Transcripts For CSPAN2 Hearing On Caring For Elderly Americans 20240713

The senate live here on cspan2. Next, a look at the challenges of caring for Senior Citizens with caregivers testifying on the lack of affordable longterm care for the elderly. [inaudible conversations] [inaudible conversations] would members and their guests please take their seats . Ways and Means Committee will come to order. Good morning and welcome. We are here to discuss a difficult issue that confronts nearly every family in our nation, and that is how to care for our loved ones as they age. It is certainly appropriate that we work to address this matter or in november, which is alzheimers Awareness Month and u. S. National Family Caregivers month. It is a deeply personal issue for many of us in the room, and for those who havent personally struggled to insure an older relative receives the care they need, you most certainly know someone in your life who has. Navigating a fragmented and insufficient longterm care system can be not only confusing and emotionally taxing, but also enormously expensive. Indeed, even unaffordable. Roundtheclock inhome care costs about 180,000 a year, costs over 80,000 a year to live in a nursing home, and assisted living costs 43,000 a year. These high prices certainly weigh heavily on aging americans and their families as they try to plan for future longterm care needs. Most americans want to age in their homes, but they need help to stay there, relying heavily on Family Members and friends for daytoday assistance. Caregivers, like our witness kristina brown, are the Unsung Heroes in many of these cases. Often family relationships become strained, exacerbating these challenges in our is our nations failure to guarantee paid family and medical leave compared to other industrialized nations. We want to thank kristina and all of our witnesses for being here today who graciously will tell their personal stories and share their expertise. At this time i want to do manager thats a bit unusual, and that is i want to yield my time to congresswoman Linda Sanchez who has recently told me of her familys moving story of caring for loved ones experiencing dementia as theyve aged. Now let me yield to her so she can share her experience with the committee. A reminder, this is neither a democratic, nor a republican issue. Ms. Sanchez. Thank you, mr. Chairman. Im incredibly grateful for your leadership on this issue, and i am so pleased that you called a full Committee Hearing so that all Committee Members have the chance to address this incredibly important area of health care. And finally are, i want to thank all of our witnesses for joining us here today and to give us ideas and their stories on what they confront. For millions of American Families much like my own, the heartbreak of watching a loved one struggle with alzheimers disease or related dementias is a pain that we know all too well. And this devastating disease disproportionately affects certain groups, especially women and the latino community. Indeed, latinos are one and a half times more likely than nonlatinas to develop alzheimers disease. By the year 2030, nearly 40 of all americans living with dementia will be latino and from time to time. But its not a disease and africanamerican. Its not a disease that is singular to minority communities. It affects every community. These statistics should scare all of us. I understand the pain that this disease brings to family, because my father, ilk gas owe, recently passed from alzheimers. We saw him struggle with the disease for more than 15 years, and it was a long, slow, painful decline. It was frustrating to watch a oncevibrant man who had sacrificed and done so much for my family slowly lose his independence. And it was equally hard knowing that there was nothing that i could do to stop the diseases progression. As if that wasnt cruel enough, two years ago my mother maria was diagnosed with the same disease. Alzheimers is relentless and it is cruel. And it doesnt progress at a constant speed. There are good days and there are bad ones. And there are times when the scale and magnitude of the disease seems pretty overwhelming. But i am one of the fortunate ones. I have a large namely. I come from a family of Seven Brothers and sisters, and we share the financial and caregiving burden for my mother as we did for my father. Having to care for aging loved ones, many are in the Sandwich Generation having to raise children and care for aging parents. Many dont live in the same state as their aging parents. So we rely on caregivers. And the statistics on caregiving in america is astounding. Over 40 million americans currently deliver unpaid care and aging relative or friend. The cdc reports that more than 16 million americans, nearly half of all caregivers provide more than 13 billion hours of unpaid care for families and friends living with alzheimers. About two thirds of these caregivers are women, thus they are disproportionately impacted and another order care for an aging parents and four children under the ageof 18. Hispanic and africanamerican caregivers experience higher burden from caregiving and their counterparts. We have to address successful strategies were dealing with our aging population. And we must help caregivers and ease their financial and caregiving burdens. Our only option for now, because we dont have a cure for alzheimers and dementia is to promote and policies that improve thelives of the patients and the caregivers. I look forward to discussing these topics with our witnesses later in the hearing. I encourage my colleagues to take it vantage of the wisdom of our panel of witnesses and again, i want to thank you mister chairman calling this hearing and i yield back thank you congresswoman and i want to acknowledge that your candor and openness to bringing the subject forward and let me recognize the Ranking Member mister brady for an Opening Statement. Thank you karen neal, republicans have a long history supported americans seniors, working tomake strides in improving the health and social services they rely on. 10,000 baby boomers retiring each day, republicans have been leaders in helping americas aging population. In 2003, under the leadership of president bush and the Republican Congress i was proud to help create the first time for the first time it portable lifesaving Prescription Drug plan for seniors. They 43 million americans enrolled in this lifesaving program which came in the present under budget still delivers affordable premiums. Additionally serving as chairman of the Health Committee i was proud to change the bipartisan. We know that how medicare takes care of patient after they leave the hospital is equally as important as the care they receive while hospitalized. The status quo often is working for aging Medicare Beneficiaries, getting care and post care settings. The impact enables medicare tocollect data to achieve three goals , compare quality among various care settings, improve the way hospitals use providers plans for patient discharge and the use of new information to make improvements to how medicare pays these facilities while ensuring that our patients are receiving the best and the correct setting for care. Over five years later this law is working. Cms is collecting data as a nonpartisan medicare patient and the pfizer commission is ahead of the curve taking steps to determine how congress can create transition, the unified post Payment System that is focused for seniors on quality and accountability. So there is still more to do, this work means americas seniors and medicare are in a better place. Also serving as Committee Chairman i was proud to join our Social Security subcommittee leader sam johnson and john larson to pass the strengthening protections for Social Security beneficiaries act. This appoints a representative and persons unable to manage or direct the management of their own Social Securitybenefits. Representative pays played an Important Role in how we care for aging americans. However there were serious concerns about pays that Congress Needed to address. Publicans and democrats who work to strengthen oversight also reduce the burden on Family Members. 88 americans giving americans the greatest say in selecting their care, ensuring this was the person they could trust. We made substantial changes to our entitlement programs to help those receiving Social Security and if its and republicans remain eager to work with their democratic colleagues to strengthen these important programs for americans. I do admit part of our work is in congress to stop what we believe are dangerous ideas being signed into law. We are very concerned. People propose fewer tours for patients act would stop viewers from being developed for seniors. A partisan legislation which passed by this commission would tell our seniors struggling with als and alzheimers and those who care for them that hope for a cure is at risk. Hr three is the first step in what we worry is a very extreme healthcare agenda including medicare for all. The effects of his radical healthcare approach would have on our seniors i think is unfathomable. The private plans seniors enjoy would be gone in a private plans American Workers including caregivers for seniors eliminated. In their place, long wait lines and not being able to go to the doctor of their choice thats a lifethreatening change, especially for our seniors, many of whom fought for us for were raised as children and grandchildren so we could work for towards living the american dream. We owing to our seniors and those who care for them to continue improving these programs. We to future generations to ensure our safety net can continue to deliver on this promise. They were going to hear from a panel of expert witnesses about serious programs plaguing the Medicare Program today, especially for the sickest patients. Some of these quality issues are so severe they jeopardized the lives of our seniors. We have to find a way to Work Together to strengthen these programs for current and seniors in the future. We need to work diligently to protect our vulnerable members as Seniors Today but we also need to empower future seniors by guaranteeing them choice in healthcare and retirement i want in the washington things will work best for them. I want to recognize one of our staffers as she departs for a new adventure in her home state of ohio, part of the exemplary work has been critical to advancing real Bipartisan Solutions to the problems americans face each and every day. Her departure is and we will miss her and wish her the best of luck. Thank you chairman. Let me speak for the majority here. We want to take time to acknowledge carla deblasios fine work as a member of this staff and ways and Means Committee and i know shes going to return to her hometown in cleveland but one of the things weve all been fortunate to have your ways and Means Committee is a terrific staff so carla has provided dedicated service to this committee , oldest council price still serve as a member as professional staff advisor to Ranking Member brady. We are grateful to work that she has gone on opiate measures in particular and we wish her well and thank her for her service as she embarks on a new journey in life. [applause] [applause] i want to thank mister brady and without objection all members Opening Statements will be made part of the record. I want to thank our distinguished witnesses for taking the time to appear before us today to discuss these very important issues. First we want to welcome christina brown, a caregiver and for medical students. Robert and he is that he Public Policy officer of the Alzheimers Association. And we have joann lynn, the health and aging policy fellow from the program to improve eldercare. Next we have robert blancato, National Coordinator for Elder Justice Coalition. Richard mullet is the executive director of longterm Care Community coalition, finally we have mister banach, ceo of the hospice and Palliative Care organization. Each of you will have your statements made part of the record. I want to ask you tosummarize your testimony in five minutes or less. To help you there is a timing light at your table. You have one minute left, the light will switch from green to yellow and finally to read when the five minutesare up. Miss brown, please proceed. Good morning karen neal, Ranking Member brady and distinguish members of the committee. For the opportunity to share my thoughts this morning area my name is christina brown, a caregiver and medical student. When i was 16 my life shifted. My mother at 43 lost the ability to walk due to multiple sclerosis. She could no longer stand, eat or bathe without assistance. I became her primary caregiver and for six years provided 10 hours of care each day. Despite what many may think , having a disability is not guarantee access to resources. Because my mother had an income of 36,000, as was younger than 65 and had a 10 year employment history he had been denied medicare, Social Security disability and medicaid despite its expansion. Her private Insurance Company like most does not cover home care for daily needs so i filled in the gaps and in high school i would wake up at 5 30 each day to lift my mother into bed or into her wheelchair. Despite being a straight a student i almost didnt graduate from high school because i had so many absences from taking care of my mother. I routinely missed meals and strove to hide my exhaustion, weight loss and isolation from the people around me. I lost my adolescence area i declined for ride merit scholarships from universities i longed to explore. And during college my sister and i movedback home because we couldnt afford next rachel. We had few alternatives. Most nursing facilities serve only seniors and even if we found one for younger adults, the cost of that care to exceed 10,000 a month area home care only slightly more affordable six or 7000 per month. Like many families cannot afford fulltime coverage. Like many caregivers i would need to feel invisible, but my health and my future matter. I had taken out loans to pay my mothers mortgage and worked a weekend job on top of being a fulltime medical student. Combined with my sisters your salary is fairlyinsured our mothers survived. We are running out of options. We could start our home to qualify for assistance or i could leave medical school to become a fulltime caregiver. But even these extreme comprising measures would only drive us further into a vicious title of financial instability. Caregiving has fueled generationalpoverty within even even greater impact on the whales and women who take on that role. When women become caregivers they become 2 and a half times more likely to live in poverty. This past september our situation took another turn to my sister who had been caring for my mother while i had been away was moving to start a new job. I canceled my board exams and dropped everything so i could fly home and since we couldnt afford a Home Care Agency i retreated into caregivers that i found online. I left reams of applications and made a flurry of phone calls to my mothers social worker at the health and Human Services department and regional disability center. Financial support area so far none have arrived. So i returned to campus, this arrangement is tenuous and allconsuming. Already Home Health Aides have quit unexpectedly leaving my mother to forgo regular meals and bathing while 1000 miles away i scramble to find replacements. From week to week i still dont know whether my mother will receive the care she needs. As this Committee Meets to discuss the caring for aging americans i ask you take steps to ensure families like minedo not continue to fall through the cracks. We must eliminate age gaps and income gaps middle aged, middle income adults with disabilities can qualify for longterm care through medicaid, especially when their home care expenses far exceed their income. The cutoff should not be based on income alone but rather on income adjusted by care costs. Second, the family and medical leave act to provide paid leave the caregivers and universities should offer support sites to help ease the burden on student caregivers like me. Third, we must aim for universal longterm care to ensure every adult with a disability has Affordable Access to sustainable care. This will be costly, but doing nothing will only serve a silent punishment to individuals with disabilities and their caregivers. No family for young caregiver should have to sacrifice their health, education and financial state ability to meet basic human needs area number after the cost my family has incurred over the past decade. From sleepless nights to a dream deferred, sometimes my mother called me to apologize for being sick. Despite the uncertainty of the situation i focus on carving up a new future formy family and others. Thank you for listening. Class thank you miss brown. Peggy, would you please proceed. Chairman neil, Ranking Member brady andmembers of the committee, thank you for holding this hearing today and for the opportunity to testify on how america caring for its aging population including those with alzheimers and related dementia. Alzheimers is a progressive brain disorder damages and destroys brain cells. Leading to a loss of memory, thinking and other brain function. Ultimately alzheimers is fatal. We have yet tocelebrate the first survivor of this devastating disease. More than 5 million americans are currently living with alzheimers and many more living with other diseases that cause dementia. Withoutsignificant action as many as 14 million alzheimers by 2050. In addition to the suffering caused by the disease, alzheimers is also creating an enormous strain on Family Finances , the Healthcare System and federal and state budgets. Alzheimers is the most expensive condition in america with cost set to skyrocket at unprecedented rates. And just this year alone medicare and medicaid will cover the cost of more than two thirds of the cost of the care of persons with alzheimers, an estimated 195 million. Fortunately, new options are now available to individuals and families affected. Beginning in 2017, medicare now reimburses physicians and other Healthcare Professionals while providing comprehensive Care Planning to individuals of Cognitive Impairment. This is a critical step towards improving the quality of life for those with alzheimers. Analysis show that dementia specific Care Planning can lead to fewer hospitalizations, fewer emergency room visits and that her medicationmanagement. Allows diagnosed individuals and their caregivers to Access Medical and nonmedical treatments, Clinical Trials and support services. However, uponanalysis of cns data , the Alzheimers Association as determined you are than one percent of those living with alzheimers and other dementias receive this muchneeded Care Planning in 2017. Fewer than one percent. With benefits of Care Planning to reach more americans affected by oldtimers, more clinicians use this Care Planning benefits. The bipartisan improving hope for alzheimers would help achieve that goal by requiring the apartment of health and Human Services to first educate clinicians on the existence and importance of medicare Care Planning benefits and second, report to congress on the barriers to individuals receiving this Care Planning service and how to increase its use. This bill has honored significant bipartisan support in both chambers. And we urge the committee on ways and means to hold the market. We look forward to working with the bill sponsor and Committee Leadership to ensure the full house and senate. Robust Care Planning is the first step to learning about longterm care options and most appropriate services for persons with dementia, their family and their caregivers. These individuals need access to a wide variety of services such as adult day, home health, respite, residential facilities and nursing home care. Because those with dementia and their caregivers have unique needs change over the course of the disease they typically use longterm Care Services differently as their condition progresses. At each stage of the disease caring for a person with alzheimers and other dementia poses special