[Senate Hearing 113-912]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-912
 
                      SANDWICH GENERATION SQUEEZE:
                      CONFRONTING THE MIDDLE CLASS
                    STRUGGLE TO RAISE KIDS, CARE FOR
                       AGING PARENTS, AND SCRAPE
                     TOGETHER ENOUGH FOR RETIREMENT
                           IN TODAY'S ECONOMY

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS


                             SECOND SESSION

                               __________

                        PITTSBURGH, PENNSYLVANIA

                               __________

                             JUNE 30, 2014

                               __________

                           Serial No. 113-25

         Printed for the use of the Special Committee on Aging
         
         
         
       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         
         
         
         


        Available via the World Wide Web: http://www.govinfo.gov     
        
         
              U.S. GOVERNMENT PUBLISHING OFFICE 
 50-652PDF           WASHINGTON : 2023
 
         
        
                       SPECIAL COMMITTEE ON AGING

                     BILL NELSON, Florida, Chairman

ROBERT P. CASEY, JR., Pennsylvania   SUSAN M. COLLINS, Maine
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ORRIN G. HATCH, Utah
KIRSTEN E. GILLIBRAND, New York      MARK KIRK, Illinois
JOE MANCHIN III West Virginia        DEAN HELLER, Nevada
RICHARD BLUMENTHAL, Connecticut      JEFF FLAKE, Arizona
TAMMY BALDWIN, Wisconsin             KELLY AYOTTE, New Hampshire
JOE DONNELLY, Indiana                TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      TED CRUZ, Texas
JOHN E. WALSH, Montana
                              ----------                              
                  Kim Lipsky, Majority Staff Director
               Priscilla Hanley, Minority Staff Director
               
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Committee 
  Member.........................................................     1

                           PANEL OF WITNESSES
                                PANEL I

Tom Moore, Member of the Sandwich Generation.....................     5
Sister Barbara Ann Boss, President, Seton Center.................     6

                                Panel II

Mildred E. Morrison, Administrator, Allegheny County Department 
  of Human Services, Area Agency on Aging........................    11
Charles F. Reynolds III, M.D., Director of the Aging Institute, 
  University of Pittsburgh, School of Medicine...................    13

                                APPENDIX
                      Prepared Witness Statements

Tom Moore, Member of the Sandwich Generation.....................    29
Sister Barbara Ann Boss, President, Seton Center.................    30
Mildred E. Morrison, Administrator, Allegheny County Department 
  of Human Services, Area Agency on Aging........................    32
Charles F. Reynolds III, M.D., Director of the Aging Institute, 
  University of Pittsburgh, School of Medicine...................    35

                       Statements for the Record

Testimony of Judy Mills, Member of the Sandwich Generation (panel 
  witness unable to attend)......................................    41
Testimony of Christine Chylak....................................    43
Testimony of Laurene Kohler......................................    45
Testimony of Michele Deegan......................................    47
Testimony of Tanya Regli.........................................    48


                      SANDWICH GENERATION SQUEEZE:

                      CONFRONTING THE MIDDLE CLASS

                    STRUGGLE TO RAISE KIDS, CARE FOR

                       AGING PARENTS, AND SCRAPE
                       .
                     TOGETHER ENOUGH FOR RETIREMENT

                           IN TODAY'S ECONOMY

                              ----------                              


                         MONDAY, JUNE 30, 2014

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 1 p.m., in the 
Allegheny County Courthouse Gold Room, Pittsburgh, 
Pennsylvania, Hon. Bob Casey, presiding.
    Present: Senator Casey.

