[Senate Hearing 115-473]
[From the U.S. Government Publishing Office]
S. Hrg. 115-473
TURNING 65: NAVIGATING CRITICAL DECISIONS TO AGE WELL
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HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
JANUARY 24, 2018
__________
Serial No. 115-13
Printed for the use of the Special Committee on Aging
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SPECIAL COMMITTEE ON AGING
SUSAN M. COLLINS, Maine, Chairman
ORRIN G. HATCH, Utah ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona BILL NELSON, Florida
TIM SCOTT, South Carolina KIRSTEN E. GILLIBRAND, New York
THOM TILLIS, North Carolina RICHARD BLUMENTHAL, Connecticut
BOB CORKER, Tennessee JOE DONNELLY, Indiana
RICHARD BURR, North Carolina ELIZABETH WARREN, Massachusetts
MARCO RUBIO, Florida CATHERINE CORTEZ MASTO, Nevada
DEB FISCHER, Nebraska DOUG JONES, Alabama
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Kevin Kelley, Majority Staff Director
Kate Mevis, Minority Staff Director
CONTENTS
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Page
Opening Statement of Senator Susan M. Collins, Chairman.......... 1
Statement of Senator Robert P. Casey, Jr., Ranking Member........ 3
PANEL OF WITNESSES
Jim Borland, Acting Deputy Commissioner for Communications,
Social Security Administration, Washington, DC................. 5
Anna Maria Chavez, J.D., Chief Strategy Officer and Senior Vice
President, External Affairs, National Council on Aging,
Arlington, Virginia............................................ 6
Mehrdad Ayati, M.D., Adjunct Clinical Assistant Professor,
Geriatric Medicine, Stanford University, Stanford, California.. 8
Sharon Hill, Apprise Volunteer, State Health Insurance Assistance
Program, Vanderbilt, Pennsylvania.............................. 10
APPENDIX
Prepared Witness Statements
Jim Borland, Acting Deputy Commissioner for Communications,
Social Security Administration, Washington, DC................. 34
Anna Maria Chavez, J.D., Chief Strategy Officer and Senior Vice
President, External Affairs, National Council on Aging,
Arlington, Virginia............................................ 44
Mehrdad Ayati, M.D., Adjunct Clinical Assistant Professor,
Geriatric Medicine, Stanford University, Stanford, California.. 61
Sharon Hill, Apprise Volunteer, State Health Insurance Assistance
Program, Vanderbilt, Pennsylvania.............................. 68
Additional Statements for the Record
Medicare Rights Center Support Letter for the BENES Act.......... 70
Centers for Medicare & Medicaid Services Support Letter for the
BENES Act...................................................... 73
Better Medicare Alliance Statement for the Record................ 75
TURNING 65: NAVIGATING CRITICAL DECISIONS TO AGE WELL
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WEDNESDAY, JANUARY 24, 2018
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 9:30 a.m., in
room SD-562, Dirksen Senate Office Building, Hon. Susan M.
Collins, Chairman of the Committee, presiding.
Present: Senators Collins, Fischer, Casey, Gillibrand,
Blumenthal, Donnelly, Warren, Cortez Masto, and Jones.
OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order.
For the next 12 years, 10,000 Americans will turn 65 each
day. Last month I officially joined that club.
By median age, Maine is the oldest state in the Nation and
is aging the most rapidly. Mainers age 65 or older accounted
for 19.4 percent of the population of the state in 2016. That
is a twenty-two percent increase from the year 2010.
No matter where in the country you live, when Americans
think of turning 65, we traditionally think of Medicare and
Social Security--as well we should. Today, more than ever,
there is also an opportunity to plan for a brand-new chapter of
life as more Americans are living far longer.
More than one out of four Americans who live to age 65 can
expect to live into their 90's. Americans age 85 and older are
the fastest-growing segment of our population. For many
seniors, this longevity means an additional three decades
following what was once considered the time to retire. We need
to plan to age successfully and achieve a new chapter of
continued growth in our lives.
At the same time, we must make those all-important
decisions regarding Medicare and Social Security. As I know
from my own visit to the Social Security office in Bangor,
Maine, where people were extraordinarily helpful, there are
important decisions to make, and the programs can be very
complex to navigate. So it is best to start considering options
before that 65th birthday comes around.
For example, the enrollment window for Medicare is limited,
and there are penalties for late enrollment. The clock to sign
up begins 3 months before the 65th birthday and extends for 3
months afterward. Signing up late, particularly for Medicare
Part B, can lead to a hefty penalty that lasts for life. It can
be confusing to navigate these hurdles and to choose the right
package to suit individual health care needs.
Those who are collecting Social Security benefits when they
turn 65 are automatically enrolled in Medicare. Increasingly,
however, Americans who are healthy are choosing to work longer,
as our Senate Aging Committee showed in its annual report
issued last year when we chose to look at America's aging
workforce. For many Americans, working longer wisely means
delaying Social Security and then being able to collect much
higher monthly benefits later.
How does one know which decision is best? What is the
optimal time to claim Social Security benefits to ensure
financial stability in the long run? When should you begin
considering Medicare options to maximize care and reduce costs?
Those are some of the questions we will be examining today.
We will also explore another issue: While we have formulas
to help guide us through the best Medicare and Social Security
decisions, there is no simple formula for healthy aging. If we
were to create a checklist for healthy aging, what would it
include?
There are proven choices that one can make to maximize
health and well-being. While genetics determines about twenty
percent of longevity, lifestyle and environment dictate the
other eighty percent.
Staying physically active, eating well, conversing with
friends, reading engaging books, doing something meaningful
every day, and taking proactive steps to improve wellness all
contribute to healthy aging. Most people know that physical,
social, and cognitive engagement is good for you. Few people
realize that it remains critical at every life stage, but
especially in older adulthood. Even for those who face multiple
chronic conditions and frailty, proactive actions can reverse a
negative life course and lead to a healthier future, but that
can be difficult in states like mine which are very rural and
where people may feel isolated from one another.
I would like to share with you the story of ``Sandy,'' a
healthy 80-year-old woman. One icy winter morning, she stepped
outside to take her dog out. She slipped and broke her right
leg. Once an active woman, Sandy found herself unable to walk.
Following surgery, rehab, and physical therapy, she was able to
get around with a walker, but stayed home for days at a time.
She felt down in the dumps. Her daughter convinced her to try a
program called ``A Matter of Balance'' offered through
MaineHealth, which is a hospital system based in Maine. This
program reduces fear of falling and improves balance. For
Sandy, the program literally changed her life. Each week she
regained strength. She traded the walker for a cane, and soon
afterward she shed the cane, too. Today Sandy is a coach for
that program. She is able to walk miles on end and feels like
she has her life back.
Sandy's story shows that even after falls, we have the
capacity to get back up and age well. It also shows how
important those programs can be in helping a senior regain his
or her life.
Today more and more Americans have a chance to live to 100.
The second fastest-growing age group in the United States is
100 and older. Turning 65 once meant that it was time to retire
and slow down. Today it is an opportunity to prepare for a
lifetime ahead--a lifetime of living, learning, and loving. A
lifetime of financial security if the right decisions are made.
As individuals and as a society, what do we need to do to get
there? What choices should we make? How can we disseminate
useful information to the senior population?
I look forward to our discussion on these important issues,
and I am pleased now to turn to our Ranking Member, Senator
Casey, for his opening statement.
OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING
MEMBER
Senator Casey. I want to thank Chairman Collins for this
hearing and for her opening statement today, and I also want to
thank her for the good work she has done in what has been a
long week here in the Senate.
Every day 10,000 Americans turn age 65 in the United States
of America. Ten thousand people every single day--that is a
staggering number. And today we will hear that people turning
age 65 face their own staggering number of decisions at that
time in their life.
They must be thinking about a range of issues: claiming
Social Security, about signing up for Medicare and about how to
get what they need to stay healthy. These are not simple
decisions. There is no one-size-fits-all choice for those
individuals.
That is what I hear from my constituents in Pennsylvania,
specifically through our constituent services team, and we hear
about it day after day. Our office regularly works with
Pennsylvanians who missed their window to sign up for Medicare,
for example. They are people with a cancer diagnosis who have
no way to pay for care simply because they did not know the
right time to sign up. They are people who made an honest
mistake, who did not know they needed to sign up for Medicare.
It could happen to any one of us. Now they are paying higher
premiums for the rest of their life.
Almost 26,000 Pennsylvanians--26,000--are paying a lifetime
late enrollment penalty for Medicare Part B. Nationwide almost
700,000 Americans are on the hook for that lifetime penalty.
The average penalty amounts to almost a thirty percent increase
in a person's monthly Medicare premium. That is outrageous and
unacceptable, especially considering that most retirees are
already living on limited and often fixed incomes.
Medicare is one of America's great success stories, and it
is our sacred responsibility to make sure that people can make
the most of the Medicare benefits that they have earned.
So that is why I introduced the Medicare Beneficiary
Enrollment Notification and Eligibility Simplification Act.
Good news, we have an acronym, the BENES Act--B-E-N-E-S. And
what that act does is to make sure that every American receives
a notice before they turn 65 that explains when to sign up for
Medicare and what can happen if you delay. That is the least
that we can do for so many Americans. This bill would also make
sure that fewer people experience a gap in health coverage.
In fact, this change would update parts of the Medicare law
that have not been revisited since the program was created more
than 50 years ago. I am proud of that legislation because it is
bipartisan and it represents how Congress should work.
We should hear about what is not working and what is most
challenging for our constituents.
We should design solutions to fix those problems--in a
bipartisan way--and we should be able to pass these laws
because they help the people we serve, the people that deserve
that kind of law.
So I look forward to today's hearing, and I hope we can
illuminate some of these problems--the same problems that
Chairman Collins and I can work together on to fix.
Thank you, Madam Chair.
The Chairman. Thank you very much.
Before turning to the introduction of our witnesses, I do
want to recognize and welcome our new Committee member, Senator
Jones from Alabama. We have had the opportunity to work very
closely together the last few days. In fact, you have probably
seen way more of me than you would have liked. But I am
delighted that you have joined the Aging Committee, and I think
you will find it to be a great Committee. And you are sitting
next to our Committee's most diligent member, and if you follow
her lead, I am sure that you will have a great experience. So
welcome.
Our first witness today is Jim Borland, the Acting Deputy
Commissioner for Communications at the Social Security
Administration. Mr. Borland will discuss the spectrum of tools
and resources available to help Americans choose the right
retirement benefits that are right for their individual needs
and circumstances.
Next we will hear from Anna Maria Chavez. Ms. Chavez is the
chief strategy officer and senior vice president of external
affairs at the National Council on Aging. In her home State of
Arizona, she launched the Governor's Aging 2020 Initiative and
created the Arizona Division of Aging and Adult Services.
Next I would like to introduce Dr. Mehrdad Ayati, an
adjunct clinical assistant professor of medicine at Stanford
University. Dr. Ayati is a board-certified physician in
geriatric and family medicine. He studies the physiology of
aging and how to promote well-being through disease management
and prevention.
And I will now turn to our Ranking Member to introduce our
witness from Pennsylvania.
Senator Casey. Thank you, Madam Chair. I am pleased to
introduce Sharon Hill from Vanderbilt, Fayette County,
Pennsylvania. And I also want to start by congratulating Ms.
Hill. I am told that you have now your seventh grandchild?
Ms. Hill. Yes.
Senator Casey. Congratulations. And it is a grandson,
correct?
Ms. Hill. Yes.
Senator Casey. That is good news. We need some of that
around here.
Sharon is a volunteer with Pennsylvania's APPRISE program.
For four years she has worked weekly to help counsel
Pennsylvanians and their families, providing them with
information to make the most of their Medicare benefits. Sharon
will tell us how she came to this counseling work and why it is
so important to help people better understand Medicare. She
will also tell us about the common questions that she helps
people with and the missteps that families make when they lack
key information.
I also want to recognize her granddaughter, August, who is
here with us at the hearing. August, thank you for being here
today and for supporting your grandmother. You must be very
proud of her, and I hope we will see you back here providing
your own testimony before Congress someday.
