Transcripts For CSPAN3 Politics Public Policy Today 20150403

Than 226 billion a year, including 153 billion in costs to medicare and medicaid. These costs will skyrocket as the baby boom generation ages. Already our nations most costly disease, alzheimers is projected to cost more than 1. 1 2050 if nothing is done to change its current trajectory. Alzheimers is also one of our nations leading causes of death. The cdc lists alzheimers as the sixth leading cause of death overall, and the fifth leading cause of death for those 65 and older. Other estimates put the mortality rate much higher at number three, right behind cancer and Heart Disease. Moreover and most frustrating alzheimers is the only one of our nations deadliest diseases without an effective means of prevention, treatment or a cure. It is now estimated that nearly 1 in 2 of the baby boomers reaching age 85 will develop alzheimers. As a consequence, chances are that the members of my generation will either be spending our golden years with alzheimers, or caring for someone who has it. In many ways alzheimers has become the defining disease of this generation. If we are to prevent alzheimers from becoming the defining disease of the next generation it is imperative that we dramatically increase our investment in Alzheimers Research. Just take a look at this lx chart. At a time when the United States is spending an astonishing 226 billion a year to care for people with alzheimers, we are spending less than. 3 of that amount, less than 600 million a year, on research. And believe it or not, thats an increase that many of us have worked for. You can barely see the expenditure level on that chart. Alzheimers receives funding that is clearly disproportionate disproportionately low compared to its human and economic toll. Look at the second chart. We currently spend 5. 4 billion a year for cancer research. 3 billion a year for research on hiv aids and 2 billion for cardiovascular research. All investments that have paid dividends. These investments in research for other diseases have yielded tremendous results. Patients have access to new treatments. Death rates for some diseases are decreasing. Yet at the same time mortality due to alzheimers is escalating can do more for alzheimers and other diseases of dementia given their tremendous human and economic price. Fortunately, there is Promising Research that holds hope for alzheimers patients and their families. The Research Community is poised to make important advances through Clinical Trials and investigating new therapeutic targets. But Adequate Funding is critical to advance this research. The National Plan to address alzheimers disease says its primary goal to effect and effectively treat alzheimers disease by 2025. To meet that goal, the chairman of the Advisory Committee on Alzheimers Research care and services, dr. Ron peterson whom we will hear from shortly told our Committee Last congress that we will need to devote at least 2 billion a year to Alzheimers Research. Well, at first blush, that may seem like a lot of money. But when you compare it to that chart, 26 billion that were spending caring for people with alzheimers . Its less than 1 . And thats the context that we need to put it in. And thats why ive introduced a resolution with several of my colleagues stating that the senate will strife to double the amount of funding that our country spends on alzheimers in fiscal year 2016 and develop a plan to meet the target of 2 billion over the next five ye or perhaps tomorrow, the budget is on the florida. I also will be offering an amendment to the budget which im pleased to say is cosponsored by my Ranking Member, senator mccaskill as well and senator warner, senator toomey, and senator manchin. And we will also be calling on the budget to reflect that kind of investment. This is an investment that we simply must make to alleviate suffering and to prevent our Health Care Programs from going bankrupt. I want to acknowledge all of the advocates who are here today from all over the country. We need your help. We need you to educate members of congress and we hope that your presence today will be a powerful statement to all of our colleagues that they too, need to help us solve this devastating disease. Senator mccaskill. Thank you. I want to thank the chairman for her commitment to this issue. I think it speaks volumes to the people in this room that the chairman has scheduled this hearing so early in her tenure as the chair of this committee. That should be a signal to you that she is committed and i can assure her and you that i, too, am committed to the issues that she has eloquently outlined in her opening statement. I think that with the chairman as an advocate on your belaugh, we are in a very good place. I also want to thank all of you for being here today. From all across the country. Your spirit is inspiring. You have faced enormous personal challenges. Years of frustration pain sorrow sorrow, moments of hopelessness, and yet you find the strength to come here from all over the country and make your voices be heard. It is democracy at its finers hour hour as far as i am concerned. I look forward to hearing the testimony from from a member of the Witness Panel that is from the missouri delegation here in washington today. Kim stinley. I will have an opportunity to introduce her more thoroughly in a few moments but shes here as a caregiver. And her experience in nav gave the navigating the financial medical and housing system is probably more than anyone in this room. At one point many people believed that alzheimers disease was a normal part of aging process and that Treatment Options were either hopeless or unnecessary. We now know today thats just flat wrong. If we make the investments now we can in fact make treatment effective and we can make those treatments available to millions of americans and in fact citizens of the world. Effective treatments are necessary to alleviate the tremendous human, economic and medical toll that this disease poses on our nations families. We need to do something soon because this is a crisis. The cost for alzheimers patients is set to reach 1 trillion over 1 trillion in just 2050. Just think about that. 1 trillion. That is not a sustainable cost for individuals, families or our federal budget. Family care gives are the Unsung Heroes of the alzheimers epidemic. They provide the largest position of care for individuals with the disease. Care gives typically experience more stress, anxiety and lost productivity as a result of their increases responsibilities. While family caregivers provide needed support for their loved ones for as long as they can many patients in the later stages of the disease require roundtheclock care and are moved to nursing homes. According to the cdc, nearly half of all nursing home residents in the United States have residents with alzheimers disease. And with a few longterm care financing options, many families in fact probably most families depend on the Medicaid Program for their nursing home funds. It is estimated that 28 of the Medicaid Budget is spent on longterm care services. Much of that for alzheimers patients. I know that ms. Stimley can speak of some of the challenges of accessing medicare in help for her mom. By the way, her mom worked hard all of her life and retired with a tension but that a pension but that was not enough to cover the high cost of the care. This week we veetote on a budget. The budget we are currently debating does massive cuts to medicaid. Nursing home care and other Health Care Services for seniors and disabled would be slashed by 5. 4 billion in missouri alone. To the budget that were currently debating. These are middle class families that would be devastated by these cuts. I also want to echo the statements of the chairman about research. Government investment in medical research has allowed our nation to be a beacon to the world for hope. For a medical advancement. For being the country that is looked to. And that adds to our National Security. Because we are seen as such a leader in the world on medical research. Funding to National Institutes of health has flattened and suffered over the previous years. I am hopeful that the amendment that i am cosponsoring with the chairman will be a moment of bipartisan agreement that we cannot continue to shirk our responsibility in the United States to advancing medical research. There is no airrizonair area that is more deserving for additional dollars for medical research than alzheimers. All that said, those are problems facing families once theyve learned of the diagnosis. Yesterday the Alzheimers Association released their 2015 facts and figures report that found that about half of all people with alzheimers disease or their caregivers are not even aware of their diagnoses. Thats incredibly troubling. We cant go back to the old days when people were not properly informed of their diagnosis and a misguided attempt to spare them the truth. Not only are many individuals not being alerted their diagnoses, but many believe the mortality rate for alzheimers patients is much higher than projected. A study done by researchers at Rush University Medical Center found that alzheimers is now likely the third leading cause of dideath in the u. S. I look forward to hearing the testimony from our panel of witnesses about how we can confront the looming challenges and plan for reaching treatment by 2025. Thank you again for your leadership chairman collins. Also thank all of you for being here today. Thank you very much senator mccaskill. Senator moran is also a cosponsor of the amendment that well be offering to the budget for those of you from kansas out there. I just want to make sure i corrected the record. Madam claire . May i be added as a cosponsor . Is there absolutely. Id be delighted. I want to also say that im so glad that senator tillis from north carolina, senator blumenthal from connecticut, and senator donnelly from indiana from joined us today. I know they care deeply about this issue. We now turn to the testimony of our panel. Im pleased that joining us today, and on the Witness Panel, are barbara better known as b smith and her husband. B is a well known super model whos graced the cover of fashion magazines. Shes also an accomplished restauranteur for those of us who have eaten at her restaurant at Union Station know that. Retailer actor, and author. But nowhere are her grace, beauty and courage more evident than in her fight against early onset alzheimers disease. Dan gatsby is an entrepreneur, television producer, and entertainment executive and has stood by his wifes side every step of the way. By sharing their story miss smith and her husband are helping to make a real difference and we thank you. Next we will hear from dr. Richard hotus, who is the director of the National Institute on aging at the National Institutes of health. He also represents nih on the hhs secretarys federal Advisory Council on Alzheimers Disease Research, cure and services. He also coordinates the nih Research Efforts under the National Plan to address alzheimers. We will then hear from dr. Ronald peterson, whom i mentioned previously. He is the director of the Mayo Clinic Alzheimers Disease Research Center and the mayo clinic study of aging. In 2011 he was appointed to serve as chair of the Advisory Committee. Kimberly stimley has already been introduced by our Ranking Member. She is from st. Louis and will be talking about the challenges that our nations many caregivers of alzheimers patients face every day. We welcome you as well. And, finally it is a great pleasure to welcome to the committee dr. Heidi weirman who is here with us here today. For more than ten years she has served as a geriatric physician at maine Medical Center in portland, maine. And specialized in the challenges both physicians and care givers face when caring for an alzheimers patient. Again it is truly touching to see the sea of purple gathered in the hearing room today. But it is also a stark reminder of how many individuals and families lives are effected by alzheimers. So i want to thank the advocates who have traveled to washington. We look forward to hearing from the testimony and we will start with b. Smith. Thank you all for having us here today. I have i havent been spending a lot of time down here. But im getting back on the saddle these days. So its been a tough time for me because i do have early onset alzheimers disease. And im here because i want to make a difference. Im here because i dont want anybody else to have to go through this. Im here to ask you to make a difference, not just for the 5 million americans who alzheimers and their care givers but for the future generations who will face that. This has been this has been something that is very new to me because ive been so healthy for such a long time that ive never had anything like that. But what im going to do is im going to fight. Im going to do exactly what i can to be the best and to be better than the other person that i really even was. So that there are lots and lots of people out there who are probably feeling the way im feeling. Like, this should never have happened to me that type of