[Senate Hearing 116-534]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 116-534

                        CARING FOR SENIORS AMID
                          THE COVID-19 CRISIS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                              MAY 21, 2020

                               __________

                           Serial No. 116-19

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


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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-030 PDF                 WASHINGTON : 2022                     
          
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                       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

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                                                                   Page

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

                           PANEL OF WITNESSES

Mark J. Mulligan, MD, Director, Division of Infectious Diseases 
  and Immunology, Langone Vaccine Center, Director, Thomas S. 
  Murphy, Sr., Professor, Department of Medicine, New York 
  University Grossman School of Medicine, New York, New York.....     5
R. Tamara Konetzka, Ph.D, Professor of Health Services Research, 
  Department of Health Sciences, University of Chicago, Chicago, 
  Illinois.......................................................     7
Steven H. Landers, MD, MPH, President and CEO, Visiting Nurse 
  Association Health Group, Holmdel, New Jersey..................     9

                                APPENDIX
                      Prepared Witness Statements

Mark J. Mulligan, MD, Director, Division of Infectious Diseases 
  and Immunology, Langone Vaccine Center, Director, Thomas S. 
  Murphy, Sr., Professor, Department of Medicine, New York 
  University Grossman School of Medicine, New York, New York.....    39
R. Tamara Konetzka, Ph.D, Professor of Health Services Research, 
  Department of Health Sciences, University of Chicago, Chicago, 
  Illinois.......................................................    43
Steven H. Landers, MD, MPH, President and CEO, Visiting Nurse 
  Association Health Group, Holmdel, New Jersey..................    55

                        Questions for the Record

Mark J. Mulligan, MD, Director, Division of Infectious Diseases 
  and Immunology, Langone Vaccine Center, Director, Thomas S. 
  Murphy, Sr., Professor, Department of Medicine, New York 
  University Grossman School of Medicine, New York, New York.....    59
R. Tamara Konetzka, Ph.D, Professor of Health Services Research, 
  Department of Health Sciences, University of Chicago, Chicago, 
  Illinois.......................................................    59

                  Additional Statements for the Record

American Seniors Housing Association.............................    63
National Adult Protective Services Association...................    69
Community Living Policy Center...................................    71
Leading Age: VNAA Elevating Home.................................    74
Consortium for Citizens with Disabilities, letter dated May 21, 
  2020, with attachments.........................................    80
The Society for Post-Acute and Long-Term Care Medicine...........    97
Alzheimer's Impact Movement......................................   102
American Association of Service Coordinators, Janice Monks 
  Statement......................................................   105
Service Coorinator Response to COVID-19..........................   109
American Association of Service Coordinators.....................   111
American Health Care Association and The National Center for 
  Assisted Living................................................   114

 
                        CARING FOR SENIORS AMID
                          THE COVID-19 CRISIS

                              ----------                              


                         THURSDAY, MAY 21, 2020

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:33 a.m., via 
Cisco WebEx and in Room 301, Russell Senate Office Building, 
Hon. Susan Collins, Chairman of the Committee, presiding.
    Present: Senators Collins, Tim Scott, McSally, Braun, Rick 
Scott, Casey, Gillibrand, Blumenthal, Warren, Jones, and Rosen.

                 OPENING STATEMENT OF SENATOR 
                   SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The hearing of the Senate Special Committee 
on Aging will come to order.
    Good morning. Welcome to today's hearing on Caring for 
Seniors amid the COVID-19 crisis.
    COVID-19 has brought tremendous hardship and tragedy, 
placing a heavy burden on the frontline workers, straining our 
healthcare and distribution systems, and imposing a deadly toll 
on seniors in particular. It has hit close to home for many on 
this Committee, and I am sure that all of our members want to 
join me in expressing our condolences to Senator Elizabeth 
Warren, who lost her 86-year-old brother to the coronavirus.
    Elizabeth, we are very sorry for your loss.
    Restrictions on visitors to nursing homes have affected 
even those families whose relatives do not have the virus. I 
know two brothers from Bangor, Maine, whose father is in a 
nursing home and has dementia. They have not been able to see 
him for some time now, and his health is failing. They are 
worried that he may not still be alive by the time they are 
allowed to visit him, something that used to happen regularly.
    This virus has already claimed the lives of more than 
90,000 Americans, the vast majority of whom were older adults. 
Adults age 65 years and older are more likely to suffer severe 
complications from COVID-19 and to have more difficult 
recoveries. They represent two out of every five 
hospitalizations and eight out of every ten deaths from the 
virus. Those in nursing homes and other congregate care centers 
are especially at risk. Nationwide, nursing home residents 
represent one-third of all coronavirus deaths.
    In Maine, the toll on nursing home residents is even 
higher. Maine is the oldest State in the Nation by median age, 
and the Centers for Disease Control and Prevention reports 
1,819 cases in our State, and the virus has claimed 73 lives. 
More than half of those deaths have been residents of long-term 
care facilities, so you can see that Maine has an even higher 
death toll in nursing homes and other long-term care facilities 
than the national average.
    Earlier this month, Senator Sinema and I wrote to the 
Administrator for the Centers on Medicare and Medicaid 
outlining a series of recommendations to better protect older 
adults in nursing homes. Among the issues that we urged be 
considered is how long-term care facilities and in-home care 
settings can access adequate testing as well as personal 
protective equipment and how the higher health risks of older 
adults living in nursing homes can be taken into account in the 
distribution plans for any future COVID-19 treatments and 
vaccines.
    New diagnostic tests, therapeutics, and vaccines are moving 
forward at remarkable speeds. I look forward to learning more 
about this research today as well as promising treatments and 
strategies that can speed recovery for the most vulnerable 
populations. Through this and subsequent hearings, I hope that 
we can gain insight into additional actions that may be needed 
to better protect our seniors.
    Congress has already taken a number of actions in response 
to the pandemic. We have passed four legislative packages 
totaling nearly $3 trillion to provide public health support to 
States and economic relief to small businesses and families. 
Phase 1, provided appropriations to supplement the Strategic 
National Stockpile; to develop and purchase diagnostics, 
therapeutics, and vaccines; to support community health 
centers; and to help hospitals and health systems respond. 
Phase 2, provided free coronavirus testing and increased 
Federal funds for Medicaid and other critical safety net 
programs. Phase 3, known as the CARES Act, provided additional 
funding to purchase critical protective equipment and testing 
for the stockpile; new resources for medical professionals on 
the front lines, to whom we owe a great debt of gratitude; 
direct aid to States; and economic support for small businesses 
and their employees through the Paycheck Protection Program.
    The CARES Act also included the Home Health Care Planning 
Improvement Act. This is a bill that I have championed for 13 
years to allow nurse practitioners and physician assistants to 
certify home health services.
    Cutting down on time-consuming, unnecessary paperwork 
requirements that not only fail to improve patient care, but 
also delays access to that care, could not have come at a 
better time.
    In addition, the CARES Act makes a number of improvements 
in the delivery of telehealth. More progress is still needed, 
and I plan to introduce a bill soon to create a framework to 
reimburse for telehealth services provided by home health 
agencies. Finally, Phase 4 provided an additional funding for 
the Paycheck Protection Program, $75 billion for our hospitals, 
and $25 billion for additional testing.
    Much of the funding provided through these bills has yet to 
be released by the Department of Health and Human Services; 
therefore, I urge the Department to act with urgency so that 
this funding can flow to areas where it is desperately needed.
    Today we will hear from a panel of experts who are leading 
the charge in supporting seniors across a variety of settings 
of care, including in hospitals, in nursing homes, and in the 
community.
    We will be joined by Dr. Mark Mulligan, a physician who 
serves as the director of the Langone Vaccine Center at New 
York University; Dr. Tamara Konetzka, a professor of Health 
Services Research at the University of Chicago whose research 
focuses on quality of care in long-term care settings; and Dr. 
Steven Landers, a geriatrician who serves as the president and 
chief executive officer of the nonprofit Visiting Nurse 
Association Health Group.
    I am grateful to each of them for the work that they are 
doing and for taking the time to join us today. Their expertise 
will help us advance public policies, to slow the spread of 
this devastating pandemic, and to lessen its impact on our 
Nation's vulnerable seniors.
    Senator Casey, I know you are joining us remotely, and I 
would now call on you for your opening statement.
    I also want to acknowledge that Senator Braun has joined us 
in person at the hearing this morning, and as I said, there are 
many that are online joining us and we expect others to be here 
physically as well.
    Senator Casey?