challenges. For example Family Caregivers help individuals managing escalating difficulties with communication and behaviors as well as increasing need for supervision and personal care. As symptoms worsen Family Caregivers experienced increased emotional stress and depression, Health Problems and depleted incomes. Effective evidencebased interventions can reduce depression among Dementia Caregivers , with their often overwhelming responsibilities and can help to keep a person living with alzheimers and the whole longer. Other needs of dementia and their caregivers also extend well beyond the Healthcare System. Upon diagnosis, effective person not only need help managing other conditions of the often needs communitybased support safety assessments, legal and financial services, transportation and help managing dementia related behaviors. Healthcare and the Longterm Service and support systems as it exists today all too often fail those who are living with dementia and their caregivers. We must do allwe can to ensure the best quality of care for those living with alzheimers and for those who care for them. We look forward to working with the committee to advance Bipartisan Solutions that will have a meaningful impact on americas seniorsincluding passage of the improving health for alzheimers. Thank you for the opportunity to testify and i look forward to answering any questions you may have thank you mister egge, doctor lynn, would you proceed. Turn on your microphone. Good morning again chairman neil, Ranking Member brady and other members of the committee. Thank you for holding this hearing aiming to focus attention on the challenges that face us within 15 years as we double the number of elderly persons living with progressivedisabilities. I commend the committee for your attention to Retirement Security and Medicare Coverage for hearing, vision and dental care and i am heartened thatyou are willing to address the challenges of longterm disability. Most americans including most of us in this room will live with serious disabilities in old age. For an average of two years, we should be able to count on living comfortably and meaningfully in those years with costs and burdens that we all can bear weather as elders, Family Members, caregivers or taxpayers. I have been a physician for 45 years serving People Living with chronic conditions in old age. Ive worked in research, education, Public Health and improving implementation. I have come to realize our beloved United States faces a serious challenge with the oncoming numbers of elderly persons who arrive old age with inadequate finances and who eventually will live with serious disabilities. Without changes within a decade most people who live their working years in the middle class will be unable to afford housing in retirement. Stop to think about that. Will we really tolerate millions of elderly people on the streets living in cars and tents . Will we still pay for expensive hospitalizations and drugs are people who cannot get lunch . Will it be okay for me to write a prescription for 1000 drug or an elderly person living in a car without food . Families will often try hard to help. Youve already heard one story of that but just the very definition of family that means we will be spreading impoverishment across the later generations. Already many cities have halfyear weights for home delivered food for people who are acknowledged to need home delivered food. The wait for disability adapted Senior Housing in most areas usually ends with nursing home placementor death. Not a house. Perhaps Family Caregivers and their adult Family Members living with disabilities will generate strong voting block to push for change. We surely should. Half of retirees now have less than 25,000 in savings beyond Social Security. Before they are ill. For many reasons, we will not be support one another in old age using contemporaneous taxes alone. There will be just too many frail and impoverished elders. We need to engineer strategies that would get more of the costs covered by savings. One appealing proposal would be to have government at some level they cut the cost of the long tail of longterm care and leavethe front and to the elders, their families and local arrangements. The waiting time for the government picks up the cost would depend on the elders earnings so well off people might have to cover five years but a low wage earner might only have to cover one area this makes it cost much less than one percent added to the medicare tax and it would open the market for a variety of savings arrangements including tailored insurance products. If we could get a substantial proportion of elderly people paying their own way through the discovery at the end of life we would be in a much better position to provide support for all of us. There are probably other ways to get this done but we need to be developing and testing them now. There is a long lead time to have effective savings plans for old age. He also need attention to both family and paid caregiving and to housing, workforce, transportation and food. We need to rediscover neighborliness. Need old innovation. We need to learn our way into a social arrangements will serve all of us well. We can do this. This is a brewing calamity that could be averted. We all have a stake in this. Everyone here will be touched either directly or through family and friends. Will we be a nation that learns to ignore elders dying without homes and food or will we learn to arrange things so that most of us lives that are as comfortable and meaningful as possible despite disabilities and the shadow of death . You have a large voice in the course we take and i hope you will take up leadership on these issues. If you do not, and the nation continues to slide into abandoning us in our last phase of life, wewill get what we deserve. Misery. We can do better and you can help. Thank you. Chairman neil, Ranking Member brady, distinguished members of the committee, as National Coordinator of the Elder Justice Coalition i am proud to participate today. Thank you also for your strong advocacy or nursing home and hospice residents. Caring for aging americans is a challenge whether theylive in facilities or independently. Achieving quality care is the goal, affording it is the main obstacle. The median National Cost of Nursing Homes is 90,000 a year, home health 50,000 a year and assisted living 40,000 a year. Savings are being tapped. The poll shows seniors went through 22 billion from longterm savings in the last 12 months to pay for Health Expenses and healthcare says half of middle income seniors over 75 wont be able to afford medical expenses or assistedliving in 10 years how to make care affordable . We must preserve medicare. Continue to have it cover more your home and communitybased care and reimburse rates for staff. Let us consider a benefit under medicare. The tax code could help more with a tax credit or deduction for purchase of longterm Care Insurance that provides choices and has strong consumer protection. Lets look at emerging state model like the washington longterm caretrust act which provides longterm benefits for care , finance in part by premiums paid. Foster is one issue, quality care is important especially in Nursing Homes. Five percent live in these homes but the gao says while efficiencies they got less than one percent of the total they know they are doubling efficiencies from 2013 to 2017. A testimony from my daughter whose mother died from dehydration in a nursing home that was given a five star rating by cms and this recent headline , three nursing home workers were charged of running a fight club of patients with dementia. There are many fine nursing zone in this country. But where problems exist must laugh act. Theres been a pattern of abdication of responsibility by certain agencies in protectingNursing Homes. We need to revisit conditions for participation for any hospice receiving medicaid. Problems like failure to report abuse, failure to recruit staff, there must be consequences tied to participation. On the hospice front i commend the introduction of the bipartisan hospice care improvement act. Agencies must report cases of abuse, lost mandating proper recording of crimes must be enforced. We need better coordination between all levels of government on Emergency Response plans and for the 95 percent of adults live in the community we must reauthorize the elder justice act. Moving to older adultsmore than 25 percent of Older Americans living in Rural America, theres colleges are real. I housing costs and the lack of economic development, but the real crisis is in healthcare. Elders have higher rates of disability and lower prevalence of healthy behaviors. Access to healthcare is a genuine issue and in addition to a pronounced shortage of healthcare personnel, we have a doubling in rural hospital closings from 2013 to 2017 compared to five years ago. Continue to expand telehealth while closing the digital divide, dedicated funds must go to rural, before a rural hospital closes, declare a Public Health emergency and expand the pace provider grant program. Also today with and 1. 1 million older adults are lgbt queue. Many have endured discrimination in employment and housing. Now as they age they encounter discrimination in longterm care which led to the longterm care quality index to promote inclusive care for lgbtq adults. We also need to designate lgbtq as an underserved population to get a accurate data on elder abuse. Whether people can obtain enough food to lead a healthylife, treating americans , just 5. 2 million americans in 2007. Factors that contribute include being low income, living in a food desert and inadequate transportation. Food insecurity poses a threat to health. One serious consequence is malnutrition. Congress can help this year. Maintain the house path funding levels for 20 2014 nutrition programs and present a path to reauthorization which has firsttime malnutrition screening, expand outreach for Older Americans to get smith, do an inventory of food deserts and have a strategy to reduce them and have cms approved malnutrition and acute care. In less than 10 years those 65 and older will the 25 percent of our population. We enjoy a greater quantity of life. Our present and future Public Policies need to focus on improving the quality of life. Mister banach, would you proceed. Thank you for holding this important hearing and inviting me to testify. My name is richard banach, director of the Community Coalition nonprofit Nonpartisan Organization and improving care and dignity for residents inNursing Homes and assisted living. Its important to note that more than 50 of residents in assistedliving Nursing Homes have some form of dementia or Cognitive Impairment in twothirds of dementia related deaths occur in Nursing Homes. Nursing home and assisted living safe in his soviet most important for those living with this disease and to their families. Thanks to 1987 nursing home reform ivory family and nursing nursing home care what the shortterm rehab and longterm care is promised they will be safe received the care and services and be treated with dignity. Unfortunately far too often the community in every state in our country those promises are broken. With their formal existing standards are strong and persistent way to ensure basic compliance with the standards by the states in this centers for medicaid and mediCare Services has resulted in a situation where sophisticated profit driven industry essentially operates at the owner. The absence of effective enforcement theres little to stop nursing Home Companies from maximizing profits at the expense of resident care prisoners comes onto their promises to residents and families but far too many do not. Most banal Nursing Homes have insufficient staffing and meet residents basic clinical and hygiene needs. Over 40 of u. S. Nursing homes have a recall chronic deficiencies repeated violations of the same regulatory requirements year after year after year. Abuse and neglect in crimes against residents are persistent and pervasive. Approximately 20 of residents are administered antipsychotic drugs everyday despite the warning not to use these drugs and elderly people due to substantial risk of harm and even death. According to the cdc quote one to 23 million serious infections occur every year in these facilities. Infections are a major cause of hospitalizations and deaths. As many 380,000 people die of infections and longterm care facilities every year unquote are not abstract problems. Avoidable pain and substandard care are part of hundreds of thousands of nursing home residents live everyday. This now includes Holocaust Survivors veterans from across the country. We certainly hear about seniors with dementia who art drugs into oblivion rather than provide essential Care Services for even rudimentary divvies to meet their needs. Basic Palliative Care freedom from pain and hospice care the chance of dying in comfort and dignity are increasingly out of reach of too many seniors because their facilities put profits first. Doesnt have to be that way. Enforcement of minimum standards as needed. Must address the disconnect between the promise of the nursing home reform law and the reality for families. Neither state agencies or semester for filling their mission to protect residents. We must hold the line against current efforts and my regulatory minimum standards and reduce the already low frequency of nursing home inspections. Residents lives and families peace of mind depend on it. We must codify standards. Widespread failure to send provide care or roe has recognized for decades as a national disgrace. They must establish a medical for nursing home. American families and taxpayers have writes no reasonable of the public funds of Nursing Homes receive the care for vulnerable seniors is going towards that care and not being siphoned off into uncapped profits unrestricted Administrative Expenses or what unlimited in the an audit to related party transactions. Lastly alternative options to Nursing Homes must be safe accessible and affordable. Families want and deserve options to Nursing Homes to provide safety in a home like setting. While most states are rightfully opening up assistedliving to medicaid beneficiaries the utter lack of federal standards unsurprisingly is too increasing reports of abuse and neglect. Her seniors and their families deserve better. Thank you again for your time and for holding this important hearing. Thank you. Mr. Banach. Chairman neil minke remmler brady and members of the committee thank you for the opportunity to testify in his hearing focusing on caring for aging americans. I want to single out congressman reed a volunteer representatives pinedo kind jaworski and others and buchanan for their strong leadership across this Palliative Care. My name is edo banach ceo of the National Hospice and Palliative Care operation founded in 1978 in the largest membership orientation for providers and professionals and people affected by endoflife illness. Each of the members include over 2000 hospice providers and Palliative Care providers that account for twothirds of those who get hospice care in this country and employ over 60,000 professionals and hundreds of thousands of volunteers. Hospice is a national treasure. It is not it has never been it shouldnt be a partisan issue. We all get sick at some point in our lives and we all die. From the beginning the hospice benefit has been bipartisan. That former senator dole and former congressman leon panetta father of mr. Bennett on this committee who were two of the bicameral leaders of the fledgling Hospice Movement on capitol hill almost 40 years ago. 19 you to this very Committee Held a hearing on the legislation that would create the medicare hospice benefit the end we have introduced and supported over 200 folks including resident bill gratis and are without their early leadership in advancing hospice to the benefit would be here today without your leadership the benefit isnt going to be working for you tomorrow. Many people in hospice provider right level of care at the right time for patience of the endoflife. At its its best hospice is everything about the Health Care System to be personcentered, compassionate. Most people assume hospice is a type of service usually delivered to people in their homes. Hospice care is for people as people. We need people and we honor veterans programs and i urge all of you to support veterans and attend a ceremony for folks in your districts. We offer much more than just hospice care for people. We also support whole communities through the Disaster Relief and assistance in the wake of 9 11 shootings in las vegas and Orlando National disasters like Hurricane Katrina and maria floods and wildfires. We care for families. We care for communities and we do much more than providing care for individuals. Half the people never get hospice. Of those who get hospice most get it for only a few days or a few weeks. We have challenges in the workforce. 10,000 people are turning 65 everyday. We have challenges in rural in underserved communities accessing hospice can be incredibly difficult. I visited a hospice in montana the surf 11 counties. We are so thankful for representatives kind and walorski for their support of federally qualified Health Centers. Above all we have to ensure patients and families to get hospice care get the best possible quality of hospice care possible. Sixers glee the oig reports with outlandish is the same as oversight of hospice and describe poor examples of character excited about working with senators portman and cardin on hospice care improvement act and look forward to working with resident representative panetta. A provider thats not fully committed to providing the best quality care should be in another line of business. Speaking of i want to spend my time echoing words of congressman sanchez talked about and this is very personal for me. I have two great aunts one who lives in richmond and one they are an example of the failure of our Health Care System. Great aunt grace was 95 she fell down her stairs she went in and out of the hospital and ended up dying in hospice care for few days preseason example of a Health Care System that requires you to be broken in order to fix you. Great aunt ruby is still at home or gse opd. She is dying but she wont accept hospice care which is my failure as well as the Health Care System failure. 