Transcripts For CSPAN Future--Health 20131229

Support to perform the routine activities of daily living and to maintain their quality of life and their independence if possible. I appreciate you calling this hearing to try to improve our current long term financing and Delivery System. As the senate cochair of the Bipartisan Congressional Task disease, izheimers am particularly concerned and sensitive to the needs of alzheimers patients and their i particularly look forward to discussing ways to more support to the 62 million Family Caregivers who in 2009 provided an estimated 450 billion in uncompensated Long Term Care, more than double the value of all paid longterm care. Majorerm care is the Catastrophic Health care expense faced by americans today in these will only increase as our nation ages. Its not just that there will be a greater number of americans, it is also that Older Americans are living longer. Are ours 85 and older socalled oldest old. They are the fastestgrowing segment of our population. This is the very population most of the multiple and in directing Health Problems that can lead to disability and a need for longterm care. At the same time, declining birth rates mean therell be fewer family members and caregivers to care for our. Today, theretion are approximately seven potential caregivers for each person over 80 as this chart indicates. By the year 2030, there will be only four. By 2050, the number drops to fewer than one in three. Fewer than three. Peoplensequence, more will have to rely on fewer caregivers. What does that mean . What are the implications for the quality of care that we will be given . Is clear we have to do more to support Family Caregivers and recruit and retain a robust and confident competent longterm care workforce. While there is the need for both public and private financing of Longterm Services and support, i do believe we must do more to encourage americans to provide for their own longterm care needs. Many mistakenly believe that medicare or their private medical insurance policies will cover the cost of longterm care should they develop a chronic illness or Cognitive Impairment like alzheimers. Unfortunately, far too many do not discover they simply dont have coverage until they are confronted with the ethical placing a frail parent or loved one in a Long Term Care facility and face the shocking realization that they will have to bear the cost themselves. Consider theird future longterm care needs just as they plan for their retirement or purchase Life Insurance to protect their families. Private lending for longterm will not only provide families with greater Financial Security but also will ease the growing financial burden on the Medicaid Programs and strengthening the ability of that program to serve as a Long Term Care safety net for those americans most in need. Again, mr. Chairman, thank you for calling this hearing and i look forward to hearing from our witnesses. Out of the spirit of and assistance, i would extend to our most distinguished Committee Say as the opportunity to word or two before we turn to our witnesses. Let me say that i appreciate mr. Chairman, you holding this hearing because it is such an important issue. I come before you as a son, grandson and former governor that out with these matters through personally. Is not al you there greater thing we can do to add dignity and respect to a persons life as they grow older than try to have them live an independent lifestyle. I will give you one story. My grandmother was 85 years of age and i would see her all the time. One time i stopped and she was very lethargic and just sitting there. She said every thing is ok and i could tell something was wrong. I told my mom and said go see grandma again because my mother always wanted to live with us and be independent. This one time my mother went to be with her. Then she stayed for 15 more years and lived to 100 years of age. The thing about it was it she was lonely. Poor nutrition, she was trying to feed herself and not cooking properly. Its right before your eyes and you dont see it trade and you do, you see the difference of a life it makes. I took that with me when i became governor and the main thing i wanted to do is create programs that drew attention to help people because they live independently. We started some programs in West Virginia that im not sure had ever been started before. And tablelottery fund games at licensing fees. 100 went into longterm care for independent living. All theit fair. Programs that was whatever you pay, you pay. Intolp and we sent people live independently. A lot of people did not have Family Support area government doesnt have to do it all, but we have to be the best partner they have ever had. That starts from the federal to the local levels. Andad a Lighthouse Program we had the fair program, families with alzheimers. You just need a break every now and then. There are some compassionate things we can do and it doesnt break the bank to do it. Im thankful that those of you dedicated your lives to helping those of us who have it on the front lines. My sisters and my nieces take care of my mother around the clock. We never put her in a nursing home and thats not where she intends to be or where she wants to be and most people dont. The support, have we have to give them the support and we look forward to your testimony. Thank you. Season tell the holiday has begun. Were sitting democrat, republican, democrat, republican. This is an odd angle for us. Im feeling lonely over here. I just did not want to get to your left. You are welcome anywhere, anytime, senator scott. , the issue of longterm care is an issue i take seriously and when i think through my grandmother was 77 when she passed away in 2001. She had parkinsons and alzheimers. The last seven years of her life, my family, thank god for my grandfather, my mother and aunt who spend an inordinate amount of time taking care of her at their home. Fortunately, we had the resources to do so. When you look at the demographic breakdown of who can stay at home and who cannot, minorities pay a heavy price that having the resources and adequate time to care for their loved ones. We had a unique experience of a very special way. I think its a wonderful opportunity to care for those who took care of you. Theres an old saying that you are twice a child. Unfortunately, we have experienced this, those who have had the opportunity to care for a loved ones. This is why this issue is incredibly important for our country. The second experience has been as the guy in the Insurance Industry for the last 23 years where i sold longterm care policies and understand the activities of daily living and how many people have not been properly educated on the opportunities to make a decision when you are young enough so that the payoff is you dont exhaust all your resources trying to get down to the 2000 or 3000 level where medicaid tics in. 1. 2 million 1. 2 billion medicaid has put out. You have a conversation about where we are going as a nation and how the government can play an Important Role is a very important decision. Thank god for a chairman and Ranking Member who have the foresight to put us in this position and i look forward to having a robust discussion about the future opportunities and creativity in the marketplace that will provide that type of resources and invest real hope that more americans will retire and live for the rest of their time with the mentee to include the last years of their lives. Time with dignity to include the last years of their lives. We are going to start with ms. And tomlinson, the Senior Vice President s at hell of your health. Halavier health. Then we will hear from members of the longterm Care Commission. They are going to share. Thebruce chernoff, president and ceo of the scan foundation. He served as the chairman of the longterm Care Commission. We will hear from the adjuncts dollar at American Enterprise institute. He is the commissions vice chairman. Fetter, one of the commissioners of the Long Term Care commission. Is a professor at Georgetown Public Policy Institute and a fellow at the urban institute. He also served at the Pepper Commissions staff director under my former colleague of which i was the president of the claude upper fan club. She served for Claude Pepper. There was an example for those of you who were not here in washington in that youre a, Claude Pepper and Ronald Reagan would go to it. But at the end of the day, they were personal friends where they could work it out together. One of the great examples of that, also with the leadership of the speaker, tip oneill, was when Social Security was within six months of becoming bankrupt in 1983. They said we are going to take it off the table so you cant hit your opponent over the head with it. They appointed a Blue Ribbon Panel and made their recommendations on what to do. They sent it to the congress and we passed it overwhelmingly. Securityocial actuarially sound for the next halfcentury. That was 1983. So those folks knew how to get along. Chairman nelson, Ranking Member holland and Ranking Members of the committee, thank you for holding this hearing and for the opportunity to testify but the future of longterm care policy. The perspective im about to share comes from my work over the past 20 years, first at the office of management and budget as the person responsible for the Medicaid Budget. Or 15 years,0 consulting for nursing home and assisted living providers and working with a number of my colleagues on the panel analyzing the budgetary impact of a variety of ideas including the class act. Weant to start by saying spent well over 200 billion that we paid for very little care. Over 60 million americans provide most of the care unpaid. Mostdo this because americans are not insured against the financial risk of longterm care and want to avoid a medicaid nursing home bed. Woefullyterm system is underfinanced for the job has to do now and for the job has to do in the future. All the other problems we talk about, the