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

    Senator Casey. Chairman Collins, you can hear me, I hope.
    [No response.]
    Senator Casey. I will assume that you are hearing me.
    Chairman Collins, thank you for convening this hearing. Our 
Nation at this point in our history is facing the greatest 
public health crisis in a century. This terrible virus is 
causing death and destruction at lightning speed.
    For seniors, the only thing that is moving faster than the 
virus itself is fear: the fear of being alone; the fear of 
contracting the virus; and of course, the fear that comes from 
isolation and that has every single member of the family 
worried, worried for our seniors.
    Thousands of seniors in hospital ICUs and nursing homes are 
dying scared and alone, with no family and no friends to 
comfort them in their final moments. Millions of seniors more 
are at home, isolated from their loved ones and scared to death 
often to leave the house even to get a bag of groceries.
    This unprecedented challenge calls for equally 
unprecedented action. The administration has to do more. 
Congress has to do more to help our seniors and our families at 
every turn.
    It is now May the 21st, and we still have no national 
testing strategy from the administration.
    The lack of personal protective equipment continues to put 
our health care providers and other frontline workers at risk. 
In turn, this puts every single person they come into contact 
with, and it also puts at risk the entire community.
    Nursing home residents make up 0.05 percent of the 
population, and yet deaths associated with nursing homes and 
other long-term care settings account for over one-third of all 
deaths from COVID-19, as Senator Collins just outlined, 0.05 
percent of the population yet one-third of the deaths are 
nursing homes and long-term care settings.
    Still to this day, we are trying to help those residents 
and workers in nursing homes with one hand tied behind our 
backs because the administration is not--is not releasing data 
on outbreaks in these facilities. This is unconscionable, and 
the administration needs to act.
    We have heard promises that by the end of May, they will. 
We need to see specific evidence that they are changing policy 
to give families, residents, and workers in nursing homes and 
other long-term care settings more information.
    Now, Congress has taken a number of steps, as Chairman 
Collins outlined. We have added unprecedented amounts of 
funding to purchase personal protective equipment to keep 
workers from contracting and transmitting the virus. We have 
funded efforts to help health care workers and health providers 
help patients in those settings. We have provided dollars to 
ensure that seniors have access to proper nutrition at home but 
not nearly enough.
    The policies and funding in these four bills that we have 
passed into law only begin to scratch the surface. Congress has 
to do more.
    Just last week, the House of Representatives passed the 
HEROES Act, and that legislation, among many things it does, 
calls for policies that I have been calling for since the 
beginning of this crisis, especially as it relates to seniors. 
It would require, the bill would, nursing homes to collect data 
on the impact of the virus on residents in nursing homes and 
other long-term care facilities so that we know how to 
distribute resources. The bill would also provide those nursing 
homes the dollars they need to contain the spread of the virus. 
The bill would also invest in home-and community-based services 
for seniors and people with disabilities, especially the 
800,000 seniors and people with disabilities on waiting lists 
for care so that they can receive the services and the supports 
that they need to keep them out of congregate settings. This 
bill would also pay our essential frontline workers for leaving 
the safety of their home to care for our aging loved ones.
    For the generation that has fought our wars and worked in 
our factories and taught our children and build the middle 
class, built the Nation that we have, and gave each of us life 
and love, we have to do more for our seniors. We cannot stop 
working. We cannot stop legislating. We cannot stop 
appropriating dollars to help our seniors. We owe it to them to 
do everything we can. There is no such thing here as doing too 
much for our seniors in the grip of this pandemic.
    Chairman Collins, I want to thank you for convening this 
critically important hearing, the first hearing in Congress on 
the impact of COVID-19 on seniors, and I look forward to the 
testimony from our witnesses as well as the questions.
    Thank you.
    The Chairman. Thank you very much, Senator Casey.
    For those of you who are watching us on C-SPAN, I want to 
explain that this room is specially configured in line with the 
social distancing recommendations of the CDC, which is why you 
see so many blank spaces, and again, we have several members 
who have already joined us remotely. I see Senator Josh Hawley. 
I see Senator Rick Scott, and there are others as well, some 
more who will be coming physically as well. There are also many 
other members whose pictures I cannot see but who have joined 
us at the hearing. I wanted to explain that this is one of only 
three hearing rooms that is configured to allow us to hold 
hearings. I see Senator Blumenthal has also arrived, and I want 
to acknowledge him as well.
    We are now going to move to our witnesses. Our first 
witness, Dr. Mark Mulligan, is joining us from New York 
University. Dr. Mulligan is the director of the Division of 
Infectious Diseases at the NYU Grossman School of Medicine, and 
director, as I have mentioned previously, of the university's 
Vaccine Center. He is a professor of medicine and a professor 
of microbiology at NYU. As the chief infectious disease 
specialist for NYU, he oversees the treatment of COVID-19 
patients at the university's health system hospitals in 
Brooklyn, Long Island, Manhattan, Bellevue, and the VA.
    Next, we will hear from Dr. Tamara Konetzka. Dr. Konetzka 
is a professor of health services research at the Department of 
Health Sciences at the University of Chicago. Her research 
focuses on the relationship between economic incentives and the 
quality of care in long-term care facilities. She is leading 
work to untangle factors associated with the disproportionate 
impact of COVID-19 on nursing home residents and staff.
    Finally, we will hear from Dr. Steven Landers, the 
president and CEO of the Visiting Nurse Association Health 
Group. VNA is the Nation's second largest not-for-profit home 
health care organization in the country. Dr. Landers is a 
family doctor and a geriatrician with a special interest in 
home care, hospice, and palliative care. He focuses on home 
visits to low-mobility older adults and has played a critical 
role in caring for seniors during this pandemic.
    Dr. Mulligan, we will begin with you. Thank you all for 
being here.

          STATEMENT OF MARK J. MULLIGAN, MD, DIRECTOR,

        DIVISION OF INFECTIOUS DISEASES AND IMMUNOLOGY,

               LANGONE VACCINE CENTER, DIRECTOR,

          THOMAS S. MURPHY, SR., PROFESSOR, DEPARTMENT

           OF MEDICINE, NEW YORK UNIVERSITY GROSSMAN

             SCHOOL OF MEDICINE, NEW YORK, NEW YORK

    Dr. Mulligan. Well, good morning, Chairman Collins, Ranking 
Member Casey, members of the Special Committee on Aging, and 
fellow witnesses.
    I also wanted to mention I am an NIH-funded investigator 
working with the New York University Vaccine and Treatment 
Evaluation Unit, part of a new NIAID-funded network, focusing 
on infectious diseases, clinical research, and including work 
on seniors. This is a very important part of the work that I do 
as the clinical investigator.
    This novel coronavirus emerged 5 months ago in China and 
rapidly led to the global pandemic that we now find ourselves 
combating. The human population, unfortunately, is highly 
susceptible; that is, we are non-immune to this virus. Most of 
us have been exposed to four distant cousins, seasonal co-
viruses that are also coronaviruses, but unfortunately, they do 
not provide cross-protective immunity against the current 
virus.
    For physicians, scientists, and leaders, the virus has 
continued to humble us. There is so much we do not know yet 
about diagnosis prevention and treatment, about medical 
countermeasures that will keep us all safe, but that is an 
important part of what I will be discussing today.
    Seniors are at increased risk due to the inexorable waning 
of the immune system, something called ``immunosenescence.'' It 
is not only their age, however, that renders seniors less able 
to mount protective immunity against microbial threats, 
including this coronavirus. It is also the chronic health 
conditions that are present more frequently in seniors such as 
cancer; immunosuppression; chronic heart, lung, and kidney 
diseases; and diabetes. The highest risk for critical disease 
due to this coronavirus is seen in the frail elderly, those 
that reside in nursing homes and long-term care facilities.
    The nurses, the doctors that I have worked with in the 
hospitals since late February taking care of patients are 
incredibly dedicated and caring. It is very moving to see how 
much they put into their jobs to help their patients, and yet, 
it has been a struggle. They have not had the medical 
countermeasures they have needed, particularly to help seniors 
fight this virus.
    Certain work for residential settings with less effective 
social distancing, the long-term care facilities we have talked 
about, factories, have had the worst outbreaks of COVID-19, and 
we have heard that while just 11 percent of COVID-19 infections 
in the U.S. have been in nursing homes, one-third of the deaths 
or perhaps more once we get good data have occurred in nursing 
homes or nursing home residents.
    Our main weapons to fight the virus continue to be non-
pharmaceutical interventions, all of the social distancing. We 
know that these work, and they are effective, and they have 
provided a strong benefit to society and individuals by 
reducing spread of the virus. However, they come as a cost to 
the economy, to society, and to the human existence. Therefore, 
a very important additional category are the Medical 
Countermeasures, which I will now talk about.
    A vaccine holds out the promise of immune-protection; that 
is, producing an immunity within our bodies that will protect 
us against the virus upon some future exposure with the virus. 
Safe vaccines have always been our most important weapons to 
battle infectious diseases with public health importance.
    Just 2 days ago, the first early report of a COVID-19 
vaccine appears, and thank goodness, it was promising. There is 
a long road ahead for development of safe, effective COVID-19 
vaccines, but it was great to have a very positive early 
signal. Seniors will be included in the all-important efficacy 
trials that are planned to be supported by the U.S. Government.
    However, the elderly do not respond as well to vaccines as 
younger adults do, so the approach of providing a monoclonal 
antibody as a pre-formed drug for treatment or prevention in 
seniors is one that is attractive. One U.S. Government and 
industry partnership that is under way is to move as quickly as 
possible with a randomized controlled trial of a monoclonal 
antibody that would be delivered to nursing home residents and 
nursing home workers in order to try to get control of 
outbreaks.
    The highest-quality medical research comes from randomized 
controlled trials. They provide the answer: Does the treatment 
work? For one antiviral drug, remdesivir, preliminary 
information from a randomized controlled trial of remdesivir 
versus placebo in hospitalized COVID-19 patients, including 
seniors, revealed a modest benefit, a 31 percent reduction in 
time to recovery. This is modest but significant and a much 
needed first signal that we have an effective approach to begin 
to start to battle this virus.
    Testing must be continued and increased. It provides a 
benefit. It allows us to identify those with infection. Until 
they recover, it can be isolated and thereby reduce further 
spread of the virus. The more we test, the more we can fight 
the virus.
    I will close by saying that the non-pharmaceutical 
interventions we have deployed against the virus have been 
highly beneficial, and this remains doubly important for 
protecting our very vulnerable seniors as we await further 
development of medical countermeasures, including vaccines and 
treatments and broader testing. Medical countermeasures may 
need to be tailored specifically for seniors, given their 
differences in their biologies.
    I thank the Committee for the excellent work they are 
doing.
    The Chairman. Thank you very much, Doctor.
    Dr. Konetzka?

