authority, financing mechanisms, benefits, and eligibility requirements. The differing characteristics of these programs reflect what is considered to be the uncoordinated nature of Federal support for long-term care services. In recent years Congress has considered ways of creating a Federal long-term care policy that would address the needs of the elderly for both institutional and home and community-based services.

As Table 1 indicates, most spending in the Nation for long-term care is for nursing home care. About $43 billion, or 82 percent of the total, was spent for nursing home care in 1988. By way of contrast, spending for home care services amounted to less than $10 billion, or 18 percent of total long-term care spending. The lack of financing for home care services has been one of the central issues in the long-term care debate for almost two decades.

Table 1 shows that Medicaid is the Nation's major program of financial support for long-term care, principally because of its coverage of nursing home care. In 1988, Medicaid spending for nursing home care amounted to 45 percent of total national nursing home spending and 36 percent of total long-term care spending. Medicaid is the Federal-State health program for the poor and for those who have become poor as the result of incurring large medical expenses. Medicaid's spending for nursing home care is primarily for coverage of persons who are not initially poor, but who become poor by depleting assets and income on the cost of care. Many persons become eligible for Medicaid because of the high costs of nursing home care, currently averaging $30,000 per year, and because Medicaid is the only program that covers long stays in nursing homes.

Comparatively little of Medicaid's funding is devoted to home care, approximately $3.3 billion in 1988. This amount, however, has been growing in recent years as States have used a variety of options authorized by Congress to allow Medicaid coverage for a broad range of community-based services, including social services, to a disabled long-term care population.

Medicare coverage of long-term care is focused primarily on acute health care costs. In 1988, Medicare's payments for home health care amounted to $2.6 billion. Eligibility for Medicare's home health care benefits is limited to persons needing skilled medical care services. Most chronically impaired persons do not need skilled care to remain in their homes, but rather nonmedical supportive care and assistance with basic self-care functions and daily routines that do not require skilled care. As a result, persons needing long-term care supportive services generally do not qualify for Medicare's benefit.

Source: A Call for Action, The Pepper Commission. Final Report, Sept. 90. Based on Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services data, and Commission staff analysis of unpublished HCFA data.

Older Americans Act funding for long-term care services is authorized under title III of the Act. The purpose of title III is to foster the development of a comprehensive and coordinated services system that will provide a continuum of care for vulnerable elderly persons and allow them to maintain maximum independence and dignity in a home environment. Title III specifically authorizes funding for many community-based long-term care services, including homemaker/home health aide services, adult day care, respite, and chore services. It also authorizes the long-term care ombudsman program whose purpose is to monitor the quality of care provided to institutionalized older persons. Title III funds a variety of other supportive services and nutrition services. Total Federal funding for all services supported under title III is $902 million in FY 1991. Support for long-term care services represents a portion of total title III funds.

During the past 15 years, the policy debate on long-term care has focused on ways to find solutions to two major financing problems: the lack of funding for home and community-based care and the potentially impoverishing consequences of needing nursing home care. Legislation introduced in the past several years to create new Federal long-term care benefits has generally used health authorities, such as the Medicare program or the Public Health Service Act, or new titles in the Social Security Act, as vehicles for new benefits. Although the Older Americans Act has not generally been seen as a major focus for changing the way these services would be financed, development of service programs for persons in need of both home and community-based and institutional long-term care services has been a focus in various amendments to the Act. Some of the State and local agencies created through the Older Americans Act have played substantial roles in the delivery of home and community-based long-term care services, and have served as catalysts for change in the development of more responsive systems of long-term care.

The following describes long-term care programs authorized under the Older Americans Act and systems development initiatives undertaken by some State and area agencies on aging for improving long-term care programs. It also describes selected long-term care research and demonstration activities supported by the Administration on Aging (AoA).

Long-Term Care Services Under the Older Americans Act

Although the Older Americans Act does not exclusively focus on long-term care, many of the services provided under title III of the Act are part of a complex array of home and community-based services that respond to a diverse elderly population, including those who have long-term care needs. Long-term care services specifically authorized under title III of the Act are home care services, home-delivered meal services, and ombudsman services for residents of nursing facilities and board and care homes. While support for home care and home-delivered meals is available under other Federal programs, the Older Americans Act is the only source of Federal support for ombudsman activities.