Delivery System, workforce, quality of care, all stem from this fundamental fact of financing. Im going to make three points that i hope will help you all in the work you are doing in the future that will make our discussion a very interesting one. Im going to start with something controversial and hopefully a former governor will not come across the table at me. The farc the problem we have to solve primarily is not one that is a Medicaid Budget problem. And i worked on the Medicaid Budget for many years. I dont see this as primarily a Medicaid Budget problem. It is an issue of course. States have to fund their medicaid or grams and there are people and title ii services under those programs. Governors and state governments will face challenges as the population ages. But in managing these challenges, even more of a financing gap will be created and that will have to be filled by families through their own personal finances and unpaid caregiving. Longterm care is shrinking as a percentage of the Medicaid Budget. At its lowest percentage in two decades. Over the last 10 years, spending of grown at an annual rate less than five percent a year. It true that we will have Older Americans but in preparing for these demographics, states are doing smart and logical things from a budget perspective and theyre demonstrating they can and they will exercise the levers they have to reduce the number of people who receive longterm Care Services at the amount they spent per person. And they will do it in all settings, not just Nursing Homes. We see that already in the growing interest among states and moving people into managed care and out of fee for service. The number of people who will need longterm care, therell be less medicaid to beast right around. So my second point is the inability of medicaid to keep up with the growing demand. 2 the real problem. That the under financing of longterm care creates and contributes to a Enormous Economic and security, which is already a major problem in this country. Is an insecurity for the majority of American Families in that they think about what they might be facing in the future. When theyre faced with this crisis, most americans cobble together a variety of resources to provide what they can. Less than 2 million of the 12 million we talked about today who need longterm care are living in a nursing home. Thats because the rest live in the community where medicaid dollars are scarcest and were third of American Families provide some type of caregiving. Somehird are providing level of caregiving. When they provide this care, they do it at a rate of 20 hours per week. That time is spent doing the really hard, physically and emotionally challenging work of caregiving. They do it while 75 of them hold down another job grade we know that a Million People are paying privately for assisted living or other type of Senior Housing and the cost 42,000 a year on average. This is not just for rich people. This is being financed to the sales of homes, contributions from Adult Children and the resident exhaust resources and have to move into a nursing home to continue their care under medicaid because medicaid is not a cover assistedliving. Very little of this is captured in our data. Working directly with providers, my conclusion that it is much more likely medicaid is generally viewed as something to be avoided rather than a mechanism to exploit for wealth or faction. As someone whose job it was to work on finding medicaid savings that he wasnt shy about it, im telling you theres not what to suggest we have an enormous opportunity. In fact its quite the opposite. My idle point and this is the least popular point that will be made here today even when people are educated about the risks of longterm care and when they are presented with long willinsurance policies, we not truly address under financing without requiring everyone to participate in the risk pool. After being a proponent of expanded coverage through voluntary private approaches. And analyzing the budgetary impact of these. I learned from that experience and have the view now that two adequately protect americans against the risk and correct for the under financing problem we currently deal with, some part of the solution must be mandatory participation. We have a vigorous debate over private versus public options but it doesnt mean anything because neither works for a well and covering enough people is optional. Its an important debate for sure, but not one we should be having without facing the reality of what it will take to protect americans. I look forward to your questions. Thank you. Thank you, mr. Chairman, Ranking Member collins and members of the committee. We are pleased to be here to present a vision and recommendations of the longterm Care Commission and i want to going tosaying im walk us through the highlights of the report. This is work mark and i did together at and it comes from a spirit of fundamental bipartisanship which we think is the way forward. Im going to make some comments on behalf of the whole report. As you know, the commission had a very compressed timeline. We were set out with a sixmonth schedule after going through the appropriations ross us, we have somewhere between 90 and 100 days to do our work. We had four public hearings with ready for witnesses, over 100 submissions of public testimony and 100 sessions. By a 96ission voted majority to issue the report as the broad agreement of the commission. I want to provide you with an overview of the process and the development of the final recommendations and begin by saying the commissioners were a talented, knowledgeable and Diverse Group of people and our expectations were we would identify as much Common Ground as possible and establish that as a foundation for moving forward. The discussion and areas of agreement and disagreement would the evidencebased and we would be open and willing to challenge accepted thinking where we could not find substantial evidence the we are pleased with collegiality and amount of Common Ground reached grade this makes the point that addressing Longterm Services is not an intractable problem. Each commissioner was asked to submit proposals. Our all proposals are included in appendix a of the report. Measures selected the idea they felt merited the most attention developed for potential recommendations. Proposals that could not be developed were not included as final recommendations. Let me state clearly that developing a thoughtful, comprehensive report in 100 days is an important success in and of itself and the direct result of the commissioners dedication. Overview. Vide an the report is framed by a call to action that we think its important for the general public to understand. That broad agreement we are trying to solve together, the shared vision serves as a framework that supports 28 specific recommendations. But me touch on a few key points grade it starts with the notion that we must have a fiscally sustainable and effective long term Delivery System built on concepts of hurson and family centered care that provides individuals with support and services in the least restrictive environment appropriate for their needs. It is delivered by a well trained and adequately supported range of caregivers and paid workers. Finally, the comprehensive financing requires an approach publicree prongs financing to ensure the most catastrophic experience, encouraging savings for media Longterm Services and providing a strong safety net for those without resources. The 28 recommendations i can take you through, but i dont have time for that. I would like to highlight for them for you in a way thats useful. Servicey areas our delivery, workforce and financing. With respect to service delivery, it all hinges on a recommendation that we start with a better balance of communitybased and institutional care choices grade finding the right balance is important since most folks community. N the other recommendations include a single point of contact, uniform and standardize assessment used by all providers that engages the family and individual themselves. Accelerating the development of a new generation of quality measures that include services and the experience of the individuals receiving care. Finally, promoting payment reforms that focus on outcomes. Workforce,t to central to these recommendations is a variety of recommendations focused on improving training and support for family including, identifying the Family Caregiver in a chart and assessing the caregiver as part of the Care Planning and team grade other important recommendations included taking on the scope of active and delegation, integrating workers more effectively in teams and encouraging states to improve standards for workers. Financing, the commission did not have a single recommendation but did outline a common vision. Then identified two different approaches that could be the basis for a broader discussion. One focused more on public social concerns the social Insurance Solutions and the other based in private solutions. When you look at both of those approaches, there are interesting commonalities that bring them together. We will say the Public Policy details and funding mechanisms for both approaches remain to be specified in many commissioners felt it would require considerable new data, design work and careful analysis before a fiscally responsible proposal could be put forward. Mother of five specific recommendations relative to medicare and medicaid. Next steps, which is one of the things that brings us here today, the commission felt strongly its critical to have a followon body to pass the baton for critical modeling work that is still needed and not complete. We called for a 2015 conference on aging in partnership with the National Council on disability to focus on services and support issues. With that, i want to thank the commissioners for their hard work, our staff who gave their summer to get us a product done on time. I want to thank mark one more time because his knowledge of leadership throughout