             STATEMENT OF R. TAMARA KONETZKA, Ph.D,

             PROFESSOR OF HEALTH SERVICES RESEARCH,

           DEPARTMENT OF HEALTH SCIENCES, UNIVERSITY

                 OF CHICAGO, CHICAGO, ILLINOIS

    Dr. Konetzka. Chairman Collins, Ranking Member Casey, and 
distinguished members of the Committee, thank you for the 
opportunity to testify today.
    My name is Tamara Konetzka. I am a professor of health 
economics and health services research at the University of 
Chicago, and I have been researching long-term and post-acute 
care for 25 years, often focusing on nursing home quality.
    The central role of nursing homes in the COVID-19 pandemic 
has become increasingly clear. Just a month ago, nursing homes 
staff and residents were estimated to account for one-fifth of 
all deaths. The estimate is now at least one-third nationally 
and, as Senator Collins noted, more than half in many States.
    In some ways, these high rates are not surprising. Nursing 
homes provide hours of hands-on care daily to large numbers of 
people with underlying health conditions living in close 
quarters. Facilities are often understaffed, a situation that 
has been exacerbated by the pandemic. Nursing homes compete 
with hospitals for both testing and PPE, which are still in 
short supply in many areas, but is the spread of COVID-19 in 
nursing homes inevitable, or have some types of nursing homes 
managed better than others to manage outbreaks? We set out to 
answer that question using data on nursing homes from 12 
geographically diverse States.
    We merged State lists of reported COVID-19 cases and deaths 
with data on nursing home characteristics, including data from 
nursing home house car, a five-star rating system published by 
CMS. We calculated the percentage of nursing homes with at 
least one case or death by star readings, profit status, and 
several resident characteristics.
    Our analysis revealed three key results. First, we found a 
strong and consistent relationship between race and the 
probability of COVID-19 cases and deaths. Nursing homes with 
the lowest percent white residents were more than twice as 
likely to have cases or deaths as those with the highest 
percent white residents.
    Second, we found no meaningful relationship between the 
nursing home five-star ratings and the probability of at least 
one case or death. In fact, even the direction of the 
relationship was inconsistent from State to State.
    Third, we found no difference between for-profit and 
nonprofit facilities and only a weak relationship with percent 
of residents on Medicaid.
    We concluded from this analysis that while some nursing 
homes undoubtedly had better infection control practices than 
others, the enormity of this pandemic coupled with the inherent 
vulnerability of the nursing home setting left even the 
highest-quality nursing homes largely unprepared, and yet the 
pattern is not random. Nursing homes are often a reflection of 
the neighborhoods in which they are located.
    Consistent with the pandemic generally, nursing homes with 
traditionally underserved, non-white populations are bearing 
the worst outcomes.
    Turning to solutions, it is increasingly clear that long-
term care facilities must be a top priority in fighting the 
pandemic, as that is where the deaths are, and we would suggest 
several short-term measures.
    First, nursing homes need a direct influx of funding and 
technical assistance in order to achieve adequate numbers of 
staff, availability, and proper use of PPE, and regular and 
rapid testing of all nursing home residents and staff to enable 
separation.
    Second, we need to enhance the ability of Medicaid 
beneficiaries to receive home-based services instead of 
institutional services. The decision between care at home or in 
a nursing home is difficult for families in the best of times. 
Now the risks and benefits have likely shifted. To best help 
families in this situation, resources need to be directed 
toward enabling them to avoid institutionalization during this 
high-risk time.
    Third, data collection and transparency about cases and 
deaths are essential. Timely reporting enables resources to be 
directed where they are needed most, and at the same time, 
older adults and their families need this information in order 
to make their own best decisions, decisions that may be about 
life or death.
    These short-term measures are urgent and necessary, but 
they do nothing to change the underlying systemic challenges to 
improving the quality of nursing home care and the lives of 
older adults who live in them. Nursing home residents are ill-
equipped to monitor their own care, to advocate for themselves, 
or to exert political influence. This makes regulation and 
oversight necessary.
    Some regulations have been relaxed during this pandemic, 
but it will be important to reinstate them once the crisis has 
passed, with increased attention to infection control 
practices, but the effectiveness of regulation is limited when 
the structure of nursing home payment is fragmented, uneven, 
and leads to systematic underfunding of essential services.
    Those of us who study long-term care are accustomed to 
hoping for fundamental change and not seeing it. One positive 
outcome of a severe financial fallout from the pandemic may be 
that it forces a fundamental reevaluation of how we pay for 
long-term care in the U.S.
    Thank you for the opportunity to provide input on this very 
critical issue.
    The Chairman. Thank you very much for your excellent 
testimony.
    Dr. Landers?