Title III-B authorizes funds for many social services for the elderly, including home and community-based long-term care services. It also authorizes the long-term care ombudsman program. Total title III-B funding is $290.8 million, representing 22 percent of the Act's total FY 1991 funding of $1.3 billion. Because States are given wide discretion to fund many social services -under title III-B, support for long-term care services represents only a portion of the total. Title III also authorizes separate programs for home-delivered meals under title III-C-2, and for in-home services for the frail elderly under title I-D. Taken together these two programs represent 7 percent, or $94.6 million, of the Act's total FY 1991 funding. Of the Act's total FY 1991 funding, almost 30 percent, or $361.1 million is devoted to the congregate nutrition program, title IIII-C-1.3 While this program is not strictly considered a long-term care

'Not counted in these totals for the nutrition programs is support for the U.S. Department of Agriculture cash or cash-in-lieu of commodities program, which represents about 11 percent of total FY 1991 funding.

program, it provides nutrition and supportive services to some frail older persons living in the community.

Home Care Services

Home care services are supported under both title III-B and title III-D of the Act. Under title III-B, State and area agencies on aging may support a wide range of supportive services. Certain supportive services, including home care services, have been given priority for title III-B funding by Congress. Home care was first designated as a priority service under title III in the 1975 amendments to the Act. Requirements as to what proportion of title III-B funds must be spent on home care (and other priority services) have changed with successive amendments to the Act. The law currently requires that State agencies on aging set a minimum percentage of title III-B funds that must be spent by area agencies for home care services. (The State agency on aging may waive the minimum expenditure requirement if a determination has been made that home care services available in the area are sufficient to meet the needs of older persons.) Home care services supported under title III-B include homemaker and home health aide services, visiting and telephone reassurance, chore maintenance, and supportive services for families of older persons with Alzheimer's disease and related disorders.

In recognition of the demand for community-based long-term care services, Congress amended the title III program in 1987 to create a separate authorization of funds for in-home services for the frail elderly, title III-D. Although support for home care services had been a priority under the title III program since 1975, prior to 1987 there was no separate authorization of funds for this purpose. In-home services, therefore, had to compete with other social service funding priorities of State and area agencies. The following services are authorized under title -D: homemaker and home health aide; visiting and telephone reassurance; chore maintenance; in-home respite care; adult day care as a respite for families; and minor home modification not to exceed $150 per client. State agencies on aging receive allotments for in-home services on the basis of the current title III formula (that is, based on the State's share of the population age 60 years or over as compared to all States). States are required to develop eligibility criteria for the use of in-home services, taking into account factors such as age, and other factors related to frailty. In FY 1991, $6.8 million was appropriated for title III-D. Allotments to States range from $633 thousand (in California) to $34 thousand (in other States, excluding territories).

Although the amount of funding which title III devotes to home care services represents a small fraction of the amount spent for such services under Medicare and Medicaid, the title III program has the flexibility to serve persons who may otherwise not be served. Since Older Americans Act services may be provided without the restriction that beneficiaries be in need of skilled care under Medicare, and without the income and asset restrictions required under Medicaid, in some cases title III is used to fill gaps in services left by these other programs.

Older Americans Act Nutrition Program: Role of Home
Delivered and Congregate Meals

Under the title III program, Congress authorizes specific amounts for congregate and home-delivered nutrition services. Home-delivered meals represent one component of comprehensive home care services for the frail elderly. Although other Federal programs support home-delivered meals, the Older Americans Act is the only Federal program which has a specific authorization of appropriations for the service. While the congregate nutrition program serves elderly who are relatively healthy and mobile as well as others who need special assistance due to chronic impairments, a national evaluation of the nutrition program found that persons receiving home delivered meals were found to be in poorer health; more likely to have been in a nursing home or hospital within the last year, and less likely to be able to perform household chores, compared to congregate nutrition participants.

Both congregate and home-delivered meals, however, may represent an important service for the frail elderly. A 1987 national survey has estimated the use of formal services by the noninstitutionalized functionally impaired elderly, including home care, and home-delivered and congregate meals. As shown on Chart 1, this survey indicated that an equal proportion of the estimated 5.6 million functionally impaired elderly used congregate and home-delivered mealsabout 6 percent used home-delivered meals and 6 percent used congregate meals. Home care services were the most frequently used home and community-based service-used by about 20 percent of the impaired elderly population. Only a little over a third of the impaired elderly used any service.

Recent trends in the nutrition program indicate that increased attention has been focused on providing meals to the homebound through the title m home-delivered meals program. As shown on Table 2, in FY 1980, homedelivered meals represented 22 percent of all meals served under title III; by FY 1989, they represented 41 percent of total meals.

*Kirschner and Associates, Inc., and Opinion Research Corporation. An Evaluation of the Nutrition Services for the Elderly. Conducted for the Administration on Aging (AaA), US. Department of Health and Human Services (DHHS). May 1983.

Short, Pam Farley and Joel Leon. Use of Home and Community Services by Persons Ages 65 and Older with Functional Difficulties. Research Findings 5. Agency for Health Care Policy and Research. US. Department of Health and Human Services. Sept. 1990. (Hereafter cited as Short and Leon, Use of Home and Community Services, 1990.)