this was really important. We worked as a team from day one and its going to be critical to get the job done. Finally, thank you for the opportunity to testify today. Thank you. Thank you, chairman also been members of the committee. I would like to add to bruces discussion my own views on the financing issues in more detail. The commission reached a consensus that on the for personal savings and significant Government Support for the lower income populations, but we did not agree on structures or proportions. Some of the diversions arose from a lack of empirical clarity on several aspects of the problem which we try to address in the commission but did not have enough time and resources im referringde to our debates on whether medicaid is for the middle income or higher income households or capacity for working age is old adults to participate in the labor force and how to improve the private Insurance Market. Focusing on the older population, some expressed the view medicaid is a program just for the poor. But i see there is a significant extent for medicaid for those solidly in the middle income groups and above into their retirement. Evidence presented to the commission as well as the eligibility rules indicated that in many states, housing, retirement, Life Insurance is set aside in considering Medicaid Eligibility than many people who are in the middle income group and above do in fact get medicaid benefits. Still, there is much to learn about how sick if again is the spend down. Whats the true what would additional efforts ring in from the state estate recovery and how much do the elderly care about leading the quest for having expanded care coverage, care options god what medicaid currently provides . Some of us believe one way to find out is to set up an option for a medicaid carve out whereby on retirement, individuals have the choice of receiving a lump sum payment for a significant portion of their expected value of their medicaid benefits. This would be most for the poor, little or nothing for the best off. Retirees could purchase Long Term Care insurance in the place of medicaid coverage. Ageing to the working population with limitations, what we discussed indicated conflicting views about the capacity return or ability to k as significant reports to my understanding, they are not encouraging about that capacity. Project torted the assist states to achieve greater uniformity in the state medicaid buyin programs. Muchully, we can learn from these projects and changes. But even assuming the results are positive, its likely the policy changes will be costly. In light of the severe physical condition and the nation, we must prioritize needs by tightening the currently loose standards for workers above age 50 to qualify for Disability Insurance for medicare. Is a disagreement about the possibility to improve the functioning of the private longterm Insurance Market. We agree that currently it is a mess, but there was less consensus on the wise which leads to the prescriptions put forward. In my view, the problem is mainly one of the crowded effectively Medicaid Program and a lack of public understanding. At the same time, there are problems on the supply side, partly stemming from a restrictive state rules on insurance policy design and federal tax law. Some of us propose the following provide a tax reference for longterm Care Insurance policies through retirement and health accounts. We feel in terms of the savings that would arise from medicaid, this would cover the cost in terms of lower tax revenues. Second, we want to support combination policies such as a lifecare annuity. Such products would marry annuity to longterm Care Insurance, allowing individuals to finance their care. That would decrease the combined cost and ease underwriting standards, enabling more seniors to obtain coverage. I would like to note that although five out of six republican commissioners voted theavor, we all stated commissions recommendations should not increase existing budgetary commitments to health care faced by state and federal governments. Likewise, we believe raising taxes to Fund Additional title months is unwise, especially given the recent tax increases to pay for the aca. I want to echo bruce by stating my appreciation of fellow commissioners. They did the impossible it produced an important project on a very tight schedule. I also want to thank bruce for his leadership. He worked diligently to install trust and create an environment conducive to collaboration and dialogue. Enqueue. Thank you. I will begin again. Mr. Chairman and Ranking Member collins and members of the committee for the opportunity to testify before you today on the path forward for Longterm Services and support grade i appreciated at the outset your mentioning my ofvices and staff director the Pepper Commission which began about 25 years ago. As you can see, ive been at this a long time and i hope i make some progress before i need longterm care. We definitely need to get on with it. The experience and most recently as a member of the Congressional Commission on longterm care is why i am testifying for you today as well as my experience. I can tell you there is a lot of work to be done. Although policymakers are grappling with the challenges of assuring americans Affordable Access to Quality Health care, we have yet to seriously tackle the equally important issue of Longterm Services and support. Despite the continued local battle, even critics of the Affordable Care act recognize the need for insurance to assure access to health care and protection against financial catastrophe. But there is much less acceptance for the need for insurance when it comes to another healthrelated risk, one for which virtually all americans are uninsured the risk of needing Extensive Health with daily living like dressing, bathing or eating how much generally referred to as Long Term Services or longterm care. The financing that is critical to the building and effective longterm system, the recently concluded the commission stopped short of recommendations. Up did notpped support the Commission Report and offered an alternative report explaining as charge why and how congress should accomplish this goal. I request you include that alternative report i have submitted with my testimony in the record. Said, about 12 Million People have the need for Long Term Care today and i would remind us that while this is a special committee on aging that five ilion of these individuals are under the age of 65. The vast majority of these individuals count on their families for help, but families can only do so much. When people need care whether at home or in an assistant assisted facility, costs soon exceed most families ability to pay. That is where insurance ought to kick in. But private Health Insurance does not cover Longterm Services support and few americans have private insurance which typically costs a lot, offers limited value, and is on the to purge public side, medicare, which order people in some younger people with disabilities rely on for Health Insurance does not cover longterm care. The federal and state medicaid a valuables serve as last resort for people who need Longterm Services and support, its protections, especially home care, very considerably from state to state and become available only when people are or have become impoverished taking care of themselves. I would have to take issue with the comment because the evidence presented to us is that medicaid is not a program for the rich. The benefits are overwhelmingly going to low and modest income people. The need for expensive Longterm Services and support is precisely the kind of have a strong effect, unpredictable risk for which we typically rely on insurance to spread costs. Only two percent of that population needs services. The likelihood of being Long Term Care and expensive Long Term Care is also unpredictable for people when they turn age 65. An estimated three in 10 people are likely to die without needing the services while two in 10 will need five or more years of service. When we think about the risk in financial terms, half the people turn age 65 today will spend nothing on longterm care depending on their families when they needed. Very small percentage will spend hundreds of thousands of dollars. If, as you indicated and is often claimed, we really want people to be financially prepared the unpredictables unpredictable, catastrophic risk, we need to establish a reliable activism whether public or private or some combination to which they can contribute. To say we need a Public Private order ship but the real challenge is what role as each sector going to play . To effectively spread the risk and reach the broadest population, public social insurance that really spreads risk and everybody participated mustmphasized much be at the core of our policy. Private insurers can play a complementary role, but even its proponents recognized building future policy around the private market will at best leave eight in 10 americans uninsured. Public insurance can be defined in different ways. A can offer relatively comprehensive and defined benefits like through benefits a can offer new program and it can be funded in different ways. Part two taxes like a surcharge on the income tax and three savings from what medicaid would otherwise have to spend. Although i would have the size although there can be some savings to medicaid, medicaid is woefully underfunded and we need new financing to support a decent system in the future. Of the specifics, a public or social insurance proposal will protect all of us at risk and require all of us to contribute. In closing, i want to emphasize public insurance will not eliminate personal or family responsibility. , it will make shouldering the responsibility manageable and affordable through a private insurance or private resources and family care. Issocial insurance mechanism likely to eliminate the need for an adequate Public Safety net, whether within it or smaller Medicaid Program. Implementationnd of the