[Senate Hearing 117-51]
[From the U.S. Government Publishing Office]


                                                         S. Hrg. 117-51

                    COVID-19 ONE YEAR LATER: ADDRESSING 
                      HEALTH CARE NEEDS FOR AT-RISK
                               AMERICANS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             MARCH 18, 2021

                               __________

                           Serial No. 117-01

         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                    
45-269 PDF                 WASHINGTON : 2021                     
          
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                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      TIM SCOTT, South Carolina
RICHARD BLUMENTHAL, Connecticut      SUSAN M. COLLINS, Maine
ELIZABETH WARREN, Massachusetts      RICHARD BURR, North Carolina
JACKY ROSEN, Nevada                  MARCO RUBIO, Florida
MARK KELLY, Arizona                  MIKE BRAUN, Indiana
RAPHAEL WARNOCK, Georgia             RICK SCOTT, Florida
                                     MIKE LEE, Utah
                              ----------                              
                 Stacy Sanders, Majority Staff Director
                 Neri Martinez, Minority Staff Director
                        
                        
                        C  O  N  T  E  N  T  S

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                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Tim Scott, Ranking Member...........     2

                           PANEL OF WITNESSES

Anand Iyer, MD, MSPH, Assistant Professor, Division of Pulmonary, 
  Allergy and Critical Care Medicine, University of Alabama at 
  Birmingham, Birmingham, Alabama................................     6
Amy Houtrow, MD, Ph.D., Professor and Vice Chair, Department of 
  Physical Medicine and Rehabilitation for Pediatric 
  Rehabilitation Medicine, University of Pittsburgh School of 
  Medicine, Pittsburgh, Pennsylvania.............................     8
Anthony Jackson, MBA, Senior Vice President and Chief Operating 
  Officer, Roper Saint Francis Healthcare, Charleston, South 
  Carolina.......................................................     9
Sandra Harris, Volunteer State President, AARP Massachusetts, 
  Boston, Massachusetts..........................................    11

                                APPENDIX
                      Prepared Witness Statements

Anand Iyer, MD, MSPH, Assistant Professor, Division of Pulmonary, 
  Allergy and Critical Care Medicine, University of Alabama at 
  Birmingham, Birmingham, Alabama................................    37
Amy Houtrow, MD, Ph.D., Professor and Vice Chair, Department of 
  Physical Medicine and Rehabilitation for Pediatric 
  Rehabilitation Medicine, University of Pittsburgh School of 
  Medicine, Pittsburgh, Pennsylvania.............................    40
Anthony Jackson, MBA, Senior Vice President and Chief Operating 
  Officer, Roper Saint Francis Healthcare, Charleston, South 
  Carolina.......................................................    54
Sandra Harris, Volunteer State President, AARP Massachusetts, 
  Boston, Massachusetts..........................................    55

                        Questions for the Record

Anand Iyer, MD, MSPH, Assistant Professor, Division of Pulmonary, 
  Allergy and Critical Care Medicine, University of Alabama at 
  Birmingham, Birmingham, Alabama................................    61

                  Additional Statements for the Record

Meals on Wheels, Arlington, Virginia.............................    65
Healthcare Leadership Council, Mary R. Grealy, President.........    67
Alzheimer's Association and Alzheimer's Impact Movement (AIM)....    68

 
                  COVID-19 ONE YEAR LATER: ADDRESSING
                HEALTH CARE NEEDS FOR AT-RISK AMERICANS

                              ----------                              


                        THURSDAY, MARCH 18, 2021

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:32 a.m., via 
Webex, Hon. Robert P. Casey, Jr., Chairman of the Committee, 
presiding.
    Present: Senators Casey, Gillibrand, Blumenthal, Warren, 
Rosen, Kelly, Warnock, Tim Scott, Braun, and Lee.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., CHAIRMAN

