[Senate Hearing 108-436]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-436

                       FAMILIES HELPING FAMILIES:
                  TAX RELIEF STRATEGIES FOR ELDER CARE

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           FEBRUARY 10, 2004

                               __________

                           Serial No. 108-28

         Printed for the use of the Special Committee on Aging



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                            WASHINGTON : 2003
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                       SPECIAL COMMITTEE ON AGING

                      LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama              JOHN B. BREAUX, Louisiana, Ranking 
SUSAN COLLINS, Maine                     Member
MIKE ENZI, Wyoming                   HARRY REID, Nevada
GORDON SMITH, Oregon                 HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri            JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois        RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah                 RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska                  EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania          THOMAS R. CARPER, Delaware
                                     DEBBIE STABENOW, Michigan
                      Lupe Wissel, Staff Director
             Michelle Easton, Ranking Member Staff Director

                                  (ii)

  
?

                            C O N T E N T S

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                                                                   Page
Opening Statement of Senator Larry Craig.........................     1

                           Panel of Witnesses

Trudy Elliott, Family Caregiver and Home Health Nurse, Coer 
  d'Alene, ID....................................................     2
Sandy Markwood, Chief Executive Officer, National Association for 
  Area Agencies on Aging, Washington, DC.........................     8
Gail Gibson Hunt, President and Chief Executive Officer, National 
  Alliance for Caregiving, Bethesda, MD..........................    21
Flora Green, The Senior's Coalition, Washington, DC..............    26
Richard Teske, Washington, DC....................................    31

                                APPENDIX

Prepared Statement of Senator Gordon Smith.......................    45

                                 (iii)

  

 
    FAMILIES HELPING FAMILIES: TAX RELIEF STRATEGIES FOR ELDER CARE

                              ----------                              --



                       TUESDAY, FEBRUARY 10, 2004

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:10 a.m., in 
room SD-628, Dirksen Senate Office Building, Hon. Larry E. 
Craig (chairman of the committee) presiding.
    Present: Senator Craig.

     OPENING STATEMENT OF SENATOR LARRY E. CRAIG, CHAIRMAN

    The Chairman. Good morning, everyone. The U.S. Senate 
Special Committee on Aging will be convened. I apologize for my 
tardiness, but I was over-booked this morning, or I should say 
double-booked. I do pride myself starting hearings on time, but 
I was trying to help figure out if we can pass a national 
energy policy this year.
    So, again, let me welcome all of you. I would like to thank 
our witnesses for joining us today on a growing issue of 
national importance, the issue of family caregiving. Today's 
hearing will highlight the stress and financial challenges 
faced by family caregivers of aging and vulnerable relatives, 
and shine a light on tax relief strategies for relieving the 
financial burdens freely undertaken by many adult children.
    Over the past few years, the Aging Committee has held 
several hearings on different facets of the growing long-term 
care crisis in our country. A major concern of mine is that the 
Federal long-term care policy mix may not have the right 
incentives, especially when it comes to the tough choices faced 
by families who want to care for their aging and vulnerable 
relatives.
    One extraordinary strength of our long-term care system is 
that families, not government, provide 80 percent of the long-
term care for older persons in the United States. That is a 
phenomenal figure. It speaks well for our people.
    The U.S. Administration on Aging reports that about 22 
million people serve as informal caregivers for seniors, with 
at least one limitation on their activities of daily living. 
These caregivers often face extreme stress and financial 
burden, especially those that we call the sandwich generation. 
Sandwich generation, many of you know--you have heard the 
term--refers to those sandwiched between caring for their aging 
parents and caring for their own children. It is difficult for 
families to balance caring for children and saving or paying 
for college, while at the same time struggling with financing 
care for their aging parents.
    For many families, the nursing home is the only solution 
for providing long-term care, and that can be a good choice. 
For other families, keeping aging or vulnerable relatives in 
their own home or in the caregiver's home makes sense. That is 
why I am interested in promoting tax relief strategies for 
families who face high stress and financial expenses as they 
care for their aging and vulnerable parents outside 
institutional arrangements.
    Tax relief strategies should not preclude seniors or those 
near retirement from purchasing long-term care insurance. 
Certainly, the package that we are now working on that was 
provided in the Medicare prescription drug bill and a variety 
of alternatives could well, through health savings accounts, 
allow the financing of long-term health care. We hope it 
becomes something that all families and individuals look at as 
a reasonable and responsible option.
    Tax relief for families' caregiving expenses should be 
provided for high-risk seniors who cannot qualify for long-term 
care insurance policies. This is a national issue requiring a 
flexible national response to ensure seniors and their families 
have high-quality choices. This hearing will help the guide the 
Congress in designing the right policy mix, I hope.
    With that preface, let me say how pleased I am once again 
to welcome all of you to our hearing today. I look forward to 
your testimony. We are going to treat you all as one panel, and 
so we will ask that all of you give your testimony and then I 
will ask questions, and some of those will be the types of 
questions that all of you might want to respond to.
    So with that, let me ask our first panelist, Trudy 
Elliott--I guess I would call her a true expert on this issue. 
Trudy is a family caregiver and home health care nurse from my 
State of Idaho, living in the north end of our State.
    So, Trudy, welcome to the committee. Why don't you proceed? 
Thank you.