                 OPENING STATEMENT OF SENATOR 
             ROBERT P. CASEY, JR., COMMITTEE MEMBER

    Senator Casey. The hearing of the U.S. Senate Special 
Committee on Aging will come to order.
    I am grateful for everyone being here today. I wanted to do 
some opening comments and then we will turn to the introduction 
of our first panel of witnesses.
    We gather today to talk about an issue that is too 
infrequently examined, and that is the pressure or the stress 
that is created and the implications for our health care 
system, family life, and so many other concerns that we have, 
when an individual, in many instances maybe in their 40's or 
50's, has kind of a dual responsibility in addition to going to 
work every day or doing other--conducting their own affairs and 
having their own responsibilities, where they have to care for 
an aging parent, sometimes directly and sometimes less 
directly, and at the same time care for the generation behind 
them, a son or daughter who requires some degree of help, 
financial or otherwise. We refer to this phenomenon and those 
who live in that age, or who are in that age category, as the 
so-called ``Sandwich Generation,'' that they are between two 
generations and they have responsibilities for both, in 
addition, as I said before, to their own responsibilities and 
their own jobs.
    We know that this affects a lot of middle-class families in 
the United States of America who are often working more and 
earning less, and, at the same time they are doing that, they 
have these responsibilities of caring for aging parents or 
raising children and scrambling--in many cases, this is a daily 
scramble, a daily challenge--to save for retirement. These 
families are those who drive the consumer spending, and we know 
that that ultimately drives the economy. As much as three-
quarters of the economy is tied up in consumer spending, so, 
maintaining a middle-class lifestyle or anything close to that 
is becoming more and more of a challenge.
    We know that in the 20-year timeframe between just 1989 and 
2010, for example, the median household income increased 70 
percent. That sounds like it is good news. Not until you 
compare it to the college tuition going up in those same 20, 21 
years, increasing over 300 percent, health care costs going up 
over 200 percent in that same time period.
    We know that even since--in the more recent past, even 
since the end of the recession, the wages of many middle-class 
jobs have continued to decline. The auto industry, for example, 
those wages are down ten percent, even though we had a great 
rescue, really, of the auto industry, but, wages are not where 
they need to be. Manufacturing job wages are down less, but 
still down 2.4 percent. Construction wages are down almost two 
percent, so, that is just the most recent numbers in terms of 
what has happened to the middle-class because of these major 
job sectors.
    If you look back further, further than the last couple of 
years, further than the last 20 years, if you go back 45 years, 
since 1968, for example, the value of the minimum wage lost 
one-third of its value, so, for example, when we are debating 
in Washington--and we are going to have another debate, 
thankfully, in the next couple weeks--of raising the minimum 
wage to $10.10 over three years, even getting to $10.10 over 
three years would not catch up to where we were, or where we 
would have been, I should say, if we kept pace from 1968 to the 
present. If we had kept pace up to the present, the minimum 
wage today would be about $10.50 or $10.60, roughly, so, we are 
way behind in keeping up with the minimum wage itself. All the 
more reason why we need to raise it.
    Compounding all of these economic concerns and challenges 
are the challenges of those in the Sandwich Generation. A 
recent study found that almost 50 percent of middle-aged 
Americans are in the so-called Sandwich Generation. As I was 
preparing for this hearing, I realized I, too, am a member of 
the Sandwich Generation, maybe not having as many stresses and 
challenges that a lot of families have, but I am certainly in 
that age category and have some sense of what it is like to 
have responsibility for at least one generation, my children, 
and those--we have two out of college now, and in one case, we 
have some responsibility, and I have a mother who is over the 
age of 65 and I have, other than making sure that I stay in 
touch with her, I do not have any direct financial 
responsibilities like so many people that are my age and the 
stress that comes with that.
    The typical caregiver is a--and these are broad categories, 
but this is about the average--the typical caregiver is a 
working woman, 49 years old, who spends up to 20 hours a week 
caring for a family member, usually her mother. She has much 
greater stress and responsibility for her family than I do, 
than I am sure some others in the room, as well.
    In Pennsylvania, there are an estimated 1.85 million 
caregivers, so almost two million caregivers, providing 1.77 
billion--not million, billion--hours of care just in one year, 
2009.
    There are financial challenges associated with providing 
care. As we know, many families access their personal savings 
to pay for care. Actual out-of-pocket costs by caregivers 
reveals that 42 percent of caregivers spend more than $5,000 a 
year on caregiving expenses.
    Some caregivers even cut back on work or leave the 
workforce. This allows them to provide care, but there are lost 
wages and less retirement savings as a result, so, they make a 
very conscious choice to take care of a family member, knowing 
that, or experiencing the fact that that will have an adverse 
impact on their own job, their own career, their own wages, 
their own retirement, and you can add to that from there.
    Wage and retirement losses due to caregiving range from 
over $283,000 for men to almost $325,000 for women. That is the 
wage and retirement loss that women experience, on average, 
because of those caregiving responsibilities if they are in 
that category of being in the Sandwich Generation and having 
those substantial responsibilities, $325,0000 in the life of 
that woman.
    We have to ask some fundamental questions. One question is, 
where is the time for these families? How do they do it? How do 
they make ends meet and still provide the kind of care and 
support that they want to provide? How do they do that is a 
question that this hearing will not answer, but it is an 
important question for us to keep asking because it, I think, 
increases our vigilance to do something about this challenge.
    Do these families have access to the programs and services 
which can make their lives easier? I think the answer to that 
is a resounding no, not in every instance, but in a lot of 
instances, because if the answer to that was yes, we probably 
would not be here. I believe, and I think the data shows, that 
far too many people with these challenges do not have access to 
programs and services to make their life just a little bit 
easier when they are doing these--providing this service, doing 
this work.
    How do families in our society handle the financial ripple 
effects of the Sandwich Generation? If someone is losing wages, 
they are obviously not going to be as productive in the 
economy. They will purchase less. They will be less of an 
economic factor if they are having to provide that kind of care 
without some kind of relief.
    There are just a handful of questions, but, I think this 
gets back to, for so many families, and I know this is true of 
so many women, they have a basic sense of obligation, an 
enduring sense of obligation to their mother, their father, and 
to their children. Men do it, as well, there is no question, 
but, I think if we add it up, probably more women are in these 
stressful circumstances.
    It is not just kind of a general value. It is the value 
they have to care for their families no matter what the 
circumstances, no matter what the financial implication, no 
matter what the stress, no matter what the challenge is, and, 
in many cases, their health as they are trying to provide 
support for, say, an older parent, their own health is 
compromised. That, too, has an economic impact.
    I think this, in some ways, is as fundamental as the 
scriptures. In the scriptures, there is a line that tells us 
that we should, ``Honor thy father and thy mother,'' and so 
many families take that scriptural admonition, or scriptural 
inspiration, to heart, and they work very hard to provide a 
better life for those who come after them and those who were 
ahead of them, and, so, they are squeezed in that sandwich.
    We have to make sure that we are taking constructive steps 
to help. The solutions are not easy to devise. The resources 
are limited, and, the challenges are substantial, but, I have 
no doubt, I have no doubt at all, that as a result of hearings 
like this and engagement, listening to people that are living 
this life and/or have some expertise in these challenges, 
either personally or by way of study and scholarship and work, 
that we can come up with solutions that will provide a measure 
of relief to those who are trying to keep that commandment, in 
a sense, trying to be that loving family member, but also know 
that they have other responsibilities that they have to 
balance.
    We have a tough challenge ahead of us, but I have no doubt 
it is a challenge that is worthy of our country, worthy of our 
Commonwealth, and for today's purposes, worthy of this great 
city and this County of Allegheny.
    I wanted to first introduce our first panel of witnesses. 
Our first witness is Tom Moore. Tom recently retired as 
President and Assistant Business Manager for the International 
Union of Operating Engineers, Local 95, in Pittsburgh. Tom 
Moore and his wife, Becky, have four children ages 18 to 23, 
and I am looking at those ages and I have almost exactly the 
same ages and same number of children, in my case four 
daughters with my wife, Terese.
    In addition to helping their children into adulthood, Tom 
and Becky are helping to care for Becky's mother, who has 
dementia, so, Tom, I will be asking you in a couple of minutes 
to provide your testimony, but we are grateful you are here and 
grateful you can offer a personal witness to this based upon 
not just your own family's experience, but your own work, as 
well.
    Our second witness is Judy Mills, although she is not going 
to be with us in person today. Judy is unable to join us today 
because she is accompanying a family member to a medical 
procedure. She is out doing the kinds of things that we are 
talking about today, but, this is a story we have heard often 
in approaching families to speak today. They are eager to 
participate, but could not because of scheduling conflicts with 
appointments and events for different family members.
    Although she cannot be with us today, I would like to 
mention that Judy Mills is the Director of the Saint 
Valentine's Preschool and has been in the position for 25 
years. She has two sons who are now in their 20's, but when her 
sons were in middle school and high school, Judy Mills' father 
also lived with the family. He now lives in an assisted living 
facility, and Judy was going to share her experience of 
supporting both generations under one roof, so, we will make 
sure that we submit Judy Mills' written statement for the 
record of this hearing.
    Our third witness is Sister Barbara Ann Boss. Sister 
Barbara Ann is President of Elizabeth Seton Center, which has a 
location in the Brookline section of Pittsburgh. The Elizabeth 
Seton Center offers intergenerational programming with adult 
day care services, and it is a center for older adults. It is 
also a child care center for children up to age 12 and a senior 
center where older citizens can socialize, learn, and engage in 
healthful activities, and, I want to thank you, Sister, for 
being here and bringing your own personal experience to this 
important topic.
    I would ask these witnesses, as well as all of our 
witnesses, to keep their testimony to about five minutes. There 
is not going to be a curtain that comes down on you if you hit 
five, but try to keep it as close to five as possible. We will 
hear from, starting with Tom, we will do your testimony, and, 
Sister, then you, and then I will do some questions, and then 
we will move to our next panel.
    Tom, why do you not get us started and provide your 
testimony.

                    STATEMENT OF TOM MOORE, 
               MEMBER OF THE SANDWICH GENERATION

    Mr. Moore. Good afternoon, Senator. My name is Tom Moore. 
Prior to my retirement in 2012, I was President of the 
International Union of Operating Engineers, Local 95. I live in 
Ross Township with my wife, four children, and grandson. Three 
of my children have special needs, two with autism.
    Ten years ago, my mother-in-law was widowed and moved from 
her home in Monroeville to the house on my street. Slowly, as 
her age increased and her health decreased, we assumed more and 
more responsibilities for her home and her daily needs. For the 
past five years, as her physical health deteriorated rapidly 
and her mind succumbed to advancing Alzheimer's disease, my 
wife and I became her caregivers. All household chores, both 
inside and outside, had to be done by us. We provided all her 
meals, did all her shopping, scheduled and drove her to all her 
appointments, administered all her medicines multiple times a 
day, took care of her finances, and saw to all of her daily 
needs.
    At the same time, we were fulfilling all those 
responsibilities for our children plus the added commitment of 
their individual school, social, and leisure activities and the 
appointments related to their special needs, all while 
providing child care for our grandson so that his mother could 
work.
    The physical demands of taking care of two families is 
tiring--two yards to cut, drives to shovel, houses to clean, 
extra meals, extra laundry, extra appointments. The extras are 
never ending. The emotional demands and time restraints are 
harder. If a child has a therapy appointment and Gram has a 
doctor's appointment, which is more important? Neither can 
attend an appointment alone.
    If you want to go to dinner with a friend, you have to find 
someone to take medicine and dinner to Gram, to check to make 
sure she got into bed. If you are out and she accidentally 
pushes her safety alarm, you have to go home. There are rarely 
long evenings out as a couple. There are never vacations as a 
couple or even as a family. Taking care of your needs becomes 
the lowest priority because you are too busy seeing to everyone 
else's needs.
    My wife and I are very committed to each other and our 
family. We both have close-knit extended families that give us 
support. We also each have a large group of friends that allow 
us an opportunity to individually spend time away from our 
daily commitments.
    Unfortunately, there are not enough reliable, affordable 
services for the elderly. What services are out there is not 
widely known and often only discovered when commiserating with 
someone else in the same situation. Medical professionals tell 
you to take your insurance to see what is available. Insurance 
tells you to ask your medical professionals. In the end, you 
just keep doing what needs to be done, hoping that not much 
falls through the cracks.
    That is my statement.
    Senator Casey. Tom, thank you very much.
    Sister.