aca demonstrates that will not be easy to enact long programs. Insurance but we should not kid ourselves. Without it, our policies will continue to fail people young and old, now and in the future who need care. Building an effective longterm Care Insurance system with Public Protection at its core is the only way to enable americans to prepare for the risk we all face. Thank you. Im going to withhold my questions and i will do cleanup so that we can get to our members. Senator collins . Thank you very much, mr. Chairman. About a decade ago, i authored legislation that became law to allow the federal government to provide a longterm Care Insurance row gram for federal employees. Not a subsidized program, but federal employees offer the benefit and the advantage of a Group Program that they could buy into. There have been some issues with the program, but one of them is not very many federal employees signed up for the program which you looke because if at the demographics of this country, one would think one at a young age could buy affordable , longterm Care Insurance and thus be protected. You talk about one of the reasons the longterm private Insurance Market is a mess is inadequate demand. Im wondering if most large employers offer this as the benefit, like fortune 500 companies . My understanding is about half of all large lawyers offered as an optional benefit. Very few will contribute to it. As an employee, pay all benefits, but half will offer it. The experience is similar to what youve indicated that many do not use it. I think you large, wellpaid 5 or 6 ofs, about their workers purchase longterm Care Insurance. I think there are a couple of reasons for that. By one eminent economist, medicaid does represent a type of social insurance and it is a crowd out to private insurance. Thats a significant factor. Retirement benefits or Health Benefits given by employers are taxed advantage, which provides an enormous incentive to get the benefit trade clearly, longterm Care Insurance is not a tax advantage benefit and i would say its a difficult subject to be frank. Has its downside and upside, retirement is something people usually look forward to. Longterm care is a difficult subject. Opinion, it is a subject best handled at the point near retirement which is why ive proposed and some of the commissioners supported this, creating combination of policies which would be at the point of retirement such as the lifecare annuity. Im very intrigued by that made certainly, if we longterm Care Insurance tax deferred, the way Health Insurance is, it seems you would employerser uptake by and employees. On the other hand, we are all aware that is the largest tax expenditure that we have with employerprovided Health Insurance. So there is a cost to doing business as well. I continue to believe another issue is people are under the misimpression that somehow im a the Medicare Program is going to their normal Health Insurance or supplemental Insurance Program is going to cover them. As people are living longer and if you look at the to stick some alzheimers disease, which are truly frightening, the need for longterm care is only going to grow. I think we need to do a better job in making private, longterm Care Insurance available and attractive to people. Just ask one more question. My time is rapidly running out. It has to do with home care. Most people i know would much prefer to receive home care rather than going to a nursing home. And yet we have a rather than going to a nursing home. And i am wondering what you think of changing the definition for the homeion health benefit. Health benefit, so it is based on the patients functional limitations and clinical condition, rather than on some arbitrary limitation on absences from home. I introduced a bill several years ago to change that. We were unable to get much traction for it. It is my understanding that the commission did address this issue, and you could tell us what the commission decided. Cracks certainly. Thank you for that question, senator collins. Let me start as a physician and general internist. It is all about function. We need to start there. Function in combination with whatus clinical illness is drives us and puts drives cost and puts pressure on families and systems. I starting there, i think you get to the right answer, and i think is slightly different than the one we have today. The homeboundt requirement is one of those areas we thought needed to be revisited. Let me say clearly on behalf of the commission that i think people understand the risk, that you do not want to create something that radically grows a program and increases cost. This is something that would need to be done thoughtfully. It is about finding the new right definition that helps the right people get the right services in the right place. The commission as a whole, republican and democratic appointees, cant you see this as a real place, where there is need for a definition that is more effective. Thank you. Senator scott. Thank you, mr. Chairman. It has been an interesting panel as relates to the topic. You are certainly welleducated on the topic and very passionate, i can see in your eyes. I may be here frustration from the number of years you worked on this project. You go from the mandatory get all in the boat together to freemarket solutions. I am going to follow more of the freemarket side. Even with the best Case Scenario we could take from dr. Feder, i think we can drastically improve the results. Having seen these homes, part of the challenge we face, it seems, is, when you go to a large group, whether the United States government or a larger group i dealt with, informing the individual who works for the company that the available benefit is there is a totally different conversation than getting them to sign up for that benefit. The real challenge is, when you have these large employers once you have enough agents or folks to help market and motivate folks to take a second look at what the actual benefits package includes, it is very difficult to get people to sign up for something they are uninformed about. That is one of the challenges dr. Mark or charles key warshawsky. Takes awayrmation from it. Somehow, your Health Insurance policy is going to cover this monday. If not, medicare will cover it. They do not understand you have to exhaust all your resources before medicaid becomes part of it. There is misinformation, in my opinion, that has to be addressed. There is a marketing opportunity. When you look at hybrid policies of annuities merging with Long Term Care, do we have an opportunity to create a different actuarial basis to reduce the rate for longterm Care Insurance, so as to make it more accessible to those in the public, adding a tax preference to that in an attempt to increase affordability and more access . Is that where we are going . Similar to the longest runon sentence in American History right now . Is that similar to what Life Insurance companies have done with the ability to get some of your Life Insurance benefit before you expire . If you know what i am talking about . Scott, you have adapted to the senate very well. [laughter] they said sooner or later i would like to hear myself talk. I am getting to that place now, sir. Pardon me. In support of what senator collins indicated, there is ample evidence that there is great confusion about what the government covers or insurance covers and what it does not. There have been surveys done by professor hal jackson at harvard law school, geoff brown at the university of illinois. It is quite pervasive, the lack of understanding. I think part of that is that there is not a good structure right now. In this, i think we all agree on the panel, regardless of our viewpoints on other issues in terms of publicprivate emphasis , there is not a good structure. I think the responsibility of government here is to create that structure. In terms of our viewpoint, in terms of emphasizing the private sector and private resources, that would include the tax incentive, and it would also include, as you have indicated, encouraging a life care annuity. The motivation there is a little insurancethan life you have indicated. In brief, the advantage is you create a pooling of populations that currently are excluded from purchasing longterm Care Insurance because they are in poor health, or Insurance Companies think they might be likely to become disabled. Therefore, they cannot purchase longterm Care Insurance. Whos precisely those people would be attractive to Insurance Companies in terms of the life annuity segment of a combined policy. If you combine the two, you track both populations and it is fair to both populations, occurs they are both getting a benefit they would not otherwise. It could be offered at a reduced cost. Most significantly, it could be offered to pretty much everybody with minimal underwriting, which is a great advantage in terms of creating the opportunity for more private longterm Care Insurance coverage. End, with the life annuity hybrid, that would work pretty well with folks who are typically your moderate income level and higher perhaps. For those folks struggling to make ends meet, the life annuity premium would probably still be significant. It is ford be people who have some retirement assets, clearly. Yes. Thank you. One final question, mr. Jones. On the mandatory i wrote down what you have said, but on too many pieces of paper. On the idea we need some kind of mandatory enrollment into an insurance product in order to create Economic Security for most americans. From my perspective my time is about up. Do you get five minutes or seven minutes on this committee . Given the felicitous nature of this prechristmas meeting, please continue. Thank you, sir. Our chairman on any of my other committees would do that. Had that confounded runon sentence, unfortunately. Hell me understand. My perspective on our entitlements today is, we cannot afford the ones that we have. The construct we work with is forget the 17 trillion in debt. The real challenge we