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include advance funding for the Older Americans Act programs, so it would help this situation.
Dr. STEINBERG. I think it would reinforce some of the people who would rather spend money wisely and target it well than spend it in a hurry within the one fiscal year. I think there has been an excess of time pressure. I have certainly seen this in many other programs. But we could carry over unexpended balances in the foreign aid
program, war on poverty, model cities, et cetera. Somehow the Older Americans Act has had much tighter limits on that, and many more checks and balances to attend to within each fiscal year.
Second, certainly I would urge continuing the trend to integrate titles 3 and 7. It may be that those area agencies which have undertaken title 7 do suffer in their ability to do other catalytic work. For example, my data show that those who are funnelling title 7, or administering or monitoring title 7, have less staff elbow room to do the catalytic kind of thing, such as to get people to go to the State capital to make sure that the elderly get their fair share of title 20—and many other examples which I could recite. The merger of titles 3 and 7 is going to be traumatic: Nobody likes to be monitored who wasn't monitored before, or would rather be monitored from the State capital than from somebody close to home. It's going to be controversiai, but I think the separation of title 7 from 3 makes for a mixed message about coordination which you have put into the act.
Third, eliminate federally mandated programs. This cuts right to the central issue that was raised by Dr. Binstock.
Senator EAGLETON. Which federally mandated programs? Oh, the four priorities!
Dr. STEINBERG. In 1975—the priorities. With quotas attached.
Senator EAGLETON. Should we just state them as being worthy areas of consideration ?
Dr. STEINBERG. Well, I think it develops the wrong kind of thinking in that you are just giving a laundry list. I don't care how lightly you play it-you are getting people to define older people's problems by what services you have to offer. Now, when you legislate the vocational rehab program, you are funding a network of people who can diagnose people's problems, try to negotiate services for them where they already have entitlements; and if necessary, buy them so that these people can be more selfsupporting. Why can't that principle be applied here in the Older Americans Act? You don't, in vocational rehab, fund so many college educations, so many tool kits, you see. You have a planning and counseling network for individualizing responses. And, therefore, I would go one step farther than was mentioned earlier-rather than saying that communities have to select one program, let them narrow down the target group; they can't do all good things for all people. Missouri is one of the States that said very early on, well
Senator EAGLETON. Would you knock out the home repair?
Dr. STEINBERG. I wouldn't State it in those terms, but rather-as I said, Michigan and Pennsylvania attempted to establish priorities for people over age 75. While we know there are frail people under 75 as well, we must develop locally, feasible ways of targetingsaying here are the most vulnerable elderly people.
In Senator Kennedy's introductory remarks, he said: Who are the people we ought to be serving? I would say let that local community identify that target population and then come up with a package of services—and I will repeat Mr. Reilly there. For example, I have seen some fabulous legal services. But while they are fighting the case about guardianship, the client is dying from criminally neglectful medical care. I don't think you can package it in terms of programs, but certainly target groups. If you specify individual programs, that's the way those agencies will define a person's problems. It's like giving a kid a new toy hammer-suddenly everything needs pounding. And we certainly discovered a lot of people who suddenly needed meals.
ì don't want to knock that program, but I think when you visit them, you should not only see how satisfied the people are who are there—but also ask about what provision they have for reaching the people who are homebound, what kind of followup they have for people who
drop outSenator EAGLETON. What percentage of the people do you think we are reaching with nutritional programs, lumping together congregate and meals-on-wheels programs? Somebody tells me we are reaching one percent of the people that need it. Of the eligible population.
Dr. STEINBERG. But, you see, maybe we will have to live with the fact that you can't come up with enough dollars to meet 100 percent of the need, but let's make sure that the one percent receiving service are the people where that service can be most crucial. And I don't think the tools have been laid out there, particularly when there is no administrative money to do the careful job of identifying the people who most need help. And, as I stated, the Opinion Research Corp. study showed that participants were primarily organization-connected people who were recruited into the nutrition program. I have not seen later data and this may have changed over the last couple of years, because I think there has been a serious effort to get the nutrition programs to address themselves to vulnerable, underserved people—as well as the fact that some of the people who joined 3 years ago are now beginning to have some troubles, and personnel aren't giving up on those individuals, though they were not able to seek out and identify similarly needy, but unknown, other individuals.
