Helping people stay in their homes as they age has been a formal, if poorly understood, goal of U.S. aging policy for some time. Experts say it's far cheaper than housing seniors in nursing homes and other institutions. And public surveys find that it's also the overwhelming preference of 9 out of 10 seniors.
As much as we want to age in our own homes, however, the network of government, volunteer, and family caregiving resources needed to support older Americans is able to meet only a fraction of the elder population's needs. And with soaring numbers of older Americans, coupled with stressed government and philanthropic budgets, the scale of unmet needs is likely to rise sharply.
America's resources for home-based seniors are coordinated chiefly by the U.S. Administration on Aging (AoA), which is part of the U.S. Department of Health and Human Services. Support services are defined and delivered through a network of state offices, some 630 local areas on aging districts, and thousands of connected local government and volunteer programs.
Still, according to a recent report by the U.S. Government Accountability Office (GAO), there is no definitive picture of the home-based services America's seniors are receiving or of their unmet needs.
"No agencies that GAO spoke with fully estimate the number of older adults with need and unmet need," its report said. "AoA and state agency officials noted that there are various challenges to collecting more information, such as cost and complexity. However, as a result of limited and inconsistent information, AoA is unable [to] assess the full extent of need and unmet need nationally, and within each state."
Food, home-based care, and transportation services are the three primary non-medical components of senior safety-net programs for people who live at home. The core groups needing such help are the 10 million Americans ages 60 and older who live in poverty and another 16.4 million "near-poor" with incomes below 185 percent of the poverty threshold ($10,326 in the annual income, using the 2008 figure in the GAO report).
In all three areas, the GAO said there was a substantial gap between delivered and needed services.
Food. "An estimated 19 percent of low-income older adults were food-insecure and about 90 percent of these individuals did not receive any meal services," GAO found. "Similarly, approximately 17 percent of those with low incomes had two or more types of difficulties with daily activities that could make it difficult to obtain or prepare food. An estimated 83 percent of those individuals with such difficulties did not receive meal services."
Care. Nearly 30 percent of older Americans have difficulty performing one or more activities of daily living (ADLs), which are formally defined functions that include dressing, bathing, toileting, walking, and eating. Among people with one or two ADL problems, the GAO said, 48 percent received no in-home help from formal programs, 31 percent got some help, and 22 percent said they received help with all of their problems. Among more profoundly incapacitated seniors—people with three or more ADL problems—11 percent got no help, 68 percent received some help, and 21 percent received help with all of their problems.
Transportation. Roughly 1 in 5 older Americans need transportation help, the GAO reported, adding that its earlier research had identified 15 federal programs providing such services, including Medicaid and Department of Transportation programs. Nowhere, however, was it able to find specifics on how much of the help needed by older Americans was actually being provided.
"As a result of limited and inconsistent state knowledge about need and unmet need," GAO concluded, "AoA is unable to measure the extent of need and unmet need for the different home- and community-based services nationally or consistently across states—information that could help them to best allocate their limited resources."
Whatever the current unmet need, demand among older Americans for at-home services has increased sharply and will continue growing for decades. "U.S. Census projections estimate the number of Americans age 65 and over will increase from 40 million in 2010 to 72 million in 2030," the GAO report said. "At the same time, expected fiscal constraints at the national, state, and local levels may limit the funds available to provide assistance to the growing population of older adults in need."