By Laura Ungar and Trudy Lieberman, Kaiser Health News

MEMPHIS, Tenn. — Army veteran Eugene Milligan is 75 years old and blind. He uses a wheelchair since losing half his right leg to diabetes and gets dialysis for kidney failure.

And he has struggled to get enough to eat.

Earlier this year, he ended up in the hospital after burning himself while boiling water for oatmeal. The long stay caused the Memphis vet to fall off a charity’s rolls for home-delivered Meals on Wheels, so he had to rely on others, such as his son, a generous off-duty nurse and a local church to bring him food.

“Many times, I’ve felt like I was starving,” he said. “There’s neighbors that need food too. There’s people at dialysis that need food. There’s hunger everywhere.”

Indeed, millions of seniors across the country quietly go hungry as the safety net designed to catch them frays. Nearly 8% of Americans 60 and older were “food insecure” in 2017, according to a recent study released by the anti-hunger group Feeding America. That’s 5.5 million seniors who don’t have consistent access to enough food for a healthy life, a number that has more than doubled since 2001 and is only expected to grow as America grays.

While the plight of hungry children elicits support and can be tackled in schools, the plight of hungry older Americans is shrouded by isolation and a generation’s pride. The problem is most acute in parts of the South and Southwest. Louisiana has the highest rate among states, with 12% of seniors facing food insecurity. Memphis fares worst among major metropolitan areas, with 17% of seniors like Milligan unsure of their next meal.

And government relief falls short. One of the main federal programs helping seniors is starved for money. The Older Americans Act — passed more than half a century ago as part of President Lyndon Johnson’s Great Society reforms — was amended in 1972 to provide for home-delivered and group meals, along with other services, for anyone 60 and older. But its funding has lagged far behind senior population growth, as well as economic inflation.

The biggest chunk of the act’s budget, nutrition services, dropped by 8% over the past 18 years when adjusted for inflation, an AARP report found in February. Home-delivered and group meals have decreased by nearly 21 million since 2005. Only a fraction of those facing food insecurity get any meal services under the act; a U.S. Government Accountability Office report examining 2013 data found 83% got none.

With the act set to expire Sept. 30, Congress is now considering its reauthorization and how much to spend going forward.

Meanwhile, according to the U.S. Department of Agriculture, only 45% of eligible adults 60 and older have signed up for another source of federal aid: SNAP, the food stamp program for America’s poorest. Those who don’t are typically either unaware they could qualify, believe their benefits would be tiny or can no longer get to a grocery store to use them.

Even fewer seniors may have SNAP in the future. More than 13% of SNAP households with elderly members would lose benefits under a recent Trump administration proposal.

For now, millions of seniors — especially low-income ones — go without. Across the nation, waits are common to receive home-delivered meals from a crucial provider, Meals on Wheels, a network of 5,000 community-based programs. In Memphis, for example, the wait to get on the Meals on Wheels schedule is more than a year long.

“It’s really sad because a meal is not an expensive thing,” said Sally Jones Heinz, president and CEO of the Metropolitan Inter-Faith Association, which provides home-delivered meals in Memphis. ”This shouldn’t be the way things are in 2019.”

Since malnutrition exacerbates diseases and prevents healing, seniors without steady, nutritious food can wind up in hospitals, which drives up Medicare and Medicaid costs, hitting taxpayers with an even bigger bill. Sometimes seniors relapse quickly after discharge — or worse.

Widower Robert Mukes, 71, starved to death on a cold December day in 2016, alone in his Cincinnati apartment.

The Hamilton County Coroner listed the primary cause of death as “starvation of unknown etiology” and noted “possible hypothermia,” pointing out that his apartment had no electricity or running water. Death records show the 5-foot-7-inch man weighed just 100.5 pounds.

A Clear Need

On a hot May morning in Memphis, seniors trickled into a food bank at the Riverside Missionary Baptist Church, 3 miles from the opulent tourist mecca of Graceland. They picked up boxes packed with canned goods, rice, vegetables and meat.

Marion Thomas, 63, placed her box in the trunk of a friend’s car. She lives with chronic back pain and high blood pressure and started coming to the pantry three years ago. She’s disabled, relies on Social Security and gets $42 a month from SNAP based on her income, household size and other factors. That’s much less than the average $125-a-month benefit for households with seniors, but more than the $16 minimum that one in five such households get. Still, Thomas said, “I can’t buy very much.”

A day later, the Mid-South Food Bank brought a “mobile pantry” to Latham Terrace, a senior housing complex, where a long line of people waited. Some inched forward in wheelchairs; others leaned on canes. One by one, they collected their allotments.

The need is just as real elsewhere. In Dallas, Texas, 69-year-old China Anderson squirrels away milk, cookies and other parts of her home-delivered lunches for dinner because she can no longer stand and cook due to scoliosis and eight deteriorating vertebral discs.

As seniors ration food, programs ration services.

Although more than a third of the Meals on Wheels money comes from the Older Americans Act, even with additional public and private dollars, funds are still so limited that some programs have no choice but to triage people using score sheets that assign points based on who needs food the most. Seniors coming from the hospital and those without family usually top waiting lists.

More than 1,000 were waiting on the Memphis area’s list recently. And in Dallas, $4.1 million in donations wiped out a 1,000-person waiting list in December, but within months it had crept back up to 100.

Nationally, “there are tens of thousands of seniors who are waiting,” said Erika Kelly, chief membership and advocacy officer for Meals on Wheels America. “While they’re waiting, their health deteriorates and, in some cases, we know seniors have died.”

Edwin Walker, a deputy assistant secretary for the federal Administration on Aging, acknowledged waits are a long-standing problem, but said 2.4 million people a year benefit from the Older Americans Act’s group or home-delivered meals, allowing them to stay independent and healthy.

