Transcripts For CSPAN3 Hearing 20240704

Care. The Senate Aging Committee hearing is about one hour, 40 minutes. The Senate National committee on aging will come to order. As chairman, my top priority is keeping our promises to Older Americans and to americans with disabilities. We owe it to have the necessary information to decide when, where, and how to receive care as they age. That has motivated my advocacy, for example, for home and committeebased services. Every american wants to receive care. It has similarly motivated my work to ensure Nursing Homes are providing safe, quality care for all of their residents. We need to address the chronic underfunding and understaffing for the state agencies that conduct nursing home oversight so they can effectively protect the health and safety of residents. And this core mission of the aging committee brings us to todays topic, the topic of assisted living. And that landscape. It has been 20 years since this Committee Held a hearing on assisted living. With the dramatic growth of the assisted living industry in recent decades, it is long past time for congress to reexamine this model and ensure that it is meeting our nations needs. The best estimates reveal that nearly one million americans live in more than 30,000 assisted living facilities across our nation and that is almost certainly an undercount of that number. Assisted living facilities are state regulated residences that support assisted living while offering help with the activities with activities of daily living like bathing and Medication Management and they also often provide meaningful engagement and activities for their residents. Assisted living was first envisioned as a social model for residents who needed lower levels of support but today, People Living in assisted living facilities are older, require more care, and have Health Care Needs similar to that of those who reside in a nursing home and the needs of the assisted living population change. As those needs change, we need to know if assisted living facilities are meeting the needs of those residents or the needs of their families. One major issue i hear a lot about his cost. Assisted living facilities are widely unaffordable to the average american and their family. Recent survey found that 80 of older adults would be unable to afford four years in as assisted living facility. The average annual cost is 54,000 a year. But the costs can be substantially higher depending upon the location and the type of care that a resident requires. The more assistance and care a resident needs, the more they pay. In some cases, residents and their families dont know the total cost until they receive their monthly bill. These substantial costs and often hidden fees make it nearly impossible for older adults and their families to accurately budget for longterm care. In now, that is one of the reasons why im starting today im asking pennsylvanians and people across the country to share their stories and their bills with us. I want to hear from you about the true cost of assisted living and understand whether families have the information that they need to make difficult financial and Health Care Decisions. Im just going to hold up the website address for those who need it. You can go to aging. Senate. Gov assistedlivingbills, all one word, to share your stories. It is very important that we hear from people about their own experience as Family Members, as people who are paying the bill and also expecting the promises that are made when someone becomes a resident of an assisted living facility. It is only by hearing those stories, only by hearing about those experiences, can we bring the needed change that i know we all agree has to come. The assisted living industry is also facing the same workforce crisis that we see across other longterm settings care settings and other longterm care. We see it in child care and other parts of our health care and care landscape. Workers are struggling to support their own families because direct care workers are paid an average of just 15 an hour nationwide. Workers provide a higher level of care to support residents rowing needs, especially residents with dementia. But training requirements and worker support look very different in each state. As we will hear from our witnesses, these challenges make it harder for families to find the information that they need about assisted living facilities including how much it will cost, the quality of the services they receive, and how safe their Family Member will be. A recent Washington Post investigation found that since 2018, more than 2000 people have left assisted living facilities unsupervised and have been left unattended outside. Tragically, 98 of these 2000 incidents have resulted in the death of the resident. And those are just the cases that have been reported. The findings of the post investigation demonstrate how urgent it is that Congress Better understand this industry. Theres also been significant reporting by the New York Times and kfs in a series written before the end of last year. To help in our understanding, i have sent letters to three of the largest corporate owners of americas assisted living facilities. These letters request information about cost, workforce, safety, and availability of information about quality of services in assisted living facilities. I hope these letters i should say the response to the letters will improve transparency in the assisted living industry and help to inform policy solutions to address some of these concerns. As families are making difficult decisions about where to age, they deserve to know that their loved ones are safe. I think we can all agree on that. Assisted living providers making promises they cannot keep is a violation of trust. As we continue to increase the quality of the continuum of longterm care for older adults, it is time we prioritize efforts to improve the assisted living care option. If we say if we, as a nation, are the greatest country in the world, then we have to have the best, not second, not third, the best longterm care in the world, and we are not there yet. Older adults and people with disabilities who call assisted living facilities home we have to remember this is their home, their residence, where they live, where their families come to see them if those older adults and people with disabilities are calling those facilities home, they should have quality Affordable Care so i look forward to hearing from our Witnesses Today and i will turn to Ranking Member for his opening statement. Thank you, chairman casey. In 2050, that you think the problem is bad now one in four americans will be 65 years of age or older. With an aging population that we know is coming at us, thank goodness we have hearings like this to highlight what you are going to do about it. Sometimes, the market doesnt do the job. I do want to say that ideally, these things are crafted through the market and probably with states leading the way. I say that for one big reason i am on the budget committee. The biggest thing that challenges this place is how you would add something even further to the list of things you want to do when we are now borrowing a trillion dollars every six months instead of annually, and that has just changed over the last five years so we have to be careful. But it still has nothing to do with a problem or an issue that is out there and this is about highlighting who can do it best and how you get there. Chronic workforce shortage, when i traveled and visited all 92 counties in indiana, precovid, that was the number one issue, and it is about double now the number of jobs in my own state. I think it is close to 130,000. It was 65,000. And caregivers, a large percentage of them, that assistance is given by independent contractors. You know, Small Business owners. We need to figure out how to enable that and make it easier, how you actually have your curriculums in various states and School Systems that show the full spectrum of what jobs are out there and where the needs are. Senator kaine and i introduced the jobs act here which allows students to use federal pell grants for high quality, shortterm jobtraining programs. That is a good federal program. It is increasing the flexibility of how you can use it. Other senators and i introduced the train more nurses act which reviews all nursing Grant Programs to find ways of increasing nursing pathways. Happy to hear some things do work well here. That path, by unanimous consent last night in the u. S. Senate now, we got to get it over to the house to do the same thing. The federal government should make it easier for people to enter the Health Care Workforce and for families to take care of their loved ones. By making sure that it is energizing the people that may be interested in it, in the places they will be doing the heavy lifting. Right now, for instance, the Biden Administration is saying one thing and actually doing another. And i come from the world of Small Business. Independent contractors, retailers, individuals that make their living out of may be running a Small Business. The independent contractor rule that is out there, which would make that more difficult, could eliminate many of the existing caregiver jobs for that reason, so you got to make sure you are not wanting to do something and then working at a cross purpose through another agency that will make it even more difficult. Unlike Nursing Homes that are regulated by both federal and state agencies, assisted living facilities are primarily regulated by states to increase safety and transparency. Indiana requires staffing ratios, dementia training, and maintains a website that discloses reports in enforcement actions. States in assisted living facilities are working to find creative ways to use existing resources to assist seniors. Indiana is using a combination of state and federal tools to provide more affordable assisted living to hoosiers. As a result, indiana has c inaffordability and quality improve. However, there is always more work to be done. Some of my colleagues may be tempted to call for a shift towards increased federal involvement in regulations. I would say be careful. Help us get best practices out there. Help us have an environment to get it done where its normally done more effectively, more affordably, at lower levels of government. I believe that states are best positioned to meet that growing need. I am glad we here at the federal level, the big microphone that has to highlight the issues, that is what were doing here today. Thank you to all