Thank you, Sharon. We are grateful you are here.
The Chairman. Thank you very much.
We will now start with Mr. Borland.
STATEMENT OF JIM BORLAND, ACTING DEPUTY COMMISSIONER FOR
COMMUNICATIONS, SOCIAL SECURITY ADMINISTRATION, WASHINGTON, DC
Mr. Borland. Thank you. Chairman Collins, Ranking Member
Casey, and members of the Special Committee, I am Jim Borland,
Acting Deputy Commissioner for Communications at the Social
Security Administration. Thank you for inviting me to discuss
how we provide information to help workers and their family
members decide when to claim Social Security retirement
benefits and when to enroll in Medicare. These decisions are
important, and we are mindful of our responsibility to provide
information to help our claimants make informed choices. We
believe that workers need to be thinking about their claiming
decisions before they arrive at the field office. This is why
our outreach and education efforts are crucial. The decisions
workers make about starting retirement benefits are very
important, as they will affect payment amounts for the rest of
their lives.
For this reason, even before individuals apply for Social
Security benefits or enroll in Medicare, we provide objective
information that they may use to plan for retirement. We do
this in a variety of ways, including our Web site,
publications, outreach, and the Social Security Statement. The
Social Security Statement in particular shows information on
lifetime earnings as well as estimates of future benefits
workers and their families may receive based on those earnings.
Individuals may access their Statement at any time through a
personal, online My Social Security Account.
We also currently mail statements to individuals aged 60
and older who are not receiving Social Security benefits and do
not have a My Social Security Account. In fiscal year 2017,
15.6 million My Social Security users accessed their Social
Security Statements nearly 46 million times, and we mailed
around 13.5 million statements.
In addition to basic benefit information, the Statement
includes information on how work affects benefits, how a
worker's claiming decision affects survivor benefits, how to
avoid Medicare late enrollment penalties, and information on
average life expectancy.
Another valuable resource is our Web site. Each month
nearly 15 million people visit us online to get the information
they need to make informed decisions about their benefits. Our
Web site includes our Retirement Estimator, which is a
powerful, popular, and accurate tool. It uses an individual's
actual earnings information from our records and allows him or
her to input a few pieces of information to receive an estimate
of benefits. It returns benefit estimates at age 62, at full
retirement age, and age 70, or at any age in between. According
to independent surveys of customer satisfaction, our Retirement
Estimator is one of government's highest-rated Web sites.
We recognize, though, that not everyone chooses to use the
Internet. Our committed employees assist the public in a
variety of ways: through face-to-face interaction in our field
offices; by telephone, including over our national 800 number;
in response to online applications; and through the mail.
We also have over 100 public affairs specialists who, along
with our field office managers, participated in more than 6,000
outreach events last fiscal year. With an estimated audience of
more than 3.7 million people, these events range from small
rural get-togethers in public libraries, senior centers,
churches, and veterans organizations, to large gatherings like
county fairs, state fairs, senior expos, and employer meetings.
Whether the attendance is in the tens or in the thousands, SSA
employees are there to help Americans better understand their
benefits.
We also play a key role in signing people up for Medicare.
Although the Centers for Medicare & Medicaid Services
administers the Medicare program, Social Security is
responsible for enrollment. We provide information and Medicare
enrollment options for those who become eligible whether or not
they are already receiving Social Security benefits.
We continue to strengthen our partnership with CMS to
improve our communications with those nearing the Medicare
eligibility age of 65. We have updated the statement insert for
older individuals to strengthen the message about when to apply
for Medicare and to make information more prominent. We have
also clarified language about late enrollment penalties in many
of our publications.
By establishing the Social Security and Medicare programs,
Congress took action to provide seniors with benefits based on
their earnings to sustain them throughout their retirement. As
stewards of these programs, our job is to help workers make
well-informed decisions that are best for their individual
circumstances.
I thank you for the invitation to be here today, and I look
forward to answering any questions you may have.
The Chairman. Thank you very much.
Ms. Chavez.
STATEMENT OF ANNA MARIA CHAVEZ, J.D., CHIEF STRATEGY OFFICER
AND SENIOR VICE PRESIDENT, EXTERNAL AFFAIRS, NATIONAL COUNCIL
ON AGING, ARLINGTON, VIRGINIA
Ms. Chavez. Chairwoman Collins, Ranking Member Casey, and
members of the Committee, thank you for the opportunity to
speak with you today on behalf of the National Council on
Aging. I am their chief strategy officer and senior vice
president for external affairs at NCOA. We are the Nation's
oldest aging advocacy organization.
Life after 65 has changed dramatically since NCOA started
in 1950. Where retirement once meant a few years of leisure
buoyed by a secure pension, today's older Americans have both
the gift and challenge of planning for a bonus 20 to 30 years
of life. Yet few are prepared.
Traditional defined benefit retirement plans have mostly
disappeared, and Americans' individual savings for retirement
have not caught up. And longer life also brings new health
challenges.
Women face unique hurdles. They begin retirement with the
challenge that has followed many throughout their lives: the
pay gap. Lower pay means less money saved. Women who choose to
leave the workforce to be a parent or a caregiver have fewer
Social Security benefits built up, and women of color face an
even deeper disparity. Over seventy percent of older Hispanic
women and over sixty-four percent of older African American
women are economically vulnerable.
At NCOA we know there are proven, cost-effective ways to
help Americans navigate life after 65. With the help of
thousands of partners, our programs address two essential
pillars of life past 65: health and economic security.
Health is essential to independence, but older adults are
disproportionately affected by chronic conditions such as
diabetes, arthritis, and heart disease. The good news is that
chronic conditions can be prevented and managed. One example is
the Chronic Disease Self-Management program available both in
the community and online. It improves health and saves money.
With help from Congress, NCOA hopes to bring this program to
thousands of older adults.
Falls are another significant health concern, and the facts
are alarming. Every 11 seconds an older adult is treated in the
emergency room for a fall, and every 19 minutes an older adult
dies from a fall. These falls cost Medicare $31 billion a year.
But falls are preventable. Programs offered in communities such
as A Matter of Balance, as you mentioned, Senator Collins, and
tai chi can reduce falls by as much as fifty-five percent. NCOA
leads two national initiatives to combat falls, and every
September we sponsor Falls Prevention Awareness Day to
spotlight the issue. Thank you to Senator Collins and Senator
Casey for sponsoring the 2017 Senate resolution. We really
appreciate it.
Social isolation and loneliness are a problem for millions
as well. Older adults without adequate social interaction have
a mortality risk comparable to smoking 15 cigarettes a day. In
the community, senior centers are a beacon for older adults
seeking social connections. They are a gateway to the Nation's
aging network, connecting seniors to support as well as fun and
friendships. NCOA runs the National Institute of Senior Centers
to promote excellence and best practices.
When it comes to health, we believe prevention should be a
national priority. Investing in programs like these improves
seniors' quality of life and saves money.
Economic security is just as critical. Today half of older
adults living alone struggle to meet their monthly expenses. I
want to share just two ways that NCOA is working to change this
statistic.
First is benefits access. Less than half of eligible
seniors are enrolled in public benefits programs. We support
local benefits counselors, and we offer BenefitsCheckUp, a
free, online benefits screening tool that has helped nearly 6.5
million people.
Second is improving Medicare. Anyone who has turned 65 can
tell you how overwhelming it can be to understand and enroll,
and making poor decisions can hurt you, through higher costs,
coverage gaps, and even lifetime penalties. And we support the
bipartisan BENES Act introduced by Senator Casey, which aims to
simplify enrollment. Thank you for your leadership.
Continued funding for low-income benefits, outreach,
enrollment, and full funding for the Medicare State Health
Insurance Assistance Program are critical. SHIPs provide local,
in-depth counseling to Medicare beneficiaries, their families,
and caregivers.
Americans want help navigating life after 65. That is why
NCOA developed our own innovative approach called the ``Aging
Mastery Program,'' which we fondly call ``AMP.'' AMP brings
together our best knowledge into a fun, engaging program that
gives seniors a pathway to age well. More than 10,000 seniors
have graduated so far.
So, in conclusion, aging well means making informed,
deliberate choices. At NCOA we offer tools and solutions to
help seniors do just that. We look forward to working with the
Committee to develop even more resources to help people
navigate life after 65.
The Chairman. Thank you.
Dr. Ayati.
STATEMENT OF MEHRDAD AYATI, M.D., ADJUNCT CLINICAL ASSISTANT
PROFESSOR, GERIATRIC MEDICINE, STANFORD UNIVERSITY, STANFORD,
CALIFORNIA
Dr. Ayati. Madam Chair, Ranking Member, and distinguished
members of the Aging Committee, thank you for inviting and
giving me this opportunity to discuss the challenges regarding
the aging population in the United States. My name is Mehrdad
Ayati. I am a board-certified geriatrician and educator. I am
presenting myself as a physician who has treated and managed
and continues to treat thousands of senior Americans.
As well said at the beginning, today the number of
Americans ages 65 and older is approximately 49 million.
Currently, there are about 7,000 geriatricians in practice in
the United States. We need about 20,000 geriatricians to staff
up for the need we have right now.
This aging population is faced with multiple challenges on
the path to healthy aging, and I am giving my opinion as a
geriatrician about these challenges.
Number one, lack of experts in the field of geriatric
medicine and gerontology. Unfortunately, our health care and
education systems have not been designed to train enough senior
care providers who can specifically manage seniors. As we age,
our physiology changes. And, therefore, it is crucial to be
managed by health care providers who have been educated and
trained in this field.
In the U.S., eighty percent of seniors have at least one
chronic condition; forty percent of the seniors take at least
five medications, not taking into account over-the-counter
supplements and herbal remedies. They see many different
specialists and are prescribed a number of different
medications through each, which can result in polypharmacy or
overmedication and drug cascade syndrome.
The next challenge is lack of scientific and research-
backed medical information regarding healthy aging. Despite the
fact that we live in an era of advanced technology, with
massive amounts of information on the subject of aging
available, the validity of much of such information is highly
questionable. For example, misleading marketing campaigns in
every corner are enticing our seniors to take drastic measures
such as taking unregulated vitamins and supplements or undergo
harmful diets to live longer and healthier. This is regardless
of the fact that the scientific data collected over many years
indicates such over-the-counter supplements and drastic diets
are not contributing to better health and could even be
detrimental to our health.
The next challenge, the elderly are becoming more racially
and ethnically diverse. In 2014, about fifteen percent of
people age 65 and older lived in a home where a language other
than English was spoken. Currently, we lack the resources to
address the challenges of these growing ethnic and racial
groups.
The next challenge, which is most important one, we live in
an anti-aging society. In traditional society, the elderly hold
an exceptional status in their community. They are considered
very sage, are highly respected, and have a central position in
the family and their community. In the U.S. that is not true.
Older adults are often forced out of the workforce and replaced
by cheaper and unskilled labor. They usually retire to the
solitude of their houses. They become isolated and lonely, and
as a consequence, they develop depression and cognitive
impairment. Later they may be institutionalized and set aside
by the society they built and the children they raised. They
can even be easily mistreated, cheated, and taken advantage of.
The next challenge, lack of infrastructure and resources.
Our seniors face a lack of appropriate resources in the areas
of transportation, affordable housing, senior centers,
organized and affordable social activities, and qualified
health care centers.
And the next, financial difficulties. A large number of
seniors are living in poverty. Often they are faced with a hard
choice between paying their rent or mortgage, buying the many
medications they cannot survive without, or purchasing food.
Too often they become not only financially but also physically
dependent on their children, which are known as the ``sandwich
generation.''
Next is robotic mentality. We live in a modern society
where more is considered better. This kind of mentality tells
us that for every single problem, there should exist a quick
fix--even if there is no logic behind it. ``Modern medicine''
dictates that things should be fixed with either medications or
interventions or procedures. But in reality, the statistics do
not support this.