 STATEMENT OF TRUDY ELLIOTT, FAMILY CAREGIVER AND HOME HEALTH 
                    NURSE, COER D'ALENE, ID

    Ms. Elliott. Thank you, Senator Craig. I would like to 
thank the committee and Senator Craig for inviting me to come 
and tell my story.
    When I was contacted, my thought was this is a story that 
needs to be told and the fact that it is not a unique story. My 
hope at the conclusion of my testimony today is that you will 
visualize a different future for our senior population, as well 
as for the family caregivers, through the congressional 
movement which you have suggested, and recognizing not only the 
emotional strain, but as well as far as the financial strain 
which is occurring.
    How do I possibly convey the feelings that I have had in 
the last 4 years, feelings of frustration, concern, honor, with 
a lot of the multiple fragmented thoughts that have gone 
through my head as I am sitting in different arenas with my 
parents and my sister as well?
    My first challenge of my middle years, which is an 
interesting concept to sit here and talk about my middle 
years--I am not sure what that means.
    The Chairman. They are really quite comfortable.
    Ms. Elliott. I am getting quite used to them.
    Where do I start? Imagine being at a family dinner with 
your mother and father, whom you have seen very frequently, and 
having your father pull you aside and say, ``I need help. What 
am I going to do? There is something wrong with your mother.'' 
I am looking at him going like what? He said, ``well, she can't 
write, she can't drive her car. I don't know what I am going to 
do. She is up all night. I can't get any sleep.''
    The promise that they made together was that they would 
never, ever put each other in a nursing home, which isn't a bad 
thing, but many of that generation promised that they would be 
together forever. In the 50 years that they had been married, I 
think maybe they had spent 2 to 3 days apart. One of those was 
to be with me when my third child was born. So you can see that 
the impact on these 70- and 80-year-old people would be more 
than just an illness.
    They had both been very modest all of their lives, hard-
working people, had saved money and had never wanted to be a 
burden to anyone. So they put away their wonderful retirement 
nest that they would get to enjoy. About the time that they 
were able to enjoy that, my mother developed Parkinsonism with 
a Lewy body dementia, which was a very rapidly progressing 
illness that took her from being an active Assessor of Garfield 
County to a person who needed total care.
    In this time, my father was attempting to be a caregiver, a 
role which he had not been trained to because my mother had 
been the caregiver all of their married lives. So there was a 
real transition for our whole family. Since that day, probably 
4 or 5 years ago, I have been with my mother and my father in 
multiple arenas, in and out of the hospital, in and out of the 
skilled nursing facility, finally with the last part of her 
life in an assisted living facility, small assisted living 
facility, which was able to care for her up until the day she 
died, along with my supervision.
    Part of my role with my parents seems to be their advocate, 
and I feel that that is a role that I am even playing today 
being here in this hearing. My mother lost her ability to 
speak, and it is interesting that when people lose their 
ability to speak, people also think that they have lost their 
ability to say what it is that they want and what they don't 
want.
    So my role with my mother was to be her advocate in these 
arenas to make sure that her needs were met, which she had 
defined to me years ago in her advance directive. Her care 
initially started in our home and then progressed to these, and 
because of my parents living with very modest means we were 
having to pay for the caregiver out of their retirement nest. I 
don't think anybody has any concept of how rapidly that will 
disappear.
    Because of my mom's illness, also it took away the ability 
of my parents to care for themselves in their home and I found 
myself having to pull on the resources that I had learned 
throughout my life in working as a home care nurse. Many times, 
people would ask me why I wanted to play that part? I can't 
imagine not. My parents were there for me. I can't imagine not 
playing that role, even though it was a very difficult role to 
play.
    My second challenge of my middle years was the fact that my 
sister was diagnosed with metastatic cancer during this time 
when my mother was also ill. Even though it wasn't the sandwich 
generation, we experienced what the impact of her care was on 
her son, who was 39.
    I am sorry. That is still a fairly emotional time period 
for me.
    How far can one person be spread? Much further than you can 
ever imagine. Actually, after a continued fight to be a 
survivor, my sister died in our home, which was an honor for 
all of us. Our family had been presented also for my mother's 
final journey, which had occurred approximately 10 days before 
my sister had died in our home. What an honor for me to be 
there for two very important people in my life.
    The third challenge of my middle years was my father, who 
is now 82 years old, and it is an ongoing thing that we are 
incurring with him today as far as his care environment. I am 
sure that this Act that is being suggested will be very much a 
financial relief for families such as myself who have 
experienced the sandwich generation.
    Thank you.
    [The prepared statement of Ms. Elliott follows:]

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    The Chairman. Trudy, thank you. That is tremendously 
powerful testimony, and I think you said it well at the 
beginning, reflective not just of your experience, but 
thousands like you across the country who feel that 
responsibility and love to do what you have done. Thank you.
    Now, let us move to Sandy Markwood. Sandy is President and 
CEO of the National Association of Area Agencies on Aging. 
Sandy, welcome to the committee.

STATEMENT OF SANDY MARKWOOD, CHIEF EXECUTIVE OFFICER, NATIONAL 
     ASSOCIATION OF AREA AGENCIES ON AGING, WASHINGTON, DC