have with that areon plans underfunded, the health plan we are overexposed to. We are of trillionuple dollars of underfunded liabilities. If we add a new component i am glad you asked. I will tell you, because of my professional background, the last thing i imagined myself doing as a budget analyst is suggesting to anybody that we need a new government program. At this foroking many, many years, and truly the idea i have been a pretty big fan of, there has got to be a way we can work with the private careterm share Insurance Market to create changes on the demand and supply side that would in fact really give many more americans a true opportunity to ensure. Right now to insure. Right now, we say people are unprepared. How can they prepare . It is not their fault they are not prepared. I do not have longterm Care Insurance. I know a lot about it. I know some agents that will help you today. I should point out my parents are signed up under the federal longterm Care Insurance. They are federal employees. For that, i really appreciate it especially. I think there are ways in which we can work with an Insurance Program so that it is financed in a way that is self funding. On this a lot in my company when we were modeling the class act a year ago. We were trying to analyze what the premium levels would the under a voluntary approach. The big problem we ran into over and over again was that you set the premiums low enough if you set the premiums too high, you are not going to get enough people to enroll, and you end up with an actuarial adverse risk pool. Exactly. I have not been able to figure out a way to come up with a Public Policy that would do what this country needs without going in that direction. I do think we know enough now to set it up in a way that the premiums would cover or the tax base, or however it is you could pay finance, for the benefits we would expect to pay out over the years. Or you are right. It is a risk. I understand and agree. My dear in the headlights look is not in authentic. It is real. My office will call your office. It will be great. It is real. My office will call your office. I want to again thank and welcome our witnesses today. And also offer my gratitude to our chairman and Ranking Member for bringing us together today, together today. Not only do you recognize that the Current System of longterm unsustainable,is but you have a resolve to continue to convene this committee to focus in on this. I appreciate that very much. To sneak in a few questions for the whole panel, if i do not have too long of a runon. I am teasing. The first focus i would like to have is sort of the role and value of state innovation in this, looking at this at the national level. Obviously, we have to tackle and debate longterm care financing at the national level. But i know lots of things are going on in the states. Have a programe called family care. It currently operates in 57 of our counties, with plans to expand to all. The gist of it is that it improves the Cost Effective coordination of longterm Care Services by creating a single flexible benefit that includes a large number and range of health and longterm Care Services that otherwise would the available in separate programs. Example of what a state is doing, i wonder what we can learn from innovation that is going on in the states on how to address our longterm care crisis. I do not know if you want to take a stab at it. Of thell start on behalf commission as a whole. I think when it comes to Delivery System and workforce, the answer is absolutely. While there are some things that can be done at the national level, care is the level vocally, they stunned the providers an array of services in the community, the city, the state. And it is based on the kinds of needs and desires of specific communities. And there is wide variation amongst the states. We, in conjunction with a commonwealth fund, produced a report card the Public Policy institute looked at, looking at the performance of various states across the country. Wisconsin was one of the top performers, number five in the country. There is robust creativity and person centeredness that drives wisconsins results. Are there opportunities to leverage state innovation with regards to how we support and how we address operational workforce questions . Absolutely. The single biggest challenge in building teams, the ability to delegate functions from doctors and nurses to other members of the caregiving team, is allstatebased, affectionately driven within state law. There are many opportunities, and wisconsin is a leader. The final question is one that comes back to the federal level. Framework, theht role of federal government in fighting leadership would be really important. Care isre aware that delivered. I think there is a lot we can learn from and a lot of success out there. Senator baldwin, i pick up on what bruce said about financing. That is in many respects the ballgame. I think we have seen a lot of innovation, a move in many states toward greater reliance on home and communitybased care. That is encouraged through the Affordable Care act, but needs more incentives to support that. Anne noted at the outset, states are facing enormous pressure on their Medicare Programs. You cannot innovate your way out of budget tightness. Even as we have seen improvements and innovation in some states, we see tremendous variation across states. That means there is home and communitybased care available fairly widely to some andlations and some states, very little to the elderly and others. Bruce says care is delivered at the local level. It is only medical care at the local level. Delivery is between the person and the caregiver. But the financing is critical to making those services available. What we see at the state level. I emphasize it at the outset the states, in order to control their obligations, create waiting lists. It is not about state innovation and delivery. They farm it out to managed care plans that may or may not have capacity, and too often do not have the capacity or experience to deliver care. It becomes a shift of the risk and a decline in insurance protection, rather than any kind of protection. Finally, i would say as we go toward, we did some analysis look at the future demands and the importance of federal financing for longterm care. If you look at the aging state, thein every numbers of elderly and the share of elderly grows substantially, will we continue to see it nor ms. Variation across enormous variation across states having fewer younger people to support all people. Tremendous variation. Said atdorse what anne the outset. If we continue the financing we already have tremendous variation and tremendous inadequacy in many places. That inequity and inadequacy is only going to grow if we do not create federal financing support. Would pretty much agree with everything that bruce and judy said. The commission did hear testimony on some of the state programs. Rhode island came in. They have a medicaid waiver. Many of us were very impressed by that program, which was save cost. Minnesota gave a great presentation on our website. It is also true that rhode talked about a waiver they had. It gave them more money, not less money. We are seeing federal policy to which proposes to take a whole lot of money out. As the chairman of rhode island, or president , we basically got paid to have a waiver. I think the administration at the time wanted to encourage waivers. They waited for someone to get rhode island and. I do not think that is going to be the common outcome. You all are very progressive in rhode island. In so many ways. Senator ayotte . Thank you, mr. Chairman. I want to thank the Ranking Member. , also want to thank paul forte who is here from portsmouth, new hampshire, who is someone who works in this area. I appreciate him being here today on this important issue. I wanted to follow up on this issue of waivers. Think it is related, certainly, to the important issue that senator collins raised. How do we make sure that the definition fits to allow more communitybased and homebased treatments, so that we are allowing people to stay in their homes longer . Because the average cost for care in a nursing home is approximately 80,000 a year. I can see this being important in terms of cost, that also in terms of people having a better quality of life. The waiver issue, thet, based on what Commission Found should we give states greater flexibility in this area for innovative programs that are going to allow more flexibility on home and communitybased care . Because i think that also fits in with this obviously would be defined by the overall federal definition that we would come up with. But i see this as an area where states would come up with a better idea than what we would come up with in washington. Maybe i will start on the half of the commission and fellow participants can weigh in as well. This was the place the commission gave a lot of thought to. Listen to the states, it was an area of real interest for us. I think the takehome message from that are two things. There was a recommendation that talks about simplifying the waiver process. Waivers often work in conflict with one another. You are not sick enough for that, too well for this. I think the notion of a much simpler approach to waivers was endorsed by the commission. I think the other concern raised by that was the issue of individual professions, beneficiary protections. Waivers deliver on the services that need to be provided. In that balancing test is, how do you create the kinds of flexibility where you get programs licks some of the ones we have heard from, but also make sure that in the process of providing more flexibility, we are not losing services for those who needprograms licks the is adequate oversight. Reviewingrience in waivers and thinking about ways in which the federal government can do a better job of getting has been thatty over the years, over the last maybe five or six years, we have seen a lot of loosening of those restrictions, to the point