            STATEMENT OF STEVEN H. LANDERS, MD, MPH,

         PRESIDENT AND CEO, VISITING NURSE ASSOCIATION

               HEALTH GROUP, HOLMDEL, NEW JERSEY

    Dr. Landers. Good morning. Chairman Collins, Ranking
    Member Casey, members of the Senate Committee on Aging, I 
am Steve Landers. I am a family doctor and geriatric medicine 
physician. My clinical work focuses on house calls to homebound 
seniors, and I serve as the president and chief executive 
officer for Visiting Nurse Association Health Group. We are a 
large nonprofit home health and hospice agency headquartered in 
New Jersey, and we serve parts of Ohio and Florida as well.
    Our team of 3,000 dedicated caregivers, they have really 
stepped up during this crisis to help medically fragile older 
adults come home from hospitals and nursing facilities and, in 
some cases, never have to go in the hospital in the first 
place.
    We serve 9,000 people in our programs and services, and we 
have taken care of over 650 older adults in the home care 
setting with known COVID-19 infection. I have never seen the 
system so stressed and at the same time never felt more proud 
of the incredible people that I work with every day.
    One of the reasons we have been able to keep serving has, 
frankly, been because of Chairman Collins and colleagues, your 
leadership, in the CARES Act, the provider relief fund. Some of 
the measures that CMS have taken have been important because 
our revenues have gone down because of the cancellation of 
elective medical procedures, and at the same time, expenses 
related to personal protective equipment, or PPE, testing, 
those expenses have gone up, so that financial support has been 
critical.
    I want to thank you, Chairman Collins and colleagues, for 
your leadership, advancing the role of nurse practitioners and 
physician assistants in home-based elder care. Homebound older 
adults have had limited access to medical care. COVID-19 has 
made it even harder, and that extension of the team with the 
nurse practitioners and physician assistants is very important 
in preserving access, and also the other measures related to 
the geriatric workforce that were in the CARES Act are very 
important.
    I have been reminded again of the incredible difference 
that home health and hospice can make on quality, compassion, 
patient safety, and we have seen the stress that hospitals in 
terms of bed capacity, emergency rooms, nursing facilities, the 
challenges that they faced and it is highlighted, the need for 
a strong home care option, an option to home care really when 
it is at its best working in concert with hospitals, 
physicians, and nursing facilities to deliver coordinated care.
    In order for us to provide that option, job number one, is 
protecting our treasured frontline caregivers. We have been 
able to maintain care because we have been able to maintain a 
supply of PPE. Now, that has been incredibly difficult to do. 
We are using, in my organization, 17,000 surgical masks a week, 
3,500 N95s a week, thousands of isolation gowns and goggles, 
and we have to pay seven to ten times the normal price and use 
vendors really from all over the world that we could not always 
vet and verify, just hoping the shipments would arrive, so 
going forward, I would encourage us to look at policies that 
could make sure home health agencies have the needed PPE at a 
reasonable price, also important to our ability to serve during 
this crisis has been our spirit of innovation. We have really 
embraced the use of telehealth and virtual visits within our 
home health agency in order to help people stay safely at home 
during this crisis.
    For the COVID-19 home-care patients, they need monitoring 
of vital signs, oxygen, and respiratory assessment, and so even 
though home health agencies are not reimbursed for telehealth, 
we felt that that was important.
    We also had seen even before this crisis that telehealth 
could play an important role in home health, and we have been 
trying to advance that. I think going forward, to make sure we 
have a strong home health option for older Americans, that 
finding a way to reimburse telehealth services within home 
health agencies is really important, also preserving the 
ability for physicians and nurse practitioners to do the face-
to-face encounter and certifies people for home health via 
telehealth is really important.
    I really thank you for including me in the hearing this 
morning, and I am very sad about all the death and suffering 
but also optimistic that we can strengthen home care and elder 
care for older American, so thank you.
    The Chairman. Thank you very much, Doctor.
    I want to note that Senator Tim Scott and Senator Martha 
McSally have also joined us in person physically today.
    What we are going to do, because there were many people who 
logged on at the very beginning, is we are just going to go in 
order of seniority. I cannot figure out any other way to do 
this, given the people who have showed up physically, but also 
the people who have been online at the very beginning of the 
hearing.
    Usually, I would like to reward those who show up first, 
but I think since there were people online, as I said, I cannot 
figure out any other way to do this fairly.
    Let me begin with my own questions, and then Senator Casey 
will question next remotely.
    First of all, when we hear the statistics, which are so 
devastating, with half of the deaths in Maine being in long-
term care facility, a third nationally, my heart just goes out 
not only to the patients, but to their families and to the 
staff of nursing homes and other assisted living facilities, 
congregate care settings. They are all praying that COVID-19 
does not find its way into their facility.
    Yesterday the Government Accountability Office released a 
report that found that nearly half of the more than 13,000 
nursing facilities surveyed had infection control deficiency 
citations in consecutive years, which the report called an 
indicator of persistent problems, yet as Dr. Konetzka said in 
her testimony, even the highest-quality nursing homes have been 
largely unprepared. What we have usually looked at, the ratings 
by CMS, the number of stars, has not proven to be a reliable 
indicator of which nursing homes are safest in this 
environment, and indeed, one of the worst outbreaks in Maine 
was at a nursing home that had five stars.
    I think what we are learning is that health care providers 
are rethinking some of their initial assumptions, and that we 
need to think more about hospital discharge planning.
    Dr. Konetzka, I want to have you expand a little bit more 
on what we can do. I believe that you recommended universal 
testing for every nursing home resident and staff, which I 
think is a good idea and have been recommending. How often, 
however, would you have to do that, and would that allow family 
members who have been tested to finally be able to visit their 
loved ones?
    [No response.]
    The Chairman. I hope we can unmute Dr. Konetzka because I 
can see that she is responding, but we cannot hear her.
    Doctor, go ahead.
    Dr. Konetzka. Can you hear me?
    The Chairman. Yes. Thank you.
    Dr. Konetzka. Okay, great.
    Yes. Thank you for that question. I think that we are 
learning a lot as we go about how best to fight this virus in 
nursing homes, and so we do not have, unfortunately, great data 
yet on exactly what testing strategies have been used and how 
successful they have been. A lot of what we are going on is 
anecdotal evidence, but what I can say is that there have been 
a few key lessons learned.
    One is that it is very important to test all residents and 
not wait until residents are asymptomatic--I mean until 
residents are symptomatic because by then it is too late. There 
is asymptomatic spread, and given the close proximity and the 
fact that staff go from resident to resident every day, the 
virus, until people get symptomatic, can spread throughout the 
facility, so we have learned that lesson, that all residents 
really should be tested, and not only tested but tested 
regularly.
    What I have heard from geriatricians is, generally, weekly 
would be good, at least biweekly, so that residents can then be 
separated, and the transmission can be stopped.
    I think it might be very hard especially as we relax some 
of the restrictions on visitors, which is essential, as you 
mentioned, essential to prevent the sense of social isolation 
among our seniors. As we lax those restrictions, it is going to 
be very hard to prevent all cases in the nursing home. The key 
then is sort of a rapid response to prevent transmission to the 
rest of residents and staff.
    The Chairman. Thank you.
    Dr. Landers, I appreciate you talking to us about the 
importance of home care, and that can help people be safer. I 
have always been a strong supporter of home care.
    One issue that we have is that people who are older are 
being increasingly isolated, and that too can have a very 
detrimental impact on their underlying health and, thus, make 
them more vulnerable to the coronavirus.
    Could you comment on how home health visits can help keep a 
senior more connected and less isolated?
    Dr. Landers. Chairman Collins, absolutely, home health is a 
way to show people that they are known and worth something, 
that they are valued. It is an act of humility, really, and in 
this crisis, it has been even more important. Sometimes our 
nurses are the only people that are even checking in on a frail 
elder, and I have heard them tell stories of having to kind of 
go out and make sure that the person had a food supply or 
undergarments or other things that are essential, so the 
isolation is critical.
    I think your focus on telehealth also adds, although it is 
not perfect, making sure that those people that are homebound 
and need home health also have access in between the visits to 
some interaction via telehealth but also improve the amount of 
attention that our older patients are getting. It is a really 
crisis in sort of loneliness and isolation, so we are trying to 
do all we can.
    The Chairman. Thank you.
    Senator Casey?
    Senator Casey. Chairman Collins, thanks very much.
    I wanted to start my questions with Dr. Konetzka. I have a 
particular question for Dr. Konetzka regarding nursing homes.
    We know that nursing homes have become, unfortunately, 
Ground Zero in this pandemic, and yet there is still no 
national strategy. I believe and I think the testimony today 
indicated in part that there is still an insufficient supply of 
personal protective equipment for nursing home staff. These are 
among the heroes in our society, literally soldiers on a 
battlefield in a war against the virus, and they are putting 
themselves at risk for the disease, contracting the virus. They 
are also putting themselves at risk for death itself, and that 
includes their families. The word ``hero'' definitely applies 
to these health care workers.
    They need, I believe, simply more leadership out of the 
administration and Congress, more help. They do not need pats 
on the back only and expressions of gratitude and acclamation. 
That is nice. What they need is direct support and more than 
that.
    I will start with the support for what they do on the job. 
The most important thing, one of the most important things we 
can do is to help them implementing what the public health 
experts tell us are proven practices.
    I have been asking the administration, first and foremost, 
for data. The Centers on Medicare and Medicaid Services and 
CDC, of course, are the ones that would have to transmit this 
data to the American people. We are talking about basic 
information on case counts, basic information on deaths, so 
that we can direct and target the resources to the nursing 
homes that need it the most.
    Now, they have said, as I indicated earlier, that it is 
coming by the end of May, but we have been hearing that for a 
long time.
    I have introduced legislation that would focus specifically 
on nursing homes and other long-term care settings. This 
particular bill, the Nursing Home COVID-19 Protection and 
Prevention Act, that I introduced with Senator Whitehouse and a 
number of our colleagues has as its focus $20 billion in 
emergency funding to invest in what works.
    We know that in nursing homes, if you have cohorting, you 
separate the residents with COVID-19 from those who do not have 
the virus. That is a good practice, but that costs money. We 
have got to help them with that.
    Other uses for the dollars could be charging of medical 
expertise into a nursing home.
    Dr. Konetzka, I would ask you, I guess, two basic 
questions. Why is it so important that we have basic data on 
COVID-19 in nursing homes? That is question number one, data 
and question number two is, What are some of the policies that 
we can use to help nursing homes put in place information, this 
information in the ample resources?
    Dr. Konetzka. Thank you, Senator Casey, for that question.
    As I touched on in my responsibility, I think data and 
transparency are critically important in this crisis. I think 
often during a crisis, we are tempted to downplay the need for 
a collection of data and prioritize other actions, but it is 
essential in this case for three main reasons.
    One, we do need to know where resources need to be 
directed. We know where there are outbreaks in nursing homes. 
We can direct resources to them, but we can also identify the 
communities in which the virus is probably spreading.
    Second, as we look back on this crisis, we need data in 
order to do the hard research to figure out what works and what 
did not work so that we can make better policies in the future, 
and, third, consumers and their families really need to have 
this information. Anybody looking for a nursing home placement 
right now or worried about their loved one in a nursing home 
right now really needs to be able to know what is going on in a 
very timely way so that they can make their best decisions.
    In terms of the exact resources, I think a lot of it is 
about staffing, and we have had a problem with chronic 
understaffing in nursing homes, and the kind of resources that 
could help most on an emergency basis for a facility that has 
an outbreak is to strategize to ensure enough staff. This means 
providing paid sick leave. This means providing adequate PPE, 
basically putting nursing home staff on a par with what we 
naturally want to provide for hospital staff. It is the same 
situation.
    Senator Casey. Well, thanks very much.
    I know I am almost out of time, and Chairman Collins has 
been generous with our time.
    I will just ask Dr. Landers a quick question about our 
frontline heroes. A number of us in the Senate--and I know this 
is true in the House as well--have made it a focus to create a 
Heroes Fund, some manifestation of our gratitude for those who 
have put themselves at risk on the front lines.
    I know that in the case of Dr. Landers, I am told that you 
have, in fact, kind of stood up and taken a lead on this, that 
approximately 50 of your employees have volunteered to help 
care for patients who have tested positive for COVID-19, and I 
understand in recognition of their work, you are providing 
these individuals with additional compensation, so we commend 
you for that.
    I guess the basic question is simple. It is a yes or no 
answer. If the Federal Government provided you with the option 