And the last challenge is Medicare expenditures. As the
Medicare system is set up today, it does not pay for the
medically necessary services, which can have tremendous impact
toward a better physical and mental quality of life for older
adults.
Thank you again for this opportunity, and I will be happy
to answer any questions and discuss about how we can fix that.
The Chairman. Thank you very much, doctor.
Mrs. Hill, welcome.
STATEMENT OF SHARON HILL, APPRISE VOLUNTEER, STATE HEALTH
INSURANCE ASSISTANCE PROGRAM, VANDERBILT, PENNSYLVANIA
Ms. Hill. Thank you, Chairman Collins, Ranking Member
Casey, and members of the Committee. Thank you so much for this
opportunity to testify today. It is a real honor to be here.
My name is Sharon Hill. I am 63 years old and a resident of
Vanderbilt, Pennsylvania. I have two sons and seven
grandchildren and my youngest grandchild, Logan, was born
Tuesday. My granddaughter August has joined me here today. She
volunteers with me at many of the senior centers that I go to.
I am a volunteer with the Pennsylvania APPRISE program.
Nationally, APPRISE is also known as the State Health Insurance
Assistance Program--SHIP.
In addition to volunteering with the APPRISE program, I
work cleaning my church. I also care for my 89-year-old father
and help care for my 92-year-old neighbor, who is blind. I have
a disability myself and rely on the support of state and
federal programs to remain active and engaged in my community.
I have been an APPRISE volunteer for four years. I
initially saw an ad in our local Senior Times newspaper, asking
for volunteers to help people with Medicare issues. At that
time I was on Medicare due to a disability and had recently
been left with $67,000 in medical bills after a cancer
diagnosis. I also recalled the difficult decisions my parents
had to make about their Medicare coverage. Both events were
behind my interest in volunteering for the APPRISE program.
To be an APPRISE volunteer, I had to attend many training
sessions. At these sessions I learned about the different parts
of Medicare, including Medicare Parts A, B, C, and D, as well
as Medigap. I also learned about the programs that can help
low-income seniors and people with disabilities. This would be
like Medicare Extra Help and even Pennsylvania-specific
programs that help individuals who have high medical expenses.
I was trained on how to use the computer system and enter
information into the Medicare Plan Finder. Each year we receive
refresher training to provide volunteers with any updated
information that the insurance companies are offering.
However, the more I learned, the more I realized I did not
know. People have a lot to consider when signing up for
Medicare, and the decisions can be daunting. I wish I would
have known about the resources sooner, because if I had known
the program that I am on now, MAWD, I would not have had the
intense medical expenses that I had earlier.
It is because of my own experiences that I am passionate
about the APPRISE program. APPRISE is the only place that older
adults can go, in person, to get unbiased information. This
helps them with their Medicare decisions. As a volunteer, I
give speeches at local senior centers and provide in-person
counseling sessions. Each counseling session is 60 to 90
minutes long, and during Medicare open enrollment season, we
are very busy.
Sometimes people come in with specific questions about
their coverage, and other times we are starting with the
basics. It is common for people to make Medicare coverage
decisions based on the well-intentioned advice of friends,
family, or other places. What I have learned during my time as
an APPRISE volunteer is that people do not have all the
information they need to make the best decisions for their
health care or financial needs.
Making a bad decision when signing up for Medicare can have
unintended, lifelong consequences. When I see people with gaps
in their coverage or seniors paying lifelong penalties, it is
often because of misinformation. Knowledge is important in
helping beneficiaries maximize their benefits and avoid the
pitfalls of lifelong penalties.
Thankfully, as an APPRISE volunteer, I am trained to help
those that are having trouble with their Medicare due to
misinformation. We can liaison with organizations to appeal a
decision or screen people for programs that help cover the cost
of their medications. APPRISE counselors not only provide
information, they help beneficiaries navigate a complex system
and serve as advocates. We also find that once people come to
APPRISE for help, they come back each year to be sure that
their coverage is right.
People's lives are changing, and they need to be educated
or they will fall through the cracks. It is because of this
that I tell everyone I meet about the program. APPRISE
counselors do not make Medicare decisions for beneficiaries. We
instead provide them with information so that they are able to
make the best choices for themselves.
Again, I thank you for the opportunity to testify before
the Committee, and I look forward to answering any of your
questions.
The Chairman. Thank you very much, Mrs. Hill. I think you
just gave a compelling case for why it would be a mistake to
implement the administration's proposal to eliminate altogether
the SHIP program. And I am pleased to say that that has been
rejected by the Appropriations Committee on which I serve. And
if anyone needs further proof, I am quoting your testimony.
[Laughter.]
The Chairman. Dr. Ayati, I want to start with you. You gave
a very compelling statistic about the number of seniors, more
than forty percent, who take at least five prescription
medications plus over-the-counter supplements and herbal
remedies. And this obviously can lead to overmedication, but
also something that I understand is called ``drug cascade
syndrome,'' in which the side effects result in yet another
prescription for the senior.
I met last year with a physician in Maine who is doing
house calls on seniors, and the first thing he has them do is
bring out all the prescription drugs and over-the-counter
remedies that they are taking. And in every case he has been
able to reduce the number. It really was extraordinary. He did
before and after pictures of the number of bottles of pills,
and it was incredible.
So elaborate a little bit more for me on why this problem
exists and why there is not better coordination among all of
the specialists that a patient may be seeing.
Dr. Ayati. That is a great point. Thank you so much.
I believe the biggest problem for older adults these days
is exactly as you said--polypharmacy/overmedication. The first
reason, which I think is just all of that, when we come to the
conclusion for everyone turning 65, I like to decide if the
package about their benefit of Medicare, we should give them
some basic information to be careful about polypharmacy in the
future, because as we age, the risk of chronic disease is going
to be higher, and then there is going to be more chance that we
get medication.
One of the reasons is because of the way that we train our
students, the way we train our doctors. We actually have 16,000
physicians that have been trained in our medical schools in the
U.S., and the way we train them--which I also have been trained
in the same way--we wanted to not disappoint our patients. We
want to, when the patients come to our office and they have a
problem--that is what I said about robotic mentality. Quick fix
means that there should be a medication to fix the problem.
We forget sometimes to discuss pros and cons of treatment
intervention, talk about side effects and adverse drug events
that can happen. As we discussed, the physiology is changing,
and as we age--and this is not happening when we are 60. It is
happening when we are even 20, 30. Every decade our physiology
is changing, and we become more susceptible to adverse drug
reactions.
One thing that has happened is that, again, the patient and
doctor, they are expecting. The reason patients go to the
doctor's office is because, ``Finally I am going to get a
medication.'' And then when they come out from the doctor's
office with that medication, they take it, there is no follow-
up, because one of the big problems is that we do not explain
therapeutic endpoint for medication. I give you this medication
because I wanted to reach this therapeutic endpoint, and if you
do not, we need to stop that. I cannot tell you how many times
I have been in the public places and just discuss about this
topic, and a lot of people, when I ask them, said, ``I take 18
kinds of medication, and I do not know why. I do not know why I
am taking this medication because the doctor just prescribed it
for me, and I just keep asking pharmacy to refill it for me.''
Now, patients do not know, and the physicians also, they do
not follow that. We have some of the programs encouraging the
doctors and hospitals to do medication reconciliation, which is
going through the list and making sure that they are taking all
these medications or not. But I think we should have another
conversation. We should really go at one point and tell the
patients that you have to, every visit when you get your annual
wellness with your Medicare with your doctor, review all the
medication. And if you are not really a candidate to continue
this medication, do not.
Many times I have 90-year-old patients that is only bone
and skin on the bed, not able to eat, and they give a high-dose
cholesterol medication. When I am calculating, the cholesterol
medication is for preventing a stroke in 5 and 10 years. I am
calculating myself, what am I treating for? Why am I giving
cholesterol medication to somebody that is not even able to
take a sip of water? And we just keep refilling this
medication.
I am glad that I have this opportunity. Many times I have a
hospice patient that has a prognosis of less than six months or
maybe two weeks. They are crushing vitamins and supplements in
applesauce, and the person is not able to swallow, and we are
force-feeding with a spoon to the mouth of these people. Why?
This needs to be changed. We need to bring first public
education, asking all the people when they start turning to
Medicare to have this information. You need to discuss about
your medication. And the next thing, go to a medical school and
train the doctors that it is OK if you tell your patient that
maybe a strategy of watch and wait is the best strategy rather
than jumping to prescribe another medication for that.
The Chairman. Thank you very much for that thorough answer.
I have many more questions, but I will save them for the next
round.
Senator Casey?
Senator Casey. Thank you, Madam Chair.
Sharon, I will start with you, and I am using your first
name. I hope you do not mind.
Ms. Hill. Fine.
Senator Casey. We are pretty formal around here, but if you
are from Pennsylvania, I think it can be informal. But I want
to thank you for being here and for your testimony. You can
tell--this is probably the first time you have ever testified.
You not only did it well, but you already got action. Senator
Collins is already working on something based upon what you
said. It is a great country, right?
Ms. Hill. Yes, it is.
Senator Casey. But thanks so much, and I was talking before
about the legislation I have, the BENES Act, and I was struck
by a lot of what you said, but in particular, one line jumped
out at me. You said in your testimony, ``People have a lot to
consider when signing up for Medicare, and the decisions can be
daunting.'' And that is a pretty good summation of one of the
points we are trying to make today. These are difficult
decisions. We are hoping we can pass the BENES Act so we can
prevent common Medicare enrollment mistakes.
Maybe if you can elaborate a little bit more on your
experience with engaging with people that are trying to make
these decisions and the need for clear and easily accessible
information to make those decisions. Can you tell us a little
bit more about that?
Ms. Hill. I think one of the funniest things that we run
into are when couples come in to do their Medicare, and they
think that they have to agree on a plan for each of them. And
when they find out they can each get their own plan, they think
you have given them, you know, another piece of candy, because
they are really happy about that so that they do not have to
limit somebody's medical information because somebody else
needs more pharmaceutical. And a lot of the things when you
come in, sometimes they do not think they want any
pharmaceutical or Part D insurance because they do not take any
medicine. And, you know, you try to explain to them that you
have got to put something in there because if not, down the
line if you ever do get medication, you are going to pay a
lifelong penalty on top of your medication.
And then there are decisions. In western Pennsylvania, we
have got the two factions going on. We have the UPMC and
Highmark, and you have got to walk people through that
distinction, too. Do you want this or do you want that? And
this doctor or this hospital that you used to go to does not
handle this company anymore, so we need to get you--you know,
which do you want to choose? And, you know, make that decision.
So it is not as simple as going in and saying, ``I am 65,
just give me something to use,'' because a year of the wrong
program can leave you in a lot of medical distress and bills.
Senator Casey. That word ``navigate'' that you and others
have been using is an apt description, I think, of what some
are up against.
In the remaining time I have in this round, Sharon, I
wanted to ask you as well, where you said in your testimony
knowledge is important to avoid the pitfalls of lifelong
penalties. The reality for a lot of people is they are paying
penalties. I said before our constituent service people hear
about this all the time across Pennsylvania, and I know you
have seen it up close.
Can you share with us why it is important for seniors to
have access to not just information but unbiased information
provided by an APPRISE counselor?
Ms. Hill. Certainly. If someone comes in to one of our
training sessions and they say, ``I got this letter, and it
says I have a penalty,'' well, your heart just sinks because
you know there is going to be a problem. And, you know, they
end up being in a pickle, more like somebody in a canoe without
a paddle, because sometimes when people say ``penalty,'' they
think, ``Oh, OK, I owe my $10, and then I am done.'' What they
find out is it is a lot more than $10, and it is every day for
the rest of their life. So I do not think that part of it is
emphasized enough in the information that we have right now. It
is just listed as a penalty. I think it definitely needs to say
``long term'' so that they would know.
Also, the problem with the prescription penalties is that
if they are not taking medication, they do not see a need for a
prescription plan. But then all of a sudden, 10 years later
they are taking a heart medication. Now they have got heart
medication medicine, which is expensive, and then lifelong
penalties on top of it. So it becomes very frustrating.
