' may include all territory of a State, the Commonwealth of Puerto Rico and the Virgin Islands, that is not within the outer boundary of any city having a population of fifty thousand or more and its immediately adjacent urbanized and urbanizing areas with a population density of more than one hundred persons per square mile, as determined by the Secretary of Agriculture according to the latest decennial census of the United States: Provided, That special consideration for such loans and grants shall be given to areas other than cities having a population of more than twentyfive thousand."

Records indicate that under the business and industrial loan program, the following activity in each of the states from inception through June 30, 1976:

IOWA

Twenty-four loans amounting to $18,888,500 have been obligated. The projects that would provide services for the elderly that funds have been obligated for are one hospital and two nursing homes. The State Office is in the process of evaluating an additional nursing home application at the present time.

SOUTH DAKOTA

Twenty-two loans in the amount of $5,955,500 have been obligated. No specific projects that cater to the elderly have been financed. The community programs division has been able to fill this State's needs for the elderly for hospitals and nursing homes.

NEBRASKA

Six loans amounting to $4,740.000 have been obligated. The community programs division has been able to fill this State's needs for the elderly for hospitals and nursing homes.

We are unable to forecast the need for additional hospitals and nursing homes and do not have any data on the number of elderly in Iowa, Nebraska, and South Dakota.

ITEM 4. LETTER FROM SAMUEL R. MARTINEZ, DIRECTOR, COMMUNITY SERVICES ADMINISTRATION, WASHINGTON, D.C.; TO SENATOR DICK CLARK, DATED AUGUST 10, 1976

DEAR SENATOR CLARK: Thank you for your recent letter concerning the field hearings on the rural elderly that you plan to conduct during August in Iowa, Nebraska and South Dakota.

We are pleased to provide you with the information you requested from the Community Services Administration. Our Headquarters response is being coordinated with the CSA Region VII and VIII Offices that administer programs

in Iowa, Nebraska and South Dakota, respectively. Our answers have been provided in the same sequence as your questions.

(1) CSA defines a rural Community Action Agency (CAA) as one that serves an area in which the household population is 50 percent or more "rural," based on the definition of the Bureau of the Census. If an area is less than 50 percent "rural" and contains no place with a household population of 10,000 or more, it is classified by CSA as "rural," too.

(2) CSA's legislation defines an "elderly poor American" as one who is 60 years of age or older, except in one section of the Headstart, Economic Opportunity, and Community Partnership Act of 1974. Section 223 of that Act uses age fifty-five (55) years and older for employment purposes and employment opportunity "as regular, part-time and short term staff in all component programs." (3) The CSA funds 18 CAA's in Iowa, 9 CAA's in Nebraska and one statewide CAA in South Dakota. The geographical areas covered by each CAA or delegate agencies and the number of agencies having elderly service components are being provided to your office by the CSA Region VII and VIII offices.

(4) The description of services being provided to the elderly poor by the CAA's in the aforenamed States, the number of elderly served, and the level of funding in fiscal years 1975 and 1976 are also being provided to your office by our regional offices. Additionally, descriptions of information and referral and outreach services which assist the elderly in the more rural areas are being included in the regional reports.

(5 and 6) The answers to these two questions will be reports provided by our regional offices.

(7) The CSA and the Congress have long recognized that the needs and the provision of services to assist the elderly poor cannot be met alone by the CAA's and SOS projects with their limited resources. Instead, CSA sees as its mission and function at the local, State, and Federal levels to be a catalytic agent which generates and mobilizes other sources of funding and to be of assistance in the formation of coalitions of agencies and joint funding efforts which meet the growing and unmet needs of our Nation's elderly poor. The Congress of Seniors Organizations located in South Dakota, is a good example of how we see the CSA best using our limited funding resources to assist the elderly poor.

(8) The President's budget for fiscal year 1977, included a request for the SOS program in the amount of $10 million. In the light of both the administration and the congressional budgetary ceilings, it does not seem practical at the present time to support a higher congressional appropriation for the SOS program. To a certain extent all of the programs funded and administered by CSA benefit older poor citizens, for our goal is to enhance the opportunities and lives of all the poor. However, because of the increasing and special needs of the elderly poor, CSA is supporting a number of research and action projects which we hope through their implementation and replication will diminish the impact of poverty on their lives.

(9) As you know, the CAA programs are designed exclusively for the poor as a whole, whereas the SOS programs focus on the elderly poor. Basically speaking, SOS programs provide the elderly poor with another means of obtaining information and assistance. While AoA's congressional mandate is to be responsible for programs for all the elderly poor in the Nation, CSA uses the SOS program through its CAA network to provide service delivery programs to the elderly poor. For example, in cases of emergencies or national disasters, SOS programs provide the means to meet the personal and special needs of the stricken elderly poor.

(10) We believe the ultimate value of our SOS program has been to improve the quality of life for individual elderly poor men and women, and we thank you for giving CSA an opportunity to express our effort to help them. Sincerely,

SAMUEL R. MARTINEZ,

ITEM 5. LETTER AND ENCLOSURE FROM FAYE G. ABDELLAH, SPECIAL ASSISTANT TO THE UNDER SECRETARY, HEW; TO SENATOR DICK CLARK, DATED JULY 16, 1976

DEAR SENATOR CLARK: The enclosed report is in response to your request that our office assist the Special Committee on Aging in preparing for field hearings on the status of rural, older Americans in Iowa, Nebraska, and South Dakota by providing information on several federally funded programs in those States. The report was formulated with the collaboration of Mrs. Helen Lazenby and

Mr. Bruce Edemy of the Social Security Administration and Dr. Jerry Solon of the National Institute on Aging.

