    [Senate Hearing 116-529]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-529

                       THE COVID-19 PANDEMIC AND SENIORS:
                      A LOOK AT RACIAL HEALTH DISPARITIES

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

                                    HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 WASHINGTON, DC

                                   __________

                                 JULY 21, 2020

                                   __________

                               Serial No. 116-21

             Printed for the use of the Special Committee on Aging

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                               ______

                  U.S. GOVERNMENT PUBLISHING OFFICE
     46-842PDF            WASHINGTON : 2022

                           SPECIAL COMMITTEE ON AGING

                       SUSAN M. COLLINS, Maine, Chairman

    TIM SCOTT, South Carolina            ROBERT P. CASEY, JR., Pennsylvania
    RICHARD BURR, North Carolina         KIRSTEN E. GILLIBRAND, New York
    MARTHA McSALLY, Arizona              RICHARD BLUMENTHAL, Connecticut
    MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
    JOSH HAWLEY, Missouri                DOUG JONES, Alabama
    MIKE BRAUN, Indiana                  KYRSTEN SINEMA, Arizona
    RICK SCOTT, Florida                  JACKY ROSEN, Nevada
                                  ----------
                  Elizabeth McDonnell, Majority Staff Director
                     Kathryn Mevis, Minority Staff Director

                             C  O  N  T  E  N  T  S

                                  ----------

                                                                       Page

    Opening Statement of Senator Susan M. Collins, Chairman..........     1
    Opening Statement of Senator Robert P. Casey, Jr., Ranking Member     3

                               PANEL OF WITNESSES

    Dominic H. Mack, MD, MBA, Professor of Family Medicine and
      Director of the National Center for Primary Care, Morehouse
      School of Medicine, Atlanta, Georgia...........................     6
    Mercedes R. Carnethon, Ph.D., Professor of Epidemiology and Vice
      Chair of the Department of Preventive Medicine, Northwestern
      University, Chicago, Illinois..................................     7
    Eugene A. Woods, MBA, MHA, FACHE, President and Chief Executive
      Officer, Atrium Health, Charlotte, North Carolina..............     9
    Rodney B. Jones, Sr., Chief Executive Officer, East Liberty
      Health Center, Pittsburgh, Pennsylvania........................    11

                                    APPENDIX
                          Prepared Witness Statements

    Dominic H. Mack, MD, MBA, Professor of Family Medicine and
      Director of the National Center for Primary Care, Morehouse
      School of Medicine, Atlanta, Georgia...........................    47
    Mercedes R. Carnethon, Ph.D., Professor of Epidemiology and Vice
      Chair of the Department of Preventive Medicine, Northwestern
      University, Chicago, Illinois..................................    53
    Eugene A. Woods, MBA, MHA, FACHE, President and Chief Executive
      Officer, Atrium Health, Charlotte, North Carolina..............    55
    Rodney B. Jones, Sr., Chief Executive Officer, East Liberty
      Health Center, Pittsburgh, Pennsylvania........................    67

                     Questions and Responses for the Record

    Eugene A. Woods, MBA, MHA, FACHE, President and Chief Executive
      Officer, Atrium Health, Charlotte, North Carolina..............    73
    Mercedes R. Carnethon, Ph.D., Professor of Epidemiology and Vice
      Chair of the Department of Preventive Medicine, Northwestern
      University, Chicago, Illinois..................................    73
    Dominic H. Mack, MD, MBA, Professor of Family Medicine and
      Director of the National Center for Primary Care, Morehouse
      School of Medicine, Atlanta, Georgia...........................    73

                      Additional Statements for the Record

    AARP Real Possibilities, Statement for the Record................    77
    Alzheimer Association AIM, Statement for the Record..............    80
    American Psychological Association, Statement for the Record.....    82
    Robert Wood Johnson Foundation, Statement for the Record.........    86
    Johnson and Johnson Services, Inc., Statement for the Record.....    90

                       THE COVID-19 PANDEMIC AND SENIORS:

                      A LOOK AT RACIAL HEALTH DISPARITIES

                                  ----------

                             TUESDAY, JULY 21, 2020

                                           U.S. Senate,
                                    Special Committee on Aging,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:32 a.m., in
    room SD-562, Dirksen Senate Office Building, Hon. Susan M.
    Collins, Chairman of the Committee, presiding.
        Present: Senators Collins, Tim Scott, Burr, McSally,
    Hawley, Braun, Rick Scott, Casey, Blumenthal, Warren, Jones,
    Sinema, and Rosen.

                     OPENING STATEMENT OF SENATOR
                       SUSAN M. COLLINS, CHAIRMAN

        The Chairman. The Committee will come to order, and we are
    already having some technical problems. There we go. Thank you.
        Before I begin my opening statement this morning, I want to
    acknowledge the loss over the weekend of Congressman John
    Lewis, a Civil Rights icon who changed history at great
    personal sacrifice. In 2015, I was honored to be among those
    who joined him in Selma to commemorate the 50th anniversary of
    the Bloody Sunday March, which he led. I sent my deepest
    condolences to his family and his loved ones.
        Today's hearing comes at a time when our Nation is
    experiencing the confluence of a health crisis and economic
    depression and a series of killings that laid bare the racial
    injustice that still taints our country.
        Our focus today is on COVID-19's disproportionate health
    impact on black and Latino seniors, as well as seniors from
    other racial and ethnic minority communities.
        According to the New York Times analysis, black and Latino
    residents are infected with the virus at three times the rate
    of their white neighbors, and they are nearly twice as likely
    to die from COVID-19.
        The State of Maine has the worst racial disparity in COVID
    cases in the country. Although blacks comprise less than 2
    percent of Maine's population, they account for approximately
    23 percent of all cases. Like many other States, many of
    Maine's outbreaks have occurred in nursing homes and congregate
    care settings.
        Nationwide, 43 percent of black and Latino workers are
    employed in service or production jobs that, for the most part,
    cannot be done remotely, while only about one in four white
    employees hold such jobs. One such field is long-term care,
    where one in four employees is black, according to the Kaiser
    Family Foundation.
        At this Committee's May hearing, Dr. Tamara Konetzka
    recommended routine history of long-term care residents, to
    testing of long-term care residents and employees, a suggestion
    that was echoed at the Senate HELP Committee hearing last month
    with former CDC Director Julie Gerberding. Dr. Gerberding
    described long-term care facilities as, ``intrinsic hot
    spots,'' and suggested that we need to test often and test
    everyone who comes and goes from those centers.
        There is still a great deal that we do not yet know about
    COVID-19, but we do know that individuals with chronic kidney
    disease, serious heart conditions, obesity, sickle cell
    disease, and type 2 diabetes are at increased risk of severe
    illness from COVID-19, and that black Americans experience
    these conditions at disproportionate rates.
        Diabetes provides a clear example. Patients hospitalized
    for COVID who have diabetes account for more than 20 percent of
    individuals admitted to intensive care units according to the
    Journal of Clinical Endocrinology and Metabolism.
        According to a survey conducted by the Centers for Medicare
    and Medicaid, although black Medicare beneficiaries were just
    as likely as white beneficiaries to perform diabetes self-
    management activities, they were less likely to have their
    blood sugar well controlled.
        As the founder and co-chair of the Senate Diabetes Caucus,
    I have worked with my co-chair, Senator Jeanne Shaheen, on
    legislation to expand Medicare diabetes self-management
    training as well as a pilot program to test the impact of
    virtual training services.
        We have also introduced legislation to create a special
    task force to eliminate Medicare coverage barriers in accessing
    the latest diabetes treatments.
        We have also worked hard for an extension of the Special
    Diabetes Programs that benefit Native Americans and children
    and adults with type I diabetes.
        Another factor in the disproportionate impact of the virus
    on black Americans appears to be a distrust of the health care
    system. A study from a California health system observed that
    black patients were more likely to have been tested at a
    hospital than in and ambulatory environment and that patients'
    prior negative experiences with the health care system can lead
    to distrust and a decision to seek care only in the most
    extreme circumstances.
        Historical injustices with medical experimentation have
    also left a legacy of mistrust and skepticism among many
    African Americans that we need to work to resolve. Part of the
    solution may be found through community partnerships and
    greater health care workforce diversity.
        Blacks make up 13 percent of the U.S. population, but only
    5 percent of physicians in the United States according to a
    recent report from the Association of American Medical
    Colleges.
        We are so fortunate today to have such a distinguished
    panel of experts with us to help us better understand the
    challenges and, more important, to identify meaningful
    solutions.
        I will introduce our witnesses momentarily, but first, let
    me turn to the Committee's Ranking Member, Senator Casey, for
    his opening remarks, and as I indicated, he is joining us by
    WebEx.

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

        Senator Casey. Chairman Collins, thank you very much for
    this hearing.
        As you noted, as we begin this important work period in the
    Senate, we mourn the passing of United States Representative
    John Lewis. Congressman Lewis was a brave Freedom Rider. He was
    a giant in the Civil Rights movement, who literally shed blood
    for the right to vote. Of course, we know that he served in the
    U.S. House of Representatives for over 33 years. His life was a
    testament to the cause of justice.
        Now as Members of Congress, in the wake of his passing, we
    must ask ourselves at least one major question: What must we
    do--what must we do in the Senate to fulfill our obligation to
    further that cause of justice, especially as it relates to the
    challenges we face right now?
        Our witnesses today will help us answer that basic
    question. They will offer solutions, amid the pandemic and for
    the future, to bring about health equity for older Americans of
    color.
        Older Americans of color, as we know and as the Chairman
    outlined, have spent a life time enduring the structural
    inequities in racism that has plagued our country since its
    inception. We must own up to that simple and shameful truth,
    and we must not only acknowledge these injustices, but we are
    summoned by the example of John Lewis to take action, to do
    something about it, as he so often urged us to do throughout
    his life.
        What are those injustices? Let me just name a few, but they
    are searing in their impact.
        The injustice of a lack of affordable housing. Based upon
    data from 2015, 46 percent of black households spent more than
    one-third of their income on rent compared to 33 percent of
    white households.
        The injustice of food insecurity, right now, black and
    Hispanic households with children are twice as likely--twice as
    likely to struggle with food insecurity as white households,
    number three, the injustice of the education gap. According to
    the Census, 40 percent of white individuals have a college
    degrees or higher, compared to just 26 percent of blacks and 18
    percent of Hispanics.
        The injustice of unemployment itself. In June, the
    unemployment rate for black Americans was 15.4 percent,
    compared to 10.1 percent for whites, a gap that is not unique,
    as we know, to the current crisis.
        Of course, we have been reminded so horrifically lately,
    the injustice of police misconduct against black Americans.
        It is no wonder that older adults of color are diagnosed
    with COVID-19 at higher rates than whites and are dying--dying
    from COVID-19 at higher rates than whites.
        The New York Times recently reported on data from the
    Centers for Disease Control and Prevention that Hispanic and
    black individuals have been three times as likely to become
    infected with the virus and twice as likely to die--twice as
    likely to die as whites, a gap that only widens with age.
        A New York Times analysis of nursing home data from 22
    States found that facilities serving significant numbers of
    black and Hispanic residents are twice as likely to have COVID-
    19 infections, even after controlling for facility size,
    location, and quality rating.
        We have a chance right now, in the next 3 weeks, to begin
    to address these injustices, and we hope to put ourselves on
    the road to actually correcting these injustices and thereby to
    advance the cause of justice for communities of color all
    across America and as we focus on older Americans in this
    hearing.
        Now, we have been told that the Senate will finally
    consider additional legislation to respond to the ongoing
    threat of COVID-19. Here is what we need to do in the near
    term. This is just for the near term, the next couple weeks and
    months: 1) we need a national testing strategy; 2) we need more
    funding for personal protective equipment; 3) we need a
    specific plan to keep nursing home residents and workers safe
    and the dollars to make it work so that we do not have another
    56,000 Americans dead in nursing homes; 4) we need an expansion
    of long-term services and supports in the community; 5)
    pandemic premium pay for the heroes on the front lines who are
    helping to care for our aged loved ones; and 6) a guarantee of
    access to quality affordable health care.
        There is more I could say, but we must do all of these, all
    of these, and more to protect older Americans of color from the
    worst public health crisis in a century. However, the actions
    we take in the short run are not a substitute for enacting
    policies to address the injustices that have plagued
    communities of color for generations--not decades but
    generations.
        Taking action on these racial health disparities that we
    are here to talk about today is what the cause of justice
    demands of us in the U.S. Senate.
        Thank you again, Chairman Collins, for convening the
    hearing. I look forward to hearing from our witnesses.
        The Chairman. Thank you, Senator Casey.
        Our first witness today is Dr. Dominic Mack. Dr. Mack is
    director of the Morehouse School of Medicine, National Center
    for Primary Care, the Nation's first congressionally sanctioned
    center to develop programs that strengthen the primary care
    system for health equity and sustainability.
        Last month, the U.S. Department of Health and Human
    Services announced a partnership with the Morehouse School of
    Medicine to fight COVID-19 and racial and ethnic minority,
    rural, and socially vulnerable communities. We look forward to
    learning more about this partnership and how this work will
    translate into better data and best practices to better serve
    seniors in those communities.
        Our next witness will be Dr. Mercedes Carnethon. Dr.
    Carnethon is the Professor of Epidemiology and Vice Chair of
    the Department of Preventive Medicine at the Feinberg School of
    Medicine at Northwestern University. Her research focuses on
    the epidemiology of cardiovascular disease, obesity, diabetes,
    lung health, and cognitive aging in population subgroups
    defined by race and ethnicity, geography, socioeconomic status,
    gender, and sexual orientation and gender identity.
        I am going to turn from introducing the witnesses myself to
    calling on Senator Burr to introduce a witness from his State.
        Senator Burr, thank you for joining us.
        Senator Burr. Thank you, Madam Chairman and Ranking Member
    Casey, for holding this hearing today, and to all of our
    witnesses, welcome.
        It is a distinct honor to be able to introduce Mr. Gene
    Woods from Charlotte, North Carolina.
        In his current role as president and CEO of Atrium Health,
    Mr. Woods is responsible for one of North Carolina's major
    health systems that manages 14 million patient interactions
    each year. Atrium encompasses 26 hospitals, 900 care locations,
    and employs nearly 70,000 people. He spent much of his career
    focused on the issues before the Committee today, decreasing
    health care disparities, and providing high-quality care to all
    members of our communities.
        Mr. Woods has gained over 30 years of experience in health
    care administration. Prior to his move to Atrium, he served as
    president of CHRISTUS Health System and CEO of St. Joseph's
    Health System. He also previously held a leadership role, Madam
    Chairman, of the hospital here in Washington, serving as CEO of
    MedStar Washington Hospital Center.
        He holds an MBA and a master's of health administration as
    well as a bachelor's degree in health planning and
    administration, all from the University of Pennsylvania.
        Gene, I want to thank you for all the important work you
    have done on behalf of North Carolinians and your tireless
    efforts during this pandemic. I look forward to hearing your
    perspective on coronavirus response thus far and what you think
    is around the next corner in our effort to stop the spread of
    COVID-19.
        Thank you, Madam Chairman, and welcome, Gene.
        The Chairman. Thank you very much, Senator Burr. You have
    been a real leader in this area for many years, and I
    appreciate you being with us.
        I would now like to turn to Senator Casey to introduce our
    fourth witness.
        Senator Casey. Thank you, Chairman Collins.
        I am pleased to introduce Mr. Rodney Jones of Pittsburgh,
    Pennsylvania. Rodney serves as the CEO of the East Liberty
    Health Center. East Liberty Health Center provides care to
    underserved populations in the Greater Pittsburgh Area.
        Mr. Jones will share with us the work that the East Liberty
    Health Center is doing to ensure that patients stay safe from
    COVID-19.
        He will also discuss the threat that the pandemic has to
    the overall health and well-being of patients served by the
    health center. As we know, stay-at-home orders and social
    distancing requirements have caused many older adults and
    people with underlying health conditions to fear leaving their
    home to get the care that they need.
        Mr. Jones has been working at various health centers and
    hospitals in Pennsylvania and Ohio for his entire professional
    life.
        Mr. Jones, we want to thank you for testifying today, for
    being with us, for sharing your expertise with this Committee.
        Thank you.
        The Chairman. Thank you, Senator Casey.
        Dr. Mack, we will start with you.