feeling. Im sure there are many of that type of people. But there are many problems out here also. And i feel that im ready to work. Im ready to do what i have to do to be the best that i can be and to help as many people that i can help. And if i have to tell somebody that they shouldnt do something because, ill do it. And they will tell me i want to do it or i dont want to do it. But its important to me. Its always been health and wellness has been something that has been a big part of my life and a part of helping young people. And so today im excited to be here, im happy to be here. And i thank you very much. Ive got a lot to do in my future and im going to do it. And im going to do it the best way i can. And if i can help people and they can help me and we can do it together, even thats fine. But however we do it we just have to do it. Thank you so much. Mr. Gasby. Thank you chairman collins. I want to thank you for having me. Ranking member mccaskey and to the members of the committee, i love my country. Proud to be an american. Im a kid from brooklyn. And i never thought i would have an opportunity to try to make a difference. And this is the one time that i know that i can make a difference. Because ive seen what my wife has gone through. Ive seen a woman who virtually could do everything, who could sing, who could dance who could look at food and taste it and then cook it exactly the way it could be in a cookbook. Who did a television show, who did a hundred radio and television commercials, who basically always gave back. And now has to wait and help wait for people to help her. You know im reminded of a song that of all people jayz and kanye west wrote. And there is a lyric in there called the pain aint cheap. And the pain aint cheap for the five million americans who are suffering with the alzheimers disease. The pain is not cheap for the 15 million care givers that each and every day, every waking hour have to struggle as we do as a couple. My best friend. Watching her get up, try to do things, look me in the eye and say honey im broken. And when you see someone that you know knows that they cant do what their body and their mind has told them for 55 60 years, you realize that you have got to try to step out, step up and make a difference. Im here to tell you that the pain is not cheap because if we dont do something now the price we are going to pay 10, 15 years down the road or 2050 when it is estimated that 15 Million People will have alzheimers and as you have so accurately said the cost will be over a trillion dollars. You know the greatest resource that we have in our country is our intellectual ability. The greatest resource that we have in our country is a twoparty system, a democracy that works. The greatest resource we have is what we learn from generation to generation that we pass down. When you have alzheimers what you have is people lose that perspective. People in their 40s, 50s, 60s and beyond. You lose the ability to give people behind them the sense of accomplishment the sense of understanding and the sense of hope. You know, we have a modern day social tsunami. This is what alzheimers is. And when you look at it. When you look at what my wife has gone through. When you look at whats ravaging the African American community, im twice as likely to have alzheimers as my you know, caucasian counterpart. When you look at the fact that within that community my community, were getting tested and treated and found at a later stage. So the chances of being able to retard or handle the situation is going to be more costly than ever. You realize that weve got to stop it right now. Now, weve invested millions of dollars, billions of dollars as you said earlier in Heart Disease and cancer but we pay a pittance to alzheimers disease. And we know that by using a pet scan we can determine amyloid beta plaque in the brain. And if we find out that has happened, we can begin the process of taking care of ourselves through diet, exercise holistic practices and through that we may be able to ward off or slow down. So that we can allow what government funding and the intellectual capacity we have in this country to develop the means and the methods to make a difference. Im here today because i believe in america. You know, 30 years ago if you walked around with a telephone, you had it on your back. And today when you walk around it is in your hand. I know that we can take the gene code and break it down that used to take forever to figure out that we even had genes and now we understand the differences in different populations. I know drug trials make a difference in different populations that help the efficacy of a drug testing and treatment and bringing powerful new medicines to market. I no eknow that we have within the breadth and depth of great country the people who are committed. Last night i was at the alzheimers dinner and i saw a thousand people plus who all know the pain from also hiems but what imsaw saw there last night was a team. I saw a group of people from the deep south to the far west from the heartland of manyamerica to new england all looking each other in the eyes and saying were in the Tipping Point and were going to push this thing over. So i come here today to tell you i dont believe in big government. I believe in good government. And i know that whats happening in this committee is going to change the face of the alzheimers community. Last night i sat at a table with 10 other people and there was a young boy there. Hi his name was tyler. And while we were talking about all of the things that were going on and we were listening to lisa genova, i was looking at him and the only thing i could think was, you know, here is a 12 or 13yearold that if i said what is a cassette deck . He would go huh . If i said what is an 8 track . He would go what . Well i want that young man. That young boy tyler to when his kids are his age, he can look back and say i remember when we conquered alzheimers. And their kids are going to say what . Huh . We have it within our capacity here in this country to make that difference. And i want to be a part of it. Not just for her but for the future tylers in this country. Thank you both for such eloquent testimony. [ applause ] thank you so much. Dr. Hodes. Thank you chairman collins, Ranking Member mccaskill and members of the committee. Thank you for the opportunity to be here and the support that you have provided to nih and for the research. And to thank everyone here in this room for the opportunity to be a part of what were doing. Id like to spend the next few minutes just giving some of the examples of the state of research in alzheimers. The state which gives us great hope hope greater than ever before that the progress were seeing now will lead to improvements andality ultimately the ability to treat, and cure alzheimers disease. The next slide, this probably needs no elaboration. This is as referred to by chairman collins but is as illustration where we stand now in terms of the number of people effected with alzheimers disease and the projection of increase. Two to threefold in the next decades if we dont change the course. And the estimates of the cost to the right. Already showing alzheimers the most expensive disease and condition we face in the country with projections of it again increasing several fold as the population at risk increases. But there is reason to think, to hope. And there is an imperative we succeed in changing the trajectory. Next slide some examples of what were alluded to. Dan gasby referred to imaging as an indication as the ways o we gain insight with alzheimers disease not possible just a few years ago. These are significance that look at the amyloid beta and tau. Until recently they were identified only at autopsy. And this represents our ability to image these. And you see the slides here. Cognitively normal individuals are little of these deposits and next slide shows the contrast of individuals affected with the alzheimers disease. And you can see by the color codes of the intensity 2increase in those brains. But the situation is even more complex and challenging than that. If we look at the next slide. Here is another individual cobbively normal who has accumulation of the amyloid and tau in the brain. And were gaining insights only now into our ability to recognize these as the potentially very early stages of the disease before symptoms. Potentially before there is irreversible damage done. A stage at which we can begin to intervene and prevent progression and appearance of symptoms. So remember this and turn to the next slide. Another illustration of the progress made. I apologize for the difficulty reading but it is a time course of the genetic discoveries and shows in the early 1990s we discovered those genes that are responsible for very rare but tragic familial forms of the also hiems and then a feared of about 15 years we didnt discover any new genes until sequencing and other things gave us a new understanding. Were able to identify in these rare and tragic families such as the one illustrated in this study, in the south American Country of the colombia. By by imaging changes which a cur in the brain. So on the bottom loeft is the relatively normal scan of individuals within their 20s whether they have this alzheimers causing gene or not. To the right the individual who is did not inherent the screen. Look relatively normal in the brain. Bottom right those individuals are the gene carriers already showing signs decades before symptoms. And exactly in these individuals were now beginning studies prevention studies before damage and loss of cognitive function occurs with a new generation of the hope that we can make a change with this kind of treatment. Next slide. Just to emphasize these studies are being done in great and novel partnerships with public and private sector in investigating to the common goals of identifying new targets or also hiemsz and then studies to attempt treatments and the conditions we can monitor the changes and bio markers and tell early in the course of studies whethers the success or not in thesz this these interventions. And then to turn to another important aspect. Searching for cures and early insights no into molecular diagnoses we are recognize the importance of taking care of all the individuals now living the t disease and those who care for them. This is a care giver study reach. Designed to look at interventions making life better for people with alzheimers and those who care fur them. And the study as with any other Clinical Trial judged by success. It was enormously successful and was able to allow people to live at home longer and protect against the health risks and is now being disseminated through the va and nationwide in effort to decrease the burden of those who take on the most important job of caring are for those living with alzheimerssozheimers disease. Next slide. And finally just want to illustrate under the aegis of the National Plan we have a spectrum of the commitment illustrate illustrated here the goal of curing preventing by 2025. And equally important goals with care and enhancing Public Awareness and tracking through time. Thank you for this opportunity to give you the brief summary and look forward to addressing any questions you may have. Thank you. Thank you very much. Dr. Petersen. Welcome back. Thank you, chairman. Good afternoon chairman collins Ranking Member mccaskill and distinguished members of the Senate Special committee on aging. Id like to thank the committee for the opportunity to discuss the importance of alzheimers for this disease for this country and commend senators collins and klobuchar for introducing the resolution to double the funding for Alzheimers Disease Research in 2016 and achieve the goal of increasing the annual Research Budget to 2 billion in five years. As you know that in 2010 congress unanimously passed and the president signed into law in 2011 the national alzheimers project act requiring the secretary of health and Human Services to generate the first plan for this country to address alzheimers disease. The Advisory Council has just completed recommendations for the 2015 in january. The primary goal of the plan as dr. Hodes has just mentioned is to effectively treat and prevent alzheimers disease by 2025. This goal is but a short 10 years away. An essential feature of the recommendations submitted to the secretary and to congress includes the recommendations to federal government spend at least 2 billion a year in research on alzheimers disease. As chairman collins has indicated this figure pales in comparison to cancer, hiv aids and cardiovascular disease and yet in those cases there has been significant progress with regards to reduceing the number of deaths per year yet alzheimers disease is escalating. Also alzheimers disease again is an incurable disorder with no survivors. The Prime Minister David Cameron use hosted a summit on dementia. For that meeting we wrote a commentary for the journal the lancet suggested that member countries consider spending 1 of their annual care budget on research. In 2014 the United States spent 226 billion caring for people with alzheimers disease. And if we were to spend 1 of that figure on research we would reach the 2 billion figure recommended by the Advisory Council and senator collins. Last week in geneva switsds land the World Health Organization sponsored the first Ministerial Conference on Global Action against dementia. At that meeting i presented figures similar to dr. Hodes had just shown as to current numbers in the country, what they are projected to be by 2050. Then we superimposed the scenario of what if we delayed the onset of the disease by five years . How wouldbe impablg pacted . Another would be what if we were toibl to slow the progression of the disease . We might have thejx8me number of individuals but more people with lesser cree of impairment or preferable both of those. In a recent report from the Alzheimers Association it is projected that the if a treatment were to be introduced by 2025 that would delay the onset of alzheimers disease by five years, that treatment would reduce the number of individuals affected by the disease by 5. 