Seniors get human connection, as well as food, from these services. Aner Lee Murphy, a 102-year-old Meals on Wheels client in Memphis, counts on the visits with volunteers Libby and Bob Anderson almost as much as the food. She calls them “my children,” hugging them close and offering a prayer each time they leave.

But others miss out on such physical and psychological nourishment. A devastating phone call brought that home for Kim Daugherty, executive director of the Aging Commission of the Mid-South, which connects seniors to service providers in the region. The woman on the line told Daugherty she’d been on the waiting list for more than a year.

“Ma’am, there are several hundred people ahead of you,” Daugherty reluctantly explained.

“I just need you all to remember,” came the caller’s haunting reply, “I’m hungry and I need food.”

A Slow Killer

James Ziliak, a poverty researcher at the University of Kentucky who worked on the Feeding America study, said food insecurity shot up with the Great Recession, starting in the late 2000s, and peaked in 2014. He said it shows no signs of dropping to pre-recession levels.

While older adults of all income levels can face difficulty accessing and preparing healthy food, rates are highest among seniors in poverty. They are also high among minorities. More than 17% of black seniors and 16% of Hispanic seniors are food insecure, compared with fewer than 7% of white seniors.

A host of issues combine to set those seniors on a downward spiral, said registered dietitian Lauri Wright, who chairs the Department of Nutrition and Dietetics at the University of North Florida. Going to the grocery store gets a lot harder if they can’t drive. Expensive medications leave less money for food. Chronic physical and mental health problems sap stamina and make it tough to cook. Inch by inch, hungry seniors decline.

And, even if it rarely kills directly, hunger can complicate illness and kill slowly.

Malnutrition blunts immunity, which already tends to weaken as people age. Once they start losing weight, they’re more likely to grow frail and are more likely to die within a year, said Dr. John Morley, director of the division of geriatric medicine at Saint Louis University.

Seniors just out of the hospital are particularly vulnerable. Many wind up getting readmitted, pushing up taxpayers’ costs for Medicare and Medicaid. A recent analysis by the Bipartisan Policy Center found that Medicare could save $1.57 for every dollar spent on home-delivered meals for chronically ill seniors after a hospitalization.

Most hospitals don’t refer senior outpatients to Meals on Wheels, and advocates say too few insurance companies get involved in making sure seniors have enough to eat to keep them healthy.

When Milligan, the Memphis veteran, burned himself with boiling water last winter and had to be hospitalized for 65 days, he fell off the Metropolitan Inter-Faith Association’s radar. The meals he’d been getting for about a decade stopped.

Heinz, Metropolitan’s CEO, said the association is usually able to start and stop meals for short hospital stays. But, Heinz said, the association didn’t hear from Milligan and kept trying to deliver meals for a time while he was in the hospital, then notified the Aging Commission of the Mid-South he wasn’t home. As is standard procedure, Metropolitan officials said, a staff member from the commission made three attempts to contact him and left a card at the blind man’s home.

But nothing happened when he got out of the hospital this spring. In mid-May, a nurse referred him for meal delivery. Still, he didn’t get meals because he faced a waitlist already more than 1,000 names long.

After questions from Kaiser Health News, Heinz looked into Milligan’s case and realized that, as a former client, Milligan could get back on the delivery schedule faster.

But even then the process still has hurdles: The aging commission would need to conduct a new home assessment for meals to resume. That has yet to happen because, amid the wait, Milligan’s health deteriorated.

A Murky Future

As the Older Americans Act awaits reauthorization this fall, many senior advocates worry about its funding.

In June, the U.S. House passed a $93 million increase to the Older Americans Act‘s nutrition programs, raising total funding by about 10% to $1 billion in the next fiscal year. In inflation-adjusted dollars, that’s still less than in 2009. And it still has to pass in the Republican-controlled Senate, where the proposed increase faces long odds.

U.S. Rep. Suzanne Bonamici, an Oregon Democrat who chairs the Civil Rights and Human Services Subcommittee, expects the panel to tackle legislation for reauthorization of the act soon after members return from the August recess. She’s now working with colleagues “to craft a strong, bipartisan update,” she said, that increases investments in nutrition programs as well as other services.

“I’m confident the House will soon pass a robust bill,” she said, “and I am hopeful that the Senate will also move quickly so we can better meet the needs of our seniors.”

In the meantime, “the need for home-delivered meals keeps increasing every year,” said Lorena Fernandez, who runs a meal delivery program in Yakima, Wash. Activists are pressing state and local governments to ensure seniors don’t starve, with mixed results. In Louisiana, for example, anti-hunger advocates stood on the state Capitol steps in May and unsuccessfully called on the state to invest $1 million to buy food from Louisiana farmers to distribute to hungry residents. Elsewhere, senior activists across the nation have participated each March in “March for Meals” events such as walks, fundraisers and rallies designed to focus attention on the problem.

Private fundraising hasn’t been easy everywhere, especially rural communities without much wealth. Philanthropy has instead tended to flow to hungry kids, who outnumber hungry seniors more than 2-to-1, according to Feeding America.

“Ten years ago, organizations had a goal of ending child hunger and a lot of innovation and resources went into what could be done,” said Jeremy Everett, executive director of Baylor University’s Texas Hunger Initiative. “The same thing has not happened in the senior adult population.” And that has left people struggling for enough food to eat.

As for Milligan, he didn’t get back on Meals on Wheels before suffering complications related to his dialysis in June. He ended up back in the hospital. Ironically, it was there that he finally had a steady, if temporary, source of food.

It’s impossible to know if his time without steady, nutritious food made a difference. What is almost certain is that feeding him at home would have been far cheaper.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.