                 STATEMENT OF DOMINIC H. MACK, MD, MBA,

               PROFESSOR OF FAMILY MEDICINE AND DIRECTOR

                OF THE NATIONAL CENTER FOR PRIMARY CARE,

             MOREHOUSE SCHOOL OF MEDICINE, ATLANTA, GEORGIA

        Dr. Mack. Chairman Collins, Ranking Member Casey, and
    members of the Special Committee on Aging, thank you for
    convening this important hearing today.
        I am Dr. Dominic Mack and am presenting testimony on behalf
    of Morehouse School of Medicine, one of four historically black
    medical schools in the Nation. I bring greetings to you from
    our president and dean, Dr. Valerie Montgomery Rice.
        At MSM, I serve as a professor of family medicine, director
    of the institution's National Center for Primary Care, and co-
    lead on our innovative partnership with the U.S. Department of
    Health and Human Services' Office of Minority Health entitled
    the National COVID-19 Resilience Network: Mitigating the Impact
    of COVID-19 on Vulnerable Populations.
        The daunting news that black Americans in the U.S. are
    disproportionately suffering and dying from the novel
    coronavirus, unfortunately, is not a surprise to those of us at
    Morehouse School of Medicine. We serve on the front lines of
    medically underserved communities and understand the Nation's
    health disparities and overall health status.
        According to the Centers for Disease Control and
    Prevention, as of late June, blacks, Native Americans, Alaska
    Natives, and Hispanics are impacted by the coronavirus at a
    rate reaching five times that of non-minority Americans. In my
    State of Georgia, blacks have accounted for nearly 50 percent
    of coronavirus deaths, and throughout this Nation, seniors
    experienced disproportionate morbidity and mortality across all
    racial and ethnic groups. These facts are a surrogate for the
    glaring lack of health infrastructure in medically underserved
    communities.
        Chairman Collins and Committee members, we are grateful for
    the opportunity to partner with OMH to do the meaningful work
    that will address the disproportionate impact of COVID-19 on
    communities of color.
        The National COVID-19 Resiliency Network, NCRN for short,
    will mitigate the impact of COVID-19 on racial and ethnic
    minorities, rural communities, and other vulnerable
    populations. Related to COVID-19, we will: 1) identify and
    engage vulnerable communities through local, State, territory,
    Tribal, and national partners; 2) establish and active
    information dissemination network; 3) disseminate culturally
    and linguistically appropriate messaging; 4) use technology to
    link communities to health care services, including testing,
    vaccination, and behavioral health counseling; 5) monitor and
    evaluate the success of NCRN services and measure quality
    outcomes; and 6) use broad and comprehensive dissemination
    methods to show lessons learned and best practices among
    vulnerable communities.
        NCRN is a significant step in the right direction, but a
    great need remains in underserved communities. The fundamental
    health needs of vulnerable populations will require
    specifically targeted measures that address the breadth of
    health disparities and the determinants which lie underneath.
    Without significant action as with the past pandemic, COVID-19
    will continue to disparately impact vulnerable populations now
    and long after this pandemic is gone.
        With your leadership, we can realize an equitable policy
    response to the crisis we are now facing. We are calling on
    Congress and the administration to include the following
    measures in the COVID-19 stimulus legislation. One, resolve the
    funding disparity from the CARES Act that short-funded the
    historically black graduate institutions like Morehouse School
    of Medicine. We are on the front line and facing real and
    substantial financial shortfalls. Two, provide robust funding
    for the improvement and development of health care
    infrastructure, including hospitals in medically underserved
    communities. Three, double funding for Title VII health
    professions training programs at HHS's Health Resources and
    Services Administration to increase diversity in the health
    care workforce. Four, invest $100 million in new annual COVID-
    19 research funding to NIH's National Institute on Minority
    Health and Health Disparities, specifically targeted at
    minority-serving institutions.
        We stand ready to work with you. If there was ever a time
    to meaningful act to address racial and ethnic health
    disparities and health inequities in the United States, it is
    now.
        Thank you for this opportunity, and I am pleased to respond
    to any questions.
        The Chairman. Thank you very much, Doctor.
        Our next witness is Dr. Carnethon.

               STATEMENT OF MERCEDES R. CARNETHON, Ph.D,

                PROFESSOR OF EPIDEMIOLOGY AND VICE CHAIR

               OF THE DEPARTMENT OF PREVENTIVE MEDICINE,

               NORTHWESTERN UNIVERSITY, CHICAGO, ILLINOIS

        Dr. Carnethon. Am I being heard? Okay, great. Thank you.
        Good morning, Chairman Collins, Ranking Member Casey, and
    other distinguished Senators of the Committee on Aging. Thank
    you for the opportunity to share my observations and
    recommendations to address disparities in COVID-19 among older
    adults in my capacity as a research expert.
        I am an epidemiologist in the Departments of Preventive
    Medicine and Medicine at the Northwestern University Feinberg
    School of Medicine where I have studied the risk factors for
    chronic disease for the previous 18 years.
        My research, which has been funded by the National
    Institutes of Health, the American Heart Association, and the
    American Lung Association, has described an earlier onset and
    more severe course of hypertension, diabetes, heart and lung
    disease among blacks, Latinx, Native American/Pacific
    Islanders, and some Asians subgroups as compared with non-
    Hispanic whites. These statistics are borne out in my personal
    experience.
        I never met my maternal grandmother, because when she was
    62 years old, she suffered a stroke followed by a fatal heart
    attack. While I knew and loved my paternal grandmother, she did
    not know me for the last 10 years of her life, because she
    battled vascular dementia following years of high blood
    pressure.
        The relevance of my story is that the vascular diseases
    that affected my grandparents are the same conditions that are
    associated with the worst outcomes from COVID-19.
        Early scientific reports from countries that preceded us in
    the pandemic described the characteristics of individuals with
    COVID-19 who were more likely to be hospitalized and to die.
    Immediately, we realized that non-whites and ethnic minorities
    in the U.S. would be disproportionately affected.
        As States and municipalities began collecting
    sociodemographic data from individuals diagnosed with COVID-19,
    racial and ethnic disparities emerged that were the most acute
    in the younger ages. Although these disparities appear to
    decrease with aging in community dwelling older adults, nursing
    homes with a greater proportion of black or Latinx residents
    have doubled the rate of COVID-19 infections than their
    predominately non-Hispanic white counterparts.
        Against the backdrop of this pandemic, I understand the
    urgency for our country to return to normal. In our research,
    we have described the link between economic factors and health.
    A strong economy that allows for stable housing, access to
    healthy food, and health care access to manage chronic
    conditions is likely to be of even greater benefit to elderly
    vulnerable populations.
        However, we cannot return to normal by prioritizing the
    economy over the people without offering strategies to mitigate
    the impact of COVID-19 on minority older adults, an so I offer
    three recommendations based on my experience as a population
    science researcher.
        First, is to expand the digital infrastructure and training
    available to older adults to support videoconferencing for
    telemedicine. The CARES Act provided provisions to expand
    coverage and offer grants to support broader use of telehealth
    services. However, while this can be carried out by telephone,
    there is likely to be an even greater benefit via
    videoconferencing. Almost half of all older adults have a
    smartphone with video capability, and ownership is similar by
    race and ethnicity.
        Accessibility is one step, but in my experience,
    technology-naive adults require training to maximize these
    technologies. When a patient and provider can see one another,
    patients can maximize the social connection with their
    providers, and providers have more information in the form of
    visual cues to gauge whether in-person visits or other home-
    based supports are needed.
        Second, the NIH needs additional financial support to
    address the short-and long-term manifestations of the SARS-COV2
    infection. The majority of the $1 billion infusion of support
    to the NIH through the CARES Act went to the NIAID to
    accelerate study of the virus and vaccine development. We have
    learned since that time that the SARS-COV2 infection damages
    multiple organs, including the heart, lung, blood, kidneys, and
    the brain.
        Further, we know that adults who are obese and have
    diabetes have the worst outcomes, and that underrepresented
    minorities and older adults are overrepresented in those
    populations. As additional financial support is considered,
    other institutes at the NIH need to be on equal footing when it
    comes to the allocation of resources.
        Third and finally, we need to engage the communities who
    have been hardest hit by COVID-19 as we develop strategies for
    prevention and treatment. Progress toward a vaccine to prevent
    COVID-19 is encouraging; however, drawing on parallels from the
    annual flu vaccine, non-white and ethnic minorities are less
    likely to get vaccinated than non-Hispanic whites. Without
    building rapport and trust in these communities, there is no
    guarantee that the highest-risk populations will get the
    vaccine or that they will even want the vaccine.
        Thank you for allowing me the opportunity to offer these
    suggestions today in hopes that we can offer our most
    vulnerable older adults our very best science and medical care.
        The Chairman. Thank you very much.
        Mr. Woods?