    The Chairman. The Senate Special Committee on Aging will 
come to order. Good morning to everyone. I want to welcome both 
new and returning members to the first hearing of this 
Committee for the 117th Congress. I am delighted that Senator 
Tim Scott of South Carolina will serve as the Committee's new 
Ranking Member. Senator Scott has been an active member of this 
Committee, and I look forward to working with him closely 
during this Congress.
    I particularly want to welcome the new members of the 
Committee. We have three: Senator Mark Kelly of Arizona, 
Senator Raphael Warnock of Georgia, and Senator Mike Lee of 
Utah. I look forward to all of our contributions over the next 
two years. We know that the Aging Committee has historically 
been a committee that fosters both bipartisanship and 
collaboration. As Chairman, I hope to adopt that same spirit of 
bipartisanship and advance an agenda to build health and 
economic security for seniors, people with disabilities, and 
their families.
    Today's hearing will focus on the continuing and grave 
threat to those Americans, and our Nation as a whole, the 
COVID-19 pandemic, and the effects it has had on the health of 
people most at risk due to the virus. We have lost more than 
24,600 Pennsylvanians to this pandemic. These were our mothers, 
fathers, grandmothers, grandfathers, sisters, brothers, 
neighbors, and friends.
    We all know that older adults have suffered the brunt of 
this pandemic, accounting for 81 percent of all deaths. A 
tragedy within the broader tragedy of this pandemic has taken 
place in our Nation's long-term care setting, where more than 
178,000--more than 178,000--residents and workers combined have 
died from COVID-19.
    Our witnesses today will help us better understand where we 
are one year into the pandemic. This is an important 
conversation, and it comes just one week after President Biden 
signed the American Rescue Plan into law. This historical 
legislation advances a bold vision to defeat the virus and 
begin to rebuild our economy. The American Rescue Plan, working 
families will have more money in their pockets, our children 
will return to school safely, and everyone who wants to, can be 
vaccinated. This bill ensures that home and community-based 
services are available for seniors and people with 
disabilities, and further will help put food on their tables. 
The bill strengthens our long-term care workforce, provides 
resources to ensure the heroes on the front lines have personal 
protective equipment, testing supplies, and even premium pay.
    The bright light at the end of this dark tunnel are, of 
course, vaccines. Distribution and administration of the 
vaccine is one of the greatest challenges the Nation has faced 
in our lifetimes. Getting the vaccine into people's arms has 
been a huge undertaking. Local churches, senior service 
agencies, and many other members of our communities met this 
challenge head-on, helping seniors and driving people to 
appointments.
    This bill gives states and communities the funding they 
need to further this important work and vaccinate those who 
need it the most. The plan will help us rise to the occasion 
and build on the progress President Biden and his 
administration have made in the last two months.
    The actions we are taking now are only the beginning. Our 
work is not done. The pandemic has highlighted long-standing 
injustices facing many Americans.
    We must enact policies to address the injustices that have 
plagued communities of color, people with disabilities, and 
older adults for far too long.
    The conversation we are having today is just the beginning 
of a much longer and critically important dialog for this 
Committee. I look forward to the work of the Committee on these 
important issues and hearing from our witnesses today.
    Just a few brief comments before I turn the microphone over 
to Ranking Member Scott. I wanted to remind Committee members 
and witnesses to please keep remarks and questions to five 
minutes. The countdown timer, otherwise known as a clock, can 
be viewed alongside the other participant windows on Webex. On 
mine it is in the upper right-hand corner.
    Following opening remarks, Senators will ask their 
questions based on seniority, and I will ask that members have 
their cameras turned on at least five minutes prior to their 
questions, so that we know they will be prepared to ask a 
question in line.
    With those final logistical notes, Ranking Member Scott, I 
am pleased to turn it over to you for your opening remarks.