to receive funding to provide what we can pandemic premium pay 
for essential workers and the work they have done in this 
pandemic, would you apply for the funding?
    Dr. Landers. Senator Casey, thank you.
    Yes, we are trying to do all we can to support our 
frontline heroes, and if there is something we were eligible 
for and the criteria were appropriate, we would certainly do 
so.
    Senator Casey. Thank you.
    The Chairman. Thank you.
    Senator Tim Scott?
    Senator Tim Scott. Thank you, Chairman Collins, Chairwoman 
Collins. I will say this. Your leadership, Chairwoman, has been 
spectacular.
    The Chairman. Thank you.
    Senator Tim Scott. From the aging community to the Paycheck 
Protection Program and to this hearing, you consistently show 
up for the seniors in Maine and the seniors in America, for the 
small businesses. How you accomplish all that you do, I am not 
sure, but you are one of the hardest-working, most dedicated 
public servants I have met. Thank you for this hearing and the 
opportunity to discuss this incredibly vital issue of 
protecting our aging communities, which I am closer and closer 
being a part of, so thank you very much.
    The Chairman. Thank you so much for your kind words.
    Senator Tim Scott. To the panel, I will just say this, that 
without any question, if you are in South Carolina or most of 
our States, what you will realize very quickly is that those 
diagnosed with COVID-19 on average is just over 50 years old 
who are hospitalized, and those who die from the disease in 
South Carolina is just over 50--over 75 years old.
    In fact, nearly 90 percent of fatalities in my State, South 
Carolina, have been from those over the age of 60. It is one of 
the reasons why I highlighted Senator Collins' dedication to 
this issue because one-third of all COVID-19 deaths in South 
Carolina happen in a nursing home or another senior care 
facility. This is an incredibly important issue and an 
incredibly timely hearing.
    In other States, the numbers are even worse than in South 
Carolina. That said, there have been some encouraging numbers 
recently, and our Governor in South Carolina and, frankly, 
Governors around the Nation--I would like to highlight the 
Governor in Florida as well, DeSantis, who decided to focus the 
attention on the nursing homes. It is exactly where we should 
start this challenge, of how we should face this challenge, by 
focusing on the most vulnerable populations.
    I have often thought about how important it is for us to 
recognize that nursing homes are the epicenter of activity. The 
folks who take care of the patients are disproportionately 
minorities, African Americans, who have perhaps the second most 
vulnerable population in our Nation.
    If you think about States like Louisiana, where 70 percent 
of the deaths are African Americans, only 33 percent of the 
population; in my home State, 53 percent of the deaths, African 
Americans, only 27 percent of the population, so you have one 
vulnerable community being served by another vulnerable 
community, and that only highlights the importance of testing, 
testing, testing in our nursing home facilities.
    I am thankful that in South Carolina that the 40,000 
nursing home residents will be tested between now and the end 
of June. I am thankful that in South Carolina, we will have 
over 220,000 tests completed in May and in June of residents of 
South Carolina, 60,000 already tested so far this month.
    These are encouraging numbers, and it is one of the reasons 
why I have introduced legislation to make this the model for 
the Nation, that our Nation should take serious, testing first 
in our nursing homes and providing more resources for the 
vulnerable populations in this country.
    Along those lines, I have encouraged HHS to set aside a 
robust share of the Provider Relief Fund that we appropriated 
through the CARES Act along with $25 billion that we dedicated 
to testing specifically for nursing homes and community 
residential care facilities. They need the resources, the 
supplies, and tests as soon as possible.
    My question to the full panel, beyond funding, what steps 
should we be taking at every level of government to help these 
providers and communities develop the tools and strategies 
necessary to detect, isolate, and address cases where they 
occur without straining existing resources by increasing 
administrative burdens?
    Dr. Konetzka. If I may answer one part of that, I think in 
addition to funding, technical assistance to nursing homes is 
essential because I think sometimes just providing the funding 
for it does not mean that nursing homes will necessarily know 
what we are learning about the best practices in terms of 
actually stemming an outbreak.
    I think to the extent that local public health departments, 
State organizations can provide technical assistance and as 
well as the funding and the resources like surge teams to stem 
an outbreak, that would be helpful.
    Dr. Mulligan. Senator Scott, I was just going to add that 
the importance of clinical research in seniors in nursing 
homes, educating families, because they are often legally 
authorized representatives, about clinical research, everything 
in our medicine cabinet is there because we have conducted 
clinical research, and we absolutely need to include seniors in 
our vaccine trials, which we will be launching in large numbers 
in July, as well as in special senior-focused studies, such as 
the monoclonal antibodies, to go into nursing homes and provide 
this option to participate in research.
    The Chairman. Thank you, Senator.
    Senator Gillibrand is joining us remotely, and she is next.
    Senator Gillibrand. Madam Chairman, can you skip me? I am 
having a technical problem. I just need 5 more minutes, so do 
the next person.
    The Chairman. Absolutely. Let me just check on your side of 
the aisle, and it is Senator Blumenthal, who is right here.
    Senator Blumenthal. Thank you, Madam Chair. Thank you, 
Senator Collins and Senator Casey, for bringing us together on 
this supremely important topic.
    I was listening to my colleagues, I could not help but 
remember last Monday when I accompanied Senior Pastor Patrick 
Collins in a ritual that he has done literally every morning. 
He places white flags on the lawn in front of the First 
Congregational Church in Greenwich, Connecticut, and I 
accompanied him last Monday as we together placed 69 new flags 
for each COVID-19 death in the State of Connecticut.
    On Tuesday, the day afterwards, Pastor Collins placed 41 
more flags, yesterday 23. Right now, literally as we hold this 
hearing, exactly to the moment, Pastor Collins is almost 
certainly placing another 57 new white flags, adding to this 
sea of markers in front of the First Congregational Church in 
Greenwich.
    Every one of those flags represents a life and the 
thousands of lives lost around the country. Seventy percent of 
them are seniors, seven in ten, and many are in nursing homes, 
so the obligation that we have to these vulnerable individuals 
is brought home very dramatically and graphically by that 
picture worth a thousand words, literally.
    That is why I have supported the hazardous duty pay, the 
Heroes Fund for our nursing home workers, who all too often are 
risking their lives and making financial sacrifices, and it is 
more than just rewarding or recognizing them. It is also to 
retain them and to recruit new nursing home workers.
    Let me ask, first of all, Dr. Konetzka a question. Is not 
it a fact that all too often, the employees of these nursing 
homes are underpaid for the risky and back-breaking work that 
they do?
    Dr. Konetzka. That is exactly right. Nursing home workers, 
especially nursing aides, are generally paid minimum wage, 
often have no paid sick leave, and often have no health 
insurance. It is natural that in normal circumstances, nursing 
homes have a hard time staffing adequately, but under these 
circumstances where staff are also afraid to get sick, afraid 
to bring the virus home to their families, or on the other hand 
may show up to work because they do not have paid sick leave, 
even though they are feeling ill, I think that all contributes 
to the issues we are seeing in nursing homes and the 
understaffing problem in particular.
    Senator Blumenthal. One of our nursing homes run by a 
friend of mine, Tyson Belanger, provides living facilities for 
the nursing home employees on the premises, so they are 
protected. They have to live away from their families, but they 
are sealed away from possible infection. The result has been to 
greatly reduce the incidence of infection.
    Is that kind of innovation, Dr. Konetzka, a possible 
promising route that others should follow?
    Dr. Konetzka. Yes, certainly. I think that nursing home 
workers should have the option of having a different place to 
stay, whether that is provided by the nursing home or, like 
many cities have done for hospital workers, perhaps providing 
them with unused hotel rooms, so that they have the choice of 
not risking infecting their families.
    Senator Blumenthal. Tyson Belanger, by the way, happens to 
be a veteran, having served multiple tours in the Afghanistan 
and Iraq Wars.
    I have introduced legislation with Senator Booker. It is 
called the Quality Care for Nursing Home Residents and Workers 
During COVID-19 Act. It would immediately address some of these 
same problems, not just more testing. In fact, it would require 
weekly testing of every resident and testing before every shift 
for health care workers. It would mandate that all health care 
workers have sufficient PPE and comprehensive safety training 
for dealing with COVID-19, and that each facility have a full-
time infection control preventionist on staff to keep residents 
and workers safe. It would guarantee that sufficient staff is 
available to facilitate weekly virtual visits between residents 
and their families.
    Those are just examples of the kinds of measures that I 
hope that may reduce the number of flags, those white markers 
that Pastor Collins places every morning in front of the First 
Congregational Church of Greenwich. We owe it to our seniors. 
We owe it to all of our families and all of their loved ones 
that we do better in our nursing homes.
    Thank you, Madam Chair.
    The Chairman. Thank you, Senator.
    Senator McSally?
    Senator McSally. Thank you, Chairman Collins. I want to 
echo Senator Scott's comments about your leadership and your 
passion for seniors, for small businesses under your leadership 
in this unprecedented challenge, so thank you, and thank you 
for this important hearing and to our witnesses for their 
testimony.
    In Arizona as of last night, there have been 747 deaths 
related to coronavirus, from the coronavirus, and 593 are over 
the age of 65, so that is about 79 percent.
    As I think about this, this is a cruel virus, as we all 
know, and it is the cruelest to our most vulnerable, and this 
is the greatest generation we are talking about. this is our 
opportunity as we learn more about the virus. We did not know a 
lot about it, but as we are learning more about it, for us to 
do everything we can to protect the greatest generation. This 
is our generation's opportunity to give back to them and there 
has been an important focus on nursing homes for the vulnerable 
who are in these congregate settings, but we also need to think 
about those in memory care, those in assisted living, those who 
are older but in independent living.
    My mom is 85. She is in good health for her age. She is in 
independent living, but she also has been isolated for now 2 
months because she is just as vulnerable as others from this 
cruel disease.
    I have neighbors and constituents who are sharing their 
stories of their loved ones who are in these settings, and we 
need to make sure that we protect them.
    As I think about going forward--and it is not a choice of 
are we going to continue to protect lives or allow people to 
safely return to work. As we move forward, we can do both, but 
for seniors in congregate settings, we need to put a moat 
around them. We need to ensure that we have high levels of 
situational awareness, that anybody who goes to work there, 
supports there, or at some point visits there, that we know 
that they are not inadvertently bringing the virus in with 
them.
    We now know, unlike several months ago, that people can 
asymptomatically be carrying the virus, so checking 
temperatures is not enough.
    I thank you for the testimony today, but I want to look 
more broadly for all congregate settings. One of the challenges 
we have is where there is oversight of our nursing homes in 
Arizona, oversight from HHS, oversight at the State and county 
level, the independent living, the assisted living, they are 
usually private entities, and so they are trying to get PPE, 
trying to get testing. It is not an easy top-down thing to do 
with the supply chains.
    We have had many innovations in Arizona. One company I 
visited, AmSafe, used to make seatbelts and airbags for 
airplanes. They just started making masks and gowns to support 
our nursing homes in Arizona. It is just an incredible story. 
More of that needs to happen. We need to bring the PPE 
manufacturing home.
    I want to ask Dr. Konetzka, can you share broadly, if we 
are looking at all seniors in these congregate settings, what 
does it look like for us to keep that moat around them? I think 
it is our testing needs to be focused on staff and ideally 
visitors and others who are going to go in there and high 
levels of situational awareness, plus the controls that we have 
learned to isolate and be able to treat quickly but what does 
that look like, not just for nursing homes, but for everyone 
who is in this vulnerable category in a congregate setting?
    Dr. Konetzka. First, thank you very much for that question 
because I think there is a tendency to focus only on nursing 
homes, and in many States, assisted living facilities look very 
much like nursing homes in terms of the level of care needed 
and provided and the vulnerability of the residents, and yet 
because assisted living facilities are licensed by States and 
do not receive generally a lot of Medicaid or Medicare funding, 
we sort of tend to ignore them in these situations and yet they 
are completely just as vulnerable.
    I think your question about the social isolation in these 
settings, not just assisted living, but also independent 
living, is a huge challenge. I think the at the riskiest time 
when we have to prohibit visitors, some things can be done in 
the meantime like making sure that these facilities have 
appropriate technology so that residents can at least 
communicate through Facetime or other video chats with their 
families on a regular basis.
    In the longer run, I think it is essential for all the 
reasons that you and others have mentioned that we do worry 
about the social isolation and start allowing visitors, and 
that is one of those things that I think we will learn as we go 
in terms of how much is too much, but that balance has to be 
struck. We have to limit that social isolation even as we try 
to stem the virus.
    Senator McSally. Thank you.
    I know I am over my time, but I also want to say this. 
Isolation, I have heard cruel story after cruel story--the 
virus is cruel--of people fighting for their lives alone and 
the amazing nurses who are with them, but not with their loved 