the panelists for being here and i am interested to see what we can come up with. Thank you, mr. Chairman. Turned to our witness introductions. I am grateful for the time and the work that goes into an appearance by our witnesses. Our first witness this morning is patty from gainesville, virginia. Her first husband, john whitney, had mentioned and lived in an assisted living facility at the end of his life. She will share some of her and her husbands experiences where she supported him and assisted in an assisted living setting. We are grateful you are here today. Thank you. Our second witness is dr. Jennifer kraft morgan. Dr. Morgan is from georgia. Dr. Morgan is a professor and director of the Gerontology Institute at Georgia State university. She studies issues related to longterm care dementia in the Health Care Workforce. Thanks for being with us today, doctor. Our third witness is dr. Julie simpkins. I will turn to Ranking Member braun for that introduction. She is the copresident of management systems. She has been in the longterm care arena for nearly 30 years. She focuses on affordable assisted living and she advocates for both providers and Older Americans. She leads on several state and National Associations including the Indiana Health Care Association board of directors and the National Center for assisted living board of directors. Thank you for testifying here today. Thank you, Ranking Member braun. Our fourth and final witness is richard. He is the executive director of the longterm Care Community coalition. This coalition works to provide families with unbiased information about Nursing Homes, assisted living facilities, and other longterm care settings. Thanks for being with us today, and we will turn to our first witness, patty. Patty good morning, chairman casey, Ranking Member braun, and members of the Senate Special committee on aging. My name is patty. Thank you for allowing me to share this testimony of my experience with assisted living for my husband, john whitney, during his journey through the middle stage of dementia. I will focus on my experiences and observations that i believe are most relevant to your national focus. In 2013, my husband was diagnosed with dementia. Although this dementia is similar to alzheimers, it manifests itself a bit differently and it is important that caregivers be informed and trained appropriately to ensure the comfort, safety, and security of their patients. Some key systems, a loss of sense of smell, rem sleep behavior disorder, which causes individuals to violently act out dreams, often falling out of bed , visual hallucinations, marked fluctuations in attention and alertness, and gastrointestinal issues including severe constipation. All of which my husband experienced. Loss of memory often occurs much later in this disease process. I took several free courses on caregiving for individuals with dementia including a Virtual Reality dementia experience. Which helped me to understand the challenges that people with this disorder face, and most importantly, why they become fearful and combative. I mentioned this to provide a basis for my ability to recognize problems with care as i saw it. These same courses offered for prevention for the rational set reasonable costs. In june of 2017, when my husbands disease was progressing more rapidly, i moved to virginia to be mere family. I cared for him alone at home until january 26, 2018, when he attempted to strangle me in my bed. The state determined that john should be placed in a longterm care facility. I found him a room in an assisted living facility in virginia that specialize in memory care. He moved in the first week of march in 2018. I provided the Management Team with johns history, his diagnosis, and disease progression. The following is a list of issues that i observed in the memory care unit during my daily visits with john. Poor facility design. There were blocks of rooms built around a large central room for Group Activities and tv. The central room was extremely loud and high levels of noise can easily agitate dementia patients. Activity stations were set up for residents. One of these had various lengths of pvc pipe, not kidding, some longer than a baseball bat. These were weapons in waiting and you can guess what happened. There was no quiet area for the residents other than their rooms. The hallways and the room blocks were isolated, making it difficult for staff to monitor. There were many incidents that i witnessed when there was no staff around. I will share one that i feel was very important. A woman fell by tripping on a raised area on the floor where the rug abutted the hard flooring. Nobody saw her fall. I found her bloody and staggering down a hallway. A company knowledgeable about Dementia Care would not design it facility this way. They would certainly understand that people with a mentor have problems with balance. And understand there were video cameras in place but they only used them for reviewing incidents after the fact. They were understaffed. Too many patients were assigned to each caregiver. In the morning, each caregiver needed to give their assigned residence, get them up and dressed and ready for breakfast. Everybody ate at the same time, putting additional pressure on the staff. They only gave residents a shower when necessary as they were always pressed for time. They needed extra time to spend on residents stages of dementia as they required help to move from their bed to a wheelchair and be hand fed. After lunch, the caregivers would place most of the residents in chairs in the main room while they worked getting the advanced stage patients back into their beds. Every day after lunch, my husband urgently needed to empty his bowels. Several times while i was there, i tried to help him but it was difficult for me as i had a broken arm at the time. I could not find anybody so i did the best i could and often when i was not there, he soiled himself while waiting for help. I once believe i saved a man life mans life. I was off the main activity area and i heard someone crying for help. I ran into the hallway and found an old man on the floor, trying to protect himself from being beaten with his own came by another resident. I called for help, quickly moving closer and redirecting the attackers attention. I kept him as the while calmly calling for assistance, trying not to further agitate him. It took several minutes before a staff number finally heard me and came to help. Night was no better as staff levels were lower as allowed by state regulations. They placed residents who had trouble sleeping in front of a tv while they dealt with other residents. Inadequate staff training. Most of their caregiver staff were trained as nurses aides but Nothing Specific to memory care that i could see. I witnessed them providing them care in a Conference Room and this consisted of a member of the Management Team showing them a movie and pointing out some behaviors that demonstrated his dementia problems. I saw that movie and it was not appropriate for training purposes. I observed instances where caregivers and nurses this play to limited knowledge of working with dementia patients, particularly those in midstage of the disease who became combative. Some examples, nurses running towards the patient, causing the resident to become combative, quick hand movements, frightening the individual. Another example, tv was on at 9 30 p. M. Attacks from the high volume. Several residents were seated in front of the tv. Anyone who understands dementia would never do this. They were overstimulating this residence instead of allowing them to relax and quieted their minds for sleep. Finally, at one point, the director of the facility told me to spend less time there and let them do their jobs. I could not abide because i felt they were not doing their jobs. In closing, unless things change, i could never recommend using this type of facility for a loved one unless things improve. Im hoping you found my testimony helpful in the committee will find a way to set some National Standards for appropriate levels of staffing and training for that staff. This would be a huge step in improving assisted living. Thank you for your time. Thank you very much. I appreciate your testimony. Dr. Morgan. Good morning. Chairman casey, Ranking Member braun, and members of the committee, i am honored and delighted to be here. Thank you for sharing that story. Assisted living is a large and growing longterm care residential option for individuals who need or want Additional Support for activities of daily living. There are approximately 30,600 communities in the u. S. With approximately 820 thousand residents, employing 500,000 workers. It is often seen by the public as interchangeable with skilled Nursing Homes. It is built and regulated as a social model of care. It is less restrictive and strives to be homelike. Residents vary greatly in levels of care. They likely require more health services. While these services could overlay al Services Much like they would if the person was needing if the person needing care was at home, these are not provided directly by the al community. The haphazard growth of this model and the tensions between social care and health care inherent have spurred calls by scholars for assisted living to be reimagined. Most al residents need help with medication and more than half need help with three or more activities of daily living. Al residents depend on their care networks. The constellation involved in residents lives to arrange medical care, to provide social support, to coordinate care, to engage residents in activities, and bring needed supplies. These care workers also play an Important Role in advocating for residents and negotiating care with staff. About 42 of al residents have a dementia diagnosis but we can assume this is underreported as many older adults are not screened, tested, or diagnosed with dementia despite showing symptoms in memory, thinking, or making decisions that impact everyday life. Like all people with chronic disease, People Living with dementia have good days and bad days. Person centered Dementia Care is needed to tailor care and support to individuals in ways that account for preferences, life experiences, communication styles, and support needs that change over time. According to the average monthly cost is 4500. It is in accessible to most americans. Yet on the spectrum of longterm care, it is often needed. Seen as a step between unpaid care by loved ones and nursing home care, al provides a very important longterm care option. When the care needs of a loved one exceeds the capacity of their care network, the person and their care network is forced to navigate with little support or education a variety of options, none of which are usually covered by health insurance. If they have significant financial resources, al is a useful and attractive option. If not, managing the care situation means that Care Partners reduce working hours, build precarious care or Financial Arrangements across families, higher piece mail personal hire piece meal care support. 