Transcripts For CSPAN2 Key Capitol Hill Hearings 20240622 :

middle class. hope if it continues to be middle class how long of the crisis because middle class wants better, goods and services and expensive and that will, drive, that is driving politics more and more. the fact leaders have to address the concerns, discontent in the streets. i think that will drive the economy even more. there is a lag effect there. doesn't matter where it comes from but they need better services. i said this before, it is not a matter anymore access to goods. there are 250 million cell phone lines in brazil for 200 million people. it is matter of access to phones that actually work. the debate shifts from the goods to the services that makes those goods useful. i think that will be a key driver for economic growth going forward. that leads opening up with the economy with the debate that is happening. on the prosecutor's office and constitution, i don't think the constitution is bad thing. there were excesses to some extent. in hindsight, the company came out after 21 years of dictatorship, i don't think this is just another corruption scandal. i think there are lessons learned. david: institutional progress in brazil this time around. you have plea bargain deals and leniency deals in place that weren't before. anti-corruption laws that bring it up to the ocd corruption standards. there is evolution there. the corrupt become more creative when there is more oversight. there is chance to rebalance the infrastructure and entitlements -- what he is trying to do, in a very tough moment but to finalize, looking at brazil, last 20 or 30 years to try to end on slightly positive note, usually reaction function in brazil when political an economic crisis deepen, reaction function of the political class tends to be more constructive. that may be slow sometimes incoherent but it tends to happen. we've seen with the real plan and lula being elected and implementing course correction over two to three years we see that again. we complain it is not a very linear process. it is in that direction, right? so that's the silver lining since the return to democracy every single major split forces in brazil governed in the country through a cycle. none of them are calling for more radical policies. the worst of them all, depending on what kind of angle you have is the one we have in power right now. >> brazilian politicians are practical people. they negotiate. the second thing, bob you mentioned i made a note of it, is that the ministerial public that cause the crisis. you said that and then you corrected later things that they revealed. what caused crisis in brazil was crimes committed against the public interest. that was the cause. what the minute tear public did first time review that to the public. that is what they should have done. i think it is very good. it is very, very painful. it is very sad to see all this happen but i am one of those that believe this is all positive and that we are going to learn lessons and come out all right with this. >> brazil may be hard to predict easier to predict quality of analysis from the three of them and i want to thank the three of them and thank all of you for coming this morning. this is enlightening, not always upbeat but there are encouraging, a lot of encouraging, positive things as well. stay tuned we'll have more coming on brazil and other issues. so thank you, enjoy the rest of your august. thanks for coming. [applause] >> with congress in its august recess we've been showing you booktv in prime time on c-span2. tonight it's programs from our of a words series. kirstin powers and her book, silencing. how the left is killing the free speech. after that arthur brooks is interviewed about his book, the conservative heart. later, cornel west, editor of the radical king talks about martin luther king's political views. watch booktv starts at 8:00 p.m. eastern. >> follow the c-span cities tour as we travel outside the washington beltway to communities across america. >> the idea behind the cities tour is to take the programing for htv, our hern history television and booktv out on the road beyond the beltway to produce pieces that are a little bit more visual. to provide again a window into these cities that viewers wouldn't normally go to that have rich histories and rich literary scene as well. >> people already heard history of big cities like new york, l.a., chicago. what about smaller ones like albany, new york? what is the history of them? >> we've been over to 75 cities. we will have hit 95 cities in april of 2016. >> most of our programing on c-span is event coverage. these are not event coverage type of pieces. they're shorter. they take you someplace. they take you to a home, a historic site. >> we partner with our cable affiliates to explore history and literary culture of various cities. >> the key entry into the city is the cable operator who contacts the city. in essence it is cable industry bringing us there. >> they're really looking for great characters. you really want your viewers to identify with these people that were talking about. >> it is an experiential type of program where we're taking people on the road to places where they can touch things, see things and learn about, you know, it is not just the local history because a lot of the local history really plays into the national story. >> if somebody is watching this, should be enticing enough they can get the idea of the story but also feel as if this is just in our backyard. let's go see it. >> we want viewers to get a answer, yeah, i know that place just from watching one of our pieces. >> the c-span mission as we do with all of our coverage bleeds into what we do out on the road. >> you have to communicate the message about this network in order to do this job. it has done the one thing we wanted it to do which is build relationships with the city and our cable partners and gather some great programing for american history tv and booktv. >> watch the cities tour on the c-span networks to see where we're going next, see our schedule at c-span.org/cities tour. >> a senate panel looking how technology can help senior citizens live independently longer. the committee heard about advances in technology like telehealth, electronic sensors and the use of medical alerts. senator susan collins chairs this special aging committee hearing. >> this hearing will come to order. good afternoon. this afternoon's hearing will explore the potential of new technologies to help seniors age in place safely and to retain their independence. the u.s. population is aging. according to census bureau projections, 21% of our population will be age 65 and older by the year 2040. that is up from just under 14% in 2012. every day 10,000 baby boomers turn 65. as many as 90% of them have one or more chronic health conditions. americans age 85 and older, our oldest old, are the fastest growing segment of our population. and this is the very population that is most at risk of multiple and interacting health problems that can lead to disability and the need for long-term care. at the very time that our population is growing older the need for care and support is increasing. the population of professional and infornal care givers is however declining. today there are seven potential caregivers for each person over age 80. at the highest risk of requiring long-term care. by the year 2030, there will be four. and by 2050, the number drops to fewer than 3. as the consequence of the future, more and more people will have to rely on fewer and fewer caregivers. as people age, they naturally want to remain active and independent for as long as possible. aging in place is the ability to live in one's own home and community safely, independently, and comfortably regardless of age or ability level. surveys taken by aarp consistently reflect the fact that aging in place is the preferred option for seniors who want to continue living independently and avoiding nursing homes and other institutionalized care for as long as possible. today's hearing will examine some of the recent advances in technology that are providing new options to allow seniors to remain in their homes longer, by monitoring their health status, detecting emergency situations such as debilitating falls and notifying families and health care providers of potential changes in health status or emergencies. while it isn't a replacement for professional care or personal attention from family members, technology can help to bridge the care gap and extend the amount and length of time a person is able to live independently. technology can also help to reduce isolation and enrich the lives of seniors by keeping them engaged and connected to their families and communities. we will also hear this afternoon about technologies that can make the lives of family caregivers easier by giving them the tools they need to support their loved ones as they age in place. finally we will hear from the veterans administration, a real pioneer in telehealth, which has used technologies such as videoconferencing and smart monitors to reduce hospital admissions and to shorten hospital stays. this has resulted in lower costs and is also allowed some of our older veterans with chronic health conditions to live independently at home right where they want to be. many of us are familiar with the decades-old and well-known phrase, i've fallen and i can't get up. that phrase of course was an advertisement for a medical alert system. while many seniors still rely on this device, break throughs in modern technology have brought us a long, long way. providing many new options for seniors and for their families. technological solutions can be cost effective and tailored to meet the specific needs of a senior and his or her situation. companies that develop these technologies are starting to realize, not only is there a growing need to design products that meet seniors needs, but also that there are many seniors who want technology and devices that look just like those used by younger generations. for example, this phone is an older generation device that is specifically designed for seniors to be easy to use. it has large numbers, for example. this new generation version of the phone is the start phone with still the same ease of use as the old version of the jitterbug phone but looks like the smartphones people's children and grandchildren use. much more important than its appearance, however, this new generation device also includes technologies that help seniors maintain their independence. for example, it has features to help with medication adherence, provide 24/7 access to medical emergency operators as well as an app that the family caregiver can download to keep them up-to-date on their loved one's well-being. we will also explore the challenges posed by these technological advances such as privacy concerns and the unequal access to the internet that exists across our country. before i turn to senator mccaskill for her opening statement, i want to give a special welcome today to dr. carol concerns the vice president for research at the university of maine. dr. kim oversees the university's successful aging initiative for living, or sail program. she traveled to washington to talk about maine's aging and thriving in place movement that will benefit the development of new technologies, products and devices. i look forward to hearing not only from her but all of our witness this is afternoon. senator mccaskill. >> thank you, chairman collins. helping our seniors remain in their communities and age with dignity is an important issue and a top priority of this committee. you have assembled