The best that we can do when we have someone like that come
to us is to try to backtrack to see if we can find, you know,
did Social Security, did Medicare, did the people's H.R.
department--where was there a breakdown in the information? So
that sometimes we can go back and see if we can get maybe a
lower penalty or on rare occasions no penalty. But it is a long
process and a difficult one that people find themselves in. And
it is very sad.
Senator Casey. Well, thank you very much for that. That is
the real life of it. Thank you.
The Chairman. Thank you.
Senator Cortez Masto?
Senator Cortez Masto. Thank you. Welcome, all of you. Thank
you so much for being here. And I am going to start with you,
Mr. Borland. I noticed you were taking notes, and that was my
first question because I think Mrs. Hill is really--it is
important to get her feedback because she is on the front lines
interacting with seniors and talking with them. And to me, the
first step in all of this, obviously, is the awareness and
education. But if what we are providing to them is not enough
information for them to make an intelligent decision, then we
are missing out on providing that educational piece.
So my first question is to you. A couple of things. One,
thank you so much for having the online My Social Security
Account that people can access and gather that information. I
noticed you also talk about doing outreach through telephone,
face-to-face, field office, community gatherings where you are
going out into the community to talk with individuals,
libraries in rural communities, everywhere. But to what extent
do you coordinate with the states? I know in the State of
Nevada we have a Division of Aging Services, and they do a lot
of outreach and education. They work with people like Mrs.
Hill. In my state, how do you coordinate with them to make sure
that we are leveraging those additional resources to get the
educational information out, at the same time getting feedback
on what we should be putting out there to make sure that our
seniors have the most important information they need?
Mr. Borland. Thank you for that question, Senator. I was
listening to Mrs. Hill speak and thinking how fortunate we are
to have people like her who are dedicating a portion of their
lives to helping the Social Security Administration be more
effective in ensuring that seniors have access to health care.
I can tell you from personal experience that our claims
specialists do many, many, many referrals to the State Health
Insurance Assistance Programs because at Social Security, while
we are responsible for enrolling people in Medicare, for
explaining the consequences of not taking Part D, not enrolling
in a prescription drug plan, we can only go so far. We are not
in a position to assist folks with selecting a plan. What plan
is best for them, what medications, that is not part of our
conversation. We can explain why you should coordinate Part B
if you have an employer-provided health insurance plan. But our
role is not to help you choose a plan.
We do, I will say, thousands of referrals to the State
Health Insurance Programs every single week, and I can talk a
little bit later about some of the work we are doing with NCOA
and CMS to improve access.
Senator Cortez Masto. Are there additional resources that
we can help you obtain that can make sure you are doing a
better job or more interaction at the state level with
individuals on the front line? Is there more that we can help
you with what you could be doing?
Mr. Borland. So I think that we have strong coalitions. For
example, with the National Council on Aging, every year when we
send our low-income subsidy notices out to those who may be
eligible for a subsidy in paying their Part D premiums, we
provide that information broken down by Zip code to NCOA who
provides it to the SHIPs so that they can do specific outreach.
They know where folks are. They know what their service demand
volume is going to be. We have strong partnerships. We can
always strengthen those partnerships.
Senator Cortez Masto. Yeah, I guess my concern is--and I am
running out of time, so I will wait until the next round, but,
Ms. Chavez, I am going to ask you to weigh in on this. That
first contact is so important, and I think if we lose people by
passing them off, we should probably figure out how we stop
that opportunity where we lose people in that gap. That first
contact to me is the key, and how do we keep them involved
instead of passing them to the next--I do not know--state
agency or whoever. And, Ms. Chavez, do you have any comments on
that?
Ms. Chavez. Sure. I think, again, that is why it is so
important that the Senate bill that Senator Casey has
introduced is all about consumer education, really alerting
people that this deadline is coming. Although turning 65 is a
great opportunity, there is also some responsibility an
individual has to take.
What I have also noticed is that it is critical--and we
have done this for decades--is not only working with the
federal agencies but also working with other community-based
organizations across the country who are in communities and
know these individuals who may need extra help. So, for
example, we run benefit enrollment centers where, again, we
train volunteers, staff members at local organizations to
actually walk people through sometimes very complicated federal
programs. And what we have found is there is a need for both.
There is a need for education from the federal agencies
directly into their mailbox, or Facebook, because a majority of
seniors are on Facebook every day. And so how are you
communicating to seniors in a way that they want to be
communicated to through the federal agency avenues, but also
funding and supporting local community-based organizations to
do the one-on-one training.
The Chairman. Senator Warren.
Senator Warren. Thank you, Madam Chairman, and thank you
for holding this hearing. Very important. You and the Ranking
Member come up with good things for us to talk about.
Now, two days ago, Congress passed a short-term budget that
will keep the Government open for another three weeks. I
believe, though, we need to look beyond the bare minimum and to
stop lurching from crisis to crisis just to try to keep the
lights on.
This is a moment for us to be able to focus on our core
values and to choose carefully about what we invest in. And I,
along with members of this Committee, believe that government
should invest in our seniors. And that starts with making sure
that the Social Security Administration offices are fully
funded so that seniors can get their hard-earned Social
Security checks when they turn 65 and when they enroll in
Medicare.
So, Mr. Borland, you are the Acting Deputy Commissioner for
Communications for the Social Security Administration. SSA has
a budget for staff and other resources. Can you just say a word
about what the Social Security Administration does with that
money?
Mr. Borland. Thank you, Senator Warren. I would be happy
to. We have over 1,200 field offices across the country. We
dedicate over fifty-six percent of our entire budget to staff,
that is, folks who work in field offices, hearing offices----
Senator Warren. But could you say a word about what they do
for seniors?
Mr. Borland. Sure, I would be happy to. So on any given
day, someone walking into our field office may be coming in to
file a retirement claim or a combination retirement and
Medicare claim. They may be coming in to file for disability
benefits, to get a replacement Social Security card. If they
are already receiving benefits, disability benefits, they may
be reporting their wages, which can impact their benefit
amounts.
We are doing program integrity reviews to ensure that
people are still eligible for benefits on a continuing basis so
that we do not create overpayments.
But we are also--and I think this is something that is less
understood--we are providing a tremendous amount of information
and counseling in a way. People have lots of questions about
Social Security, and our front-line staff are very
knowledgeable, very well trained, and they interact with the
public every day to ensure they are making informed decisions.
Senator Warren. So that is powerfully important. People
have rights, and you make sure that they get what they are
entitled to. It is clear to me that the Social Security
Administration's work is very important and that the field
offices are critical to making sure that Americans get the
benefits that they are entitled to. But cuts to the Social
Security Administration budget in recent years have resulted in
staff shortages, field office closures, and longer wait times.
So, Mr. Borland, despite years of underfunding, Senate
appropriators have proposed a more than $400 million cut to the
Social Security Administration budget for this year. Now, that
is nearly four percent of your budget. Can you just say a brief
word about how those cuts would affect seniors who are applying
for benefits?
Mr. Borland. So, first of all, I would like to say that at
the Social Security Administration we believe that if we
receive the President's fiscal year 2018 budget request, we
will be able to address the agency's priorities. But to give
you a couple of examples, how does budget impact the service
that we provide? For every $100 million, that will buy you
826,000 retirement and survivor claims. That is taking the
claim, adjudicating the claim, and making the payment. It will
buy you 51,000 disability hearings.
Senator Warren. So let me just multiply that by four, since
those are the numbers we have got here. We are looking at
around 200,000 hearings for Americans trying to get their
disability benefits and more than 3 million claims processed
for retirement benefits for seniors. Is that right on the
numbers?
Mr. Borland. That sounds exactly right.
Senator Warren. Well, thank you, Mr. Borland. You know,
here is how I see it: Social Security and Medicare are
contracts that we make with each other. Americans have paid
into Social Security and Medicare on the understanding that the
government would be a good steward of their money and that they
would have the protection available when they need it. The
government cannot be a good steward of Social Security and
Medicare if it does not have the money to run the Social
Security offices.
You know, this one should be easy. I believe we should
increase the funding for the Social Security Administration so
that you have the resources that you need to make sure that our
seniors get the benefits that they have earned. Thank you.
Thank you, Madam Chair.
The Chairman. Thank you.
Senator Jones?
Senator Jones. Thank you, Chairman Collins.
I have a couple of things just to go briefly. Ms. Chavez, I
was especially struck by testimony giving the statistics about
the challenges of women of color and Hispanic women, seventy
percent, sixty percent. Obviously, that is because of the pay
gap, which, if it had been worked on years ago, that would not
be a problem. But the fact is we are where we are.
And I know that we have to be concerned with the budgets
for Medicare and Social Security and other things, but is there
something that can be done from the federal policies, knowing
that these women have often no choice--or I would say very
little choice, they are either caregivers, they drop out to
raise their children, all of which contribute to society in so
many other ways. Is there anything that you can suggest from a
federal policy standpoint that might help level the playing
field for those who are taking on significant important jobs--
and they are jobs. You can ask any one of them. They are
probably more challenging than anybody sitting up here right
now. Anything we can do to help level that playing field so
that those people cannot be punished for doing their duties?
Ms. Chavez. So, Senator Jones, I wish we could have another
hearing just on this subject because the data is overwhelming.
It is actually bigger than the pay gap. It is a wealth
disparity issue. It impacts girls and women throughout their
lifetime.
I think from a federal policy level, it goes to how we
educate women, how we ensure that employment rules and
regulations are followed. But I also want to say that by
reinforcing the aging sector, by looking at all the human
services that impact seniors, you are actually going to impact
women in a very terrific way. Interestingly enough, as we were
looking at our data around the programs that we administer--for
example, we run the National Institute of Senior Centers, and
we looked at thousands of senior centers across the country and
daily activities, and we found out that more than seventy-five
percent of people who go to senior centers on a daily basis are
women. We looked at our BenefitsCheckUp. It is a free, online
system where you simply go on and put a few data entries about
your Zip code, female/male, and we found that of the millions
of people we serve, the majority of the people on the system
are women. Either they are checking their benefits or they are
caregiving their spouse or their children.
So, again, I think that because aging disproportionately
impacts women, anything we can do to reinforce these systems is
incredible. I will say--perhaps the gentleman to my right could
not say it, but I think any federal funding cuts to the Social
Security Administration, for the Administration on Community
Living, will have a disproportionate impact on women and
children in families living with seniors across this country
because, again, as I hear from my partners across the country
that are running non profits, who are running state units on
aging, their systems are overwhelmed and overburdened. And as
we know, although we appreciate the federal laws that were put
in place 50 years ago, they have not really been reformed in
decades.
So I welcome the opportunity to work with this Committee to
figure out a way how we would leverage the experience that we
have gained over these few decades, but also how we reinforce
those connections between the federal, state, and local
community organizations that are doing great work.
Senator Jones. All right. Well, thank you for that.
Senator Collins, Madam Chairman, I would respectfully
suggest that might be a pretty good topic for this Committee at
some point in the future. So thank you so much for that.
Dr. Ayati, just briefly in the time that I have got left, I
understand and can relate to the challenges faced. Over the
last year or so, I have faced many of those with my aging
parents, and we are fortunate in Birmingham to have a fair
amount of resources available, but it was still a challenge.
But Alabama in particular also has a very rural population, and
rural health care delivery in Alabama is challenged in and of
itself, much less to the aging population.
Do you have any suggestions of what we can do that might
address the challenges specifically to our rural segments of
this country?
Dr. Ayati. Thank you so much. It is a great question. It
actually is one of the biggest challenges that we always
discuss, especially in our area.
One of the models that has been suggested is that we
actually utilize the resources that we have right now for rural
areas. For example, we are having a lot of things in technology
today. We can use telemedicine, which actually Medicare even
approved for reimbursement for telemedicine for rural areas.
But one of the suggestions is we expand geriatric consultation
for these areas. We have wonderful primary care physicians that
work in rural areas, but the problem is that the patients need
a second opinion because they are frail, they have a lot of
geriatric syndrome, but there is not any expert to help them.