            OPENING STATEMENT OF SENATOR TIM SCOTT, 
                         RANKING MEMBER

    Senator Tim Scott. Thank you, Chairman Casey, and 
congratulations on your new chairmanship, and I look forward to 
continuing the long tradition of having the Aging Committee be 
the most bipartisan committee in the United States Senate and 
hopefully all of Congress. It is certainly a wonderful 
opportunity for me, as the Ranking Member, to have an 
opportunity to lead our side in the conversation, the 
discussion around issues of the aging community.
    I think back to my own life and my mother, Frances Scott, 
who was a nurse's assistant. Many of the folks who are on the 
front lines are CNAs in nursing homes, certified nursing 
assistants, and having been raised by a single mother who spent 
16 hours a day working in hospitals, and really doing the 
entry-level jobs at the hospital, I thank God for someone who 
instilled in me the dignity of work, the hard work, focus, and 
going the extra mile for those who cannot do it for themselves. 
That is something that I hope that we, as a committee, focus 
on. I do want to welcome all of the new Committee members to 
this Committee.
    Interestingly enough, by the year 2034, the seniors in 
America will, for the first time, outnumber the children in 
America. That means we are literally sitting on the type of 
transformation in our country that requires complete and total 
focus on improving the quality of the outcome of our aging 
population. Unlike Bob, who seems to not have aged at all, I am 
aware of the fact that I continue to age myself.
    Nearly 18 percent of South Carolina's population, 900,000 
people in South Carolina, are over the age of 65. The 
demographic shift highlights the importance of the Aging 
Committee and the work that we will have to do in the years to 
come.
    I will certainly champion, every single day, the priorities 
of those folks who continue to age, including issues of 
financial security and health care. These are two pillars that 
must be our focus on the Aging Committee.
    I also want to extend my gratitude to the entire health 
care community as they confronted COVID-19 in a way that 
brought tears to our eyes, a lump in our throats, as well as 
warmth in our hearts. We were heartened by those who were 
literally going into dangerous places because of this COVID-19, 
nurses and doctors traveling across the country to the 
hotspots. I once again focus on those CNAs who are working in 
nursing homes, where we have seen nearly 40 percent of all 
deaths in America come out of nursing home facilities. That 
means that so many folks who are on the front line trying their 
best to save a life, and so many of those folks, 60, 70 percent 
of those folks who are CNAs are African Americans, and about 80 
percent of those folks are women.
    We cannot say it often enough. I certainly cannot say it 
often enough, thank you. Thank you for your willingness to be 
the difference for so many people, who were trapped without 
their loved ones, isolated and scared. You were the loved ones. 
You were the extended family. For that, our Nation will always 
be grateful.
    When this Committee held its first hearing on COVID last 
May, the idea that we would find a way to a vaccine quickly 
was, according to NBC News, impossible. It would take a 
miracle, they said, and thank God for miracles.
    Operation Warp Speed was that miracle, and in historic 
fashion, President Trump's administration, partnering with the 
private sector, found a way to bring a vaccine to the market so 
that in December, less than nine months or so after it started, 
about nine months after the virus started, in earnest, thinking 
back on our first vote in March--obviously it started before 
March--but nine months after we started focusing our attention 
on the virus we had a vaccine being shot into arms. He also 
purchased 300 million doses from three different companies, 
which allowed us to see the type of revolutionary start that we 
have seen.
    I am also thankful and welcome President Biden's 
declaration that by the middle of May, every single American 
adult will have an opportunity to be vaccinated if they want 
to. Now this is a very important point, because as we watch the 
rollout today, the numbers in the African American community 
and the Hispanic community are lower than we would want them to 
be. We are going to have to shore up vaccine confidence and 
availability.
    Our rural communities suffer the same fate in so many ways. 
They, too, need easier access to the vaccine, and we need to do 
a better job of making sure that our seniors and all of our 
Americans in our rural landscape understand the importance of 
getting the vaccine and participating in this process. South 
Carolina has certainly been a model of transparency throughout 
the pandemic. I look at the fact that 40 percent of the deaths 
nationwide come out of nursing homes, and our State of South 
Carolina it has been around 20 percent. I think what we want to 
see nationwide is a real focus on helping us improve the 
outcomes in nursing homes throughout this Nation, and 
specifically for our senior population throughout this Nation. 
To me, this is common sense.
    I am not exactly sure where the timer is, Chairman Casey, 
but I hope I have a few minutes, one more minute to finish up. 