7 million by 2050 and save all the payers including Medicare Medicaid and families more than 220 billion within the first five years. As recommended by the Advisory Council, if the government were to invest 2 billion per year the country would recoup this investment within the first three years after the treatment became available. All of the economic models converge on this point. They indicate that the savings to the federal government would more than capture the increase in investment and research in a relatively short period of time with an effective therapy. I would like to commend my colleagues at the department of health and Human Services for their work towards enacting the National Alzheimers Plan thaus far. Great strides have been taken with respect to alzheimers disease. However a great deal of work needs to be accomplished since we are not close to our goal of effectively treating and preventing the disease by 2025. I can say with confidence that the Research Community is poised to make a significant contribution towards the goal of if Adequate Funding were available. As outlined by dr. Hodes of the National Institute on aging he and his staff have established mile stones for the execution of the plan and now with the package to the alzheimers accountability act are working diligently to prepare a professional judgm congress outlining expenditures necessary to accomplish the goals set forth in the National Plan. We cannot wait until there is a more convenient time to increase funding for this disease. Projections indicate that alzheimers disease will bankrupt the Healthcare System as we know it today. We simply cannot afford to spend the afford mentioned over 1 trillion a year as projected in 2050 to care for individuals with alzheimers disease. The impact on individuals and families is the cost to society is unsustainable. We appreciate the difficult constraints under which the federal government is currently operating but our patients and families cannot wait. With 10000 baby boomers turning 65 on a daily basis, this problem is not going to be resolved by itself. We are all poised to make a difference given the opportunity. And considering there was a recent report of a new and promising drug made at an International Meeting last week in niese france we are encouraged that something is in the pipeline. Ultimately it will be up to the individuals such as those on this committee to make very difficult decisions regarding funding for alzheimers disease and related disordered Going Forward. We call upon congress to make bold decisions to alter the course of this disease now so it is not a burden to the next generation. And providing them with an intractable situation. The National Plan to address also hiemds disease has established a blueprint that would make this possible and we need your spotty. Upport. I appreciate the opportunity to address the committee. Thank you. Thank you doctor. Ms. Stemley. Good afternoon. On behalf of the 15. 7 million care givers for individuals living with alzheimers and other dementias, thank you for the opportunity to testify before you today. Alzheimers is a devastating progressive and ultimately fatal disease. More than 5 million americans are currently living with alzheimers disease or another dementia. The men and women living with alzheimers are your friends your neighbors some may even be be your family members. They are Business Leaders school teachers, store clerks and construction workers. There are both republican and democrat. And my beloved mother dorothy stemley is one of them. I am honored here today to share our story and discuss issues facing people with alzheimers and their care givers. I find the more vocal i am about how this disease has impacted my family, the more i hear from other people who have gone through or going through similar situations. Today my mother is lived in a Skilled Nursing facility in missouri and im confident she is receiving appropriate care and shes in the right setting. However, getting to this point was a challenge. And there are many families out there who never get the care and support they desperately need to face this terrible disease. For several years my mother and i were in denial about the changes in her behavior. I did a great job rationalizing unusual incidents. And she did an even better job hiding others. With all the rationalizing and denial came to an abrupt halt the morning i received a call from a stranger telling me my mother was in the middle of Martin Luther king, jr. Drive in st. Louis, alone and confused. She had slept all night in her car on the side of the street. My mother was a long way from home. And that day marked the beginning of our journey with alzheimers. My mothers diagnosis was the result of three different evaluations. Neurologists performed a number of blood and cognitive tests on her, ultimately concluding that it was in fact alzheimers disease. So there i was, an only child caring for my single mother who had alzheimers. I knew then that the world we had shared was no longer. And at the age of 30 i was thrown into a world that was completely foreign to me. A world of alzheimers disease. And i felt completely lost. After her diagnosis we didnt receive much information from her doctors about the disease or much advice on what do next. A friend of mine recommended looking online for help. I found the Alzheimers Association which is the first time light began to shine through the darkness. I was able to learn about the disease, what the diagnosis meant for both myself and my mother as well as what the next step should be in considering options for her care. I also learned how to cope with all the emotions i was feeling throughout the whole process. This is important because the stress of being a care giver was only compounded by the stress that i faced at work. My physical health started to suffer. I would wake up in the middle of the night with back spasms and my back pain was so severe that my own doctor recommended i make a lifestyle change just to maintain my own health. I did and now i exercise three times a week and i have been eating a healthier diet. However the emotional part of it continues to be very difficult for me. And when i see my mother now, it feels like day one every single time. At the time she was diagnosed my mother was living alone. She had exhibited other warning signs that raised concerns about her safety. For example my mother started a fire in her condo one day. And although no one was hurt, i knew then it was time to consider other living arrangements for her. We moved her into a seniors independent living apartment. Which provided her with the security hospitality and social outlet that she needed. She was able to live there on her own for another four years until her memory loss progressed to the point where additional care and attention were needed. The next step was my own personal nightmare coming true. Moving my mother to the Skilled Nursing facility where she currently lives today. Although my mother worked for 33 years and retired with a healthy pension, the high costs of longterm care exhausted her funds. We needed the Medicaid Program to afford the longterm care, and i am very grateful for the assistance. Based on my experience i know im not the only one who has had difficulty getting help after learning about an alzheimers diagnosis. I have experienced firsthand the gaps in our Healthcare System when it comes to dealing with this disease. Far too many physicians are not familiar with how to properly advise patients and their care givers after an alzheimers diagnosis. It took a friends advice not my mothers Healthcare Provider and finding the Alzheimers Association for us to even get basic information about what to expect next. No one could ever feel as lost or no one should ever feel as lost as i felt back then. There is no treatment for alzheimers disease. However there are many things that can be done to improve a familys ability to cope with the disease especially immediately following a diagnosis. This is why the hope for alzheimers act, which was reintroduced this week, is critically needed. The hope act will ensure that families like mine who are facing an alzheimers diagnosis are providing with Care Planning services to help guide them through their next steps. To some extent i feel blessed. I eventually found the resources and support i needed to manage my mothers condition and my own well being. If hoped han around at the time im certain i would have felt much less alone in the fight at the beginning. Until a cure is around we must work to support the family, the care givers and people with the disease immediately following the diagnosis. We need care. We need help. Which is exactly what the hope for alzheimers act would provide. Ive also had the opportunity to speak with many researchers about the current progress that has been made towards the development of a cure for alzheimers. Im disheartened because i realize that despite progress we still have a very long road to walk. Seeing in advancements in other areas as a result of strong federal investments and research makes me think of the opportunity that kes exist for scientists to develop a truly Ground Breaking treatment for this disease. One that could save families the heart ache i feel every time i see my mother. Alzheimers disease is one of the worst out there. I implore you do teamwork find additional funding for Alzheimers Research. Research is the only way we can truly create a World Without alzheimers. I thank you for the opportunity to testify today. I appreciate the support of the committee. And its focus on improving the lives of those affected by alzheimers. If there is one thing i would ask that you would take away from my testimony it would be that alzheimers disease not only impacts the diagnosed person but those that love them very daerl. Thank you so much. Thank you very much for giving us your perspective. [ applause ] thank you. Dr. Wierman. Good afternoon chairman collins, Ranking Member mccaskill and the distinguished members of the Senate Special committee on aging. I am very appreciative of this opportunity to be here with you. For who share my experiences treating and working with individuals with dementia and working with their care givers. I am a jeria tradition in maine with roots in or and my work is focused on dementia. I evaluate individuals and work with their families at outpatient center. I also spend time in the hospital working with programs. I work to prevent delirium which is particularly devastating for individuals who have dementia and experience that it changes the trajectory of their dementia in a very negative fashion. Dementia really is a looming crisis for our state and the nation. Maine has the oldest median age. Nearly 6 years older than the average median age in the United States. Which means we have fewer working aged individuals to help care for our older adults and particularly those with dementia as the their disease progresses. Projections from maine are that the 65 and older population is the only population that is going to grow in the next 10 years. Our total population will remain flat at about 1. 