             STATEMENT OF SISTER BARBARA ANN BOSS,
                    PRESIDENT, SETON CENTER

    Sister Boss. Good afternoon. My name is Sister Barbara Ann 
Boss, a Sister of Charity of Seton Hill from Greensburg, 
Pennsylvania. At the present time, I am the CEO of Elizabeth 
Seton Center, located in the South Hills of Pittsburgh.
    Seton Center is an intergenerational center dedicated to 
the belief that no matter what age we are, growing and learning 
are lifetime activities, and that people of all ages are bound 
together by what they share, not separated by age or interest. 
Our programs include care for children age six weeks through 12 
years of age, enrichment programs for seniors, arts programs 
such as instrumental music instruction and theater activities 
for all ages, and care for the frail elderly.
    Today, I am not here to give you facts, numbers, or 
statistics about what each of these programs need to survive. I 
come to talk about the struggles, stress, and strain that 
people caught in the middle, better known as the Sandwich 
Generation, are experiencing.
    Just last week, we were interviewing for a position at 
Seton Center, so this story is very fresh in my memory. First, 
picture this, a grandmother, now not one old in age, but one in 
her late 50's or early 60's, young looking and willing, able, 
and out of necessity has to work. All of a sudden, she finds 
herself faced with the custody of a four-year-old grandson. The 
grandson attends Seton Center during the weekdays and she 
receives subsidized care. However, she is employed at a fast 
food restaurant that schedules her to work evenings and 
weekends. How does she choose between the safety and security 
of the child and her job? Her only choice is to find a nine-to-
five job or go on welfare. Believe it or not, there are some 
people out there who feel that their self-worth is measured by 
their ability to provide for themselves and their families. 
Maybe we need to think outside the box. A sandwich has a top, 
middle, and bottom. What if the top is the grandparent, taking 
the responsibility of the child and grandchild.
    Seton Center has expanded its adult day care hours to 6 
a.m. to 9 p.m., and on Saturdays from nine to five, to 
accommodate the needs of the Sandwich Generation. One reason is 
to enable the adult child of the frail elderly person to attend 
the sports games, rehearsals, or other events that are a 
growing part of their own child's life. Many times, we hear, 
``Can Mom or Dad stay at the Center longer today so that I can 
go to my child's game?'' or, ``Can Mom or Dad come on Saturday 
so that we can spend some quality time with our children?''
    We all know that family is the core of our society. Many 
times, the Sandwich Generation find themselves caught in the 
middle between parents and child. This generation needs respite 
time or they become overwhelmed and stressed. An overwhelmed 
and stressed caretaker is not able to give quality care to 
parent or child.
    Most clients we care for at Seton Center are victims of 
Parkinson's disease, dementia, or Alzheimer's. People with 
these diseases often do not sleep at night. My father was a 
victim of Parkinson's. Being an independent person all his 
life, he would wake up at night and try to get out of bed, 
causing many falls. If my mother was to get any rest, it meant 
that the children had to take turns doing night duty. This 
became very stressful, knowing that you had to go to work the 
next day with little or no sleep.
    Financially, the strain on the Sandwich Generation is huge. 
If the parent has any retirement funds set aside, the adult 
child tries to make the funds stretch as long as possible. 
Before placing the loved one in a nursing home, they will try 
to juggle their own job schedule to care for them, or find 
someone to come into the home, or place them in an adult day 
care facility.
    There needs to be more education on funding sources that 
are available and the services that adult day care can provide. 
In most cases, this kind of information is given when the adult 
child comes to inquire about the services at the center. 
However, most centers do not have the funds for a marketing 
budget. How do those in need even know where to go for 
assistance?
    Child care can be expensive. If the adult child qualifies 
for subsidized care, there is usually a long waiting list for 
the funding. Transportation is an issue. Families often need 
help getting their parents to the adult day care site. 
Transportation rules prohibit families from choosing the best 
center for their loved one, because multiple companies service 
areas in the county and do not cross into another's area, 
clients often cannot go between their homes and the center of 
their choice.
    Thank you for this opportunity to speak on behalf of our 
clients who find themselves caught in the middle.
    Senator Casey. Sister, thank you very much for your 
testimony.
    I will begin a round of questioning for both of our 
witnesses in panel number one.
    I was struck, as well, by a couple of things you said, Tom. 
You said at one point, and I am quoting--I want to make sure I 
get your words right here--you said in the end of the fourth 
paragraph, ``There are rarely long evenings out as a couple. 
There are never vacations as a couple or even as a family. 
Taking care of your own needs becomes your lowest priority 
because you are too busy seeing to everyone else's needs.'' 
Never a vacation. Your needs become your lowest priority. That 
probably encapsulates as well as anything I could say the 
challenge that you and so many others face.
    I guess one of the questions I have is when you have these 
responsibilities and the challenge that comes with that, 
describe, if you can, kind of your typical day. What is your--
if you can walk through kind of a typical day for you or for 
your family in terms of all the things you have to juggle. Or, 
maybe there is not a typical day, but as best you can----
    Mr. Moore. There is not a typical day, but--my mother-in-
law, we put her in the Kane Nursing Home about three months 
ago, but, before that, the typical day was get up in the 
morning at 5:30 and take a walk, clear your head, and start. 
Now, I would have to make sure that she had breakfast and was 
out of bed and got her in the living room, and then go home and 
cut the grass or whatever you are going to do and get the kids 
out to school earlier than that, and then at lunchtime, go back 
again, make sure she ate and took her medicine, which she said 
she would, but never would, and then just, every once in a 
while, I would sneak a round of golf in, of course, and then at 
dinnertime, the same thing. Go down and make sure she had 
dinner and her second dose of medicine and come home and do 
your housework or whatever at the house, and then go down at 
night and make sure she was back in bed and comfortable, and 
hopefully, everything would be okay, but that would be your 
typical day.
    My wife was, the same thing. She was caring for the 
grandchild at home and the kids with the special needs, so it 
is hectic, but you just do it. That is what you do.
    Senator Casey. I know it is hard to--there are a lot of 
ways to measure this challenge. One is time. One is the stress 
and the strain. As Sister said, she described it as struggle, 
stress and strain, and that is a pretty good summary of what 
people are up against every day.
    I know this is one way to measure it, but it is not the 
only way, but it is one measure that at some point you have to 
assess, the financial impact and what that means. Any way to 
give us an example of how this caring for two generations, or 
having responsibility for two generations, has a financial 
impact?
    Mr. Moore. Well, sure. I mean, my mother-in-law got Social 
Security. That was her income, but, you know, outside of that, 
we bought all the food. We bought all her medicine. We provided 
all her needs, took care of her house. You know, everything 
that she needed financially, we supported. Fortunately, you 
know, my former position, I had a pretty decent pension, which 