911 as is her default Health Care System. We can do better to get people more interdisciplinary centered care before they declined there would be provided personcentered interdisciplinary care for people before they fall down stairs and for help and what we did without people having to give up . We offer changes a vacancy in our Health Care System and hospice itself and we look forward to discussing that with you during questions and answers. Thank you for your time. Thank you. The map received to questioning under the fiveminute rule in consistent with practice i will recognize those present the time in order of seniority. He began by recognizing myself. Dr. Lynn and mr. Blancato youve highlighted we are unprepared for aging on a series of front lawn care needs and beneficiary protections amongst others. Dr. Lynn im a longtime champion of Financial Security in retirement. You testified have americans from 65 to 74 have no Retirement Savings at all and caregivers lose hundreds of thousands of dollars in retirement for caregiving. What suggestions would you have for those of us on the committee who would address that issue . Would you please all speak into the microphone. Theres clearly going to need to be governmental action. That could be a federal backstop on the cost of longterm care. If we had a federal backstop on the cost of longterm care that means the front end, the first part of longterm care would be the government would pick up the long tail. And i think it would be possible for there to be savings plans and Insurance Schemes that would allow people to come into old age with much more preparation. I dropped my own longterm Care Insurance this year when the premium doubled. I think in the president market it is not a viable product and it could be but im sure there are other ways that Washington State is started the front end Insurance Scheme where if a worker paid for 10 years they are guaranteed up to 36,500 in front and coverage. Minnesota is considering adding the same sort of hang to medigap and m. A. Plans. I think there probably are number of ways to get more financing into the longterm care system beyond medicaid. Im very worried about medicaid being the main way to pay for longterm care. It is very difficult to administer it at the boundary. We have many more people in the income gap just about medicaid but cannot afford to pay for what they need who cant get into medicaid has a have to much income. We had an example of that earlier. That number will grow and the state that does that to be balance will probably have to restrict eligibility for medicaid overtime, or at least not wrote at the rate of population needs. We really need a vigorous comprehensive approach predicting the government is going to have to be involved. They think we are also going to have to develop strategies that end up making it possible for ordinary people to go into requirement retirement of adequate savings and was security against the cost of longterm care. Thank you and representative blancato there a number of your testimony is discuss malnutrition in older adults in this day and age said to balance their Older Americans who dont have food on their tables. What do you think we could be doing in terms of health care and medicare to ensure that our seniors have enough to eat . Mr. Chairman massachusetts is a leader. We have a great net network of nutrition providers across the state of massachusetts is one of two states with a nutrition commission. I hope i can have a summary to my statement. In addition to boston medical im proud to serve on the National Advisory board of the human natures and Resource Center which is also Important Research work in practicing food security. Going to the issue what could we do more us begin by monitoring closely Medicare Advantage is its moves into the more nonmedical Supplemental Services especially for the chronically ill. Nutrition is a key Medicare Advantage program but can cover expanded home delivered meals as well as meals in a setting in provide produce. The key will be what will they do and plan your 2021 . Its important or local connections to be made between future providers and the medicaid plan. It could be more funding streams for more meals and more food and of we should be thinking about extending to feeforservice medicare if the Medicare Advantage works well. I think we should add medical therapy senators and care service said as we talked about earlier lets move forward on a dental benefit for medicare. Poor oral health contributes to malnutrition this will continue with positive medicare covering more Preventative Services than ever before. I would also say lets determine through Data Collection how much programs like Home Delivered Meals Program save medicare and medicaid each year and file back some of those savings into communitybased programs are biting meals on a regular basis. Youve raised concerns about the quality of care that some patients are facing almost nor sing him to provide the care you describe sub standard care. Ive been working with hhs to just issue a vantage or scraping it is to cut its nursing home residents and what suggestions would you have along those lines for congress as we begin to talk about longterm Care Initiatives c thank you for asking that. The over overuse an inappropriate use of antipsychotic drugs in the resident Nursing Homes and assisted living and other settings is disgraceful frankly. Hundreds of thousands of people are affected everyday. A lot of families who talked to dont even know their loved one is receiving these drugs are they are explicitly told by caregivers not to look up the drugs on line. Its important we have informed consent and is part of Apple Congress could do is to pass an informed consent bill that would include a written consent of that provides for the residents of the families that periodic leg review and give informed consent is necessary if the drugs are to continue. Its very limited circumstances under which someone should be receiving in at the saccadic drug for any extended period of time must they have the condition of schizophrenia or another significant illness but secondly we need to require minimum staffing. I mention my testimony earlier the lack of staffing in the majority of Nursing Homes results in people not getting the care that they need and results in too many residents being given these drugs and sedatives to make them easy to care for for the convenience of staff like they are people who really need to make sure there are at least enough staff to meet the clinical needs of residents. We desperately need a new oig study and they think recognition nationally understanding over use of antipsychotic drugs in this country. Americans families of residents should be outraged. That was eight years ago. Lastly i would say enforcement. A track enforcement carefully around the country as well as the drug raid in cms when it launched socalled partnership through group Dementia Care is promised there was going to be enforcement of longstanding requirements in regards to not giving unnecessary drugs. That enforcement never happened. I thank the gentleman to let me recognize the Ranking Member. Thank you for calling this important hearing. Republicans and democrats can Work Together on the sandy talked about hospice care and how reforms developed in a bipartisan way the benefit was originally created with bringing hospice into the 21st century to address growing needs. Chairman neil and i after we in the wake of two disturbing reports detailed deficiencies in quality care delivered to some medicare hospice quote we join together to send a letter to senators to cms questioning information regarding efforts. We also agree with you drug pricing has become down in all these areas. We have to lower drug prices for patients and encourage more lifesaving cures as we do it. We have been working together as a committee on lowering those prices. That work has been set aside for h. R. 3 the drug bill which we as republicans are very concerned that it will actually. Cure especially for the diseases i had a neighbor who died at geoblastoma to two friends died of als and a neighbor once vibrant struggles with we are hoping and working for cures in these areas that are genuine worry that h. R. 3 which isnt going so much to pass the house would manage those cures and the hope for them. I was at the alzheimers walk. I try to go there every year in montgomery county. Its really inspiring. 2000 walkers and they raised a ton of money. There are 300,000 people dealing with dementia and 1 million caregivers. Its really just a great all around. I was so appreciative of being part of that and we talk about how effective your inefficacy Research Support services all the association does. My question is given the current Political Landscape which is a little rough around here do you think having bias finding a bipartisan solution to drug prices longtermcare finding that talents between lower prices and encouraging more cures how important you think that is for the alzheimers committee . C thank you for that question. I think everybody agrees a point for many diseases but certainly alzheimers as i mentioned. We certainly need to have bad innovation. Thats fully important that we make sure when those treatments are available to millions who need them have access to those treatments. Its fundamentally important that Congress Continues to focus on the set of issues and how the interlata find a solution we need in the alzheimers committee and so many others. Thank you mr. Egge. My mom come you would have enjoyed that her. She raised five of us by herself as my dad was killed when she was young. Even though living with my sister last couple of years was pretty tough come in the last few weeks especially, hospice was great. It was a great comfort for her. It was a huge help to the family. We got great care there but its regrettable to learn that many hospices have a deficiency in 2016. 20 of hospices according to the oig have serious deficiencies in cms does not have the tools in its toolbox to enforce quality of care other than simply shutting them down the tree dont want to do for seniors. Would it be helpful for congress to provide cms with additional Statutory Authority to provide remedies for that core performance short of shutting them down to ensure that seniors get that highquality of care that you deem for them to have been if so are there any intermediate remedies that would be helpful to increase that quality and eliminate those deficiencies . Thank you so much for the question congressman brady. As i said before i think one of the problems with hospices most folks dont know about until its too late. There arent enough people getting hospice care and in may of the second question and the issue talked about which is poor performing hospices. We fully support giving cms additional tools to provide better oversight of hospice. We are really focused in a couple of areas. One cms oversight, two education of hospices themselves. Thats part of the work that hp ceo does and three is information for consumers. To the consumers to be making informed decisions. Better tools for consumers additional oversight for cms and additional education which is something we can all do together i think its something we can all agree to. C thank you mr. Brady. But brady. But may recognizes a woman from georgia mr. Lewis. Thank. Thank you very much mr. Chairman for holding todays hearing and i would like to welcome and thank each and everyone of you for being here today. In particular i want to thank ms. Brown for telling us about your family. The story is a very moving one. Its unbelievable to me what you have been through. I know many people across america experience story similar to yours and i thank you for sharing your personal story. Its not easy to do. The story of care for a loved one. For your mother. Ms. Brown, we know 60 of all caregivers are women and we know low income women caregiving is associated with an increased risk of poverty. Ms. Brown is a black woman studying to be a doctor, taking out loans to care for your mother, can you share more about the challenges you face . Thank you for that wonderful introduction to your question and yes in terms of the challenges that i face in addition to the financial strain theres also the challenge of thinking about my future and having that feature put a wrist multiple times over the course of my lifetime because of the gaps in health care. Another big challenge has been with my family. All of those have made sacrifices and all of us are very concerned that we dont have a way forward. Does that help answer your question . If you would care to elaborate more. As i had mentioned in my statement most recently ive had to consider withdrawing from medical school. I think thats consideration should not be anything than anyone should have to work through especially since i have worked hard my entire life to pursue the school and hopefully to make a change. They do ask for everyone to at least think about your own children are the young people in your life whom you want to see succeed and i think we need to do more for caregivers like me. Thank you. Dr. Lynn, how could congress to ease diversion for others who are in similar circumstances . What can congress do and what can we do . Congress has authorized a firstyear of developing a Community Care core that would organize neighborhoods to help out. We only have the funding for the first year so you could appropriate it can authorize funding for the national Community Care core which would provide Infrastructure Construction and so forth, not much money but much more local innovation. We could also start supporting caregivers. The federal requirements for certification of Electronic Medical records does not require a slot for identifying the caregiver when a person is in the medical situation. Can you imagine having an electronic record that didnt identify the parents of a child and yet a dementia patient or a person with a severe disability could be in the hospital and their caregivers name and identity is not even in the record. How blind can we be . We have caregivers who have no income come who are impoverishing themselves. We have an example of impoverishment that goes down generations. He used to be that people burn their mortgage before they retired. They had a pension and Social Security and the kids got their legacy. Legacies are evaporating in longterm care. We need to have ways to protect the caregiver. Many countries give a care credit care gerber caregiver credit. We do none of that. Its as if we have plot to make it difficult to be a Family Caregiver. Very few employers give flexibility for Family Caregivers. They end up losing their jobs because they had to suddenly go home or in a got sick. We need to really acknowledge where we are in having a very large number of people who need that sort of support and the changes are in a number of ways. Many are not terribly expensive. They are confronting what it is we need to do and what would help ms. Browns situation . Obviously there ought to be away in which she didnt have to give up our future and or education nord order to take care of her mother. Thank you dr. Lynn. My time has expired. Let a recognizes the gentleman from florida and mr. Mr. Buchanan to inquire. Thank you mr. Chairman. As you mentioned this is not a democrat or republican issue. This is very much a bipartisan issue and we all understand the significance of it. I also want to thank our panel of witnesses. We have a great panel here today as you mention 10,000 people a day turn 65. I met district in sarasota the tampa bay region. 225,000 seniors. All the things we are talking about are very personal. I want to also just mention with what mrs. Sanchez brought up that it wasnt going to say anything but i thought it was appropriate she share her story. I was one of six kids, the oldest in a 33 my dad, 58 years old worked in a factory and never spent a night in the hospital imperfect health of big strong strapping guy and he found out he had alzheimers. He came out of nowhere. The family was in denial for couple of years. We addressed it and i was fortunate because i dont know what we would have done otherwise. I was fortunate financially. I took my dad with us, my wife and myself but it was tough to see Something Like that happen. I wasnt sure what alzheimers was at that time but again it was something that was devastating and thats why my heart goes out to mrs. Brown. We were more fortunate because we could provide nursing and other capabilities that i can imagine someone that is in your shoes. We need to do more to help you. Let me mention mr. Egge with you being involved with the Alzheimers Association is there anything from a prevention standpoint that i know there a lot of things you are probably looking at their earliest to diet or exercise. And others on a magic pill but are you spending much time in looking at this because some people say was type two diabetics a lot of it is lifestyle, not all of it but some of it and i was just curious from your standpoint. Thank you. Its a great question and we have seen emerging evidence that is in fact the case. Recent study was very suggested of controlling Blood Pressure in this regard. The alzheimers appreciation appreciates congresss support for funding for alzheimers to allow this research to move forward with bipartisan support. Trials are looking at just those kinds of interventions. We have evidencebased the reason im asking theres a lot of it in cola. You know what it is. Im in trouble. Let me ask you just quickly in a roundtable the other day in her area in sarasota we have a hospice there and im sure you are familiar with tide will. They provide over 1 million of their budget with a finance of themselves for tragedies locally whether National Tragedies shootings opa deaths in our area but they weigh in a big way in terms of providing families support present the case with other hospices around the country or are we just lucky to have tide well in our area . You are look at have tied will congressman buchanan. There are a number of other hospices around the country that not only provide the bear minimum conditions of participation that provide support for folks in hospice and the year after hospice provide support for their families but goes way above and beyond that. Hospice in new york got involved during and after 9 11. Hospice is in orlando and las vegas got involved during the shootings and every time a flood or wildfire for any National Disaster what ends up happening is the first to sponsors and the folks who are impacted by that disaster have a certain amount of grief that follows after the news cameras move on and they are the ones that provide support. The other thing locally they provide a lot in terms of opioids in our region. Its been an investigation but i want to touch on a 55cent 55 of people that use hospice and other things. What can we do to educate and help them and encourage them . A say that the cause of my parents passed away and my wifes parents and if it wasnt for them it would have been a lot or difficult process to get through. Some of two things. One is in term of education hospices not about giving it. Hospice is not about giving up. The second thing as changing some of the rules. It is true and people are eligible they have to make this hard choice do i continue to receive Curative Care or tolerated care instead . A should be able to get those services. Doesnt cost more money and he keeps out of the hospital and thats performing up to work on. Thank you and i yield back. C i thank the gentleman. Let me recognize the gentleman from texas. Thank you mr. Chairman thinks to each of you for your insightful testimony this morning. National Family Caregiver month is an appropriate time to have this hearing to honor millions of people out there providing caregiving at great personal cost. Ive seen estimates in my home state of texas of as many as 3. 4 million Family Caregivers that are provided over 3 billion hours of caregiving each year to secure the health and care of their loved ones. In and the highs of midlife and the lows of last caregiving can put her life on hold and when caregivers are less likely to accelerate in their careers often missing workdays are leaving the workforce altogether we know this burden is overwhelmingly on women. Economists estimate that is such a burden that it has affected the level of participation by women in the workforce. I know from the range of legislation you mentioned this morning that there is no panacea for this problem but i think one answer that is important is the legislation and they join with my colleague rosa delauro in sponsoring the family leave to the family leave act. For those who receive Long Term Care outside the home there are also obstacles within the medicare system on naxos to Skilled Nursing Skilled Nursing benefits contingent on a threeday hospital stay. Back in 2015 i have heard of bill that became law to provide notice of the patients would be aware its been placed in the status that we very much need to move beyond that. Its a great financial burden when a patient is placed in observation. Our colleague congressman joe courtney has the improving access to medicare at it legislation and a more modest measure is one that i have followed with my colleague jason smith the Medicare Home Health flexibility act. Its designed to provide access for occupational their posts because thats the initial Home Health System setting. As ms. Browns testimony indicates there is more of a problem here than just the impact on seniors near the end of their life. I think particularly those individuals who struggle with total and permanent disability. There are shortcomings in our Social Security and medicare system in this regard. A person who maybe has to go wolf the way through the appeal process to acquire Social Security disability benefits is required to wait five months before they get a dollar of those disability benefits and an explicit full two years before they access coverage. Need to correct that. Theres no justification for that giant gap. Of course assuring health care one of the most important steps this congress has taken is the Affordable Care act itself. I believe with regard to Nursing Homes what mr. Blancato and mr. Mr. Mollot address i saw a frontpage story in the san Antonio Express about identifying a number of area Nursing Homes with major deficiencies and questionable care. One of the things we have seen in Emergency Care is the increasing involvement of private equity which sometimes raises costs and is a major optical to surprise billing. What impact has it had in the nursing home area mr. Blancato . Im not completely sure of an answer. Im happy to look into the record today think what relates to that is to examine the transparency of ownership of Nursing Homes but there seems to be a growing issue with about accountability issues we need to address. Mr. Mollot or her doctor led . Thank you. The Investment Real Estate Investment Trusts and other entities have nothing to do with health care in a nursing home world has savaged the industry across the country. We are seeing that more and more with entities that buy up Nursing Homes and they have no experience in the business. They sell out the underlying property. There was a case a couple of years ago went largest change in the country sold to Investment Trusts. Something like 7. 