Definitely some sort of satellite program, telemedicine,
virtual care, these kinds of models which, again, in a lot of
areas they are using right now have been very helpful. And I
think that the more we invest in that, we are able to have one
physician that is taking care of the patient but always have a
backup. One of the issues that we have here, which I think just
goes more toward Government, is reimbursement for this model.
The fees that we are currently paying for geriatric
consultation in telemedicine does not make it satisfactory for
the health care system to invest more money on it. If we have a
better solution for that, definitely there is going to be a lot
of encouragement for medical centers to expand this program,
which is going to be very, very crucial. It is going to be a
huge benefit for all the--because as you mentioned very well,
many of the aging population, actually they live in rural areas
in the United States. It is not only about Alabama. And that is
why we can have this service and expertise for them to have the
second opinion and, again, help them through that.
Senator Jones. Well, great. Thank you. I also would like to
mention--and I know my time is up--the telemedicine leads to
another issue that we have in rural America, and that is access
to broadband. So that is something we are going to be working
on as well.
Thank you, Madam Chairman. I appreciate the opportunity.
The Chairman. Thank you very much, and that is a great
lead-in to my next question for Mr. Borland.
It is wonderful that the Social Security Administration has
developed so many online tools that can help our seniors, but
the fact is, in a state like mine, there are large sections of
the state that do not have access to broadband services on the
Internet. And there are also seniors who simply do not have
computers in their homes and are not familiar with it.
Finally, I would suggest that there are seniors who are
much more comfortable with a face-to-face interaction than they
are going down to their local library and trying to figure out
how to access Social Security information online.
We had an office closed in Rumford, Maine, which created
real hardship for a lot of the people living in that community
because the nearest Social Security office was in Lewiston. And
in the winter that is quite a drive for seniors to have to
make, and they were just uncomfortable.
So what can you tell us about how Social Security is trying
to reach rural seniors who may not have computers at all?
Again, I think your online services are excellent, but they do
not reach everybody.
Mr. Borland. Thank you, Senator Collins, and you are right.
We have to make sure that we have the services that we can
deliver to all Americans, whether they live in urban areas or
live in rural areas, whether they have Internet access,
broadband access, or not. We have a commitment, a longstanding
commitment to our field office structure. We have 1,200 offices
around the country, including many in rural areas, small cities
and towns across America. We have our 800 number. Certainly
that is a lifeline for many people in rural America that have
service delivery needs or have questions for Social Security.
But we do not stop there. The part of the agency that I
represent, we are responsible for outreach. We are responsible
for communicating with the public. I think any of you who live
in rural areas or have lived in rural areas know that weekly
and monthly newspapers are a lifeline, that radio is a lifeline
in rural communities. Our public affairs specialists work with
local media. Many of our public affairs specialists have weekly
radio shows where they talk about services and benefits; they
talk about when to claim benefits. They talk about Medicare
enrollment and the importance of enrolling in Medicare before
you are 65.
So we are using some of the more traditional means of
communications to ensure that we reach rural America, but we
are not stopping there. Also, you mentioned libraries. Not all
seniors are comfortable using a computer at the library, but
many are. That is why we have the SSA Express program where we
partner with libraries to provide one-click access to our
online information and services.
The Chairman. Thank you.
My next question is for both Dr. Ayati and for Ms. Chavez.
Doctor, I was so intrigued in your written testimony by your
phrase that, ``We live in an anti-aging society,'' because I
think this is a key issue in addressing isolation, in
addressing how we treat our seniors, in keeping them engaged.
And I would like both of you to address that issue.
What advice do you have for older Americans and their
families so that we can counter this pervasive anti-aging
feeling in our society that sometimes leads to our seniors
being devalued or pushed aside? And, Doctor, I am going to
start with you because you have lived in two different
countries. You were trained in Iran, and you now live in the
United States. So I would be interested if you see differences
in those societies. But, in general, please comment, and then,
Ms. Chavez, I would like to hear from you, too.
Dr. Ayati. Thank you, Chairman Collins. I am always asking
this question for myself as a physician being in a Third World
country and traditional society and then practicing here, why
older adults in this countries, even there are--they do not
have access to medical field. They do not have access to
nutrition supplements, all vitamins that we have here, why they
are physically and mentally doing better, but very interesting
observation. These people, when they migrate to United States,
they actually are going to get worse. They are starting to have
depression or cognitive impairment. And I see it every day.
Especially I practice in the State of California with a lot of
immigrants actually living there, why this going to be changed?
And, again, as you well mention, it is mentality. We are
very obsessed about youth, and this culture is going from--from
the beginning, I am always criticizing--or maybe I am doing as
well, this is the wrong thing, that we teach our children that
there is something wrong with aging, or aging is the microbe or
the germ that we have to avoid that.
When I go to every place shopping, I see the sign of anti-
aging supplements. It makes me very nervous because I just tell
my son, who is 4 years old, if I show it to him, that now your
Dad is aging, it means something wrong with him.
We should just the word of fighting with aging. I see a lot
of time when they are trying to do public education, it says we
have a seminar about fighting with aging. There is no fighting
with aging. Fighting with aging, we are likely fighting with
nature, with the solar system. We cannot fight with it. We need
to adapt to aging. It is a process, starting from beginning of
life. If you start this culture, which has changed the dialog
in the community, in the society about aging, then we can
accept the aging. That is why I have a very educated Ph.D.
patient that, when he comes to me and asks me for depression
treatment, he said, ``Every time when I apply for a job, I have
to dye my hair, and I do not reveal my age, because I have more
experience and they are not going to pay me, and they
actually''--``and they tell me that because I am aged, I am not
innovative.'' Who said aging people are not innovative?
We actually have many studies that show as we age, our
social skills improve, or why they are actually doing better,
and we have many a study--not in United States, in Germany, BMW
or Benz company, they actually had the study about older
laborers versus younger laborers. The older laborers in the
line of the production of the BMW, they actually do better,
more productive, less mistakes.
We need to change this dialog. When we change this dialog,
older adult people do not feel frustrated, fear of aging. When
we have this dialog change, then we can help this aging
population to not focus on negative things; stay on positive.
And then we can have these things going to be changed.
Just one comment. I have the same problem with my students
and nurses to encourage them to work in aging field, because
when we look at the media, the picture of the doctors or
nurses, our heroes in the TV series, they are in scrubs, they
have ten pagers, they are all body builders, and they are
just----
[Laughter.]
Dr. Ayati. This is the picture that my students see, and
when I ask them to come work in nursing home, they say, ``I do
not like to come here. It just smells very bad. I have to take
care of many old people there.'' And the same with the young
nurses. But this is not medicine. The people went into medicine
because they have a passion to help these people. That is the
philosophy of medicine.
But we are changing. I think we need to definitely change
for public education media, and then we will start from--I am
sorry I have been a little bit over time.
The Chairman. Thank you.
Ms. Chavez?
Ms. Chavez. I enjoy sitting next to the doctor who is
clearly passionate about this subject. It is wonderful.
I have the same philosophy, actually. When I was running
the state unit on aging in Arizona a few decades ago, people
would look at me and they would say, ``You are too young to be
running a state agency on aging issues.'' So I used to wear
this button. It said: ``Aging: If it is not your issue, it will
be.''
[Laughter.]
Ms. Chavez. Because for me it is a rite of passage, and in
my culture as a Latina, seniors are the epicenter of our
universe, so for me it is just something you do. But I would
say three major things at NCOA we tell people to think about.
The first is really think about your financial plan. For
women, again, even more important. Start thinking about it now.
Even for women and young men in college, start putting away for
that longer retirement you are going to have, that bonus 20 or
30 years you are going to have at the end of life. Also,
understand the benefits that are coming to you at that point in
time, because there are ways of really leveraging those
benefits.
The second is engage in healthy behaviors. Doctors and
scientists will tell you that the things you do in your 20's
and 30's actually can have a great impact on what you will be
able to do in your 60's and 70's. And if you look at my father,
who is 89 years old and doing 200 push-ups a day, nobody can
tell him that aging is a bad thing. It is a great thing. And so
start doing great things now with your body, both mentally and
physically.
And, third, stay active and engaged in your community. Find
a passion, something you are truly, truly excited about that
gets you up every day. You know, having been in the field
working on these issues for decades, I will tell you the number
one reason seniors are able to get over a fall, or are able to
get through chronic disease, is they have something other than
disease that they are focused on every day. And so I encourage
everybody to always think through, just as we say in our Aging
Mastery Program, what are you grateful for? Because every day
is a gift. And how are you going to use that gift of time, not
only wisely but for the better things in life?
The Chairman. Thank you very much.
Senator Casey, feel free to take some additional time, as I
did.
Senator Casey. Madam Chair, thank you very much.
I want to start with just something for the record. I would
ask consent on two matters--two letters, I should say. The
first letter was organized by the Medicare Rights Center. It is
from more than 75 national and state organizations urging
Congress to pass the BENES Act. That is one. And the second is
from former administrators of the Medicare program from both
Democratic and Republican administrations who also support the
bill. So I would ask consent, Madam Chair, to submit both
letters to the record, one dated December 19, 2017, and the
other dated August 22, 2016.
The Chairman. Without objection.
Senator Casey. Thank you, Madam Chair.
I also want to express support for two statements made here
today, the first by our Chair with regard to the cuts the
administration would propose or have proposed with regard to
the so-called SHIPs program that allows us to have programs
like the APPRISE program that Sharon has done such good work
on. So, Madam Chair, I appreciate your saying that here today,
and I certainly support that.
And Senator Warren's call for the Social Security
Administration, we want to make sure that those kinds of cuts
do not become the norm and do everything we can to prevent
those cuts.
I will go there with Mr. Borland. You have been asked a
couple times today about the work that your team does, and we
can, as you have, and we should cite efforts you have already
undertaken and will continue to undertake, all of the outreach
that you do, and we appreciate that.
I hope, though, that when--maybe I will ask two questions.
One is--I will make a statement and ask a question. The first
is I hope if you think you need more resources, you or someone
in your agency would tell us. I know that in every
administration--I am not saying this just focused on this
administration. Every administration instructs people sometimes
not to say much, not to advocate for more resources. I do not
know if that is the case here, and I do not want to make that
charge. But I hope--I hope--that if you need more resources,
you would come to the Congress and express that.
I know what it is like to criticize agencies. I was for two
terms Pennsylvania's auditor general. I kicked the hell out of
a lot of state agencies with tough investigations that really
were critical of people and their work in the agencies. I did a
lot of audits that criticized how state government agencies
work. They never wanted to hear from me.
But I also tried to couple that criticism and critique our
investigation or audit with recommendations for how to improve,
how to improve the work that you do, and sometimes that comes
down to money. Sometimes you cannot fix a problem without the
resources. You can be efficient, you can be effective and all
that. I get that. I do not need anyone to tell me about that.
But sometimes you need to ask for more dollars. I am not asking
you to do that today. I do not want to get you in trouble. But
I hope that you would come to us, and not just to
appropriators, but maybe especially to appropriators when you
need more resources.
So I guess, Mr. Borland, here is the question: How does the
Social Security Administration make sure that people are
prepared to sign up for Medicare? And if you want to reiterate
some of what you have already said, I think it bears repeating.
But maybe the more important question is: What initiatives or
partnerships are underway right now at the Social Security
Administration to strengthen the communications that you
undertake and to prevent the misinformation that sometimes
leads people to make decisions or fail to make a decision that
can hurt them down the road?
Mr. Borland. Thank you, Senator Casey. Let me talk first
about some of the efforts that we are currently making. I have
certainly talked and made a pitch for My Social Security
Accounts. For Americans who do not have a My Social Security
Account, they are missing out on an opportunity to learn an
awful lot about the benefits that they may become entitled to
in the future, including, yes, retirement benefits but
obviously also survivor's benefits for their family, disability
benefits, but also Medicare. And as I mentioned earlier, we
mail a Social Security Statement with an insert to everyone 60
years and older every year, until they claim Social Security
benefits.