where states in fact have a tremendous amount of leeway, and the degree to which people do not have access to home and Community Based services has a lot more to andith budgetary issues keeping programs to certain numbers of people and certain , rather thanperson flexibility around the federal requirements of what states can do. With regard to cost, the waiver process, particularly moving people from Nursing Homes to home care, would save money or cost money was debated. We heard evidence on both sides. Witnesses came in. One said we would in fact save cost. Some of the Commission Members who are providers of longterm Care Services were skeptical of that. They said the system is pretty in the righteople spaces already. We did not hear a consensus in terms of whether that would be a cost saver or spender. Per point. To build on that. Home andxperience with communitybased care over many years we have been trying to expand it. I think there is general agreement that we get better value for the dollar when we are able to serve people at home and not in institutions when they do not need them. What we have so many people in need that we frequently need to build a system. We are under serving today, so when we offer services at home, we serve more people, which is a good thing, but it costs. With flexibility, and things i have heard, representatives of the governors say flexibility is not enough. They have got flexibility. What they do not have are the dollars. For many years, until recently, and i think that is the notion of politics, governors of both parties have joined to call on the federal government to take over the Long Term Care responsibility for dual eligibles, for Medicare Beneficiaries that are also medicaid beneficiaries, recognizing they are lacking the resources to do that job. It does not mean that cannot be involved in the delivery and there cannot be innovative delivery on the ground, that they are looking to the feds for dollars. I appreciate all of your answers. I am going to submit some questions for the record. And some of the followup on the things you said i appreciate all of you for being here. Thank you. Senator warren . Holding thisfor hearing, another important one. It seems to me this is another example of how middleclass families are getting squeezed. Important one. It seems to me this is another example of how middleclass families are getting squeezed. It is hard enough for any family to put aside anything for savings today, given the squeeze on families. And now we expect families to save for retirement and for longterm care at the same time that many are absorbing the costs of caring for an elderly family member. We are doubled up, here. Growing conversation about the Retirement Crisis in america. And in the face of this, the lack of a basic safety net on longterm care is just more fuel to the fire on the kind of problems we are going to face. And as you have made clear, retiring baby boomers are ill equipped to cover the full cost of their longterm care needs. Theys you have madewe have got have got lower savings as they hit retirement than their parents did. Only 18 have retired benefit lands. A third of all seniors, as they approach their senior years, have less than a years worth of income. Noyou have a third have savings at all. That leaves us with medicaid as a backup program, which can cover some of the cost. But the Current System forces seniors to spend most of their assets in order to qualify. Every bit helps, but to qualify when they have got to sell off all their assets this has other economic implications. Dr. Qualify when they have got to sell off all their assets this has other economic implications. I want to start by asking, feder, can you tell us a little bit about the financial instability that selling off assets causes our seniors . Thank you, senator warren. I think that when people talk savingsniors relying on care, iance longterm think they are insensitive to the variety of risks that come with getting older. There is the risk of a concern about having adequate resources to cover your needs. You do not know how long you are going to live, so you have to plan for that. There are ups and downs in what happens to your assets, as we have seen painfully with our recent economy, what happened to resources in that. Is the ability to assist your children, taking on their new lives, enabling them to do what grandparents did for the nowparents. And dealing with the fact that we have many young people, even those with an education, not able to get jobs, needing more assistance from parents as they age. And i am a grandmother, and looking forward to supporting my grandchildren and encouraging them in their education and building their independent lives. And there is uncertainty all the way around. When people talk about relying on your assets in order to take care of those needs, what you is saying is that that one lump. When you use them, they are gone. So many risks. I did not even mention the health care risk, the uncovered Health Care Costs seniors face. You are using your assets. Have got to you protect you against an array of risks. Catastrophic risk, like a serious need or intensive Long Term Care, is beyond the egg,ity of this nest little or moderate, or in some cases larger, to take care of. That is why it is so important that we need some kind of insurance mechanism to which people can contribute in order to give everybody security. Let me just go on that and frame the question a little bit differently. If you could explain why medicaid is not a very good substitute for a predesigned wellfunctioning longterm care system if you can just kind of summarize that for us. I will try to be thoughtful in this response. Primary when you think about what medicaid was really designed to do, it was not designed to it is not designed to protect individuals against risk. It is really designed to be there when Everything Else has failed. Which is really the opposite of insurance. Go ahead. That is a very good point. And i think it is critical to understand. A lot of people think, we have got medicaid, so i will be ok if there is a problem out there. Maybe another way to say it is to ask, is this a sustainable path that is, counting on medicaid to be the safety net, and at best only modest savings people are putting aside during their working years . Inwhat i see people doing the marketplace right now is essentially using their savings to purchase something that will keep them from being on the Medicaid Program eventually. In other words, it is not, in theory what you would want an insurance policy to do is to enable you to purchase what you need in the setting most appropriate for your needs. Whereas a Safety Net Program is , ingned simply to absorb the most custodial and warehousing situation, bare bonesfunded it is kind of the opposite of what you would expect a good insurance product to do. When in my own parents, encouraged them to buy insurance, my dad said, my federal pension will cover the cost of a nursing home. And i said, what wouldnt you like to stay at home . Let us ensure against being in a nursing home. Insure against being in a nursing home. May i ask dr. Chernoff to respond dr. Chernof to respond . We have Public Policy i have said this before. Public policy that is perfectly for 1972. The reality is that medicaid is a program that was predominately focused on women of childbearing age and their children. Was kind of its constitutional core, way back when. The average Life Expectancy was 69. As a physician in practice then, you would have just seen the first icu. The likelihood of surviving a fairly morbid event like a serious stroke or heart attack a different time and place. People are living much longer and will live with more serious functionalness and limitations. The problem is, Public Policy has not kept up with that. I agree with annes description the role of medicaid. I would offer that they know hypothesis, if we do nothing, is incredibly expensive that the null hypothesis, if we do nothing, is incredibly expensive. Medicaid. I would offer that they know hypothesis, if we do nothing, is incredibly expensive that the null hypothesis, if we do nothing, is incredibly expensive. We will all bear the burden families, states, and federal the problem is, Public Policy has not kept up with that. I agree withgovernment in an unstructured way. Make a specific financing recommendation and are having a broad discussion about the ranges of ways we might consider solving it, every single commissioner thinks it needs to be solved. I think this notion of a different model, and one that actually confronts the longterm care needs this country faces, as a way of taking pressure off some of the Public Programs what would it really take . What would it really take to design a program that fundamentally shores up medicaid, but also medicare . I will say as a doctor my last point, and then i will stop. The nightlight in this system is the emergency room. Medicare point that does not pay for longterm care. What when something happens in family and you throw up your hands, it is a trip to the emergency room. The emergency room doctor takes one look at that person and says, upstairs we go. And the process begins. What we are having together is the fundamental discussion about the need to think about a different structure to take on this issue in the process of shoring up our Public Programs. Ask the questions addressed r to ms. Tomlinson the questions addressed earlier to ms. Tumlison, you remind us that we are going to pay for this in terrible ways. Thank you, mr. Chairman. Thank you. Senator whitehouse . I hesitate to jump in, because as far as closing words go, what senator warren just said if we do in, because as far as closing not do something, we are still going to pay for it. We are just going to pay for it in really terrible ways. That is kindthat is kind of a gg soundbite for the whole thing. What i go after you, so i get to followup on a great closing. Ms. Tumlison about what we are seeing in rhode ms. Tumlison