a great panel today. i'm looking forward to hearing about the exciting innovations that can help seniors and their families. there is a real disconnect between the number of seniors who say they want to stay in their homes, and communities, and number of seniors who end up having to move into nursing facilities. in fact a recent aarp study found that 87% of older adults would prefer to remain in the communities, in their own communities as they age. while it may not be possible for every person, depending on a number of factors to remain in their homes, for many of us, with the right supports it is possible. and it is preferable both in terms of quality of life and certainly for financial implications. recent advances in technology are providing these new options for seniors and their families to allow them to remain at home longer by monitoring health status, detecting emergency situations and notifying health care providers about changes in health status. these technologies can also make family members and caregiver's life easier providing them with tools to support their loved ones and giving them peace of mind. this is really a win-win situation. seniors much happier continuing normal routines and social activities where they feel comfortable, family members make sure their loved ones are safe and society as a whole benefits from significantly reduced health care and long-term costs. there are many assistive technologies already on the market. home improvement stores, big boggs retailers and telecommunications companies sell versions of connected home citizens that can keep seniors secure in their homes. developers are creating senior specific monitoring devices such as bed, toilet, pillbox sensors that can monitor activity within the home. pillbox sensors are so simple in nature but can prevent tragic accidents, making sure seniors are not mixing medications or taking too many pills. wearable devices are popular for track being physician -- physical activity or falses. falls are leading cause of injuries in older adults with one out of three seniors falling each year. some newer monitoring devices don't require push of a button. they detect a person falling using a meter. technology is critical to the growth of telehealth and helpful for seniors who by using telehealth services can most of their health monitored from the comfort of their home, rather than a doctor's office. these innovative technologies are being developed by researchers all across the country, one of whom is with us here today. i'm so pleased and proud to introduce dr. marjorie scubic. dr. skew big is the director of the technology at university of missouri. the center in partnership with americare created tiger place. dr. skubic and her team found a way to use radar and 3d sensors to monitors senior risk level for falls. i look forward to learning more about this and other emerging technologies from dr. skubic's testimony. there is concern about preserving privacy for seniors. using webcams might have challenges. we want to assure privacy of seniors and their dignity using this technology. we also want to make sure that we are looking out for their safety. i know that ms. sue utilized privately techniqueses using silhouettes on monitors that help ease privacy concerns of older adults. the challenge for those that develop these technologies to maximize sight with minimal invasion of privacy. thank you to chairman collins and our witnesses taking time to be here today. i look forward to listening an learning from your testimony. >> thank you very much. i want to know we're joined by senator kaine, senator sass senator casey. we're pleased you can join us this afternoon. we'll turn to our panel. we'll first hear from laurie or love, orlov. aging in place technology watch. i understand she also has the wisdom to have summer home in the state of maine on frey island. that for me cinches as far as inviting you to testify here today. i've already introduce dr. carol kim who is the vice president for research at the university of of maine. our next witness will be dr. maureen mccarthy of the department of veterans affairs. she is the acting chief consultant for telehealth services. will discuss the va's telehealth program which by many measures has been a success and has helped to reduce costs. professor marjorie skubic from the university of missouri has been introduced by the committee's ranking member. finally i would like to welcome charles strict letter to today's hearing. mr. strict letter from knows abt of the scenes years that have desire to age in place. how he used technology to assist in the care of his mother and mother-in-law. so first we will start with miss orlov. >> thank you, chairman collins, chairman mccaskill and -- [inaudible] i want to thank you for the opportunity to testify about the potential and requirement for technology innovation to help older adults age in place. as you have noted demographics make this technology market essential. these categories of enabling technology bill help make it feasible for older adults to meet their needs as they age. as we already noted nearly 90% of adults age 65 want to remain in their own home and today are actually remaining in their own homes. successful aging has been described ability to do things for myself, feel safe and have good health. aging in place therefore is the ability to successfully age in your home of choice. and aging in place products and services including technology, provide a useful, underpinning enhancement of quality of life for seniors as they age in place. we have talked a bit about demographics. i just want to add a couple of refinements what we already heard. we know there are 46 million adults 65 or older today. of those 20 million are 75 or older. 46% of women age 75 plus today are living alone. the society of actuaries recently updated life expectancy of age 65 to reflect a new reality that women age 65 can now expect to live on average to be 88.8. with 25% of them living to 90 or more. men at 65 are going to live on average to 86.6. the average one year cost of assisted living in the united states will be $51,000 a year by 2020. in the northeast, san francisco, chicago, and most memory care unit, that number has already been reached and exceeded. seniors know this. they are deferring move-in assisted living communities until they reach the mid 80s, but most of them still remain at home. let's talk about the categories of together for aging in place. if you could bring up the slide. thank you. they are best represented by what i describe ad interlocking pieces of a puzzle and the puzzle paradigm specifically used here to show if you leave out any one of these pieces of the puzzle, people are at risk of depression, of isolation and undee dee teched illnesses and all sorts of complications in their lives. older adults benefit from training how to benefit from them that address their ability to connect with other people and opportunities, been gauged in their communities, be safe and manage their health and well-being. looking each category starting with the upper left puzzle piece. let's examine them one at a time. in the category of communication an engagement technologies while the devices may change over time and have changed significantly as you showed by your examples of phones, their purpose remains the same. they help older adults stay connected to others through email, online text and video chat. searching the internet, participating in forums, playing games, finding people with shared interests and just as important, finding services and resources that meet their changing needs. and in particular, with video, it can be used to monitor but can also be used to engage people in some social chemicalses with their families and friends. today, while 59% of the 65 plus population have access to the internet and 27% have smartphones, both percentages drop off noticeably at age 75. the second category on the right upper corner is the safety and security category. the most important aspect in this category is a home alarm system that can monitor an alert about fire, temperature and excessive moisture in the home. without it, the other technologies are just nice to have. other useful technologies listed here include personal emergency response pendants which we already talked about and safety watches. fall detectors in the home, home-based motion sensors and activity monitors that can now monitor absence of activity and decline over time. increasingly information from various devices will be combined to detect changes in patterns over time and we're hoping detect gait changes and other signs that indicate risk of falling. health technologies is category at pot right that include telehealth as we heard, also wearables, smartphone apps. as people acquire smartphones that may be useful and online health information. there are new tools being developed all the time to help with dementia care, support care coordination and help find home care workers. variety of these new devices can also assist with people of low vision and people with hearing impairment. bottom left-hand corner is about learning and contribution and how we stay engaged in our society, continue to learn new things which is how we remain content with our lives and interested and, helps keep our minds sharp. tools that help people tell and record their life stories, for example, online sites that enable them to volunteer and enable them to find work. 20% of the people after the age of 65 these days are actually working. many of them full time. people can learn new skills. they can learn new skills that are leisure-related and work-related. all of this online training is free. this is times we live in now. it's free. forums are available to find expertise, ask questions. biggest problem we have is that mobile device data plans today average between 60 and $80 a month. and wi-fi access is typically being used by people in coffee shops and libraries because having a high-speed internet connection to the home can be quite costly, $50 a month or more. that is limitation on access for lots of folks. so as people age, all the four categories are enhanced by inclusion of role of formal and informal caregiver which you see in the middle. and, that could include the professional caregiver. there are newer technologies that not only track time and attendance of caregivers but also communicate care status. that is what is going on with activities of daily living, communication with family members about, mobility and eating and cognitive functions. one last point, the future market potential of this market is greater than the availability of smartphone features, in-car technologies and will move even into robotics. sized at low end of $20 billion by 2020 but in the future you will see fewer special purpose offerings for seniors. there will be more examples of standard hardware and device platforms with customizable software that will meet specific needs of the user, so we won't have to invent special purpose technologies for everything. that concept is called design for all and can be seen today in the customizable features in your car, in tablets, in smartphones, in television and con super electronics. design once, customize for the individual. i hope this overview has been helpful to you. i want to thank you very much for your time. >> thank you for your testimony. dr. kim. >> good afternoon, chairman collins, ranking member mccaskill and distinguished members of the senate special committee on aging. my came is dr. carol kim and i'm appreciative of the opportunity to share with you the technologies of the university of maine is developing to allow older