    Ms. Markwood. Thank you so much for having me. Good 
morning, Chairman Craig. My name is Sandy Markwood. I am the 
Chief Executive Officer of the National Association of Area 
Agencies on Aging, and I really want to thank you for inviting 
me here today to talk about family caregiving.
    I am pleased to be here today to represent the Nation's 
area agencies on aging, and also the Title VI Native American 
aging programs, whose fundamental mission is to support people 
to live in their homes and in their communities with dignity 
for as long as possible.
    The 655 area agencies on aging and the 232 Title VI aging 
programs are dedicated to enhancing the quality of life of 
older Americans and providing support to their families. In 
this way, they provide supportive services and a whole range of 
preventive services. They are the single point of entry and 
information for older adults and their caregivers to find out 
about the range of community-based services that exist to 
support older adults and their caregivers.
    These services include congregate meals, in-home meals. 
They also include personal care, chore services, the nursing 
home ombudsman program, transportation, and senior centers. But 
critically, since the reauthorization of the Older Americans 
Act in 2000, it also includes a whole range of family support 
for caregivers. Through working with caregivers, we know that 
family caregivers are the heart of the long-term care system in 
this country, and they are also the backbone of it.
    Uncompensated care by family members makes it possible for 
millions of older adults with long-term care needs to avoid 
costly and often unnecessary and unwelcome placement in formal 
care settings. Recent estimates have valued the services 
provided by family caregivers at $257 billion a year. That is 
an astounding figure.
    Caregiving, however, also has a cost to the caregiver, 
though many would not want to admit it. Numerous studies have 
shown that caregiving exacts a great financial, emotional and 
physical toll on caregivers. Many caregivers forgo job 
advancements, reduce their hours on the job, cut back to part-
time, take temporary or extensive leaves of absence to be able 
to stay home to care for family members. These actions result 
in lost compensation, diminished contributions to employee-
sponsored pension programs, as well as limitations on employee 
benefits. Additionally, caregivers often deplete their own 
family personal savings to be able to try to compensate for 
that loss of income.
    Caregiving also has associated costs. As Trudy mentioned, 
direct expenses incurred by family caregivers include the 
purchase of prescription drugs, durable medical equipment, home 
modifications, and physical therapy for the care recipient. 
These all have a cost. It is a cost that caregivers welcome to 
pay, but sometimes it adds up.
    There is no doubt that caregivers, many of whom are raising 
children, working full- or part-time and are facing challenges 
of aging themselves, are stressed with multiple 
responsibilities and they need help. It is only right that 
those that give help should receive help.
    Congress took the first steps in recognizing both the 
tremendous contributions of family caregivers and the need to 
provide them with some critical relief by including the 
National Family Caregiver Support Program in the 
reauthorization of the Older Americans Act in 2000.
    This program provides critically needed assistance to 
families as they struggle to provide help to loved ones. It 
builds upon services that already exist in the community 
through the Older Americans Act, but it expands on it and 
provides value-added services for caregivers.
    In the 4 years since its establishment, appropriations for 
this program have gone from $125 to $129 million. While we 
appreciate the yearly increases, given the vast numbers of 
family caregivers and the extent of the need, I would be remiss 
in my role as an advocate if I didn't draw attention to the 
fact that the program still is underfunded.
    These dollars, though they are augmented by the State and 
local level, are stretched thin. AAAs report that they work 
very hard to be able to provide the needed services. The most 
used service is respite care, and that is also the most 
expensive service. Respite has been able to provide proven care 
to alleviate, at least temporarily, some of the physical and 
emotional stresses related to caregiving. It also helps to 
delay expensive institutionalization. However, because of the 
cost, caregivers often need more respite than they can afford 
privately, and they also need more respite than AAAs are able 
to provide with competing service needs and limited funding.
    Additional services provided by AAAs in Title VI aging 
programs under the National Family Caregiver Support Program 
include supportive and supplemental services, such home 
modification, transportation and chore services. Given the 
flexibility of this program, what area agencies have been able 
to do is to provide small sums of money to caregivers to be 
able to help them get chore services, personal care, even to 
get assistance in mowing the lawn. These small services can 
make the difference between the exhaustion level of a caregiver 
and their ability to be able to keep somebody in their home or 
reaching a crisis level where they feel like they need 
institutionalization.
    In saying this, what we found out through this program, and 
thousands of examples of wonderful services provided at the 
community level, is that the needs of caregivers are unique, 
but they all have needs and they all need assistance. They need 
emotional assistance, they need physical assistance, and they 
need financial assistance.
    Caregivers truly are the heart of the long-term care system 
and we as a Nation must do more to address the emotional, 
physical and financial challenges associated with caregiving. 
The National Family Caregivers Support Program was a 
significant first step in providing some relief and support to 
caregivers, and we look forward to working with you and your 
committed staff to ensure that the passage of the SECURE Act 
takes a further step forward toward providing needed financial 
relief to this selfless population.
    [The prepared statement of Ms. Markwood follows:]

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    The Chairman. Well, Sandy, thank you very much. I think you 
have broadened the scope of the picture of this issue very 
effectively and I appreciate that for the hearing record.
    Now, let us turn to Gail Hunt. Gail is President and CEO of 
the National Alliance for Caregiving. Gail, welcome to the 
committee.

 STATEMENT OF GAIL GIBSON HUNT, PRESIDENT AND CHIEF EXECUTIVE 
    OFFICER, NATIONAL ALLIANCE FOR CAREGIVING, BETHESDA, MD

    Ms. Hunt. Thank you, Senator Craig, for the opportunity to 
provide information on family caregiving. In light of your 
interest in helping older people to stay in the community and 
help caregivers in their effort to continue caring for 
relatives and friends as long as possible, I thought I would 
focus on some of the latest data on caregiving. Who are the 
family caregivers and what do we know about them, and what 
impact does caregiving have on their lives?
    First, some basic data on family caregivers. Nearly a 
quarter of U.S. households are involved in family caregiving. 
This number is important because it shows how involved family 
members are in caring for one another and how large an issue 
family caregiving is in our country. It is a myth that 
Americans abandon their older relatives to nursing homes. 
Approximately 80 percent of the care, as you mentioned, for 
older people is done by family and friends.
    The profile of the family caregiver is a 46-year-old baby-
boomer woman who is married and works and cares for her 77-
year-old mother who lives nearby. The caregiver spends an 
average of more than 20 hours a week providing care, and 
caregiving typically lasts more than 4 years.
    There are three trends I wanted to mention. Despite the 
fact that we think of most caregivers as women--and in the past 
nearly 80 percent of them were--there is evidence that this 
trend is changing. The latest research shows that nearly 4 in 
10 family caregivers is a man, and in the workplace there is 
nearly an even gender split.
    This issue is gaining more visibility because employers see 
greater impact on their bottom line when both male and female 
come in late, leave early, take leaves of absence or early 
retirement. Over half of working caregivers of both sexes have 
to modify their work schedules.
    Our recent Sons at Work study indicated that men were as 
likely as women to report that they were the primary caregiver 
and that caregiving had negative consequences on their work. 
Men are much more likely to modify work travel and less likely 
to speak with either their coworkers or their supervisors. Less 
than half the men in the study had spoken to their supervisors 
about their elder care responsibilities. One quote from the 
study: ``Caring for a sick child is an acceptable reason to be 
taking off. Caring for a sick older relative is not.'' In terms 
of services they would use, more men than women said they would 
like geriatric care management services, along with help with 
legal, financial and insurance issues.
    Another issue is caregiver health. Caregivers sometimes 
sacrifice their own health in their focus on the health of 
their aging relative. Their desire to be a good daughter or a 
good husband and the stress of juggling the roles of parent, 
employee, spouse and caregiver can make them overlook good 
health care prevention, like immunizations and regular 
physician check-ups.
    The latest data show that one-third of those providing the 
most intense caregiving--that is personal care for 40 hours a 
week or more--report their own health as only fair or poor. 
This is in contrast to 12 percent of caregivers with the least 
level of burden.
    In addition, one-third of these Level 5 caregivers doing 
the most intense caregiving report that their health has become 
worse as a result of caregiving. Fifteen percent of caregivers 
as a whole report caregiving is somewhat or very much a 
physical strain, and over a third report it is very stressful. 
We can definitely see the issue of caregiver health becoming a 
public health issue as the numbers of caregivers grow and the 
duration of caregiving lasts 4 years and longer.
    Finances: Since 1997 we have seen a 30-percent increase in 
out-of-pocket spending by caregivers, from $171 a month on home 
modifications, groceries and other financial support, to $221 a 
month in 2003, or $2,700 a year. We know family caregivers 
often speak about the financial hardship caregiving can place 
on a family--decisions they have to make when choosing to help 
their parents or their kids, sometimes sacrificing vacations, 
college and other things so they can pay for long-term care. 
While only 1 in 10 caregivers as a whole says that caring for a 
family member represents a significant financial hardship, 
nearly one-quarter of black caregivers do.
    Paying for long-term care can be viewed as especially hard 
because so few people anticipate they will have to pay for it. 
Most people, baby-boomers and older Americans alike, think that 
Medicare will cover long-term care expenses, and they also have 
little idea how expensive it is.
    Surveys of America's public perceptions of long-term care 
costs consistently show people believe they will not need 
caregiving when they get old, and if they do, it will not cost 
that much. It is only when families actually face caregiving 
that they realize the cost in terms of emotional stress, money, 
and even the toll on their own health.
    Thank you.
    [The prepared statement of Ms. Hunt follows:]