Sounds good. Thank you, sir.
    Increasing funding for the production of the distribution 
of the COVID-19 vaccine is incredibly important. For us to 
focus our attention on the logistics right now is necessary.
    The one thing I will say about the COVID relief package 
that was disappointing is that only one percent of the 
resources went for more vaccinations, went toward vaccination 
production, and only nine percent focused specifically on 
health care issues around the vaccine. This is one of the 
reasons why many of us on the right had troubles with this 
package, because too few dollars actually focused on the COVID-
19 challenge that we have before us, and too many dollars 
focused on a progressive policy position that is not supported 
by the right.
    We loved the day in 2020, when we were all voting. Ninety-
plus Senators voted for five different packages. I certainly 
hope we find ourselves back letting the Aging Committee lead 
the rest of the Senators in a bipartisan fashion, presenting 
solutions to the American people that we can all be proud of.
    Thank you all to the witnesses for being here with us 
today, and I look forward to the meaningful dialog that we will 
have about the way forward. Thank you, Chairman Casey.
    The Chairman. Ranking Member Scott, thank you very much. As 
someone who has served, as I did, as the Ranking Member, I 
always want to give the Ranking Member any additional time he 
might need.
    Senator Tim Scott. Thank you, sir.
    The Chairman. Let me just turn now to our witness 
introduction, and just for the witnesses' benefit, what we will 
do is introduce each witness one after another, and then after 
all witnesses are introduced that is when we will turn to the 
testimony, just so folks know the order of things.
    Let me start with our first witness. I am pleased to 
introduce Dr. Anand Iyer. Dr. Iyer is from Birmingham, Alabama. 
Dr. Iyer is a pulmonologist working in the intensive care unit 
at the University of Alabama at Birmingham. He also runs the 
local pulmonary clinic for underserved residents of Jefferson 
County, Alabama. Over the last year, Dr. Iyer has been on the 
front lines of the pandemic, caring for the critically ill in 
the ICU.
    He will share his experiences caring for a primarily rural 
African American patient population in Alabama. He will also 
discuss barriers to access, the access to care experienced by 
his patients, and the work he and his colleagues are doing to 
decrease vaccine hesitancy.
    Dr. Iyer, thank you for being with us today and for sharing 
your work with the Committee.
    Second, I want to introduce another doctor, Dr. Amy 
Houtrow. Dr. Houtrow is from my home State of Pennsylvania. In 
fact, she is from Pittsburgh, Pennsylvania, in the southwestern 
corner of our state. She is a physical and medical director of 
the Rehabilitation Institute at Children's Hospital of 
Pittsburgh. She is also a PhD public health researcher, 
examining models of health care delivery, and as a person with 
a disability she has multiple perspectives on disability, 
health care, and the pandemic we have been experiencing this 
past year.
    I want to thank Dr. Houtrow for being with us today and for 
sharing your expertise with the Committee.
    Third, Sandra Harris. I am pleased to introduce her. She is 
a Massachusetts resident. I know Senator Warren is pleased to 
have her with us today. Senator Warren will be joining us later 
in the hearing for questions.
    Ms. Harris is the Volunteer State President of AARP 
Massachusetts and serves as the chairwoman of the AARP 
Massachusetts Executive Council. She has a long history as an 
advocate for older Americans. She will speak to the health care 
needs of older adults during the pandemic, with a focus on 
long-term care residents as well as seniors living in the 
community. She will also discuss the importance of vaccinations 
and access to nutrition and supportive services.
    Ms. Harris, thank you for being with us today and for 
sharing your work with the Committee.
    I will now turn to Ranking Member Scott to introduce our 
witness from South Carolina.
    Senator Tim Scott. Thank you, Chairman Casey. I am pleased 
to introduce my good friend from the Palmetto State, Anthony 
Jackson. Anthony is a leader in the competitive hospital 
industry in South Carolina. Anthony's testimony today is based 
on his extensive work in South Carolina's private and nonprofit 
health care systems, and I know that this is a personal passion 
for him, as it is for me.
    Anthony was named the Senior Vice President and Chief 
Operating Officer of Roper Saint Francis Hospitals in the 
spring of 2019. His historic hiring happened about 50 years 
after Roper Hospital was first required to admit Black 
patients, and Anthony became Roper's first African American 
CEO. He has come a long way, starting out his careers as a 
radiology tech at Roper Hospital, and now, after more than 20 
years of executive experience, he is one of the top leaders in 
the health care industry.
    Thank you, Mr. Jackson, for being with us here today, and I 
look forward to hearing your testimony.
    The Chairman. Thank you, Ranking Member Scott. Now we will 
turn to our witnesses for their statements. We will begin with 
Dr. Iyer.
    Dr. Iyer, you may begin.