4 billion it turned around and sold Underlying Properties for 7. 2 billion leaving 99 of the assets. As a result some of those Nursing Homes went on to other providers that werent capable of handling them. This was a multistate issue but we are seeing it and in us just one case but we are seeing it over and over again. Monies are being siphoned away from Nursing Homes. They are just being devalued and closing. C i thank the gentleman. Let me recognize the gentleman from nebraska. Spent thank you mr. Chairman thank you for all of our witnesses were here today. We are discussing very relevant issues in caring for seniors. I know we want a lot of options and i do want to reflect briefly on hospice care and a salute to every single hospice worker in america for walking alongside families during difficult journeys but celebrating life along the way. I really salute and respect all of the hospice care providers for all that they do. As we examine the various issues and options i appreciate that we can share ideas here with the legislation we are working on. Think a lot of Commonsense Solutions are out there with proposed legislation. Let me just cover a little bit here. One example home care for seniors at h. R. 2878 which provides qualified home Care Services ineligible to be covered by Health Savings accounts. I think that would give good approach but also the Rural Health Clinic modernization act h. R. 2788 which i traduced earlier this year with k. Keep Rural Health Care centers open and provide for her rural seniors. H. R. 2693 wooding kreis access to osteoporosis prevention and treatment by correcting and under reimbursed and under reimbursement issue what makes it more difficult for seniors to access the necessary screening. While these are Commonsense Solutions and can bring about immediate positive impacts its also necessary for us to think a little bit outside the box and come up with unabated solutions that can improve outcomes for seniors and help Lower Health Care costs at the same time. One billiton working on this year and hope to introduce soon as the reducing unnecessary hospitalizations for seniors act or as we call it the rush at this bill would utilize telemedicine to reduce unnecessary transfers of patients from, Skilled Nursing facilities to the emergency room unfortunately especially during nights and weekends seniors in the Skilled Nursing facilities are transferred to the emergency room due to relatively minor illness is her accident simply because theres no qualified medical trance practitioner onsite to diagnose or treat the page. This bill would reduce transfers by using telemedicine to connect the Skilled Nursing facility staff with a remote remotely located medical practitioner for diagnosis and treatment of minor issues or make the determination to transport the patient to an emergency room in a more complicated urgent scenario. We see these transfer saves money by preventing emergency room visits and improving Patient Outcomes by preventing the unnecessary stress and trauma for transfer to an already vulnerable patient. We look forward to working with my colleagues to work on these issues. I know its been referenced are ready with the aging population and many of our districts especially a district like mine where 93 nebraska counties so much of the population is concentrated in three counties. I have so many counties in my district. Some are i would call rural and others i would call remote where some are lucky to have access to hospitals. We need to look at the flexibility where and when we can and certainly telemedicine will plays an Important Role in that. Would any of you care to reflect on telemedicine and the role you see playing in the topics we are discussing . Dr. Lynn. Telemedicine offers a tremendous opportunity both in the ways you are talking about an Emergency Care and access to specialists and the kind of things that have happened out of project echo in mexico to support local doctors. We also in many areas could have a nursing home and inhome direct services to service the model of pace. A dramatic reductions they have in the use of the arts and hospitals because they have 27 24 7 care of aroundtheclock all the time with the comprehensive care plan so they know this person with referred to have the diagnosis at home. Most of the u. S. Population not necessarily they is urban or suburban and would be relatively easy to mobilize that kind of service. It may require continuity and Care Planning which we do not value in our care system at the president time. A person getting close to the end of life and should be treated at home rather than undergoing emergency room and being frightened and left alone and so one. Or a person who just had a fall in the do have an xray. He can get the xray at home. There is a lot of opportunity there that we have not use. That may call upon the gentleman from california mr. Thompson. Mr. Chairman thank you and thank you for having this hearing today. Ms. Sanchez thank you for the role you played in bringing this important matter to the forefront in tanks to all the witnesses who are here. Youve all been been an outstanding job in a particular ms. Brown thank you. What a courageous story of dedication and love and commitment. Sadly a story that you shouldnt have to tell because she shouldnt have had to have done that but you were a very impressive young woman for the role that you took. I would like to talk a little bit about hospice. I have heard from hospice in my district a lot. The one thing, the one called mckeagues coming up its Workforce Shortages. The labor shortages are a challenge to all of health care as we know. Nursing shortages, caregiver shortages and hospice is far from immune. The problem is particularly acute in the rural parts my district and im assuming that is the same across the country. Mr. Banach could you talk a little bit more about those Workforce Shortages and the effect to access to hospice care and quality of care . Thank you for the question congressman thompson. Indeed access is strained when the number of caregivers and books available to care for the population is shrinking and the population is growing. But hospice its even worse because you are not only talking about the shortage of physicians and nurses and social workers and therapists, you are talking about the shortage of all of them. They are a couple of things we can do. One involves training. The bill passed by the house would provide better training on hospice and Palliative Care and the other thing is taking a look at the pay that they provide to some of these folks. Its difficult for hospice and many care providers to compete with the packaging plan we can earn 20 an hour putting books in boxes. Its far more arduous work being a hospice aide. They think we have to make priorities in the society and prioritize caregivers, prioritize Home Health Aides and other aid to provide those services as well as providing more training to physicians and nurses and social workers. I also hear the impact that the cost of living has that speaks directly to the issue of paper that some people who are driving 90 minutes both ways just to be able to provide hospice care and afford to live. I think you are spot on. Thats especially acute in california places like that. Mr. Walorski of the same problems in Skilled Nursing facilities that we have and hospice . Well i think especially when the economy is good we see theres more pressure on health care. We see that in Nursing Homes because Nursing Homes are historically a really poor place to work. The profession of being a nurse aide is often a thankless job we have done studies that look at working conditions. Salary is important. When someone can make the same amount of money working at mcdonalds for a packaging plant than caring for a resident and they are not allowed to care for that resident. Theres so much pressure in such a bad environment that the turnover again that they will leave. Its a huge issue. C thank you. Id like to talk about Something Else another problem. My district has recently been devastated by fires over the course of the last four years. As a result we have had constituents who have had their power shut off for days on end. They just heard from a hospice in my district where the power has been shut off for a days in 30degree weather. Was so bad that they had clients who had to go sometimes with medical equipment attached to them and sit in their cars just to get warm. Its not just a california problem. I know florida has similar problems in their hurricanes. Mr. Edo banach what kinds of things in congress to do to make facilities more prepared for natural disasters . It at the National Hospice and Palliative Care organization is a foundation of provide support for hospices when disasters hit by the clearly its insufficient we look at Disaster Relief fund that are released they dont help hospices. They dont help Health Care Providers deal with the consequences of a shutdown. They dont buy the supplies that they need to supply power during a shutdown. One thing we do need to look at his prioritizing support as we see disaster seemingly every month. We see a different disaster of a different sort. We need to prioritize the flow of Disaster Relief fund to help providers keep going. Id like to talk to you offline. I would love that. I thank the gentleman. Let me recognize atonement from texas mr. Marchant. Saying thank you. This issue is beginning to affect all of us. I have an 89yearold mother and she is very appreciative of the Home Health Care that she gets and i care about the subject every sunday afternoon when i go and visit her. Over the last couple of years several of the postacute care centers have experienced a transition to a new Payment System. Cms is mostly chosen to wait for data to become available from the new models before instituting behavioral assumptions into their payment methodology. I believe Home Health Providers are being treated differently. Cms is instituting behavioral assumption rate cuts to the detriment of Home Health Providers and seniors. The elderly Medicare Beneficiaries want to receive medically Necessary Health care in their homes but may no longer have the ability to do so which with such a payment reduction to mr. Chairman with that i would ask that we look to consider h. R. 2573, the Home Health Payment innovation act. Ms. Sewell has worked tirelessly on this bill to address the patient driven groupings model behavioral assumptions in the bill would require medicare providers to ride adjustments only after home Health Behavioral changes actually occur and ensure medicare budget and limit the risk of the disruption by a new Payment System. Lastly i would like to once again asked the committee to consider h. R. 2073 appellate cosponsored with congresswoman katie porter to permanently extend the 7. 5 threshold for metal colin expense deduction for the medical expense deduction provides relief to families especially Older Americans and seniors to offset the cost of their Health Care Expenses and give it a certainty to those families is something that this committee should take up as soon as possible. Thank you mr. Chairman niall back. I thank the gentleman to let me recognize the gentleman from hartford, connecticut mr. Larson to inquire. Thank you mr. Chairman and i want to thank all of the panelists for their expert testimony. This is an extraordinarily important hearing and i commend the chairman for bringing these issues to the forefront. I also would like to thank Ranking Member brady who mentioned in his opening comments that if the seniors no longer able to manage their own Social Security benefits for Social Security administration will appoint a representative payee to help them. This program is an important part of our nations care system and in 2018 this Committee Work buy partisanly to strengthen it that i commend the Ranking Member and the work that i am proud to have participated in. If there is no family or friend available the Social Security administration will consider creditors such as Nursing Homes and assisted living facilities. Because of the conflict of interest this is supposed to be a last resort. Unfortunately we have heard testimony and prior hearings that some Nursing Homes require that they be made a resident payee. Even when relatives are available to serve as the payee. We have asked the Social Security administration to review how it selects pay including these facilities. I thank Ranking Member brady for raising the issue of Social Security representative payees. I look forward to continuing to Work Together to protect vulnerable beneficiaries including when creditors such as Nursing Homes are the payees. Without mr. Chairman i yield back. I thank the gentleman to let me recognize the gentleman from new york mr. Reed franqui. Thank you mr. Chairman and thank you for holding this hearing today as well as the comments from my colleague from california about her personal experience and for your work. As we have talked numerous times im so glad to discuss hospice care in america and how that fits into the delivery of health care for seniors and for folks as we face those years of advanced aging. What i wanted to focus on is a hospice and Palliative Care advocate and also a volunteer myself, certified volunteer who has spent time volunteering in hospice facilities and sitting and standing with families and patients of hospice care. Maybe we could touch on something that gets lost with regard to hospice and Palliative Care and that is one failure to embrace it with regards to the oz conversation i think we need to have an america about endoflife and facing those issues of death and dying in our community and not in a negative way but in a positive way. I will tell you firsthand given the experience i had from the day my mom was diagnosed with lymphoma and the day she passed my arms and hospice and Palliative Caregivers that provided a care and comfort that allowed us to enjoy those days in a very positive fashion in her own home and in her own bed. Maybe if you could talk a little bit about how hospice and Palliative Care should not be viewed in sometimes a negative way but the positive impact it has on the quality of life of patients receiving that care and how their lives are improved by having the ability to control how they are going to exit this world but also family and loved ones in how they are going to spend time in a quality fashion. Could you offer insights as to why hospice and Palliative Care should be viewed in a positive light . Thank you congressman reed and thank you for your leadership around the Senior Leadership around achieving other legislation. There are two issues that we are talking about here. One is structural and one is educational. The structural issue is when we talk to people we say look we have this great benefit for you that provides all the services that the rest of medicare doesnt. You can get a nurse. He nurse. You can get a social worker and you can get a chaplain. You have to give up Curative Care in order to get it and the people here that they say you know what im not ready for it. My greater rupees in that situation but i think we should remove that barrier in order to remove the stigma but the other part is that we end up having these conversations about what peoples wishes are way too late. If we had the much earlier this is about choice. This is about what kind of care oaks want to get so the right time to educate folks around the hospice and advanced illness care is before they are in a position of an advanced illness and require hospice. People are more open to have a conversation at that point i think removing the stigma and removing some of the barriers that exist in the legislation i think would help get people into hospice earlier. I think we should actually create a benefit to perceive hospice so folks get some version of interdisciplinary care. Is that assessment accurate quick. I cannot speak to the savings but i can tell you they would be considerable but you are light loan right moral if you want them to have choice or agency over the care they will get everybody who gets onto medicare should have a welcome to medicare physical a part of that conversation should be what are your wishes and again if you have that conversation with people that are healthy getting onto medicare and normalizes that conversation so it doesnt happen during a crisis later. Absolutely. I think one of the most encouraging hearings we have had i appreciate you putting a human face on this with your leadership and i think to help us move this along. It is long overdue and i appreciate it. Ms. Brown you are proof of what the doctor said we are evaporating or as the legacy evaporates because of longterm care. And simple common sense. And value on talking to patients and their families with their needs were we have a long way to go. We will be able to continue a bipartisan dialogue. To deal with specific steps that will make a difference for families and caregivers to save taxpayer dollars. We pay so much on failure with wasted money and wasted lives. Doctor, you have discussed the program and that enables people to get more out of the resources and to be focusing on one area that we think for middle and low income expressive part d premium cost to make it unaffordable 800 a month or more to either using the standalone marketplace for part d. We have legislation focused on this to try to help this tiny adjustment to make such a difference in peoples lives. I understand the pace program submitted a waiver request and they were denied the waiver request with a statutory prohibition. Can you elaborate quick. We submitted the waiver twice the first time they said it was a Statutory Authority. The issue is the part d statute came into place after the pay statute that requires there to be no copays or deductibles. Part d turns on there being copays and deductibles. And then to do all the Wraparound Services. And then those Wraparound Services would cost more compared to copays and deductibles because at the present time medicare only beneficiaries cannot access anything from part d. Thank you. I hope we can clear up that ambiguity. Thank you all for being here. All of us at some point in our life look whats going on with our seniors and how we will handle this as my mother was getting older she said one thing we dont want to be is a burden on your brothers and sisters i thought that was unusual someone that dedicated their whole life to raise us was worried about being a burden so its good to hear from you. So we get involved in the feelings of all of this and where do we get the revenues is it a Government Program or the patient quex so who exactly i think chairman brady was talking about the things that