In that insert very prominently displayed--the insert is
entitled, ``Thinking of Retiring,'' but very prominently
displayed is a note, a reminder: ``Make sure you sign up for
Medicare three months before your 65th birthday.'' That notice
goes out at age 60, at age 61, at age 62. It is certainly a
message that bears repeating, and we certainly repeat it. That
is a primary way that we communicate to individuals who are not
receiving Social Security benefits that they need to sign up
for Medicare at 65.
But I want, I think more importantly, to talk about some
things that we are working on. Literally just three weeks ago,
I sat down along with my counterparts from Social Security,
from Policy, Communications, the folks that run our 800 number,
across the table with the folks from CMS. We think there are
great opportunities for strengthening the partnership between
the agencies to prevent unnecessary hand-offs and to
increasingly serve the public at the first point of contact.
Senator Casey. Well, I appreciate that. I know I am over
time. I will just wrap up with this. The point that has been
made here about even if you are making all of those efforts,
there is a gap because of lack of broadband access and high-
speed Internet, that is one of the many reasons why we have got
to get to an infrastructure bill around here or something that
would focus on broadband. Many people in the Senate, including
Senator Gillibrand, who is here, have worked on these issues
for years, but we have not gotten to the point where rural
America has the kind of connectivity it deserves. Something on
the order of thirty-nine percent of the people--not the places,
the people--who live in rural America have no high-speed
Internet. Thirty-nine percent of all the people living in rural
America. So if there was ever a time to push for it, now is the
time.
Thanks very much.
The Chairman. Thank you.
Senator Gillibrand, welcome.
Senator Gillibrand. Thank you. I did not expect to----
The Chairman. If you would prefer that----
Senator Gillibrand. No, I am ready. I just did not want to
bump her. I thought she had not gone yet.
As the number of individuals eligible to claim Social
Security benefits is rapidly rising, it is more important than
ever that we ensure the Social Security Administration is fully
funded and capable of providing the essential services older
Americans need. SSA sites are being forced to close across my
State of New York, making it inaccessible for seniors to get
the benefits that they have earned and worked hard to pay into.
Mr. Borland, can you tell us what steps SSA is taking to
keep up with the growing demand for its services and how SSA
will ensure that the quality of its services will not decline
as it serves so many individuals?
And, second, the Social Security Administration provides
critical information to millions of individuals figuring out
when to claim Social Security every year. Can you tell us a
little bit about some of the issues surrounding claiming
benefits that seem to confuse people the most and what topics
it is most apparent people could use more information?
Mr. Borland. Thank you, Senator. I would be happy to. Let
me first talk about some of the areas where people have a lot
of questions when they come into our offices. Probably the most
important information that we provide folks is the basic fact
that the longer you wait to claim benefits, the higher your
benefits will be for the rest of your life. There is some
confusion around early retirement age, full retirement age, and
the impact of delayed retirement credits at age 70.
But the basic message that we deliver to every person that
asks us, whether it is over the Internet or via the 800 number
or in a field office, is the longer you wait, the higher your
benefit amount will be for the rest of your life. And that is a
point of confusion.
Others include that your benefits are based on your 35
highest years of earnings. Many people think that it may be
your highest three or your highest five. It is your highest 35
years of earnings. Why is that important? Well, if you have 30
years of earnings or 33 years of earnings, you are going to
have zeroes instead of an earning amount in those years. It may
encourage people to work a few more years, to fill in those
zeroes and potentially boost their benefit amounts, again, for
the rest of their life.
Senator Gillibrand. Medicare beneficiaries rely on SHIP
counselors for unbiased, one-on-one Medicare counseling. In New
York we call the SHIP the Health Insurance Information
Counseling and Assistance Program, or HIICAP. In 2007, SHIP
counselors provided one-on-one counseling to nearly 130,000
individuals and held more than 3,000 educational presentations
in enrollment events across New York. Many say that 1-800-
Medicare is a sufficient source of information for
beneficiaries, but I have heard from many New Yorkers that SHIP
is essential for them to get access to benefits.
Ms. Chavez, could you share with us the importance of SHIP
counselors as a source of unbiased information beyond the 1-800
number?
Ms. Chavez. Thank you, Senator, for that question.
Absolutely, we are a very big supporter of the SHIP program. We
clearly know that it is going to take many different points of
contact with the senior to ensure they really understand their
benefits. We administer the Center for Benefits Access through
a grant from the Federal Government, and so we physically put
benefits counselors in the field to assist seniors.
But we also know that there are other volunteers through
other programs that we need to work with. So we are very glad
on a daily basis to work with individuals like Mrs. Hill who
are doing those community interventions and interviews and one-
on-one discussions with seniors. And we also work very closely
with other federal and state agencies to ensure that we are
getting the latest, greatest information.
One of the things that we have also gotten feedback on is
because we run one of the largest online benefit access tools,
which is free to the public, and we update that consistently to
ensure that both the SHIP counselors and other benefits
counselors across the country have access at their computer,
not only to the federal benefits that those seniors may be
eligible for but also at the state level, and sometimes even
sort of municipality level.
So, again, I think what you will see here today is that
this ecosystem that we have built between federal partners,
state agencies, volunteers such as the SHIP volunteers, and
national nonprofits who are serving these seniors, this
ecosystem is critical and would not be doing this great work
without the support of Congress and the appropriations they
provide.
Senator Gillibrand. For the record, would you guys please
submit an analysis of the impact of enrollment errors? Because
I know that there is a percentage or a number of people who
make mistakes enrolling, and almost 700,000 Americans paid Part
B late enrollment penalties because it was late. Can you at
least submit for the record so I can understand, when people
make mistakes, how do we fix them? What is the burden? And what
are your best recommendations on how to limit that?
Thank you, Madam Chairwoman.
The Chairman. Thank you very much.
Senator Cortez Masto?
Senator Cortez Masto. Thank you, Madam Chair, and thank you
for this second round because this is part of the discussion I
wanted to get into. I echo my colleagues on the concerns with
cuts to Social Security, and the reason why I wanted to go down
this path--and I so appreciate, Ms. Chavez, your comments on
this. You know, I was fortunate enough to be raised by not only
incredible parents but also grandparents and great-
grandparents. Not only were they in our every day lives, I saw
what happened to them as they aged. And I have a Mexican-
American grandmother who worked her entire life as a sales
clerk, and her retirement was Social Security. And I will tell
you that pay gap had an impact on the type of retirement she
had later on in life, and that is why I know, looking at the
statistics, when it comes to Social Security and the
beneficiaries of that retirement or that the money they count
on and they worked so hard for, are women and children like my
grandmother.
And so I do not support any cuts to Social Security, and,
Mr. Borland, I appreciate the position that you are in, but I
also know talking with some of your employees that live in my
state and the interaction that I have seen in my state and the
benefits of having those offices open and the interaction with
state and local, which you are right, there is that
interaction, and that working together there are so many
beneficiaries of Social Security that are out there that are
aging, that are going to need that interaction and those
offices open. So I do not support cuts and will never support
cuts to Social Security. There are ways that we can address
this issue, but it does not start with harming all of those
people out there that rely--that have worked so hard in their
lives and they are relying on that type of retirement. So I
thank you for that.
The other thing, I appreciate the conversation today as
well. I also have Italian-American grandparents, and, Doctor, I
can tell you are a very good doctor. I have an Italian
grandfather who loved to smoke cigars, play golf, and believe
it or not, likes Christian Brothers brandy with orange juice,
which I am not sure most people would. But as he aged and he
got older, he became very familiar with his doctor, and he was
always in the doctor's office with an ache or pain or, ``I
cannot walk,'' or, ``I am dizzy.'' And finally the doctor
looked at him and said, ``Lawrence, you are just getting old. I
do not have a magic pill for you. This is about lifestyle. This
is about healthiness, and this is about how you eat.''
And so would you please--and we have not touched on this--I
think part of this though, is this education that somehow not
just nutritional food, but healthy food has an impact on your
health. I think we need to learn at an early age, but at the
same time, as you age, this has an impact on your health. And,
Doctor, if you do not mind talking a little bit about that?
Dr. Ayati. Thank you so much. I appreciate it. Before I
started, whenever I talk about healthy lifestyle, I always
admire Italian culture because they talk, and this is the best
exercise for the brain. And that is why whenever I have an
elderly person that complains about isolation, I say, ``Live
like Italians. Talk, talk, and talk. This is the best way to
go.''
[Laughter.]
Dr. Ayati. It is a very, very important thing that you
brought up. It is about nutrition. One thing about that, one of
the biggest challenges we have for a lot of our patients, they
are always looking for a magic formula. They say, ``What are
the best vitamins and supplements I can take?'' The problem is
that this is exactly part of the education that we should
provide for them, that nutrition is part of exactly at the
beginning, as Chairman Collins started, of the healthy
lifestyle, which is eighty percent--or longevity depends on it,
and only twenty percent on genetics. And nutrition should be a
balanced diet.
When we talk about balanced diet, a lot of people--again,
we go back again to the conversation that I started, that we
sometimes obsess about the diets. Sometimes the people
recommend you have to take lots of fiber, you have to take lots
of vegetables. I wrote years ago in the San Francisco
Chronicle, the local newspaper, that too much fiber actually
can be harmful for the elderly. We should have only a balanced
diet which has protein, carbohydrates, and fat. Even fat, fat
can be helpful for the elderly, but only in moderation, not in
exaggeration.
That is why it is important for all the older people to
know, first of all, they do not need to take extra supplements.
If they eat just a healthy, balanced diet, that is going to be
enough for them. Definitely more focus on healthy parts of the
diet. But, again, one of the things is that we do not educate
them, because in a majority of our health centers, we do not
have educated nutritionists in senior care that they come and
talk to them, review their diet. A lot of seniors are living on
some of the programs that they actually deliver the food for
them.
But it is very interesting because one thing is only that
they do not eat. The other thing is a social problem, lack of
companionship. A majority of my patients, they have the program
like Meals on Wheels, and when I do a house visit, I see all
the foods in the refrigerator and nobody touched that because
they do not have this feeling to eat. And there are a lot of
other things related to nutrition, like good dental hygiene,
and dental issues are one of the biggest problems. A lot of
things happen for us because we prescribe too much medication,
and they change the taste buds of the older adult people, and
that is why they do not feel that they are eating food.
One of my advice to senior centers is to make a good
presentation for your food. Make them motivated and engaged
that actually they are feeling that it is only not a piece of
bread and a piece of meat. I mean, this art can make them to
become motivated. But definitely nutrition is one of the
biggest factors for healthy aging that we need to emphasize,
and more public education.
Senator Cortez Masto. Thank you. Thank you very much. And,
again, to the Chair and Ranking Member, thank you for this
great panel and this great discussion today. I so appreciate
it.
The Chairman. Thank you very much.
I want to thank all of our great witnesses for your
testimony today and, more important, for your work that you are
doing to assist older Americans who are navigating what can
often be a confusing maze of information, to help our society
recognize and value our seniors, and to assist older Americans
in living healthier lives.
Dr. Ayati, we really need you in Maine.
[Laughter.]
The Chairman. California has plenty of specialists. And we
are the oldest state in the Nation by median age, and we have a
real shortage of physicians who are trained in geriatrics. So I
am serious about this. If you really, really want to make a
difference, I am positive that I can get you a good job in the
State of Maine.
Dr. Ayati. I will prepare my resume today.
[Laughter.]
The Chairman. So it is a real problem. In states with aging
populations, there are not people who have the kind of training
that you have and that you discussed. And this problem is only
going to become more severe as our population continues to age.
When the fastest-growing cohort of our population are those 85
and older and the second fastest-growing are those 100 and
older, the future is staring at us. And I am really concerned
about having the workforce that is trained and experts to help
us adjust and ensure good, healthy lives for people as long as
possible.