about what we are seeing in rhode island is people who have made the responsible choice, invested their money into a longterm Care Insurance policy, are now finding that the premium is going up pretty dramatically, to the point where for some people it is no longer doable. That is particularly frustrating, because you have paid in all this time. You have a connection to that policy. To bail on it makes everything you have pain already look like money down the drain, which in fact it is. So it strikes me that in terms of relying on the private sector to handle this problem, they are actually going the wrong way in terms of where the prices are heading and where the likely market share of affordable Long Term Care coverage is headed. Is that your feeling nationally, or is that just that is definitely national. Again, not to be missed rome too premiums my parents went up quite a bit, and that is in a really good program, about the best run Insurance Program that exists. And i think it points to not necessarily that the private sector is not up to the task, but that we do not have enough people in the risk pool for it to be a stable financial bet for an insurance company, particularly when you are paying benefits on a set of products that are coming due 30 years after you have sold them. When we modeled them for a class act, it is an incredibly challenging thing to do. Insurance companies out at the actuarial front, here. It is. I wish i had thought at that. Exactly. That is where we have been standing, and it is not comfortable. The problems they have let me turn to ms. Feder. We have known each other for a while. Good to see you. Take you for being here. I did want to follow up withyouy about privatepublic models. What would a couple of what you think the most likely and sensible models look like, very generally, in terms of bringing private contribution and Public Participation into this . As i said, and it is a pleasure to see you, a Public Benefit has to be at the core. What i have begun to consider and would like to see us spend more time on, and think there is some interesting, is thinking of a limited Public Benefit that would be available to people iod thatwaiting per would be determined i am thinking of the retiree population. We would adapt it for the younger disabled population. The waiting period would depend on what your lifetime earnings looked like a retirement. That would give a clear indication to families of what they were expected to pay before a Public Benefit would kick in. It would give Insurance Companies and i was interested to see recently that general you would know in advance what the waiting period would be on the Public Program. You would have to buy the first months or years. You would know that, going in. People who have not earned as much would have a shorter waiting period, and people who have earned a lot would have a longer waiting period. It would be adjusted to income. The Insurance Industry has the biggest problem when it is out , with actuarial frontier the biggest expenditures. Essentially, you are giving them some protection at the backend. I think that is something to explore. I think as we explore our options, there is another option. You give a limited benefit upfront, but everybody gets it. But that leaves the tail for the Insurance Industry to cover. That may be less comfortable for them. But i think we need to look at these options and see, what is it the Public Sector can do and guarantee that creates some space for private Sector Innovation . That is where i would like to see us explore. If the lasting i will ask, and it is a question for the record, is if any of the witnesses have information about what you believe the government costs present exposure to longterm care liability is right now, as we speak, your no hypothesis null hypothesis model. Cost, have an idea of the that would help us work with cbo and other people. If we are going to pay for people and there is a smarter way to do it, i would like to have that conversation, bearing in mind what the experts say we are going to pay for this anyway. I seem to recall that cms at one point did a present value calculation, sort of a mini trustees report, for that number. I do not know if they continued to do it. I do not know. That is why i made it a question for the record. If info could get back, i yield. I think you for wonderful leadership on these issues. It is not clear to me where we go. We have had two different opinions expressed. Argues that Public Benefit is the answer. Warshawsky, why dont you give us an opinion by setting aside the financial and difficulties. Why wouldnt a Public Benefit help . Those are very large set asides, senator. Particularly in these times. I think people need to be given choices. I think they need to design things as best fit their situation. And to be given the support they. Eed in a prudent way certainly, there is a role for government. But i think they need to be provided as much in the way of choices and opportunities as they can. And that provides the right incentives. Wantse we certainly do people who can afford, and i , tok minicam, many can finance these costs and to insure these costs, and that it is not an unfair burden on others for that to happen. Furthermore, i think they really do need i think it is a strong possibility and a strong likelihood that the private sector, with the right structure, would design different options of different policy designs that would appeal to different situations and different needs. What a think is impossible for a Public Program to do. Public programs, to be efficient at able to be administered we are seeing this right now in the aca have to be very simple and straightforward. That is why Social Security works. Choicesive people through a Public Program, it is administratively extremely difficult. Dilemma. Rein lies the because it is another public row graham that we would be creating Robert Program another Public Program we would be creating. Senate, iame to the was the elected insurance commissioner of florida. And the behavior of humans with regard to buying insurance, unless they think they absolutely need it they are not going to buy it. And this is almost out of sight, out of mind. Baseu want to spread that by getting the young as well as the old into it, it is going to be very, very hard to get people to buy this insurance. What do you think, dr. Feder . I agree with you, senator nelson. We have a lot of experience with that. I am always interested when we talk about rugged insurance and longterm care that we look at same timeat the looking at our experience with the nongroup, the individual Insurance Market for health care. We know that is a market that is because,ith problems in part, of a desire of insurers to avoid people with pre existing conditions and to limit their risk. And that is what you see, unless you have everybody participating. The idea i was discussing with senator white house whieth tehouse, which i hope we will all consider in the future i think it is based on a view that we can better educate and help people prepare, and how an industry respond. That do set up a structure creates some clarity about how you can prepare, so that if a Public Program takes on the tail risk, in some ways, and tells people, based on their resources, what they have to prepare for, you can better educate around participation in preparation. But that backend federal program has emphasized, everybody participates in, with taxes or premiums or whatever we are calling it. It needs to be a shared risk in order to work. That am a i cannot dr. Chernof help but smile, thinking about how you can get people to buy this insurance well ahead of time. You could have an individual mandate. If that sounds familiar, we have just had quite a debate about and it was declared constitutional by the supreme court. But it is not easy. You, on a completely whatrent kind of subject, we really had some problems in florida with assisted living facilities basically taking advantage of seniors. Nursing homes. Do you have any suggestions . We have got people starting these things up that are unlicensed. Obviously, they are breaking the law. But we are talking about the care and nurturing of our seniors. Did your commission suggest any things we ought to be doing . So, you raise a really important question, senator nelson. Actually, as a commission, this is not an area that we had a lot of focus on directly. , we had adirectly real concern that we we do not really understand how to think about or measure quality in this space. It is this is a space that has a lot of resources that are paid for privately or come out of or voluntary services. It lives in a different place than the rest of health care lives. Kind of our rubric for both regulatory oversight, quality control, and integration need a lot more work. But the commission itself, to answer your question directly, did not specifically go into great detail about these sort of alternative forms of Community Based support, there oversight it lives in oversight and regulation. I think we had more testimony on that then you are remembering, bruce. We had a lot of discussion on the workforce side. We had a great deal of discussion and concern about also had testimony as to quality problems in Nursing Homes, as well as assisted living facilities. Has been aars, there lot of policy effort to try to mitigate those, particularly on the nursing home side, but they persist. Inadequate standards and poorly trained staff. Because medicaid does not cover or does not finance assisted living facilities, there is a real concern about an absence of standards, as you say. I believe we heard a lot of testimony. I know in our alternative report we made recommendations we addressed staff on the training side. Iti know in our alternative rept we made recommendations we addressed staff on the training side. It has been an expose recently of a particular assisted living facility of grocery inadequate staff, while claiming to be offering specialized care for alzheimers patients or