we look at and where we are coming up shor short. I have constituents in erie pennsylvania working in these facilities they have five facilities in pennsylvania so i talked to mark i have been to the homes its good for all of us to see what is going on in these homes and how the people we are most concerned about are handling it. One thing i like is that they have a robust procedure for the actual people have a chance to interact and to see where they come up short so there is a satisfaction to making sure they are taking care of. All of you do this for you have a great deal of background and depth of how we should handle it. And then to seem okay and he started to cry and said i am 86 now my wife has alzheimers im her primary caregiver. Went to the store when i came home she was not there. And i was panicked trying to figure out where she had gone then the neighbor said she was walking down the street we got her and brought her home she is here. He said im just so upset about this and he said but people know my wife is going to something but they have no idea what im going through. And that is what comes down to how we help those who we want you are helping others. We keep looking to the government to come up with an answer instead of the people that we serve. So if you can, i know we have very limited time we have so much legislation out there but to have a Sustainable Business model with some ideas. We did an analysis how much could be pulled from the system with that era of substantial innovation and look at erie pennsylvania to figure how to provide excellent care like having homecare entities work in a Geographic Area so to work on culture change and Nursing Homes but we need examples that pull us back we have tremendous amount of money going into this population that just goes in and all the wrong ways. I could get 100,000 drugs at the sweep of my pen and that is wrong in the fact we develop a system that does not allow people to make savings for their own future or creates barriers like her mother didnt work 40 quarters. That doesnt mean the family has to sink into poverty. We build around that idea people died abruptly from strokes the average age was 68 was very uncommon to make it to the eighties and nineties but now that is commonplace. We need to redesign and in order to do that we need a few years of substantial innovation instead of having trivial little things. They are important but also the more fundamental stuff to the end of the 21st century without bankrupting and watching a lot of people die from no food and housing. And we need to step forward and say we will take this on we need to support it and free them from regulations why in the heck cant medicare get into pace . Why cant a mother get medicaid we put a rule in place everybody here tells a story and says we are lucky know we are just lucky. The point is not have to be lucky to get a fair deal in this country. Its no onesizefitsall if we actually allow the people who are serving to have the input. Thank you for what you have done for your mom you are a great example of what family means i yield back. I recognize the gentleman from wisconsin. Thank you for your testimony today thank you for this hearing we are just scratching the surface on such an overwhelmingly important issue and also ms. Sanchez for her point of focus to share her own personal testimony impacting millions of families and with all these baby boomers retiring its at her doorstep another issue that we also need to be promoting to a much greater extent is advance directives i have seen how well this works with my own Health Care Provider and the respective Choices Program and having these conversations my whole family has them on record even my children talking to them at an early age knowing what people are expecting with longterm Health Care Needs can go a long way to define these solutions thank you for your support for the hospice act we are trying to move this forward in a bipartisan fashion its not in the medicare reimbursement system it would allow the qualified Health Centers to receive for the hospice attending physician over 24 million americans use these qualified Health Centers every year so hopefully with the support of the committee we look forward to working with you and doctor thank you for the passion you brought to your testimony you talked about the cost of longterm care i am living this with my own parents or 90 years old right now my dad paid into a longterm Health Care Policy over 30 years checking the boxes now hes in a facility to make sure he qualifies and now its only a fraction of the overall cost. So with the state of the marketplace it seems like longterm care policies are failing but because of ever rising premiums and they make these difficult decisions do i still write that monthly check or let the policy lap . Is difficult to see what that care will look like. Do you have thoughts on the longterm care marketplace . It is dead except for those few that have a fairly decent shake it is the only huge risk we do not insure for and you cannot tell today if you will have 20 years of longterm care or not. It just so happens although it is pretty rare people have none frailty still takes a few years of selfcare disability before you die so we really need to create the possibility to have products that work that could be governmentsponsored like in Washington State something that were willing to buy like a medigap policy or freestanding policies but then the huge risk has to be born somewhere else we cannot create a market of three days or 30 years. A first are working in nursing the person who had a stroke was before i was born. We have to get that kind of risk into a pool. You put your finger on it right now it is mainly the individual or the family and they bear the risk for all of this so the spreading of that risk is the only way you mentioned in your Opening Statement with the Tax Credit Program we will watch that with intense interest but also talk about the failure of metal one medicare we took a run at under the Affordable Care act we couldnt get the numbers to work but you still think there is hope with medicare to work on this quick. I would like to think so and one of the approaches we are thinking out is to get people in the door the people are concerned about larger questions down the road with communitybased care that it has to be much more consumer input into these longterm Care Insurance plans. Thank you to the witnesses for being here. Theres nothing i take more seriously than helping my constituents navigate the problems working with the federal government, their healthcare and as ive told the members of this committee before the number one problem i hear is access to healthcare just last week we received a call from a hospital about a veteran who was dying. The hospital was attempting to get him into hospice care. It was 3 30 p. M. On a friday afternoon we call the number of contacts trying to help this gentleman. The hospital permitted him to stay over the weekend. Unfortunately monday morning he died never receiving his hospice care. So as you know in your testimony the average length of stay in hospice care is 18 days with timelines this short its crucial they are fully staffed and able to treat every single patient otherwise patients will die before they have access to hospice care while problems with the v. A. Health system are outside of our jurisdiction in this case the root cause of the wide spread problem for our entire nation facing a crippling shortage of Healthcare Providers as of september 1. 1 million Healthcare Social Service jobs openings if we do not do something this problem will grow putting up solutions to the Workforce Shortage but these misguided proposals will cost our country billions of dollars and sadly no impact to fill the gap or the unmet market needed rule america in the hospice industry alone the cost to train medical professionals in Palliative Care is not enough to ensure aging americans have quality care current estimate show there is no more than 1 percent growth in Palliative Care in the workforce in the next 20 years while the number of people eligible for Palliative Care will increase by over 20 percent of our population is getting older my parents generation will all reach the age of 65 by 2030. We must address the shortages in the Healthcare Workforce because demand for highquality care will only increase. What do you see in Workforce Needs how do you characterize the gap of trained professionals with the needs of the elderly was serious and chronic illnesses and how does it affect hospice . Thank you for your question. The start of the law the house past and thank you for that to provide better education and training but it is a drop in the bucket and not enough we do have a change in priorities there are plenty of investments going to inpatient settings and hospitals but there is very little investment of training of workers so part of it is take a look at our priorities and shift those resources to where people dont want to be and dont want to die and where they do want to be in want to die hospice is acute not to get hospice care is partially not having enough people to care but also rules one hospice doesnt want to take a patient sometimes its the product of we dont know if they are ready if we take them and that the government says you should not have taken them we need to change that as well but also provide a path for those who are not ready for hospice that want care at an earlier benefit the pin here is we honor veterans programs we are very proud of and could have helped more in this situation but the idea if they cant get access to hospice care is appalling and we want to work on that. We will now proceed with our two democrats and then republican. Thank you mister chairman all of our guests have been terrific specifically mister brown thank you for telling us your life story the real story in thank you congresswoman for your propelling story as well. And thank you for helping to get this in front of us the aging population is growing tremendously. We all agreed to that the number of americans age 65 and older is predicted to nearly double from 52 million in 2018 to 95 million in 2060. And at 65 and Older Age Group share population will rise from 16 percent to 23 percent that is critical for where we are going the gentleman from and should address it as to the priority but the aging population and that is extraordinarily expensive how much it cost per month they almost begin to match each other. These costs can be even higher depending on the level of care needed. Thank you for the work that you do is National Coordinator of elder justice. Basso were looking for. So you have highlighted in your testimony that accurate data is key to inform consumers through the cms website how can cms improve data, audits and enforcement measures so consumers can make an educated decision on longterm care options . Families are thrown into the no go zone they dont know where to go or who to call on. How can we be sure thats accurate . Thank you for the question. In response to that story very recently cms took a step to now place an icon on their website so you could see that to place somebody in that facility that was seen as an important first step but until you reach the point doing regular audits you are missing the boat. When we send our kids to school we want a report that you have to have a report on fire safety and they get out of their building or out of their dorms. We have federal legislation for that, Bipartisan Legislation at that. How about the legislation to deal with this problem quick. In the next few weeks the reauthorization which will come to the committee for review and there are proposals how to deal with issues around auditing and i look forward to see if we can get the strongest possible language on behalf of consumers. In 2016 hospital readmission rates was a little over 17 percent for medicare patients. It is nearly twice as high as those of private insurance. Taken together elder abuse cost a billion dollars per year. So not only have a sustainable system and then to have a sustainable review of its working or how its working because i know of the abuse of many of these residences we are talking about. Your time has expired. Now we move to the gentle man from illinois. Thank you. I want to commend you for those with the tearing to take place in all of the witnesses for participating with us today. I seriously believe you can measure the greatness of a society about how well it treats its old, its young , and how well it treats those who have difficulty caring for themselves. We heard a great deal about the personal sacrifices of individuals like ms. Brown caring for her mother but unfortunately many people are under care to become the caregivers that we need do to those circumstances or the inability of resources caregivers may be Family Members, friends , professionals, social workers, members of the clergy to provide care at home or in an institutional setting. The unpaid assistance for those who cannot care for themselves it is estimated 34 Million People ages 18 and older for those with all kinds of Health Issues right in their own community. According to the Family Caregiver alliance they reported the value of this unpaid labor force is estimated to be 306 billion annually. Nearly double the combined cost of Home Healthcare and nursing home care 115 billion. Many analysts have reported Family Members and loved ones provide care to individuals with chronic conditions and they themselves are at risk of physical and Mental Health disorder. Went way to age an american to have access to paid the four caregivers to hardworking americans to make a false choice but we all know taking care of a loved one facing a Serious Health condition is not a choic choice. It is a responsibility. You do what you have to do. My Congressional District is one of the highest percentages of children being cared for by their grandparents followed closely by two other chicago area districts in the Africanamerican Community extended family of aunties and cousins and friends are kinship caregivers in addition to grandparents. Thats why we held hearings on the need of paid family medical leave both in my subcommittee and work and Family Support and then in the full committee. Doctor, when you talk about the lack of flexibility employers give to Family Caregivers, and the way it causes them to take unpaid leave and retire early, i was reminded one of my constituents who testified at the subCommittee Hearing caring for her friends son and had to give up a good job that paid better because it didnt provide enough flexibility to accommodate caregiving and she worries every day about her own health and how her family would get by if she could not work. Doctor, how does this kind of access help relieve some of the problem with leave . We certainly need to find ways to provide the for caregivers like medical Care Insurance and Social Security are working full time taking care of somebody. Caregivers get the short shift in the kinds of things you talk about ought to be on the table with a package to make it work and we havent. Caregivers are invisible in the system they vanish from work and go into poverty and nobody notices or cares. Its important for us to speak up on speak up on behalf of all of us. I yelled back. I also went to think the Witnesses Today for your valuable testimony to share your stories its a great opportunity to raise awareness as most of us know the month of november is alzheimers Awareness Month and last week in my district i got together in bloomington illinois with a group from illinois chapter of the Alzheimers Association. Around the table we had a robust discussion with caregivers and doctors and Family Members on this issue. One of the issues highlighted for me in that discussion was the hard work and dedication and the sacrifice it takes to be a caregiver. We got to specifics one of the overarching issues was the lack of a uniform diagnosis tool and lack of education that we have in medicare to have a coordinated treatment plan for the patient and caregiver. Twelve oh we already have in medicare is the annual wellness visit the percentage of the medicare patients as that increases for alzheimers they can work with the beneficiary to have a personalized prevention plan for alzheimers or dementia one aspect is the assessment of Cognitive Impairment catching the earliest critical thats why im proud to cosponsor to maximize the value of the medicare annual wellness visit to catch signs early other provisions testing for Cognitive Impairment during the wellness visit and progression of future visits to make sure more advanced screenings. Thank you for your testimony and as you know medicare began was not planning appointments for individuals and back in 2017 this allowed new individuals and caregivers to learn about medical and nonmedical treatments in Clinical Trials and support Services Available in our communities. Unfortunately that utilization rate is low. The annual wellness visit is underutilized among beneficiaries. So how do you think we can increase the publics awareness of these services and how can they be enhanced to provide the most value to the medicare population . In a district like mine i have 19 countries one counties it is rural we heard how do we get the word out and communicate and advocate to those rural areas. Thank you for the question. And everything you said i could not agree more the importance of Early Detection diagnosis is critical. It is a misunderstanding how important that is and what can be done when that diagnosis takes place which is lacking thats why we have focused so much attention to make sure this benefit that you have mentioned that people are aware and make the connections we know can be made such as training for caregivers in connection to what already exist. It is a linchpin moment for everybody in dementia and their caregivers perk on thats why it makes that linkage between Early Detection diagnosis with a Healthcare Provider to those services that exist that should be strengthened but they are there. First i want to take a moment to recognize myself working over the past few months with dhs to address Patient Safety issues and longterm care the Ranking Member and i wrote the hospice areas in the recent Inspector General report we have written a number of letters talking to Medicaid Services to take more aggressive action of overprescribing antipsychotics to those with dementia yet we know they are still being prescribed excessively without objection i would like to submit these for the record i recognize the gentle lady from california. Thank you to our witnesses for your testimony today. Earlier in my remarks mention policies to improve the lives of patients and caregivers and thats why im proud to have introduced the concentrating on high value alzheimers needs which is known as the change act it is a bicameral bill to give providers the tools they need to diagnose alzheimers at the earliest stages we know it often goes under detected for many years and its typically not detected until very late in the cycle and in communities of color and women face higher risk of the disease of barriers to treatment and research its one of the areas we can focus to allow patients to be referred for additional testing for communitybased services and trials as well. I want to shift and talk about caregivers because they do an incredible job under trying circumstances tell us of the needs of the individuals and what more needs to be done to help the population of caregivers . Some of those unique needs surround the evolving nature for somebody who deals with this feels they have it handled how it is unfolding you may know intellectually it will change because it could and thats why its so important to have trading for caregivers in particular they can identify whats likely to happen, how that will necessary necessitate changes when they know what services are available. And then to interpret behaviors especially as communication becomes more difficult than that leads placing into a nursing home if the person centered approach to understand what is driving those behaviors. Another piece