Again, I too, give a high priority to legal services, but not as a single best solution permitted to be isolated from a package of services. For example—in an outreach program in Los Angeles, over 10 years ago, we did a medicare alert outreach program. We found 5,000 people in south central Los Angeles, Watts, and east Los Angeles who not only didn't know about their medicare benefits, they weren't even getting the social security benefits to which they were entitled. Now, I don't think a legal services office alone can identify those 5,000 people. So in a given community when they say, OK, we want first to get to the people who have come into trouble, either legal or medical—but let's then bring the whole array of services and use those targetted people as test cases-rather than bringing legal services alone for everybody. I think you will find a lot have to do with wills and marriage status and so on, which certainly can matter to a person and to their wellbeing, but I am not sure that's the priority. It's not legal services but legal services of a certain kind for certain people.
Senator EAGLETON. You want already targeted programs, more pinpoint? You want legal services for the elderly, but you want to use it for outreach to find out those 5,000 people who don't even know their entitlements under social security. So you want greater specificity, as I hear you.
Dr. STEINBERG. No; I am not asking for Congress to do that. On the contrary, leave that to local determination. But don't reinforce this behavior of defining problems by stating solutions; let them state the problem. For example: We have a lot of people in our area who are simply not using the entitlements that they have. Then this year we will do the aggressive outreach; we will have it backed up by legal services to have the test cases; we will have a medical screening, related to that so that people aren't dying while their cases are being decided.
Senator EAGLETON. You would let all that be decided-you are from where, Los Angeles ?
Dr. STEINBERG. Yes.
Senator EAGLETON. You would let that be decided by the Los Angeles Council on Aging or whatever you call it?
Dr. STEINBERG. Yes. I would state the mandate in terms of procedural standards: Stop trying to tell us it's first-come-first serve, because that means the well, active, ready people who are already connected with the system will get most of the services. Let's say: Tell us how you are going to reach or select a special target group, and do it.
You raised the issue earlier, by the way, about representation. I thought a very interesting thing was done in north Kentucky, where, as many area agencies have done, they did a random sample survey of the whole community. Well, I think there has been a little bit of overkill on that, because people aren't often motivated by what the statistics show. But they also had their advisory committee take that same questionnaire and interview older people that they had access to. When they got the two sets of results in, they saw that the people they were talking to who were elderly simply were much, much better off than this random sample of elderly. The comparison motivated that group to increase their attention to the vulnerable elderly.
I think now the Cleveland study of GAO will give many communities
Senator EAGLETON. Well, there are a whole host of studies in a whole host of areas that show precisely that. It's like some of the youth employment programs. Government has come up with some brilliant information and studies-(a) that the class valedictorianhe gets a job better than the ninth-grade dropout. And in Government, we like successes, and we like to say we solve things, so we will cope with the easiest problems. The easiest problem is somebody who already knows about a program and knows that if they go to such and such center thev will have a nutritional meal on Monday, Tuesday, Wednesday, Thursday, Friday—and we call that success.
But there are many thousands out there that we are not reaching who maybe need that one meal more than the fellow and the lady that do show up.
Dr. STEINBERG. But don't mandate the meals then. Mandate that a genuine process be shown whereby people are targeted, identified, drawn in and responded to as whole people. And that means there might be a variety of services some of which they have entitlement to, some might have to be developed to fill in the gaps.
And, you see, you get out of this kind of trough mentality which says let's divide up the pie according to program.
And, again, I think this Cleveland study that your GAO is doing at this point will show that there are multiple problems, and to simply work on the one to the neglect of the other is really a waste of resources and a human tragedy.