    STATEMENT OF ANAND IYER, MD, MSPH, ASSISTANT PROFESSOR, 
  DIVISION OF PULMONARY, ALLERGY AND CRITICAL CARE MEDICINE, 
    UNIVERSITY OF ALABAMA AT BIRMINGHAM, BIRMINGHAM, ALABAMA

    Dr. Iyer. Good morning. My name is Anand Iyer. I am a 
pulmonologist and geriatric and palliative care researcher at 
the University of Alabama Birmingham School of Medicine. I 
serve in the ICU and founded a pulmonary clinic down the street 
from our medical center that provides care for hundreds of 
underserved citizens. In my clinic, 80 percent of patients are 
black, 20 percent are over 65, and most are uninsured. These 
are the people at highest risk for poor outcomes due to COVID-
19 and are now the ones having the most difficulty accessing 
vaccines.
    One of my patients is a woman in her 70's with COPD, who 
lives alone in public housing. She requires oxygen and has no 
Internet and no transportation. Every trip outside her home is 
a huge ordeal. It is against this backdrop of caring for people 
like her that I entered the pandemic. A year ago, we admitted 
the first people with COVID-19 to our ICU. Since then, over 
10,363 of my fellow Alabamians have died. We stared directly 
down their vocal cords to place them on ventilators while their 
families anxiously waited at home. All along, we were terrified 
of bringing this virus home to our own families. Though the 
physical scars of wearing N-95 masks for our entire shifts 
fade, the emotional scars will not. While caring for people in 
the ICU at UAB I was keenly aware of the struggles my 
colleagues faced at smaller rural facilities across Alabama. 
Telehealth improved outcomes and offered an innovative way to 
safely reach out to people isolated in their homes during the 
pandemic. However, barriers to equitable broadband access 
created a hurdle for many. The Telehealth Modernization Act 
continues many of the emergency provisions enacted during the 
pandemic that must carry forward, and support for the 
Accessible Affordable Internet for All Act improves critical 
broadband access to close the digital divide.
    The long year finally gave rise to hope in December when 
the vaccines appeared. I have spent every clinic visit since 
then encouraging my patients to get vaccinated. I describe my 
own vaccine experience and respond to their questions about 
side effects. The problem for most of my patients is not 
vaccine hesitancy. Many want one when it is their turn. Rather, 
the biggest issue for most is vaccine access. Attributing the 
low vaccination rates among minority populations only to 
vaccine hesitancy fails to acknowledge real racial and 
socioeconomic disparities in vaccine access that require urgent 
solutions.
    COVID-19 also exposed significant geographic disparities in 
access, especially in the rural South. When I was young, I 
joined my father, a family physician, on house calls to farms 
in northeast Alabama. He listened to his patients' lungs and I 
brought home baskets of tomatoes. I witnessed early on their 
isolation and the struggles they faced accessing care in rural 
Alabama.
    Rural Americans have a 13 percent higher risk of death due 
to COVID-19. More and more are dying from chronic health 
conditions like COPD, and 17 rural hospitals have closed in my 
state in the past decade. Expansion of Medicaid could improve 
access to comprehensive care for rural Americans and stem the 
tide of rural hospital closures so people can seek help when 
they need it.
    Our country has made great strides vaccinating older 
Americans. However, millions are at risk for missing their 
shot. This gap will widen as eligibility expands and the most 
vulnerable are unable to compete for spots. One in five seniors 
could be at risk for missing their vaccine due to age-related 
barriers like limited mobility, lack of transportation, no 
caregiver support, functional and cognitive impairments, and 
digital and social isolation.
    The American Rescue Plan makes essential investments to 
improve vaccine outreach to these populations. Here are three 
ideas that could help these efforts succeed and dismantle 
access barriers for vulnerable populations.
    First, create a centralized system that identifies those 
most at risk for missing the vaccine and partner with area 
Agencies on Aging and others to fill the data gap.
    Second, simplify the process. Use telephone registration 
and expand proactive outreach through programs like Senior 
Buddies and Vaccine Community Connecters, who are going door to 
door to schedule vaccinations and arrange transportation.
    Third, get the vaccine out to where people live. Expand 
mobile vaccination programs, get COVID vaccines to people in 
their homes, set up vaccination sites in the hardest hit 
communities, and build relationships with trusted community 
partners.
    Leaders at UAB prioritized vaccine equity from the 
beginning and partnered with the city to set up vaccination 
sites in underserved areas around Birmingham. These efforts 
helped vaccinate minority communities locally at four times the 
state and national averages.
    The COVID pandemic exposed significant disparities and 
divides in our health care system, especially among older and 
at-risk Americans. Accessible vaccines will urgently save their 
lives, and what we learn from the process will have long-
lasting, positive impacts on our health care system.
    I am honored to be here today to reflect on the past year 
and to bring a voice to the challenge that my patients face. 
The most vulnerable will not be able to raise their hand and 
tell us they need help. We must reach out to them.
    Thank you.
    The Chairman. Dr. Iyer, thank you very much. Dr. Houtrow.