individuals to age and thrive in place. it could not be timelier. we are convinced that the aging and thriving in place movement is destined to benefit greatly from the rapid deployment of technologies, products and devices that maximize human performance, improve mobility, navigation, home environments and intelligent living. improve emergency detection, and contribute to older adult falls, prevention, mitigation and response. the university of maine launched a major cross campus aging research initiative in partnership with community agencies and organizations and established interdisciplinary research incubator from social work to engineering to disability studies that is responding to major public health issues that affect aging americans. in the area of home safety optimization and false prevention we're developing technologies to promote mobility, avert falling, increase contrast sensitivity, promote outdoor exercise and improve balance. one of the most challenges that occur with age is loss of visual contrast. turns commonplace low contrast features shown here in the slide such as cement stairs, curbs or benches into falling hazards. our goal to improve safety and reduce falling via cost efficient solution that can be implemented without any infrastructure buildout. to do this we're exploring use of computer vision as means to detect low contrast edges in the environment and improve their visibility. this technology is likely to reduce the falling problem because it optimizes, it is optimized to address known percent sent wall and cognitive changes that occur with age. although walkers, crutches and canes have long been availables, these are minimally functionable for outdoor exercise and seen as stigmatizing and inconvenient. in this movie the assistive jogger was created for fulfilling unmet need without adequate mobility support, less likely unable or unwilling to participate in ambulatory exercise. the assist tiff jogger is aesthetically designed, convenient, foldable, actively steered, three-wheel support device that improves balance, weight bearing assistance for walking running, jocking. it has biofeedback and innovative load sensing technology. it is early in phase of commercialization. fall impact minimization what developing energy absorbing clothing technology. a team at university of maine is working to develop non-stigmatizing protective gear to mitt fate injury for individuals at risk of false. the main company, a humane corporate partner has develop ad highly effective, impact resisting material system and offer as headwear option for older adults that can be integrated into fashionable headwear providing protection against head injury shown in the slide. this technology is lightweight can be incorporated into caps, scarves and hats. performance test demonstrated significant potential for reducing head injury. in 2013, 258,000 people over the age of 65 were admitted to treatment for hip fracture. the hip project expands our current work with headwear to innovative, wearable hip protection for elders. university of maine researchers are working to design hip protection with under garments and changeable shell regularly worn by elders at risk for falling. i have examples of this material here if anyone is interested in taking a look at that. in the airs of fall response, we are developing wireless networking technologies with wireless detection and vital sign sensors to assist first-responders. loss of sensory, cognitive and motor function that occurs as people age can lead to many safety risks for older adults living independently. current responses to the concern, involve installation of expensive and intrusive video monitoring. we recreated a typical apartment setting for testing new, system that makes use of minute and low-cost technology such as rfid tags and microcontrollers. rfid tags can easily be embedded into the physical structure of an apartment. under carpets, behind the paint on walls and ceilings. our rfid reading deviceis small and designed to be worn comfortably by individual. the system tracks user's location as they move about the home and sends an alert if there is a froblem. the system will help to reduce in-home falls, improve safety, efficiency and independence. finally i would like to thank the committee for the opportunity to describe some of the exciting and necessary technologies that research is at the university of maine are pursuing to improve the quality of life for our older population >> thank you very much, dr. kim. dr. mccarthy. >> thank you. chairwoman collins, ranking member mccaskill and distinguished members of the senate committee on aging, thank you for the opportunity to discuss the high quality care and support that the department of veterans affairs, veterans health administration and telehealth services programs are privileged to provide to our nation's veterans. joining me today are dr. richard almond, chief consultant for geriatric long term services and catherine buff, clinical nurse analyst for telehealth services. senator, she is from richmond. leader in the development and use of telehealth services. telehealth services are mission critical for va care for veterans and one of the va's major transformational initiatives and to insure care is convenient, accessible and patient centered. telehealth increases access to quality health services using communication technologies to. in physical year 2015 va telehealth occurred in nine hundred sites of care, allowing 717,000 patients, that would be 12.6% of our enrolled veterans to receive care through telehealth. this amounted to over two million telehealth episodes of care. currently, telehealth is available over 45 specialty care areas. at va we use three telehealth modalities to insure excellence in care delivery. clinical telehealth is use of real time interactive videoconferencing sometimes with supportive peripheral technologies to assess, treat and provide care to a patient remotely. home telehealth is a program for veterans that applies care and case management principles to coordinate care using health info mat ticks, disease management protocols and technologies such as in-home and mobile monitoring messaging and video technologies. lastly, storing forward telehealth is the use of technologies to synchronous acquire and store clinical information that is then forwarded to or retrieved by a provider at another location for clinical evaluation. home-based primary care began in 1970 and provides long-term primary medical care to chronic ill veterans in their hopes under the coordination after interdisplain nary team. it can include recording weight of patient, sending regular reminders about medication, taking medication. asking key symptoms that indicate the need for a particular intervention. telehealth support also allows the patient to send pictures of healing wound to a nurse or doctor who can then advise on what additional care is needed. in addition telehealth can act as educational tool and support system for a caregiver. for example a spouse might be overwhelmed by complexity for caring for a loved one is provided with needed knowledge and skills as well as access to emotional support. va telehealth services delivered many possible outcomes. we have increased access to primary care and specialist consultations leading to reduced wait times. telehealth improved patient outcomes resulting in reduced utilization of inpatient care. for example, in physical year '14 when we studied veterans receiving home telehealth services for non-institutional care needs and non-chronic care management, those enrolled veterans had 54% decrease in va bed days and 32% decree in va hospital admissions veterans compared to themselves in the year prior to their enrollment in home telehealth. veterans receiving mental health services what we call telemental health, had 35% reduction in acute psychiatric bed days of care. in addition va telehealth services programs reduce the necessity for veterans to travel to va facilities for care. clinical video telehealth and storing forward tell a health shown to result in average cost savings of 35 to $40 per patient consultation. home telehealth decreased costs for va and non-va care and reduced cost by $2,000 per veteran that are receiving home telehealth that year. most importantly veteran satisfaction scores rated high between 88 and 94% approval for these kinds of telehealth modalities. in conclusion va is transforming health care services to being provider centric to being veteran centric. for many veterans and loved ones travel to va medical centers can be complicated and sometimes arduous task. travel time is away from the veteran's work or family. va telehealth services program revolutionize the travel time challenge by changing the location where health care services are routinely provided. improving access to care for veterans, and helping veterans take a more active role in the management of their health and well being. madam chair, this concludes my testimony. i'm prepared to answer any questions you or other members of the committee may have. >> thank you very much. dr. skubic. >> thank you for the opportunity to be here among the distinguished panel and all of the senators and visitors. i want to tell you a story about eva who lived at tiger place, the facility that senator mccaskill mentioned, an aging in place senior housing facility in columbia, missouri, with 54 independent apartments. residents can stay there through the end of life. if they need extra help, services are delivered to them. a private corporation, americare, built tiger place and operates the housing, housekeeping and dining, clinical operations are handled through the nursing school at university of missouri. dr. maher lan rand, a nursing professor at mu, set up tiger place to investigate new ways to help seniors age in place. we started testing technologies there in 2005. back to my story, eva had a history of congestive heart failure and cycle of rehospitalization as her condition worsened, got better and worsened again. she volunteered to be a participant in our sensor study. we installed motion, and chair sensors in her apartment. they detected changes in eva's pattern. when marilyn saw this, she knew eva's health was worsening. if we didn't act now she would have to go back to the hospital again. in this case it meant changing her medication. eva's doctor was resistant to this request because eva had not gained enough weight to satisfy his standard protocol. however his one size fits all protocol did not work for eva. she needed the change now. marilyn finally convinced the doctor to change eva's medications and she never went back to the hospital for heart failure again. this broke the cycle of rehospitalization. the sensors in eva's apartment picked up subtle changes before eva or her doctor noticed it. since then, we have developed a clinical decision support system with automated health alerts sent to nursing staff. the system now includes a bed sensor that captures pulse, respiration, restlessness, a fall detection system, and a walking gait analysis system. sensors are discretely mounted in the environment and operate without the sensor required to wear anything or do anything special. for example, the bed sons sore is installed under the bed mattress. two sensors can be installed in the same bed for couples. to respect seniors privacy, no surveillance cameras are used. we use depth images that produce shadowy silhouettes. the sensor system observes seniors, learns their typical patterns and sends alert to clinical staff when there are signs of health problems. we have detected early signs of pneumonia, urinary track