60 of them are aid or direct care workers. They are predominantly women, people of color, and disproportionately immigrants. The typical care worker makes about 15 an hour, works 36 hours a week in assisted living, and works for a forprofit company. Al workers, like most direct care workers, tend to go into this line of work to give back, to make a difference, because they value elders, or because it is a calling for them. Unfortunately, the system we set up works against them. Direct care workers in longterm care settings experience low wages, few benefits, heavy workloads, dangerous jobs, and little to no career mobility. In her book, disrupting the status quo of Senior Living, she lays out the crux of the problem facing Senior Living. Al is marketed to those who can afford it with a hospitality mindset. They advertise and compete on the basis of beautiful campuses, luxury food and furnishings, and concierge services. This model encourages residents and families to think about this next step as though they are going to a hotel or resort. This framing, where residents are guests and staff are encouraged to cater to their winds, increases what dr. Bill thomas calls the three plagues of longterm care, helplessness, boredom, and loneliness. By encouraging passivity, we leave residents with few opportunities for giving back or creative pursuits. Instead, longterm care that is person centered, committee minded, and empowering for residents, staff, and Care Partners has a much better chance of success. My recommendations include improve and standardized training, initial and continued Education Training for workers and assisted staff. Professionalize the workforce. Incentivize and reward good employers who deliver highquality care, increase access to assisted living, improve care coordination and resources for People Living with dementia and their Care Partners, and support standardization of monitoring and resources to increase state based oversight and transparency. Thank you. Thank you for your testimony. You may begin. Thank you. Jim and casey, Ranking Member, and members of the special committee on aging, thank you for inviting me here today to be part of this important discussion on assisted living, a topic that is very near to my heart. I am the copresident of garden management solutions. We are a provider that develops and operates Senior Living, assisted living, and memory care communities. We are the fifthlargest provided in the country and have communities in five states. Illinois, indiana, ohio, maryland, and west virginia. I have dedicated most of my life to Senior Living with over 30 years to the assisted living sector. This is my calling and i would like to speak to you today about the unique model as we share thoughts on how we can Work Together on important issues facing those who work in assisted living. Garden is uniquely focused on offering affordable assisted living to low income seniors. Our company was founded in 1999 after the creation of the Supportive Living Program which is a home and committee based waiver program. Now as we expand it into florida state, our commitment to serving this population remains. Many residents living in garden communities rely on medicaid for their care through these waiver programs. Garden has been limited in where we can offer our services due to the variability with state Medicaid Waiver Programs. It depends on the availability of state programs, state reimbursement levels, and the number of available waiver spots. Offering affordable assisted living exclusively or even for a majority of residents requires an entirely different Business Model altogether. We have had to persistently seek out loans and tax credits to stay viable. Therefore, we support efforts to make longterm care, including assisted living, more affordable to individuals. The rapidly growing elderly population, we need a public and private partnership to incentivize providers to develop these models. We talk about assisted living and its important to note that every state to come every committee, and every resident is different. Efforts to standardize all assisted Living Communities would be both unworkable and irresponsible for resident care. State regulations recognize the diversity in assisted living by holding our profession accountable and they are consistently updated to reflect the evolving nature of our sector and our residents. In oil, garden is committed to exceeding the state requirements when we believe it is in the best interest of our residents. We will take memory care as an example and something that is top of mind for this committee as well as our residents and family. Every staff member receives education and training in dementia related diseases as well as training as a practitioner. While it is rare, we only report to the state immediately, even something as technical as a resident walking out the door, instantly returning with a staff member. We know they did not leave our community and our staff immediately addressed the situation but we still report it. The recent reports of resident elopements that were ultimately fatal are heartbreaking and my thoughts and prayers go out to the loved ones of those residents. I serve in leadership positions in numerous organizations dedicated to longterm care and i know these tragic incidents are extremely rare and not indicative of the facility experience. The overwhelming majority of families and residents have a lifeaffirming, safe experience. Assisted living providers are committed to upholding our policies and procedures as well as continuing to learn all that we can about Dementia Care to prevent these incidents. It is critical that policies and regulations help protect residents while supporting their freedom of movement and independence. Assisted living is a credible aspect of that critical aspect. We need collaborative, comprehensive solutions that ensure our ability as assisted Living Communities to continue doing what we do best, providing safe, quality care to our residents. From extending more affordable longterm care options to workforce programs to addressing the growing caregiver shortages, these efforts could make a real difference. We must all Work Together to ensure current and future assisted living resident is seen, safe, and sure to enjoy the highest quality of life possible. Thank you for your time and i look forward to answering your questions today. Thank you for your testimony. We will turn to our fourth and final witness. Good morning, chairman casey, and members of the committee. Thank you for inviting me to testify today on this important issue. I am the executive director of the longterm Care Community coalition. It is a national nonprofit, Nonpartisan Organization dedicated to improving care and quality of life for residents in Nursing Homes and assisted living. We conduct research on longterm care policies and the extent to which essential standards of care are realized by residents who are typically elderly and frail. In addition to conducting analysis and advocacy, we engage residents, families, and those who work with them so that they are aware of their rights and are equipped to overcome the challenges that so many of our seniors face when they need residential care. Our interest in assisted living is longstanding and we appreciate your commitment to sharing the promise of assisted living is realized in the lives of our growing senior population. It emerged in the 1980s as an alternate for Nursing Homes for seniors who want to live in a congregant setting where they can get help with tasks like housekeeping, meal preparation, and access to activities and preparation. Three development have drastically changed the nature and character of the assisted living sector with both positive and negative implications. They are, one, the needs of assisted living residents have dramatically increased. Assisted living operators have adopted increasingly sophisticated and largescale corporate models including ownership by Real Estate Investment trusts, private equity, and other sophisticated private investment structures. Public payment for and government interest in assisted living has increased significantly. Assisted living facilities now care for people who in many ways have the same needs and vulnerabilities as nursing home residents. Assisted living residents are actually older on average than those in Nursing Homes. 40 to 70 of assisted living residents have alzheimers disease or some other cognitive impairment. Over half have hypertension. About half of that need help walking into thirds need help with bathing. Over 10 of residents with dementia receive antipsychotic drugs. Unfortunately, we as a country have failed to keep up with these trends. While some assisted living can be wonderful places to live and work, too many take in or retain residents who they are not able to provide safe care. Too many are at risk for financial exportation and even friday. Too many seniors and families get taken in by promises of memory care when in fact these are more often marketing terms than accurate representations of specialized care. The absence of any federal quality or Safety Standards coupled with the absence of reliable Public Information on the quality, safety, and cost of assisted living, have made it a sector right before investment by sophisticated private enterprises who can shuffle around resources and take profit with little or guard for the promises made to seniors and their families. These problems occur at every economic level, from 50,000 a month or more luxury assisted living to the 20 of seniors who access it through public funds like medicaid waivers. It does not have to be this way. 40 years ago when Nursing Homes were in crisis, Congress Took action. From numerous reports to the growing chorus of local and National News reports of neglect, disastrous elopement and financial shenanigans, its clear we have reached that point now with assisted living. We recommend three things. One, establish and implement National Standards to promote quality, safety, and