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long-term care also. They have also been out there providing care management. And I see us repeating often some of the mistakes that they made that they could have told us not to do in the Older Americans Act.

So, there is very little communication, and we have such a fragmented system right now. We have to find a way of better integrating the whole long-term care system together rather than again pushing more into an age-based or a disability-based system.

Senator ADAMS. Ms. Jones, do you think we should remain-you have had a great deal of experience, both as an attorney and otherwise with the programs as we have them now?

Ms. JONES. I would be very distressed to see the whole culture and fabric and structure of the Older Americans Act being in any way abandoned. I see us moving hopefully toward national health insurance. That is going to take care of a lot of the chronic, acute care and other kinds of illnesses that people have in this country. It seems to me the component it probably will not take care of are the social services. That comes out of the Older Americans Act. I do not think we can in any way disband it.

I do agree that long-term care is a continuum of care, but I want to see long-term care put into national health care, put our energies into developing that system, keeping the Older Americans Act as it is to take care of the social service needs of the elderly.

Dr. REDFORD. And basically that is what I am saying. They have that role.

Senator ADAMS. I understand that.

Dr. REDFORD. I am certainly not saying abandon it.

Senator ADAMS. I understood that is what you were saying, and yet, one of the greatest problems faced by the elderly-and you heard statements of a 75 year old taking care of her 90 year old mother-in-law-is that Medicare and Medicaid are not directed toward what you are talking about. And national health insurance, which a number of us have favored for many years, is not going to arrive in time for most of us to see it.

Ms. JONES. We may be creating self-fulfilling prophecies, though, by taking that position.

Senator ADAMS. I want to ensure that through the reauthorization of this act where we place it in this total spectrum address the appropriate role of the OAA in the total spectrum of long-term


I do not think any of us feels at least I certainly do not that we could get sufficient funding in this act to provide for a solution to the long-term care problem. That is why I used the charts. It is obvious that much money has already been and is being spent.

I am very concerned about the facts presented on the first chart, which is not really addressed by your testimony. We already have these people here, and they are in these circumstances. And as a number of our witnesses stated, we have and I think you stated it, Ms. Jones-many people, particularly older women, doing double time, and it is breaking them in spirit and other ways because they do not have the alternatives.

And so, what we have been hearing today is that the OAA provides for a wide variety of health and social services, that are available to people at home. And we are trying to meet a wide variety

of needs through this rather small act. A little more than a billion dollars is a lot of money but, compared to the size of other programs, is not that big. Our chart shows the very great disparities in the amount we are spending.

I am about to take a small step here sometime during the course of this year, and when you indicate to me that you do not want us to change the act to move more toward long-term health care, you are saying to me you do not want me to attack that big orange in the first chart. I am not sure I am satisfied with that.

If you would like to submit some more things in writing please do so. I understand your position very well. As I have repeatedly said in this hearing and at others, it would seem to me with the technology we have now-computers and otherwise we should be able to both identify needs better and to link individuals with the services.

But under the financial situations that I see by sitting on the Appropriations Committee-I sit on that committee also and I just heard 35 witnesses the day before yesterday on the health care needs of the population-there is not going to be much new money for anybody. And I do not want us all sitting in front of one committee fighting it out. And I do not know how to handle that orange yet. And it may be that we don't, as Dr. Redford suggests, do anything in terms of converting this program or changing it to be more focused on long-term care.

I thank you both for testifying.

Senator Cochran, I am pleased to see you here. Do you have anything that you wish to add to this before we finish? He is our ranking member and my good friend, and I just wanted to know if he had any statement he would like to make.

Senator COCHRAN. Mr. Chairman, I just came by to thank you for having the hearing, and apologize that an Appropriations Committee hearing kept me from being here for the rest of the time that this hearing has been taking place, but also to thank you for letting us have a hearing in Mississippi next week. We are going to be having a hearing in Clarksdale, MS, looking at some of the problems that we hope to be addressed by the Older Americans Act. And we thank you for the cooperation and assistance that you are providing in helping to develop these ideas and changes and ways to improve the Older Americans Act. Thank you.

Senator ADAMS. Thank you, Senator.

The prepared statement of the Congressional Research Service and additional material submitted for the record appear in the appendix.[The appendix follows:]

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U.S. Senator


Subcommittee on Aging
April 26, 1991

"The Older Americans Act and the Aging Network:
The Importance of Home and Community-based
Long-term Care Services"

Labor and Human Resources
Rules and Administration

of Washington

Good morning. I am pleased to convene today's hearing of the Aging Subcommittee of the Senate's Committee on Labor and Human Resources. This is the fourth in a series of hearings which I am holding on the reauthorization of the Older Americans Act (OAA).

Today's hearing will show the significant and diverse roles the OAA and the aging network have played in long-term care.

Debate over developing a comprehensive long-term care system for our nation is well underway. One part of this debate concerns the extent and appropriateness of the Older Americans Act in long-term care.

The fact is, in many states and local communities across the country, the Older Americans Act is having a significant impact in long-term care as we speak. Many states and communities already have in place innovative long-term care efforts. And, at the heart of many of these programs is the "aging network" that is, state and area agencies on aging and local OAA-funded service providers.

The aging network, in the absence of a national long-term care program, has become the principal source of key home and community-based services in many parts of America. Moreover, the aging network is serving a crucial role as a catalyst for planning, coordination and development of long-term care. Surprisingly, however, the contributions made by the OAA and the aging network in this area often go unnoticed. Today's hearing will help to correct that oversight. We will not only hear about the Act's current roles, but consider potential future roles for the Act and the aging network in long-term care.

Most of the public funds, excluding the OAA, spent on long-term care are spent for institutional care -- for nursing home care. By contrast, the overwhelming majority of those needing long-term care live at home — and that's where the OAA comes in.

The chart to my far right illustrates this fact. As you can see, 84 percent of those needing long-term care live at home. Yet, our expenditures are in inverse proportion - out of nearly $53 billion spent on long-term care in 1988, 82 percent, was for nursing home care, not home-based care.

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The other chart to my right shows expenditures on long-term care for the elderly by five states that have similar sized aged 60 and over populations. This chart shows that the OAA the red column is but one component in the home and community-based care system and the total dollars spent on non-institutional long-term care are small. Today's witnesses, including Charles Reed, a leader in long-term care from Washington State, will show that OAA funds, however, provide a important foundation for home and community-based long

term care

The OAA dollars are not large but their impact is. With OAA dollars, homemakers and chore workers can cook meals, grocery shop, and do difficult household chores for those who are unable to do these tasks. The OAA also provides congregate and home-delivered meals, case management, adult day care, and respite care, and other needed services. The best part is that the recipients of these services can stay in their homes rather than a nursing home. We will hear from several brave older Americans about how these services have helped them maintain their autonomy in the community.

The need for long-term care is clearly on many people's minds. National polls repeatedly show the great concem Americans have about long-term care. The recent Pepper Commission report provides us with a thoughtful and important starting point. Senator Rockefeller will tell us more about the Pepper Commission's recommendations and discuss its relevance to the Older Americans Act.

I hope that we can make real progress toward a national long-term care program. Regardless of what form a future long-term care system takes, this hearing will show that the OAA has helped to lay the groundwork and its experience should be carefully taken into account in the future.

## For more information, contact William Benson or Jo Ann Lee at (202) 224-3239.

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