helped pay for it, but you still go in the hole. You know, I 
bought my house twenty-five years ago for a fifteen-year 
mortgage and I still owe seven years on it because I have had 
to refinance. That is how you do it. You have got no choice.
    Senator Casey. Well, even as we analyze the financial 
impact, the other ways we measure, or the other ways we assess 
this are almost incalculable. There is no way to put a number 
or a metric on it.
    I wanted to ask you, as well, we are just beginning, I 
think, to begin to wrestle, at least in terms of the work that 
will get done in the House and the Senate on issues like this, 
just beginning to wrestle with some of the answers to these 
questions, or the solutions that would provide a measure of 
relief, but, do you have any ideas about things you hope we 
would pursue or any policy you would hope we would have enacted 
so that it would provide some relief?
    Mr. Moore. I think the main thing, even with the kids with 
the special needs and the elderly, my mother-in-law, is the 
services are out there. You have got to go find them. You know, 
you have got to talk to people and find them. There is no 
direct route to try to find out what they are, so, you have to 
talk to people and talk to agencies. There is help out there. 
It is, you know, you are inventing the wheel every time. That 
is the big problem that we found.
    Senator Casey. Not necessarily a resource toward which you 
can turn.
    Mr. Moore. Yes.
    Senator Casey. A resource of services or help you can get 
to provide some relief.
    Sister, I know you shared a story of the young woman that 
you recently encountered that came to Seton Center seeking work 
and described kind of her challenges and her dilemmas. Any 
other way to describe that from your own experience? You have 
seen a lot of these circumstances, and you provided one 
example. Any others that you wanted to highlight?
    Sister Boss. Well, I think there are a lot of single 
parents out there----
    Senator Casey. Right.
    Sister Boss.--who have jobs, but they are minimum-wage 
jobs. I believe if there was some way that they could have 
flexibility in the hours that they work, but, when an 
organization schedules you at night or on weekends and you are 
responsible for a young grandchild or something, you have to 
make the difficult choice of do I continue to work here or do I 
find someplace that will fit my schedule, so, I think it is 
important that there is some kind of flexibility--businesses 
allow some kind of flexibility in their hours of employment.
    Senator Casey. At one point, I know, you described that 
lack of flexibility, or at least a question about it, when you 
said, ``How does she choose between the safety and security of 
the child and her job? Her only choices are to find a nine-to-
five job or go on welfare.'' Then you talk about the self-
worth.
    It is an important note in your testimony where you say, 
quote, ``Their self-worth is measured by their ability to 
provide for themselves and their families.'' In other words, 
that is the standard against which they measure their own 
worth.
    Sister Boss. That is right.
    Senator Casey. In a world where sometimes we measure it by 
other metrics--fame, fortune, and other measurements--that is a 
good description of what they are up against.
    Sister, in your experience, is this--I guess you would 
agree with me, the problem is worse now than it was 15 years 
ago or 20----
    Sister Boss. Oh, yes. I think--well, we are living longer, 
let us face it.
    Senator Casey. Right.
    Sister Boss. I think that in many cases, the child of an 
elderly person, with children of their own, feel, my mom or dad 
raised me, so now it is my responsibility to take care of them, 
and, they stretch their budgets as much as they can, their own, 
and, like I said, if the parents do have retirement, they try 
to stretch that as much as they can before placing them, 
because placing a parent into a nursing home can give the 
individual a guilt trip, let us face it. They took care of me 
when I was young. I should be able to take care of them in 
their old age. It is like a family responsibility.
    Senator Casey. If you had to, and I guess I would address 
this to both Tom and Sister, but I will start with you, Sister, 
if you could recommend one policy, or if you could recommend a 
menu of things we could take a look at, what do you think would 
be the most meaningful, that would have the most positive 
impact?
    Sister Boss. Well, I kind of agree with what Tom had to 
say.
    Senator Casey. Mm-hmm.
    Sister Boss. There needs to be more education in what is 
out there----
    Senator Casey. Right.
    Sister Boss.--for the Sandwich Generation. There are places 
where they can get a--and they can get help, but they do not 
know where to go. There is not enough, do I want to say, 
marketing on what is out there for the people. The only way 
they find that is, like, to talk to someone who can give them 
that information, so, I think, education is a big part of it.
    Senator Casey. Mm-hmm. Tom, anything you wanted to add to 
that?
    Mr. Moore. When I was [inaudible] just the other day, we 
met with hospice, and, you know, to me, hospice is an end-of-
life thing and die with dignity, but, we found out that they do 
a lot more than that, that they come into the Kane and they 
bathe her, they make sure the medicine is right, they take care 
of all her needs. You know, they will do that for years, if 
needed to be. I did not know that. Nobody knew that. Once you 
come in and meet with them, they explain it to you and you say, 
well, how come somebody did not tell us that?
    Senator Casey. I guess part of what undergirds that sense 
or that measurement that you had talked about, Sister, that 
your own sense of what you are worth is what you are 
contributing, I guess part of what motivates people is not just 
love and obligation, but also the sense that, as a journalist 
said about 15, a little more than 15 years ago, now maybe 16 
years ago, a series that I read in a newspaper in Pennsylvania 
had a series about long-term care, and one line I will never 
forget, he said, advocates for the elderly, experts in the 
field, say that life can have quality and meaning even until 
the very last breath, and, so, I think there is a sense that 
people have both love and obligation in addition to the 
commitment they have or the belief they have that every life is 
precious and has meaning and value, even until the very last 
breath.
    I cannot say that my experience in any way matches yours in 
having seen this up close, either personally or professionally, 
and we are grateful for your willingness to help us.
    I think that is all, the only questions I have. If either 
of you has to go, feel free to go. If you could stay, you can 
certainly be a part of the discussion, and, I may think of some 
other questions as we go, so if you are still here, I might ask 
you a few more.
    Let me move for now to our second panel and then we can 
open it up for questions for both panels.
    Our first witness of our second panel is Mildred Morrison. 
Mildred is the Administrator of the Allegheny County Department 
of Human Services, the Area Agency on Aging. The Area Agency on 
Aging plans and coordinates services for 43,000 older adults 
annually. We know that before joining the Area Agency on Aging 
in 2000, Mildred Morrison served as the Executive Director for 
a community agency serving older adults, so, Mildred, we are 
grateful you are here, and I will have you give your testimony 
first in a few moments.
    Our second witness is Dr. Charles Reynolds III. Dr. 
Reynolds directs the Aging Institute at the University of 
Pittsburgh School of Medicine. He is the UPMC Endowed Professor 
in Geriatric Psychiatry at the University of Pittsburgh School 
of Medicine and Professor of Behavioral and Community Health 
Sciences at the Graduate School of Public Health. Doctor, thank 
you for being with us.
    Mildred, we will start with you. As my early admonition 
suggests, try to keep it as close as you can to five minutes. 
Thank you.