             STATEMENT OF EUGENE A. WOODS, MBA, MHA, FACHE,

                 PRESIDENT AND CHIEF EXECUTIVE OFFICER,

                ATRIUM HEALTH, CHARLOTTE, NORTH CAROLINA

        Mr. Woods. Yes. Good morning, and, Senator Burr, thank you
    for that kind introduction and for being a friend of Atrium and
    also a champion for the communities we serve in North Carolina,
    both rural and urban.
        Chairman Collins and Ranking Member Casey and members of
    the Senate Special Committee on Aging, my name is Gene Woods,
    and I am president and CEO of Atrium Health. While I have had
    the privilege of meeting Senator Collins during my time as
    chair of the American Hospital Association, it is an honor to
    now present my testimony on behalf of Atrium Health.
        As Senator Burr shared, Atrium Health is headquartered in
    Charlotte, North Carolina. We are one of the largest not-for-
    profit health organizations in the Nation and have had the
    privilege of serving our community for more than 80 years. We
    are the largest provider of Medicaid, for example, in North
    Carolina, and further, we provide more than $2 billion in
    community benefit annually to those that we are privileged to
    serve.
        As I reflect back on the past few months of combating
    COVID, we have had to really rethink everything that we do as a
    health system. I will remember the faces of my leadership team
    the first time we reconvened to recognize the dimensions of
    this crisis, serious faces, resolute faces, but I am so proud
    of the team and of our frontline caregivers for the selfless
    dedication in keeping our patients and community safe, and our
    mission to care for all has never shined brighter
        That said, we realized the road ahead is long, and there
    were many challenges that remained. We, for example, can do
    4,000 COVID tests at Atrium every day because we are one of the
    few systems in the Nation that had special in-house lab
    equipment that can process our own testing; however, due to a
    national supply shortage in reagents, we are only doing one-
    fifth of our capacity, so opportunities remain to significantly
    expand testing supplies so that we can care for more people,
    especially the elderly, and we stand ready to be part of that
    solution.
        That said, in many other ways, we have taken health care to
    a new impact level and accessibility that will outlast this
    pandemic.
        Take our COVID virtual hospital, for example, which has
    allowed us to care for patients in the comforts of their own
    home while preserving critical capacity inside of our
    hospitals, and to date, our virtual hospital has cared for more
    than 11,000 patients at home and I believe this is a glimpse of
    the future of health care, using technology to increase access,
    including for the most vulnerable among us, closest to where
    they live.
        As another example to help our minority communities, we
    used analytical capabilities to pinpoint geographic hotspots
    where there were disparities in COVID testing and treatment,
    and partnering with local churches and community organizations,
    we deployed our roving health units to the most vulnerable
    underserved areas and I am proud to share that in a matter of
    weeks, we were able to completely eliminate any racial testing
    disparities that existed in the Charlotte region.
        We continue to be deeply troubled by the statistics that
    have been mentioned, the percentage of positive cases and
    deaths among our Hispanic and African American neighbors, so we
    recently launched a public-private partnership to collect and
    distribute 2 million face masks in North Carolina. We at Atrium
    partnered with businesses like Bank of America, the Carolina
    Panthers, Honeywell, Lowe's, Wells Fargo, and others, including
    the health department, and I am proud to say in the past 3
    weeks along, we have already distributed nearly 500,000 masks
    with a specific focus on minority and elderly communities.
        This partnership is an example of how health professionals
    working in concert with businesses and government can help us
    open up our economy as safely as possible.
        We also have focused on another very important vulnerable
    population, our seniors and especially those in nursing homes.
    Atrium Health was one of the first in the Nation to cohort
    elderly COVID-infected patients to a single designated site for
    advanced treatment in care, with half of our patients coming
    from other nursing homes who were not part of a larger system
    like ours and therefore lacked the capacity to provide the
    support needed, including with respect to infection prevention
    resources, respiratory care therapists, and PPE.
        To date, while the national mortality rate for COVID in
    long-term facilities is nearly 40 percent, our skilled nursing
    facility has a mortality rate of 8 percent, and with regards to
    racial demographic mix, we cared for more than 35 percent of
    minority patients, with most being Latinx.
        I would also like to acknowledge and thank Senator Casey
    for his leadership in helping secure more funding through S.
    3768. Senator, that has definitely saved lives.
        Whether through virtual technology, hospital at home,
    roving mobile vans in minority communities, or through our
    skilled nursing facilities that are focused on the vulnerable
    elderly, I am especially proud that we have worked tirelessly
    to care for the most vulnerable among us during these times.
        We certainly cannot do it alone, and that is why we
    appreciate forums like this that continue to explore real
    solutions.
        On behalf of Atrium Health, thank you for the opportunity
    to share our experiences and insights regarding how to mitigate
    the impact of this pandemic and one day, hopefully soon, look
    to eradicate it.
        Thank you.
        The Chairman. Thank you very much, Mr. Woods. I will now
    call on Mr. Jones.