integrity in assisted living. Two, establish a National Assisted Living database with information and metrics that the public needs to evaluate both cost and quality. Three, promote resident and Family Engagement to ensure that assisted living is truly a home and communitybased service. As i mentioned earlier, assisted living experiences can range from positive to alarming, posing potential risks and explication. I think we can all agree that the lives of seniors should not be left to chance, ambiguity, and insecurity. Thank you for inviting me to testify today. Thank you very much for your testimony. I will begin the first round of questions but i want to note for the record, we have senators that are in and out because thursday is a pretty busy hearing morning so some senators here some will be here and then ask questions and folks will be appearing intermittently throughout the hearing, but so far, i know that senator rick scott was here and senator blumenthal. And we will be awaiting others after my questions and those of the Ranking Member but i wanted to start with you about your own experience and i want to start by saying how much i appreciate and how much the committee appreciates your willingness to share a personal story. That happens in hearings like this on a pretty regular basis. An individual comes forward and talks about their own experience or that of their family and from a distance, it might seem easy but i cannot imagine how difficult it is to recount painful moments, and doing it in the interests, of course, of helping others, so we are grateful for your willingness to do that in telling your story which is a very important part of the work we are trying to do together. I know that your husband was in an assisted living facility and as you indicated, you were paying privately for those services to make sure that he would get the care that he needed for dementia. And i know i have heard from my own constituents back home similar stories. For example, angela was a constituent of mine from johnstown, pennsylvania, cambria county, in the southwestern region of our state. She wrote to me and said that her father was in one facility that charged 7200 dollars a month. I know that is not the average. It is very high. That works out to about 90,000 a year. And angela shared, and am quoting her here there is always a sense that no one cared for the residents beyond their monthly payments. Thats one experience and that is one persons personal experience. But i wanted to ask, based upon your experience with your husband, did the facilities he lived in deliver on the care that they promised to provide . Thank you, senator. Thank you for appreciating me coming and doing this and i think the good news is it has been six years and i am able to do it without getting overly emotional. No. They did not deliver. They definitely overpromise to. Understand that they were absolutely a memory care facility, specialized in it, and new what they were doing. His basic needs were not often met as you can hear from some of the examples i gave, and i observed other people the same way. They would actually recommend that you pay an additional private caregiver to come in to give them the care they really should have gotten but their staff was just there just was not enough of them to get it done. Do understand that their staff was friendly and caring and they were wonderful people. They were overwhelmed. But they definitely did not deliver, and by the way, it did come out of my pocket because my husband had chosen not to do lawn Care Insurance and that number that the woman gave you was low. That was my starting figure, 7,900. It cost me closer to 13,000 a month. We are grateful for you sharing your own story, your own experience, and i wanted tonights turn to richard. You mentioned a need for more substantive and meaningful ways for residents who might choose a particular facility or their families to know which services they receive, how much those services cost, the outcomes for residents living in a specific assisted living facility. For a family searching for care, and we hear about this all the time im not sure i doubt theres anyone in this room who doesnt know someone who has had the experience of having to search for care and to try to navigate it. Its obviously difficult to find the information that folks need about assisted living facilities and sometimes, they only have the word of an assisted living provider. Maybe someone else who has had their own experience they can rely upon. Can you elaborate more on the challenges that families have in finding both Accurate Information and unbiased information about services, about costs, about care outcomes for residents in assisted living facilities . Thank you. So essentially, there is no independent, validated information on assisted living for the consumers, for policymakers, or for the general public so families, as you noted, have to rely on facilities, facility marketing materials, and they also quite often rely on Companies Like a place for mom and other socalled consumer resources that are not independent of the industry. Companies like caring. Com, a place for mom, that actually get money from facilities to be listed. So that is not independent either. That is not something people can rely on as being necessarily Accurate Information for what has happened, what they will pay for, and what they will get and the state websites are really the last resource and they tend to be very flimsy. I have not looked at every single one. Flimsy. Most often what we will see is they just list a facility, the facilitys administrator, phone number, and the address. Sometimes, there is a little bit of information but you cannot in my experience ever get into finding out really what has what the staffing is, what the costs are going to be, or what the quality has been. I know that going back to your testimony, you mentioned the three recommendations. The first was establish and implement National Standards for quality, safety, and integrity in assisted living. The second was establish a National Assisted Living database. Is that what you are referring to . Yes, similar to care compare. There is health care compare, hospital care compare on the medicare website. There should be an assisted living compare. Look, i think its pretty fundamental that people should have the opportunity to place reliance upon a source that is objective, and to use your word, independent. I think that is true in any walk of life. Why would someone only why should we settle for just relying upon assertions by those who are operating facilities . So i think thats pretty elementary, but we have not reached that point yet in terms of a change in policy. I know i am over time but i will turn to our Ranking Member, Ranking Member brian. Thank you mr. Chairman. Thank you, mr. Chairman. Would not be good. I have been a proponent since i have been here that this place ought to focus as much on that as anything because we are a portal of information that if she collated properly, that would seem to make sense, and i think that goes across the spectrum of health care as well. I have been the most vocal senator that our Health Care System has broken. We dont have transparency. We dont have competition. It is almost like an unregulated utility and you get your bill after you had a Significant Health care scrape or a bad accident. You have to hold your breath to see a much it is going to cost or if you can afford it. You mentioned that it was 7,200 a month and it could have been more than that is in virginia, correct . Is that where that yes, but that is not the number i gave you. His room charge was 7,800 to start and it cost me close to 13,000 a month. 13,000 a month . Ok. That sounds unaffordable. If he had not passed away rather quickly by the time for the length of time he was in there, it would have used up all of my next day nest egg. That is the kind of stuff i have been appalled by by the time i took on Health Care Reform in my own business 15, 16 years ago, how lucky the industry would tell you its only going up 5 to 10 each year in your health care premiums. Sooner or later, people cannot afford it and something has got to give. I was noticing in your background, you focus on low income. Because some people are going to be able to afford it despite the quality of care and the level, but most people will not so in indiana and the four other states where you operate, what would that range be per month as you would compare it to 7000 to 13,000 a month . It seems like when it was all in, it was closer to that higher figure. Just curious. Thank you, Ranking Member. The rains that a resident or resident family would pay under the home activitybased services is really nothing. In illinois, there is a small personal portion. Its based on resident income, allowing them to do things and still have money in their pocket. In indiana, there is no personal portion so the state of indiana will pay for those services through the state. In your facilities, for low income individuals, theres basically very little out of pocket . Very little outofpocket. There might be some personal portion based on what they actually received in income and it does not go any it does not go over any Social Security amount. How would you be able to generalize that across the rest of the country . Program . Are other states doing that . In ohio, they are doing it really well, recognizing that there is a need within their state there is an underserved population. There are people that cannot afford it and so that is what we were founded for. That is our Business Model, to say there is an unmet need in here is how we are going to do it. There are waiver programs in place that makes sense. So you would not have qualified for any low Income Opportunities then. Is that what kept you into what seems to be outrageous in terms of the cost per month . That is correct. Even though we are both retired, they look at all of your savings and if you have a decent ira out there, that counts. It begs the question then, is the low income stratum across the country being served adequately . That almost we seem to be surprising to me if that were the case. But what we are seeing on the other side, there just would not be many families that could afford it and i dont know what the criteria where the cut off is. Can you fill me in a little bit . It sounds like an indiana, and especially if there are other options to choose from other than just your organization, that the low to maybe middle income strata are being served well. Is