               STATEMENT OF MILDRED E. MORRISON,

           ADMINISTRATOR, ALLEGHENY COUNTY DEPARTMENT

            OF HUMAN SERVICES, AREA AGENCY ON AGING

    Ms. Morrison. I will do my best, but when you are caught 
between Sister and psychiatry----Senator Casey, the Allegheny 
County Department of Human Services espouses to deliver a 
comprehensive human service system that ensures holistic 
services to Allegheny County residents, in particular, 
vulnerable populations.
    Annually, our Area Agency on Aging serves 8,000 older 
adults with social work services, developing plans of care and 
delivering hands-on direct care in partnership with family 
members and friends who provide essential care at home. While 
we serve an additional 35,000 seniors with a variety of senior 
center, advocacy, transportation, and informational services, I 
wish to take this opportunity to address the growing challenges 
of caregivers that assist the 8,000 older adults at home that 
we are aware of.
    As the Administrator of an urban Area Agency on Aging with 
one of the country's highest density of seniors, let me begin 
by thanking you for holding this field hearing to share with 
the Special Committee on Aging our deep concerns and some of 
the solutions we have found. I must also voice our appreciation 
for the Older Americans Act and other Federal funds, which, 
when combined with the considerable State resources of 
Pennsylvania, make providing services possible, and, I make 
that distinction knowing that Pennsylvania contributes far more 
resources than virtually any other State in the Union.
    With the growing number of seniors, especially the rising 
rates of those living to advanced years, those experiencing 
dementia, and the increasing frequency of complex late life, or 
life limiting medical conditions, we have seen a 24 percent 
increase over the last 10 years in the number of families we 
assist in caring for a frail elder.
    This has been a complete reversal of circumstances from 50 
years ago, when an adult woman in her 40's or 50's provided 
care at home, usually for just the last two years of a parent's 
life. Typically, she was married. She was a full-time 
homemaker. Her children were grown, and, she had the assistance 
of siblings.
    Today, her life is very different in Southwestern 
Pennsylvania. She works full time and that income is essential 
for her household. Her children may have been born later, and, 
therefore, are more likely to still be at home. Furthermore, 
those beloved parents are far older and frailer, but wishing to 
remain in their own homes. This caregiving family is, indeed, 
the Sandwich Generation, if not what I call the Double Decker, 
that is caring for children and for grandchildren in the same 
household.
    National studies indicate that 20 percent of adults 
continue to provide more than 75 percent of the care for elders 
that allow that frail population to remain at home. It is 
essential that public services enhance families' capacity to 
maintain this commitment, as it is unimaginable that government 
should or even could assume that degree of responsibility, but, 
many of those caregivers are caught trying to understand the 
medical and cognitive changes they are seeing in this elder, of 
access those invisible resources Mr. Moore referred to, of 
maneuvering in an unfamiliar but complex long-term care system, 
as well as coping emotionally, physically, and indeed, 
financially.
    The normal scenarios we witness, the major thing is they 
happen at a point of crisis, when the family has exhausted 
their abilities and they really are no longer able to manage. 
Then, in desperation, there is the memory of what that hospital 
discharge worker or somebody said about call the AAA, not the 
motor club, but the other ones.
    These families often are living with very modest incomes or 
through very difficult times that might have been caused 
because of low wages or because of a job loss. They were trying 
to save for retirement and trying to educate young adult 
children, but, they often also are experiencing in their own 
right a major health incident or a major home repair. Note our 
recent flooding of the last few days. Nobody planned to spend 
thousands of dollars suddenly to do a repair, and, the strain 
is even greater when it is a single parent household.
    In the past few years, we have witnessed situations with 
the four generations of a family that are being cared for by 
adults raising grandparents. Yes, there is the sort of the 
stereotypical drug abuse or incarceration reasons, but, more 
frequently, we are also seeing it is because someone has to 
travel out of the area to find a well-paying job and, 
therefore, relying on grandparents to help with raising the 
children. Or, they are serving in the military. Again, a family 
needs to kick in.
    When the call comes to us, they ask us for help with 
bathing a parent, respite, or oversight so the caregiver can 
handle their personal business, that they can go to work, that 
they can just attend to family matters. Other requests are for 
meals, housecleaning, transportation, and escort to medical 
appointments, and sometimes an electric stairglide or an 
expansion of a bathroom doorway.
    We have found that whether the circumstances are best met 
by a Medicaid-funded service or a program using a combination 
of Federal and State dollars, there is almost always a need for 
additional support and a creative response, so, this AAA and 
many of our peers have figured out ways to use program 
resources as given in ways that may or may not have been a part 
of what they were originally imagined to be.
    Yes, we reimburse in low-income households family members 
who provide some direct care, but even that has a limit of only 
a few hundred dollars per month. We also work with many 
families who are then able to hire a relative to be the 
caregiver and provide for that caregiver all of the full 
benefits and protections of any employee, but, it is only 
available in certain restricted circumstances. We routinely do 
extraordinary counseling on benefits, be it everything from 
LIHEAP to the ability to claim a VA disability if a person had 
served in combat, as well as SNAP, and as well as how to find 
low-cost medical equipment, et cetera, et cetera, how to find a 
subsidized apartment.
    We provide advice, sometimes, it is just common sense that 
makes a life possible. If you have an elder with dementia who 
wanders, we can tell you where to go buy the shoes that have 
the built-in GPS device so you can find them more quickly.
    We are strong advocates for adult day care because it is 
simply cheaper to spend $70 a day for the wonderful care of 
adult day care than to have an individual person coming into 
your home at an hourly rate.
    We recommend little changes. If you love your mother-in-
law, change the shower head from fixed to hand-held because it 
is going to be easier to bathe her with dignity, et cetera, so, 
the recommendations are small, they are little, or they are 
large.
    What we cannot do as a AAA is we cannot cause or force 
families to purchase long-term care, if it were affordable, 
early enough. We cannot help them claim an income tax deduction 
for caring for an elder because the elder resides in a separate 
household. We cannot create the massive awareness campaigns 
that both members of the first panel spoke to that would help 
many families know when and what to ask for help.
    Be it measures great or small as a country, we must face 
the aging tsunami so that family caregivers do not suffer 
financial hardship along with the other burdens of caring for 
their loved ones. Thank you.
    Senator Casey. Thanks very much.
    Dr. Reynolds.