ones and family members, people taking their last breath alone 
without their loved ones and family members, not being able to 
even be there for their funeral. We have got to be able to 
focus on allowing people when we can as quickly as possible to 
be with their loved ones safely during these times so that they 
can be there.
    It is impactful not just for the senior, but also for the 
other family members who feel helpless, so working together, we 
have got to address this issue to allow people to safely be 
able to visit at the right time.
    Thank you. Thank you, Madam Chair. Thank you for your 
grace.
    The Chairman. Thank you, Senator.
    Senator Gillibrand has fixed her technical problem, and she 
is next.
    Senator Gillibrand. Thank you, Madam Chairwoman. I 
appreciate this hearing very much.
    In my State of New York, the most terrible horror stories 
are coming out of our nursing homes, and a lot of the people 
who have lost their lives have lost them in nursing homes.
    One of the concerns I have is for the workers who work 
there, and if we had had national paid leave in place at the 
beginning of this, then any worker who had to take care of a 
family member or was sick themselves or had a child home would 
have been able to keep their job, keep their health care, and 
take up to 3 months leave, so that the length of the schools 
being closed or the length of an illness or sickness within 
their family, and without that, we have no safety net that 
would structurally be there for our workers when they have this 
kind of emergency, and this pandemic is a perfect example of 
how it could have been used more effectively.
    I want to ask Dr. Konetzka, do you agree that if workers, 
especially nursing home and home health workers, were allowed 
to consider their health or the health of their families by 
having access to a comprehensive paid leave program that that 
could better protect their patients and clients to slow the 
spread of the virus?
    Dr. Konetzka. I think a national paid leave program could 
help in a number of ways. I think in a broader sense, providing 
paid leave for health care workers and long-term care workers 
would allow them that flexibility, as you just mentioned. It 
would also allow perhaps other people the choice of taking care 
of their appearance or another family member instead of putting 
them in a nursing home, so I think it would affect all kinds of 
decisions at the margin.
    Under this particular crisis, I think we would still have a 
staffing shortage because people leaving and having the paid 
leave to take care of family members as they need does not help 
with staffing in nursing homes, so I think there are two sides 
to that.
    Senator Gillibrand. Yes.
    The other concern I have is that our nursing homes are 
still struggling to get access to testing and PPE, and we know 
that nursing home workers and people they serve are among the 
most vulnerable around the country.
    Both Dr. Landers' and Dr. Konetzka's testimony reinforce 
the need for an essential workers bill of rights to protect our 
essential workers, including nursing home and direct-care 
professionals during this public health emergency.
    Every essential worker in our country should have access to 
safety and health protections. They should have access to 
frequent testing and PPE. They should have more robust 
compensation. They should have paid leave. They should have 
universal sick days. They should have the kind of support that 
they deserve because they really are our frontline workers in 
this pandemic.
    Dr. Landers, do you believe that the health outcomes for 
patients are improved? Do we have high-quality, well-paid, and 
well-protected direct-care professional workforces? and do you 
agree that we need Federal investment in direct-care workforce?
    Dr. Landers. Senator, thank you.
    The aging care, home care, nursing home care, it is all 
about people caring for people. That is really what matters. 
People need that tender loving care, and to the extent that we 
have a strong, well-trained, well-supported workforce, the 
outcomes are going to be better for patients and families. I do 
believe that, and I am concerned about the shortages, shortages 
of nurses in particular, because I hear our nursing schools are 
turning away half of the qualified applicants, even though we 
have 80 million aging older adults, so I am thankful that you 
and your colleagues are thinking about the workers.
    Senator Gillibrand. I have one idea that I would like 
anyone to comment on. For the shortage of health care worker 
and home health workers and workers in nursing homes, one of 
the things I think we should be doing is having a health force, 
where we train a million workers in the next 2 months to do the 
contact tracing, to do the testing, and to do eventually 
vaccinations.
    For any on the panel, do you think training up this health 
force in the next 2 months would be able to help us have health 
care workers for the future so you would not have shortages for 
people who work in health care for our older adults, whether it 
is in direct care or whether it is in an assisted living 
facility? You can each give an opinion on that.
    Dr. Mulligan. Thank you, Senator Gillibrand.
    I do think that having resources in place in advance of 
future crises is absolutely what we need. What we find is if we 
are not ready ahead of time, when we chase our tails, so we do 
have to invest in advance in order to be ready when the crises 
come in the future, so having a group of young people who might 
then get very inspired by the work that they are doing and go 
on to become full-time, lifelong medical professionals, health 
care professionals, I think that is a very inspiring thought 
and something we should aspire to.
    Dr. Landers. Senator, I think, absolutely, getting new 
people into the workforce in these caring fields is really 
important, particularly home health aides and personal care 
workforce. There is definitely a need for more people to enter 
that field.
    Things like nursing, I mean, the nurses really are the keys 
to a lot of these teams, and we need really smart bachelor-
prepared nurses, and that is something that is going to require 
more long-term policymaking, so that going forward that we are 
in a better position because those cannot be created overnight, 
same with primary care physicians and geriatricians, but in 
terms of the frontline personal care, funding could help with 
that.
    Senator Gillibrand. Thank you.
    Dr. Konetzka?
    Dr. Konetzka. I will just add that I think it is a really 
good idea for both the short term and the long term. It seems 
like something where it could help with the urgency of this 
situation to increase staffing in nursing homes and in home 
health, and it could help with the pipeline problem in that we 
just do not have enough people coming out of training programs 
wanting to work in long-term care and getting people interested 
early on. Even as we try to improve the working conditions so 
that they want to stay in it is a good idea.
    Senator Gillibrand. Thank you, Madam Chairwoman.
    The Chairman. Thank you.
    Senator Braun?
    Senator Braun. Thank you, Madam Chair.
    I want to echo what Senator Scott said. I am on several 
committees here in the Senate, and I think the best hearings 
have been in this Committee because you generally pick a topic 
that needs to be talked about at that moment in time, so thank 
you.
    The Chairman. Thank you.
    Senator Braun. I have got several questions teed up. As a 
business guy and entrepreneur, when I look at trying to apply 
the skills that work there, generally, you need to be agile. 
You need to think out of the box. You need to do things 
differently if you are going to be successful in a market.
    I am interested because we have made the case that 
disproportionately nursing homes have been impacted. What has 
been the rate of improvement in these few months that we have 
been grappling with it? Have we seen the rate of infections and 
deaths come down, or are we still at a level that I know is 
bad, but have we seen any improvement? and then the corollary 
with that would be, what best practices, what things have we 
seen in the successful nursing homes that would be maybe of key 
importance, one, two, and three? so has the rate improved, and 
then what best practices have surfaced in this time we have 
been tackling it?
    Any on the panel, feel free to jump in.
    Dr. Konetzka. I will be happy to start with that.
    I think the answer to your first question is we do not 
quite know because we do not have great data yet. Even for our 
study, we had to sort of pull State lists off the Internet and 
do a lot of data cleaning to make sure that we were analyzing 
something valid, and without the data to really know exactly 
where the infections and cases and deaths are, we will not be 
able to really answer that question.
    I suspect we are still learning as we are going and that 
many areas will still see outbreaks in nursing homes.
    For your second question in terms of best practices, I do 
think there are a few things we have learned, as I mentioned 
earlier. Testing everybody in a nursing home on a regular 
basis, to prevent asymptomatic spread, and then separating 
residents as possible into COVID-and non-COVID-positive parts 
of a facility, I think has been successful in many places.
    Dr. Landers. Senator, I think that----
    Dr. Mulligan. Senator Braun--go ahead.
    Dr. Landers. I just want to say to the Senator that we are 
seeing in the home health setting over time that it seems like 
the rates of infection of our treasured workforce, it does seem 
to becoming less common week by week. These are people working 
in the hardest-hit areas of northern New Jersey where we have 
seen some of the highest levels of infection in the country.
    I do think week by week, the social distancing measures, 
the PPE, the expanded testing which still needs to expand 
further, but we are certainly in a better spot than we were in, 
in early March, where there was nothing, so we have a long ways 
to go, but the screening and education of the workforce, making 
sure they know when and how to ask for help and when to get 
them out of the workforce, and then also the testing programs 
for the workers is increasingly important.
    Dr. Mulligan. I think, Senator, the only thing I would like 
to add--and this gets at the innovation piece--is the research, 
the clinical trials.
    I agree with what my fellow panelist said about what we 
should be doing immediately in terms of implementing what 
appear to be best practices.
    In addition, we have to invest in research as a Nation 
supporting the NIH and doing the clinical trials that will help 
us get out of this thing as a whole, but in doing that, we will 
support the seniors.
    For example, one of the Senators talked about--Senator 
McSally--making a moat around our seniors. It made me think 
about herd immunity. If we can vaccinate the population 
broadly, even if seniors do not respond as well to vaccines, 
get the population immune. Then the workers who often bring the 
virus into nursing homes, this will not happen because they 
will have been protected and would not have become infected, so 
investment in clinical research.
    Senator Braun. Thank you.
    This one will be for Dr. Landers because I think as we 
debrief this over time, finding out what works, these best 
practices, but we have noticed that in Florida where arguably 
you might have the most vulnerable populations, is there 
something there that we can glean? I think the laboratory of 
States gives us a much better way to learn than maybe that one-
size-fits-all site.
    The CDC, when we first looked at testing, cost us 30, 40, 
50 days because of that focus on just one way.
    Is there something there in Florida that anybody can weigh 
in on? Dr. Landers, do you think that this will speed the move 
from nursing homes to home care over time? It seems like you 
are probably more safe in your home than you would be in a 
place that has got a lot of folks in the same building.
    Dr. Landers. Thank you, Senator.
    There is no question that there is increasing interest in 
home health care, and I have been in several living rooms, 
quite frankly, in the last couple weeks with families who have 
brought family members home from facilities to continue their 
recovery at home. They have been relieved and happy to get the 
home health and visiting nurse support, which is really 
critical for them being able to come home.
    In terms of the differences in different locations, 
absolutely, there are--we have seen geographic variations, and 
we should try and learn from those. Living in New Jersey, a lot 
of the people we serve actually travel between Florida and New 
Jersey. It is a fairly common consideration for snowbirds and 
such, and a lot of the questioning we have gotten has been 
around can people come back for their--you know, those people 
that are fortunate enough to be able to travel as such and is 
it safe.
    We are all interconnected, but at the same time, there are 
differences. We will have to learn from this going forward.
    Senator Braun. Thank you.
    The Chairman. Thank you.
    Senator Warren, I do not know whether you heard my opening 
remarks, but I do want you to know that I know I speak for 
every member of this Committee in expressing our condolences to 
you. You have been touched very personally by this virus, so 
welcome.
    Senator Warren. Thank you so much. I appreciate it, Madam 
Chair. You reached out to me personally right after my brother 
died, and he died in a comforted setting facility, in a rehab, 
so thank you. I appreciate it, and I very much appreciate that 
you are holding this hearing today.
    In fact, what I want to talk about is I want to talk more 
about how seniors are bearing the brunt of COVID-19. Nursing 
homes have become the epicenter of the crisis, and it is 
important that we do everything we can, that there is testing 
and that there is contact tracing, and that we get a vaccine, 
and that we develop treatments.
    One of the things we need to do is collect more data. I 
want to start by asking Dr. Konetzka, Why is it so important 
that nursing homes collect and report, in a timely manner and 
transparently, data about COVID-19 infections?
    Dr. Konetzka. I think it is critical for several reasons. 
One is just that we need to know where to direct resources. 
Nursing homes need help when they are having an outbreak, and 
so we need to know that right away. It also gives us a signal 
about what is happening in the communities in which nursing 
homes are located. Second, it will enable us to do research 
that will help us later figure out what worked and what did not 
work so that we can perhaps do better the next time. Finally, 
it is really critical for consumers. We have been encouraging 
consumers since 2009 to get on Nursing Home Compare and look at 
information for their nursing homes good care, but right now, 
they cannot easily find which ones have COVID outbreaks. We 
would like to give them that information so they can make good 
decisions.
    Senator Warren. Thank you. I think that is really 
important.
    It is such a serious issue. In Massachusetts, for example, 
more than half of the COVID-19 deaths are directly linked to 
long-term care facilities.
    Now, the Center for Medicare and Medicaid Services, the 