that a fair statement or not . That is a fair statement number Ranking Member. Do you think that is the case across the country as well as you know, because you serve on some boards where i think you would have that information. It is not across the country. So nationally, there needs to be programs in each state to provide access to affordable assisted living and they are not all there yet. Courts generally. And that is at least a little bit surprising. Generally, to folks at the other end of the spectrum, the low and middle, especially low, they dont get adequate services so i think that is something you need to get those practices spread out to where we at least can get that in most other states and then you have to tackle Something Like this that i dont know how well you would have to be to afford that easily and for a long time. Something has got to give. I will have another round of questions if we do it. Think you, Ranking Member. Thank you, mr. Chairman. Thanks to all our witnesses for being here today. The Arizona Republic, the paper of record in my state, published a series of investigative reports last year about the state of longterm care facilities in arizona, and these journalists spent more than one year on this investigation. They reviewed police reports. They reviewed footage. In some facilities, they analyzed regulatory reports from the state and they interviewed families and experts and what they found mottos, and think it is her to say, horrifying. They reported graphic stories of a resident dying after being attacked by a roommate who had not received her medication in time, another report of a resident being sexually assaulted by another resident. Incidents of violence that often are not reported because they are not required to be reported under state law. And they highlighted the failure of state agencies to investigate these cases in a coherent, transparent way that would allow families looking for a safe place for their loved one to know what really goes on in these facilities, and i think a lot of us knew there were issues in the system. We knew that. But i dont think we knew how bad it was. Since these articles were published, arizonas governor has put together a strong legislative package to standardize inspections, promote transparency for residents and their families and empower Adult Protective Services to investigate appropriately. And the state legislature is looking at proposals. So mr. Mollot, are these the type of steps that can help tackle these issues . Mr. Mollot i believe so. Of course the details matter. These are nuanced issues about caring for people with dementia, making sure things are reported appropriately, that there is good oversight. As much as possible we would hope a state would be looking to implement policies and practices that prevent bad things from happening as well as of course ensuring that when they do happen, that they are rectified and reported appropriately. Sen. Kelly so arizona cannot be the only state that is facing these challenges. Mr. Mollot not at all. Sen. Kelly should the federal government may be consider having a role here in providing oversight for assisted living facilities . Mr. Mollot i think it is time for the federal government to step in. 40 years ago when Nursing Homes were in crisis, congress stepped in and initiated action. And we are here now with assisted living as well. You same number of people are in assisted living as they are in Nursing Homes, but we dont know what is happening to them, we dont know the care they are receiving. There is unfortunately a lot of fraud. Sen. Kelly apparently, more than 20 years ago this committee helped to facilitate the creation of an assisted living workgroup, which was made up of 50 organizations. And this workgroup was tasked with coming up with recommendations for best practices in assisted living facilities to ensure a more consistent Quality Landscape across states. The result was a 380 page report with a lot of recommendations. And these were hard to agree upon. So mr. Mollot, what has happened with these recommendations since this report was finished, if you are familiar with it . Mr. Mollot i have not read it in a long time but i am familiar with it. Frankly, on the federal level, nothing has happened with it. As ms. Simpkins said, we do see things going on in the state, but generally speaking the states are not inclined to take action on a lot of the work they do. Hopefully they will be different in arizona. But it really is time i believe for the federal government to step in and ensure that whenever someone accesses Dementia Care, that means something. It is not just a term of art. And wherever they go for safety, wherever they are going into, they know what the expenses are going to be. Sen. Kelly thank you. I do want to note for my constituents, a resource created by aarp arizona and by the Arizona Republic following this investigative series that i mentioned. Its a background on longterm care, the definition, definitions of different terms, what families should look for, and what questions to ask. And folks can find us on the aarp arizona website, and my office will be posting this on our social media accounts. And i am going to submit this for the record as well, mr. Chairman. And i urge arizonans or anybody else interested to check it out. Thank you. Chair casey thank you, senator kelly. That will be accepted for the record, not just submitted. We will turn next to senator vance. Sen. Vance thank you. Welcome to our witnesses. Thank you for being here and welcome to all of our guests. I want to direct questions to you, ms. Simpkins. I appreciate you being here. I am particularly concerned about some of the estimates i have seen about labor shortages at our longterm care facilities. Not just now. I know there is an immediate problem of not enough people at some of our elderly care facilities. But i saw an estimate that by 2030 we will need obviously people will retire and drop out of the workforce, but we also have changing demographics in this country. We are growing older is a country. I read we will need an additional 7 million longterm caregivers at these elder care facilities. That seems like a shocking estimate to me. It is hard to imagine how we could possibly hire effectively one million additional people per year at these facilities, given the already existing labor shortages. I am curious if you think that estimate is within the reasonable range. And if it is not, how many more workers do we need within the next five to 10 years . Ms. Simpkins thank you for the question, senator vance. I have not heard 7 million. I have heard 5 million. But i will followup and send you the information i have. In my response to that, we got hit by the pandemic really hard. Health care workers left and they are never coming back. They said this is hard and they are not going to do it, and we have had to recover. Assisted living has recovered pretty well. Our workforce is aging out and our seniors are aging and we are doubling and tripling numbers when we get to 2040 and 2050. So, having a really intense effort to recruit and maintain. I would like to share quickly what we are doing. From a recruitment standpoint, that is how we recover. We were able to get really creative. We looked at people and said, what do you need, what will help your household. We needed to increase wages. You can have Rate Methodology that allows you to pay a living wage and higher than a minimum wage. And we looked at maintaining retaining. People come into assisted living and they stay because they are so passionate about it. In honor of their passion we need to create something for them. What we do is from the first interview, we ask them what they envision six months from today, one year from today, three years from today. We want them to envision a future with us and a future with the assisted living industry. Then we have to meet that need by career pathing, career mapping, and so we have done a lot of that. What we have realized through those interviews and people saying this is my career path, is we also need a skill path. We need to provide them with the resources, whether it is through the nursing branch, additional education we are reimbursing them for, additional training they need. If you are going to commit to working within this space in our workforce, you also need to create in having a workforce that will continue to be passionate, make a living wage, and have the tools they need and want to state. Sen. Vance got it. Appreciate that. One additional thought here is, you hear about these cases of elopements at these health care facilities, and they are relatively rare. We have close to one million americans and elder care facilities right now. Maybe 2000 elopements happen per year. That is a small number, but i worry, with increasing labor shortages, whether that number goes up. I have heard some suggestions that you could fill a labor shortage gap by expanding certain immigration programs, certain visa programs. And the one worry that i have there of course is if you take a person caring for an elderly citizen, you want to make sure there is not a language barrier, especially with people going through dementia, might be losing some cognitive capacity. So we really have to wrap our minds around this. I appreciate the work you are doing on this, but are you worried we might see an increase in elopements over the next few years, or do you think not . Ms. Simpkins we need to plan for how our seniors are aging and the additional care they need. And we do that through person centered planning. I believe dr. Craft morgan mentioned that. Our plans revolve around what a resident needs. Somebody can have the same diagnosis and their needs are completely different. If you are not having personcentered plan for that individual that is collaborative with their family, as much as they can participate in it, with their caregivers, you are not going to have the best plan to keep them as safe and secure as you possibly can. On the immigration side, theres an opportunity here with unused visas to start bringing in some health care workers. And to your point, there are some markets that were within that have the residents who also have language barriers. Having staff that speak spanish, polish, based on where the needs are. Sen. Vance thank you. Chair casey thank you senator vance. Senator reckons senator ricketts. Sen. Ricketts i represent the great state of nebraska. And in nebraska we have Skilled Nursing facilities and assisted living facilities scattered throughout our state. And