When you think about how much our world has changed in the
last 65 years since 1953, that is the year that color
television first started appearing. Gas back then cost 20 cents
a gallon. Nobody ever heard of iPhones or computers being
widely available. In fact, when you were talking about the need
for people to talk more face-to-face, this is a major obstacle
to people having conversations. I could not live without it,
but it is a major obstacle. And you cannot probably see from
there, but my 92-year-old father in his World War II uniform is
my screen saver on it.
But we need to do so much more to adjust to the new reality
that we are in, and that has been one of the purposes of this
hearing today. So I thank you all so much for helping us to
better understand the world that we are living in. And I also
want to thank our staff for their hard work.
Committee members will have until Friday, February 2nd, to
submit additional questions for the record, so you may be
getting some additional inquiries.
And I would now turn to Senator Casey for any closing
remarks that he would like to make.
Senator Casey. Chairman Collins, thank you. I want to thank
you for this hearing and for the good work that led up to it by
your staff and our staff as well.
I want to thank our witnesses. I will pay special tribute
to Sharon because she did such a good job and she is from
Pennsylvania. We have a special place in our heart for Fayette
County. I want you to know that. But I am grateful for all of
that and especially because we are dealing with such a
difficult issue when we talk about the many issues we had to
confront today. People turning 65 are facing a staggering
number of decisions related to their health and financial
security. These are complex decisions that can have lifelong
consequences. It is our responsibility to provide people with
information to make the best decision possible. Without
information that is easy to access and understand, people are
being punished for honest mistakes, and that is unacceptable. I
think we can all agree on that.
We have got a lot of work to do this year on these issues.
I hope that we can pass the BENES Act. I will put another plug
in for that. We are grateful for this opportunity, and I am
looking forward to continuing to work on these issues.
Thank you, Madam Chair.
The Chairman. Thank you.
Senator Cortez Masto, do you have anything?
Senator Cortez Masto. No. Thank you.
The Chairman. Thank you. This hearing is now adjourned.
[Whereupon, at 11:14 a.m., the Committee was adjourned.]
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APPENDIX
Prepared Witness Statements
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Executive Summary
Dear Madam Chair, Ranking Member, and distinguished members of the
U.S. Senate Special Committee on Aging. Thank you for inviting and
giving me the opportunity to discuss critical challenges regarding the
aging population in the U.S. My name is Dr. Mehrdad Ayati. I am a
board-certified Geriatrician and an educator. I am also board certified
in Family Medicine. I am presenting myself as a physician who has
treated and managed, and continues to treat and manage, thousands of
senior Americans.
I would like to start with some statistics. Today, the number of
Americans ages 65 and older is approximately 49 million. This number is
estimated to grow to 98 million by 2060. Currently, there are about
7,000 geriatricians in practice in the United States, yet according to
the Alliance for Aging Research, we should instead have 20,000
geriatricians--nearly three times our current number--just to
accommodate the needs we have right now. By 2030, this group estimates
that our country will need about 37,000 of these specialists.
Since 2011, approximately 10,000 Americans have been enrolling in
Medicare every day. This aging population is faced with multiple
challenges on the path to healthy aging. I would like to outline eight
of these challenges briefly and suggest some directions for overcoming
them.
There is a Lack of Experts in the Field of Geriatric Medicine and
Gerontology
Unfortunately, our health care and education systems have not been
designed to train enough senior care providers such as doctors, nurses,
physician assistants, pharmacists, social workers, dementia experts,
and physical and occupational therapist who can specifically manage
seniors. As we age, our physiology changes. For example, absorption of
drugs through our digestive system can be altered. Our liver function
decreases, and it becomes harder for our body to metabolize and
eliminate drugs. Changes in our circulatory and nervous systems affect
our reactions to drugs. Therefore, we might need lower or higher doses
of medications compared to other age groups. Additionally, there are
medications that while working perfectly well for younger adults,
should not be prescribed for the geriatric population. Therefore, it is
crucial for the elderly to be managed by healthcare providers who have
been educated and trained in this field. In the U.S., 80% of those 65
and older have at least one chronic condition (more than 3 out of 4)
and 50% have two chronic conditions. Forty percent of the seniors take
at least five medications, not taking into account over-the-counter
supplements and herbal remedies. They see many different specialists
and are prescribed a number of different medications through each. This
situation can result in polypharmacy or over-medication, and even Drug
Cascade Syndrome, where an undesirable side effect is misinterpreted as
a medical condition and results in a new prescription. That is the
reason why 4.5 million Americans visit the emergency rooms and
physician offices each year. Adverse drug events account for a large
number of hospital stays and deaths among the elderly. Therefore, there
is a critical need for training more senior care providers.
There is a Dearth of Scientific and Research-backed Medical Information
Regarding Healthy Aging
Despite the fact that we live in an era of advanced technology,
with massive amounts of information on the subject of aging at our
fingertips, the validity of much of such information is highly
questionable. Our seniors are bombarded with contradictory claims,
literature that is overly technical and hard to understand,
recommendations that are impossible to follow, and often marketing-
oriented myths about how to take care of themselves. They lack simple,
straight forward, easy to follow information about aging on topics such
as nutrition, mental and physical health, frailty, medications, finding
the right physician, and end of life decisions. For example, misleading
marketing campaigns at every corner are enticing our seniors to take
drastic measures such as taking unregulated vitamins and supplements or
undergo harmful diets to live longer and healthier. This is regardless
of the fact that scientific data collected over many years indicate
that such over-the-counter supplements and drastic diets are not
contributing to better health and could even be detrimental to our
health. Consequently, there is a critical need for reliable
information, valid guidelines, and effective strategies so that senior
can avoid or more effectively manage chronic diseases and have a better
quality of life.
Very few clinical research and trials are designed for or even
include older people, which consume majority of the pharmaceuticals
currently available in the market. As such, the safety of most
medications in the elder population is not well researched.
There is also a lack of academic and scientific research on the
subject of aging. There is also an urgent need for the development of
innovative tools to help the elderly stay in the comfort of their homes
as long as possible and avoid spending time in nursing homes.
The Elderly are Becoming more Racially and Ethnically Diverse
In 2010, more than one in eight U.S. adults 65 and older were
foreign born, a share that is expected to continue to grow. The U.S.
elderly immigrant population rose from 2.7 million in 1990 to 4.6
million in 2010, a 70% increase in 20 years. It is estimated that the
number of U.S. immigrants 65 and older will quadruple to more than 16
million by 2050. This increase is due to the aging of the long-term
foreign-born population and the recent migration of older adults as
part of family reunification and refugee admissions. In 2014, about 15%
of people age 65 and older lived in a home where a language other than
English was spoken. Currently, we lack the resources to address the
challenges of this growing ethnic and racial groups. These challenges
include language barriers, cultural differences, religious and belief
differences, physiological factors such as genetic backgrounds, and
financial inequalities.
We Live in an Anti-Aging Society
We are a youth-oriented society that is not properly focused on
aging and the older generation. As people grow older, they need more
attention, care, support, companionship, and love. We need to raise
awareness about the needs of the elderly as well as the hardships they
face and to promote the respect, gratitude and appreciation they
deserve. All too often, older adults are forced out of the workforce
and replaced by cheaper and unskilled labor. They may then retire to
the solitude of their homes, where they can become isolated and lonely,
and as a consequence, develop depression and cognitive impairment.
Later, they may be institutionalized and set aside by the society they
built and the children they raised. They can even be mistreated,
cheated and taken advantage of.
We Need More Infrastructure and Resources
Our seniors face a lack of appropriate resources in the areas of
transportation, affordable housing, senior centers, organized and
affordable social activities, and qualified healthcare centers. These
problems are magnified for those suffering from dementia. Currently
five million Americans suffer from this condition, and in the next 15
years this number is expected to triple. However, we lack the dementia
units as well as the professionally trained staff to provide care for
this population.
Seniors are Experiencing Financial Difficulties
A large number of seniors are living in poverty. The recent global
economic crisis of 2008, the collapse of the housing market and the
astronomically high cost of healthcare in the U.S. are among the many
factors contributing to the growth of debt among the elderly. Some of
them are forced to forgo retirement and seek very low paying jobs,
which they may still have a very hard time finding due to age
discrimination. Often, they are faced with a hard choice between paying
their mortgage, buying the many medications they can't survive without,
or purchasing food. Too often, they become not only financially but
also physical dependent on their children, which are known as the
``sandwich generation'' when they care for parents while at the same
time raising their own children.
We Expect Quick Fixes
We live in a modern society where more is considered better. This
kind of mentality tells us that for every single problem, there should
exist a quick fix--even if there is no logic behind it. ``Modern
medicine'' dictates that health issues should be resolved with either
medications or interventions. But in reality, the statistics do not
support this. The Congressional Budget Office in 2015 estimated that 5%
of the nation's gross domestic product, $700 billion per year, goes to
tests and procedures that do not improve health outcomes. Therefore,
modern medicine, with its emphasis on attempted solutions rather than
prevention, does not necessarily make happier and healthier citizens.
Medicare Expenditures Are Not Aligned With Needs
As the Medicare system is set up today, it does not pay for the
medically necessary services, which can have tremendous impact toward a
better physical and mental quality of life for adults. For instance, if
an older adult needs more physical therapy to help with mobility or
needs a necessary piece of equipment to have a better quality of life,
it will be denied by Medicare. However, if the same person wants to
undergo an expensive diagnostic test, the test will be quickly
authorized. Unfortunately, as we discussed, many of these diagnostic
tests do not change the quality of life for the elderly. Sometimes they
do not even improve the management of the disease. I see on a daily
basis that Medicare would fully pay for diagnosing and treating my
patient's cancer, even if it would extend their life for just a few
weeks. However, Medicare would not pay a penny if the same patient
needed help at home, nor would it pay if he/she required counseling to
overcome anxiety and depression. I had a patient a few years back with
advanced dementia in a nursing home. He also had advanced colon cancer.
He could not eat, was in severe distress and could not recognize
anyone. His life expectancy was less than 2 months. On one of his
visits to the ER, his family members were instructed to consult with a
cardiologist. The cardiologist advised them to get a pacemaker for him.
They put a patient with advanced dementia and cancer under general
anesthesia to give him a pacemaker. And Medicare paid for it. He died
less than a month later.
Solutions
Expansion of Geriatric Education
A large number of the teaching physicians in the U.S. medical
schools don't have the appropriate expertise or background in the field
of Geriatrics. As a result, medical students, residents, fellows, and
practicing physicians who currently treat the elderly lack the basic
knowledge in the field of geriatrics. Therefore, too often the elderly
are misdiagnosed and mismanaged. In contrast, in Great Britain, every
medical school has a department of geriatrics, as do one-half of
Japanese medical schools. Of the 145 U.S. medical schools, only 11 have
geriatric departments (7.6%). Plus, the geriatric curriculum at over
three-quarters of the U.S. medical schools is an elective, not a
required field of study. As a consequence, many older Americans will
not get the most knowledgeable care they need when they most
desperately need it. In fact, it's already too late for a solution that
involves training enough certified geriatricians. The experts admit
this and offer an alternative solution. This solution hinges on
creating enough geriatric educators to ensure that every new physician,
of which there are over 16,000 per year, will have been sufficiently
trained in geriatrics in medical school to know the differences between
medical care for non-geriatric patients and medicine for the oldest of
us. Another recommendation is that all primary care physicians and
specialists should have mandatory training in the field of geriatrics
as part of their CME (Continuing Medical Education). This rule should
also be mandatory for nursing, advanced nursing and physician assistant
practice education.
Earlier this year, the American Geriatric Society endorsed the
Geriatrics Workforce and Caregiver Enhancement Act (H.R. 3713), a
bipartisan proposal for programs addressing the shortage of health
professionals equipped to care for the elderly. Introduced by Reps. Jan
Schakowsky (D-IL), Doris Matsui (D-CA), and David McKinley (R-WV), the
bill draws on considerable insights from the Eldercare Workforce
Alliance (EWA), a collaborative comprised of more than 30 member
organizations co-convened by the AGS and now reflecting the diverse
expertise of millions of professionals who support health in aging for
older Americans. The proposed legislation would codify into law and
authorize funding for the Geriatrics Workforce Enhancement Program
(GWEP). The GWEP is the only federal program designed to increase the
number of health professionals with the skills and training to care for
older adults.