Federal entity that regulates nursing homes, is taking some 
important steps to ensure better data, and just last month, as 
you may know, CMS started requiring nursing homes to report new 
COVID-19 infections, outbreaks, hospitalizations, and deaths 
directly related and they have to report it to the CDC. Nursing 
homes also must notify residents and families of these 
infections.
    Nursing homes are not the only facilities, long-term care 
facilities that have been hit hard by this pandemic. Roughly 
800,000 Americans live in assisted living facilities. In 
Massachusetts, about two-thirds of assisted living facilities 
have reported COVID-19 infections.
    Now, residents in assisted living facilities that serve 
older Americans require less frequent medical care than those 
in nursing homes and less help with activities for daily 
living, but populations in both places are similar, older 
people who need some help from caregivers in order to conduct 
daily tasks.
    Dr. Mulligan, you have been serving on the front lines of 
the coronavirus pandemic. When it comes to the patients that 
you have seen, does coronavirus affect nursing home residents 
any differently from how it affects assisted living residents, 
or are people living in both settings vulnerable to the crisis?
    Dr. Mulligan. There is no question that they are both very 
vulnerable.
    I think the assisted living facility and even the community 
dwelling seniors are at equal risk. If you think about a third 
of deaths are nursing home residents, but 80 percent of deaths 
are in seniors, that means there is an equal number to the 
nursing home deaths that are outside the nursing home.
    Senator Warren. That is right.
    Dr. Mulligan. Absolutely, Senator, you are correct.
    Senator Warren. Okay. That is really important.
    The reality is this virus does not care whether seniors are 
living in assisted living facilities or living in nursing 
homes. It can affect them, regardless.
    Let me go back to you, Dr. Konetzka. Are assisted living 
facilities required to report the same coronavirus information 
as nursing homes like report on infections or hospitalizations 
or deaths or outbreaks to the Federal Government and to the 
families and to the people who live there?
    Dr. Konetzka. No, they are not. Just like data collection 
and long-term care, generally, we do not collect much data from 
assisted living because they are not as dependent on Federal 
funding.
    Under the CMS guidance, as I understand it, we are also not 
collecting information from assisted living facilities, which 
for all the reasons you mentioned is unfortunate.
    Senator Warren. Yes. Assisted living facilities have 
similar populations as nursing homes. They face similar 
infection risks, but they are not subject to the same 
regulations when it comes to the coronavirus, and that is why I 
have launched an investigation with Senator Markey and with 
Congresswoman Maloney into how assisted living facilities are 
tracking coronavirus infections and preventive measures at 
these facilities and whether they have enough preventive 
measures in place.
    Assisted living facility residents and their families 
deserve to know whether or not their facilities are 
experiencing a coronavirus outbreak just like nursing home 
residents are entitled to know that, so I believe we owe it to 
our seniors to get this done.
    Thank you all for being here today, and thank you again, 
Madam Chairman.
    The Chairman. Thank you.
    Senator Rick Scott had to leave and go preside. He had 
joined us remotely. Now we still turn to Senator Doug Jones.
    Senator Jones. Thank you, Madam Chairman. Thank you very 
much for holding this hearing. I appreciate it, and thanks to 
all of our panelists for this very, very important hearing.
    I kind of want to followup a little bit about not just the 
assisted living but nursing homes in particular. My mom is in 
an assisted living, so it has been a challenge for all of us 
and especially her over the last few weeks. We lost dad in 
December. The isolation has been a struggle. We lost dad to 
Alzheimer's, and I think it has been particularly tough on 
Alzheimer's patients and caregivers. Those forms of dementia 
create special problems, regardless, it has been said.
    To listen to my mom, she has been talking every week. She 
will mentioned that as much as she misses my dad who she was 
married to for 70 years, she is also somewhat thankful that he 
passed before all of this pandemic hit. In part, I think that 
is because of the problems that she would have faced. She used 
to go down and visit him every day, and that is especially 
troubling.
    My friend, John Archibald, who writes for al.com, wrote an 
article this week called ``Coronavirus Creates a Special Hell 
for Dementia Caregivers,'' and he talked about trying to 
imagine what it is like for an Alzheimer's patient or 
caregivers. Imagine what it is like to try to explain social 
distancing to a person who does not share the reality, and he 
quotes Pam Leonard, who is a program director in Birmingham of 
the CJFS CARES program. She talks about caregivers and said 
that it is kind of like being on an airplane. You got to take 
care of yourself. You got to put on your own oxygen mask before 
you are able to help those around you.
    I would like to get to anyone on the panel. Given the 
special and unique needs and challenges that we are seeing, 
what can we do to more support individuals with dementia, both 
in these facilities and out, and their families and caregivers, 
and are there special trainings that might be needed for any of 
these long-term care and dementia facilities in a situation 
like we are in now which we have not seen before, but we could 
see again?
    I will open it to anybody.
    Dr. Mulligan. Senator Jones, I really think that you have 
touched on something so important. I think as a society, we 
will always be judged by how we take care of the most 
vulnerable, and certainly, our dementia seniors at this point 
are among the most vulnerable. They are not able to express, 
for example. If they are becoming ill, they would not 
necessarily be able to express that they do not feel well, that 
they feel hot, that they are short of breath, et cetera. They 
have medical as well as the sort of psychological, emotional 
vulnerabilities at this time of this pandemic that are unique 
to them, I think.
    I do not know that I have any specific answer for you, but 
I would encourage any effort to bring together a think tank to 
brainstorm about this. I think it is absolutely needed, and 
thank you for raising it.
    Dr. Landers. Senator Jones, thank you for raising this 
critical issue, and I share your deep concern for the well-
being of people living with dementia.
    Actually, one of the sad parts about all this has just been 
hearing my staff explain what is going on when they are doing 
nursing visits with older adults with severe dementia. In cases 
when they have had to do a test, those nasopharyngeal swab 
tests, for example, that has in some cases been fairly 
traumatic and upsetting even to do the test because the person 
just does not understand.
    One thing in assisted living and independent living, 
because that has been a big topic in this hearing, we should 
point out home health agencies are able to come into those 
settings, as are hospice agencies in certain instances, to 
buttress the care in those facilities, so to the extent that we 
continue to have a strong home health option and focus on the 
things that Senator Collins is focused on around telehealth, I 
think that is going to strengthen dementia are and assisting 
living and also encouraging people to focus on goals of care 
and family caregiving plans also can help, but really tough 
issues we are facing.
    Senator Jones. Great. Well, thank you. Thank you very much, 
both of you, for that.
    Dr. Konetzka, real quick, as my time runs out, your 
research has indicated that racial and ethnic minorities and 
low-income individuals have been disproportionately affected 
with nursing homes that have larger minority populations, more 
likely to have coronavirus cases and deaths. I think there is 
an article about that also in the New York Times.
    Could you briefly share more about what factors might 
contribute to those disparities?
    Dr. Konetzka. Yes. Thank you for that question.
    Disparities in nursing home outcomes from COVID are not 
unlike disparities we see across the health care system, and it 
is the result of many years of differences by race in health 
infrastructure and resources and risk factors of populations.
    What we found in our research was not necessarily that 
nonwhite residents were more--were having worse outcomes within 
a facility. It was about the percent white in a facility. To 
me, it is really about the neighborhoods in which nursing homes 
are located and staff going back and forth between those 
facilities and the neighborhoods.
    I think it is a lot about where the virus is circulating 
and who is in those facilities and who is going back and forth.
    Senator Jones. All right. Well, thank you, and thank you, 
Madam Chairman, for holding this hearing. It is very, very 
important. Thank you.
    The Chairman. Thank you, Senator.
    Senator Rosen.
    Senator Rosen. Thank you, Senator Collins, for holding this 
very important hearing. It is incredibly sad to see what is 
happening in our nursing homes and our assisted livings, what 
is going on with our caregivers across our country.
    I was a caregiver for my parents and in-laws. I understand 
this from a firsthand perspective, and it is overwhelming, 
frightening, and frustrating particularly at this time.
    One thing that I think we really need to focus on is 
research, research to fully understand how this virus works and 
how to best treat and prevent it. It is so critical.
    I recently introduced legislation with Senator Rubio, the 
Ensuring Understanding of COVID-19 to Protect Public Health 
Act. It is going to require a longitudinal study of COVID-19, 
including individuals of all ages along with diversity in race, 
ethnicity, gender, geography, underlying health conditions. We 
need to understand why the virus impacts some people like our 
seniors differently than others. We need to understand what the 
presence of antibodies really needs, if seniors or others who 
get sick gain an immune response or not.
    That is the theory that they gain an immune response, but 
reports of groups of patients becoming ill a second time is 
really concerning, and there has been recent reports, of 
course, across that group of sailors on the USS Theodore 
Roosevelt getting reinfected.
    Dr. Mulligan, I have a two-part question. Do you know what 
the latest research is, or can you talk about it, the latest 
research that is following patients who are diagnosed a second 
time with coronavirus, including seniors? this could have a 
further impact on our senior living centers. Do we know if this 
is a brand-new infection or if this is the original infection 
making them sick again, and what do you think this information 
might have? What impact might it have on vaccine development?
    Dr. Mulligan. Thank you, Senator Rosen, for this question.
    I do think that the jury is out in terms of formal proof 
that having recovered successfully, one is immune. Certainly, 
most people that recover make antibodies. We have seen that in 
our own studies, and many others have reported that.
    With most viral infections, it is true that once you have 
had it, you are protected at least for a period of time. I 
personally expected that should be true here as well. The 
formal proof of that will be done in studies such as you 
described, and I think that is a fantastic study.
    We are entering a time point where we have more and more 
convalescent patients, and now we can study how they do over 
time.
    I think the jury is out on these reports of possible 
reinfections that may well represent an intermittent negative 
test than a positive test that occurred as a result of their 
original infection. We know that can occur. The test is not 
perfect, and so that would not surprise me if that was the 
cause of some of those, but the jury is out, and for vaccine 
development, it is the same. I am a scientist. I want to know 
what the evidence says. If we do our studies correctly, if we 
are well supported, we will get the truth. We will get the 
answer, and that is what science will do for us.
    Senator Rosen. I want you to also--in your testimony, you 
said that medical countermeasures may need to be tailored to 
seniors in order to optimally protect them. Would you expand on 
that a little bit in a minute or so that I have left, please? 
Give us some good examples.
    Dr. Mulligan. Sure, I am very happy to do that.
    Maybe the most prominent example is that we have a couple 
of special vaccines for flu for seniors. We have a high-dose 
vaccine. We have a vaccine with adjuvant. We know, as I said, 
seniors' immune systems are weaker, and they do not respond as 
well to vaccines. Having a stronger vaccine, one with an 
adjuvant, one with a higher dose, may be necessary for COVID-19 
in seniors as well. We need to do those kinds of special 
studies.
    We also want to be sure that treatments are tolerated well 
and are safe in seniors. Their system is different, and so we 
need to be sure to include seniors in our treatment studies as 
well as our vaccine studies.
    Then another great example is the monoclonal antibody 
approach. If a senior cannot make a nice antibody themselves, 
perhaps we can infuse the antibody, this monoclonal antibody 
drug, and that is something that is going to be explored in the 
nursing home setting, and I think is very important.
    Senator Rosen. Well, I thank you and all the other 
witnesses for your work, your passion, your commitment. We 
really need you. We thank you all. We are very thankful you are 
doing what you are doing, and please stay well and safe. Thank 
you.
    The Chairman. Thank you, Senator.
    Dr. Mulligan, I want to followup on the questions you were 
just asked by Senator Rosen about your work on vaccines, and 
you have made the very important point that older adults 
sometimes do not respond as well as younger adults to vaccines, 
but that vaccines can convert this herd immunity that can help 
protect seniors.
    You have also distinguished about different kinds of 
vaccines. Could you describe to us the two vaccine trials that 
I understand you are currently involved with and whether or not 
you have seniors enrolled in those trials?
    Dr. Mulligan. Sure. Thank you, Senator Collins, for the 
question.
    We are currently conducting a Phase 1 trial in healthy 
younger adults, age 18 to 55, with one candidate vaccine. As 
soon as we see in this trial that the vaccine is tolerated and 
safe in these younger adults, we will go to a second group, 
including seniors. It is not unusual in medical research to 
make sure in the first in human studies that the new treatment 
or vaccine is safe and well tolerated in healthier younger 
adults before you go to a more vulnerable population, which 
might be seniors or children or pregnant women. We will quickly 
move to seniors in the trial we are currently conducting at our 
university.
    The second trial is a very large efficacy trial that will 
be launched in July supported by the U.S. Government, NIH, in 
collaboration with the vaccine that had the very promising 
early report, earlier this week with that company. That trial 