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    The Chairman. Gail, thank you very much for those important 
observations. I think the spread of knowledge as to the extent 
of the costs and the commitment of America's families is an 
important part of the record.
    Now, let me turn to Flora Green, better known as Grandma 
Green.
    Ms. Green. I deserve it.
    The Chairman. Yes, you do, Flora, and we appreciate that.
    She is representing The Seniors Coalition. Welcome to the 
committee again.

STATEMENT OF FLORA GREEN, THE SENIORS COALITION, WASHINGTON, DC

    Ms. Green. Thank you. Mr. Chairman, members of the 
committee, I am Flora Green, the national spokesperson for The 
Seniors Coalition. On behalf of our organization's 4 million 
members and supporters, I would like to thank you for convening 
this hearing and for your continued work on behalf of American 
senior citizens, particularly those in need of long-term care 
services and their families, who donate their home, their time, 
financial resources to care for them.
    I am honored to have been invited to testify this morning 
and emphasize our support for the passage of the Senior Elder 
Care Relief and Empowerment, or SECURE, Act, and I wish to 
thank you for the opportunity to do so.
    According to the National Center on Caregiving, 12.1 
million Americans require assistance to carry out the very 
simple, everyday activities that you and I may take for 
granted. 6.4 million of these Americans are age 65 and over, 
and nearly two-thirds of these seniors depend upon family 
members as their only source of help.
    Family caregiving is an essential and often overlooked 
component of long-term care in this country. Approximately 7 
million people spend an average of 17.9 hours per week caring 
for their elderly family members. In addition, the National 
Alliance for Caregiving reported that over 64 percent of these 
caregivers have full- or part-time jobs, and many are forced to 
take decreased hours and unscheduled leave in order to fulfill 
their responsibility as caregiver.
    These individuals sacrifice much in order to provide the 
noble and compassionate service of caring for their elderly 
family members, so they deserve our full support. Supporting 
these caregivers does not mean utilizing more subsidies for 
institutional care. Today, 79 percent of those seniors who 
require long-term care services prefer the dignity and security 
that comes with living in their own homes, with family, or in a 
community setting rather than being institutionalized.
    I recently spoke with Patricia McCarthy Michel, in Florida, 
who told me her personal story involving her mother who became 
very ill with Hodgkin's lymphoma in December 2002. She told me 
that her mother had always been very independent, taking care 
of all her personal and physical needs, up until this point. By 
March 2003, it became necessary for her mother to move in with 
her. Her mother only lived until May 1 of that year. In that 
short timeframe of less than 2 months, over $2,000 in expenses 
were incurred. These expenses included unreimbursable costs by 
Medicare/HMO and home health visits that were necessary to 
assist her.
    In addition to Patricia, I also spoke with a Mr. Brown, who 
is in desperate need of help in caring for his 85-year-old 
father who has a leg amputated above the knee, a major stroke 
in 2001 and several heart attacks that left him virtually bed-
ridden. Mr. Brown informed me that he is caring for his father 
24 hours a day, 7 days a week, bathing him, preparing and 
administering his medications, feeding him and providing wound 
care and physical therapy. He made a touching statement. He 
said this has been a labor of love, but it is becoming a labor. 
This man needs help.
    These are just stories of everyday, humble Americans who 
are faced with the unavoidable burden of caring for loved ones, 
a burden which they must add to their regular everyday 
responsibilities. That the social group to which these 
individuals belong may include some with limited means simply 
adds to the problem which this legislation is designed to 
address.
    On behalf of The Seniors Coalition and its 4 million 
members, I strongly urge you, Mr. Chairman and members of this 
distinguished committee, to stand in support of the SECURE Act 
and urge the Senate to move forward with the proposed law.
    Thank you so much.
    [The prepared statement of Ms. Green follows:]

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    The Chairman. Well, Flora, thank you for that testimony. We 
are pleased that The Seniors Coalition can endorse the SECURE 
Act. I think that piece of legislation has some real 
opportunity. I think it addresses a variety of needs. But as I 
said in my opening statement, it is one of a lot of pieces that 
need to come together to fit the different circumstances of 
situations that people find themselves in out there. Thank you.
    Now, let me turn to Richard Teske. Richard is a long-term 
care expert and former Health and Human Services official.
    Richard, thank you for being with us. Please proceed.