of legislation is the credit for care act which would provide much needed tax credit for caregivers with many missed opportunities because of the responsibility to provide support and trying to relieve just a little bit of the burden financially. I really cant thank you enough for sharing your powerful story and while the hearing seems to be focused on older american caregivers you definitely deserve our attention and support. Interested in hearing from you talk about possibly leaving the study of medicine because of your caregiving burden. Like to focus on what were the missed opportunities you experienced as a result to be a caregiver for your mother . Thank you for that question. Yes some of the missed opportunities included educational goals at high school i knew i would not graduate despite working very hard so the opportunity to be a young person i missed prom i didnt spend time with friends very much growing up in that is unfair for a young adult caregiver or even a child to have to sacrifice so that in addition to the Educational Opportunities are the most striking sacrifices i have made. And those Educational Opportunities have impacted your financial opportunities . In some ways i have Student Loans to pay my mothers mortgage i take out more than i need to. I do have concerns of my future Financial Stability program hopefully i can complete medical school this year and become a doctor to carve out a financial path for myself thats a huge barrier and something i worry about. Thank you for sharing your story i yield back. I recognize the woman the gentle lady from Washington State. Thank you tour witnesses for joining us today and ms. Brown thank you for sharing your story. In my state of washington we passed the new longterm care trust act i believe are the first state in the country to do so so washington residents will have payroll tax and the return by 2025 they will receive support services actuaries estimate the benefit will save the state Medicaid Program for Million Dollars by 2052 hawaii and california are also in planning stages of similar benefits. Doctor can you talk about how the federal government helps the state efforts with those Long Term Support for beneficiaries . If the states are under the gun and the cost of medicaid is eating their budget summer doing very Creative Things Washington State has not only done that but also has a very vibrant data analytic capability growing that most states do not yet have. There are innovations in minnesota to try to put some cost into medigap and Medicare Advantage. Hawaii has a proposal to support caregivers. We need to encourage the states to do these things so there ought to be a way to interface with the sorts of things at the federal level to have more federal involvement not every state can do what Washington State has done or be inclined to but some will in some will do Creative Things it would be good if the cmm i offered to recruit states that are willing to have some community in their states with the care system of the future to meet the business requirements that you speak of then we could have the vibrant laboratory to teach us and we could say this is where we go to where is this being done right in the country . There are places in other countries but nobody believes them. So we need to build them and then celebrate them so Washington State we need to nail a group in hhs to have a responsibility and to generate the energy to have much more aggressive things we really only have a short time before we have so many people. I was in Washington State recently and then there was a poll done with the work voters 18 through 34 behind the long care trust act that intergenerational of a viable longterm care plan and the other part thats important with those savings thats how the country needs to get if we can accomplish through services and support against medicare or Medicaid Program and to be better off. Is states do then what is the impact on medicare quex that is being covered through Washington State. And it will benefit from this sort of thing. And to get that support that is essential into people doing well so medicare will benefit and when medicare says they do total cost of care it is absolutely maddening they dont tell longterm care costs to medicaid or to the family and the family takes it on the chin. And then to figure how to make a viable arrangement for the whole society. You know this is one of my personal fixation i get teased by the chairman is one of the few times why do you laugh at my charts . [laughter] this is a big deal but its even bigger it is Retirement Security and endoflife. States like arizona that have tried very hard what we like to refer to as living wills and advanced directives and the dual eligible population with that optimism with the 4 million baby boomers when we talk about National Debt it is substantially driven by a demographic. And looking at the National Debt growth it is the benefits that are earned from the baby boomers but also we are not the only country to go through Something Like this. So first to ask for optimism and creativity i have a series of articles we have been collecting the wall street journal recently that baby boomers prefer to stay home. And then to provide services for seniors to stay at home. Some concept with ridesharing and meals on wheels. And that consolidation of the data for outreach to seniors that choose to stay home with those that see adoption of technology or consolidation of these resources. Yes there are many startups to go into the aging market thats where the excitement rest. And with those aging services and programs with the private sector it is tremendous cause for optimism. Can you be more specific . Do you see anything that is specific in your optimism . This hearing. People are beginning to take notice. It is the kinds of things you are talking about like robots with japan and those that are much more efficient but we need the focus to get that done. We are working on this. I think those demographics will have less money to go around we have to be smarter the fact is we are spending a lot of money and we have to shift some of that with caregivers to provide support in the community. I am encouraged by amazon getting into this space to provide services and support to their employees. Is not only the government but also private industry that says our employees are spending way too much time away from their desks dealing with these issues we have to provide some support so they can be more productive. Do you remember a couple weeks ago when i showed the board of a pill dispenser to make sure somebody at home may have forgetful issues is taking the right combination at the right time. We had an additional study and it was stunning because individuals are not taking properly their pharmaceuticals. That Simple Machine is a pill dispenser at certain times there was only one little tiny cog in the wheel. This is incredibly human telling the stories like in maine they cannot find enough workers in the nursing facilities and are shutting down because they dont have enough labor that is just a demographic. It is only a small part. How do we entertain that. This topic is so important to me once vibrant person that was so happy in her late eighties when she developed dementia at first she would ask questions repeatedly not only that we had answered and then she stopped smiling and finally she stopped recognizing us, her children. But even if your parents dont recognize you so i like to address this youre one of the only developed countries in the World Without paid family leave and it is not paid and to take off time from work now my state of california does have paid family leave and it has worked well. But without that so many are left in the lurch. And for economic stability for retirement to lead to Better Health outcomes. We do have a bill called the family act 199 cosponsors in those groups that support the bill to provide 12 weeks of partial income. And those with Serious Health conditions so do you think it is a useful tool to help caregivers provide to loved ones . Im happy to hear about this act if you think especially for young women that have 20 percent of their lifetime earnings to care for a Family Member and then to stay in their jobs nobody can predict a loved ones course. And those that are supported to be caregivers. Yes of course we need to do this its amazing how difficult it has been. It would not have helped you from the time you are drawn into it. And those small businesses. And then to but as a springboar springboard. I was so dismayed to see the numerous violations that one facility in my district failed to use clean kitchen items to serve patients. Another failed when giving patients medication. Patients medication. Thank you for that question because theres so much that can be done and this affects people in the nursing home for longterm care as well as shortterm rehab. It really does impact everyone. Most importantly, as i mentioned in my testimony, we have really strong standards based upon their birth form. At least for now. The problem is those are not enforced. So the state they are essentially contract ds of cms for enforcement. But they have no Quality Assurance to make sure the states are doing a good job. So what we could do, congress and certainly cms is to make the state do a better job. They are actually regional jobs at cms around the country whose sole role is to make sure the states are doing what we are paying them to do, which is protect our residents. And they just do not do it. Thank you. We recognize the gentle lady from indiana. Thank you, mr. Chairman and thank you to our panel here today. You know if it was possible and i would get congressional honor. I would honor every hospice worker, every federally qualified Health Clinic that serves the people of this country. I cannot say enough about those services in my district. Unsung heroes for sure. Workforce issues, lack of pools of people to hire and train, and those kinds of things. But i just want to thank all of you for being here, for representing those groups. I do believe that preserving medicare is a priority. I do believe we have to honor our promises to the American People and to ensure that those who have worked their entire lives to earn their Social Security and medicare benefits can utilize those programs during their retirement years. It is also important that we strengthen those programs they remain available to future generations. I have been working on my colleagues for bipartisan solution as well, to support Older Americans in communities across the country and help them leave lead healthy in healthy lives. Some of the bills of already talked about and heard about, but the rural access to hospital act, which insures patients in Rural Communities can receive hospice care from their hot primary hair care provider. The home care for seniors act would help seniors access the care they need allowing them to use hsas for Home Healthcare. That beneficiary enrollment notification and eligibility simplification act which would simplify the Medicare Part b process and help prevent lifetime light enrollment penalties. The improving hope for alzheimers acts which builds on the hope for alzheimers act by requiring department of health and Human Services to inform Healthcare Providers about Care Planning benefits available through medicare, and hr 2693, build a help Medicare Beneficiaries with osteoporosis by updating reimbursements for exams that are used to identifying and treating osteoporosis in atrisk seniors. I also worked with congress and cms administrator on finalizing the rule for the programs for allinclusive care for the elderly or the pace program. Which gives more flexibility for pace organizations interdisciplinary teams, and allows certain nonphysician for primary care providers to offer services. And i do look forward to continuing to work with my colleagues on initiatives to lower costs and to improve access to care and services. So more seniors can enjoy quality of life. Mr. Manning thank you for joining us here. I appreciate listening to testimony. I mention the world access to hospice which i introduced as my colleague mr. Kind. Can you explain to the committee the statutory barrier that currently prevents hospice patients from seeing their attending physician, thats what the federally qualified Healthcare Center and how that hinders a patients quality of life will there at hospice . Thank you congressman for your leadership on this. Folks to get their primary care through a Rural Health Clinic or call fight Health Center are forced to make a really hard decision. Keep your doctor, and stay with the Rural Health Clinic and stay with the federally qualified Health Center or choose hospice. But you cant keep both ear doctor and hospice of the same time. Which is insane. Its a bit like the choice we make folks go through and choosing hospice to begin with. Dry went to hospice or drawing Curative Care also . With this bill would do is to remove that barrier. Youd keep your doctor and they would be attending physician and hospice which is a great step forward. Thank you. I appreciate that, doctor lynn i wonder thank you for your work. Like you i am a huge fan of the pace program. Especially after visiting a facility in my district last year realizing though, not a lot of my colleagues have the pace program in their districts. So can you explain to them the innovative ways they provide services and care to seniors with complex healthcare needs, number one. And you have any recommendation on how we can expand this healthcare across the country queen mark. Pace is marvelous for a set price they provide everything but housing. For people who are sick enough into be disabled enough to be in Nursing Homes. So its a very disabled population and their record and keeping people at home, and supported, and safe, is remarkable. Almost no one leaves pace once theyre in pace. Pace is effectively barred to medicare only people for reasons we talked about before. Part d has a bizarre regulation requiring that you buy the pace part d plan, which is medicare only person sees from going roughly 50 to over thousand dollars a month. So nobody will do that. We need to fix that. We need to probably allow there to be some pay services, head of nursing home eligibility. Course eligibility varies by state. Many people need that comprehensive service for maybe six weeks after hospitalization. I have to cut off right there and i appreciated by yield back my time. Thank you gentle lady without objection i wish to include those statements and have them entered into the statements. She will submit in writing. But that the have the gentle lady from wisconsin. Thank you so much mr. Chairman and i want to thank all their witnesses for their patients. This is been a very long morning. I just want to say to ms. Brown, please dont drop out of medical school. I am almost prepared, i will contribute to your gofundme page, im almost ready to volunteer one of our colleagues, a couple of them from colorado to try to figure out whats called the lutherans call, its the catholics, the jews, the naacp, everybody. To find people to help you deal with your mom she would not be pleased if you dropped out of medical school. I am sure. As a grandmother and greatgrandmother im speaking for her as well. I would think all of you all professionals for being here today, i really think you have all pointed out that there is no way that the government, the people can afford longterm care. Not at this. And the uptake of longterm Care Insurance has been something that the majority of the population has taken on to the extent that its going to get rid of the social problem that it creates. I am from wisconsin, and for long periods of time, wisconsin had the largest number of people who were institutionalized and not being able to stay at home. So a couple of things, i guess i would love to see you address. First of all, just to talk a little bit more about the proposed cuts in medicaid, that this administration is proposing in my state. It would mean 21. Day. Person, cutting and care. The extent to which that would complicate the shortage of workers, lack of workers, and what we got to do in regard to that. And i guess, the next thing i would love for you guys to weigh in, i have an earned income tax credit proposal that would actually provide the earned income tax credit to caregivers. To sort of meets some of the expenses of people who actually can keep their loved ones at home. So would you please lean in on that. Thank you. Medicaid payment in most states is so marginal that any reduction means they are just not going to have the workers that you need. As recently in a city in ohio that has 250 people already assessed to need inhome care. And they cannot fill that need because they cant hire the people. The workforce is just not there. And they are not there at 1180 an hour. And the medicaid reimbursement rate makes it impossible for an agency to provide more than 11. 80. Hour which is you are stuck between iraq and a hard place. Those 250 people are waiting for a calamity which will get them in a hospital, which will then get them into a nursing home under medicaid. Thats a disastrous way to proceed. As designed by the devil. So yes, we really must watch for the cuts in medicaid, we have to look for ways for which people who are working as frontline aides get a living wage. Your issue on the tax credits for caregivers, is a very small step in the right direction. As sort like the previous question about having something of a family leave payments. Its a small step in the right direction. It acknowledges the importance, but it also will not really help longterm situations like ms. Browns situation. Which is what is becoming standard. Remember the average person now, just look around the room the average person will have two years of selfcare disability requiring somebody elses help all the time, every day. If you dont happen to have six or Seven Brothers or sisters or spouse who is still able to take care of you, you are in a spot. So we need these small steps, we need to do those and do them quickly. We also need to address the longerterm issues. If i may just add to that, i just want to speak to the idea of having that tax credit for caregivers. I think that is a step in the right direction, but i do think that it doesnt solve the greater issue. Because that only puts more burden on caregivers to do an already impossible task. So i think it would be helpful down the line, i think what we need is more support and more services to be able to hire trained professionals to care for our loved one so that caregivers can have freedom and Financial Stability going forward. Thank you. Thank you gentle lady with that i recognize the gentleman from pennsylvania. Thank you, mr. Chairman. Mr. Chairman, i too would like to join my great colleague from the state of wisconsin enjoying her effort with ms. Brown in any way from the city of philadelphia brotherly love and sisterly affection and would like to join in anyway have a guy can be of help. But what im asking ms. Brown, which like to see congress do to address this issue . You have a chance to tell us what you would like to see us do to address this issue. Yes thank you for that question. As i mentioned in my testimony i think we need to take a few steps going forward, the first is we need to address these gaps. There many families like mine that are falling through the crooks because they are middleaged and middle income, not qualifying for medicaid, medicare, or Social Security disability insurance. I think we can start by expanding medicaid such that individuals with disabilities are receiving the care that they need. We can do that by taking the cut off we have so that it reflects the cost of care. Because no one should have to spend more than their income, have their children go into debt, and missed school, and not have a future just to meet these basic needs. I also do think we need to have a greater investment at home and community resources. Families like mine, many seniors as well deserve to live in their homes and have a happy and healthy life there. I do think that given the cost of home and