it is incredibly important it takes important to take care of the 20,000 some people in our facilities. They can get that care for about 3875 a month. Anybody who was providing assisted Living Services in the state of nebraska that has four or more residents is designated as an assisted living facility reg glidden by the state. While as governor, i signed into law an assisted facility living act to update the standards and requirements that we have for our assisted living facilities. They are critical especially in rural parts of nebraska, to to be able to help care for people. We want to make sure we continue to have that service for our folks. Ms. Simpkins, as you know, they are regulated at the state level which allows states flexibility to be able to be responsible to local consumer demands. Are there any states in particular doing an exceptionally good job that we can draw lessons from . A state where they have good problem programs or things we should be adopting throughout the country. Ms. Simpkins i can speak for the states in which we operate. Illinois, indiana, and ohio have exceptional programs. And with that, senator ricketts, one of the things we noted in reporting all of those states will require reporting of any of the incidences we were talking about previously. Sen. Ricketts are there other characteristics you think have led, or some approaches that you say these states are doing a good job . What are they doing right . You mentioned the reporting. That is obviously an important factor. Are there other things they are doing where you say this is why they have good systems . Ms. Simpkins this is why they are a good system is because we have access within a state, and a state that where assisted living is regulated. Talking about home and Community Based service. Access to the regulators, access to families, access to everybody who you have this local model that can create and innovate and come up with best practices. Im a big proponent of lets share our best practices. It is nothing proprietary when it comes to caring for somebody. That is what those states are doing well. My fear is, if you move those conversations further away we will no longer have those things. The states in which we serve, and i will talk about indiana specifically, the Medicaid Waiver Program is really dynamic. They promote and encourage having a local model where there is collaboration and innovation. And that is where we come up invest practices. I would say that is also a model. Sen. Ricketts great. Thank you, because that leads into another question i have. We hold a hearing that highlighted the strained inspection system. Nursing homes are regulated at the federal level, as you know. Heavily collated at the federal level. Assisted living facilities are subjected to the same onesizefitsall federaltype of regulation. What can we do as lawmakers to ensure that assisted living facilities dont have the same sort of problems we are seeing in Skilled Nursing facilities . How do we protect that local model and best practices . Ms. Simpkins from the state level we encourage all the states. The things we were talking about, we even talk about reporting those critical events, reporting those up to the federal government. Each state has an obligation to report up in order to continue to have their federal funding. They also are well aware of the transparency that comes from, and the opportunity, once the states report up, we have a transparency and the opportunity to see where the home and communityservices are doing across the nation we will have a more have a window to see what they are doing. Sen. Ricketts getting back to the idea of if you have the federal government regulating things, how do we preserve that ability of local folks to be able to really tailor how they are doing the regulation to make sure that we are not pushing a onesizefitsall answer . Ms. Simpkins we need to, from our perspective, we need to tell our story much better. There are really good stories to tell from a state perspective and home and communitybased services and we need to do a better job telling those stories. The things going on in other states, the innovations that has happened, the times providers have been asked to sit at the table before there is a rule change. If this rule changes, how does it impact the resident you are caring for and your workforce caring for that resident . Sen. Ricketts that interaction directly with people doing the job before directions rules are changed so we dont have unintended consequences with regard to the rules made that will harm the care that is being delivered in assisted living facilities. Is that fair . Ms. Simpkins that is fair and i like the way you put that. Sen. Ricketts thank you very much. Chair casey we will turn next to senator warnock. Sen. Warnock i would be remiss if i didnt take a moment to remove the legacy of the late first Lady Rosalynn carter, whom i was privileged to know and Whose Mission was to center and uplift our caregivers. Her extraordinary work demonstrates how a Health Care System that leaves so many drowning in caregiving costs, costs most of us will one day face. It is a Health Care System that falls short of his basic obligations. Dr. Morgan, in your experience as a gerontologist, how does the cost of assisted living burden seniors, their caregivers, and their families . Dr. Craft morgan the cost of assisted living is both financial and emotional. And real. For many, many americans. We have a system where there is not access to assisted living. In some states there are medicare waivers that cover a larger portion of those who need it at the lower income. But there are also states that have virtually no waiver programs, so that the only people who can afford assisted living are those who have significant financial resources. And so, the middle tier of america tends to do things that i talked about in my testimony. They reduce their working hours. They set up arrangements to talk to families to pay for assisted living if that is that what they can do. They bring in people who may not be trained to support their person living at home. They make these precarious work and family arrangements to be able to make it through whatever longterm care they have for their loved one. If they are lucky enough to get into assisted living, then they are still coming after work and they are still bringing the supplies and bring the snacks and engaging the residents residents. Its another job on top of the job that they are trying to do if they are still working, if they are still able to work. And that is really important in young onset dementia as well. Because in young onset dementia, these people are still earning. And they have young onset dementia, and then the family have very few options for thinking about their forward retirement. Retirement is not what we end up doing. We end up mortgaging everything to do the care and to clean out our savings in order to support this person living with dementia, who may not be able to be at home. A lot of the young onset dementias have these sort of things that petty were talking patty was talking about. We have a different course of disease and it is difficult for people to care for those folks at home. And so, even if they are able to afford assisted living for a time, they run out of resources. And then what do they do . And sometimes they can get into nursing home placement, and sometimes there are good Nursing Homes to go to. But not always. Its awfully precarious for many folks. Sen. Warnock thank you. Your experience with this underscores the ways in which this costs not only the families, but all of us. It has implications for our workforce and our economy. And so we have to have longrange, comprehensive thinking about this. The chair has been a leader in this. And i am happy to join him. I was happy in joining him to ask that the g. A. O. Look into how federal Health Care Affordability programs like medicaid and metal medicare, which you mentioned, interact with assisted living facilities, how we can do better there. And whether families choose an assisted living facility or inhome care, they need help. The average cost of 4500 a month, that is the average cost. But you rightly point out the ways in which, for example, with early onset dementia, peopless Retirement Funds actually drained just taking care of the individual. And so, that is why i support efforts to lower caregiving costs for aging adults. It is a critical issue for our country. I will continue to work with my colleagues on this committee, informed by the expertise by people like the folks on our panel to improve longterm care for folks across georgia and across the country. Thank you so much for your work in this area. Chair casey thank you very much for your questions. I will now move a little bit out of order. We will move to a second round as we are waiting for senators to ask first round questions, some of whom are on their way. I know the Ranking Member has questions as well. Dr. Morgan, your testimony provided a helpful overview of the importance of welltrained staff in assisted living facilities. We heard that the director of staff can have as few as six or eight hours of training only before beginning their care duties. They might be responsible in some cases for 20 or more residents. The constituent of mine i mentioned earlier, angela, said in part when she wrote to us, quote, when i mentioned my concerns about my father falling repeatedly, the facility had nurse said quote, falls are just part of aging, unquote. I ask you, are falls under other accidents in assisted living just part of living, or are there procedures, strategies, rules, they can be put in place to address the risks that older adults face . Dr. Craft morgan falls is a really important topic in aging. There are a lot of great tools people can use. The National Institute on health has a great flyer on this topic. Six tips to help prevent falls. Falls is about prevention. Educating staff on Fall Prevention is vital. There are plenty of environmental audits that can be made. Some may have this training in place but certainly its an important aspect of initial and ongoing training that the al workforce should do. The other thing that is tricky about falls is that there is a fear of falling that has a real impact on whether you are going to fall, and a fear from families who are scared that their mom or dad are going to fall. And one of the things that my father would say to his patients is, if you dont use it, you lose it. And in aging, its important to keep up with balance and