          STATEMENT OF CHARLES F. REYNOLDS III, M.D.,

          DIRECTOR OF THE AGING INSTITUTE, UNIVERSITY

               OF PITTSBURGH, SCHOOL OF MEDICINE

    Dr. Reynolds. Thank you very much, Senator Casey. Good to 
be here.
    I would also like to convey to you thanks from my 
colleagues on the Pennsylvania Long-Term Care Commission, on 
which I am currently serving.
    What I would like to do for just a few minutes is focus on 
some of the themes that have been coming up at the Long-Term 
Care Commission and try to offer some thoughts that we have 
that might be policy relevant at this point. I have captured 
some of this in my written testimony and will focus primarily 
on that in my remarks to you today.
    You have heard Mildred Morrison talk about how the lives of 
caregivers have changed so dramatically here in Western 
Pennsylvania, and that is very typical for what we see 
nationally. I think a good point here is that Mildred's 
comments really highlight the caregivers who are at particular 
risk for the adverse consequences of caregiving. We need to 
disseminate that information more broadly so that clinicians 
like me and agencies can recognize people at particular risk 
and go the extra mile to be of particular service for those 
folks.
    As Mildred has emphasized, these are people who provide 
high levels of care. They may have low income. They live with 
the care recipient. They may have less education. Often, they 
had no choice in assuming caregiving roles, and, as both Tom 
and Sister Barbara have emphasized, their own self-care is 
diminished and they may neglect their own health. They have low 
levels of support, and very often, they experience very 
difficult problem behaviors on the part of the loved one for 
whom they are caring, so, I think the importance there is 
disseminating information about caregivers at particularly high 
risk.
    Tom's testimony emphasized how long the journey of 
caregiving can be. It covers a lot of territory, and, so, part 
of what we need to do, and I think, Mildred, you spoke to this 
very well, is to incentivize clinicians and agencies to tailor 
interventions to the journey of caregiving, intervening 
earlier, if possible, to help protect people from the adverse 
health effects of caregiving, so, that is going to include 
things like addressing safety issues with home assessments and 
alterations, the little things that Mildred Morrison referred 
to that are so important, patient monitoring devices, removing 
access to guns, addressing self-care and preventive health 
behaviors so that caregivers learn to take better care of 
themselves.
    As all three of us have emphasized so far, providing a 
range of support--informational, instrumental, and emotional, 
to help navigate to needed resources, so often, the resources 
are there. Agencies like the Area Agency on Aging help to put 
caregivers in touch with those resources, and we need greater 
emphasis, I think, on that.
    Finally, again, as both Tom and Sister Barbara emphasized, 
help with depression and distress because this is part of the 
burden of caregiving. Over time, as people become heavy duty 
caregivers, their health declines more rapidly than non-
caregivers. Indeed, we have learned that caregiving can be a 
risk for mortality in its own right.
    I would like to focus a couple of remarks now on 
recommendations that came out of the Institute of Medicine's 
panel which dealt with the aging of America, retooling for an 
aging of America. There were two key recommendations from that 
panel that pertain to caregivers.
    One is the need for public, private, and community 
organizations to provide funding to ensure that caregivers have 
adequate training for the roles that they are now being asked 
to undertake. Tom has emphasized, for example, how much he had 
to learn the hard way, and would it not be better if we could 
provide some basic training, and there are good examples of 
this that can be cited.
    The other recommendation from the Institute of Medicine was 
that Federal agencies, including Labor and including Health and 
Human Services, provide support for the development and 
promulgation of technological advances that could enhance an 
individual's capacity to provide care for older adults. These 
include technologies to assist with the activities of daily 
living and health information technologies, as well.
    Finally, to come back to a point that Mildred Morrison 
made, having greater flexibility with home health care-based 
services as we move toward managed long-term care or move 
toward the integration of Medicare and Medicaid services, 
having greater flexibility in these programs would be more 
responsive to the needs of caregivers. The current experiment 
in California, the MediConnect pilot experiment, may be 
something that we can learn from.
    I will stop there. Thank you.
    Senator Casey. Doctor, thank you very much.
    I will start with Mildred Morrison, and thanks for your own 
service, how many years now with the county?
    Ms. Morrison. Fourteen.
    Senator Casey. Fourteen. We are grateful for that.
    I wanted to ask you about--one point that you made is one 
that bears repeating. Sometimes, when we think of a Sandwich 
Generation, we think of one generation in the middle in between 
two others, but you are pointing out, because of a number of 
factors, that sometimes we are talking about four generations. 
We are talking about an individual who has a son or daughter, 
and then a granddaughter or grandson or sons, plural, or 
granddaughters, plural, and then sometimes great-grandchildren, 
as well, so, that is a new phenomenon, and, the description 
that you gave of a woman in Allegheny County facing these 
challenges, I think, is an update for a lot of us in terms of 
what is happening today.
    I guess one of the questions I had is, from your own 
experience, how do people make ends meet? That becomes a big 
part of the challenge. I mean, one of the basic problems we 
have now is that, in my judgment, if you do not have a minimum 
wage that keeps up, obviously, that is going to be a stress on 
the whole family, and we have an economy where, too often, one 
income, even a good income, is not enough, so, that alone has 
created the kind of ``how do you make ends meet'' challenge 
ever more difficult, but, tell us about what your sense of this 
is.
    Ms. Morrison. Right, and, we see the question at two 
levels. When it is a low-income family, it is possible to 
counsel, to recommend, to really bring hands on to what are 
other public resources, be they governmental or they be 
charitably provided, so, when you have got the food banks and 
the food pantries.
    To help a family recognize that they are allowed to tap 
into that, not only for the younger part of the family, but it 
is also on behalf of the older person, perfectly acceptable, to 
try to make sure every kind of--a utility benefit, every--that 
is involved.
    What we often see with very low-income families, that 
economics is a reason for why households have become blended, 
that it changes. When we move to a more middle-income family, 
it becomes blended for convenience and for safety, but, the 
factor of being able to--how many people can we put into a 
household, and it is usually a matter of, physically, which 
facility is larger determines where they go.
    Does the younger family--when a low-income family often 
does not own a home and, therefore, their ability to move in 
with an elder, then we have issues of convincing the elder that 
it really is time to purge some of the things in the house so 
that there is room for them to come in. One of the major 
problems families have when they do that is if it requires a 
change of school district, because virtually no one wants to 
disrupt the children's education school district.
    How do they make do? We see a lot of filling in, and by 
that, I mean we are fortunate that, even before Medicare Part 
D, because of the drug prescription subsidies that this 
Commonwealth provides, that is a huge relief, so, for families 
who have not had the senior utilize that, that is an enormous 
game changer, to say you can literally save thousands of 
dollars a year by taking advantage of this public benefit.
    Senator Casey. I guess some are unaware that they are out 
there.
    Ms. Morrison. It did not occur, and then you say, well, 
with that, you also have a right to tax rebates, even if you 
are a renter, or a property owner, so, you are putting 
together--it is not one solution, it is the menu, and, the list 
just goes on and on.
    What I do find for families in that circumstance, and 
because they have to annually reapply or redo or go back, that 
that becomes a mixed blessing. They want the benefit, because 
it helps all, but the effort to claim it is sometimes awkward.
    I was very impressed last year when the United Way locally 
worked with county government and others and really opened the 
doors wider for people to do tax returns at a non-commercial 
setting and to take full advantage of the Earned Income Tax 
Credits in ways they had not before.
    Here, it was just a matter of, often, for the families that 
survive, it is to tap into the benefits that exist is what is 
the difference between drowning and making it.
    In preparing my remarks, I had asked our social workers, 
tell me the stories, and one of the ones that I heard about was 
a man who was working two jobs. They had two small children who 
were literally eight and six as his divorce was finalized, 
because his father's income put him out of eligibility for 
medical assistance services, the family covered it and that was 
why the two jobs and paying for the bills, whatever, and that 
there was this desperate wish not to use the nursing home 
facility, and so the care, but, upon his father's death, 
shortly thereafter, that man filed for bankruptcy, and, it was 
not his health care, it was a family member's. It has taken him 
five years and he is coming out of that. I am not saying most 
situations are that desperate, but for a very low-income, that 
is a possibility.
    For middle-income families, how do they survive? That is 
where the willingness to offer your employer, can I work extra 
hours? Can I take the second job? And that works when a family 
almost works off of a calendar. Okay, you are doing what, when, 
you are doing what, whatever. When you have the opportunity to 
extend your work in balance with a family member who is able to 
extend the care, that is when the families literally are hardly 
seeing each other because they are just so busy at it, my 
observation.
    Senator Casey. Making the ends meet becomes an almost 24-
hour challenge.
    Ms. Morrison. Yes.
    Senator Casey. Doctor, I wanted to ask you about--you 
talked about, and others have either talked directly or 
referenced the emotional and physical strain it has, this 
challenge of caring for, or having responsibility for two 
generations causes, and, if the caregivers are providing some 
measure, some level of care to the older relative at the same 
time they are raising children, can you speak to the effects on 
the children?
    Dr. Reynolds. I think your theme, Senator Casey, of making 