                   STATEMENT OF RODNEY B. JONES, SR.,

                 CHIEF EXECUTIVE OFFICER, EAST LIBERTY

                HEALTH CENTER, PITTSBURGH, PENNSYLVANIA

        Mr. Jones. Chairman Collins, Ranking Member, and members of
    the Committee, thank you for this opportunity to testify before
    you today. I am CEO of East Liberty Family Health Care Center,
    which is a Federally Qualified Health Center located in the
    East End of Pittsburgh, Pennsylvania. Federally Qualified
    Health Centers, or FQHCs, are also community health centers in
    which the mission is to enhance primary care services in
    underserved, urban, and rural communities. They provide
    services to all persons, regardless of the ability to pay, and
    charge for services on a community-based, board-approved,
    sliding fee scale that is based on family size and income.
        FQHCs serve as a safety net for patients who are uninsured,
    underinsured, and underserved. Health centers are staples in
    their communities. There are nearly 1,400 health centers across
    the country that approximate 120,000 service delivery sites in
    underserved communities across the country.
        East Liberty Family Health Care Center service area
    encompasses 69 ZIP codes and has a population of over 11,000
    unduplicated patients which yield approximately 40,000 visits
    annually. Of the patients we see, one-third are over the age of
    50, 1,300 are over the age of 65. Approximately 18 percent have
    no insurance, 57 percent are at or below 100 percent of poverty
    guidelines, and 86 percent are at or below 200 percent of
    poverty guidelines. Thirty-nine percent are insured through
    Medicaid, and 13 percent have Medicare. The remainder are
    insured through Managed Care.
        Seventy-seven percent of the patients we treat are part of
    a racial or ethnic minority. Sixty-six percent of the total
    population we serve are black. Ten percent are Latino or
    Hispanic.
        Our data shows that half the patients we treat who are over
    the age of 50 have hypertension. Over 800 patients we treat in
    this age group have diabetes, and nearly 650 patients are
    overweight or obese.
        Research shows that underlying health conditions, like the
    conditions I just mentioned, are more prevalent in minorities
    due to social determinants of health, which are conditions in
    which people are born, grow, live, work, and age. They include
    such factors as socioeconomic status, education, neighborhood
    and physical environment, employment, social support, and
    access to health care and housing.
        These social determinants of health are medical conditions
    they bring about are major factors contributing to the
    disproportionate number of low-income individuals and people of
    color testing positive and dying from COVID-19 along with age.
        The virus has become a flashpoint on racial inequities,
    financial inequities, and social determinants of health. COVID-
    19 has exposed our health care system's vulnerabilities and
    revealed our inability to respond effectively to a pandemic. It
    has also highlighted the fact that low-income older adults and
    older adults of color have suffered in significantly greater
    proportion than their white counterparts.
        As a result of the pandemic, ELFHCC providers have seen a
    significant decrease in the patients who are receiving critical
    primary and preventative care as well as treatment for acute
    illnesses.
        In response to this concern, ELFHCC has initiated a
    comprehensive telehealth program. Since March 2020,
    approximately 85 percent of all the patients have been treated
    through telehealth. We also started performing COVID-19 testing
    in March. In addition to the testing, we use this as an
    opportunity to educate patients regarding the importance of
    having a medical home and preventative care, because of the
    ACA, ELFHCC has been able to reach an event larger population,
    including older adults of color, and deliver the care they
    need.
        As of July 2020, more than 780,000 individuals have
    coverage for health care services be cause of Medicaid
    expansion. Pennsylvania's uninsured rates fell from 10.2
    percent in 2010 to 5.5 percent in 2018, the lowest rate on
    record.
        Medicaid expansion is a lifeline for people who otherwise
    would not be able to access quality health care. It is critical
    that health centers continue to receive funding to continue to
    serve our patients.
        Thank you for recognizing the role of health centers and
    making this investment in patients through the CARES Act.
    However, a strong public health system requires a strong
    commitment of community health centers, which include long-term
    stable funding for those community health centers. Community
    health centers will be critical in recovering from COVID-19
    pandemic.
        I look forward to answering any questions from the
    Committee about how to further the goals of health equity,
    including older adults, which is a major goal for ELFHCC to
    strive to achieve each and every day.
        Thank you.
        The Chairman. Thank you, Mr. Jones.
        We will now turn to questions, and I want to explain to
    those who are watching this hearing that we have many members
    who have joined us by WebEx in addition to the members who are
    here physically, as Senator Braun, Senator Burr, and Senator
    Blumenthal. Apparently, if your name begins with ``B,'' you
    come personally to the hearing.
        We will be recognizing members to ask their questions in
    order of seniority. I will turn to alternating between the
    majority and minority.
        If a Senator is not present or logged into WebEx when it is
    his or her turn to ask questions, then that person will go to
    the end of the queue, and we will go to the next person.
    Senators will be given 5 minutes each on this first round.
        I am going to start with my questions, and my first one is
    for Dr. Mack. Dr. Mack, I mentioned in my opening statement
    that Maine has the largest racial disparity in the Nation in
    terms of COVID-19 infection. Many in our State's black
    community are immigrants from Somalia, Congo, and other African
    countries as well as from Haiti. Expanding our State to overall
    testing capacity and reaching these individuals are critically
    important to staying ahead of this virus, and it is imperative
    that those who are most at risk for contracting the coronavirus
    are able to access training.
        I know that your school of medicine has been tapped by the
    U.S. Department of Health and Human Services to start
    collecting and presenting data that will lead to best practices
    for minority populations.
        My question for you is, are you taking a look at recent
    immigrant populations, such as those in Maine, as well as
    African Americans or black Americans who have lived in this
    country their entire lives?
        Dr. Mack. Thank you, Chairman, for the question.
        Yes, we are. Likewise in Georgia, I think there was an
    article in one of the major publications earlier this week that
    the migrant population within Georgia were experiencing
    barriers to being tested and leaving the hospital. Those who
    could access care were leaving the hospital with these major
    bills, so we are suffering some of those same issues among
    vulnerable populations outside of the African American
    population. It is happening all across the country, so not only
    insurance is a barrier, education, training, and as you stated
    in your opening statement, mistrust of the system--and some of
    this mistrust lies on a historical path of issues that happen
    within these communities that have left this mistrust within
    their hearts, so we are looking at that, the importance of
    education, overcoming the stigma of vaccination. We know there
    is a lot of misinformation out there, and this has no
    boundaries with education, however, when you talk about that,
    so, yes, with all populations.
        One part of the program--and I will end with this--is to
    make sure that everything is culturally and linguistically
    appropriate for those audiences. A major part of the effort is
    to have focus groups but also community partners who have what
    we call boots on the ground ability within those populations
    and within those communities to actually work with that
    population, people who live in that population like community
    health workers who actually understand the barriers to testing,
    to care, to vaccinations, et cetera, so we are looking at a
    diverse approach to diverse communities.
        The Chairman. Thank you, and that is a great segue to my
    next question, which I am going to ask the remainder of the
    panel to respond to.
        We just heard Dr. Mack mention the importance of having
    culturally and linguistically appropriate services to reach
    people, particularly in the immigrant community, and this is
    particularly important for contact tracing.
        In Maine, the organization serving our immigrant community
    suggests that contact tracing will be most successful if it is
    accomplished in a culturally and linguistically appropriate way
    by people who are leaders of that community, and we talked with
    one such leader just last evening.
        How do we better activate, recruit, and tap into the
    expertise of these community partners who may not have
    established relationships with traditional public health
    agencies so that we can better reach and target testing and
    followup services to these at-risk communities?
        We will start with Dr. Carnethon.
        Dr. Carnethon. Thank you, Senator Collins, for this
    critical question.
        The need to engage communities is one of the
    recommendations that I highlighted in my statement, and the
    reasons for engaging communities are exactly what you
    described. It is so that when it comes time for contact
    tracing, one of our critical strategies to prevent the spread
    of COVID-19, it is so that we can use individuals from that
    community who are trusted to go around asking questions.
        As you can imagine, in the current climate, suggesting that
    someone from the Government is calling to ask questions about
    where you have been, that can create a lot of anxiety and
    concern, particularly in immigrant communities, and so that if
    we can actually find ways to build partnerships through our
    academic, between our academic institution and community
    leaders, between our health care organizations and community
    leaders, we can bridge that gap and be able to reach people in
    order to promote prevention, and reaching people in their
    language is critical. One of the most challenging features of
    this is that we have got to try to build trust in an urgent
    situation where the very individuals who are experiencing the
    worst outcomes are the most concerned about trust within the
    health care system. I think this can best be done through
    community partnerships.
        The Chairman. Thank you very much.
        My time has expired. I am going to ask the other two
    witnesses to respond in writing with their suggestions and call
    on Senator Casey.
        Senator Casey. Chairman Collins, thanks very much.
        I wanted to start with the issue of health insurance and
    health coverage. We cannot talk about the health disparities
    among seniors and communities of color without talking about
    health insurance coverage.
        We know from many sources, one of them being the
    Commonwealth Fund that indicated that, ``the ACA's coverage
    expansion,'' has led to historic reductions in health
    disparities since 2013.
        Just a couple of examples, the gap between black and white
    adults, uninsured rates dropped by 4.1 percent. The difference
    between Hispanic and white uninsured rates fell by 9.4 percent,
    and third, black adults living in States that expanded Medicaid
    report coverage rates and access to care as good as or better
    than what white adults experience.
        Unfortunately, the pandemic is wiping away some of these
    hard-won gains. With job loss that so many Americans are
    experiencing right now, millions and millions of people that
    have lost their job, we also know that has an impact on health
    care; 5.4 million Americans have lost their health insurance
    just from February to May.
        On top of that, we know the administration is not only
    opposed--or supportive, I should say, of the case in the
    Supreme Court to repeal and, I would argue, destroy the
    Affordable Care Act, but it just filed, the administration did,
    an 82-page brief indicating support for repealing the ACA.
        I think at a time like this, that is unconscionable, and I
    think there are more words that can be used to describe it.
        I have got two bills that I think speak to this. One is a
    bill that would automatically be matching dollars the Federal
    Government pays for help for States with Medicaid, and it would
    match--it would connect, I should say, those dollars to the
    States' unemployment level, so that Federal aid would be
    adjusted based upon the State's economic condition and protect
    coverage, and it has wide support.
        Mr. Jones, I will start with you, not only because you are
    a Pittsburgher, but that certainly helps.
        Can you explain, Mr. Jones, in your experience, the work
    you have done in Pittsburgh and in Ohio? Can you explain the
    role that Medicaid and the Affordable Care Act has played in
    insuring that people, including older adults of color, that
    they have the care that they need? That is question one.
        Question two is, What would be the implication for
    communities of color if these programs were in jeopardy?
        Mr. Jones. First of all, thank you for the question,
    Senator Casey.
        Medicaid is critical. Before COVID times, 20 percent of
    Pennsylvanians received coverage through Medicaid. However,
    that is not all who benefit from Medicaid. One in three
    children in our State also benefited. Two-thirds of all nursing
    home residents in Pennsylvania benefit from Medicaid, and two
    in five people with disabilities depend on Medicaid in our
    State.
        I mentioned in my testimony that at my own organization, 57
    percent of our patients are at or below 100 percent of poverty,
    and 86 percent of our patients are at or below 200 percent of
    poverty. Nearly every patient we treat, 77 percent of whom are
    people of color, is eligible for Medicaid or subsidies to the
    marketplace to help with coverage.
        Back during the recession, people lost their coverage
    through their employer. Medicaid was there to help, and that is
    the reason we have it.
        In 2008 and 2009, what we saw then is going to be
    reflecting of what we see now if things do not change. I do not
    think it should take an act of Congress to make sure that
    States that can respond to the need. I do not think that States
    should be allowed to cut Medicaid just when we need it.
        I would like to thank you for introducing legislation that
    will protect Medicaid coverage for individuals and families and
    ensure Pennsylvania by extension, community health centers like
    East Liberty Family Health Care Center continue to have
    resources to meet the need.
        As far as the Affordable Care Act is concerned, that
    expanded Medicaid has given people the opportunity to seek
    health care as a preventative measure, not just when there is
    an acute condition. People forget about the fact that an ounce
    of prevention is worth a pound of cure, and we do not focus as
    much on prevention as we should.
        The group of people that are overrepresented in this area
    are blacks and Hispanics. Expanded Medicaid also produces
    economic benefits for both the individuals and cover society as
    a whole, but what are the implications if this were to go away?
        You know, let me just say human lives matter. The
    implications are that human beings will not be able to get
    affordable health care, and from a business perspective or
    economic perspective, that is going to be a significant cost.
    There is a significant human cost and a significant financial
    cost.
        Senator Casey. Thank you.
        Thank you, Chairman Collins.
        The Chairman. Thank you.
        Senator Burr?
        Senator Burr. Thank you, Madam Chairman.
        This first question is for Gene Woods. Gene, your success
    in Charlotte is, in large part, your health system's reliance
    on the data helping in real time to direct the care provided
    both to patients and to the broader Charlotte community. What
    are some of the key metrics that provided early warning signs
    of the disproportionate impact of the pandemic on minority
    populations in Charlotte?
        Mr. Woods. Thank you, Senator, for the question, because of
    the nature of our organization, we have our own internal
    scientists and data specialists, and early on, we were trying
    to make sense of where exactly this disease was growing.
        What we have, geospatial hotspotting analytics that allowed
    us to really focus on mostly the six ZIP codes in Charlotte
    that we were finding out that had disproportionate incidence of
    COVID, and also, we realized early on that they did not have
    adequate testing, so that went to my opening statement.
        In a matter of three days when we saw that data, because it
    is about action, not just about data, we had two roving vans,
    and we went directly to those communities.
        To the earlier comment, the reason where we knew where to
    go is really working with the faith community and working with
    community leaders. We worked, engaged with the Hispanic
    community on an initiative called ``Para Tu Salud,'' for Your
    Health, and so we engaged people in the community to really
    help us with that.
        Some of the data early on was a bit noisy, and we were
    trying to get data from all kinds of sources initially and we
    realized we have to do that internally. We refined our ability
    not just to pinpoint what communities need our care, but also
    this data was important to analyze our staffing needs, our PPE
    needs, and so forth, so this analytical capability also we
    provided to the public health department here in Charlotte. One
    of the recommendations we would have is there is organizations
    like ours that have the capabilities and the expertise to do
    this by ourselves, but there are many communities throughout
    the country that do not have that, so we would encourage an
    investment in public health with respect to analytical
    capabilities. As I said, we were providing that data to public
    health versus the other way around, but it is critical to be
    able to manage this going forward, to have that type of
    capability to really respond to communities in need.
        Senator Burr. Thank you, Gene.
        My second question is to Ms. Carnethon. North Carolina has
    been reporting facility-level COVID-19 data for nursing homes
    and other congregate living facilities throughout the whole in
    coronavirus responses. What information or metrics would be
    most useful for researchers to study the impact of the outbreak
    in nursing homes and other congregate settings?
        Dr. Carnethon. Thank you for that question.
        The burden of COVID-19 in nursing homes emerged very early
    on as a significant problem that we are facing. As I described
    in my testimony, we know that nursing homes with a higher
    proportion of black and Latinx residents have higher death
    rates.
        However, there is not universal reporting of the race and
    ethnicity of those individuals within nursing homes who have
    been affected by COVID, and that presents for us a significant
    challenge when it comes to targeting resources in order to
    prevent the transmission of COVID, because when COVID-19 enters
    a nursing home, it is because somebody has brought it in, a
    care provider, a loved one, and really what it is telling us,