balance exercises, and keep with Strength Training and doing those sorts of activities. And certainly assisted living and other places could do that to really help with improving balance. Because we know that balance is really important in terms of predicting mortality. And so, if we think about it and we support falls prevention, that is what we can really make a difference. That is also educating families. If you use your assisted devices, if you get up slowly, if you manage your medications, you make sense to really think about falls prevention. Because a falcon really have an impact on the trajectory of aging, for sure. And it is really important that longterm care take that seriously. Chair casey thank you so much. I am going to cut myself short here, a little bit of a jump ball between Ranking Member brauns second question and senator warrens first round question. I think i will start with someone who is arriving. Thank you, senator warren. Sen. Braun that is very gracious. But i will yield back to you. Sen. Warren thank you both. And thank you for holding this hearing. I appreciate that we are having this hearing. I appreciate your leadership on ensuring quality care for seniors in assisted living facilities. This issue is not a new one for me. In july 2020, my Office Released the findings from the First National survey of covid19 in assisted living facilities. Revealing that about 7000 residents had died from covid in just the first half of 2020. In many ways, the threat of covid in assisted living facilities was just as serious as it was in Nursing Homes. But these facilities received little help, and little attention. Now, before that, in 2018, i released the First Ever National assessment of quality care issues in assisted living facilities. Which was completed by the Government Accountability office at my request. That report revealed that over 20,000 Serious Health and safety problems occurring at assisted living facilities in just 22 s tates. From physical assaults, to medication errors, to unexplained deaths. In the years since my office did that work, new studies have revealed additional problems in assisted living facilities. Mr. Mollot, you leave the longterm Care Community coalition, which is dedicated to improving the quality and accountability of Senior Living facilities. Can you say a word about what kind of threats seniors at assisted living facilities face, and how serious the risk is . Mr. Mollot thank you. I think there are two major risks and both of them are serious. First, due to increasing needs and vulnerability of people who go to assisted living, the risk of harm has gone way up. People are vulnerable. People are depending upon assisted living for medical care, etc. , and we just dont know if they are getting. And we often dont know when terrible things happen. And by the way, your report was so important. Due to the increased sophistication of operators, we have property equity, Real Estate Investment trusts circling around the industry. The risk of financial exploitation has gone up tremendously in recent years. Sen. Warren and yorkie word your key word, we just dont know. These are Serious Problems that have been going on for years. But we hear so much less about what is going on in assisted living facilities than we do in other facilities like Nursing Homes. Mr. Mollot, why do you think assisted living facilities receive so much less attention than, say, Nursing Homes . Mr. Mollot that is a really interesting question. If i may, in the 1970s and 1980s we had tremendous scandals in a nursing home world, and that led congress to Pay Attention and finally to take action. And i think that is where we are with assisted living now. Were hearing more and more of these stories. The gao report from 1999 and the more recent reports you mentioned, local news reporting from around the country, over and over we are seeing these issues are coming up, and now is the time to take action. Sen. Warren with Nursing Homes, we put in federal standards on this, got more federal oversight. But assisted living facilities are governed by a patchwork of state laws without any meaningful federal oversight. And that means no National Standards at assisted living facilities are expected to make. That is particularly worrisome, because private equity firms and Real Estate Investment firms have gone on a buying spree of senior and assisted living facilities. We know how their model works. Private equity comes in, strips the assets, cuts to staff, and sends the quality of care down the tubes. So mr. Mollot, your organization has worked looked carefully at the data and you have heard from the residents at these facilities. When private equity comes into an assisted living facility and slashes jobs, what impact does that have on the residents . Mr. Mollot workers are the most important component of care, in any setting, especially assisted living. So that can be devastating for residents. But unfortunately we dont have a lot of data directly on the facility. We have some on senior care in general and Nursing Homes. In other care settings, we know when private equity comes into a sector, they often pillage it. Sen. Warren in other words, more people will suffer when private equity comes in. We need to do more here. At a minimum the Biden Administration should require additional reporting on problems at assisted living facilities. In fact, that is a priority recommendation from the 2018 g. A. O. Report. While cns is making progress on implementing this recommendation, they should finalize it quickly. This has gone on long enough without oversight. And Congress Must look at ways to improve accountability, transparency, and quality of care in assisted living facilities. So again, i want to say to the chair into the Ranking Member, thank you for holding this hearing. Into the Ranking Member, thank you for graciously let me do this. I am trying to cover two hearings simultaneously, and i appreciate you letting me ask these questions. Thank you all for being here. Chair casey thank you, senator warren. An senator braun is once again ceding to a fellow congressman, senator fetterman. Sen. Fetterman thank you. Ms. Simpkins, your website states your companys operating margins are consistently among the top and the country. And i understand that your company manages upwards of 700 million from the low Income Housing tax credit program. And a majority of your residents rely on medicaid through medicaid waiver. So, ms. Simpkins, is it fair to say that your company is viable because of government subsidies . Ms. Simpkins thank you for the question. It is viable for a few reasons. Because we do have investors. And we are grateful to those who want to invest in affordable assisted living across the country. Otherwise we would not be providing to almost 6000 Seniors Today who are on medicaid waiver. We also need a viable Business Plan, and it needs to be a Business Plan on our website when it talks about our margins, our margins compared to when you look at Affordable Housing across the continuance because of investors that we have margins that we continue to do, like, certified dementia practitioner training and give education reimbursements, and look into different workforce opportunities. And the third thing that happens in a viable business is you have to have a service plan. You have to have a service plan that is focused on quality outcomes and focused on high Resident Satisfaction and focused on high employee satisfaction. What youll see on our website and thank you for noticing that. We are redoing our website and i will be glad to send you a link as soon as is done, because we will start posting quality outcome results. And that should probably be in march. I will send you a link. Sen. Fetterman of course, i would be grateful. Also, i am glad that there are investors, and they are a critical part of it. But i think it is safe to say that the subsidies from the government is important too, right . Ms. Simpkins it is definitely important. We need both to have a viable business. Sen. Fetterman that is not a criticism or an attack, i just want to establish that. So, given the governments undeniable role in this, in your operations, why do you believe that a company should not be able to use federal dollars to make a profit . And i dont judge anyone of course earning a profit. But if you are making that kind of a profit, but maintaining that at the same time the federal care standard . Ms. Simpkins thank you for the question, senator. The federal funds go into the state in the state then decides what that program is going to look like and what it will be. The opportunity at the state level is that we can have conversations with our state regulators and improve upon shared best practices across the continuum. I know senator warren mentioned the 2020 report she had uncovered, and we were part of that report. Our outcomes you dont want anything to happen, but our outcomes were really good in comparison to others. We relied heavily on state regulators and resources within the state to help coach and educate and resource and everything we needed to do. I dont believe it could have happened at the federal level, the amount of attention we were able to get from the state. Sen. Fetterman sure. And i want to be very clear. Earlier of course, we count on other investors to allow you to operate. And i dont have an issue with u geting a profit. That is one of the reasons people are in this, of course. In fact, that is why it works, and i am grateful that it is. And really, this line of questioning wasnt an attack or anything other than just to establish that, because we are partnering through the kind of subsidies that i think we should maintain those kind of federal standards as well, too. And because they all combined together to allow this to work and to provide that kind of very important service. Would you agree with that . Ms. Simpkins they are providing a very important service. And senator, i actually appreciate your line of questioning. Because if we didnt have these kind of discussions and differing opinions, opposing views and different views, that is where great ideas come from. So i do appreciate your question. Sen. Fetterman thank you. Chair casey thank you. We will now turn to Ranking Member braun. Sen. Braun what we have just been hearing here is what i like about a Committee Like this. You are hearing a broad array of viewpoints. Health care has been something i have wrestled with long ago. In the whole spectrum, from Early Childhood through when you are needing to look at how you are