3 million. But we currently have about 37,000 individuals diagnosed with dementia. And it is projected to increase by nearly 50 to about 53,000 in five years. Dementia is an epidemic and it will have dire consequences on our economy, our Health System and our Family Structures if we do not act now to do something. Dementia stresses our state in many ways, including increased burden placed on care giver both paid and unpaid. A lack of safe housing. Needs for transportation in our rural state and a Healthcare System that is already overburdened. Many maine a about 2 3 of patients with dementia die in nursing homes. We have fewer younger people which means fewer former and Informal Caregivers to help. Without our Health System we are having trouble finding suitable places for care. This results in patients remaining at the wrong level of care in an acute Care Hospital when what they need is an environment to kier for them with their chronic and progressive dementia. This puts a lot of stress on family, on the patients themselves as well as the medical community providing the care. It creates a tremendous financial burden. Diagnosis and treatment of patients with dementia is not a routine part of Clinical Training for most providers and staff in many care settings. It is really critical our primary care system become prepared to deal with cognitive assesslement and Care Planning to provide the resources the individual and families needs to deal with this progressive disease. Currently dementia is a chronic terminal illness. And we need to prepare our Healthcare System and communities to provide planning and support to patients once they are diagnosed even as we search for that cure. I would like to take a moment to share a couple of stories. I have utilized pseudonyms for these stories. I first met mr. And mrs. Keller about 10 years ago when i diagnosed him with mild Cognitive Impairment. Sadly his disease progressed to alzheimers dementia. And over the next several years he had a gradual decline and developed issues with walking and swallowing. Eventually he began having more issues with eating and started to development frequent pneumonias. I began visiting him in his home, asa 2 u j nearly impossible for him to make it into the office. He had support from his wife from paid caregivers and entertainment intermittently from other family. Eventually we involved hospice and he was able to die in his own home as his wish. During that period i got to know his wife well. She was a very active woman involved in her senior community. She suffered significant anxiety as her husbands disease progressed and required treatment of her own. After her husband passed away i did not see her for a year. And then one day she appeared in my schedule as the new patient. She had developed memory loss. She no longer had a spouse who could help care for her. Her children lived away. They were around in the summer and could provide support. Mrs. Keller konded to live independently with caregiver support and eventually to assisted living level of environment. Her transition did not go well. She fell had a head injury. Developed delirium and has continued to decline today. She and her husband had tried to plan financially for all of their needs. But their private caregivers are expensive and the money ran out. She now resides in a nursing home. Her children felt very guilty that they were not able to provide the same support for their mother that allowed their father to die at home but the resources are simply not there. We need more flexibility and funding for caregiver support and alternative options for housing to care for individuals with dementia. And i believe in this case we would have had a better outcome. I have other cases and scenarios that i can share but i see im running out of time. So i would like to thank you for taking the time to hear my story. I implore you to continue to support increased funding for the support of caregivers and the individuals with dementia now to support alternative Housing Options and Creative Community supports for individuals with the dementia. Ultimately of utmost importance is the identifying ways for prevention and cure of this devastating disease. Thank you. Thank you very much for your moving testimony. Ms. Smith and mr. Gasby. When we were talking informally before the hearing you talked about the Public Service announcement that you had made. Could you share with everyone here what you did to try to expand awareness and participation in Clinical Trials. Yes, senator. We are affiliated with the Brain Health Registry. And what the Brain Health Registry does is it goes to get people to participate in giving information so that they could be considered for drug trials. One of the main impediments to getting more funding more research, more drugs online is that we dont have enough people to participate so that they can be considered for these drug trials. And particularly in minority communities. Theres been a with the tuskegee experiment with things that have happened in the past, myths and some realities African Americans and people who are not caucasian are not participating. What most people dont realize is that to bring a drug to market costs billions of dollars. And you need to have a genetic pool, a diverse pool. And so you need different people from different backgrounds. You need women, you need men. You know you know asian you need latinos. You need African Americans. And this brain Health Registries registers folks so they can be considered for these drug trials. And what we wanted to do was we wanted to break down that stigma stigma, that its okay. You know that government does do good things and going to trials it is not going to be the tuskegee experiment all over again. There are so many myths and so many taboos that have been existing out there. And we wanted to make sure by being involved we wanted to let people know we have to do this. Not just for ourselves but for the future to find the right medicines. Thank you. I want to thank you for doing that psa also. Ive had the Opportunity One of the great things about that psa that we did was that it increased the overall participation by, you know, 6 within the minority community. But also overall more people signed up. Because they werent aware they needed this diversity in the gene pool. Thats really terrific. Particularly since African Americans are more likely, as you pointed out in your system to get alzheimers. I think your being out there has really helped to increase awareness. And i thank you both for that. Thank you senator. Dr. Hodes, ive started visiting research centers. And ive talked to dr. Petersen at length about the wonderful work at mayo. And just two weeks ago i spent an hour and a half at Massachusetts General Hospital talking to the Alzheimers Researchers there. And i must say and i want to share with this audience that i see great promise and great hope on the horizon. One of your charts talked about the imaging that is now possible, which wasnt just a few years ago. Alzheimers could only be diagnosed definitively through a brain autopsy. Now we can do imaging that shows the beta amyloid plaques and the tangles and the tau. And i learned at mass general that there is actually an antibody that can be given when the beta amyloid is developed. And i dont know how effective or what stage that is at. But there was so much Exciting Research going on just at mayo and mass general. I cant wait to go to university of pennsylvania and to other research centers. Im sure there is one in missouri as well. But the problem is with only 600 million you cant possibly fund all of those Exciting Research applications. Can you give us some idea of what percentage you are able to fund of the promising projects that are out there . Thank you for the question. It is very much the case that the wealth of excitement opportunities gifted and committed scientists are proposing research far in excess of our ability to fund it now. The answer to your question in terms of percent can be answered in a very real but in a sense superficial way just by looking at the success rate we have for the pay line for applications. So that of the applications that come in in Alzheimers Research we are able to fund now in the range of 11 or 12 . It is easily said that twice that number or more are considered by peer review experts in the field as absolutely outstanding e e meritorious of support. So even at that level of the research weve already proposed there is great room for more that could be and should be funded if there are adequate resources. Beyond that the ability to initiate and recruit new areas not even yet the minds is a dividend we very much look forward to. And of course if researchers saw a bigger pot of money available, that too would produce more submissions. But 11 to 12 when at least double that number are worthy of funding i think is another strong argument. Senator mccaskill. Thank you. I want to thank all of you. It is true this disease also disproportionately effected women, correct . More women than men . And more African Americans than caucasians . Lets talk a little bit about the reality of medicaid in this equation. We have two issues really were talking about here. One is investing in the research. The other is making sure that care can be given. Ms. Stemley, we live in a state where they have refused to expand medicaid. Refused to draw down the federal dollars available for healthcare in our state. And the budget we are currently debating cuts medicaid by another 400 billion. In this country. Im not sure that most people realize the percentage of nursing home patients that are a, suffering from alzheimers, and b, needing help from medicaid medicaid. What would you have done and i think there are stereotypes around medicaid that are terribly unfair to women like your mother. Your mother worked 33 years. She had a pension. She had a plan. And then she got alzheimers. And you found yourself having to access Medicaid Services for her longterm care. What would you have done if those Medicaid Services were not available . If there had been a block grant in missouri like the house is done in their budget and the money was gone because it was october, what would you have had to do . Senator mccaskill, i dont know. That thought first of all i was not familiar with the medicaid process until we were thrown into this world. And so there have been many nights through this process when understanding the costs of longterm care and the realities of what we were facing. Because you are now facing the financial fight. Because now you have an extraordinary price tag to this disease. And then you have the emotional, the physical. And then you have that fight to go through. Initially just understanding the costs that we were about to go down this path there were many nights that i was very scared. Because i know she does have a good pension but she doesnt have the pension and we dont have the resources to pay 5,000 plus 8,000 10,000 in certain cases a month to have a longterm care facility. I didnt know what we could do if we were going to be denied. I didnt know if she made too much if she had you know, all of these fears come into your mind. Do i make too much . Do i make too little . Am i going to be denied. And it wasnt an option to be denied. I had to have the care. One of the very disheartening parts for this from me. And you pointed it out. Is my mother is a very proud woman. And she did work for 33 years. And she worked for the federal government for 33 years. And shes very proud of it. And even today her mind sometimes thinks she still has to go to work. For the government. And so we, you know, we play and do those sorts of things. But to know that all of those years of work are exhausted by a disease and not transported forward through an inheritance or her grandchildren dont get to see it. And there arent things that she is leaving behind for her family. But this disease is exhausting everything is heartbreaking. So i dont know what we would do. But that alone has been my fear many a nights. And thats why i said, i thank god for medicaid. And at the same time weve never needed for anything. You know, we are i guess a middle class family. And so ive never been in a position to have a need. And that was humbling to be honest. But i am sure am and are grateful for it because where would we be . Well i sure hope you and all of the advocates in the room carry that message. Because i think there is the the stereotype is harming the Medicaid Program. I think there are people comfortable assuming that the only people who need medicaid are people who havent worked hard, are people who arent trying. No. And nothing could be further from the truth. Particularly when it relates to the longterm care in this country. It seems to me that not Funding Research is dumb. Because it is going to cost us a lot of money. And refusing to fund care is cruel. And so i hope that you all will continue to advocate in every office in the capital on those issues. Thank you. Senator warren. Thank you madam chair. And i apologize for delay in trying to get here. I was also trying to cover a banking hearing. But i wanted to be here. Alzheimers forces families to watch helplessly as their loved ones slip away. The high cost of care also frequently stretches families to the breaking point as youve just testified. According to the Alzheimers Association well spend 226 billion dollars caring for people with alzheimers this year. And by the year 2050, the yearly cost will be more than 1. 