infections, pain, delerium and hypoglycemia. in one case we were able to recognize changes in walking speed and stride length of the husband in the home that corresponded to his early dementia. even when his wife was living there and they had many visitors coming into the home. in the case of a fall, alerts are sent to staff with a link to a depth video, so they can see what happened leading up to the fall. residents get help immediately. pictures, i don't have a presentation, but pictures and links are included in my written testimony so you can see what these look like and i would be happy to show them to anybody. as a professor i carry all of my slides with me. i have lots. i have another story about my mother-in-law, yvette, who did not have this technology. she got up in the middle of the night, fell down, and broke her shoulder. my father-in-law, andy was sleeping soundly without his hearing aids so he did not hear her call. she lay on the floor for hours in pain. the next morning andy found her but by then the damage had been done. her shoulder never healed properly, and she was in constant pain for the rest of her life. with her damaged shoulder her mobility was severely limited. she couldn't cook or bake anymore, or pick up her great grandchildren. and the constant pain was a drain. even though she survivedded the fall, her quality of life was drastically diminished. i can imagine a different outcome if we had our sensors in her home and had gotten help immediately. research studies have shown that the in-home health alert system works. seniors with the sensors have better health outcomes. seniors with sensors have a longer stay in independent apartments at tiger place compared to those without sensors by nearly two years longer. we now have a commercial partner, fosyth health care that is bringing this technology to seniors. many of my colleagues at other universities have also developed exciting technology to help seniors such as we've already heard today. the potential for proactive health care is significant. detecting health problems early so that early treatment can be offered is more effective and less expensive than the current approach. and will help keep seniors healthier so they can stay in their own homes. we have seen this work in missouri. i would like to see it used throughout our country so that others can benefit, including my mom and dad in south dakota, and your loved ones too. >> thank you very much for your testimony. mr. strickler. >> good afternoon, chairman collins, ranking member mccaskill and members of the committee. thank you for the opportunity to testify before you today. it has been a difficult process to find the right assistive technologies to help our parents achieve their goal to age in place in a home environment. my wife and i have widowed mothers who are ages 85 and 76 respectively. they always desired to live at home if possible. needless challenge to stay in tune with their state of mind, safety, well being and respecting their spirit of independence and privacy, living several hours apart makes it more challenging. my mother is very independent and lives alone. she is active in her community and continues to enjoy guarding. consequently she uses cellular pendant to remain independent and have security of alert system to summon help with touch after button or automatically if she is incapacitated. she is diligent about wearing her pen dan. but solutions are ineffective for vast majority of users for many reasons. my mother-in-law's aging experience is one such case. my mother-in-law experience ad much different aging scenario than my mother. she has dementia. arriving at her home finding a toeser oven left on for 24 hours. it was apparent she needed more assistance and we needed to have her closer to us. we modified a cottage next to our home with walk-in tub and handicap accessibility features. she moved in full time september of 2012. our existing home security system would alert us to doors opening and detect motion in each of the four rooms in the cost damage. we were able to know when she was active. as the dementia progressed we became concerned about falls. we tried several products but she refused to wear pendants and would not respond to unfamiliar voice in the box. in short the products were ineffective and failed to solve our concerns. we worked with our home security company to find and install some alternative technologies including a bed sons sore, chair sensors, toilet sensors, refrigerator sensor and three big easy buttons to summon help. incorporated with the existing door and motion sensors this system enabled her to have some independence and privacy while we were able to monitor her normal schedule and get alerts when patterns changed or issues arose that required immediacies stance. we set parameters that allowed us to be alert by cell phones to potential false or wandering alerts to immediately check on her. for example bed sensors detected normal and changing sleep patterns. fridge straight tore sensor would recognize when she would forget to eat. before full-time care giving, pressing a button someone would help. they provide alerts based on individual sensors it provides a comprehensive wellness overview and data summary tools that make it much easier to see trends and patterns. user-friendly graphics make it easy to understand what is gradually changing in her life-style. the system enabled us to know when to layer in additional care and assistance. matching it to her state of health as her capabilities changed. my wife and her twin sister are the two primary caregivers tell you three most valued benefits of system are encompassed by breadth and totality of the solution. first and foremost the system provides a tremendous peace of mind assuring us mom is safe, even allowing to us check on her when we're not in her cottage. second major benefit the technology is priceless gift enabling us to honor mom's request to stay at home and live as independently as her capabilities allow. my wife also said, financially it has been a relief to be able to preserve her resources allowing to us provide the best possible one-on-one care now that she needs it. had we moved her into assisted living the cost would be significant. to date the cumulative cost for 2 1/2 years moving into an average virginia nursing home would be 223,000, plus an additional 104,000 for homemaker and health aid services n contrast the cost of our system was about $2200 plus a $50 monthly fee. we need to supplement our care giving efforts with contracted home care support, the nominal investment in technology has a huge cost savings, higher standard of care in more comfortable environment. the company we're working with continued to innovate. now our system has more capabilities that would have been very useful for our family when liv was more mobile. a stove sensor alerts caregivers when the stove is left on for prolonged periods. remote droll over thermostats and lights and locks. motion sensors activating lights. alert pendants unlock the doors. quick emergency notifications away from home. aging in place technologies are not a magic solution that will solve all of our problems of cost effectively caring for our aging population but from our experience they can be a very integral part of the solution. these technologies can be objective tools that can help with difficult conversations, prolong independence, and help guide assistance intervention all in very cost effective and non-intrusive manner, affording caregivers an aging loved ones excellent lifestyle choices. thank you. >> thank you very much for your first-hand experience and sharing it with the committee. dr. kim, as i watch technology you illustrate for us today, i could not help think but i would have thought for years and never come up with the assistive jogger. i realize that there is a certain stigma that is associated with walkers, for example, and that seniors are very eager to avoid those. but do you come up with the technologies and the products that you are developing at the university of maine? >> so, in terms of that assistive jogger, for instance, the that started with two faculty members in disability studies. one of the faculty members, she herself has walking and balance issues and wanted to develop some kind of a system so that she could exercise outside and remain active and part of the community. she would want, her goal was to participate in a 5 hk. so she partnered with a professor in mechanical engineering and students as well and developed this assistive jogger and she was able to complete a-k. even though the -- 5-k. this was designed as someone with walking issues and someone with disability this is a good for someone aging or with a knee or hip replacement and going through rehabilitation. as i mentioned in my testimony, there are also sensors that are included the assistive jogger so you can make sure you aren't putting too much weight on a joint, especially if you're again rehabing. so, lots of technologies that can come from the original technology that can be transferred to the aging population. >> but do you, that's an example of where some professors came up with it. do you survey seniors to see what their biggest problems? >> yes. >> do you reach out to health care providers, home health agencies? >> all the above. so as an example, you know, just, even with a small group of students going to the local assisted living facility in ornos, that is right there, the students in engineering met with residents at this facility and in one hour period of time, they were asked, the residents were asked, what could we design that would help you in your daily lives n a one-hour period, they came up with 50 different items that they would like to have designed. >> that is incredible. it shows there is really such a need for this kind of innovative devices. miss orlov, let's look at other side of this issue. i read an article you wrote, aging in place does not imply watching us age, end quote. i do understand the concerns about privacy that some of these technologies may raise, particularly webcams, implanted devices even. what, how can we make sure that we're striking the right balance between maximizing safety so that people can stay in their own homes and yet not making them feel that big brother or maybe, actually not big brother, but, the adult child, who is watching them? >> well, the first thing i would like to say about the use of any monitoring technology is, there is a concept of opting in. and giving permission basically, that you're willing. i know a lot of implementations of monitoring technology have been done under sort of the, i wouldn't call it the guise but on a basis of threats. basically if you don't let me put this technology in your home i will have to have you move to assisted living because i'm too nervous about your well-being to you living alone. i call that sort of the loving threat. the loving threat has worked in many cases but, it's very important that people understand what they're opting into. they're not opting in necessarily to having their every move watched. and people who design technology properly design for alerts that show, for example, the absence of activity in a particular window of time, or the absence of going near the refrigerator. the presence of a cat or a dog that may jump by the sensors. the idea you may go on vacation, there are your sensors say you're not moving but you're really away for several weeks. a lot of thought has to go in for the things are set up and configured, but when configured properly they can work well. >> thank you, senator mccaskill. >> thank you. i would like to talk a little bit