    that if those nursing homes are following the same safety
    procedures of restricting visitors, of ensuring that providers
    have clean PPE every time they are coming in, then we should
    not see these disparities; however, we do, and the likelihood
    that leads to disparities in rates of COVID infections within
    nursing homes are going to occur are going to be even higher in
    communities with a higher burden of COVID-19.
        What we are seeing in the nursing homes is really a
    snapshot of what is going on in a community, and so we really
    need the data coming out of the nursing homes on who, on the
    sociodemographic characteristics of who is contracting COVID in
    order for us to stop this transmission and prevent these
    disparities.
        Senator Burr. Just to clarify, have the disparity in
    congregate setting outbreaks been similar or different from
    what you are seeing in the broader population?
        Dr. Carnethon. The disparities in congregate care settings
    are quite similar to what we are seeing in the broader
    population; however, I will offer the caveat that at community-
    dwelling older adults, the disparities tend to be smaller than
    they are younger ages, and the disparities that we see in
    younger ages are likely due to a higher burden of earlier onset
    cardiovascular diseases, kidney diseases, and diabetes.
        By the time we have older adults living in communities,
    those rates tend to even out a little bit more; however, the
    intensity of the disparity is still significantly higher in
    congregate care settings, two to five times higher for black
    and Latinx residents than for white congregate care residents.
        Senator Burr. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Thank you.
        Senator Blumenthal?
        Senator Blumenthal. Thank you, Chairman Collins. Thank you,
    Senator Casey, to both of you, for having this hearing on such
    a critically important topic, and it could not be more timely.
        Like many of my colleagues, over the last few weeks in
    Connecticut, I have been to a number of demonstrations,
    peaceful and passionate, and more than seventeen myself all
    across the State. I have been so inspired and impressed by the
    cries for justice not only in policing but also in housing,
    education, health care, maternal mortality, addressing the
    disparity that exists in so many areas of health care.
        In Connecticut, black and Latinx residents are more than
    three times as likely to have tested positive for COVID-19 as
    white people, and black residents are more than two and a half
    times as likely to have died from the disease as white people.
    Latinx people are more than one and a half times as likely, and
    just one last statistic, almost 60 to 70 percent of all our
    deaths from this insidious disease have occurred in nursing
    homes, so if you are older and you are black or Latinx, this
    disease has a target on your back, not one that you have
    created, but one that has results from lack of proper health
    care, housing, maybe education, and that is a kind of injustice
    that this Nation must overcome.
        I thank all of the witnesses for your testimony, and I want
    to begin by asking Dr. Carnethon. You mentioned in your
    testimony the lack of trust and rapport that must be overcome
    if vaccines are to be effective. What specifically would you
    recommend doing to overcome lack of trust and rapport?
        Dr. Carnethon. Yes. There is an historic lack of trust in
    the health care system going back to the days of the Tuskegee
    syphilis experiment, which is cited most often, and even more
    recently, there is evidence to suggest that non-white
    minorities are not receiving the same evidence-based care in
    certain settings as non-Hispanic whites, so building trust,
    what my colleagues who are working most heavily in this space--
    and I believe Dr. Mack can likely speak to this as well--
    building trust involves spending time with the community,
    ensuring that we are explaining the why along with the how of
    what we are doing to community members, and most of all,
    spending time to listen to members of the community so that we
    are addressing their needs as well as our own.
        What we really need to do is put ourselves in the shoes of
    community members to try to understand what those barriers are
    to wanting to engage in preventive health behaviors, to wanting
    to accept these vaccines.
        Senator Blumenthal. Thank you.
        I want to focus, Dr. Jones, on an issue that I think is
    tremendously important to our Federally Qualified Health
    Centers.
        I visited with our seventeen Federally Qualified Health
    Centers in a call on Friday, and I have visited physically
    almost all of them over the last couple of years, and I know
    how critical they are.
        In fact, you mentioned that 77 percent of the patients you
    care for are from racial or ethnic minorities. In Connecticut,
    we have 17 of those kinds of centers, and the numbers are
    almost the same. Nearly 75 percent of Connecticut community
    health center patients are from racial or ethnic minority.
        The HEROES Act was passed by the House not that long ago,
    with an additional $7.6 billion in emergency funding for
    community health centers. It is month later, but we still have
    not voted on it. It is a critical bill.
        Can you tell us how those additional resources would be
    used by your health centers and others?
        Mr. Jones. Sure. Thank you for the question.
        I hear people talking about building trust and how do we
    reach people. I am proud to represent over 1,400 FQHCs across
    120,000 sites across the country. That is who we are, and that
    is what we do. The trust is there.
        Our focus is just a safety net for the uninsured,
    underinsured, and underserved. I think that FQHCs need to be
    more involved with getting people into the community. We have
    relationships with community leaders, churches, businesses,
    etc.
        The funding should be set up in such a way that there are
    resources available, so that people can have access to care,
    there is resources available so that everyone has PPE, there is
    resources available so that people can be tested; and there is
    also resources available so that people can find medical homes
    and get preventative care, so the money that we have received
    thus far has been used to keep our staff employed so that we
    can treat this vulnerable population. Without that money, a lot
    of my peers across the country would have had to downsize, and
    the amount of care that we would have been able to deliver
    would have been significantly less.
        Senator Blumenthal. Thank you, Mr. Jones.
        Mr. Jones. One last thing, people respond to people that
    look like them, and the idea of being comfortable with people
    that look like me and understand me is significant.
        Thank you.
        Senator Blumenthal. Thank you very much.
        Thank you, Madam Chair.
        The Chairman. Thank you.
        I am uncertain whether Tim Scott has returned yet, and it
    looks like he has been a bit delayed. We will next call on Josh
    Hawley.
        Senator Hawley. Thank you. Thank you, Madam Chair, and
    thank you for holding this hearing today. I also want to thank
    the Ranking Member for his participation and help in setting
    this hearing up. Thanks to all of the witnesses here for your
    testimonies.
        Like other regions, my home State of Missouri has seen and
    continues to seen disproportionate rates of infection and death
    among our seniors and also among communities of color, and this
    is a tragic reality that merits attention by Congress and
    action by Congress, and so I want to thank again Madam
    Chairwoman and the Ranking Member for holding this hearing.
        Mr. Jones, I would just like to come back to a question
    that Senator Blumenthal was just asking you a moment ago about
    community health centers. The CARES Act provided--I believe it
    is $127 billion supplemental funding for public health and
    social services emergencies, including funding for community
    health centers.
        In April, I asked Secretary Azar at HHS to prioritize
    funding for community health centers in my home State of
    Missouri, and I did this after speaking with representatives of
    the health care community, pastors, and others who emphasized
    to me the vitally important role that community health centers
    can play in meeting the needs of underserved communities that
    are being disproportionately affected by this virus.
        I just wanted to give you the opportunity to expand on the
    line of answers that you started with Senator Blumenthal a
    moment ago. Could you just tell us more about why community
    health centers play such a important role and what they can do
    in helping to address some of the needs that we are seeing
    here, some of the unique needs faced by older Americans and
    historically underserved communities?
        Go ahead.
        Mr. Jones. Thank you for the question.
        It centers around social determinants of health. We have
    been plagued as a race, as human beings, with this overall
    arching concept, and what it simply means is that people are at
    a disadvantage based on housing, education, where they live,
    the environment by which they matriculate.
        The way the funding has helped is the fact that we have
    been able to reduce the barriers by which people can seek
    health care. Most of the health care centers across the country
    run about a 30 to 40 percent no-show, meaning that people are
    scheduled for appointment. They do not call. They do not count.
    They just do not show. More often than not, it is because of
    things they cannot control, also, the other issue that people
    need to think about, people are focusing on living, no life.
    Health care is important, but it is not important if you do not
    have a way to put a roof over your head or to feed your family.
        The thing that has been really important for FQHCs is that
    we have moved from a culture or process of seeing people in our
    health centers to telehealth. Telehealth has been significant
    in this way that we are trying to address the disparities and
    primary health care. We are now able to see people in their own
    homes, able to remove the barriers that have been in place that
    would stop them from seeking health care, so the funding not
    only provides ways to break down the barriers associated with
    social determinants of health, but it allows us to provide
    health care in an environment by which we were not able to do
    before. It also gives us the funding to get into our mobile
    vans and get out into the community and provide the care that
    we need.
        As I said before, let us not forget the fact that this
    pandemic has--and I say this in my testimony. It is a
    flashpoint on the health inequities and also the inequities of
    our overall health care system, that there needs to be a way
    that everyone has access to care, and again, the funding will
    allow us to broaden our scope and to deepen our resources to
    provide the care for people that need it.
        Senator Hawley. Thank you very much for that.
        Let me pick up on the telehealth points that you mentioned
    just now and that you also mentioned in your written testimony
    and about how vital that can be, telehealth can be, to
    expanding health care access during the pandemic, this
    pandemic, and in general.
        Of course, one of the things we know, however, is that many
    elderly, low-income, communities of color, rural communities
    have significant barriers to accessing telehealth, and this is
    certainly true in my own State where we have a very significant
    rural population and where all of those things are true.
        Tell me a little bit about how you have addressed concerns
    related to technology access and what more you think we can do
    to improve that so we can improve this vital tool.
        Mr. Jones. Sure. Back when I was a young child, I used to
    laugh because our doctor used to carry a little black bag and
    actually walk up and down our street and see people in their
    homes.
        We have a division in our organization called Homebound
    Outreach. Our Homebound Outreach, we have nurses that we send
    into the community, and they see people who for whatever reason
    cannot come into our health center, and also they are the eyes
    and ears of our providers, so one of the things we have done to
    those people that do not have the technology, we send the nurse
    into the home, and we use the technology of our laptops to
    communicate with our providers in the office.
        I know at our particular health center and I know my peers
    in western Pennsylvania, we have applied for funding so we can
    get technology into the home of the aged and the feeble, so
    they have the opportunity to turn on a computer to be able to
    see what is going on. That is only half the battle because the
    technology is still a challenge, so there needs to be staffing.
    There needs to be community Ambassadors. They do not have to be
    medical people. They have the ability to get into the community
    and get into the homes with people that need care. It could be
    a very inexpensive proposition. They are not the highest-paid
    people, and they can be the ears and eyes of providers to
    provide timely care, which again we are doing that on a small
    scale at our health center. We plan to expand that as we
    continue to identify the needs.
        Senator Hawley. Well, thank you very much, Mr. Jones.
    Thanks for the tremendous work you are doing. Thanks to the
    other witnesses for being here, and I will have a few questions
    for you in the record.
        Thank you, Madam Chair.
        The Chairman. Thank you.
        Senator Warren?
        Senator Warren. Thank you very much, Madam Chair, and t
    hank you very much for putting together this hearing. Seniors
    are bearing the brunt of the COVID-19 pandemic. People over 65
    account for just 18 percent of coronavirus infections, but they
    make up 80 percent of the deaths.
        Nursing homes, where 1.3 million seniors live, have emerged
    as hotspots of infection, and systemic racism has put seniors
    of color at even greater risk of catching and dying from COVID-
    19. We are nowhere near controlling this pandemic.
        Public health officials are reporting tens of thousands of
    new cases and hundreds of deaths every day. Congress must act
    fast, really fast, to protect our seniors and contain this
    virus. We need to ramp up testing. We need to create a national
    contact tracing program. We need to stabilize our supply chain,
    and we need better data to ensure that communities of color are
    getting the COVID-19 resources that they need.
        Let me start with you, Mr. Woods. In your testimony, you
    talk about how Atrium Health developed a COVID-19 dashboard to
    track cases and deaths in real time. All of this data was
    stratified by race and ethnicity as well as additional factors
    like geography, so, Mr. Woods, what did the data reveal about
    how communities of color were experiencing the COVID-19
    pandemic?
        Mr. Woods. Thank you for the question, Senator, and for
    your leadership in this regard.
        I think, quickly, we realize--and some of what the
    testimony of some of the other panelists is those social
    determinants of health have--the cracks have been laid bare.
    The issues of lack of access to food, lack of access to health
    care, all of those in these communities, we found that they
    were magnified during this COVID pandemic, so I think what we
    are realizing is that it is years of lack of investment in core
    communities, the things we have talked about, affordable
    housing. We have invested $10 million in affordable housing
    before this pandemic because we knew if you do not have a warm
    place and a warm home, you are not going to be healthy.
        We have fed about 10,000 kids through our Kids Eat Free
    program because we realize that if you do not have food, you
    cannot be healthy, so I think it has just magnified the social
    and economic and health care disparities that we have known for
    a long time, and we have been fortunate to have been part of a
    coalition to help address that straight on.
        Senator Warren. I really do appreciate your work in this,
    and what I am hearing you say is the demographic data you
    collected showed that communities of color face barriers and
    accessing COVID-19 resources and then the responses, so let me
    just followup with this, though, Mr. Woods. It is one thing to
    detect disparities, but it is another to actually tackle them.
    Did the data allow you to actually reduce racial inequity in
    your coronavirus response?
        Mr. Woods. We did, and as I mentioned in my testimony,
    because we have the unique ability to run our own internal
    COVID tests, we were able to launch very quickly when we saw
    this data and the six different ZIP codes in Charlotte area. We
    were able to work with the churches, work with Hispanic
    community, and we said rather than you come to us, we have nine
    fixed testing sites. Let us go to you, but we do not want to
    assume we know where to go, so please tell us where it is, so
    we were in church parking lots. We were at YMCA parking lots,
    and we also--it was mentioned earlier. The one thing I want to
    focus on as much as anything, we have invested this past year,
    $7 million just on interpretive and language services. We know
    that, for example, that is a really important part of reaching
    this community, so it is not just taking the data, going to
    where the communities or needs are, but really making sure we
    had the language to be able to speak to people on their terms.
        Senator Warren. Right, so in other words, by collecting
    detailed demographic data, you could develop a targeted data-
    driven response to COVID-19 and send resources where they were
    most needed and send the appropriate kind of resources to those
    places, so from the outset of this pandemic, the Trump
    administration should have collected demographic data to guide
    its COVID-19 response, but it did not, so instead, my
    colleagues and I have spent months pushing HHS to publicly
    report race and ethnicity data, and in the end, we had to force
    HHS to issue a report on COVID-19 racial disparities.
        Still, only 55 percent of cases reported to CDC to date
    include information on race and ethnicity, so let me ask it a
    different way, Mr. Woods. Without up-to-date, comprehensive
    demographic data about COVID-19, do you believe that the
    Federal Government will be able to craft a pandemic response
    that provides communities of color with the resources that they
    need?
        Mr. Woods. What I can do is speak from our experience.
    Without the data that we had to respond to this community in
    real time--our data is updated actually every 2 hours. We know
    exactly where the disparities are, where the incidents of
    COVID. We have a map that I look at every single day in terms
    of how it is spreading, so from our experience, without that
    data, without that real-time data, it is really difficult to
    contain and ultimately eliminate the COVID.
        Senator Warren. That is really important, so it is part of
    the reason why I am still fighting for comprehensive
    coronavirus data.
        Just last week, Ranking Member Casey and I asked HHS to
    report demographic data on residents and workers in nursing
    homes to better track COVID-19 infections and better track
    deaths among seniors. We need to put the public health impacts
    of systemic racism at the very heart of the CDC's work--and I
    am working on legislation to do this--in this pandemic and
    beyond.
        If the Trump administration does not start taking this
    virus seriously, tens of thousands more Americans will die, and
    a disproportionate number of those seniors will be people of