1 trillion. Now when the director of the National Institute of Mental Health testified in front of the help committee during the last congress he noted if we can prevent or even delay the on sept of dementia we could save billions of dollars. He also said this is really a matter of choosing to invest in research now or choosing to pay up in a big way later on. Clearly congress is choosing to pay up in a big way later on. Congress has reduced the purchasing power of the nih by nearly 25 . And last year, nih spent only 562 million on Alzheimers Disease Research. That is about 2 10 of 1 of what the disease cost us last year. Dr. Hodes, can you tell us very briefly how the reduction in support for nih funding affects you and your colleagueses on alzheimers . Thank you for question. It is the case that the progress is not being limited by great idea os for scientists of capable of carry ought the research but our ability to support it. And as an earlier comment i noted, even if one looks at the number of outstanding applications currently being proposed by scientists and the proportion of those that we can fund, it is a conservative estimate that we could fund twice as much as we do now simply by the ideas being proposed and being moved forward a at a greater speed. And that is the first iteration. Undoubtedly with more resources we would be able to recruit new investigators and establish new infrastructure for more innovative approaches. So what you are really saying is were funding half or fewer of the potential research avenues that might give us a the cure of alzheimers. Of the outstanding proposals that are currently being submitted to us yes. Thank you. And dr. Petersen could you just audit add to that please. I think another ramification of that senator warren is the fact that with the reduction of federal funding there is also reduction of number of new investigators going into the field and that is going to krim cripple us down the road. If the young investigators see the old guys like myself struggling for fmwng in Research Settings they are saying how am i going to survive . So im afraid were turning off a young generation of investigators. That is a real concern. So high cost right now by not funding Alzheimers Research. High lost longterm. Every member of congress ive spoken with says they support nih and more medical research. But medical Research Takes money and congress has done absolutely nothing to get more money into the agency. The House Republican budget and the Senate Republican budget were released last week and both say they support medical Research Funding but what the republican budgets actually do is lower the budget caps that are already crushing our research agencies. Making it likely that the agencies like the nih would see cuts, not increases, under those plans. Now earlier this year i introduced the medical innovation act. A bill that would boost nih funding by about 6 billion dollars a year. That is not enough. But it is a start. And we can do it without raising taxes. Without gutting critical programs. Without gutting Vital Research and without adding a dime to the deficit. I hope that my colleagues who are serious about funding the me in this effort or bring other ideas to the table. Because talk is cheap. We have an opportunity to make a real difference in the fight against alzheimers. An opportunity to save billions of dollars in Unnecessary Health and longterm care spending. And to give families their loved ones for more precious time. Were going to miss that opportunity unless Congress Steps up and funds the nih. Thank you madam chairman. [ applause ] senator scott. Thank you. Senator scott welcome. Thank you chairwoman collins. Thank you for holding this hearing and giving us all an opportunity to interface with so many people that are committed to the cause and for all those folks out there with purple on today, thank you for your investment of your time and your energy on such an incredibly important topic. Know all of your offices have been filled with your enthusiasm and your real life stories. I cant think of anyone here on this panel who has not been impacted personally by alzheimers. And for me at least alzheimers and parkinsons in watching the challenges of our loved ones. My grandmother passed pay in 2001 and just seeing the devastation and challenges we faced. But also those who have been support systems. If you have been blessed with the opportunity to care for someone with alzheimers would you raise your hands . God bless you. And thank you. Its amazing the impact that the disease has not only on the patient but on the family. And on the loved ones. And it is such a powerful witness that the focus that stopped by my office today spent a lot of time talking about their loved one, their commitment to making sure that the research and the resources are available for the others who may be impacted by the disease as well. So i thank you for your energy and your enthusiasm. That keeps all of us focused on the topic. My question is for dr. Hodes. Thank you for your expertise and thank you for your contribution here today. As the great opportunity for me to really spend time talking about the success that weve had at home in South Carolina, the medical university of South Carolina. And so many folks representing st. Francis Hospital System that has invested a lot of time to make progress. In particular in charleston has received more than 20 million in grants researching treatments and caring for hundreds of alzheimers patients each and every month. Since 2006 the South Carolina aging Research Network has also been doing some really great work on this issue in conjunction with other hospitals and research universities. There is still so much work to be done. I hear optimism though from researchers in our state who believe with the right resource they can do the most amazing things. The question i have for you doctor is what does progress look like over the next 10 years from for your perspective . And are we meetsing the nationalize alzheimers project act milestones and updating them appropriately so our researchers are the working on the critical projects. Thank you for comment senator scott. I think there is well justified and newed enthusiasm as potential for progress. As we a convergence on more and more insight into basic molecular cellular mechanisms behind alzheimers disease. In terms of the planning that is now in place as an intensified product of the National Plan, we on a regular basis, most recently with a summit held just last month here in bethesda in the Washington Area convened regularly experts to help us update and renew areas of the highest priority and establishing mile stones what we need to accomplish year by year and that is the object oift in terms of some of the accomplishments that weve seen in recent years as noted in some of my opening comments and comments for the record weve seen progress in the act to identify early stages of alzheimers disease to intervene with new treatments, aimed at newly molecular targets and if theyre working or not by tracking markers long before we notify profession to symptom disease. I should add as much as were pursuing this, were working to sustain quality of life for those. Research proposals from your state and across the country are enormously grat lyly gratifying and exciting. The disappointment and pain and anguish of great number of applications were unable to support. Were making progress without question toward the result a mat goal. The pace is linltmited be by the amount of research we can support. Thank you. Thank you very much senator. Senator whitehouse. Thank you madame chair. Let me open with a question and comment. Dr. Peterson i was on the budget committee. I havent been here for the whole hearing. Could you be more specific about what you think the prospects are for a cure . How confident you are . How many viable paths towards a cure there are so that a non doctor like me can get a sense of how much confidence we can have . Thank you senator whitehouse. Excellent question difficult one to answer definitively of course. I think theres enough Exciting Research out there now, perhaps on new targets. This is a complex disease. Its not just a single cell disease. Really involves networks in the brain. There are multiple targets out there. Were somewhat encouraged by a report just last week that one of the drugs thats under investigation for alzheimers disease to remove the plaques in the brain in early phase one results indicated in fact there may be a path forward with this particular therapeutic. Plaques were reduced in patients measured over a year and patients improved. Very early phase one study. Theyre moving forward with phase three. This type of discovery is going to lead to a hit or more than one hit in the relatively near future. To say how many, when is difficult. Im encouraged a that were on the precipice of handling this disease one way or another. Dr. Hodis briefly. To reinforce what ron said. We dont know yet which are going to be the optimal targets combination of targets. The input from brilliance of minds we can converge on is taking example on some of the best candidates for treatment and beginning the most rigorous Clinical Trials and at the same time recognizing. Its important to maintain early science looking for molecular genetic targets building those to the next candidates. We may have short term successes with current understanding we have. We couple that with commitment to deeper and better approaches to the future. Well, its inspiring to hear that. Im struck by the same fact that my colleague senator warren was struck by. Having worked through the budget level at on the committee being on the floor with budgets now. People can talk a good game but the fact of the matter is if you like sequester, the house budget cuts below sequester on discretionary non defense spending by nearly 300 billion. Its going to be devastating if a budget like that goes through. And the fact the House Republicans were willing to support that is a statement that nobody in this room should ignore about the value of the support. Not just for research but also support of families who have got it already. Mrs. Stemly said so eloquently. Ive heard speeches about how critical our deficit is and we have to address our deficit. A pair of senators said on the floor last night how critical it was to invest in National Security. We hear people saying how critical it is to invest in medical research. When it actually comes to the budget, well over a trillion dollars goes out the back door of the tax code through tax loopholes, favored rates for people. Guess what a lot of that got brought in by people using political power to get benefits for themselves. A lot of this is disgraceful on the merits. Do you know how many tax loop holes either the Senate Republican budget or House Republican budget closed to address the deficit or closed to address National Security or closed to address medical research . Zero. So the true primary operating principle of both budgets is every tax loophole is sacred. Everything else comes second. Its very frustrating to hear you testify in such good faith and hear such prospects for progress and know how many people this illness effects and be in an environment in which every tax loophole is viewed by some of us as more important than those issues. My time is expired. Before i call on the former chairman [ applause ] before i call on the former chairman of this committee senator nelson with whom i worked so closely in the last congress i do feel compelled to respond to the senators comments. You know, alzheimers affects people whether theyre democrats, republicans, independent, greens, males, females, caucasians asians, africanamericans. It affects all of us. It touches all of us. The worst thing we can do is to make this a partisan issue. [ applause ] i have led the fight for more funding for alzheimers for years. Weve made not nearly enough progress, but we have made some incremental progress. It has never been a partisan issue. So with all do respect to my dear friend from rhode island, i would say if we want to achieve what everyone in this room wants to achieve and that is to get a doubling of the funding as soon as possible, and then increase the funding to the 2 billion that has been recommended by the council, lets work together. Together. [ applause ] and i agree with everything the chairman has said. I just want to say that we do have our colleagues that will work together. We are fortunate that one of them is chairman of this committee. But we do have challenges that are represented by im not pointing out just republicans or just democrats. There are members of congress that do not see the value in funding Government Agencies that do research is. And you know, what well find is there will be some colleagues will work in a bipartisan way. You know senator nelson is one of those. You are one of those. I am one of those. Dont leave me out. Im one of those. And youre one of those. I want advocates to realize its time to hold everyones a feet to the fire regardless of their party. That the reality needs to match their rhetoric. You cant engage in the rhetoric of i support Alzheimers Research and then cut funding to iah. That wont work. It wont be my colleague, but there will be some. Those are the people you need to focus on no matter what party. Thats the issue some of my colleagues on our side were discussing. Not everyone is as reasonable as the chairman of this committee in terms of working in a bipartisan way. Some want to dismantle public funding of everything from many Long Term Care programs to in fact nih funding. Not you but others. Senator nelson great to have you here today. Its great to be back madame chairman. Thank you for the great partner that you were in leading this committee over