Fourth: One of the things that is perhaps more controversial I haven't heard spoken of here today—when comes legislation time, we all tend to think maybe all these things could be done with no administrative cost. I think this needs to be reexamined. I don't know what the optimum is, but I think universally trying to set 15 percent for all communities across this country is
Senator EAGLETOX. Any figure suggested, sir, is arbitrary by the very nature of suggesting the figure. However, Congress has found itself in the position of creating programs where the largest amount of the money appropriated is consumed in administration. We don't like that.
So I will be the first to admit that 15 percent is arbitrary; pick any figure you want—it's arbitrary. But we find ourselves helpless in trying to keep the whole damn thing being consumed by people on public payrolls.
Dr. STEINBERG. I think the wording of the act is not "administration,” but 15 percent for “planning,” is that correct? To my mind, planning is not the same as administration.
I would support a limit of 10 percent to monitor programs, hold them accountable for the funds they use, make sure that they are delivering services in the most effective and efficient way-fine. But when you are talking about the planning needs in Los Angeles as against Pocatello. Idaho, as against a really declining rural area in Montana-I think you are talking about different degrees of need for spending money on building new agencies, creating a system, developing comprehensive and coordinated systems of services, you are really calling in specialists to work at that. And I don't think that's administration. I won't belabor that point, but I think it's one that I have data on, and I think so does Westat-that those who underattend to the planning function often have not as good a success record in getting changes in aging services. You get what you pay for.
Five: As you know, there is a mixed message as to who is to be served by the Older Americans Act. We don't turn anybody away with a means test. But I think the consequence is: First come, first served; and they are not the most needy. I am by no means sug. gesting a means test. On the other hand, title 3 says "with special emphasis upon minority, poor and the homebound.”
Here again I think some incentives have to be devised so that the program which more successfully targets and responds to the vulnerable elderly or the frail elderly—to use the Federal Council on Aging's terminology—then should be regarded more highly than those who have high head counts because they are skimming.
Senator EAGLETON. Very good. And I think your observation on the nutrition program is appropriate. As much as I like the program, I am not sure that the most needy are there every day or even 1 day a week. And, again, another dilemma: If you have a means test-well, our experience with that in other situations has not been terribly satisfactory.
Dr. STEINBERG. Just one other comment on the nutrition program. I certainly don't want my remarks to suggest that some valuable work isn't going on. But if the emphasis is upon head counts and meals served, you see, then is it really serving as a revolving door, which is one of the concepts! But that revolving door policy means that somebody has to be on hand who is not serving meals, who is helping people get acquainted and organizing those who are capable of sustaining mutual aid groups—that if indeed you have the legal service coming once a week that it is used effectively. It needs someone on hand who is a good listener, who is seeing people come and go, to make sure they get connected, because it doesn't happen automatically. The people who hurt most, often ask for least.
Senator EAGLETON. Would you philosophize with us a little on this dialog I have had with Dr. Binstock about lumping all those things together, forgetting social security, and upping the ante considerably, maybe up to $1 billion, and then letting Albuquerque decide how to do it and what to do.
Mr. REILLY. Mr. Chairman, if I could, just to clean up the record, to pick up on Mr. Steinberg's recollection about what it says in the act about that 15 percent. It's a short paragraph. "Such amount as the State agency determines, but not more than 15 per centum thereof, shall be available for paying such percentage as such agency determines, but not more than 75 percent of the cost of administration of area plans" is the language. It is not planning per se.
Dr. STEINBERG. Yes; in terms of the risks of letting local people decide, I opt for that, knowing that they will make mistakes and hopefully learn from those mistakes. I would certainly be for putting in some process provisions ratther than what kind of program they have to come up with. For example, you were talking earlier about how do you make sure you have representation of the “at-risk” elderly in decisions-and I liked the idea mentioned earlier that sometimes children of frail elderly people might better represent the homebound on councils than someone who is active in some recreation center program.
But I think holding local decisionmakers accountable that they undertake a genuine process of working with the community, in identifying needs and developing solutions, is adequate.
The setting of priorities at the national level doesn't work. In addition to demographic differences across communities, you have communities in different stages of development in terms of human services agencies. And I think the monitoring, for example, in a large city which already has people far more able than I would be as a generalist in monitoring them, is one thing, whereas in some