           STATEMENT OF RICHARD TESKE, WASHINGTON, DC

    Mr. Teske. Mr. Chairman, it is an honor to be invited to 
address this committee on family caregiving. I commend the 
committee for exploring the largest problem facing this country 
that attracts virtually no public policy attention. For too 
long, our health programs were run primarily for the providers, 
payers and the government. Patients came last. It is time for a 
patients-first approach.
    The goal of providing incentives to keep families together 
is admirable. The use of tax credits to provide incentives for 
non-institutional long-term care is headed in the right 
direction. Medicaid is the Federal and State governments' 
primary long-term care program. But according to Wilbur Cohen, 
President Johnson's last HEW Secretary, Medicaid's 1965 passage 
was an after-thought. Inclusion of a nursing home benefit was 
thought to be a rounding error. Instead, it created an 
industry. Today, Medicaid covers two-thirds of all nursing home 
patients and pays half of the Nation's nursing home costs. In 
the 1980's, home- and community-based waivers were supposed to 
save nursing home money. Nursing home costs continued to 
increase, home health costs exploded, and we created another 
industry.
    I would recommend that we learn from these experiences. We 
need to proceed carefully, lest we again suffer huge unintended 
consequences. That is why my first recommendation is for you to 
consider a demonstration project rather than to launch a tax 
credit program nationwide.
    That is also why I applaud President Bush's inclusion in 
his fiscal year 2005 budget of $256 million over 5 years for 
three demonstration projects promoting home care. The budget 
also proposes $500 million for a demonstration for current 
institutionalized patients to return to their communities.
    This is the third year that total Medicaid expenditures 
will exceed Medicare expenditures. This explosion in costs is 
the primary reason States are facing a fiscal crisis. The 
recession essentially caused the expansion of Medicaid 
enrollees from 40 to 50 million in the past 5 years. Most were 
children and adults who, with economic recovery, hopefully will 
return to the workforce. However, while less than one percent 
of the growth is due to the elderly, blind and disabled, they 
were responsible for 60 percent of the cost increase.
    It is imperative that we understand the demographic and 
services matrix. Adults and children are 72 percent of Medicaid 
enrollees, but represent only 27 percent of the costs and only 
6 percent of home health costs. By contrast, elderly and 
disabled constitute 27 percent of the enrollees, but two-thirds 
of all expenditures and a whopping 93 percent of home health 
care costs.
    With the retirement of the baby-boom generation, we can 
expect a possible quadrupling of long-term care costs in the 
next 15 years. This would bankrupt every State in the Union. 
This is why we need to model a non-institutional tax credit so 
that many people will have the incentive to use their own 
resources rather than rely on Medicaid for their private long-
term care insurance.
    I would recommend a higher deductible with a more 
catastrophic coverage focus. The deductible would be covered 
possibly by private long-term care insurance or HSAs or maybe 
Medicaid. But with nursing home costing approximately $60,000 
per year, home health $50,000 and assisted living $40,000, we 
must get this detail right or we will only add to the States' 
plight.
    Should the tax credit be refundable? I don't know, but 
there is a unique problem to consider. If the goal is to keep 
families together, most seniors wouldn't qualify for a pure tax 
credit. This is because a majority of seniors have so little or 
no income; they pay no income taxes. Perhaps for this group, a 
refundable tax credit could be considered. In addition, the 
majority of disabled are under 65. I don't know if your plan 
intends to eventually include them, but they would be difficult 
to exclude, given the tax credit's goals.
    By using a tax credit rather than the existing entitlement 
structure, you may introduce consumer choice options. Presently 
called cash and counseling, Florida, New Jersey and Arkansas 
has successfully used this to reform the services for disabled 
enrollees. With the disabled potentially the largest and 
costliest population, this approach needs to be considered.
    Another advantage of the tax credit approach is that it 
avoids the inequities of the Federal match. In 1995, the 
Government Accounting Office called the Federal match a 
complete failure.
    Another problem that must be addressed is induced demand. 
With 80 percent of all care given to people with two or more 
ADLs receiving the care from unpaid caregivers, this demand 
will be unleashed. Also, since this care is usually provided by 
a family member, care shifts from the family to professionals. 
That may be good, but it should be noted. There is one last but 
crucial advantage to tax credits. The CMS won't necessarily 
have to administer it.
    I will stop at this point and look forward to your 
questions. Thank you again for permitting me to address the 
committee.
    [The prepared statement of Mr. Teske follows:]