about cost savings and financial implications of all this and taking things to scale. professor skubic, what are the cost savings that you all can attribute to some of these advancements as it rights -- one of the things we tried to vest in this committee, i think many people out ho are not directly involved, they don't understand that a huge proportion of the medicaid dollars that are spent in this country are not spent on struggling families who are not working but rather spent on our seniors in nursing homes. that the high proportion of nursing home beds are medicaid beds makes this a really important hearing for our debt and our defer sit. because if we can figure this out, the cost savings are, and implications of those cost savings are dramatic to the long-term problem we have with the demographic bubble that is represented with my generation going into medicare and ultimately if not having sufficient money saved to a medicare nursing home bed. .. . in the stairstep fashion where you're going to plateau until something dramatic happens and you get dropped down to the next level very quickly until the next dramatic things happens. so our premise, if we can recognize the beginning of that decline so that an innovation could be offered we can keep people about the top of that level, and some people call this squaring the life curb or you go along for some period of time and then there's a sharp drop off when you die. i'm hoping this is what happens to my parents actually. >> and to me. >> yes, to all of us, that we would end up being very functionally active until the end. trying to quantify that in terms of cost savings is really hard. we have not yet done a study that really quantifies the effectiveness in those terms, in economic terms, that technology alone. we are involved in nih funded randomized controlled study right now that is scaled up and hoping of some economic cost-saving figures associate with this. i concluded that my collaborator has looked at -- can tell you -- economic impact of using nursing care coordination in this context which is what they're doing it tighter place as well. it's how they do the nursing care as well as how you had the technology part on top of that. they've shown quite a dramatic potential cost savings associated with what they been able to do with just the organized, coordinated care. we seeing as we've compared the standard level of care and tiger place, between those of census and those who did not we see much improved health outcomes and a longer set of independent living. i don't have the actual quantitative numbers for you but i suspect there are quite significant. if you look in my written testimony i did include some numbers that are based on just nursing care coordination. those are pretty dramatic by themselves. this one statement that's in here, and this comes from maryland's work, that about 10 million people need long-term care in the u.s. of these 4.6 million are older than 65 and living the community. these 4.5 million represent a potential 89 billion clasped savings everyone have access and participate in the nurse care coordination intervention that has been tested at the university of missouri. that's huge. >> we would love to get the details of the survey. just as soon as the academic community can begin to put some numbers on some of these advancements. i know tigerplace is mark spencer than some of the other facilities that are in the area in terms of -- more expensive. i understand this one you guys are doing research and i understand all that, but i think we got to start monetizing the savings as quickly as possible. the more quickly, the more quickly we can begin adopting them as part of public policy preferences which would have a huge impact on their availability to most people. >> tigerplace is not that much more expensive than a lot of other facilities. >> slightly more. >> it's not too much more. >> listen, i'm a big fan of what you're doing. i'm just saying i want to try to deliver just as many people as possible. not only does it of their lives but helps us struggle with how we're going to make sure our grandchildren are not inheriting a debt they can't speak and i'm all in support of that. >> thank you. >> senator perdue. >> i want to echo the ranking member for her comments. as an alternative mode. we want the best care for parents in a generation. second is, i'm hearing an opportunity, a tremendous opportunity to do with one of the largest cost items with coming at us in the next 20-30 years. like several of you, i have a personal experience with this. contrary to some my political opponents i do have a mother and she's 89 and she's very tech savvy. she's independent, but this aging in place is a new phrase for me, a new phrase for patients living that out. contrary to that my wife's mother is a bit younger, just been diagnosed with alzheimer's disease. we have a different trajectory to do with. dr. mccarthy, i'm very excited about what you are doing with the va. you've got a perfect laboratory to answer these questions are doing, particularly about cost, accessibility united perfect laboratory project independent patients who are sometimes in denial about me. get the medical staff that may be less than receptive potentially to some of these sort of new technologies, or not. maybe it's a perfect lab to develop these but i'd like to get your experience, give us a general sense of that, accessibility with the patients and those with the medical staff that you deal with. >> i'd like to start by answering about health in particular we have an example of a little device that would be placed, for instance, -- i'm not going to turn on -- this would monitor the blood pressure or the weight or the temperature a something of a veteran. we provide those devices to a device like it costs about $350 could be repurposed when one veteran is done with it. the costs for using a device like that are about 1600 also you. when i talk to cost savings i didn't translate into savings but if you think a better before the use of a device like this and after the use of a device like that, last year for the patients last year, 54% decrease in bed days of care, numbers of days in facility. then 32% decrease in actual numbers of admissions. that translate into significant cost savings. it's important to know the devices don't exist alone. the devices are part of a system. for us we upon telehealth care quarters. for every 100 enrolled, for about every 100 we have one care coordinator. people smarter than you published about the data and we've had inquiries. i've been in the role of -- since september, increases cash the increased mobile world where people give reproducible results. some the problems that people in other countries have experienced, for instance, not having to care coordinator available or perhaps selecting the wrong group of patients here they are for pcs conditions which are extremely helpful. one is congestive heart failure. people have mentioned before. congestive heart failure basically means the heart is a function of strongly, effectively as it used to. of luis ppaca. when the fluid backup you see things like weight gain. so weight is an incredibly important sensor for when someone with congestive heart failure is starting to detroit because of their diet or some other condition. when the david about weight is conveyed to the home to help care quartet, that's an important piece of information. another one is copd, lung disease, what people sometimes call emphysema. devices are attached within measure oxygen saturation and give us a hand when someone needs to intervene. the beauty of the device is for the better and the caregiver do not have to get in the car and travel by the intervention can be made based on the result that's available. i also wanted to wagin mention e tsv which of important condition for us. people are able to track the moods of the symptoms and so forth. the fourth one was diabetes where blood sugars can be monitored. other conditions as well. be care coordinator serve such a crucial role in changing the data come in communicating with the patient, communicating with health care to to make sure they interventions have been appropriately. >> thank you for a very thorough answer. thank you all. >> senator blumenthal. >> thank you, madam chairman. thank you very much for holding this very important hearing. and i want to focus on an aspect of security, which perhaps hasn't been mentioned so far, and that is the security of the data and information that is collected. and perhaps begin with you, ms. orlov, did you could tell us what specific steps have been taken and what more has to be done to make sure that the personal information, confidential medical and other information can be kept secure? >> we are in the midst of a data crisis right now in the united states. you on the about the and some, 80 million records that were stolen -- anthem, and identity theft that is associate with that. i would say this has created a heightened awareness of all of the players got into continuum of care for not just older adults but for everyone, and that includes insurance companies for which the state -- this data was also stolen but includes health care providers and their management and electronic medical records. so good news is that awareness has been dramatically heightened in the past four to six months. >> awareness has been increased but should've been hiding the years ago. >> years ago. >> and anthem the data was not encrypted. is your? >> i don't have any data, thank god. the va -- spent hours is encrypted, yes, sir. >> would you recommend that data be encrypted as part of this program speak was we certainly would recommend the protection of privacy, it's interesting for us because our journey started around, in the early -- the technology available to ensure privacy and security has changed. some of our requirements reflect what was available been. some of our get into the veterans homes is using devices or technologies that was required at that point. there are newer means to conduct those kinds of visits, telehealth visits. we are migrating out technology that way but without compromising security and safe safety. >> i want to ask what may seem to be a complicated question. going to try to make it simple. as you know, and i' i'm the rang them by the veterans affairs committee. with an ongoing controversy about the 40-mile rule, whether the 40-mile rule should apply to clinics or to the clinics that can provide the care that the better needs. the better they be within 40 miles of the clinic but the clinic may not be able to provide the care that is needed. so than a veteran is able to go to a private health provider. what i'm wondering is whether the telehealth program from hospitals, the 100 plus hospitals that are to the hundreds of clinics would fill a gap that would enable more veterans to go to the clinics and get the care that they need. how much of that potential have we explored and actually fulfilled? i hope my question is comprehensible to you. >> it is and thanks for your service on the veterans committee. we appreciate. so what you're talking about is part of telehealth and we call clinical video in particular in which providers see a patient. a lot of folks off my with skype or facebook -- not facebook, face time, i'm sorry. but that's the technology that people are most familiar with which replicates what go on with clinical data telehealth. those clinical visits can happen from one of our shared hospitals to the entity based outpatient clinics. they can happen from one community based outpatient clinic to another. they are also happening in the patient's homes. with