the last couple of years. Now, to those of you in the audience, you applauded two things. You applauded higher money spending for nih for research. Certainly that graph right there indicates more is needed over 5 billion for cancer, 3 billion for hiv aids 386 million for alzheimers. You also applauded2zzjc bipartisan ship. Well, i want to give you an assignment. Now, this committee is bipartisan. Thats the way it has been run the last couple of years and the way its being run now by the two leaders. When money is being cut according to something called a sequester which is nothing more than a meat cleaver across the board of the entire budget and that happens to get nih as it did three years ago when dr. Frances collins the head of nih had to cancel 700 medical Research Grants to Research Institutions including universities and medical Research Institutions. Thats going to affect the very thing that youre so concerned. And so my assignment is that you need to have a prayer session with the members of congress who are voting to cut nih. Now, let me say to mrs. Stemly and mr. Gasby. Youre doing incredible work to make sure your family is taken care of. We understand the sacrifice and the unselfishness with which you approached. Mrs. Smith, it takes courage to raise awareness of the disease. So thank you for being here and highlighting that. Dr. Holds and dr. Peterson its great to see both of you again. Thank you for coming back to update us. Thank you for your continuing work. Dr. Weirman. When you have conversations with your patients can you broach the subject . Do you tell them what theyre going to have to plan because hes a report in the Washington Post that says that less than half the people with alzheimers reported that they had been told about their dementia. So, what do you do when you advise your patients . I work with folks with dementia at all stages. So what they hear is different different stages. Early on its about the diagnoses and what treatments are available and where theyre at now addressing current issues. Usually in subsequent visits its future planning. That involves them and caregivers and surrogate Decision Makers assuring they have a plan in place for what they want to do whats important to them. That also includes looking at their financial situation and understanding whats realistic for them to plan for this the future. I recommend a lot of consultation with law attorneys. I can ask caregivers to be realistic about what they can offer. Thats really important giving caregivers permission not to take it all on their shoulders. Unfortunately, i do have to advice at times that our Hospital System is the ultimate back up if they get into crisis. Despite all our planning thats where people have to go in our community. Its really unfortunate because its really not a great place to be when you have Cognitive Impairment. Its very much part of my practice to do that. Its challenging for primary care physicians that take care of a broad array of parkts to approach that routinely in practices. Were working with them hopefully to begin incorporating that. I think whether you have dementia or anything else, youve got to talk to your families, make sure youre thinking about the what ifs. Its hard to do that but we all need to whether we have dementia or not. Well, all of you this is one of the larger audiences for a Committee Hearing in the months that weve started this new congress. I would take your concern, your energy, your activism and share it. We are right on the cusp. The researchers out in nih will tell you this. Were right on the cusp of finding cures for many different kinds of cancers. We know a lot more about cardiovascular. Look at all the advances in hiv aids. Theyre even talking about taking some medicines, attaching them to hiv virus as a way to attack some cancers. I mean, it just blows your mind whats going on. What we need to do now is focus and get the Research Done to be on the cusp of solving this problem in alzheimers. Thank you madame chairman. Thank you very much senator nelson. I know that senator cane is on his way. Well do a couple more questions and hope he can get here. And boy what good timing. While hes getting set up, im going to follow up with a quick question for dr. Wireman. I was surprised to learn from your testimony that the diagnoses and treatment of patients with dementia is not a routine part of the Clinical Training for most health care providers. If you look at the trajectory of alzheimers and other dementias and the number of people and their families that are going to be affected in the near term, we hope well have a cure or means of prevention or effective treatments for long term. That lack of training really surprises me. Is that changing now in your judgment . Why do you think there isnt much emphasis put on that training . There has been a lot more emphasis in the last few years as far as setting milestones for medical education all the way up through residency training. I think weve made headway in the medical community. I think its incredible variable when different individuals go to different programs what they get. Most get training in older adults but not specifically in Cognitive Impairment and working with dementia. What they get probably isnt enough at this time. In my experience each of us has our own individual personality and experiences. You throw a disease that affects your thinking ability on top of that, and it looks very different in different individuals. It takes a lot of experience and a lot of training to work with these individuals and their families. You really need to do that. There needs to be more emphasis and more time on this. This goes from medical providers, from your front line staff whether Office Assistants and people answering the phone and scheduling appointment miss medical communities. We need to be working within our outside the medical community in our larger communities with education and training for identification. Weve done a lot many in the Banking Community about looking for exploitation and that sort of thing. We need to continue that. At one time we were training hairdressers to look for and talk to clients for evidence about physical and emotional abuse. We need to do similar things with others in the community to help us identify individuals having issues so we can work with then. Thank you. Senator cane. Thank you madame chairwoman. Thank you for filler bustering a bit until i got here. This was deeply important to me. I was in an Armed Services hearing. I want to thank you guys so much for doing the work youre doing to really educate and demonstrate the challenges of early onset alzheimers. Its a difficult thing. Obviously in the midst of a difficult thing to try to help others is really a lot. I want to express my appreciation to you for that. This is an issue im dealing with in my own family. Its new and hard to figure out. The challenge for family members and caregivers. Its a hard thing. Can i just begin by expressing gratitude to you for being courageous and hopefully educate others about this. Thank you very much senator cane. Were here because, weve been fortunate and blessed with great fruits of this great country of ours. When you look around and start to get involved and give back and see people struggling and see sincegle head of houses that dont have anyone, any resources and dependent totally upon the system. You see how theyre falling through the cracks. You realize that if youre going to stand for something, its got to be more than just yourself. Coming from brooklyn from Humble Beginnings and having had a chance to meet one of the greatest human beings, my wife, the nicest person. She taught me how to give and what philanthropy was all about. I know what we have to do. Its not about us. Its about the folks behind us the folks who at night when you cant sleep because you know theres a person in another room that is going through holy hell. Youve got to get up and go to work or go help change them or go quiet them down. Or you just have to be able to hold them. You understand that if youre going to stand for anything, stand for people who need the help the most. The caregivers need it. Weve got to make a difference. Im blessed that i have a great partner, but i am alsoblessed because of opportunities weve been able to give back. We dont choose chance to us but we choose what we do with it. Youve made a good choice and all of you trying to be a bea con of hope in a situation. Senator, ive learned one thing in life. You play the hand youre dealt. You play it to win. Amen to that. I want to ask other witnesses especially those from the Research Community. Talk to me about early onset a alzheimers and what research is telling the you. How is it different or not really different just occurs earlier in life . Is it the same medical condition as later onset or is it different in significant ways we understand if you could . Thank you senator cane for that question and comment. Early onset disease is divided into various stages and really defined by the age of onset. Weve learned in recent years its probably the same underlying disease process. Having said that, a person affected with alzheimers in his or her 50s versus somebody in their 80s may have different contributions to the clinical picture. They look the same, forgetful, develop problems with thinking and activities of daily living. In the older person, theres the some other pathologies, vascular disease and other things. In a younger person its the pure form of the disease with the protein. Both are comparable. Treatments likely effective for young onset will work for old on set and vice versa. There may be genetic onset with earlier. Basically the biology of the disease is comparable. Any other answers to that question. How about the caregivers side . We have folks representing organizations that do a lot of work with caregivers. Im certain youve testified a good bit about recommendations you have for us. Caregivers in all of our states. Its kind of staggering. What are the things we should consider from a policy level to make the Caregiver Task maybe a little bit lighten the load a little bit. Thank you senator cane. Im here on behalf of caregivers. Im one of 15 million. Many caregivers in this room have different stories. Many stories this week ive heard a lot of stories this week. Theyre all different. We share very similar things though. We share the same sorrow same pain. We also share the same hope. We share the same vision that this is going to end in our lifetime and were going to fight until we see this end. One of the things that we are here and collectively coming together as one fist is asking for whether we need know. What we need now is for the hope act to be passed. We need it to be passed in this congress. We need it because its going to improve Care Planning services for individuals like myself for families, those living with dementia. Once they receive that diagnoses, they walk out of their doctors offices. One receiving the diagnoses and two, knowing what the next steps are that that alzheimers disease diagnoses will be in their medical records follow them and go wherever their lives may take them. Whether they begin to develop diabetes or anything else. Theyll know this doctor will know hey this patient has alzheimers. Theres different intricate needs i need to provide for this individual to give the best possible care that i can. So, we need this act to be passed in this congress. We need it now if for my situation is a little different. Im five to six years down the road now. Care Planning Services didnt happen for me exactly the way i probably would have wanted it to had the hope act been in place for me. It can help a lot of other people millions of people. We need help to make this load easier because its hard. We need help to carry this burden. Were carrying it the best we can. Were asking for help. Great. Thank you very much. Thank you madame chair. Thank you senator. Senator tillis is on his way back. I get to ask another question. My question is for both dr. Y . Vnpeterson and dr. Wireman. Dr. Wireman mentioned earlier you look at delirm as well. Im wondering if theres research that shows delirium after surgery where a general anesthesia a has been involved. I see cases that can be a trigger. Maybe ill start with dr. Hodas. Is there a link . Can that be a trigger of alzheimers . Is there a link between the delirium you sometimes see in older people after an operation that involves a general anesthetic and dementia . Good point. In fact theres good data to a couple of points. The first whether delirium can be succeeded or followed by decreased cognitive function and dementia. The answer a appears to be yes. For general anesthesia even if theres not delirium. Often there can be a short term decline. Most recover fine. The failure to recover quickly is predictive of long term decline. Both of these, whatever that means to the brain as a result of deep anesthesia or delirium do seem to be capable of accelerating the decline. Dr. Peterson . I agree with dr. Hodas. If the brain is injured how much resilience does it have to respond. Sometimes with people who are developing a dementia