communitybased services, specifically homecare through agencies, thats less than a nursing home, so i do think that it could be a very safe and more affordable option. And of course i think the greater support for caregivers overall so the family in the medical leave act, giving paid time off as well as perhaps having universities and workplaces give additional stipends to caregivers who might still be sacrificing a lot of their Financial Stability and their earnings to help their Family Members. Thank you. Doctor lynn, one of the most pressing issues i can think of when it comes to healthcare is the issue of inequality and in terms of access and treatment. My district district in philadelphia is a poverty rate of 20 which is something that affects people throughout the course of their lifetime often because of a lack of opportunity and resources. Like healthy food, good schools, affordable housing, wellpaying jobs. We live in a world with unfortunately your zip code can be a strong factor in determining your life expectancy. This is this definitely true as we look at the aging population. We face difficult finding care, affordable housing, and Home Delivery foods. We depend on limited Retirement Savings, they could not possibly physically or mentally live by themselves as they get older. Doctor lynn how can we work to make sure all older adults, regarding that of their background can access the quality they need . This really goes to the huge and growing gap in income for all disadvantage groups. Which adds up over a lifetime. Mr. Brown will have to pay off all of those debts. So she will start way behind somebody who comes out without the debts. The average black head of household that retirement has one seventh of what the average white head of household has a retirement. Because disadvantage has accumulated over a lifetime. We really need to be attentive to this inequity. But at the present time, medical care and longterm care, very poor, at least heathers safety net of medicaid. Its a people just above medicaid that have really put in a bad spot. Some states have developed ways in which home and Community Based services can be provided with a partial payment by the person. So if your income is low to hi, as your mother says, she might have been asked to pay half of that income and in the rest he picked up by medicaid. Most states just have a cliff. If you make 1 dollar more than with the medicaid edge ability is, the only way medicaid will help you is to move into a nursing home whereby all of your income is compensated except maybe 50 a month. That is a really cruel choice. To go into a nursing home at 30 or 40 years old and have no income beyond a little bit of pin money from their forward until you die. So people try very hard to resist that. We need to have these sort of sliding scales approaches, we also need to have fair equity during lifetimes. In fact, we have to have a vibrant economy to support an aging population. So the fact that we dont invest in children, actually ends up at crippling our ability to support the people in your community. We need to be not incarcerating nearly half of black young men. We need to be investing in children. Thanks the gentleman we recognize the gentleman from texas. Thank you, mr. Chairman, thanks for holding the hearing, this is very, very important to everybody up here, i can assure you. And thank each of the panelists for your insights and your commitment to our aging population. Our fellow senior americans and ive got a tremendous number of seniors in my district in west texas. We have some unique challenges being in a majority rural region of texas. I am listening and learning, ive got a lot to learn quite frankly on this subject in quite candor. I just returned from my last workweek, and i spent some time in a nursing facility called silver spring. And i was reminded what a treasure our seniors are. I feel like often we push them out of sight, out of mind. They are part of the forgotten community in this country. And they have so much to offer. I mean i left that place, happier, and in a better state of mind just having been around them. There was a lady who was holding a hymnal with one hand because she had to bring it so close to read it, and was playing the piano with the other. And she could play any song in that hymnal and we sang together and we prayed together. There is just a special, something about our seniors. We need to honor them. Thats the bottom line for me, we need to honor them. This is squarely in the mission of the federal government in the sense that we need to provide for the general welfare of the public. This is a public good. And its the right thing to do. Now the question is how do we do it right . These programs are not sustainable. We talk about Medicare Trust funds, Social Security trust fund, will look at the total ecosystem, the safety nets for seniors. They are not sustainable and we all know that. But at the same time, neither is our fiscal condition for this great country. 23trillion in debt, and i know you guys care about the next generation of seniors and americans, not just our seniors, right . So we have to figure out how to solve this problem while not breaking the back of this country. And putting more deferred taxes, because thats with a 23 trillion is its a deferred tax. Someone is going to pay it. We may not, but our children are. And i havent been to one hearing where we just had children and grandchildren out there were you are. Saying please, please lead me the same freedoms and opportunities that you guys had. Please. Its just so easy to fix problems, its easy to find the ways to fix problems without consideration for the memes of how to do it. I know thats our challenge, and not necessarily something weve asked you to consider. But i want to put that out there, because we dont talk about it enough. And thats the biggest challenge. What tradeoffs . I would love for you to address that. I fell again preaching up here. First of all hospice is one of those places that actually sort of provides that supports and provides dignity. It divides chaplain services, but i think the problem as it is at the very and then you have to give something up to get it. Two examples from my own life in terms of folks that ive experienced care with, that i mentioned my testimony. My great aunt ruby who still live in is just about 90, uses 911 as her primary care system. So when we talk about what we can pay for what we cant pay for, the problem is a status quo. Some like ruby, every week calls 911 and ends up in the hospital every week. And medicare pays for that. But if remains attached, if ruby needs a conversation or support, forget it, she doesnt get it. The other thing, the other woman i mention my great aunt grace who died at 95, she declined, declined, declined shed and a fifth floor walkup for years and years and years. So theres really nothing in this country that prevents that decline. But when she fell down the stairs and ended up in the hospital, ended up in a nursing home, all of that is covered. So again i think its about the priorities we make as a country. And being reactive when something goes wrong we put people together once they are broken. And we dont actually make those investments much earlier than that. I agree with you and i think we can argue with the same with leveraging technology on the front end, but i dont have any more time. I look forward to working with you individually to learn more and help create a more sustainable safety net for seniors. Thank you for the gentleman lets recognize a gem in virginia. Thank you very much thank you for what you do every day not just being here. I mentioned earlier when were meeting in the back, that my sister developed early dementia and the expense on the family was extraordinary. We were able to afford it, but i just cant imagine if you did not have a successful Family Business how you would ever be able to afford it. I was also thrilled this morning to learn that for the first time ever, the World Economic form and 2020 is going to have a focus on alzheimers. That is a major step forward when you have the leaders of the world with 50 some president s of Companies Country are for that. And mr. , i want to thank you my mother, my father, and my sister all died under hospice care which made an anonymous difference for us. So thank you. Didnt think i was fascinated to learn as we struggle as democrats and republicans on our federal debt. And we all know you could not make any progress on it by just looking at the Defense Budget or nondistressed meant discretionary, Social Security, medicare or medicaid. Jon larson has the eminently thoughtful Social Security 2100 bill that i hope we will pass this year or next. It will solve one third of that Medicare Medicaid Social Security leg. But the notion that we can successfully address dementia and longterm care, that could make a real dancing with the Medicare Medicaid spending is. Its pretty exciting for us. So thank you. I want to look specifically at the issue of longterm Care Insurance. I am a federal employee so i get to sign up. So my rate only wood up to 5000 year. I understand from my wonderful staff that have 2700 overall. But a lot of federal employees other things go up, 226 of what they were before. And now theres this new kick in on the premium state of is a 3. 0 plan, to try to hold these things down. But mr. Blank otto, bob with all of your experience of aging, we talk not only about how you fund it, but what are the other creative ways to hold the cost downs . And is keeping people in their homes at least a subset of that . On the second part of that absolutely. Home Care Services will be a much more costeffective way to do business. The issue is it has to be more of an inducement on the part of the contributors to longterm care. In other words the working people contribute into the program so that its not all about the claims that come later, and bankrupt the individual plan. The more attractive a longterm care policy is to a consumer, the more likely the arctic take it up. And if enough people come into the program, theoretically, you cannot project all of these things because joanne says theres a long tail involved with longterm insurance. It has to do with more people recognizing a need to purchase long turn Care Insurance. It is also the responsibility of the industry to make the product more responsive to what consumers want. Its not, weve moved away from being just nursing Home Insurance and thats a good thing. And the federal plan that covers a lot of other things including assistedliving and inhome care coordination. But thats got to be the way the market looks too. It has to look at whats important to an individual to make them want to make that investment. And i think thats where we have to go in going forward. Doctor lynn . We have the idls the instrumental activities of daily living, that really should be able to be done in a neighborly way. And not have to be paid for. So if theres a period of time and the decline of most people where they need help getting the groceries in, or repairing the handrail, or repairing a lightbulb. Those things right now often fall to having to pay someone to do that. We are working on an National Volunteer care core, that is a very small thin read that Congress Allowed last year. I really should be worked up. It should have villagers, and care coordinators, and most communities that are doing that part of the work. They do that so that the personal care is all that has to be paid for. Let me make one last. , thank you doctor lynn. In july of this should the Trump Administration reversed the obamacare protection for aging seniors enforce arbitration with the nursing home agreements. And they are fictitiously baked in the fine print. Its almost impossible for these residents or the decisionmakers, to be fully informed of of whats being sent to arbitration. So cms center for medicaid and mediCare Services is significant evidence that predispute will have a an impact on patients. Im at a time but i just want to make a clear. That this is Public Policy moving in the wrong direction. Thank you gentleman let me recognize a gentleman from from illinois to inquire. Thank you, mr. Chairman allen to thank the witnesses for joining us today, for sharing your perspective, your experience, your expertise. In particular i want to thank you ms. Brown for the bravery and sharing your story. For. Civilians and what your story reflects and demonstrates. You plainly describe how taxing and timeconsuming caring for her failing memory can be. I will say this on a personal lever is a proud cherry creek graduate also from denver, your colorado roots, but your aspirations are inspiring. And i will join with my other colleagues whatever it takes, dont quit. Let us know how we can help. As your personal story is distinct to you, the impact of your story is not unique. So many people share that circumstance, its often too common where children and grandchildren of parents are going through different cults circumstances are left to ensure that their loved ones get the care that they need and deserve. And this is a looming crisis. We are at a. Or an entire generation is just beginning to hit the peak of their demand as patients and the need for care with as we talked about today not enough caregivers to provide that care. What it means is a situation that you described is increasingly going to become the norm. Not the exception. Unless we establish the supports and resources necessary as you talked about doctor lynn. Some of that may come from the community but much of it needs to come through, as you pointed out ms. Brown allowing people to access care without having to give up their lives. Compounding the crisis is a growing share of seniors with alzheimers and dementia. And that number continues to go up each and every year. With the past Decade Congress has rightfully increased funding for alzheimers research. We are still a very, very long way, hopefully getting closer but still away from early diagnosis much less a treatment and cure. We are anxiously awaiting for the very first survivor. Continuing investment in research is vital. But we also have to invest in those caregivers. For seniors suffering from alzheimers and dementia right now, we have to find new and innovative ways to treat them, but we also have to take care of those around them. Are there any early demonstration projects or services that a been particularly effective in caring for seniors with alzheimers . Either at the state or federal level and how can we expand on those to ensure more patients get the care they need . Sumac yes we do have a great deal of good news about what does work and what we can do. What we can build on. One of our major challenges is to connect those who need the services, given the awareness for how to make those connections. To take advantage of what is available and what can work. Programs like reach va which is an intervention and the va system to train caregivers on how to provide more effective care, is one of many examples. We also mention we have tools on early diagnosis. We have to make sure our clinicians are using that. And then make those connections. We have a lot more to learn as well. And that is one reason why increase and research of the is also focused on giving the Healthcare System solutions for those with dementia. Because that is an important part of what we need to get better at. So i appreciate the look all across the system at the things we can do. We have to make sure they happen. But its a much more we need to learn as we have heard from all the panelists today. Thank you i appreciate that. In my minute left, i want to direct to you ms. Brown, and maybe take it from a different angle. You describe your situation high school when your mother was diagnosed with ms, and you talked about keeping it from your teachers, from the other people you disclose. As you look back, are there ideas for programs you might do for in particular young people, people are still in their studies whether its high school universities, to help them reach out, ask for help, but continue with their studies and continue to pursue their dreams . Yes, thank you for that question. So you are absently right in high school i didnt have people to reach out to. Mostly it felts that we had gone down our whole list of options and there was no alternatives. I do think that for other young caregivers who might be in my shoes, i think we could help support them by first adding visibility and awareness of this issue. I think that many teachers, many adults simply arent aware that their young caregivers out there. So having them acknowledge knowledgeable about this issue and willing to lend a listening ear, and as i mentioned also, be able to have Financial Support for young adult caregivers. Whether thats through supporting their loved ones themselves, i think that is very important. Because that would allow people like me to it just be a teenager and young people, and not have the social i civilization and all the things i experience. Thank you meta time i yield back. With that id like to recognize adjustment from ohio. Thank you, mr. Chairman, thank you all for being here. Ms. Brown i want to start with you. I dont how youre doing it. I dont know how youre doing it. I know when i was in school i worked but i did not have a sick parents. And i can be 500 miles away or so, and so i recognize what youre going through. You are to be a great caregiver. And i think about when i was a resident and we are going through oncology rotations and it was more valid that youd second this patient has this and heres what we do for. But i did not see the big picture. I didnt see the big sister until my sister got leukemia. And then you realize that this is a family events. This is not just that patient. This is everybody involved. So you already got that heads up. It took me till residency to figure it out. The detail issues are more than just the person there. But i do an essay to i dont want you to quit, because we can talk about all these things, we have a caregiver shortage. We have a physician shortage and a shortage of residencies. And all the talk that we have in here whether its medicare for all or what ever the case may be, if we dont have people like you continuing on your course, we are in big trouble. And it is upon us to try to make sure that we can increase the number of providers, and residency programs available. I hope you get your first pic when the time comes. Good luck to you. But it also, doctor lynn you talk about longterm plans. I am in a situation is a doctor put money away, and developed a longterm plan. I got married late, ive got young kids, light wife and i i dont want to leave this all on them. So we bought into a longterm plan. Not everyone has that wherewithal or can think that far ahead. We need to go in that way and we talk about neighborliness. There is a lot of that that is missing. Care for your nextdoor neighbor sometimes. I remember my greatgrandmother would spend four months with my grandparents, than four months with my great aunt and uncle, then four months with my great aunts. And she would move around. People dont have that like they had in the past. But i do recognize, especially for my patients that had alzheimers what it did to the rest of the family. Especially to a spouse. And i would have conversations with them and say you know, you are going to have to get help. Unfortunately to patients i know had the wherewithal to get help. Because it was taking your health down to. Because of the hours you put in and the challenges that comes with that. So these are real issues that i am so grateful you are all addressing. Bringing to our attention and knowing it is something that is important. We have more seniors and leave ever had before. I hope that is we go forward, we find ways to maybe make recommendations to prevent alzheimers. And to treat alzheimers. It took the 1960s to say smoking causes lung cancer. Maybe well find some things that we are doing that we should be doing. Better leading to the problem aside from just getting older. And miss hospice was wonderful when my father was sick and was gone three months. There are wonderful, they