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    The Chairman. You have broadened the perspective of this 
hearing substantially, Richard. Thank you very much. I think 
that is provocative testimony.
    Trudy, you have obviously expressed the experience you felt 
or had both with a mother and a sister, and now a father. To 
what degree would a tax credit have enhanced the support you 
have already provided? What would that have offered to you and 
your family?
    Ms. Elliott. I think it would have been a true benefit 
because we had the emotional as well as the financial concern 
with nowhere to go to get relief. One of the things that I 
thought was interesting with the comments about Medicaid is 
that that was a real encouragement from the very beginning when 
my parents became ill, was to spend down everything they had so 
that then Medicaid could take care of them, which was a very 
negative concept for our family. Our family had made a 
commitment to take care of them, so for us to immediately try 
to spend down so Medicaid could take care of them was not the 
mission of our family. So this would be a very positive thing 
for a family.
    The Chairman. Well, that is so well-spoken. I don't know 
how many times I have had families tell me just that. They are 
caught in this phenomenal personal conflict as a result of a 
need for assistance, and yet at the same time needing, if you 
will, to spend down resources to cause a qualifying situation 
to exist.
    You obviously with your professional experience assist 
others in caregiving. Would you say that from what you have 
seen based on that experience this legislation that we are 
talking about, a tax credit, would be helpful to a broad cross-
section of citizens?
    Ms. Elliott. Yes, it definitely would. My story, as I 
emphasize, is not unique. In my job that I do as far as a 
director for home care, I hear this so many times throughout 
the day: What are we going to do? It is definitely a good 
starting point, and when you said it is multi-faceted, it is a 
beginning to help families.
    One of the family members that contacted me just last week 
after I was contacted to do the testimony is a primary 
caregiver for his wife with MS, and he is older and he said, 
isn't there anywhere I can go to get a tax credit, which I 
thought was interesting. I had not had anybody ask me that 
question, so it must be a vital thing.
    The Chairman. Thank you very much.
    Sandy, you indicated in your testimony that there is a long 
waiting list for respite support at the local area agencies on 
aging. How would extending a tax credit for caregiving reduce 
the waiting list, or would it?
    Ms. Markwood. Well, I think that at this point the area 
agencies on aging use their National Family Caregiver Support 
Program monies to be able to provide that respite care. That is 
where the waiting lists are. If caregivers had some resources 
on their own, they could supplement by being able to provide 
some private respite care.
    It has just become very clear through this program how 
important that respite component is. Sometimes, people just 
need a little relief, a couple of hours a day every once in a 
while to be able to recharge. As Gail said, the emotional and 
the health burdens that caregiving impose on caregivers is 
something that they need relief from, and respite provides an 
opportunity. A tax credit would be able to afford caregivers to 
be able to search out other than public options to be able to 
get that respite need met.
    The Chairman. Sandy, you heard Richard's statement that 
action causes reaction, and it does and there is no question 
about it. If what I am proposing were to become law, it would 
create new and different dynamics.
    Do you agree with Richard in some of what he commented on 
as it relates to how those dynamics might begin to shape 
themselves?
    Ms. Markwood. I don't see that the National Family 
Caregiver Support Program has created a new industry of 
services that is looking to make money on caregivers. What I 
see is that the programs and the services that have been 
provided under the National Family Caregiver Support Program 
have enabled people to do what they want to do, which is to 
provide care for their loved ones at home.
    A tax credit would just be an added benefit to be able to 
help them do what they want to do already. I don't see it as 
encouraging people to look for public resources versus using 
their own private resources. I think the issue becomes 
oftentimes, as we discussed, the private resources get 
exhausted. The private resources are stretched too thin. Any 
financial assistance to be able to help them augment services 
that they already get or to be able to augment the care they 
are already providing is just the right thing to do.
    The Chairman. Richard, I used some of your comments in 
relation to this question. Would you wish to respond at this 
time on this issue?
    Mr. Teske. Well, we have already heard on this panel 
testimony about how families spend down and get rid of their 
assets, and that is a huge problem in the Medicaid program. 
Only 5 percent of the people have long-term care insurance, but 
half the people get their long-term care in nursing homes from 
Medicaid. It is way out of proportion. Basically, the middle 
class is using Medicaid.
    An incentive using a tax credit to keep the middle class in 
the middle class, not spending down, would be helpful. The 
present tax laws, however, don't permit that. The incentive is 
to spend down. There is a whole huge industry of financial 
advisers in this country that will help you within maybe 3 
months to get rid of your assets and go into the nursing home 
under Medicaid.
    Congress passed laws in the early 1990's to go after the 
financial advisers, make penalties, go after the assets of the 
senior citizen, the so-called ``get granny'' laws. One problem 
is they are never enforced because politically they are poison. 
So we have to find incentives and this tax credit is a step in 
that direction for people to remain middle-class, use their 
assets and encourage them not to drop into the Medicaid 
program.
    The Chairman. Thank you.
    Maybe it was you--yes, it was you, Trudy, who said you had 
been contacted by a gentleman in relation to assisting his wife 
and was there a possible tax credit.
    I think it goes, Gail, to expanding on your testimony a bit 
as it relates to the number of men who are now providing care. 
I see it in working with seniors and the elderly in my State 
that oftentimes the husband is very quietly taking care of his 
wife in a relationship that, as you have said with your 
parents, was so binding for so long, and is phenomenally 
burdened by that situation.
    Would you elaborate on that new statistic that you are 
bringing into this discussion? If I were to have been asked the 
question which group is the larger of the caregivers, I would 
say, well, it is obviously the woman, and that is what our 
statistics show and that is where most of our stories, or at 
least experiences, demonstrate. Could you comment on that?
    Ms. Hunt. Well, it is still true that the majority of 
caregivers are women.
    The Chairman. It is.
    Ms. Hunt. That is definitely right; as I said, the profile 
of the 46-year-old baby-boomer woman. But we are seeing a shift 
just since 1996 when we did the national caregiver survey. It 
was 72.5 percent were women, and now 60 percent are women. So 
we can see there is a significant drop just in that time, a 
shift.
    Part of it is more women in the workplace, so their 
husbands are sharing in the responsibility of being caregivers. 
Also, because of divorce, it is really tough to get the wife to 
take care of the ex-mother-in-law. She is not going to do that.
    The Chairman. More than likely not.
    Ms. Hunt. Exactly, exactly. Well, maybe you have to pay her 
to do it or something. But in any case, we are seeing more men 
who are taking this on as a responsibility, and I think we need 
to recognize that because, as I said, in terms of the workplace 
that begins to have, again, just as with women, a big 
implication in terms of their taking time off and taking leaves 
of absence and dropping back to part-time. So it begins to 
affect both their bottom line as caregivers, but also 
employers. So perhaps we could begin to address this as we see 
it being more and more of a genderless issue. We can begin to 
recognize this and provide more financial support for the 
caregiver.
    The Chairman. What are the most important challenges for 
addressing stress-related health problems of family caregivers?
    Ms. Hunt. Well, we would suggest that things such as going 
to see your physician. That is an important issue. There is 
actually a caregiver self-assessment instrument that the AMA 
has on its website where if you take this and it looks as if 
you are suffering from some stress, you should be talking to 
your physician about this. You should be going to your 
physician anyway for those regular check-ups and that sort of 
thing.
    There are other programs. Respite is something that helps 
with stress, as Sandy mentioned; actually, focusing more on 
being able to take care of yourself, getting exercise, eating 
right. I think it would be of importance, for example, for the 
CDC to begin to address this issue as a public health issue and 
say to caregivers, you need to take care of your own health or 
you are not going to be around to take care of that wife that 
you are concerned about or that mother that you are concerned 
about.
    The Chairman. Thank you very much. I think we all recognize 
and we all now know so much more about the impact of stress. 
Obviously, the experience caregivers have can be very stressful 
because they don't tend, as I have looked at it, to put things 
aside that they were once doing. They add more to what they are 
doing and simply stretch their time out, and stress is usually 
the product of that kind of enterprise. So thank you so much 
for your testimony.
    Flora, in your testimony you said something that is really 
at the heart of the SECURE Act, and that is trying to keep 
people in their own homes or to assist families so that that 
dignity of the individual staying in their home, if at all 
possible, is extended.
    Would you elaborate on that? In talking with seniors, their 
greater fear is to lose their home that has been their 
sanctuary for in many instances most of their lives and to end 
up in a nursing home. While I have said, and I think we all 
agree, that there are circumstances and situations where 
nursing homes fit and are necessary--I don't dispute that, but 
if you would expand on that feeling that seniors have about 
those kinds of choices.
    Ms. Green. This is a very critical issue. In the 3 years 
that I have spent traveling throughout the United States 
talking with seniors in the day centers, in the retirement 
communities, so many say, I wish I were home; I wish there 
would have been some way that somebody could have gone to the 
doctor with me. You know, when we lose our ability to drive, we 
are at the mercy of our family, which doesn't always work out. 
But there are so many issues like this that folks find to be 
such a drastic change in life.
    I am going to tell you a very personal story about my very 
own sister, a retired anesthesiologist. She was fortunate 
enough to have a son living in her home and taking care of her. 
She suffers from osteoporosis, rheumatoid arthritis and some 
things she doesn't talk about.
    Unfortunately, her son, a Vietnam veteran, shot himself 
about 8 months ago. Within a week, her family had her into an 
assisted living community, without giving her the opportunity 
to make a choice, to decide if there was some way. I hear this 
over and over: There has to be some way that I can get help to 
stay in my own apartment, my own home, to take care of myself. 
My generation are pretty independent.
    The Chairman. Oh, yes, they are. Well, well-spoken, and 
thank you for your testimony and your advocacy. It is extremely 
valuable.
    Richard, your testimony opened with a reference to a 
patient-first approach. Would you elaborate on that?