of one kind or another and undergo anesthesia, they may have a threshold for becoming delirious in that. It may contribute to downward decline. It may also be a stress test on a system that is starting to gradually fail and consequently be a harbor of what could be den sha be dementia. Dr. Wireman your response also. Ive been discussing this for a couple of years with anesthesiologists and others to be careful about what kind of anesthetic they use. Only use one general if necessary. Could you a illuminate us on this as well . That gets us more research to we know what to advise. Clinically i see people that seem to be functions quite well before the surgery and not doing so well after. As we have more research now where we can identify changes happening before its evident in daytoday life. My suspicion its those we see that have the decline after. Its like a stress test you fail is how ive thought of it as well. I think we just dont know. I think that definitely in an older population doing more assessment prior to major surgeries surgeries. If its a planned process you understand the risks going into it so that people incorporate that into Decision Making is really important. As out lined, we need more research into what anesthesia is best and how it further does folks so we cannot put them down the path we cant stop. Dr. Peterson and dr. Hodas. This is an important issue that the Alzheimers Association has established a group looking in this very issue. They meet at the International Conference every summer. This is a hot topic with regard to brain resilience and cognitive function and its role in development of dementia. Thats really interesting. I was not aware of that. Dr. Hodas. Extremely good and important question. Research directed at this actively now includes approaches to using eeg measurements of brain function during anesthesia with attempt to monitor the level of anesthetic with eye toward brain activity and look at effect of that monitoring on cognitive outcome. Thats one area we may develop quick answers to make a difference. Interesting. Thank you. Senator tillis were delighted you made the effort to come back. If i seem out of breath, i am. I had a conflicting committee. I want to thank the chair and Ranking Member. This is an important issue to me personally because ive been a caregiver. I just want to let you know we not only need to focus on research, but we also need to make sure that we have the right funding. Madame chair excuse me. To make sure that the caregivers that they have the resources and education that they need to do the best job for care giving. My personal experience i was a grandson of a grandmother who got alsozheimers at a relatively young age. I wasnt sure what i needed to do to help my grandmother. I was certain my mother and two sisters were not doing it the right way and other family members. I went back and took College Courses to better prepare me to help my mother and my two aunts who were the primary caregivers to be a better caregiver. Im not going to ask you questions. I know youve been questioned to death. Ill read the record. I wanted to communicate how important it is for Something Like this. This is another area i have passion around autism. This is a classic example where i think the head and heart meet because with the investment of resources, we do the right fiscal thing but we do tremendous transformation impact for those affected with alzheimers. We need to invest in right research. I read this week about promising treatments and make sure were putting those on the front burner. In a state like mcnorth carolina where population of 65 and over and going up 30 those suffering from alzheimers in a state growing increasingly large aging population. We need to educate house and senate on compelling fiscal reasons to do something that produces transformational outcome. I want to thank you all for being here. I want to thank the folks in purple. My daughter would love this because its her favorite color. I want to thank you for being here and advocating. I encourage you to reach out and explain the transformational opportunity we have to make this a priority. Thank you madame chair. Thank you senator. Well said. We were talking earlier that when spending 226 billion as a society on a disease thats going to bankrupt our medicare and Medicaid Programs that if a suffering of families doesnt move you, the economics ought to move congress to do the investments that are necessary. Your focus on caregivers is absolutely appropriate too. I want to thank our Witnesses Today for their extraordinary testimony. Each of you has brought so much to the debate and discussion today. I think youve given us very comprehensive look at a devastating disease. I want to assure you as the co chair of the alzheimers task force and senate, ill continue to work with my colleagues to make sure we are keeping a focus on the disease, that were educating our colleagues and that were increasing the funding. We cant do it without your help. As i said, i have an amendment im going to ask your help on on the budget to have essentially get the senate on record for increasing the funding level that nih gets for Alzheimers Research. I hope as you do your Office Visits that youll urge your senators to support that amendment. Its either going to come up this afternoon or tomorrow. You may not have time. All over the country to come to washington to tell your personal stories and help advance the fight against alzheimers. As weve said today, the color purple represents the alzheimers movement. Its my hope some day soon the color purple will also represent those who survive alzheimers. [ applause ] were going to keep the hearing open, the hearing record open until friday april 3rd. There may be additional testimony or questions for the record. Again, my sincere thanks to this wonderful panel and to all advocates who are here today and everyone who participated in todays hearing including my staff and senator mckaskels staff who works hard and shares a commitment to the cause. This concludes the hearing. Thank you for being here. [ applause ] i remember when the institute of madison first reported 1999 and reported 100 now, people were dieing from preventable causes in the u. S. Hospitals every year. I was shocked. A lot of great, smart people jumped in. I thought okay, theyre going to take care of it. I went on doing what i did. A few years ago, the new data came out showing over 200,000 people were getting killed in our hospitals from preventable causes. Thats when i realized maybe its time i step up and try to do something about it. Ive been fortunate enough to get to know a lot of companies in medical technology space, a lot of great hospitals and clinicians, a lot of amazing people like you, president clinton. I thought if we brought everybody together. Bring in companies, hospitals, government, Patient Advocates that provide powerful voice. When you think about 200,000 people dying every year, its a number that runs through your head unfortunately. I think stallon said one death a tragedy, a million is a statistic. Think about the one life and the family thats left behind it grabs you. Screeria nigeria. Then on weekends, cspan 3 is home to American History tv with programs that tell our nations story including six unique. Visiting battlefields and key events. American artifacts touring museums and sites to discover what artifacts reveal about americas past. The presidency looking at the policies and legacies of our nations commanders in chief. Lecturers in history top College Professors looking at americas past. Educational educationge cspan 3 funded by your local cable or satellite provider. Like us on facebook and follow us on twitter. Next the acting chairman of the Postal Service commission. They talk about changes needed to modernize and impose future success. The berkeley institution hosted this last month. Im director of the center for effective Public Management here atmn c brookings. Heres here to a talk about a large and very important entity t United States Postal Service, one of the perhaps oldest along with the United States army organizations in the u. S. Government and about which theres been much written and even a movie made or two or three. The post office is at a particular cross roads. I will ask you to just think of the following. When is the last time any of you got a letter with a stamp on it . Okay. Now, some of you did. I suspect those of you born after about 1980 dont even really own any stamps. Just for edification of young people here, stamps are the things you used to stick on envelopes and put in post office box. It would go to your grandmother or someone like that. So, we are at a cross roads here. There are big and very serious issues to be addressed. Theres also been a reluctance to confront these issues in the congress. Not only do they have a lot to do, but they, as you may have noticed, have a hard time doing anything these days. They disagree about so much. We are here to i say its time to stop kicking the can down the road and to start having an intelligent conversation about some of these big issues. So to start us off today, im going to call on four people who know a great deal about this. Im going to introduce all of them now and then theyll speak in turn. Well open up for questions from the audience. To my left is roberts talb. He was designated acting chairman of the Postal Regulatory Commission by president Obama December 4 2014. Hes a little new to the job, but he was also sworn in as a commissioner in 2011 and elected vice chair 2013. He came to the post office from the army. Before that he served as chief of staff to u. S. Congressman john mccue for a whole decade. To his left is dr. Robert shapiro. Hes president and co chairman and founder of sonicon llc highly rated Consulting Company here in washington. Hes a senior fellow at the Georgetown School of business and advisor to the Monetary Fund director of the Globalization Center and in the Clinton Administration he was under secretary of commerce for Economic Affairs where he oversaw the statistical agencies and the census. Not at all a small job. To his left we have david williams. David is is Inspector General of the United States Postal Service. He was sworn in as second Inspector General for the post office in august 2003. He has a lot of years looking at this institution. Hes responsible for a large staff located all over the country. He investigates the largest civilian agency in the government. He in 2011 was appointed by the Obama Administration to serve as vice chair on the Government Accountability of transparency board which will develop plans for enhanced transparency for apparently spending. Gene has been there 31 years. Hes highly regarded in the Postal Community as an effective advocate on bhafrehalf of those that use mail for business. Hes received highest honor granted in recognition of distinguished service from the nations Postal Community. As you can see weve got a powerhouse up here of people. I dont know that theyll all agree on everything, but thats the fun part. Id like to start by having each of them make introductory remarks. Then well open out up. Thank you elaine. For each of us to set the table shall we say, hit three issues. One to give a thumbnail of what the Postal Regulatory Commission is and more importantly give you a sense of whats going on today, particularly financially. Theres bad news and good news. Ill try to hit on both. Lastly, hit upon what i think is an important issue for us to consider Going Forward which to me is issue of universal service. Why else do we have a Government Institution in the postal sphere if it isnt to provide to the American Public at home or work, wherever you live. Today its a nearly 67 billion operation with half a million employees. Its 100 part of the government, 100 part of the executive branch. Its not hybrid anything. Its 100 part of the United States government however receives no tax dollars to fund operations. Its solely selfsustaining through rates charged us through the services it provides. The entity is polices and has final authority over Postal Service prices products, services ss s services, clants complaints. It is independent and totally separate from the Postal Service. The commission is the regulator not the operator of our nations system is. Why the regulator . The Postal Service is 100 part of the government. It has one of the few agencies everyday operating in a commercial marketplace. It has many captive customers that have no alternatives to use the mail. When it comes to prices and products, the cost is 100 Government Entity with customers in the marketplace. The commission is there to protect the Public Interest in these. Let me move to a snapshot where things are at with the Postal Service today. Obviously most attention weve seen and heard is bad news about their financials. It is bad news. They ended last year with a five and is a half billion net loss that brought their total net losses over eight years to 51. 7 billion. Pause is and think about that for a minute. 51. 