ends meet is pertinent not only to the financial issues that, 
Mildred, you discussed, but also to issues of time resources, 
emotional resources, and otherwise. I think children feel the 
strain that you are talking about. We think of stress and 
depression, in a sense, as contagious illnesses, and if one 
member of a family is becoming depressed, it is not unlikely 
that another one will, as well.
    Recognizing that, then, becomes very important, because 
there are many ways that you can be of help. You often hear the 
word ``respite'' used, the need for time to recharge 
emotionally. Tom Moore talked about that in his eloquent 
testimony, and, that can go a long way toward restoring 
someone's morale, recharging them to enable them to continue 
trucking, to continue tackling the very difficult tasks that 
are with them, and, I think that can repay benefits to the 
kids, as well, but, certainly, the kids feel that stress and 
strain no less than other members of the family.
    I thought that Mildred's response to your question is 
really a great example of the kind of navigational assistance 
that so many caregivers need. The resources are there, but 
helping them navigate, to find those resources, to pull them 
together to meet the needs is a key issue.
    In our report to Governor Corbett on Pennsylvania's 
Alzheimer's Planning Committee, we underscored the existence of 
the resources. We talked about the great help that the Area 
Agencies on Aging can provide, and, hopefully, more people will 
learn about these.
    Senator Casey. Just a brief followup on that question as it 
relates to the effects on children. If you have a particularly 
stressful--not that everyone fits this category, but if you 
have a particularly stressful, burdensome situation where the 
individual in her, say, her 40's or 50's, is caring for an 
older parent, and in a situation where there is an impact on 
his or her--I will use ``her'' for the example--her children, I 
guess one of the concerns is that it is gradual and it is 
almost imperceptible so that it is not as if the child stands 
up one day and declares, ``Mom, you are not giving me enough 
attention. You need to spend more time with me.'' It is just, 
little by little, it is having an impact, and you may not have 
a full sense of it until somewhere down the road. Is that 
accurate?
    Dr. Reynolds. Yes, it is. A child who is experiencing 
stress and strain, and perhaps developing some type of 
depression, may, for example, experience changes in the way 
they behave with members of the family. They may withdraw. They 
may become irritable. They may withdraw from peers, or their 
work at school may suffer. There are any number of ways in 
which child or adolescent stress and strain can manifest 
itself, and it is a signal that help is needed.
    Senator Casey. I guess in those circumstances, part of the 
tragic irony is that even when there is an adverse impact on 
the child, that child is being presented with a great example 
of how to care for a family member, so, they are seeing an 
example that is very positive, but they are also having to bear 
some of the impact of it in ways that they cannot always 
manage.
    Dr. Reynolds. Or quite understand at the point where they 
are in the life cycle. You know, at the same time, I think many 
kids and adolescents come to love their grandparents deeply and 
have very positive experiences and the memory of their 
grandparents becomes a blessing for them the balance of their 
lives.
    Senator Casey. Mildred, I wanted to ask you about the---you 
talked about programs through the Area Agency on Aging here 
where you provide the option for the elder to hire a relative 
as a trusted care provider. Tell us how that works, to the 
extent that you can use it as a model for other areas.
    Ms. Morrison. Yes. Around the country, there are slightly 
different versions, the mechanics of it, but, we have seen in a 
number of programs, particularly some of the Medicaid programs, 
where a family member is deciding, do I need to stop work in 
order to physically continue to care for my mother, to care for 
my uncle, whomever that person is, if, as an alternative, we 
can say to them, you can do both, you can quit your other job 
and let your relative hire you, that brings the joy of being an 
employee of a relative, which may or may not have its own 
stresses, but so be it.
    It allows that person to earn $10 an hour or $15 an hour, 
depending upon the nature of the work. We do it, and we always 
recommend it be done under a formal structure. There is an 
agreement. There is a third party who handles the payroll and 
makes sure there is Workers Compensation, because if you lift 
someone the wrong way, you have a job site injury and you need 
to be protected and recover from that. It is then reported for 
tax purposes and income, and it is very much above the board.
    What it allows is that that senior--and we often see this 
particularly in cases of dementia, where somebody may be 
anxious about having a stranger or someone they do not know 
care for them--but if it is someone they know, then it also 
helps the rest of the family relax a little bit. We can trust 
that we know it is Joey, and Joey is very responsible.
    In some parts of the country, we are seeing this is a 
particularly positive model, and, one of the unexpected 
resources is with young Hispanic men as an employer. Low-
income, difficult to find work sometimes, but, the tradition, 
the cultural tradition of caring for an older relative, it 
works both ways. It is a formal agreement, but it works. We 
have seen it work for years and years when we have this kind of 
a structure.
    With families with greater resources, we say, formalize it. 
Go to an attorney. Have this documented. This is economic 
value. It is important. It is a contribution to the care of the 
elder.
    For the senior, it is a validation of their role as a 
senior in the family, in terms of having some control, having 
some say so, but done in partnership, and, we are able to 
arrange that a person could have a couple of different 
relatives. It does not have to be just one. That person is put 
through full criminal history clearance, and if there is 
anything that is a blemish or a concern, we are able to have 
the discreet discussion with the elder about what is their 
judgment, what is their wish, and, if they say, ``Oh, he did 
that 23 years ago. I know it. It is over. I am fine.'' When we 
are in doubt, we will pull in a psychologist who will do a home 
visitation just to make sure that the person is competent and 
able to make a reasonable judgment, so, you are trying to 
protect everyone's interest.
    What we find is with families that are wanting to do this, 
they are perfectly willing to go through the machinations and 
the paperwork because it is a win-win for everyone.
    Then the other thing, what we have seen in that case is 
that beyond the scheduled time that person is supposed to work, 
when something else goes wrong, that elder is far more likely 
to call them and say--and it is everything from, ``My oxygen 
tank is not working,'' and they will come running, literally 
come running in terms of providing the care, and often, we get 
to avoid a hospitalization or a whole another incident. The 
trust is there. They will call the relative, and the relative, 
if they cannot come, they know who else in the family to get 
over to that house ASAP. It really works.
    Senator Casey. I guess if it is working well, it has a lot 
of positive features. It is almost wholly intra-family----
    Ms. Morrison. Mm-hmm.
    Senator Casey [continuing] so, there is a level of trust in 
most instances. Maybe, in some instances, there would not be 
and it will not work. There is an agreement that is binding. 
There is background work that is done and all of that to 
ensure, and, there is a degree of kind of buy-in by both sides, 
so, I guess, in a sense, it affirms the person's dignity, as 
well----
    Ms. Morrison. Right.
    Senator Casey [continuing] that their care plan is 
something they are participating in with a family member, and, 
it does have the obvious benefit of relieving some of the 
stress. Ten dollars an hour may not be the be all and the end 
all for someone, but it does provide----
    Ms. Morrison. Something.
    Senator Casey [continuing] some of that. That is good.
    Ms. Morrison. If you will excuse me, the one thing I failed 
to say is that when we do that, what we clearly do is define 
what are the primary tasks that person is supposed to do, so 
that you are still able to complement the other things the 
family does. The family member will fill--somebody else will 
still cook. Somebody else will still cut the grass, so, it 
really does blend, and, therefore, it keeps some degree of 
peace within the family, that they are all pulling together to 
support that elder. Excuse me.
    Senator Casey. We will wrap up in a minute or two and I 
will open it up for one broader question, but, Doctor, you also 
spoke about the need for education and training. Any ideas on 
how best to meet some of those objectives?
    Dr. Reynolds. Yes. I think there are some very good 
examples of that both here in the U.S., Senator Casey, and also 
abroad. I think the types of programs that Mildred is 
describing through the AOAs offers a very flexible, responsive 
approach to education and training to caregivers and it would 
be hard to overstate their value, but, that is an extremely 
important, I think, area of policy going forward.
    In the United Kingdom, there are programs that have trained 
family members of older relatives that have been hospitalized 
with stroke on the basic care of family members when they come 
home from a hospital, and these have been shown to save 
considerably in health care costs, so, we need that kind of 
training program.
    The other comment I would make, and it connects with 
something Mildred said in your reference, Mildred, to Latino 
families, and that is, Senator Casey, as you know, not only are 
we living longer, but the racial and ethnic diversity of the 
Nation's seniors is steadily increasing, and, to Mildred's 
point about the need for flexible, responsive approaches to the 
use of Medicaid waivers, this becomes particularly key, I 
think, for families of different racial and ethnic origins, 
where there are different cultural norms, if you will, for 
caring for older adults.
    Senator Casey. I know there was the Pew study that we have 
looked at. I will not go into the details of it, but there are 
some pretty significant demographic data. This was a study that 
I know several people here are familiar with, January 30, 2013, 
``The Sandwich Generation: Rising Financial Burdens for Middle-
Age Americans,'' by the Pew Research Center. Among lots and 
lots of--probably hundreds of individual findings, they did 
mention--they mention on page three here, in terms of different 
groups that are more directly impacted by this challenge, a 
very high number of Hispanics are more likely to be in this 
situation, so, you would hope that the prevalence would match 
the commitment that a particular family or particular group 