space as a challenge would also look at exploring ways for the provider to not have to take up the space of a medical center to be able to provide this kind of care. we have probably about 12 points of the% of our patients are engaged in clinical video telehealth or other kinds of telehealth. there's a large opportunity for expansion. we are working down the barriers that we see and expanding this as an option. i can type some of the road in the mid '90s, wrote that the biggest barriers to the extension of telehealth are not the technologies, they are the administrative burdens. what we often refer to, the fact our nation has helped a system that's excellent but it's bricks and mortar based on hospital. in third world countries where there's not a system of hospitals but there are many smart phones, telehealth has taken off in an incredible way to provide access to patients who have the smartphone. it's our goal that we'll get to the point where they care can be provided timely, veterans centered way, not clunky so it's easy for the provider, easy for the veteran, family member to have that care. >> and you used the percentage i think 12-20%? >> i said 12 points 7%. >> twelve points seven. thank you. thank you all for your excellent work. >> thank you. senator cardin, welcome. >> thank you. thank you all. doctor mccarthyite like to continue along the lines that senator blumenthal was discussing. at the va you focus a lot on various telehealth approaches. want to expand a little bit and talk more about home telehealth. at a rural state like arkansas we face a couple challenges. one is a small number of health care providers in rural areas. second is also the sometimes slow nature of broadband services in rural areas in particular areas like these arkansas, very low population density or the ozarks given the line of sight issue. what you have experienced at the va, how much of the telehealth challenges do you think they're going to revolve around that kind of infrastructure limitations on how much will revolve around novelty of it or the resistance to change that we all have as a natural human instinct? >> that's a good question. i think there's a requirement for buy-in on multiple parts administratively from the provider's perspective and from the patient's perspective. we can tell you stories about of patients that have coached our younger providers through the first telehealth visit in a way that has been very positive for everybody engaged. technology is an issue. we have for home telehealth three kinds of technology that we use. we use the device connections. we use the interactive voice response and then we use the web browser the interactive voice response, people used to do their banking, but in the number and the phone and what they want to do with what account and so forth. you can do that by pushing buttons or by voice recognition. the device connections can be through the telephone system, just a regular telephone system. it's sometimes called the plain old telephone system. the cellular system or with internet protocol. and then through the web browser. we have some devices that we're rolling out that has a built-in cellular antennas that allow for that kind of connection. but sometimes the technology is a barrier, and adoption of the technology, but it's been my experience that so many of our aging veterans who have grandchildren at a distance are becoming more and more fully with a stein and skype and so they're very engaged. the incredible convenience of not having to travel, to take out what's going on, to move around the medical such as afford to kind of have an appointment and see a provider and be done and not have to engage in all the whole process has been very well received. the home telehealth is very, very, very positive. >> in your work if you develop perspective on infrastructure challenges on the one hand and consumer taste preferences habits on the other and? >> i have looked into, one of the things we're not talked about is the role of carriers, telecommunication carriers, and boosting connectivity for older adults. better than pilot programs to provide discount for internet connectivity -- there have been -- for seniors but at this point there is not a standard program across all the carriers in the united states that would make internet access to affordable for many people of lower incomes. that is an opportunity it seems to me that we can do a lot more with. same thing with cell plans. i think the average cellular plan in the united states now this around $60 a month. internet service plan now manger a $120 a month which is beyond the means of many people of lower income. i believe there is an opportunity to work with the carriers and come with a better idea. >> i would say for the record just another example of the importance of rural broadband. may provide some cost up front but the savings we can achieve through the government and medicare or in our society as a whole through private insurance are no doubt substantial. ms. orlov, building on some of the work you've done i have no doubt that our first on antennas on the markets to provide the technology could have seen you are a rapidly growing population as the baby boom generation retires. to our strong market incentives but there are strong legal barriers for markets, aging in place to develop your the things we can address as congress. >> legal barriers? well, i mean, just look at the physical environment for aging in place which is the home, right, and look at building code and looking at the we even knew housing for older adults is being designed, there is the nationwide building code that would make homes even modestly accessible. it's nothing that requires smooth thresholds, nothing requires wide doorways for patterns that nothing requires sync heights they could -- enable faucets did ask us if you're in a wheelchair. if you want to think about something that we done to enable people to a joint income from a policy standpoint it would be to talk to organizations that lobby on behalf of those like the national association of home builders and but what are the barriers and probably barriers at the state level in 50 states one way or the other. to enabling use of the standards, even if and i can, even if, in fact, invented him enter completely able-bodied and have no issues at all, if you are, is your home able to age with you? that's the question. >> thank you all again. >> thank you very much, senator cotton. very glad you brought up the issue of rural broadband because that's a real issue in my state as well and i was thinking about some of the sensors and other devices would simply not work in some parts of the state of maine. it's something that nationwide we really need to do more work on. i'm just going to, i've got a couple of other questions. mr. strickler, i noticed that you did do the cost comparison that all of us are interested in common and we talked about the cost of the setup, $2000 a monthly fee of $59. and if my math is right, when you look over the two and half years if you nursing home plus home health it's more than $300,000. and so i think this does have very important cost implications for us. one of the issues i think we as congress needs to work with the administration on is what is reimbursed of all to health care providers under the medicare, medicaid program? because a lot of times we will pay for the consequences of unchecked diabetes but we won't pay for the ongoing consultation that prevents the person from having the complications. and i can see many of you nodding on this. so that's something we need to look at as well. mr. strickler, one final question i want to ask you, and that is your testimony, you mentioned that it think it was your mother-in-law didn't want to wear that emergency alert pendant. how did you find out about the alternative ways of keeping her safe by the use of sensors, by putting them all over, sounds like all of the houston make sure she's eating, but one in the refrigerator door. i don't think most people would even know where to begin. how did you get the advice you needed on what you should purchase for her and what was available? >> i think the approach that we try to take was to find a trusted advisor that could help us. kind of say we started grappling in the dark, groping in the dark a little bit if you would, and export a couple of things that were not successful and we reached out and visit with other people added some solutions that did work. and then said okay, let's find somebody that really knows and understands the technology and can help guide us through this process. my advice to anybody also trying to do that would be find a trusted advisor and then they can help you identify which technologies are appropriate. different technologies are appropriate in different circumstances. and so i think in our case we reached out to our home security folks and they were able to sort of help us zero in on things that really spoke to the needs that my mother-in-law had. when we couldn't get her to wear a pin didn't we needed to be alerted when she fell, so having those sensors being able to identify issues up and about and didn't reach point a or point me in a timely fashion, it would send a cellular alert to let us know you need to go check on her to make sure, if something is amiss. so that was very helpful. to be up to reach out and have that resource. >> thank you. and my final question is for dr. mccarthy. and that is, you mentioned that you were doing telemedicine i believe from 900 sites, is about correct? >> i believe that's the correct figure. >> i guess my real question about that is, is this happening from your community based clinics and your va hospital? or is not individual, outside providers that you are contracting with? >> it could include that but that's primarily be a driven for marketing to based outpatient clinic. some of the sites with a care provider would be other clinics other parts across the country as a network what it's supporting one another but also to the veterans home spirit and again i think the cost savings that you quoted, $2000 per veteran per year, when you start multiplying that you're getting the real numbers very quickly. this has been a very interesting hearing. i want to call an senator mccaskill for any final questions she might have. >> i really don't have any other questions. i think we need to go back and look and see how we began distributing scooters with reckless abandon at one point in time in the medicare program. i know when i began talking about scooters we actually found a couple, one woman who worked in the office whose grandmother had three, in the lift chairs and all of those things where we are, in many cases they are needed, but how do we get approval for all those to be paid for by the medicare program? what do we need to, instead of paying for those, pay for sensors that can monitor things that will allow us to intervene in a way that is cost effective and healthy and allow seniors to age in place? and more quickly, the entrepreneurial free market in this country -- free market in this country comes with products that can be brought to scale that they can present to the medicare system for possible reimbursement that would result in these savings are i think the more quickly we can really turn this thing. so i certainly urge all of you that are in academia to continue to reach out in a public-private partnerships that i know many of your engaged in which accompanies at the university of maine and with your partners at the university of missouri, and i know the va has a lot of commercial partners. the more quickly we can get this technology to the point