going to spend your last years. It has been cloaked behind closed doors. Large Insurance Companies and hospitals we spend most of our money on the way to maybe a nursing home, assisted living, or if you are lucky enough to live it out in your own abode. Its got to be swamped with transparency and where we can see. Ms. Vessenmeyers story, how can Something Like that happen and that was in virginia when we are hearing 3800 a month in nebraska . Every state is going to have a different costofliving, a different cost structure. But that idea of transparency portal, and at least some things that are going to make it easier to shine a light on the issues that are out there. To me, when you are against that, you are just trying to hide something. For instance, on the bigger picture. This is an interesting combination of individuals. Myself, senator sanders, senator grassley, senator smith, senator hickenlooper, three republicans and two democrats, have been working on this since i have been in the senate. Competition and transparency. If you want to be in the biggest part of our economy, health care, and especially at the tail end of our lives, be out there, be open. Ms. Simpkins, i was wondering, because you have done a good job, and like senator fetterman said, the pay doors are coming through either state or federal governments. And you are aimed at low income. What is your cost, roughly, to do what you are doing across those five states . Because we heard 3800. I just asked my staff, it is closer to 4500 per month in indiana. What are you finding . You are serving low income residents. What does that cost structure look like . Ms. Simpkins thank you for the question, Ranking Member braun. Sen. Braun that would just mean in terms of, you have a business. Without giving any trade secrets away, what does it roughly cost in those states to provide a service . Your payor is mostly in government. In the case over here, did not have the advantage, and you so what happened. And that was in a state like virginia, which i would have thought would be moderate on cost. Ms. Simpkins the thing i am struggling with and i certainly agree with transparency. That is something we are going to be showing today, the cost of care, making sure there are no hidden fees. The expenseside really depends on the state in which you are in. Sen. Braun lets just pick indiana to keep it simple. What do you charge the governments the end up paying you mostly . I want to get an idea of what the variation is in costs across the country. And then whoever is in any component of health care should be always willing to make it easy for us to understand. And on health care, that leads up to assisted living or Nursing Homes, it is terrible. And in my own business i try to create health care consumers, so you can actually manage her own wellbeing. Even when i attempted it, it was not easy, but we did it. Ms. Simpkins thank you for the clarity. The cost of care if we are looking at indiana specifically, and i think the best gauge is probably in our operating margin. Because the cost of care of of an insurance and workforce is about 15 , 20 . Sometimes it is a little bit higher. Sen. Braun you can give me a range, too. Ms. Simpkins the operating margins are going to be roughly between 20 and 28 when everything is considered. Sen. Braun that is operating margins. I am talking about with the government ends up paying per month. Ms. Simpkins i would be glad to send it to you. Sen. Braun i dont want to belabor the point, but just a difficulty of this. You guys are doing a good job, by all standards. We have got to have transparency across the spectrum of health care. And when you get to the tail end of life, i think its as important as it is along the way. And until the industry and everyone in health care embraces transparency and competition, dont be surprised if there is going to be more of an interest to show how to do it from the federal level. And i am a believer that that generally is not necessarily a solution. It can end up even costing more. But unless you at least embrace what is done in all other industries, which is, make it easy for people that want to buy your services, know what is going to cost, embrace competition, dont try to keep people out of the business. You are never going to find solutions in health care. It is now 20 of our gdp. And as recently as three or four decades ago it was only 5 of our gdp. It is breaking the bank, even through the programs we offer here that elderly depend on. Medicare and Social Security on the retirement. Something has got to give. Ms. Simpkins i understand. I will send you that information. Im willing to share it, im willing to share whatever you want. I just dont want to misspeak on what the numbers are. Sen. Braun i respect that, and i want to thank the other panelists for enlightening us on this subject. Chair casey thank you, Ranking Member braun. We could spend a lot more hours on these issues. We are grateful for all of you helping us. I will have a closing statement and then i will turn to Ranking Member braun, and then we will wrap up. I know a vote, if it hasnt started, it is about to start. As we heard today, assisted living facilities are right now a growing piece of the longterm care continuum. But more work is needed to ensure these facilities are quality facilities, that they are safe, and that costs are transparent and clear to families. As ms. Vessenmeyer stated in her testimony today, assisted living facilities must provide what Older Americans need to be safe and to be healthy as they age. This hearing has demonstrated that assisted living facilities face similar challenges to other longterm care options, including maintaining a welltrained workforce, providing safety, highquality services, and being affordable. Throughout my career, i have been working to improve care, to improve transparency, and quality throughout the longterm care sector. We have a responsibility to make sure every american can age with dignity in a safe place of their choosing. That is why i have worked with my colleagues to expand access to home and communitybased services, improve nursing home oversight, and strengthen the longterm care workforce. Now were going to continue our work on assisted living. As this sector grows, we must work to provide similar protections and safeguards that are in place for residents and their families as we strive in the nursing home context. We also want to ensure that any facilities and corporate owners that violate the trust of American Families are held accountable. I look forward to working with my colleagues to ensure everyone who needs longterm care has safe and accessible options. One way we will do that is to determine what the costs of assisted living are to families, and how federal dollars are being used. To ensure these funds are being used responsibly to pay for quality care, along with all of my democratic aging committee colleagues, we have sent a letter to the Government Accountability Office Asking them to conduct a study of assisted living costs and how available and transparent that information is to families. As i said in my opening statement, i want to know more about what people are paying for assisted living, and to have people tell their stories, as we heard some of the stories today. So again, we will be asking people from across my home state as well as the country to share stories and to share your bills with us, if you would want to do that. We want to hear from you about the true cost of assisted living, and understand whether families have the information, the information that they need to make this difficult financial and Health Care Decision for a Family Member, and for the family. So, i will turn to Ranking Member braun now for his closing remarks. Sen. Braun thank you, mr. Chairman. And thank you again to all the witnesses. This committee is unique in that you really cannot craft legislation out of it. A lot of it, though, from this discussion happens through other committees. So, always keep that in mind. We heard how critical it is that federal policy support the caregiving workforce. Senator vance pointed that out back in indiana. I mentioned how it workforce in general has a lot to do with our School Systems, making sure that the emphasize career and Technical Education along with fouryear pathways. Because across the country, maybe a third of jobs need the four year degree, and we need a Better High School education for many of these issues so that you can hit the ground running. It should be policies from here i think should focus on boosting workforce. I think we all kind of agree on that. Many bills are out they are to do that. And to make careers in health care easier to attain. Got to make sure you dont work at cross purposes, like some of the policies that are going through the labor agencies and that side of it that are wanting to make it harder for independent contractors, for individuals, where a lot of this assisted living help comes from. So, i want to make sure we dont work at cross purposes. We also heard how states and the providers themselves are doing things. Sadly, though, no tall not all states seem to be doing it well, because you cannot have that many instances of that and say you have an industry that is working. That should be the rare exception, and never the rule. And then when we are talking about how this place actually helps, when you are promoting transparency, it can bring odd partners together. I have seen that. Two ends of the spectrum. Because no one should ever be against being able to have more information to make a good decision. And when it comes to standards, i think that is important. Databases. That is all something we can do, share it with all the states. I think those are good ideas. Im encouraged by the conversation we have had here today. That is how you get better ideas, really good practices. This should be something, whoever is doing it the best, you need to shout it out so that the rest of the country can participate in it. Thank you again. Chair casey thank you, Ranking Member braun. I want to thank again our witnesses for contributing both of their time and their expertise, and of course bringing your own personal stories, your own personal experience to this issue. If any senators have additional questions for the witnesses or statements to be added to the hearing record, the record will be open kept open for seven days until next thursday, february 1. Thank you all for participating today. This concludes our hearing. 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