STATEMENT OF AMY HOUTROW, MD, Ph.D., PROFESSOR AND VICE CHAIR, 
    DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION FOR 
  PEDIATRIC REHABILITATION MEDICINE, UNIVERSITY OF PITTSBURGH 
          SCHOOL OF MEDICINE, PITTSBURGH, PENNSYLVANIA

    Dr. Houtrow. Chairman Casey, Ranking Member Scott, and 
honorable Committee members, thank you for inviting me to speak 
today. My name is Amy Houtrow. I am the chief of rehabilitation 
medicine at UPMC Children's Hospital of Pittsburgh and 
professor and endowed chair at the University of Pittsburgh.
    I am approaching my testimony from the perspective of a 
person with disabilities, a physician who cares for people with 
disabilities, as an advocate for health equity, and as an 
academic with training and research expertise in health 
services and policy. As they say, we are all weathering the 
storm together, but we are not all in the same boat.
    My boat is small and scarred. I was born with an 
exceptionally rare genetic condition that shaped my body in 
dysmorphic atypical ways and has shaped me into the person I am 
today. I know of limitations; I live with them. I also know of 
perseverance and circumstance. In late February 2020, before 
most of Americans knew what was happening, I was preparing to 
isolate myself. My spine is twisted, my lungs crammed, the 
lower lobe of my right lung always vulnerable to infection 
because of the deformities of my chest. I take 
immunosuppressive medications. I knew right away that COVID-19 
could easily kill me. I am an at-risk American.
    My work here on this planet is not done, so I set about 
protecting myself and all of my patients. I am lucky that I 
could move the entirety of my work to the virtual space, all of 
my meetings, all of the planning we were doing for our pandemic 
response, all of my research, and yes, all of my patient care 
went virtual. Thankfully, with emergency waivers, we have been 
able to successfully deliver telehealth care, and recent 
telehealth innovations and expansions have benefited many 
patients with disabilities during the pandemic and will beyond 
if they are promoted and supported.
    For the past year, we all watched, in horror and with 
sadness, as COVID-19 ravaged congregate care facilities. For 
every dark cloud, we must find the silver lining. As we plan 
for the future we must assure the health and the safety of 
people living in congregate care settings, but we also should 
develop and promote strategies to keep older adults and people 
with disabilities living in their homes with the supports and 
services they need. To do this we need to strengthen the home 
and community-based services and develop a robust home care 
workforce. It behooves us to do so, because most people desire 
staying in their homes, and according to CMS, home care is less 
costly than residential care. The $12.7 billion fought for by 
Senator Casey in the American Rescue Plan for expansion of 
Medicaid home and community-based services is an excellent step 
forward to realizing the promise of Olmstead.
    Perhaps the biggest triumph of this pandemic has been the 
speed at which vaccines were developed. Unfortunately, 
equitable distribution of the vaccines has proven challenging. 
As a starting point, vaccine registration systems and 
administration sites must meet the standards of the ADA and 
Section 504 of the Rehabilitation Act. Moneys in the American 
Rescue Plan are much needed to address this urgent problem.
    Active outreach in communities is also necessary to help 
reduce existing disparities in vaccine access that exist right 
now, today. Strategies to reach those in need such as mobile 
vaccination units that can administer vaccines inside people's 
homes should be expanded to vaccinate semi- or completely 
homebound individuals and people for whom home administration 
would be safer and easier than administration at vaccination 
sites. We should empower trusted community leaders to help 
reach people, whether through churches or in barber shops, to 
improve the vaccine distribution to those hardest hit by 
disparities. We need this now, and we need to have plans put in 
place for the next pandemic.
    This pandemic is an inflection point for the United States. 
Do not let it go to waste. We need to address the structural 
problems that make certain members of our communities more 
vulnerable to COVID-19 and other diseases. We need to make 
changes to our public health infrastructure and health care 
systems so that we are better prepared for the next crisis. We 
need to make it possible for all of us to thrive--today, 
tomorrow, and beyond.
    Thank you for the opportunity to present to the Committee 
and I would be pleased to answer your questions. As I close my 
oral testimony, I offer you this quote from Maya Angelou: ``Do 
the best you can until you know better. Then, when you know 
better, do better.''
    The Chairman. Dr. Houtrow, thank you very much. I want to 
turn the microphone over to Mr. Jackson for his remarks.

 STATEMENT OF ANTHONY JACKSON, MBA, SENIOR VICE PRESIDENT AND 
   CHIEF OPERATING OFFICER, ROPER SAINT FRANCIS HEALTHCARE, 
                   CHARLESTON, SOUTH CAROLINA