    color. That outcome is unacceptable. Congress must act.
        Thank you, Madam Chair.
        The Chairman. Thank you.
        Senator Braun?
        Senator Braun. Thank you, Madam Chair.
        This is just another topic regarding health care. I have
    spent so much time on the issue prior to becoming a Senator,
    and social determinants, underlying issues with chronic
    conditions as well as how minorities are being treated through
    an epidemic like this, to me, still begs the question of what
    is wrong with our health care system before we got to this
    junction.
        In my opinion--I am going to ask the question of Mr. Woods
    and Mr. Jones. Our issue with health care when it comes to
    access, to covering preexisting conditions, no caps on
    coverage, all the things, 80 Senators weighed in prior to COVID
    coming along are still there, and to me, the number one issue--
    it has been referred to as the ``tapeworm on our economy''--is
    the high cost of health care. Eighteen to 19 percent of our GDP
    here in this country and, of course, nearly half that in 20 to
    25 other countries with results that are as good as ours, so,
    to me, in my own business in trying to tackle this 12 years
    ago, until I engaged the individual in his or her own well-
    being and tried to provide transparency, so you could see what
    things cost, whatever we decide to do here, whatever we can
    accomplish through the Federal Government to maybe look at
    disparities, we still get back to the same old system. It is
    dysfunctional. It is run increasingly by large corporations
    that have no interest in fixing the system.
        I want to ask you this. Transparency. President Trump, by
    the way, has been the most aggressive individual in trying to
    reform certain dysfunctional parts of our health care system.
    Every time it occurs, it lands up in the courts because the
    industry takes him to court.
        We here as Senators, I think, tiptoe around the industry
    too often.
        What about basic reforms to actually not only address
    issues like we are talking about here, like transparency? What
    value would transparency give us?
        The hospitals recently took the President to Court on a
    directive to where he wanted to make the charge masters
    transparent. Now I think it has been overturned by a judge.
    Thank goodness, we are making headway.
        The question is directed to Mr. Woods. Do you believe
    transparency would be the tool to not only fixing health care
    in general, but also to help us better navigate through a
    disaster like a microorganism that is confronting us now?
        Mr. Woods. Thank you, Senator, for the question.
        I think transparency is certainly one of the solutions, and
    we are like other health systems that have provided charges
    online, so I think that is one avenue, but I think,
    fundamentally, the issues that we deal with, at least in our
    communities as a safety net provider, go back to some of the
    things that were alluded to earlier. We are the safety net
    provide for the entire State of North Carolina. We see more
    Medicaid, more compensated than anyone else in the State, and
    so I think we still--there is a lot of opportunities to
    continue to fix health care and through the health system lens.
        We have got to come together to deal with some of these,
    which was referred to earlier, some of the social determinants
    of health that really are being magnified in this crisis. The
    lack of affordable housing, that is fundamental to dealing with
    the health care cost and crisis in this community, because
    ultimately, these patients are showing up in our facilities, so
    I think it is a multifactorial equation that we have to solve.
    Transparency is certainly part of it, but there is a lot of
    other pieces, I think, that needs to be addressed and the one
    thing that I would just suggest is that these things can only
    be addressed through private-public partnerships, such as the
    one that I just mentioned earlier; for example, for masking,
    where we have big business and also health systems working
    together and I think working together with the health
    department, so I think it is a complex equation. The President
    said health care is complicated. I certainly agree with him.
    Transparency is one of many ways to help address those.
        Senator Braun. Imagine the dividend we would get from
    saving that we could invest in some of the other things you
    were talking about.
        Mr. Jones, would you briefly comment on it as well? My time
    is about up, but please tell me what you think.
        Mr. Jones. Sure. Transparency is only part of it.
        It is under the broad umbrella of socioeconomic status. As
    I mentioned before, this pandemic has served as a flashpoint,
    but the bigger picture is we have to get fundamentally into the
    situation of why is there disparity. It all has to do with
    education, neighborhood, housing, social supports, access to
    health care.
        The broader picture is we need to take care of this
    pandemic. It needs to be a Federal global approach, but once we
    get on the other side of this, we need to peel it all the way
    back and get to the root of what the issues are and, again, it
    is about people not having equity and equality in accessing
    jobs, education, and health care.
        Senator Braun. Thank you so much.
        The Chairman. Thank you, Senator.
        Senator Jones?
        Senator Jones. Thank you, Madam Chairman, and thank you,
    Ranking Member Casey, for holding this really important
    hearing. This is especially, I think, significant in all of our
    States, but I have been acutely aware of the problems in
    Alabama.
        You know, Mr. Woods, I would like to kind of followup with
    you initially about some--Senator Casey made some comments
    about Medicaid.
        You practice. You have got hospitals, I think, in both
    North Carolina and Georgia, and like Alabama, those States did
    not expand Medicaid. You are one of the largest providers of
    Medicaid services.
        Every study that I have seen has indicated that health
    outcomes are raised in States that have expanded Medicaid, but
    yet we still seem to have a great deal of political pushback on
    Medicaid expansion, not only in our States, but also in the
    Congress. We have got billions of Federal dollars that we are
    putting into every State right now that deal with this
    pandemic, and it only makes sense to me that we try to do that
    in a way to give States the incentives to expand Medicaid.
        We have made a lot of strides. The Commonwealth Foundation
    indicated that black working-age adults across the country have
    greatly benefited from Medicaid expansion, and there is a huge
    proportion of those folks that reside in our State, so I would
    like to ask you about Medicaid expansion and the benefit that
    the population that you serve, how it would benefit, how it
    would improve your hospitals if we can go forward and try to
    get something in this next package to give States the
    incentives to expand Medicaid.
        Mr. Woods. Thank you for the question, Senator Jones.
        One real live example of what we are seeing, especially
    during this COVID, is one out of five Americans have behavioral
    health issues, dealing with mental health issues, and we are
    seeing our outreach, especially right now with behavioral
    health, has magnified significantly.
        One of the things that Medicaid expansion would do is
    provide additional funding for care of mentally ill patients. I
    think that is just one example that were we to have that
    coverage now, we would be able to expand our efforts
    significantly.
        The other thing I would just say, as a safety net provider,
    as I alluded to earlier, if you look at we never turn anyone
    away, irrespective of ability to pay, right now we probably
    cover about 2 cents for every dollar of cost that we have for
    someone who is uninsured. Medicaid expansion would probably
    increase that to about 11 or 12 cents, and what do we do with
    those additional funding as we continue to reinvest in the
    community through skilled nursing facilities, through outreach
    to minority communities, etc.
        It is important, I think, to continue to explore Medicaid
    expansion in States like ours because I think it will help the
    community be healthy.
        Senator Jones. Great. Well, thank you very much. I
    completely agree with you about the mental health aspect of
    this. I think folks often forget as we focus so much on this
    virus right now that I think a lot of the mental health
    outcomes or mental health issues are going to be with us for a
    long time based on this virus.
        Dr. Mack, let me ask you a little bit about Morehouse.
    Since coming to the Senate, I have been a pretty strong
    advocate for additional funds for HBCUs. We got additional
    funds for the first 2 years, and then we were able to get some
    permanent funding.
        In the CARES package, we had a billion dollars that went to
    HBCUs, and recently, I have joined a letter with my colleagues,
    Senator Harris and Senator Booker, to try to encourage an
    additional $6.5 billion to HBCUs and particularly graduate
    institutions like yours.
        If we could get only a portion of that, how would that
    benefit colleges like Morehouse? How would you use additional
    funds in the middle of this pandemic to help us get out, and
    how would it benefit the college and the communities that you
    serve?
        Dr. Mack. Thank you, sir.
        As I stated earlier, we are on the front lines with these
    communities not only from the experience aspect, but what we
    are doing today with the testing, also with the treatment, and
    also with the push to give vaccinations. If we would have that
    additional funding, it could help us educate and train
    providers and MDs who actually work within the underserved
    communities.
        At Morehouse School of Medicine, almost 50 percent of our
    graduates actually work in the State of Georgia. The State of
    Georgia is mostly a rural place, so our graduates actually go
    into these underserved communities of multi-cultures and
    actually work in those communities.
        I think it would benefit from a training perspective,
    benefits when it comes to scholarships, to provide training for
    the students, but also the care that we provide on the
    frontline.
        As you stated, quickly, I would like to say about the
    insurance around COVID today. The lines are longer in those
    communities that are uninsured or underinsured, and also the
    testing sites happen not to be in those underserved
    communities, so it is really affecting us today when it comes
    to access to care, so it could help us in many ways.
        Senator Jones. Great. Well, thank you all for being here
    with us today. Thank you for the work you are doing in all of
    this.
        Thank you, Madam Chair, for this hearing, the important
    hearing today. Thank you.
        The Chairman. Thank you.
        Senator Tim Scott?
        Senator Tim Scott. Good morning, Chairwoman, and thank you
    for all your hard work and dedication on so many of these
    issues that are important to the Nation. Frankly, you have been
    the leading voice in our Congress and, I mean, either the House
    or the Senate, so in our Congress for issues around disparity
    and around taking care of people who simply need help. You have
    been the type of chair who looks only at Americans, not at
    parties, not at color, but at people in need, so thank you for
    being that kind of chairman, and I really appreciate your
    leadership.
        Let me just say this. As we have looked at the numbers in
    South Carolina, 27 percent of the population happens to be
    black. About 43 percent of the fatalities are African American.
    Thirty-two percent of the diagnoses are. Those numbers were
    alarming to me initially, and as I looked around the country, I
    found that 14 percent of Michiganders are African American, but
    41 percent of the mortality were black.
        I started realizing that there seems to be a racial impact,
    and I asked HHS to step up and start giving us more information
    broken down by racial categories, and they did that. I asked my
    Governor to do the same thing, and he did that, so we were able
    to then start targeting more of our energy and our focus on
    these health care outcomes and disparities, number one. Number
    two, as I spoke with NIH, Dr. Collins started talking about the
    importance of programs like the RADx, so we could put more
    resources, more testing in communities.
        Frankly, I pushed my Governor and our health care apparatus
    in South Carolina. I am so thankful that they responded so
    constructively and positively. We have had pop-up sites for
    testing at churches and at schools in minority communities.
    These are really important.
        One of the things that I see as headwinds is that even with
    all of the new ground that we are making up--and there is a
    whole lot of ground to make up--that when you look at the
    confidence within our communities, particularly the communities
    of color, as it relates to taking a vaccine, 25 percent of
    African Americans say they are willing to take the vaccine, 37
    percent of Hispanics.
        To the panel, what can we do to increase those numbers?
        Mr. Jones. I would like to take a stab at that, Senator.
        Senator Tim Scott. Thank you, Mr. Jones.
        Mr. Jones. Again, the issue has to do with trust, and you
    do not start trust during a pandemic. The trust starts way
    before then, and I needs to give a shout out to FQHCs. That is
    who we are; that is what we do. We are in the communities.
    People trust us. People come see us. They are treated with
    dignity and respect. It does not matter if they have insurance
    or they do not have insurance, so the way we can do that is
    identify agencies, organizations, and churches that people
    trust. Once you get the trust, then you can start the
    conversation of convincing people the value of getting the
    things that they need to have.
        Senator Tim Scott. Thank you, Mr. Jones.
        Dr. Carnethon. I would like to follow with that. This is
    Dr. Carnethon.
        We right now are working through a cross-NIH initiative led
    by NHLDI as well as NIMHD, minority health and health
    disparities, because we understand. Certainly, as Dr. Jones has
    stated, it would have been ideal to start sooner; however, we
    have to start now and we have to get out there. We have got to
    build these bridges, and I think what is going to be critical
    is to communicate the urgency and also to really empower
    community members to understand that they have to be the ones
    to step up to help us stop the impact that we are having on
    minority communities, so what I would really like to do with
    our messaging is really promote this partnership that we have
    to step up in order to help ourselves.
        Senator Tim Scott. Let me just make this comment before I
    hear from other panelists.
        On the Paycheck Protection Program, one of the things that
    I saw as a small business owner or at least a previous small
    business owner was the importance of having a marketing
    mechanism in place, so I went to the Minority Business
    Development Agency, the MBDA, and said, ``I am going to put $10
    million in the MBDA so that we have the type of marketing that
    reaches specifically into communities of color and targets the
    outcomes that we are looking for,'' which is higher utilization
    of the PPP.
        What I hear, I would say that I hear the need for something
    similar, and if that is true, where is that similar
    organization? Certainly the churches. I know the HBCUs. I have
    worked with them, and frankly, our office led the charge to get
    more resources for the HBCU in the CARES Act, and frankly,
    according to the UNCF, we have record-breaking dollars coming
    in during the last 3 years, so how do we find those one or two
    organizations that penetrate so deeply that we can have that
    kind of focus?
        Mr. Woods. Senator, this is Gene Woods.
        One thing, I think we just got to recognize that part of
    the issue is after 3 million cases of COVID and 140,000 deaths,
    we still have a fundamental--just a general in the country--50
    percent of people still do not want to get vaccinated.
        If you look at even during flu season, last flu season, we
    had 40 percent of the population that said, ``We are not going
    to get a flu shot.''
        I think the messaging has to occur on multiple levels.
    There should be a national strategy right now, a PR campaign,
    as you mentioned, that touts the benefits of vaccination. I
    think that is layer one, and then with respect to your
    suggestion, what we have done here and in the communities we
    serve is we have partnered with media outlets that specifically
    focus on minority communities. I think there could be a
    national strategy, but there has to be a local strategy as well
    because different outlets have different insights into the
    particular community. I think it has got to be a multi-
    factorial type of campaign, but that begins that vaccinations
    are important as part of containing COVID but also influenza.
        Senator Tim Scott. I would love to talk to you after this
    is over if you have time, 1 day this week. I would love to
    continue this conversation.
        Mr. Woods. Absolutely.
        Senator Tim Scott. Yes, sir.
        Dr. Mack. Senator, if I could say one thing quickly. I
    think we have to stop funding the usual suspects all the time.
    We have to look for new organizations that have deep tentacles
    within the community, and that is the initiative we are doing
    now.
        There are organizations that the community respects as
    leaders. I think we have to partner with those organizations,
    as we have said earlier, and make sure some of the resources
    empower those organizations to do the work and be the lead for
    that work within the community.
        Senator Tim Scott. Thank you, sir.
        I look forward to reaching out to some of the panelists, if
    you all are interested in engaging in this conversation further
    when we are not limited to 5 minutes of questions and answers.
    I read through your backgrounds, and frankly, an incredibly
    impressive group of folks who are dedicating a lot of your life
    to making a difference. I would love to just partner with those
    who may be interested in doing so.
        Thank you.
        The Chairman. Thank you very much, Senator Scott.
        Senator Rosen?
        Senator Rosen. Well, good morning, everyone. Thank you,
    Senator Collins, Ranking Member Casey, for holding this
    important hearing, and of course, like Senator Scott said, for
    the impressive group of panelists. You have spent so much of
    you life and efforts on health care in so many areas and
    particularly this one.
        I want to address the racial health disparities and how we
    can work through education, training, and resources to make
    things better, because racial and ethnic health disparities,
    they persist because of longstanding inequities and working,
    living, health, and social conditions.
        You see the manifestations of such disparities everywhere.
    For example, during COVID-19, data from my home State, the
    Southern Nevada House District, shows that Latinos are dying at
    a higher rate than any other group in the region. In Northern
    Nevada, the Latino population has the highest number of COVID-
    19 patients in Washoe County, even though the Latinos only make
    up a quarter of the county's total population, so, of course,
    we know too often, inadequate access to care, underlying
    biases, both ethnic and racial minorities, and especially
    seniors of color at greater risk of complications due to COVID-
    19 and other diseases as well, so research also suggests that