    Mr. Teske. Certainly. Most of our health care programs are 
designed to control costs, not necessarily provide quality 
care. Just an anecdote: When I was at HCFA many years ago, we 
had three policy bureaus. One was called Coverage, one was 
called Eligibility, and one was called Reimbursement. There 
wasn't a quality bureau. The people there get bonuses based on 
the money they save, not the quality of care they give. So the 
entire structure is not modeled to provide incentives for 
quality care.
    In the Medicaid program, you are assigned a provider; you 
don't choose your provider, like in the middle class. In fact, 
you don't even have a single physician watching out for your 
continuity of care. Companies go in and out of the program. You 
get a new physician each time another company takes over the 
plan.
    This is especially harmful in the rural areas and in the 
urban areas. Only a few years ago, half the physicians were 
taking Medicaid patients; now, only 37 percent. They are 
dropping out of the program. So there are a number of things 
within the actual structure of our programs that don't really 
help the patient. It is there to help the provider save money 
for the government or save some money for the payors.
    The Chairman. Well, we hope that this reform package we 
have put in place begins to go at some of that.
    Mr. Teske. Absolutely.
    The Chairman. I think it will, especially that urban/rural 
differential problem that we have clearly experienced in the 
rural States. Hopefully, that has been substantially corrected 
in the provider area, and it will offer some flexibility, I 
think, to the consumer.
    The Medicaid program is a State-Federal partnership, as you 
have spoken to. Demand for long-term care is certain to 
increase in the next decade, and State leaders are increasingly 
aware of that trend. It was true in my State of Idaho this past 
year. But it was not untypical of other States that had budget 
shortfalls. One of the greatest struggles was trying to deal 
with the matching money and the services offered through 
Medicaid and how that got done or where do we cut, because that 
is obviously part of a decisionmaking process with funding.
    Are States using tax credit relief to help address this 
trend?
    Mr. Teske. Yes, they are. I think it is something like 22 
States are using a tax credit or a tax deduction to help in 
this area, and this might be the route you wish to take. In my 
testimony I recommended a demonstration project rather than 
going nationwide, but maybe looking at these individual States 
and how they administer these credits could be very useful.
    For example, the services covered as non-institutional 
long-term care could be different. Is it a credit or a tax 
deduction? Is it a refundable credit or a regular credit? At 
what level of the Federal poverty level or income level, or is 
there no income application involved? Is the total benefit 
capped or uncapped, and the number of ADLs you have to have 
before the credit clicks in?
    All these things are probably different in all of these 
States and they will provide different incentives for different 
types of behavior. I would suggest that the committee take a 
look at these different State credits and deductions and see 
how they operate and see how broad or narrow they are, et 
cetera. It might be very helpful.
    The Chairman. I think that is excellent advice. We will see 
what we can do in that area.
    You talked about the Federal medical assistance percentage 
or Federal match to Medicaid. Can you describe what this is and 
how it works?
    Mr. Teske. It is a complicated formula that is calculated 
based on the State's per-capita income. The Federal Government 
will match a certain percentage of expenditures that the State 
makes for Medicaid. In the rich States, it is a 50-50 match, 
like in New York. New York will spend, let's say, I think it is 
close to $10,000 now per capita. The Federal Government will 
match it at a 50-50 rate. They will get $5,000 from the Federal 
Government to match their $5,000.
    It goes up as high at times as an 83/17-percent match. In 
Mississippi, a few years ago it was 83-17. It was calculated 
that way so the poorer States wouldn't be hurt and that the 
Federal Government would provide additional revenue.
    But the problem is, given the different qualification and 
eligibility and benefit packages between the States, what has 
happened is that New York, even though it is at a 50-50 match, 
spends almost three times the amount per capita as Mississippi 
does. That inequity is built into the structure again, and any 
attempt to change that obviously New York's congressional 
delegation wouldn't be too happy with. Let's put it this way. 
The inequities in the Federal match has frozen structural 
reform in the Medicaid program for almost 40 years.
    The Chairman. I appreciate that observation. I have 
experienced that debate and/or discussion on the floor of the 
Senate more than once.
    How might a tax credit approach similar to my proposal help 
address Medicaid spending pressures?
    Mr. Teske. Well, as I say, the big pressure right now in 
the long term is the problem of long-term care. Right now, as 
my testimony said, we have the problems of the recession 
putting a burden on the Medicaid program, and that is the No. 1 
issue for the National Governors Association saying that it is 
driving the States into fiscal crisis. The Congress recognized 
this with their $20 billion special appropriation last year.
    I would just point to the people on this panel and their 
testimony. It is almost universal that people want to stay in 
their homes, and they would prefer not to be on Medicaid. 
Anything that we can do to provide those kinds of incentives 
obviously would take the burden off the Medicaid program.
    I think the tax credit idea, which, as modeled, is probably 
targeted more to the middle class right now, would indeed 
address that problem. It would probably not change the 
percentages too much between the States, but it would obviously 
have a large impact on their long-term care costs.
    The Chairman. Thank you.
    Before we conclude, let me turn to the whole panel. Is 
there anything left to be said?
    Yes, Flora.
    Ms. Green. As I am listening, I am thinking about the--let 
me give you a case in point, a single woman maybe with a couple 
of children who lives in an apartment. Her only source of 
income is, let's say, $1,200 a month Social Security. She is 
over the cap on Medicaid. She doesn't have enough money to 
continue her medical care. It is a real problem.
    This is the kind of situation that needs to be addressed 
because there is a big gap there. Again, the pride issue comes 
into effect. They have more money; well, at least someone 
thinks they have more money, so they are not eligible for any 
kind of help within the State welfare program. So they float 
around, hoping from day to day. This is really true that they 
are going to survive until the 3rd of next month.
    The Chairman. I am sure it is, because they are right on 
the margin in many instances.
    Is there anything else that any one of you would like to 
say about this issue?
    Yes, Gail.
    Ms. Hunt. I would just like to say I think this bill that 
you are proposing is really positive in that it is looking for 
the first time to give support to middle-class people who are 
doing caregiving. There have been programs that have dealt to 
some extent with the lower-income people, but I hear all the 
time from people who are middle class or sort of somewhat above 
the poverty level saying isn't there something out there, isn't 
there some way that I could get some financial support to help 
me take care of my parents who are living at home? I would like 
to be able to keep them nearby. There is really nothing out 
there, so this is a good step.
    The Chairman. It is also directed right at that spouse who 
ends up being the caregiver of the spouse, and baby-boomers. 
But more importantly at this moment, in that other age group 
that my parents fall into and others. They thought they had 
planned well. They thought they had a lot of money for 
retirement. They find out they didn't and so they keep 
tightening down, tightening down. They are very conservative 
folks to begin with. They spend less and less so they can take 
care of themselves. Then something like this hits that really 
is beyond--and I think most of you have expressed that--their 
ability, or it is an unanticipated expense beyond their 
resources.
    All of a sudden, that well-planned retirement disappears, 
and that is part of what we are looking at here. There is no 
question, it is looking at the middle class who has a resource. 
But it is a resource that can be rapidly depleted with the cost 
of health care today, simply because they had not acquired that 
long-term health care insurance or it wasn't available at a 
time when it might have been more affordable for them. This 
hopes to fill that hole a bit.
    Ms. Hunt. I just wanted to also mention the thing to keep 
in mind is you can get baby-boomers of today and encourage them 
to purchase long-term care insurance. Older people typically 
can't buy long-term care insurance.
    The Chairman. That is right.
    Ms. Hunt. They maybe can't be underwritten. They have 
diabetes or whatever the illness is, or it is just not 
affordable if they are in their 70's or so. So this is really 
something to help people for today.
    The Chairman. Well, that is very true. I think that clearly 
long-term health care insurance is becoming and will continue 
to become a very attractive package for well-planned-out baby-
boomers, if you will, and younger who are looking at their 
retirement years and looking at being self-sufficient and being 
able to sustain their lifestyles without family and/or Federal 
assistance.
    Any other comments? Yes, Richard.
    Mr. Teske. I just thought of another salutary effect of 
this approach vis-a-vis the States. One of the thorniest 
problems existing is the problem of so-called dual Medicare and 
Medicaid eligibles--6 percent of the enrollees, 35 percent of 
the total costs.
    As any Governor can tell you, this issue is so complex, 
that whole area, that this tax credit again provides an 
incentive for those people not to go into the Medicaid program 
and become a dual-eligible, but get the services outside.
    The Chairman. That is a fascinating observation. I mean, I 
have struggled with the definition of and those funding 
problems with dual eligibility. I had not thought of it in that 
context.
    Yes, Sandy.
    Ms. Markwood. Senator Craig, playing on what Gail had 
mentioned, I think this is a wonderful--the tax credit is a 
wonderful benefit for individuals. I think it goes into the 
context of making sure that people have the discussions with 
their families on planning for old age, planning for long-term 
care needs, and this would be a wonderful tool to help people 
in that regard.
    For the generation who is 65-plus now, as you said, they 
thought they had planned for their retirement, they thought 
they had saved, and then because of the cost of health care 
found out that they haven't. There is a whole generation of 
baby-boomers who, we are fearful, are not planning for their 
retirement years and their long-term care years.
    This tax credit is something that can help them as 
educational materials go out to help them think of how this 
fits into the overall context of their plans for their latter 
years. I think that there needs to be a broader discussion in 
this country about planning for old age.
    The Chairman. Well, that is very well-said. In fact, it is 
so well-said that we will let that be the last word. Thank you 
all very much for your time this morning. We will stay in touch 
with all of you as we work this issue and develop a support 
base for it, but I do believe it is an issue whose time is here 
and we are going to enlist the Senate and the House to become 
very active in support of it.
    Thank you all. The committee will stand adjourned.
    [Whereupon, at 11:11 a.m., the committee was adjourned.]