    Mr. Jackson. Chairman Casey, Ranking Member Scott, and 
members of the Committee, thank you for inviting me to testify 
today. My name is Anthony Jackson and I am the Senior Vice 
President and Chief Operating Officer of Roper St. Francis 
Healthcare here in Charleston, South Carolina. Roper St. 
Francis is the only private, not-for-profit, faith-based health 
care system in Charleston. We have four hospitals with 657 beds 
across five counties. We are the region's largest private 
employer, with more than 6,000 employees, and we have more than 
1,000 doctors on our medical staff.
    The impact of COVID-19 on Roper St. Francis Healthcare has 
been dramatic. Since the start of 2020, there have been 455,495 
confirmed cases of COVID in South Carolina. This pandemic has 
disproportionately affected older Americans, and that was 
especially true at Roper St. Francis Healthcare. Over this past 
year we experienced many difficult moments as our doctors and 
nurses bravely and tirelessly worked to treat COVID patients. 
This includes patients such as Lethia Moore, a 78-year-old 
great-great-grandmother who was admitted to Roper St. Francis 
Healthcare on April 3rd, and sadly passed away on April 12th, 
comforted by a nurse who refused to leave her side.
    As COVID continued to spread, our hospital system adapted. 
While we already had a platform in place for telehealth, the 
COVID pandemic required us to scale up quickly. Telehealth has 
proven so valuable that we intend to continue it in the long-
run. We have set a goal of maintaining 20 percent of all visits 
via telehealth, which opens doors for many vulnerable older 
Americans, particularly those who are homebound, those living 
with disabilities, and those who live in rural areas.
    We are hopeful that this pandemic will be brought to an end 
this year with the advent of the COVID-19 vaccine. Roper St. 
Francis Healthcare is working closely with the State of South 
Carolina to administer COVID vaccinations. We received our 
first batch of vaccine in December and began administering them 
to our health care workers on December 15. In January, we 
opened a COVID vaccination drive-thru for patients in the 
parking lot of the North Charleston Coliseum, a site that is 
used to accommodating crowds of more than 13,000 for events. We 
have the capacity to vaccinate up to 1,500 residents per day.
    Additionally, this week, we launched a pop-up drive thru 
location in Berkeley County for residents 55 and older. This is 
important because about three-quarters of Berkeley County's 65-
and-older population has yet to be vaccinated. Vaccine drive-
thru centers can play an integral role in expanding our 
vaccination campaign beyond urban areas to reach a population 
that is often left behind. Communities and states must be 
proactive and creative to reach residents who cannot get 
vaccinated through more traditional visits to hospitals and 