Launched in 2015 by the Health Resources and Services
Administration (HRSA) with forty-four 3-year grants provided to
awardees in 29 states, the GWEP is helping geriatrics experts develop
innovative local solutions. When approved, H.R. 3713 will authorize
GWEP funding of more than $45 million annually through 2023, allowing
current and future GWEP awardees to educate and engage with family
caregivers, promote interdisciplinary team-based care, and improve the
quality of care delivered to older adults. I hope this bill will be
finalized soon, as this can be a big victory for our vulnerable older
adults, allowing them to receive better care for their future. But this
is only a beginning and we need more funding in the future.
Medicare Reimbursement Model
With the passage of the Affordable Care Act, the reimbursement
basis is slowly shifting from a Fee for Service (FFS) structure to one
which puts emphasis on improving performance and outcomes. However, the
level of reimbursement is still not adequate. Geriatric counseling and
geriatric assessments require time. Keep in mind that there is a
shortage of geriatricians and there is a large population of geriatric
patients with multiple chronic conditions on many medications. As such,
the amount of time spent per patient needs to be long enough to be
effective. However, at the current low reimbursement levels, geriatric
professionals need to see many patients in a short timeframe to survive
financially. Geriatrics is one of the lowest-paying specialties, and
experts say this low pay and factors such as the high cost of living
and office overheads as well as the long work hours are driving new
physicians away from the field. Increasing reimbursement fees for
geriatric consultations would undoubtedly create more attraction for
medical centers and doctors' offices to expand their geriatric care and
hire more geriatric care providers. It would also allow the care
providers to spend an effective amount of time with each patient to
provide all the necessary assessments, management and education.
Expand Geriatric Consultation
One efficient way of properly taking advantage of the currently low
number of geriatricians in the field is to use geriatricians as
consultants rather than primary care providers for the elderly. To
accomplish this, all healthcare providers could send their elderly
patients for a geriatric consult at least once or twice a year. This
would allow geriatric professionals to evaluate patients and their list
of medications and make the proper recommendations to their primary
care physicians and other specialists. It should also be made mandatory
for primary care physicians to consult with a board certified
geriatrician or a gero-psychiatrist for their patients suffering from
dementia. Of course, a proper reimbursement method is necessary for
this model to survive.
Medicare Annual Wellness Visits
Medicare has a comprehensive and well detailed annual wellness
visit structure. Unfortunately, many physicians do not follow the well-
established CMS annual wellness instructions. The majority of
discussion time between patients and the physicians is spent on
management of high blood pressure, high cholesterol, refill of
medications, and/or vaccinations. Although these are relevant topics
which need to be well addressed, this annual wellness visit should in
addition include a thorough geriatric assessment and evaluation. This
includes screening for depression, discussing nutrition, and screening
for memory loss. It should also include discussing goals of care and
life preferences. Primary care physicians should consult geriatricians
during these CMS annual wellness visits to properly assess their older
patients.
Coordination of Care
Bringing together a team of health care providers, with a
geriatrician at the center, and working closely with the senior
patients, family caregivers, primary care physicians, specialists, case
managers, and other care professionals is of essence to ensure healthy
aging. This team can coordinate individual needs, synchronize the
variety of short-term and long-term medical services, improve health
care access and outcomes, support and improve communication resulting
in improved individual well-being and health outcomes.
Physical Health of our Older Adults
Frailty is defined as a progressive deterioration of multiple body
systems resulting in physical and functional decline. It is
characterized as a drop in the body's energy production and utilization
as well as a deterioration of its repair systems. It can occur at any
age but is much more prevalent in the elderly. As we grow older, we
eventually lose about 40% of our muscle tissue. Unfortunately, as we
discussed, our seniors lack the basic infrastructure to stay healthy
and fit. For example, there is a lack of senior-friendly exercise
centers in this country. Such centers should have suitable equipment
designed for seniors and have certified trainers who can help them stay
physically strong, and to prevent, slow, or reverse the development of
frailty. Seniors also need transportation systems to reach such
physical and social centers.
We also need more effective, continuous adult education in medical
centers, physician offices, media, and public programs about the
importance of exercise for older adults. It is essential that providers
be honest with their patients and explain to them that medications and
procedures alone are insufficient: they must be accompanied by regular
physical activity in order to maintain their mental and physical well-
being.
Mental Health of our Older Adults
Mental health is the most important aspect of healthy aging. As we
discussed, people in this group are highly susceptible to becoming
lonely and isolated and to suffer from depression and/or anxiety.
Unfortunately, this will lead them toward increased cognitive
impairment and disability over time. Data is showing that loneliness in
the elderly is associated with the use of psychotropic drugs. Further,
seniors who feel lonely and isolated are more likely to report having
poor physical and mental health, as indicated in a 2009 study using
data from the National Social Life, Health, and Aging Project. It is
therefore essential to expand senior day center programs providing
intellectual stimulation, extend adult educational programs, and
increase community support for the seniors. There is also a strong need
for social engagement and interaction centers for the elderly. We
should also develop mechanisms to help our older adults to engage in
voluntary programs in their community.
Another important factor is the lack of professional geriatric
counselors or therapists who can treat depression and anxiety in this
population. Medicare does not currently provide funding to support
geriatric counseling or psychotherapy. Consequently, depressed seniors
are only to receive pharmacological treatment options. Furthermore,
with the increase of ethnic and racial groups in the U.S., there is a
crucial need for therapists with different cultural and language
backgrounds.
Nutrition
Proper diet and nutrition are essential factors for health.
Unfortunately, many of our seniors are looking for the best supplement
that could act as a magic solution for better health. Sadly, this
unfounded belief in the power of supplements has become a practice
model in our society and is gradually replacing the healthy diet for
this population.
As we age, we lose bone mass, muscle, and water content while
increasing fat content. Other physiological factors such as losing
taste buds and sense of smell, dental issues, lack of companionship,
medical and psychological illness, and stress also result in weight
loss. Many medications also cause loss of appetite and weight loss.
Medical and social education for this group should put emphasis on
proper hydration, maintaining a balanced diet, practicing mindful
eating, avoiding fad diets, and not relying on over-the-counter
supplements and herbal remedies. Social support programs providing
meals for older adults are crucial. Eating meals in senior centers can
help not only nutrition but also help to avoid loneliness in this
group.
Polypharmacy and Drug Cascade Syndrome
As discussed before, prescribing for older patients offers unique
challenges. A periodic evaluation of the drug regimen that a patient is
taking is an essential component of the medical care of an older
person. Such a review may indicate the need for changes to prescribed
drug therapy. These changes may include discontinuation of a treatment
prescribed for an indication that no longer exists, substitution of a
required treatment with a potentially safer agent, reduction in the
dosage of a drug that the patient still needs to take, or an increase
in dose or even addition of a new medication. An interdisciplinary
geriatric team will be the best group to help our older adults avoid
the negative impacts of polypharmacy. It is essential that all medical
centers follow Beers criteria. These are guidelines for healthcare
professionals to help improve the safety of prescribing medications for
older adults.
Physicians who have not been trained enough in the geriatric field
should avoid prescribing psychotropic medications for dementia-related
behavioral disturbances. These medications have very serious side
effects such as confusion, disorientation, hallucinations, seizures and
delirium, and memory loss. In the elderly, they can result in falls and
death.
Through medical and social media, it is essential to educate the
seniors and their care givers to have a current list of their illnesses
and their medications, including the dosage, and to share that list
with all their physicians and pharmacists. Patients and their
caregivers are often unaware of the reasons why some of their
medications have been prescribed. Patients should question their
physicians thoroughly about each of the medications prescribed for
them. They should ask what side effects to look out for.
They should also ask their physicians to ensure that any new
medications do not interact with or inactivate their existing
medications. The public should also be aware that over-the-counter
medications, vitamins, antioxidants, supplements and herbal remedies
are not necessarily safe to use and can interact with their existing
medications.
Conclusion
A joint effort involving better public education, widespread
training of caregivers in the field of geriatrics, and changing
Medicare and government regulations is required to ensure that the
growing wave of seniors live healthier and happier lives.
I would like to thank the Senate Special Committee on Aging for
giving me the opportunity to discuss healthy aging and the challenges
currently faced by the aging population in the U.S. as well as offering
solutions.
[GRAPHIC] [TIFF OMITTED] T2636.029
Prepared Statement of Sharon Hill, Apprise Volunteer, State Health
Insurance Assistance Program, Vanderbilt, Pennsylvania
Chairman Collins, Ranking Member Casey, and Members of the
Committee, thank you for inviting me to testify today. It is an honor
to be here.
My name is Sharon Hill. I am 63 years old and a resident of
Vanderbilt, Pennsylvania. I have two sons and six grandchildren, with a
seventh due any day. My granddaughter, August, has joined me here
today. I am a volunteer with the Pennsylvania APPRISE program.
Nationally, APPRISE is also known as the State Health Insurance
Assistance Program or SHIP.
In addition to volunteering with the APPRISE program, I work
cleaning my church. I also care for my 89-year-old father and help care
for my 92-year-old neighbor, who is blind. I have a disability and rely
on the support of state and federal programs to remain active and
engaged in my community.
I have been an APPRISE volunteer for 4 years. I initially saw an ad
in our local senior newspaper, called the Senior Times News, asking for
volunteers to help people with Medicare issues. At that time, I was on
Medicare due to a disability and had recently been left with $67,000 in
medical bills after a cancer diagnosis. I also recalled the difficult
decisions my parents had to make about their Medicare coverage. Both
events were behind my interest in volunteering for the APPRISE Program.
To be an APPRISE volunteer I had to attend many training sessions.
At these sessions, I learned about the different parts of Medicare,
including Medicare Part A, Part B, Part C, Part D as well as Medigap. I
also learned about programs that can help low-income seniors and people
with disabilities, like Medicare Extra Help, and even Pennsylvania-
specific programs that help individuals who have high medical expenses.
I was trained on how to use the computer system and enter information
into Medicare Plan Finder. Each year we receive a refresher training to
provide volunteers with updated information.
The more I learned, the more I realized I did not know. People have
a lot to consider when signing up for Medicare, and the decisions can
be daunting. I wish I would have known about these resources sooner,
because had I known that programs like this existed, I do not think I
would have faced the hardship that I described.
It is because of my own experiences that I am passionate about the
APPRISE program. APPRISE is the only place that older adults can go, in
person, to get unbiased information to help with their Medicare
decisions. As a volunteer, I give speeches at local senior centers and
provide in-person counseling sessions. Each counseling session is 60 to
90 minutes long, and during Medicare open enrollment season, we are
very busy.
Sometimes people come in with specific questions about their
coverage and other times we are starting with the basics. It is common
for people to make Medicare coverage decisions based on the well-
intended advice of friends, family, or others. What I have learned
during my time as an APPRISE volunteer is that people do not have all
the information they need to make the best decisions for their health
care or financial needs.
Making a bad decision when signing up for Medicare can have
unintended, life-long consequences. When I see people with gaps in
coverage or seniors paying life-long penalties, it is often because of
misinformation. Knowledge is important in helping beneficiaries
maximize their benefits and avoid the pitfalls of life-long penalties.
Thankfully, as an APPRISE counselor, I am trained to help those
that are having trouble with their Medicare due to misinformation. We
can liaison with organizations to appeal a decision or screen people
for programs that help cover the cost of their medication. APPRISE
counselors not only provide information, they help beneficiaries
navigate a complex system and serve as advocates. We also find that
once people come to APPRISE for help, they come back each year to be
sure their coverage is right for them.
People's lives are changing and they need to be educated or they
will fall through the cracks. It is because of this that I tell
everyone I meet about the program. APPRISE counselors do not make
Medicare decisions for beneficiaries, we instead provide them with
information to make the best choices for themselves.
Again, thank you for the invitation to testify before the
Committee. I look forward to answering your questions.
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Additional Statements for the Record
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