7 billion in net losses over eight years. Last years loss was 500 million higher than the year before and higher than planned. In 2015, their total net loss is 750 million more. Now they paid 21 billion during the first five years of this eight year period to prefunded overly ambitious funding mandate. They defaulted on that and unable to make any future payments into prefunding for future Retiree Health benefits. Theyve maxed out on Borrowing Authority. They have no Borrowing Authority available. Mail volume is continuing to dez kline over all. Total mail volume in 2014 dropped to levels not seen since 1987. Now in the face of all that, if Postal Service over past seven years reduced work force 20,000 employees, cut cost 16 billion. Theyve increased productivity. Today the Postal Service delivers roughly the same amount it delivered in 1987 but with 173,000 fewer employees. Even with these reductions and many more planned, they dont have the cash to pay down their debt or make much needed Capital Investment into their infrastructure. They need new delivery vehicles. If a downturn on economy or stressing event should affect the Postal Service its concerning about their will liquidity. They have about 21 days estimated. Despite all the bad news, theres good news. Theres strength in the system. As i mentioned, the Postal Service is one entity that touches every american whether home or at work. The Postal Service literally delivers 150 million delivery points every day on a typical day to american households and businesses. It facilitates trillions of in commerce. 900 billion is estimate of hailing industry the Postal Service is a part of. Employeeing nearly 8 million americans. There are positive signs of late. The total First Quarter volume in revenue has shown some good science. On a net operating basis, without non cash workers comp and prefunding mandates i mentioned, the Postal Service has a Net Operating Income of about a billion, about 360 million better than planned. While higher margin first class mail continues to decline theyre starting to see modest increases in revenue particularly driven by increases in heavyrevenue from shipping and packing services. This history of Postal Service, despite challenges today theres immense strength in the system. I argue the Postal Service throughout the 240 year history has dealt with numerous disasters, challenges and great depression. Expected calls for imminent decline has not continued to operate but has thrived. I would argue the Postal Service is strengthen the system. The last point i mentioned. How do we deal with the larger issue though of challenges, given the very scary Financial News . I would argue its this issue of universal service. Why else is the Postal Service going to provide universal service . Back in 2008 there was a study mandated by law to define what it is in the United States. What do we define universal service as . The commission came up to seven criterias, attributes. Geographic, range of products access to services, delivery frequency, prices, affordability affordability, quality of service, and users rights enforcement. Most other nations around the planet have very specific guidelines for many if not all seven attributes. Theyre in law either regulation or licenses. In the United States for much of our 240 years instead we have not defined it. We have expected the Postal Service to meet the needs of nation, balance constraints and provide six day delivery. Its been left to the Postal Service. The commission by law annually estimates what is this cost of universal service. Our current estimate is about 5 billion a year. So the challenge for the Postal Service it seems to me, given the other financial challenges on its plate how do we insure the cost is continuing to get into the Postal Service so it remains selfsustaining . Where do we look for those answers . Look at ourselves. What is it we, as the American Public need from a Postal Service in 2015 to provide universal service . What is it we as the americans expect from the universal service, and what is the cost . Once we know that it seems we can insure the Postal Service is structured in a way to insure that money gets to the bottom line of the Postal Service. Elaine mentioned both congresss house and senate move forward bills. They didnt get enacted. Administration has had its proposal. All have been helpful, but none deal with the issue what is it we expect from our nations postal system . Its that from my perspective we should focus on Public Policy debate. Okay. Thank you. Second robert. Thank you elaine. Its always a pleasure to be back at brookings. Im not here to either praise or to demean the Postal Service. Im try to describe how an economist thinks about these questions and conclusions, economic thinking bringing to this problem. Now, you know almost all governments have compelling reasons to communicate with their subjects or citizens. So some form of Postal Service has been a public good that most governments provide for a very long time. Businesses and individuals also want to communicate with each other. Private companies compare to compete with Postal Services for at least a piece of their business when allowed to by the law for example delivery of packages in the United States. Example, delivery of packages in the United States. Theyve also been around for a long time. The spread of advanced technology, information, communications technologies, as elaine noted, has only intensified that competition since Internet Communications have increasingly displaced the central monopoly of most postal systems, which is the monopoly over the near universal delivery of letter mail. We all used to get our bills in the mail. And not so often anymore. Now, this subject always draws a lot of attention. I. E. All of you who showed up today, because most people and most businesses still need dependable Postal Service. Mail service. And providing that service on a universal basis costs a lot of money. And when a public, or semipublic entity receives subsidies for providing a Public Service, theres a danger of those subsidies being leveraged into a competitive market. One of the one of the singular characteristics of the Postal Service is that it exists simultaneously in a monopoly market where no one can compete, is allowed to compete, and in a competitive market, with pretty intense competition. Before addressing those issues, i recently studied the subsidies themselves, which the Postal Service receives, and in the context of the cost that congress imposes on the Postal Service, as robert suggested. For example, congress requires the Postal Service to maintain residential delivery six days a week. And the prc under robert is estimated that reducing deliveries to five days a week, which most of the public would support, would save the Postal Service about 2. 2 billion per year. Congress mandates discounted rates for religious, educational, charitable, political, other nonprofit organizations, which the prc figures costs the Postal Service more than 1. 1 billion every year. Every time i say prc i think of china, im sorry. Congress also directs the Postal Service to provide a special mailing rate for periodicals, restricts the ability to close inefficient post offices, they estimate that costs about 300 million a year. And all tolled, as robert suggested, prc estimates that legal and regulatory requirements cost the Postal Service around 4. 5 billion a year. Now this happens to correspond roughly to the Postal Service average reported deficit over the last decade, 5. 5 this year but 4. 2 billion average over the last decade. And to the commissions estimate of the total value of the Postal Service special privileges. Including its monopoly on delivering letters, its exclusive access to residential and business mailboxes, and the exemption from a lot of state and local taxes and fees. So by this accounting the Postal Service is effectively selfsufficient financially. An economist approaches it differently and comes to a different accounting. Which suggests that the subsidies are substantially greater. I estimate worth about 18 billion per year. Rather than 4. 5 billion. For example, the commission estimates that the Postal Service monopoly on access to residential and business mailboxes worth about 810 million in the 2013 fiscal year. Now, this is a very interesting provision, and one that i was not aware of until i became immersed in the research for this. It says that the Postal Service and only the Postal Service, can leave a letter or package in a residential or business mailbox. Whether its a curbside mailbox or one in a central mail room. Everybody else that makes deliveries, u. P. S. , fedex, dhl, whomever, individuals, has to leave them at the front door. Of the residence or business. Thats a substantial burden in a large apartment house, or business. Or office building. The Postal Service itself estimated that in 2008, that ending the current bar on private Delivery Companies accessing mailboxes would cost the Postal Service 1. 5 billion to 2. 6 billion per year. And that was after all, 2008. So thats seven years ago. And is two to three times the estimate of the value of the subsidy. Its going at it a different way. Im not saying that there was any problem in the accounting. Its the way you approach it. How you conceptualize the subsidy. This is how an economist would conceptualize it, and that is that you would look at the volume of mail delivered to curbside mailboxes and centralized mail rooms, and the cost of doing so compared to delivery to each customers door. Because thats the privilege they get as compared to the requirement for private companies. By that accounting, the mailbox monopoly saved the Postal Service 14. 9 billion in fiscal 2013. Which is another way of looking at the additional burden on private Delivery Companies. The Commission Also valued the Postal Services legal exemption from state and local property and real estate taxes. At about 315 billion in 2006, last time it was done, adjusted for inflation, that would be about 370 million today. But this estimate is based on the Financial Statements issued by the Postal Service, which value its Real Estate Holdings at 27. 5 billion. But, as the Inspector General reported recently, this valuation represents the historical cost of the property. Not their fair market value. Which is how property taxes are applied. Using the fair market value, those properties were worth in 2012 85 billion, not 27. 5 billion. And if we use an average property tax rate, thats what economists do, of 1. 8 that exemption from taxes actually provides a subsidy of about 1. 5 billion. In 2012, it would be a little bigger today. Again, a different way of approaching the problem of the value of this. And of course this is only one of a number of exemptions the Postal Service enjoys from state and local requirements including vehicle registration fees, road tolls, state sales taxes on fuels, parking tickets. Imagine, no parking tickets. There are also some other subsidies which have not been reported and calculated for. But which from an economic point of view are pertinent to this discussion. For example, the Postal Service borrows from the treasury through the federal Financing Bank up to 15 billion, theyve hit that limit, but it does so at very highly subsidized Interest Rates. Currently it has 15 billion in debt. Its legal limit it pays on average a very below market Interest Rate of 1. 2 . That cost is 184 billion in interest last year. If they had to borrow at commercial rates, and as a aaa credit risk, as its competitors do, its Interest Payments would have been 600 million to 675 million. So that creates another subsidy from an economic point of view of between 415 million and 500 million. Theres also the special arrangements for the federal income tax on the profits that the Postal Service generates from selling competitive goods and services. In its competitive side it has to pay taxes on the profits that it earns from delivering packages where its competing with fedex and u. P. S. But theres a very interesting arrangement. I wish i could pull it off. The treasury credits those tax payments to the Postal Service fund. The Postal Service fund is a special Revolving Fund that at the treasury which the Postal Service draws on to cover any expense. So the federal tax payments circulate back to the Postal Service. Thats a subsidy worth 850 million last year. Finally, and this is really where we get into the economics of it, the Postal Service the monopoly over letter mail has created what economists call Major Economies of scale and scope. Protected from competition and its monopoly area, it maintains this huge network of post offices and postal workers that reaches, as congress requires, and as robert noted, 153 million delivery points six days a week. However, the Postal Service can leverage these economies of scale and scope to cut its cost in its competitive markets for Package Delivery and express mail. In the most consequential example, the Postal Services core function of delivering letter mail to most homes and businesses on a daily basis means it can pick up and deliver packages to or from any home or business at little additional cost. This produces what economists call a Network Advantage since a