will be for adults aged 18 and older. From the very beginning, 
that efficacy trial will include seniors and will do so at a 
significant proportion. At least a quarter or more will be 
seniors as it is currently planned.
    The Chairman. That is very encouraging to hear.
    Could you also talk a little bit more and explain to us the 
fact that you could have the monoclonal antibodies approach? It 
is my understanding that when you give a vaccine, it is usually 
with a live virus, and then your body produces the antibodies 
that would allow you to fight off exposure to the virus later 
on, but if you use the--are you suggesting that an alternative 
approach is rather than injecting the virus, you would inject 
antibodies? Is that correct? Did I understand that correctly?
    Dr. Mulligan. Yes, Senator, you did.
    The standard approach is known as ``active immunization.'' 
We deliver a vaccine, which might be a weakened virus. It might 
just be a protein, a piece of the virus. It could be RNA, as 
was reported this week, and we ask the body to produce a bit of 
the vaccine protein and make an immune response, make the 
antibody.
    Seniors are not as good at doing that, and so an alternate 
is what is called ``passive'' rather than ``active 
immunization.'' In that case, you actually infuse the antibody, 
and the antibody has a half life of a month. There are ways to 
tweak it where it could even last for a couple of months. It is 
an interim approach, perhaps, to get us through the worst of 
this where we could protect our very vulnerable seniors, and it 
has to be tested in a randomized control trial.
    The Chairman. That is fascinating.
    Where are those antibodies produced? Are they taken from 
individuals who have already had the coronavirus, or are they 
manufactured, if you will, in a lab? How are they produced?
    Dr. Mulligan. Yes. Thank you. It really is fascinating.
    I will give you one example. Actually, the first human in 
the United States to come down with coronavirus, his antibodies 
were cloned by a company and created--converted in a laboratory 
to a drug. You can mass produce the antibody molecules and then 
have that available for infusion into research participates in 
the future, so you take--and you pick an antibody, I should 
have said. You pick the antibody that is very potent at 
neutralizing the virus, so you pick basically the champion 
virus and then champion antibody, and then that becomes your 
monoclonal antibody drug for testing.
    The Chairman. Very interesting. Thank you.
    Senator Casey?
    Senator Casey. Madam Chair, thank you very much for the 
hearing and also for the brief second round of questions.
    I just have two. I want to start with Dr. Konetzka. I had 
mentioned earlier the wait lists, the 800,000 individuals who 
are on waiting lists for both services and supports in their 
homes and their communities. I get that number from Kaiser 
Family Foundation. It is an awfully big number.
    That number did not arise since the crisis began. That has 
been a number that predated the crisis, but I want to emphasize 
these are people on waiting lists that qualify for services but 
there is insufficient funding to provide those services.
    We have some States, I know, that are increasing pay for 
direct-service providers, and that is one of the steps we 
should consider.
    I have a bill that would encourage every State to do what 
some States are doing, which has served as a foundation for the 
enhanced matching dollars the Federal Government provides for 
Medicaid in their recent legislation.
    Dr. Konetzka, can you explain the importance of addressing 
these wait lists for what is known as home-and community-based 
services in the context of the current pandemic?
    Dr. Konetzka. Thank you. I would be happy to talk to that.
    First, I should note, though, that interpreting these wait 
lists is a little bit difficult. These are wait lists for home-
and community-based care waiver programs under the Medicaid 
program, and each State does it a little bit differently, so 
800,000 sounds like a lot, but in some States, they just do not 
use wait lists. We may be underestimating the people who 
actually need services there.
    In other States, they do not assess people for eligibility 
before putting on the wait lists, so the wait lists are huge in 
those States.
    That aside, I think we can certainly agree that there are 
probably many more people who could benefit from these services 
that are getting them, and during this crisis, I think it is 
absolutely essential that we do what we can to try to enable 
more people to get those home-based services because the risks 
of entering a nursing home right now have just grown 
astronomically, so enabling more home-and community-based care 
right now may really save lives.
    Senator Casey. Thank you very much, Doctor.
    The last question I have is for Dr. Landers. I just want to 
go back because I was jotting down numbers before, and I think 
I missed one of the numbers in your testimony. It is regarding 
the personal protective equipment, PPE.
    You had indicated, I thought, that you needed for just a 
week, 17,000, and I was not sure what that was. If you could 
repeat those numbers, because one of the real failures--and 
this is a colossal failure--of the PPE is not simply that we 
have all kinds of instances where there is not enough in care 
settings, not to mention first responders and other 
circumstances, but what is going to happen in the months ahead? 
It is not just a question of what we need for this month or 
next month, and I think we do not have a sense yet of the 
numbers, the scale of the problem.
    I guess I just wanted to give and provide an emphasis on 
one provider or one care setting and what you need.
    Dr. Landers. Senator Casey, thank you.
    Yes. Our current kind of ``burn rate'' is kind of the term 
that is being used in terms of how fast we are going through 
PPEs as a company is that just over 17,000 of the surgical 
masks and then over 3,500 of the N95 masks every week. When I 
look to our chief operating officer and chief financial officer 
who are responsible for procuring this stuff, that is kind of 
what they are trying to find on the market with various 
vendors. It still remains a challenge for them to track down 
enough vendors.
    I am thankful that you are considering that going forward 
because it is an ongoing issue, and that is who we are able to 
continue to serve is by having that protective equipment.
    I actually did a home visit. It was a little bit warm last 
week. I was in an apartment building that was not very well 
ventilated, and I was sweating, and I was realizing, oh, I need 
to change my mask because the mask is getting soaked, so we do 
have to remember that sometimes these get soiled. There is a 
lot of need there, and so thank you for looking out for that 
issue.
    Senator Casey. Thank you.
    Thank you, Chairman Collins.
    The Chairman. Thank you very much, Senator Casey, and I 
would second your concern about the availability of PPE for our 
home health agencies. That has been a problem in the State of 
Maine as well that I have been working on personally to deliver 
some PPE to our home health agencies. It is something that is 
very difficult for them to do their jobs without it.
    I want to thank our terrific witnesses for being with us 
today and for their work and their research. It really makes a 
difference. I want to thank the staff for figuring out how we 
can safely hold this hearing and observe social distancing, 
which we did throughout.
    I would note that virtually every member of the Committee 
joined the hearing either in person here in the hearing room or 
remotely, and I am very pleased with that. I think it shows how 
much people care about this issue.
    I also want to give a special shout-out to the technical 
experts who made this possible. When you have that many 
Senators who are joining us remotely, Senators who are joining 
us here, and witnesses in three different places in the 
country, it is amazing to me that our technical experts were 
able to make everything go so smoothly, and I thank them.
    This week, the overall death toll in the United States from 
the COVID-19 virus surpassed 90,000 people, 80 percent of whom 
were older adults. This means that we have lost more than 
72,000 older adults to this pandemic.
    At the beginning of this hearing, I remarked on the 
enormous challenges and tragedy that COVID-19 has brought to 
our country. It has also brought countless examples of great 
courage and selflessness from those on the front lines of this 
pandemic, including our medical personnel and our direct-care 
workforce, but they are not the only ones. We see it at the 
grocery stores. We see it with those who are stocking the 
shelves and running our gas stations and other essential 
businesses. We see it as those as I have seen in the State of 
Maine who are making the swabs in rural Maine that are 
essential for our testing. We see it all over our country as 
people step forward and businesses step up to convert their 
lines and do their part. I appreciate all of that sacrifice, 
that compassion, that effort.
    I also want to pay special tribute to our witnesses today. 
I thought they were absolutely excellent and really increased 
our understanding.
    Dr. Mulligan's leadership on vaccine development helps 
advance tangible medical countermeasures for those most in 
need, and I appreciated his giving us a great education today.
    Dr. Konetzka's research helps us better inform our efforts 
to protect the residents not only of nursing homes but of 
assisted housing that our seniors have and other congregate 
care facilities.
    Dr. Landers focused on home health care, which has always 
been a special passion of mine, and technologies such as 
telehealth which helps us to improve care of older adults in 
their own homes, and after all, that is where most older adults 
want to be. They want to be in the privacy, security, comfort 
of their own homes if they can be.
    This Committee will continue to explore potential solutions 
to the challenges discussed in this hearing as well as other 
impediments to the health and safety of our Nation's senior.
    This week, members of the Aging Committee introduced a 
resolution to designate this month as Older Americans Month. As 
we work to improve care for older adults amid this pandemic, we 
also should take the time to recognize our seniors as valued 
members of our society, our culture, and our lives. The health 
and well-being of seniors strengthen our Nation as a whole and 
is the very mission of this Committee.
    Senator Casey, I would like to call upon you for any 
closing comments.
    Senator Casey. Chairman Collins, thank you for convening 
this hearing on such an important topic, and I am grateful for 
the opportunity that we have had. I am certainly grateful for 
the testimony of our witnesses who bring to bear a degree of 
expertise and experience with these issues that are so 
important to families when it comes to caring for our seniors 
in all settings, and we are grateful that the witnesses are 
with us today, and I know there will be even more followup.
    I do want to thank and reiterate what Chairman Collins said 
about the staff. This is a technical challenge, and they helped 
all of us through this. We are grateful for their good work, as 
we always should commend the staff in the Senate who do such 
good work and especially under these circumstances.
    We also want to thank, of course, as we all have in one way 
or another, all of the health care and home health workers 
throughout the country, service providers as well, caregivers 
for caring for our aging loved ones all the time but especially 
during this terrible virus, which has caused such devastating 
across the country.
    We owe all of those workers a debt of gratitude. I think we 
should do more than just say thanks. We talked about pandemic 
premium pay and other ways to reward their work because they 
are not just frontline workers. In many cases, they are at the 
front of the front line, exposing themselves and putting 
themselves at risk, and our Nation should reward them as we did 
returning soldiers from other battlefields in our history.
    Congress has done a number of things to help seniors in the 
four pieces if legislation that have been passed, but I would 
argue not nearly enough, not nearly what we must do for our 
seniors. That is why we have to keep acting legislatively.
    I am frustrated, as I know a number of Senators are, that 
we spent virtually the whole month of May on nominations and 
not voting on COVID-19 policy or appropriations, and 
unfortunately, we are going into June with that same setting or 
that same circumstance in the Senate. I think we should be 
voting--if we are going to be here and voting every week, we 
should be voting on COVID-19. That should be the top priority 
and, of course, the economic consequences that flow in the wake 
of this terrible virus, so we have more to do. We certainly 
need to do more on testing nationally. I think the 
administration should outline a strategy at long last.
    We mentioned personal protective equipment for our 
frontline workers. We cannot talk about or work on this issue 
enough. There is just no way to comprehend that in a Nation as 
powerful as ours, a Nation that was able to produce the 
armaments and other production capacity to win World War I and 
all the wars in between, including World War II, the idea that 
that same Nation cannot produce enough masks--masks or gloves 
or personal protective equipment for everyone that needs it is 
really an appalling--it is an appalling failure and we have to 
worry about the next couple of months. I know that as of eight 
o'clock this morning in the State of Pennsylvania, 64,412 
cases, the death number in Pennsylvania is now 4,767. That is 
only for March, April, and May. I do not want to be sitting 
here in December because we did not do enough on testing and 
personal protective equipment and find out that another 4,700 
or 5,000 Pennsylvanians have died.
    We need the productive capacity, and we are not doing 
enough as a Nation. The Federal Government has to demand that 
we set forth the production capacity on PPE. If we could do it 
in the past to win wars, we can do it now to win this war, and 
the administration has to do a lot more to make sure we can 
produce what we need, so we have a long way to go, lots more 
work to do, lots more legislating and appropriating, but we are 
grateful, Chairman Collins, for this hearing and thank you for 
giving us this opportunity.
    The Chairman. Thank you.
    Committee members will have until Friday May 29th to submit 
additional questions for the record. If we do receive some, we 
will pass them on to our witnesses.
    Again, I want to thank everyone for participating, and this 
hearing is now adjourned.
    [Whereupon, at 11:35 a.m., the Committee was adjourned.]
  
      
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                                APPENDIX

      
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                      Prepared Witness Statements

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                        Questions for the Record

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                  Additional Statements for the Record

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