    provider actions could be influenced by implicit biases, which
    impact the delivery of over all medical care, sometimes without
    medical providers even realizing it.
        I am glad to see that the University of Nevada Reno's
    Sanford Center for Aging is taking the steps to combat the
    impact of implicit racial bias by requiring staff to attend
    trainings on the subject. The Sanford Center is also taking
    steps to review all of its internal policies and the
    gerontology academic program curriculum overall to ensure that
    they include economic, social, and policy content that address
    the impact of racial disparities.
        To Dr. Mack and Dr. Carnethon, as both researchers and
    educators, how can we best train our medical students and, in
    fact, all of our medical professionals to identify and
    understand their own implicit biases, so that they can
    recognize how this contributes to their decisionmaking and
    delivery of care? What types of practices do you think are
    worth us investing in to make the most success?
        Let us start with Dr. Mack, and then we can go to Dr.
    Carnethon, please.
        Dr. Mack. Thank you.
        Well, when we consider the practicing, we have always
    focused on the importance of primary care and the behavioral
    health component that it actually highlights within primary
    care, and that is what we are talking about.
        There is a larger aspect to the training which should
    provide the sensitivity of the student to the total patient and
    the health care of the patient. We realize that only 20 to 25
    percent is contributing to health care, so it is very important
    that we take in consideration those socioeconomic determinants,
    and that includes the bias of physicians, the bias of the
    health system when it comes to treating patients, so that has
    to be put into the curriculum. It has to be expressed and to
    train, whether it is in the ambulatory setting or it is in the
    hospital, and some of that training means we have to train the
    trainers. Educators have to be aware of the biases, and while
    there, the student that is shadowing them, they have to also
    make sure that they are addressing that.
        I think we have to make sure it is in the curriculum, it is
    taught on the wards, but also that the academicians, including
    myself, professors and associates, etc, are aware and are
    properly trained to train the students properly to be aware of
    those biases.
        Senator Rosen. Thank you.
        Dr. Carnethon?
        Dr. Carnethon. Thank you for this opportunity. These are
    discussions that we are actively having right now at our
    medical school about how best to incorporate these critical
    skills and the ways in which we teach our clinicians to treat
    patients and how to interact with them.
        My experience in the educational field suggests that
    experiential learning is one way to really cement the lessons
    that are out there. I think that the ability for medical
    students and training to actually hear directly from patients,
    the ability to hold panels or even invite community members to
    share their experiences, providing recordings so that health
    care providers can hear the very subtle languages, language
    that they may use that does seem to imply that the problem lies
    with the patient.
        Consider the example of managing somebody with diabetes to
    say, ``You need to eat more fresh fruits and vegetables.'' To
    hear directly from a community member about how difficult it is
    for them to access those fresh fruits and vegetables in the
    neighborhoods where they live may help to guide the ways in
    which they hold conversations with patients, so I think this
    content, it should be required, and I think experiential
    learning is an excellent technique in order to train medical
    providers on how to best pay attention to these factors.
        Senator Rosen. Well, thank you. I appreciate that. I do
    agree. The way that we listen and respond and the way that we
    offer advice, all of us can learn from those kinds of
    conversations. I appreciate that.
        Thank you, Senator Collins.
        The Chairman. Thank you.
        Senator Rick Scott?
        Senator Rick Scott. Well, first, I want to thank Senator
    Collins and Ranking Member Casey for holding the hearing. I
    want to thank all the witnesses for being here today.
        This is an unprecedented time in our country. One of my
    concerns has been all along that we do not have enough testing,
    and I have also heard that health insurers are limiting or
    denying coronavirus testing coverage for some of their
    enrollees, which that is clearly unacceptable and dangerous.
        I introduced a bill, the Affordable Coronavirus Testing
    Act, that will make sure every American could have access
    because I think it is going to be hard to get back to a normal
    life if we cannot make sure everybody can get a test that feels
    that need to get a test, and I hope we can get something like
    that done to make sure that happens.
        Mr. Jones, can you talk about how the business of our
    Federally Qualified Health Centers have changed since the
    coronavirus started back in, really, I guess February, but
    early March?
        Mr. Jones. Absolutely. In a word, we went from seeing
    people in our health center to doing telehealth. In my own
    health center, we were seeing, starting in the middle of March,
    about 85 percent of the people we saw was through telehealth,
    and as I mentioned in my statement, it was because we knew the
    practice of social distancing need to protect our patients,
    need to protect our staff, so the best way for us to do that
    was doing it remotely.
        The other way out of this change that we have included in
    our scope of practice testing every day. In addition to
    treating patients the way we normally do--and incidentally,
    when a patient--when a lot of patients come to our health
    center, oftentimes they are coming way beyond the acute stage.
    It is not unusual for a typical patient to have three to five
    comorbidities. They come into the health center for high blood
    pressure, and you find other things.
        That being said, in addition to doing that, we are doing
    our testing, and we are trying to make sure that we get the
    testing back in a reasonable amount of time, so that when you
    start looking at contact tracing, you can figure something out,
    so our whole model has changed significantly. Even though our
    staffs are working, a lot are working remotely because it is
    changed significantly, so we have gone into a space that we are
    not comfortable with, but we have adapted very quickly, and
    amidst to all of this, we have people that are afraid to come
    out of the house. We have people that are afraid to actually
    get tested and people that are still trying to wonder how do I
    get back to normalcy.
        Senator Rick Scott. Have your overall volumes gone down or
    gone up?
        Mr. Jones. They have gone down. There are more in my
    presentation I had to take out because of 5 minutes, but we
    have gone down by approximately 33 percent on the medical side.
    The dental side is nonexistent, because of all of the CDC
    guidelines our dental team is helping doing the testing. They
    are not really seeing patients because it is really unsafe.
    They are only doing emergent cases and a little bit of denture,
    so our volume has gone significantly.
        The PPP has enabled us to keep going and not lose the level
    of care that we have had, so without that funding, we would
    have had a very difficult time having a viable organization to
    address this problem.
        Senator Rick Scott. How are you doing on getting your
    protective gear?
        Mr. Jones. We are fortunate in the western part of the
    State. We partner with various vendors. We collaborate as FQHCs
    in the western part, so we have not had a lot of difficulty
    getting PPEs and really have not had a lot of difficulty
    getting the testing.
        Our difficulty has come in getting the test results. In
    some situations, it has taken 7 to 10 days, so we are working
    feverishly trying to find tests. If we can get the results a
    lot quicker, then we can actually communicate that to people so
    that they will know what to do in order to protect themselves.
        Senator Rick Scott. So you have not had access to any of
    the rapid tests that may not----
        Mr. Jones. It is interesting. I just received an email this
    morning from my supply department saying, ``we are going to be
    getting those tests in like the next week,'' so prior or that,
    we did not have them available to us, no.
        Senator Rick Scott. All right. Well, thank you for what you
    do. In Florida, we have a lot of great Federally Qualified
    Health Centers in Florida, and I know they are a safety net for
    a lot of communities, so thank you for what you do.
        Mr. Woods, can you talk about how you are doing with regard
    to getting protective equipment and gear and how you are doing
    with regard to testing at your facilities?
        Mr. Woods. Thank you for the question, Senator.
        You know, back in March because we were looking at peak, we
    had canceled all of our electives. We actually did it before
    there was any requirement to do so, so, actually, we took that
    time to really reinforce our PPE.
        For the most part, we are in a much better situation than
    obviously we were several months ago. With isolated challenges,
    we have a predominantly female workforce. We need more small
    N95 masks, so that is something. There are some supply items we
    have months of supply for, but that is something that on a
    weekly basis, we make sure that we focus on.
        On testing, I shared earlier we do have our special lab
    equipment, so we can run our own tests. We could probably do
    four times the amount of tests and have close to the same-day
    turnaround. The challenge is reagents, and so some of the--and
    still, in some respects, swabs, so I think we really need to
    continue to beef up the supplies of reagents so that we can
    expedite the testing. That would be our request.
        The other thing--and there has been some conversation on
    testing about a national registry and how that testing and
    those reagents are distributed to hotspots, so I think that is
    something that we are having some conversation, about
    opportunities to do that as well.
        Senator Rick Scott. Hopefully, this will pass, right? What
    will you do differently from the standpoint of making sure you
    have whether it is the issues you are dealing with now, the
    protective equipment, the reagents, the swabs? What are you
    going to do differently in the future to make sure you do not
    have the same problem again?
        Mr. Woods. Yes. Well, we certainly have significantly
    expanded our sources of supplies. A lot of times, you are
    buying in bulk to get savings. Organizations like ours, you do
    that and you get a lot of savings, but we realized that we need
    to have a good diversified supply line, so we have vendors that
    we might have never had before, before COVID, and obviously our
    par levels are where might have been several months now, in
    some respects, extended to a year or beyond, so we have
    invested probably about $45 million or so just to make sure we
    have stockpiles of PPE, because this thing could be with us for
    a while, so those are some of the things that we have been
    focused on.
        Senator Rick Scott. Is your elective surgery coming back?
        Mr. Woods. It is. Probably right now, it is about 85
    percent on some of the elective surgeries. Our inpatient
    surgeries are pretty much pre-COVID levels.
        Where we are seeing some challenges mostly is on the
    emergency room, probably about 70 percent. That concerns us
    because a lot of people that are in their homes, there is a lot
    of studies, as you know, that people are having heart attacks
    at home, and they are afraid of coming into the emergency room.
    We are really focused on our own campaign. We call it our
    COVID-Safe Campaign. We are sharing with the community exactly
    what we are doing to keep people safe.
        The other thing we have, we are doing rapid cycle surveys
    of patients, and so when they come in, so far 95 percent of
    patients have said they felt safe when they come in and for the
    5 percent that have questions, what we do is we take that data
    and rapid cycle improvements to make sure that people feel more
    comfortable, but right now, we are seeing it coming back. Now,
    we will see what happens in the fall when influenza comes, how
    the trends continue then, but right now our focus, our main
    concern is emergency room
        Senator Rick Scott. Well, thank you, each of you, for being
    here, and thank you for what you are doing to take care of
    patients.
        Thank you, Chairman Collins, for putting this together.
        The Chairman. Thank you.
        Senator McSally?
        Senator McSally. Thank you, Chairwoman Collins. Thanks to
    all of you for your expertise during this very unprecedented
    time.
        I first want to echo I am a cosponsor of Rick Scott's bill
    that is focused on testing and ensuring that people can get
    free testing during this once-in-a-century pandemic, and
    insurance companies are not denying that to people where there
    is a financial burden. Hopefully, that is something that
    everybody can agree upon, and we need to get that passed. We
    should just not have finances be a barrier for people getting
    tested.
        I want to talk about the impact of the coronavirus on
    Native American communities. As you have all mentioned,
    underlying health conditions such as diabetes, we know is one
    of the strongest risk factors for COVID-19.
        We also know diabetes is far more prevalent in minority
    communities, and we have 22 Native American Tribes in Arizona.
    They have a greater chance of having type 2 diabetes than any
    other population.
        In fact, in Arizona, the Gila River Indian Community has
    the highest rate of type 2 diabetes in the world, so we have
    established, Congress has established the Special Diabetes
    Program for Indians, the SDPI, in 1997 to provide funds for
    diabetes prevention and treatment services. Through the SDPI
    grant programs, Tribal communities have been able to develop
    much needed diabetes programs and increase access to quality
    diabetic care.
        While this is very popular and effective, it suffered from
    short-term reauthorizations and stagnant funding, which is why
    I introduced legislation along with my colleague from Arizona,
    Senator Sinema, to reauthorize the Special Diabetes Program for
    Indians for an additional 5 years and increase the funding to
    $200 million per year.
        Dr. Carnethon, in the midst of a pandemic where there is a
    multitude of, obviously, health care funding priorities, can
    you talk about the importance of maintaining focus and
    treatment for underlying conditions like diabetes and the
    importance of programs like the SDPI?
        Dr. Carnethon. Absolutely. Thank you so much for bringing
    up this important point.
        Pre-COVID, I spent most of my time on diabetes,
    cardiovascular disease, and lung disease, and these conditions
    are not going away and are the conditions that are leading to
    these adverse health outcomes from COVID-19 exposures.
        One thing that is not going to happen is that COVID is not
    going to magically go away. We are going to be living with
    COVID for a long period of time, and there is no indication
    that the underlying health conditions are going to become less
    problematic for people who are exposed to COVID.
        Using that rationale, we need to continue to support
    research that prevents the development of chronic diseases such
    as diabetes, hypertension, chronic kidney disease, heart
    disease that are predisposing to worse outcomes. We need to
    provide strategies for managing those conditions.
        In my testimony, I mentioned the use of telehealth and
    telemedicine, particularly via video. I think this is critical
    because older adults may find themselves skipping their
    maintenance visits, and the opportunity to be on a call or,
    better yet, a video call with their physicians to make sure
    that they are managing their chronic conditions is going to be
    critical throughout this so that we can protect them from
    developing the worst outcomes, so I think the work that you
    have done so far to provide support for these resources,
    particularly in Native communities who are suffering mightily,
    definitely needs to continue.
        Senator McSally. Thanks, Dr. Carnethon. That actually
    brings up a follow-on for me.
        I have legislation with Senator Doug Jones, also on this
    Committee, about medical monitoring, especially for rural
    communities, so it is not just the telehealth It is the actual
    medical monitoring. If you have continuous glucose monitoring
    and things like that, you can transmit that information without
    having to take transportation long distances to get to the
    doctor, so how important is the medical monitoring as well as
    the telehealth?
        Dr. Carnethon. I think the medical monitoring is critical,
    and you bring this up at a time when we are working to adapt
    our research programs to use Bluetooth-enabled devices, so that
    we can have blood pressure measurements sent regularly to a
    physicians, glucose monitors sent regularly to treating
    physicians and clinicians, so that we can monitor. I mean, it
    has always been a wonderful strategy for those in rural areas
    who are far away from health care providers to be able to track
    more regularly, and these are critical things that need to
    happen, but in addition to making the technology available,
    ``If you build it, they will come,'' is not enough. We need to
    leverage people who can go out and teach our older adults to
    use it. I have gotten a number of Zoom explanation with my
    family members, and I know that people need help with these
    technologies and even how to set them up, but all of that is
    really critical to making sure that we can keep the population
    as healthy as possible.
        Senator McSally. Great. Thanks.
        Madam Chair, before I forget, the Navajo Nation has
    submitted a statement on the COVID-19 impacts for Navajo elders
    in particular. I would like to submit this to the record.
        The Chairman. Without objection. Thank you.
        Senator McSally. Thank you.
        I want to shift to Arizona that has a growing Hispanic
    population. According to the American Psychological Association
    and National Survey looked at people 70 years and older. Forty-
    four percent of Latinos received home-based family caregivers
    compared to 25 percent of non-Hispanic whites, and epic
    differences were found among those with regard to the care
    recipient. Among those age 70 and older who required care,
    whites are more likely to receive help from spouses compared to
    Hispanics more likely to receive help from their adult
    children.
        The instance of the adult children being caregivers for
    more likely for the Hispanic population, we know anyone who is
    a caregiver, you are also taking time off from your job to care
    for your loved one. That impacts your livelihood and support
    for your own family.
        Dr. Mack, can you talk about just these issues with
    caregivers specifically? What other challenges to minority
    caregivers face and preventative measures we can take to ensure
    the protection of both the caregivers and the elderly?
        Dr. Mack. Yes. Thank you.
        Minority caregivers tend to, of course, have less
    resources, as you know, Unemployment is usually high in those
    communities, less time to take off work, and oftentimes the
    kids are engaged. Sometimes the children are actually missing
    school.
        I think those goes into more resources to not only care for