you don't have to have, most of us don't have a trusted tech advisor. therein lies the problem. of americans don't even know where to find a trusted tech advisor because if you look up online for a trusted tech advisor you're liable to get someone who is not a trusted tech advisor. so i think the more quickly we can do that, the more quickly we can really make some progress in this area, and i really appreciate this hearing. i learned a lot. i think all of us are motivated to seek we can't push this envelope, and i think all of you for your work. and thank you once again, chairman, for a really good hearing. >> i think your comments are very well taken. this committee has held a number of hearings on scams that we want to make sure that as we start promoting this kind of new technologies that can get peace of mind to caregivers, and help our seniors age in place and the and the comfort, security and privacy of their own homes that we are not opening a whole new avenue for con artists out there who will exploit any possible opening as we have found in our various investigations. i want to thank all of our witnesses for being here today. dr. kim, i love the fact that you are involving a student at the university of maine and taking them i suspect to talk with seniors at there. incredible that one out of visit came up with 50 different ideas, so that should keep them busy for quite some time. each of our witnesses has contributed to our understanding of this issue, and i thank you for taking the time to testify before us today. committee members will have until friday may 22 to that question to any of our witnesses or additional materials for the record. i want to thank senator mccaskill and all the members of our committee who participated, as well as the committee staff have put together an excellent herring for us today. most of all thank you to our witnesses. this hearing is now adjourned. [inaudible conversations] >> jimmy carter announced last week he has cancer. this morning and 90 of former president hold a news conference to talk about his diagnosis. live coverage from the carter center in atlanta at 10 a.m. eastern on c-span. after the republican president a candidate rick santorum talk about immigration at the national press club. that is live at 11 eastern. >> i wrote to the widest coverage of the presidential candidates continues live from the iowa state fair on c-span, c-span rated and c-span.org as the candidates walk the fairgrounds and speak at the "des moines register" candidate soapbox. >> next, look at u.s. policy in the arctic region. we live arctic region. will do from the former coast guard commandant admiral robert papp who is not a state department special representative for the region. the heritage foundation hosted the event. >> welcome to the heritage foundation. where we are going to look at some arctic issues today. the name of our program is examining arctic opportunities and capabilities, does the u.s. have the infrastructure, ships and equipment required? before it gets to let me introduce myself. i'm jack spencer, vice president for institute for economic freedom and opportunity. i know on the invitation you were promised james carafano is probably more qualified than i to do this. unfortunately, he got stuck with some travel difficulties so you give me. while i am the vice president of our economic shop at the heritage foundation i used to gavel in national security related issues which i think are relevant here. many years ago. so we have that at least. this is really critical issue. it's one that doctor care of honor, if you are here, five years ago he would've said how important this issue was. a lot of us here at the heritage foundation would've said yes, it's important to whatever you go on and keep scientific but since he started that argument, we've been on a clergy jeffrey we became very clear how important this issue was. how important the arctic region was and how important that united states policy regarding the arctic region is to get support for three specific reasons, at least three. there are real environmental issues that you do we need to deal with or that as the region gets developed we are going to have to deal with. there are real economic issues. there are folks out there who want to increase their standard of living, i want to develop where they live, develop their it comes to there are real security issues. that's what i think most people think of first and foremost or not the children in the arctic. i would just suggest that if the united states does not participate in arctic policy, doesn't come up with a coherent rational policy towards the arctic, others will and perhaps we will find that we are not as happy how others engaged the reason is what we would have. so that's why i'm so honored and happy today and privileged to introduce our speaker. our speaker is admiral robert papp, special representative for the arctic. admiral papp he came to state department special representative for the arctic and july 2014 and lead effort to advance u.s. interests in the arctic region. with a focus on arctic ocean governments, climate change, economics, environmental security issues as the united states prepared to assume the chairmanship of the arctic council in 2015. part to his appointment admiral papp serve as the 24th,.gov u.s. coast guard and let the largest component of the department of homeland security. as a flag officer admiral papp serve as commander, coast guard atlantic area as the chief of staff and command office of coast guard headquarters. as commander, and as director of reserve and training, admiral papp was a career counterman, having served in six, having served and six coast guard cutter's commanding for them, red beach, forward and the training bark eagle. in 1975 graduate of the united states coast guard academy. additional penalty masters of arts and nation security and strategic studies from the united states naval war college and investors and management. admiral papp, the microphone is yours. >> thank you. thank you, jack. good afternoon, everybody. it's a delight to see the crowd here today. believe me as i spoken about the arctic over the last year in this job, sometimes i speak about half a dozen people. sometimes i speak to a couple hundred. actually in ambassador haarde, how many did we have at arctic circle in reykjavík? i think 1300 from about 35 different countries. so it varies but i take every opportunity i can because jack was right. it's an important issue, importation of our country first and foremost because we are sharing the arctic council right now -- cherry pick the to be more and more responsibility for our country as the arctic continues to develop. as i said, part of my job is to raise awareness of the arctic and some the challenges we're facing. i'd like to start off by telling people how does one become the united states special representative for the arctic. it's very easy to track that back because we've only had one, so obviously there's only one answer. first and foremost you have to be very careful on how you select your assignment leaving the coast guard academy. back in 1975 i was engaged and i thought that i would probably select an assignment either in boston or new york because my wife's parents live in between in new london, connecticut. when i got into the actual night with the assignments, by chance i walk in there and there was a ship that was remain in alaska that was available. and on a spur of the moment i said that sounds exciting. that sounds like an adventure. alaska, the last frontier. and i look at it was the coast guard cutter and would in a place called -- i said i don't know where that is what is alaska. out to be great and it would be an adventure. i put my card in the slot, went back to my room and broke out in alastair ichat av to do this. getting atlas of the united states enter into the alaska page. on the alaska a juicy mainland alaska became a in the lower left hand corner see a little bit of the alaskan peninsula. then there's a couple of inserts at the bottom. the first insert has the remainder of the alaskan peninsula and maybe two or 300 miles of the aleutian islands. the second insert has the remaining portion of the aleutian islands and adak is about two-thirds of the way out in the second insert which means it's a very famous book about world war ii and the aleutian islands called the thousand mile border. adak is about 800 miles out in the aleutian chain so it's pretty far out there. when i went to see my fiancée she said, so where we going? boston or new york? i said adak, alaska. that's the response i got from her. it was even worse when i showed her the atlas come and i'm very fortunate that she still continued to consent to marry me. i'm very fortunate she's been with me now for 40 years. what she will tell you is that adak and our two years out there, a navy base at the time, but also our home port was probably two of the most informative years of our marriage. because i was never there. the ship was constantly under way. so she learned resilience. she learned self-confidence. she learned to imitate. she learned human relation skills that have served her for many, many years and really major a wonderful first lady of the coast guard during my time as commandant because she could identify with a lot of challenges our young families face as they start a new career. but for me it was even more formative because i wanted to be a sailor. i can't think of any more challenging proving ground than the bering sea to learn how to be a sailor. we were in a small ship during the two years i was up there. we covered an area from seattle, washington, although it up above the arctic circle and every inch of coastline in between, the entire aleutian islands. we sailed down to honolulu for training to recover a lot of ocean. but i can tell you that never, i had an additional 14 years of c. duty during my career, and never have i ever experienced whether as severe and sustained has been bering sea. there are storms out there that based on their characteristics in the caribbean you would call them a hurricane. in alaska in the bering sea it's normal weather during the wintertime. instead of passing over a 24 hour period it stays there for sometimes weeks on end and you just get the batter. it will either make you choose not to be a sailor anymore or will convince you that this is what i want to do. fortunate for the topic that this is what i wanted to be. i would also say i learned about what i call the tyranny of time and distance. that 800 miles out to adak, when you steaming around the ship at holy ghost 12 months it to get places in alaska. from adak although it up above the arctic circle was about 900 miles, from dutch harbor, the largest deep water port in alaska out in the aleutian chain, it's about 900 miles up to where shell is operating right now. to the nearest deep water port for shell is about 900 miles away. of coast guard cutters are up in the arctic, the nearest place they can refuel the dutch harbor. so the united states is rather limited in terms of infrastructure. deep water ports, telecommunication challenges and. that is the island but these things 40 years ago. we were navigating -- just making its way in the were many times if we had any stars or son would have use celestial navigation. some of the places we went into a charged that were handmade which been taken over the years by other coast guardsman they would get into these areas. wobbling a gps and love it better communication, there's still challenges just as we found with the shell those of us coming out of dutch harbor that doctor was plenty of water and ripped