would want to provide.
    I know there is a lot more that we can cover, but I wanted 
to get to kind of the--oh, I did want to mention one thing, 
Doctor. Some of the data that you provided here at the 
beginning of your testimony, your written testimony, you say, 
and I am quoting, in talking about the Sandwich Generation, 
``Twelve-point-nine million have provided care to both adult 
and child recipients,'' just an incredibly high number, and, 
again, I am quoting, ``The market value of 'free' services 
provided by family members is $350 billion annually.'' That is 
a staggering number, and, what we do not want to do is diminish 
that. We want to keep those hours--we want to be racking up 
those hours and that value, but give people who are doing that 
hard work some relief.
    Maybe we can just go from left to right. We will start with 
Tom and go down. We do not usually keep the first panel here, 
but since you are here, we will include you again in terms of 
our questions. If there was a one, two--one or two policy 
changes, or even just one, that you would recommend that we 
make, what would they be?
    I say it for this reason. I believe that when you look at a 
problem like this, there are two things that are in existence 
at the same time. A lot of good programs and policies that are 
available and folks just do not know about them, so making 
people more aware is one part of the solution, but, I also 
think we have got some gaps, some things we are not doing, or 
some regions are and others are not, or some communities are 
and others are not, so, to the extent that you can make 
specific recommendations, sometimes it is just repeating what 
you have already said in one way or another, repeating what 
might be in your testimony, but it is a good way to kind of 
summarize kind of next steps that we can take, but, anything in 
particular, Tom, that you would hope that we would do?
    Mr. Moore. I think, as I said before, that somehow----
    Senator Casey. Maybe you could just move that microphone 
so----
    Mr. Moore. Somehow where people can get the information and 
find out what programs are there and how they are used and who 
they can talk to. Like I said, right now, it is a guessing 
game. To me, that is the most important thing----
    Senator Casey. Yes.
    Mr. Moore [continuing] that we are facing, trying to find 
out what programs are there and how to use them and who to talk 
to, but, that is the biggest challenge we have right now.
    Senator Casey. Thank you.
    Sister.
    Sister Boss. I would have to agree with that, and I think 
there are a lot of choices out there, but, the families have to 
know what those choices are and then select the one that fits 
their needs and their wants for their loved one. I think that 
would be it.
    Senator Casey. Thank you.
    Mildred.
    Ms. Morrison. Wow, there are many. I would very much agree, 
but I would almost like to say, take one service and let it be 
really well known, and if were to pick one, I would pick adult 
day care----
    Senator Casey. Mm-hmm.
    Ms. Morrison [continuing]. having run an agency that 
offered it, because people might be able to see it as a 
gateway, as a door to open up. Oh, there are other 
possibilities. I can ask. I can find out. Sometimes, I think 
when we try to go so broadly, we still miss it, but I might 
target there as a beginning point.
    Senator Casey. Doctor.
    Dr. Reynolds. Maybe the key words here, Senator Casey, are 
things like training caregivers to do a better job, and to 
Mildred's point about day care services, that is one really 
good way to do that.
    Another is navigation, helping people find the services, 
and, again, the gateway concept here is one that appeals to me 
immensely as a clinician.
    I think, flexibility. One of the themes that you have heard 
today has to do with the flexibility of financial support. 
Models like Cash and Counseling, like we see in Florida, for 
example, and, I think, Pennsylvania has a program like this, 
can do a great deal of good.
    There is a lot that we can do, and I would like to end this 
on a hopeful note by underscoring that there are many good 
things that we can do, and we would like to stay in touch with 
you from the Pennsylvania Long-Term Care Commission and 
continue to communicate with your good office about the things 
that we are doing there.
    Senator Casey. We will do that.
    Dr. Reynolds. Thank you.
    Senator Casey. That goes for all of our witnesses and 
anyone else who wants to help on this challenge.
    There are certainly, I am sure, a lot of families who say, 
I am providing care and support to more than one generation, 
and some days it is tough, but I am okay and we are all set, 
and then there are others who have a more difficult challenge.
    This hearing is very helpful for us, to be able to speak to 
people that are, either by way of their own personal stories, 
your own personal experiences, or your professional work, can 
give us both information and inspiration about how to confront 
this challenge.
    You know, we sometimes turn to the Bible for inspiration. 
Once in a while, you run across a politician who can inspire 
you, too. Hubert Humphrey was one of those people who often 
would talk about the moral test of government. He used to say 
that the moral test of government is how we treat those in the 
dawn of life, those in the shadows of life, and those in the 
twilight of life. Of course, he was talking about, all three of 
those categories, he was talking about some of the people we 
are concerned about here.
    I think there are some things we can do in the near term 
which will have a, not just a positive impact on the economy 
overall, but an impact, a positive impact on these families 
that have these particular challenges and burdens. Raise the 
minimum wage, I mentioned before. Worker training can be very 
important. We know that the Workforce Investment Act 
legislation we just passed in the Senate the other day is an 
attempt to narrow the gap between the skilled jobs of the 
future we need to fill and the systems or the programs that 
support the skill levels that need to be achieved to fill those 
high-wage and high-skilled jobs of the future.
    Many of you talk about flexibility, giving workers the kind 
of flexibility they need to have time off and to adjust to 
family circumstances. We could be here a long time talking 
about that.
    Time is a big factor here for a lot of people, time to take 
a break, time to get a little relief, and, sometimes, there are 
people who only ask for that. They do not ask for any kind of 
new initiative. They do not ask for any new or substantial 
help. They just say, give me a little time. Give me a little 
break.
    I know that--I will brag about my father a little bit here. 
When he was Governor--I am not sure, I think it was his first 
term--his team developed the Family Caregiver Support Program, 
and, like a lot of things, it started in the State and became a 
national model and then a national program. That was a very 
singular attempt to provide a little bit of time off, as Doctor 
and others said, respite care.
    I also think, to support families and members of the so-
called Sandwich Generation, we have got to initiate new 
answers, new strategies, new approaches. One of them is a bill 
that we are working on now--we have not introduced it yet, but 
we are working on it--to have a Caregiver Corps, folks that--a 
lot of people have such a commitment to volunteerism, 
volunteering to help strangers, volunteering to help family 
members and others, and we need to empower them, to assist 
them. We do not need to motivate them. They are already 
motivated, by love or by obligation or some other impetus, but, 
we are going to be working on that, and as we finely tune that 
legislation, we will be seeking your continued help and your 
assistance on that.
    If you have another idea for another bill, even if it is 
a--it does not have to be a broad and comprehensive bill, even 
if it is something very specific to deal with some of these 
challenges, we welcome that.
    Let me just conclude with this thought. A long time ago, 
like a lot of families in Allegheny County and Southwestern 
Pennsylvania who have loved ones who worked in coal mines or 
steel mills or factories, their lives are the source of great 
example and inspiration to us. Even more than one generation 
after a lot of those jobs are gone, those individuals, those 
families provide inspiration.
    My father was always inspired by his own father's life. He 
was in the coal mines at the age of 11, and that was not 
uncommon. He was not some unique Horatio Alger story, but, he 
always drew inspiration from that, always said his life was 
made easier by his father's work, and, he talked about, you 
know, his father worked in the mines as a young guy, young boy, 
really, then became an adult, held all kinds of jobs, became a 
lawyer, I guess, in his mid-to late-30's, many, many years 
later, but, he did not have a life that was up in the 
headlines, but my father said his own father's life was a life 
that could be described as quietly triumphant, and, he used to 
use that phrase describing the lives of a lot of other people 
in Pennsylvania.
    Everyone in this courtroom today could point to some member 
of your own family whose lives have been quietly triumphant, 
that they have overcome, they have surmounted barriers in a way 
that really is triumphant, even though it was not in a headline 
or was not the subject of some movie or documentary or acclaim.
    Many of these millions, literally, tens of millions of 
people doing this work, and all those billions of hours, I 
think, are a testament to lives that are led and that achieve a 
measure of triumph, that they overcome so much, are able to 
work so hard just to make ends meet, but in addition to that, 
they are caring for or having some positive impact on more than 
one generation, or at least one other generation in their 
family, so, they lead quietly triumphant lives. All of you have 
met those people. Many of you have lived those same quietly 
triumphant lives.
    What we have got to do is to align the policy with the 
commitment, to align the policy with the fervor that people 
have to volunteer and to help either their own family or some 
other families, and, some of that is just letting people know 
it is out there and guiding them better, or giving them 
information and empowering them, but, some of it is filling in 
those gaps.
    That is an inspiration for me to keep going and keep trying 
to find these answers, and, your testimony, your witness, and 
your work is also an inspiration and I thank you for that 
today.
    I appreciate your time, everyone, and our hearing is 
adjourned.
    [Whereupon, at 2:30 p.m., the Committee was adjourned.]

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                                APPENDIX

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                      Prepared Witness Statements

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                       Statements for the Record

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