residents. It was both embarrassing and appalling and you saw it on national tv. And it is not a loan example. Example. We did hear examples of Training Programs and the need for them. I heard one in the state of washington. Better standards training for workers. Better, obviously, for the patients who they staff, while claiming to be offering. Pecialized serve and also creates better jobs, accompanied by better pay, for the workers we are relying on to care for our families. I would say and the commission made many recommendations on workforce. Your question was about the oversight and regulation of delivery entities. While we did hear a little testimony in that space, that is not a place where the commission made any recommendations. The workforce peace is onlyi dor older individuals with serious chronic illness or functional limitations or Cognitive Impairment. , verya very fractured providercentric system. And it leads individuals and their families to do the care coordination which is missing from most models and most systems of care. We heard about some models that are better. There are parts of better processes. The commission has a series of her commendations of things that could be better. I. And also creates better think ir younger individuals. Many of the systems that serve them were actually not built for them. For may have been built older people were built for a different population. I think for younger individuals with serious Cognitive Impairments, they have their whole lives in front of them. They are in a different place in their life trajectory than an older person is, and have the front desires and family work. I do think we have a long way to and particularly for younger folks with serious needs. Suppose we enacted a plan for private insurance. Then, the question comes, who is going to regulate it . To the turn it over state Insurance Commissioners or the state Health Regulatory agencies . Ms. Tumlinson . That is a good question. If we move in the direction of creating more incentives to reform the marketplace, to improve demand and supply and all of those things, we would continue to regulate it at the state level the way it always has been. But there has to be more of a federal role in setting the , and ines standards guess you could call it parameters about how these policies would be designed and work. I think performs have to come from the federal level. Issues around the regulation around the regulation around the insurance pools and of thing continue to operate at the state level. Senator nelson, i will just point out in the current regulatory setup, obviously, the states have the main regulatory responsibility. , thes part of tax issues federal government already does have some role in terms of both design of longterm care , and one policies would imagine that if there were additional tax incentives provided, naturally, it would go that there would be increase in responsibility. I will also note that one of the reasons for the increases in premiums is related to federal policy. That is the policy of the Federal Reserve board, with very low interest rates. Those policies were priced assuming a six percent interest rate. Clearly, we are nowhere near that. Is an interesting mix of federal and state issues at hand. The Commission Recommended that you remove the requirement that a patient must stay in the hospital for three days before they can receive services in a Skilled Nursing facility. There are a few of us up here that i agree with that. That agree with that. Can you tell us why you ended up recommending that . Sure. I think there was a sense that that rule was created in a different time and place. I would say that the commission felt that what it needs to be is revisited. It needs to be replaced, but it needs to be revisited in a model of care that is thought through. The idea has come down over time that the goal should be to get people to the right care by the right provider. By having this threeday length of stay requirement, there are people who maybe could step down to a lower level of care sooner, but are not able to access that level of care, or are put in a higher level of care or a different level of care, such as more rehab, which is expensive than the Skilled Nursing facility might be. I think our call was for there to be an opportunity to revisit and remove that threeday length of stay, and replace it with an approach that is more sensible and consistent with current care more expensive than the Skilled Nursing facility might be. Practices, being mindful that it was put there for a reason, which was really a cost control mechanism more than anything else. Taking it away creates new opportunities. We think in the current environment, it is not serving the cost control goal it was originally put in place to try to achieve. I will add that that was a consensus of the commission. And another element of it was that there has been a trend of patients being in hospitals, thinking they were admitted, and never actually being admitted. Count,re, that does not even if they are in the hospital five days. That struck us as plain wrong. It does raise the question of, what is the mechanism that does control that next phase, as bruce indicated . We did not have enough time to figure out the replacement. But the threeday rule struck us as not the right one. We are going to include in the record an article by Bloomberg News that illustrates how difficult it is to be able to afford longterm care. And this is our last hearing of the year, save for some unusual inng that we might be session on new years eve, like we were last year. [laughter] will you bring the champagne if we are . As a matter of fact, you remember new years eve, we were all on the floor, and i spotted one of my dear friends in his tux, sitting in as a the gall. I went over to him and said, charlie, what are you doing here . He said, jackie and i went out to dinner, and we decided this was the best entertainment in town. [laughter] except, perhaps, for the performers. [laughter] well, you all have been great. Thank you. It is a tough issue. And so thank you for helping us get into it and start to peel back the onion. We appreciate it. Happy holidays. The meeting is adjourned. On the next washington journal, we look at housing and mortgage trends and the in dash impact on the economy with lawrence yun of the National Association of realtors. Then discussion of the health care law. Our rent table roundtable guests are from Los Angeles Times and National Public radio. Every morning at 7 00 a. M. Eastern on cspan. Book tv is in primetime all week. Tomorrow night we look at the courts. About herle talks work, the roberts court. Then thomas healy discusses his book about Oliver Wendell holmes. Then a look at the terror courts. Watch book tv all week on cspan 2. Host author and president ial historian Richard Norton smith joins us now discussion on second term presidencies as as president obama is about to turn the page on the first year of his second term. Mr. Smith, at this point what can we say yet whether or not present obamas going to fall into a certain mold of a second term president . Guest it is amazing how people are in a rush to get beyond the next three years, theres a large part of the media that cannot wait for the next campaign horserace. They forget that that we have a president for the next three years. It is true that he has been experiencing what one might call the second term jinx. It is something that goes back to the very beginning. With rare exceptions. George washington had a very stormy second term. Largely over foreign policy. Americans were sharply divided over the french revolution and the impact upon this country. Thomas jefferson, who in his first term bought louisiana, and it was enough to get on mount rushmore, but in his second term again, european power politics, the threat of war, and he and imposed an economic embargo on american shipping to europe that really blew up in his face. Host how do president s make themselves relevant in their second term, especially in recent decades, there has been so much focus on the next election. Guest it is harder. The nature of our modern media are such that under the best of circumstances, with the notable exception of cspan, are disinclined to spend a lot of time examining the innards of Public Policy, theyre much more attracted to the horserace. Who is up, who is down, whos in, whos out, what do the latest polls show . I think it is interesting, if you look at the last two president s, one conservative republican, one left of Center Democrat each of them have have significant challenges going into the second term. Bill clinton had some real problems in his second term. It raises the question, maybe it tells us more about us and how we cover president s, than it does about the president s themselves. If it applies to president s across the political spectrum, maybe do something about the modern coverage of president s that predisposes them to problems in a second term. Host where is president obama right now in terms of historically relating to past president s . Politico in a recent story gave this comparison. In the december 8, 2005 gallup three months after hurricane katrina, president bush registered a 43 Approval Rating with 52 saying they disapproved of his performance. Almost eight years later to the day, president obamas Approval Rating in a gallup poll declined to 41 . Guest first of all, you have two different situations. In the case of the bush presidency, there was a slow, steady, almost leaking of the air out of a balloon. Katrina was a critical moment, but you had a fairly steady loss of support for the iraq war and that was kind of a heavy baggage that the president had to carry. If you remember, he also tried a couple of instances of Social Security reform, and he tried immigration reform, and he was unable to get his own party, let alone the democrats, interested. President is unique. In this case you have a president who actually is coming off of some pretty good numbers at the time