i think a nine-foot priest in its whole as it tried to exit the harbor. what they did was pick out a little rock commentary that was never charted before, and now it is. but you have got throughout alaska. it taught me lessons that stayed with me my entire career. open to the public became commandant eddie became obvious that equities for the united states coast guard and for the united states were increasing as this large arctic ocean area was having reduced ice in the open water or longer in the year and they consequently increasing human activity. i wanted to make sure that my service was prepared for the future but we didn't a coast guard arctic strategy which was released directly after the national arctic strategy assigned by the president. back in 2013. so i went back as commandant in 2010. my first experience was 1975-77. i went back and 2010, to refamiliarize myself a target and i there was one significant thing that i noticed. because in 1976 when across the arctic silver for the first time we went to a city and we were looking for ice lead. i flew a helicopter and when we landed, i could see ice from the shorelines out as far as i could see towards the horizon. this was in july 1976. the same time of year 36 years later, 2010, i flew in and a cool stream this time to send from a couple thousand feet, and as i looked down at the show and as far as i could see on the horizon, my horizon was much further out than in 1976, there was no place to be seen whatsoever. about 36 years difference and i went back and look at the records. what i saw in 1976 was not an anomaly the it was normal for the time in our history. what i saw in 2010 was not an anomaly is a. it is the new normal, the lack of ice. the arctic council gives me an opportunity first of all to work within the government to make sure we're prepared for our chairmanship of the arctic council but also an opportunity to work within the arctic executive steering committee which was created by the presence executive order last january. we are making progress on both fronts, of international and domestic league. and i'm here to talk just to briefly about the arctic council and what we are doing better but then transition to perhaps give you a thought piece as we prepare for the folks that will come on here later. so the slides off to the side, and to want to make sure that -- you guys advanced too far. a history of the arctic council is to start out in 1991 as the arctic governmental protection strategy, which was initiated by finland that finland has been a leader in arctic affairs. abroad the it country for the arctic council together, for those who are not th through wih the countries of the arctic is the united states, canada, iceland, denmark, norway, sweden, finland and russia. these are the eight countries that make up the arctic council for the arctic council was created by the ottawa declaration in 1996 with a focus with its charter to promote cooperation, coordination and interaction between the arctic states with a focus on sustainable development and environmental protection. dose-dependent tenets of the arctic council ever since over the last 20 years with very little variation to everything is done, is done by consensus. we don't take up in issues and less as consensus from all eight countries. so when you propose a rather aggressive chairmanship program like the united states has, it takes a lot of negotiation, a lot of listening. upstarts within the united states. our arctic council structure -- and i have it in for them as well. makes it much issue. destruction as i said is a. we have 22 observers including 12 on server states. we have a number of observers are waiting to come onto the council as well. i think perhaps most importantly one of the major components of what we did is we have this experiment participants which other groups that represent indigenous peoples of the high latitude. while they are nonvoting members, we seek their advice and counsel and it's very important to take into consideration, taking into consideration people who have lived there by some reports up to 10,000 years inhabit own cultures, the own way of life and how do we come up with programs that are compatible with that as well. a couple of the landmark projects in my estimation from the arctic council was 2004 climate impact assessment. the 2009 arctic marine shipping assessment, and two of my favorites, and 2011 came up with a maritime search and rescue agreement and in 2013 the brain oil spill preparedness and response agreement. as a person with an operator who served in the coast guard for nearly 40 years, agreement or find a part of our chairmanship program is to start exercising those agreements. it's only for exercising those agreements that we were able to get lessons learned to document for our shortcomings are, where we might be able to share resources amongst the country of the arctic. i'm excited about the prospect of that. we had a search and rescue exercise tabletop event up in alaska this fall. all eight of the arctic countries under the auspices of the arctic coast guard forum will come together for the exercise, and then were very hopeful and our plans call for full-scale operational exercises with the arctic in the summer of 2016. the chairmanship team, secretary kerry is the official chairman of the arctic council for our two-year endeavor. as you might imagine that secretary of state of the united states has a few other things on his plate as well so we brought me on in this capacity to take care of the day-to-day dealings with the arctic council and also to coordinate activity across all the peers within the state department, and also be the liaison for the state department and interagency process in washington. fran ulmer, former lieutenant governor of alaska is one of our special advisors. and the chair of the senior arctic officials, the arctic officials, the eighth senior arctic officials is where most of the business gets done. julie is our acetone. she's been on the job for about a decade never ambassador david altman, we get the chair as well since we have the chairmanship. ambassador david boulton has a breadth of experience in ocean and arctic activities and fisheries and we are very fortunate to get them in that position. want other things we tried to do and i spoke about this with a group earlier is required to have a very balanced program. if you focus on any one issue whether arctic security issues, dealing with the effects of climate change and others, unless you have something that is balanced, unless there's institute these see something in it for them you will cut off some dirt important groups. we want all groups to be interested. so we broke down our program into three areas but the first is arctic ocean safety, security, and stewardship with about six different projects including exercising the search and rescue agreement and the marine pollution response agreement. the second is improving economic and living conditions. very important, particularly after you meet the people of the north. we have about half a dozen projects under that as well. the third is addressing the impacts of climate change. and what i found as i kind of spoken to groups both in alaska, here in washington and visiting each and everyone of the arctic council countries is first and foremost they have appreciated the fact that it is balanced. the second comment i get the most is, it's a very ambitious, admiral, except from one person. secretary john kerry. he causally ask are we doing enough? is there anything else we can be doing? i think we found some balance there as well. the third is what about russia. suffice to say, it's a consensus-based organization. it's important russia on board and i've been doing a lot of work with our russian colleagues to make sure we are engaged in cooperative and communicating most importantly. the fourth most common comment is were excited about the united states leadership, within the fifth comment whic which is proy gym and what we are discussing this afternoon is, we are excited about u.s. leadership but we are concerned about united states commitment. by commitment i think most people and they say what sort of resources are you devoting to the arctic? when we can't get replacement icebreaker built, when we haven't been able to develop a deep water port windows challenges with telecommunications and other things, people legitimately question our commitment. i think there's some good news to be told, particularly since the president's executive order, ma the creation of the steering committee and the fact we're starting to prioritize some of the challenges that we faced over there. so that's just a quick overview of our chairmanship program. one of the things i'm very excited about as we stated it is where about a week away from something called glacier. glacier stands for global leadership in the arctic, innovation, engagement -- i saw, cooperation, innovation, -- that's really cute phrase. it has a connection to what we are doing in the arctic. but most importantly for me i selected it because of the name of one of our coast guard icebreaker's which is decommissioned and, of course, we're still trying to advocate for icebreakers and hopefully we will have a look at the discussion on that here this afternoon. i want to get into deep thought piece this afternoon and this is something that started coming to me when i attended the arctic circle event in reykjavík, and then was further advanced by went to the arctic council ministerial in april when we assumed the chairmanship. the thought process started because when we went there, i'm interested in history someone to love it about the place and i learned that used to be called frobisher. it was changed to the indian name later on but it still sits on frobisher bay. who was frobisher? martin frobisher, and english sea captain who in the late 1500s, 1576, was exploring for the northwest passage. the 1500 great britain was looking for the northwest passage to try to find a more efficient route to the far east in order to conduct trade. even back then prosperity, economics and coming up with more efficiency root was important. why was it important? and why nearly 200 years later i visited an exhibit in anchorage bracelet, the exhibit is about captain james cook, of course anchorage, it was discovered by coke i can 1778 -- cook. i started looking at the reason he was there was 200 years after frobisher, greg brings out was still giving orders to search for northwest passage except he was looking at it from the other direction. his last crews out to the pacific, his third crews, talking on orders of around the north american continent into the arctic ocean, of course which was stopped by ty stewart he had to turn around and i was unfortunate as to because it did not been stopped and turned that he probably would've gone back to hawaii -- hubby wouldn't have come back to hawaii where he was unfortunately killed. why were they searching for it and why were they so persistent, and why we still talking about coming up with those roots today? well, i did a little studying, and they became -- i became very interested in maritime sea powers and i started working my way back to frobisher and great britain in the late 1500s. what i ended up with was studying venus. dennis -- venice, the late 1300s into the mid-1500s. they were small. they still are a small probe island nation, small in population, small and geography. but they maintained great geopolitics. they were able to survive and conduct trade between the ottoman empire, the byzantine empire and christian europe. ..

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