                            A P P E N D I X

                              ----------                              


               Prepared Statement of Senator Gordon Smith

    Thank you, Mr. Chairman, for holding a hearing on this 
important issue. Caring for a loved one in the home can be 
expensive and trying for everyone involved. Family members 
often have to quit their jobs to care for a family member. 
Tremendous resources are drained by families in order to pay 
for in-home service providers.
    Often, due to the high expense of care and dwindling 
resources, seniors are pushed into the Medicaid system. 
According to the National Family Caregiver Association, more 
than 335,000 Oregonians serve as caregivers. In dollar terms, 
this translates to 360 million caregiver hours per year, with a 
market value of $3.2 billion.
    Nationally, more than 22 million families in this country 
have caregiver responsibilities of some kind or another. 
According to a recent American Medical Association article, 80 
percent of home care services are provided by caregivers, and 
the aggregate value of their services exceeds $200 billion per 
year. In addition, the estimated annual impact of caregiving on 
American business--in terms of lost days, reduced 
productivity--is $29 billion.
    Clearly, this is an issue that is only going to grow in 
importance as the greying of America progresses. One thing we 
in Congress can do is support legislation that uses the tax 
code to help family caregivers. I am a cosponsor of Senator 
Grassley's Long Term Care and Retirement Security Act, and I am 
eager to learn more about Senator Craig's Senior Eldercare 
Relief and Empowerment Act.
    On a related topic, I am also a supporter of Senator 
Breaux's Elder Justice Act, which recognizes that seniors 
encounter many abuse, neglect, exploitation. Passing this bill 
would provide resources for programs to train caregivers on how 
to avoid elder abuse, and I hope the Senate will address both 
these bills before the end of the year. Our seniors deserve 
nothing less.

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