[Senate Hearing 115-473]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-473

         TURNING 65: NAVIGATING CRITICAL DECISIONS TO AGE WELL

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

                                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
                              
                              
                              ----------
                              
                 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

                              ----------                              


                      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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