were respectful, honorable, he was able to pass at home with his family all around. Thats as good as its going to get with the situation. I am also one to mention something to that was mentioned that i think doctor lynn or somebody, you have to get broken to be fixed. And ive been saying for some time that is a health system, we are graded innovation treatment and things like that. That we need to prioritize keeping people healthier longer. And the more we can do, you talk about falling, how many times can people fall and break their hip and thats the beginning of the end. And i see things in group some people working cooperative legal come in and fix your home so even your toilet paper holder is a grab bar. All these things that we can try to do to prevent calamities that lead to bad outcome. And i think we need to keep sinking in that direction. And we should work on the health span of people not just their lifespan but how do we keep them healthier longer. Im doing a lot of talking and i want you to comment quickly on the challenges of world rural hospice. Because my district is about the urban and rural. Thank you and thank you for your comments congressman. In Rural America the challenges often just to get someone to come out in and provide you with help. So its clearly an area where technology can help. I think we also see the challenges in Rural America of social isolation. Of depression, of addiction, which you really need there is someone to come and provide you some support. Unfortunately hospice is only there at the tail and. In as you said, you should not need to get broken, you shouldnt need to be at the very end to get supportive services. The volunteerism of hospice is of the rest of the Healthcare System can get an wiki i think we are seeing signs of that. I think the support of the family of hospice as well. So thank you. Let me recognize the gentleman from new york to inquire. Thank you, mr. Chairman and this is such an important issue that youve called about today. You hear all these personal stories i want want to thank the witnesses, certainly you miss brown as everyone is pointed out such a wonderful story in devoting your lives to this issue we appreciate your expertise. We appreciate awaiting here all the time that we have been hearing we been inandout, but youve been sitting here all the time. Doctor lynn is getting more cold because her sweater keeps coming on. We really appreciate your expertise and we need your help. Im just to tell you my personal story. I grew up in a house all four of my grandparents grew up with this. All three were really sick, i look at it now and my mother was so remarkable and how she took care of them. She was a registered nurse but she was a fulltime caregiver for everyone. My parents recently passed away, my father is 95, had dementia issues at the end of life, my mother was 93, they both have longterm healthCare Insurance. And we had Home Health Care givers. My sister came to live at the house for the last three months of my mothers life. I was the mayor of my hometown right had three Nursing Homes and when i was the mayor back in the 90s we help to build three assistedliving facilities. A big model that started to grow in the 1990s. And i was the county executive of the big county in york state where we had this unusual model where the local governments, the city of new york and the local they pay towards medicaid we had most of that went to Nursing Homes. And looking at it i learned so much about this industry that exist of encouraging families of elderly people to get rid of their assets, give it to their kids, give it to their spouse and then have spousal refusal or the kids refuse to take get rid of them. Its a legalize the fraud, but its legal i dona ms. Categorize them. They get rid of their assets in the government pays for medicaid. Theres a storm coming because there are so many more people that are going to be in this situation as the years go on. Senior citizens especially growing in enormous numbers. And they have to be cared for in Nursing Homes, which is not the best way to end life i would argue. And you have to pay for through medicaid, its going to break the bank and is going to be a bad system that peoples lives have no quality of life. So we have to do . We have to talk about this more than we are. We have to talk about peoples endoflife issues. We have to talk about what it means to become frail of what you gonna do. With a talk about your death decisions and what you have to make. And we have to get people to plan for the future. Many people to buy longterm healthCare Insurance for its unaffordable right now. Theres no good model out there right now for longterm healthCare Insurance. So we have to figure out how to get a affordable longterm care plan for people. I want to suggest that is a partnership of some type. So i want to offer right now especially to you doctor lynn and anybody else is willing to work on this, lets try to figure out what would be the model. Whats work with industry, lets get the Insurance Companies that used to do longterm care and dont lets look at your suggestion doctor lynn figuring out the public peace of the governmentsubsidized, and working with industry for them to create what it would take for a Publicprivate Partnership for the government helps industry, industry helps, i will work on that with you. I will ask my republican colleagues have someone work with me on this that we develop a bipartisan proposal to finally start addressing longterm healthCare Insurance. Because the storm is coming. Its right around the corner. And it may be here already. And for some families it is here already like ms. Browns. Or people just cannot live with this. To doctor lynn, you talk about a Pilot Program. Would you be interested in trying to explore either working with industry are doing a Pilot Program . Absolutely that is what we need. Worse the voice of optimism. This is the voice of optimism. Thats mama very optimistic person. So i want to meet with you i want to talk with you about this, i want to actually develop a model and maybe we can do it as a Pilot Program in my home county for example or some other place. Maybe find a republican elicited in their county. Blood still Pilot Program or lets go right industry and set up a model. Thank you would anybody else be interested in participating in that effort . Yes. Yes a lot of new york Insurance Companies or be understood to. You heard all the stories from all the members here. This touches every single family. This is so real. This is something people care about a lot more than what they see on television these days. How do we address longterm healthcare . This will really resignation as a political matter and it was actually make peoples lives better. We just need to get together and do the hard work necessary to figure out the answer. So i think you some much for your testimony today we are so thankful mr. Chairman. We do have votes on the floor but we would like if possible to finish up here. We will we will acknowledge the gentleman from california. Thank you few witnesses for your preparation experience. And for being here today. Sitting here for this amount of time, more importantly what you have to say. Obviously this can be a tough topic to talk about. But fortunately, you are here to provide the testimony, but also you have been here. And i appreciate that. And other members have responded to you as well. Not just members on this dice that you see here, especially congresswoman sanchez, but also members before us who have picked up the torch. And basically put forward legislation like the bipartisan efforts that mr. Bannock you mentioned several years ago. And talk about the medicare hospice program. You provided great comfort to beneficiaries their families and obviously to caregivers that leaves people to finish up their lives with dignity dignity. But over the last decade, that program is grown in popularity. It has led to new challenges insured a high quality of care. In july, the hhs, the health and Human Services office of Inspector General put out a couple reports that the gao put out as well. One entitled caring for aging americans, the other by the gao talking about Nursing Homes that are oversight that is needed to protect residents for abuse. I would ask unanimous consent to enter these into read the record. So ordered. Fortunately we have the reports but unfortunately they highlighted several cases of extreme neglect and patient abuse. And facility deficiencies. These reports make it clear that we do need to strengthen oversight enter hospice program. We need to do that in order to protect the integrity of this program and those who seek comfort at the end of their lives. Now obviously i want to thank you and the ways and Means Committee as well as industry strake holders in the nh pco. For working with me on legislation to improve the programs and to ensure the most vulnerable patients are provided services that they need in a setting that they can trust. Now mr. Banach if i could, as you know the only remedy for hospice providers that is cited is significant deficiencies is removal from the Medicare Program. Correct . Current that is correct. Smack and the oig recommended cms get alternative items besides hospice and that was a bill introduced. How will hospice providers adapt to those types of alternative sanctions . Congressman thank you for your leadership around this. We are fully supportive of the idea that we really have to do three things around program integrity. One is better education, the others better transparency for consumer and the 30 were just talking about is better oversight. Hospital put hospice providers have to adapt. The fact is that the ones that are following the rules and are doing things the right way, actually welcome additional intermediate sanctions that are somewhere in between you can be a program to you cant be a program. An effort is to really sort of improve their ability to provide care. We are partnering that there is education being provided and the government as a partner in that. One side does not see it all. In other words a government oversight the program that is been existence for one year end one that is been existence of 40 years they may be at Different Levels but they are surveyed and they oversee an exact same way. So the ability of the government to have more tools at their disposal is something that we support. Thank you for your work on this. Thank you for your help, and as all the snow we cant do this without the support from all of you. So thank you very much. So also, are you continuing to work with cms on implementation and providing guidance to hospices . Absolutely with cms are oig both. We had a town hall meeting recently with the oig and took questions and provided input to our members and we have had significant discussions with cms as well. I think for better or worse, we have learned from the ways other industries have sort of often pretended that there are no problems. There are problems. And its our responsibility to make sure we enhance the services that are provided to folks. Our northstar is the consumer thats on the receiving end of the care, we want them to get the best care possible. Thinking of the forge that responsively bill you with you. Who let us recognize the gentling from kansas. Thank you, mr. Chairman and thank you witnesses for joining us today. I know youve had a long day and helping us get this effort. In the 10000 baby lawyers retiring every day would support we make sure our current healthcare longterm care systems have the capacity to help support our agents americans. However the kat pacitti right now is about half of what needs to be. And we need to make sure that that process is improved. We need to improve the quality clear care thats delivered to seniors it facilities. As we talk to the oig report. Shortcomings capacity include quality care are due in part under medicare the federal government is the customer not the patient. To address some of these issues facing americans, there are some specific error because i would like to address. First it talks about nursing home care. One of the ways to improve nursing home care make sure we do a thorough overhaul of the system. We also need to make sure their simple process improvements that we streamline the administrative burdens to put the focus back on patient care, and not on paperwork and bureaucracy. Thats one of the reasons i was proud to introduce along with my colleague represented evans, hr 4468 the nursing home care act. This legislation has commonsense improvements, but also ensures the quality standards of Nursing Homes are upheld, allows for additional oversight of Nursing Homes with systemic problems, and addresses critical shortages of nurses assistance. So specifically the legislation allows Nursing Homes have triggered the twoyear ban on inhouse cna training. Too immediately resume such programs after the secretary has certified that all quality concerns cited and fined have been addressed and resolved. This ensures that Nursing Homes continue to meet high quality standards without losing levels that windows critical to what people received. Its one of the things that i see going through my district not having enough of a Skilled Workforce ready to provide with those needs. Well im looking forward to looking forward to working on this, i want to make sure the abuse and neglect and other systemic problems that cause patient harm, or to receive lower quality care, cannot and will not be tolerated. I have a question here its my understanding that hospitals, Skilled Nursing facilities, Home Health Agencies in inpatient rehab facilities have regulations of the patients rights to be free from abuse and neglect. But only Skilled Nursing facilities only define those terms. Our those defined adequately in your opinion . For Nursing Homes . Yes. I think they are good definitions i think maybe they are not well enforced. It implies there is a disconnect its hard to say because those definitions are really good, i think we work with cms for years on working on the guidance around then of course initial regulations. And so the language is there, the bones are there, as i mentioned before, they just are not implemented by cms or by the state. Should we have similar definitions across some of the other facilities as well . I think in terms of abuse and neglect its a same anywhere. Just like good Dementia Care is good Dementia Care anywhere. So i am not an expert at all on any means on hospitals or other settings besides Nursing Homes and residential care. But i would say yes, it makes sense to me. I appreciate that in addition to talking about that care lets make a quick comment about alzheimers and her fight against that. We all know ice alzheimers is the most costly diseases for Elderly Population specifically longterm care cost but thankfully we live in a time with medical intervention and just last month there was approval for new drug to treat alzheimers prayed this is news that im sure will give a lot of hope to many doctors, patients, caregivers touched by this devastating disease. I hope that in my lifetime way you will be able to find new treatment for alzheimers and improve the quality of life of these patients and ultimately reduce the costs dealing with this disease. With that i yelled at my time. Thank you gentlemen the pending vote on the floor gives us very little time. So id like to recognize the gentleman from nevada to inquire. Thank you very much chairman and for the Ranking Member for holding this hearing. Like so many others of this room, providing quality care to our loved ones who are seniors is deeply personal and i want to thank my colleague congresswoman sanchez and mr. Pannetta as well as the entire panel for your expertise and your personal perspective, and mr. Brown again, for bringing a young perspective to the challenges that so many people face. When i was just nine weeks old, my grandmother suffered a debilitating stroke and went into a, for six months when she came out she was paralyzed on the left side of her body. And she ended up needing aroundtheclock nursing care in order to provide the quality of life she had for 27 years until she passed away. I visited my grandmother the virtually every week in a nursing home until she passed. And so i know what good nursing home care looks like and what bad care looks like. You can literally smell it when you walk into a facility on whether they care for their patients properly or not. I also want to share another story. Mr. Billy elson from north las vegas. Billy is 81 years old and recently spent time at a shortterm post acute hospital. His wife sylvia reached out to my office recently seeking help for billy and shared her horrific experience, and experience which is all too common for seniors and some facilities throughout the country. Billys care providers, the individuals that are responsible for his health and safety, stopped caring for him appropriately. Especially when it came to cleaning his ailing body. They stopped to bathing him properly and would not rotate him on his sites frequently which led to painful bedsores. He has since left the facility and is healing in his home, but when he was released, sylvia was worried about who is going to help her take care of billy. A challenge we have discussed in this hearing and it impacts one in seven american womens who will become the primary caregivers for loved ones in their lifetimes. According to the aarp comic caregiving is particularly so im sensitive, time intensive for those caring for a spouse. Most spouses provide nearly 44. 6 hours a week, truly a fulltime job. Luckily my office was able to work with the Ellison Family and help them secure a home health nurse. Since we communicated with them last, billy and sylvia have reported they are happy with the nurse who comes to their home and supports their families caregiving and family needs. Im glad my office was able to assist billy and sylvia, but it shouldnt take congressional assistance for american seniors or their loved ones to live their lives with dignity and respect buyer Healthcare System. So i went to ask you specialize in longterm care on which my grandmother dependent. Can you speak to how congress can help work to provide seniors with alternatives to traditional Nursing Homes and how these alternatives may improve a patients quality of life . Thank you for that question. First i want to touched a lot upon Nursing Homes and they are supposed to provide a homelike setting and care with dignity, resident choice, resident direction et cetera. And the fact that it doesnt, and you know right away, it smells bad, there is something wrong here. Sometimes even when its good, theres something wrong there. Because those requirements are ignored. And we just hope and plead his Family Members, and advocates to avoid being drug to death. That being said there other return lives and more and more people are looking for those alternatives. The problem from our perspective is we are seeing a population that you have noted have needs that are considerable. And if they are getting care in their home or if theyre getting hair in setting, that is great. But there has to be some kind of quality and monitoring that is meaningful and consistent. By think going towards assisted living as i mentioned in my statement more and more states, 48 states now have medicaid assisted living. Its a good deal for the providers well. The higher reimbursement rate. But we have facilities that are taking people with dementia people with high physical and clinical needs without even having a nurse there. Thank you generally. With that id like to recognize a gentle lady from florida. Thank you mitch chairman and thank you for holding this hearing. Im looking at how to lower the cost of drugs. And i talk here dignity is one of the issues i hear most about. But given with limits of times i would like to submit my statement of questions for the record. See maxell order. And ill yield the remainder my time. Thank you for that. Let me think the witnesses for the testimony please be advised or two weeks to be answered in questions and made as part of the formal hearing and that we stand adjourned