    the populations in a preventative manner to make sure that they
    do not get sick, but also have those too such as telehealth,
    etc, but also those social programs that help support families,
    whether it is around meals or whether it is around caregivers.
        As you know, today if you are elderly and ability to
    actually go into a nursing home--I have people in my family
    that have Alzheimer's disease. People had to retire early, and
    they are looking for resources because the insurance does not
    pay or we do not have any way to pay for them to put them in a
    personal care home.
        I think, again, we talked about those social determinants.
    The health care system itself cannot take care of those. We
    have to put resources in those areas of prevention but that are
    outside the walls of the facility to support these and not only
    health care services but also social services that the kids can
    continue to be educated, and etc.
        Let me just say this, The Wi-Fi gap, we call it the
    ``homework gap.'' It is also the telehealth gap, so the same
    folks who cannot get the homework, especially during this time,
    they are going to fall behind, so education is an indicator of
    health.
        Senator McSally. Wonderful. Thank you.
        Thank you, Madam Chair, for having this hearing.
        The Chairman. Thank you.
        Senator Sinema?
        Senator Sinema. Well, thank you, Madam Chair and Ranking
    Member, and I want to thank our witnesses for being with us
    today for this critical coronavirus hearing.
        Arizona is currently experiencing one of the worst
    outbreaks in the Nation. Our State is also home to many
    communities are that in high-risk groups. We think they are
    more likely to become severely ill should they contract the
    virus.
        In Arizona, many of our communities of color have been
    disproportionately impacted by the virus, both from a public
    health perspective and an economic one.
        Arizona is home to many groups that are considered high
    risk, including seniors and our Hispanic and Latino communities
    and amongst our Tribal populations. It is clear that
    policymakers must address the existing disparities that exist
    in different communities if we are to effectively combat this
    pandemic.
        My first question is for Dr. Mack, but I welcome everyone's
    thoughts.
        Dr. Mack, I was struck by the part of your testimony that
    called for increased investment in our health care
    infrastructure. Native Americans face increased risk relative
    to COVID-19 and other illnesses in part because some
    communities do not have access to running water for sanitation
    and other basic needs.
        Tribes in Arizona have been particularly hard hit by this
    pandemic. The Navajo Nation at one point had the highest rate
    of coronavirus rates in the country, and nearly 1 in 10
    residents of the White Mountain Apache Tribe have tested
    positive for the virus. These health care challenges exist in
    other underserved communities as well.
        Could you elaborate on how a lack of access to basic
    services like running water and other resources can impact
    public health during a pandemic, especially for vulnerable
    seniors?
        Dr. Mack. Yes. Thank you.
        That is entailed in the conversation about what happens
    outside of the walls of the health facility. That is a
    significant impact to health, and that is why prevention is so
    important and resources for prevention that extend into the
    homes of the Native Americans and other underserved
    populations.
        How much can we save if we provided that water, we provided
    the food assets, if we provided equitable living for those
    communities? That in and of itself--and education and those
    things--improves the health of the population. It has been
    proven. It has been studied, so that is an extension of the
    health system. That is what the health system is called upon to
    do.
        To your point, it is not only testing. It is very
    important, the testing, but the uninsured and those who are on
    Medicaid are standing in longer lines. They are sleeping
    overnight to get tested, and then the test results are coming
    delayed, so, to sum it up, we have to consider to extend health
    into the home and health care into the home and more around
    preventative services in addressing the social determinants of
    the health as opposed to waiting until people get sick before
    we start to take care of them.
        Senator Sinema. Thank you.
        Would any other members of the panel like to respond?
        Mr. Woods. Senator, what I would add is, also, because in
    many of these Native communities, access to basic health
    services is also a big challenge and having to travel. I think
    it does speak to continuing to invest and fund telehealth
    services well beyond this pandemic so that we can reach those
    communities with respect that they are getting the right
    physicians and caregivers into those communities without them
    having to travel sometimes for basic care, so I think that is
    another part of the solution to help those in need in many of
    these Tribal communities.
        Senator Sinema. Thank you.
        Actually, my next question is for you, Mr. Woods. Your
    testimony mentioned different strategies to help break down
    barriers to testing information amongst our communities of
    color. One recommendation was to ensure the availability of
    culturally relevant information and access to language
    interpretation services. I can see how this would be important
    not just for public health information, but also to help
    seniors access other social services or avoid coronavirus-
    related scams.
        That is why I have made it a priority to have my press
    releases and other resources that we share in my office
    translated into Spanish and to work for local community
    organizations to reach more people.
        When it comes to our aging populations, how important is it
    to design coronavirus information services that are both
    culturally relevant and specific to their needs as a member of
    a high-risk population?
        Second, how can culturally relevant information access to
    language services help combat the socialized isolation that
    many seniors in high-risk populations are experiencing when
    they are unable to see family and friends due to the pandemic?
        Mr. Woods. Yes, it is absolutely essential.
        One of the things you mentioned, actually what we are
    finding out, that it is--and I am half Spanish and half African
    American, and what we are finding out is it is actually a
    problem sometimes to translate both English to Spanish, so
    really, when we are writing out our PR and our public service
    communications and speaking, we are really doing it in the
    Native language, so that is one thing I would just add.
        The other thing is class or culturally linguistically
    appropriate services has been a requirement for about 10 years.
    We only have 10 States that provide Medicaid support for that.
    Medicare does not.
        I mentioned earlier we have invested about $7 million this
    past year just on translation and interpretative services.
        Then when we have gone out to these minority communities
    with testing, it was very, very important to have on our mobile
    vans, people that can speak the language.
        I think one of the panelists mentioned that people are
    sometimes more comfortable with others that are caring for them
    that look like them also speak like them is really important.
        I think this is an essential fundamental way of addressing
    this, and I do think providing funding, Medicare and Medicaid
    funding for interpreters and translators, could go a long ways,
    not just for this pandemic, but for dealing with some of the
    things that you brought up, including social determinants of
    health that extend beyond this pandemic in vulnerable
    communities.
        Senator Sinema. Thank you.
        Thank you, Madam Chairman.
        The Chairman. Thank you, Senator.
        We are about to start some votes, but I am hopeful that the
    Ranking Member and I can ask just a couple more quick questions
    before we adjourn the hearing.
        My first one is for Mr. Woods. I have had many health care
    providers in Maine tell me that they are very concerned that
    the delayed and deferred health care screenings and elective
    procedures, which while they are called elective are still
    necessary, will produce downstream effects where people will
    have increased cancers, heart disease, strokes, undiagnosed
    diabetes as a result of the delay of health care during this
    pandemic and it is interesting because researchers found that
    after Hurricane Maria hit Puerto Rico, the leading cause of
    death was due to that interrupted access to health care.
        Similarly, after Hurricane Sandy shutdown the Veterans
    Affairs hospital in Manhattan for 6 months, veterans had worse
    blood pressure control for at least 2 years after reopening
    compared to veterans in Connecticut, whose access was
    uninterrupted.
        For those who are already struggling within equitable
    access to health care in general, how can we ensure that the
    actions taken to defer routine health care do not create a
    second health care crisis downstream?
        Mr. Woods. Senator, thanks for that question, and that
    really is keeping many of the people in my seat awake at night.
        I mean, the lockdown, for example, that we have had in
    different areas has had a large impact on routine screenings,
    mammographies, colonoscopies, and there was a story of a
    senior, a patient who had actually needed hip surgery, put it
    out for 4 months, and the pain that she experienced until she
    was able to get in and be taken care of, so I think it is a
    real concern.
        I think part of the solution comes in inspiring confidence
    both at the health system level, as I alluded earlier, that we
    are doing everything possible to really keep a patient safe
    when they come into our facilities. We are testing staff. We
    are giving PPE to patients as they come in. We are temperature
    checking, and we are doing all the things with cleaning between
    rooms that are taking two and three times longer than we would
    otherwise do, but we are really sharing with the community that
    we are doing everything we can to keep them safe.
        I think also there is an opportunity for policymakers for
    some of the conversations we have had today of testing and
    contact tracing and so forth to give a measure of confidence to
    the communities that we are also doing everything we can to
    keep them safe.
        We share that concern. Every day, we see the manifestations
    of delayed care, and as you indicated, at one time, it might
    have been called ``elective.'' It goes quickly to urgent, then
    to emergent, so we are reaching out to the community through
    many, many different forums to say, ``If you think you have
    elective care needs, come to us. We will help guide you,'' but
    it is that sense of confidence that is important that we
    provide the communities and we are doing everything possible to
    keep them and their loved ones safe.
        The Chairman. Thank you so much.
        My final question is for Dr. Carnethon, and it has to do
    with clinical trials. Making clinical trials more inclusive of
    women and minority groups has been an issue that Senator Warren
    and I worked on and became part of the 21st Century Cures Act,
    but we know that many older black Americans are reticent to
    participate, given past medical exploitations such as the
    misappropriation of cancer cells belonging to Henrietta Lacks,
    for example.
        My question to you, Doctor, is, what recommendations do you
    have to help ensure that clinical trials are more
    representative of those who face the highest risk of COVID-19?
        Dr. Carnethon. Thank you so much for pointing out that
    significant challenge that we face when it comes to making sure
    that the therapies that we develop work for everybody.
        There are cases through our history where we have shown
    that not including women in clinical trials left us with a gap
    in understanding about the biological mechanisms of action of a
    given drug.
        I think we are in a similar--we face the risk of being in a
    similar position here when we talk about vaccine trials for
    managing and preventing the infection, and the ways that we
    have worked to try to engage communities to participate in
    observational research are the partnership strategies that I
    described earlier. I think we need to start that now so that we
    can prime communities to be ready to partner with the medical
    and research establishment so that we can test strategies that
    will protect us.
        I think messaging around a shared sense of responsibility
    to protect ourselves may help to motivate individuals who may
    be reticent to join.
        I think putting forth spaces that the community trusts, the
    faith-based spaces that Dr. Jones mentioned, engaging Federally
    Qualified Health Centers, as well as HBCUs can help to lend a
    bit of understanding and trust.
        Finally, really seeing the investigators behind this work,
    we do have a diverse biomedical workforce. It is not as diverse
    as we would certainly like to have, but there are key
    individuals out there who represent the very communities who
    are the hardest hit.
        I think putting these individuals at the forefront of
    messaging, the shared responsibility that we have to
    participate in science, will help us achieve our goals of
    developing therapies that work for all
        The Chairman. Thank you so much.
        Senator Casey?
        Senator Casey. Thank you, Chairman Collins.
        I just had a quick question for Dr. Carnethon. I know you
    just had a question. I just have one more, and then I know we
    have to wrap up.
        It is on home-and community-based services. We have
    referred to all of the deaths in long-term care settings. Part
    of the answer to getting those deaths down is to have care
    settings that are not congregate, and one of the ways to do
    that, of course, is home-and community-based services.
        I wanted to ask you, Doctor, about explaining how
    additional Medicaid dollars for these home-and community-based
    benefits would be critical for older adults.
        Dr. Carnethon. Yes. I really appreciate that, especially
    your efforts on behalf of shoring up the financial resources
    for these home-and community-based workers because, as you
    point out, keeping seniors in their home can be safer.
    Providing them with opportunities to receive the care that they
    need and maintain their independence is critical.
        I think there are two key issues here. One is the need to
    protect the home care workers. Essentially, they need to have
    the same level of protective equipment that we are providing
    for our health care providers within health care settings. They
    are going from home to home. The last thing we want is for
    those individuals to be transmitting disease from home to home.
        While many professionals within health care settings have
    protection about their income if they happen to be sick or
    unable to work, a number of home-and community-based workers do
    not have those protections, and so their incentive to be
    conservative about symptoms is lowered when if they do not go
    to work, they do not get the care that they need.
        I think those are critical ways in which money can be used
    to protect those individuals.
        Senator Casey. Thank you.
        Thank you, Madam Chair.
        The Chairman. Thank you very much, Senator Casey.
        I want to thank all of our witnesses for joining us today
    and sharing your extraordinary dedication and expertise. I
    particularly appreciated that each of you focus so much on
    recommendations, on practical solutions that we can pursue in
    order to lessen the disparity, the racial disparity in the
    COVID infections and also in general in our health care system.
        This week, the overall death toll in the United States from
    COVID-19 now stands at more than 140,000 deaths. More than 3.7
    million have been infected. Nearly one in three black Americans
    knows someone personally who has died from the coronavirus, far
    exceeding their white counterparts.
        As I have mentioned, it is appalling to me that my State of
    Maine has the worst rate of COVID racial disparities in the
    Nation, and I know that is of concern to the people of Maine
    and to health care providers as well as to the Governor. We
    face many of the same core challenges and risk factors that are
    present throughout the country, how to drive down COVID
    infections among populations where many hold jobs as frontline
    or essential workers who may not be able to easily engage in
    the same level of social distancing as some of their white
    neighbors due to transportation or housing arrangements and
    those who may have cultural or linguistic barriers,
    particularly among our immigrant population.
        I particularly appreciate the suggestions for how to ensure
    that Federal dollars committed to prevent or mitigate COVID
    actually reach all members of our communities as we intend.
        Support for translation and interpreter services, direct
    engagement of trusted community partners, telehealth services
    which we heard a lot about today can enhance that response. For
    seniors who are at the highest risk of severe complications or
    even death, the value of these interventions is even greater.
        I hope that our Committee will continue to work together on
    policies that not only can help change the trajectory of this
    current pandemic but also solve some of the disparities that
    have become so evident during the COVID pandemic.
        Senator Casey, I would like to turn to you for any closing
    remarks.
        Senator Casey. Chairman Collins, thank you for this
    important hearing, and I want to thank, of course, our
    witnesses for their testimonies and the ideas they gave us for
    solutions.
        We know that over the next several weeks, the Senate will
    negotiate legislation to provide help, a measure of help to
    tens of millions of Americans who are suffering from the COVID-
    19 disease and the job crisis. This legislation is an
    opportunity to advance the cause of justice for older Americans
    and communities of color as well as many other Americans.
        This bill should include policies to save the lives of
    nursing home residents and nursing home workers. The bill
    should also guarantee access to affordable quality health care.
    The bill should also recognize and pay the heroes on the front
    lines.
        I hope that we will pass this test that our national
    challenges have presented to us and that we will also pass the
    bill that strives to achieve a measure of justice for our
    seniors in communities of color.
        Thank you.
        The Chairman. Thank you.
        Again, my thanks to all of our witnesses, to the many
    Committee members who participated in today's hearing, and to
    our staff which worked so hard to bring these witnesses to us
    and to put this hearing together.
        Committee members have until Friday, July 31st, to submit
    any additional questions for the record.
        Again, my thanks, and this concludes our hearing. We are
    adjourned.
        [Whereupon, at 11:55 a.m., the Committee was adjourned.]

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                                    APPENDIX

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                          Prepared Witness Statements

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                     Questions and Responses for the Record

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                      Additional Statements for the Record

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