I trust that this information is sufficient for your current needs. Please do not hesitate to contact this office in your future preparations for hearings in other States.

Sincerely yours,

[Enclosure]

FAYE G. ABDELLAH.

(1) Question. What is the official definition of a rural area in your agency? Answer. For purposes of classifying the older population by place of residence, this office accepts the definition of a rural area as utilized by the Public Health Services' National Center for Health Statistics (NCHS) in its 1971 National Health Survey. The NCHS definition geographically separated the population into persons residing in urban areas, inside a standard metropolitan statistical area (SMSA), and persons residing in rural areas, outside a SMSA. The U.S. Office of Management and Budget considered two primary steps of factors in establishing the boundaries and titles of SMSA's: First, a city or cities of specified population which constitute the central city and identify the county in which it is located as the central county; second, economic and social relationships with contiguous counties which are metropolitan in character.

(2) Question. Do you agree with the designation-as in Administration on Aging programs-that an "older American" is of age 60 or older?

Answer. Depending upon the program area involved, we believe the answer to this question may be either yes or no. In service administration or benefit programs, such as the Administration on Aging, the Social and Rehabilitative Services, and the Social Security Administration, it may become necessary to select an age at which eligibility for services or benefits begin. When, for example, legislative or administrative authority dictates that services are to be made available only to a population, specifically defined by age, the operating agency must accept and adhere to a prescribed definition. In the research and policy development areas, however, a greater flexibility in formulating concepts about age is permissible and desirable. Thus, in the latter areas, a sensitivity to the invalidity of choosing one time at which old age begins is important, and the term "older American" may take on a functional definition in which the individual is defined with reference to physical, physiological or mental capacities. (3) (a) Question. How many persons in these three States are receiving longterm care services under the Medicare program?

Answer. Information was obtained on the number of admissions to skilled nursing facilities (SNF's) under the Medicare program during 1974 and 1975. Since Medicare for long-term care patients covers only services in a SNF and coverage may not be extended past 100 days for any one admission, we believe the following information presents a fairly accurate picture of the actual numbers of persons in long-term care facilities in the three States who received Medicare reimbursement.

(3) (b) Question. How many persons are receiving reimbursable home health services under the Medicare program in these States?

Answer. Since 1971 the Social Security Administration (SSA) has not tabulated information on the numbers of persons receiving reimbursable home health services under the Medicare program. The most relevant information attainable from SSA, in response to your question. pertains to the total number of bills paid for home health services under title XVIII, part A, hospital insurance, and part B, medical insurance, during 1974 and 1975 and to the number of bills paid for every thousand Medicare enrollees. This information does not reflect the actual number of persons receiving home health services, since one individual may have been responsible for more than one bill. The following statistics were provided:

80-319-1977- -5

(3) (c) Question. Can your office provide the Committee with a listing of home health agencies and day care centers for the elderly in these States, particularly those serving rural areas?

Answer. A list* of the home health agencies in Iowa, Nebraska, and South Dakota is attached. However, the Department of Health, Education, and Welfare's only responsibility, to date, for funding day care centers has been through Section 222(b) of P.L. 92-603 which authorized expenditures of monies for demonstration projects, none of which is located in Iowa, Nebraska, or Sonth Dakota.

ITEM 6. LETTER AND ENCLOSURE FROM ARTHUR S. FLEMMING, COMMISSIONER ON AGING, HEW; TO SENATOR DICK CLARK, DATED JULY 17, 1976

DEAR SENATOR CLARK: This is in response to your inquiry of June 22, 1976 in which you asked me to prepare a summary on rural areas and the effectiveness of certain Federal Programs for the States of South Dakota, Iowa, and Nebraska. To answer your first question concerning the official definition of a rural area. the Administration on Aging issued IM-73-28, April 16, 1973 to the State agencies on aging as a guideline to determine a sparsely populated rural area. This guideline said in part:

"If the project area of an award has boundaries essentially coterminous with those of any community (city, town, borough, village, etc.), whether incorporated or unincorporated, that has a population of less than 2,500 such project area may be considered a sparsely populated rural area. However, if an award is made to an area larger than such community and the average population density of the whole project area is less than 100 persons per square mile, then such project area may also be considered a sparsely populated rural area. However, if such larger project area contains one or more communities having a population greater than 2.500, then, the elderly outside of those communities must be served at least in proportion to their numbers within the entire project area."

The responses to the remaining questions are contained in the attached chart.
If I can be of any further assistance please do not hesitate to contact me.
Very sincerely and cordially yours,

*Retained in committee files.

[Enclosure]

ARTHUR S. FLEMMING.

1 Single planning and service area has 1 area agency which has responsibility for the complete State. Note: Special significance to rural elderly. Iowa-Project provides a means of part-time employment for the 60-plus person. Nebraska-Project provides for the winterizing of homes.