doctors' offices. Our drive-thru vaccination sites would be a 
great model for others to follow.
    The pandemic and vaccine rollout also have shown the 
importance of treating seniors across all facets of the health 
care continuum. Whether it is hospitals, community health 
centers, or nursing homes, we all have a role to play. Why is 
that? We know that when we consider social environmental 
factors such as social mobility, work, retirement, education, 
income, and wealth, caring for our seniors becomes even more 
complex.
    Health care for seniors is dynamic and multidimensional, 
and to address them adequately, the pandemic has taught us that 
in the community we have to be collaborative, innovative, 
intentional, and equitable. Roper St. Francis is proud of the 
thousands of hours of community care that we provide in 
Charleston and the surrounding communities alongside our 
community partners and volunteers.
    As a former licensed nursing home provider, I understand 
the value of senior-care communities. Our patients have turned 
to us for guidance over this past year, and we cannot and will 
not lose their trust. We need to continue to have transparency 
and accountability, and I am proud of the work that all the 
staff at Roper St. Francis has done and will continue to do as 
the pandemic is not over.
    Ensuring healthcare providers have a sufficient and 
dependable supply of COVID-19 vaccine is central to our ability 
to successfully plan and operate vaccination events, so thank 
you for your continued efforts around this issue. I am thankful 
to every member of the Committee for their work to ensure that 
our hospitals have the resources they needed to fight the 
pandemic, and I am looking forward to continuing to serve our 
patients in the Lowcountry. Thank you.
    The Chairman. Mr. Jackson, thanks for your remarks.
    We will turn finally now to Ms. Harris.

  STATEMENT OF SANDRA HARRIS, VOLUNTEER STATE PRESIDENT, AARP 
              MASSACHUSETTS, BOSTON, MASSACHUSETTS

    Ms. Harris. Chairman Casey, Ranking Member Scott, and 
members of the Committee, thank you for inviting AARP to 
testify today. My name is Sandra Harris and I am the volunteer 
State President for AARP Massachusetts. On behalf of our 38 
million members, including 776,506 in Massachusetts, and all 
older Americans nationwide, AARP appreciates the opportunity to 
provide testimony at today's hearing.
    COVID-19 has been particularly hard on Americans over the 
age of 50 and people of color. Since the start of the pandemic, 
nearly 95 percent of the deaths have been among people age 50 
and older. Additionally, millions of Americans, older adults, 
have been alone and spending precious time away from loved one. 
I have not seen my five and eight year-old grandsons in almost 
16 months. Can you imagine how much I have missed in their 
lives?
    We have heard from so many other grandmothers and 
grandfathers. We are all eager to see our grandchildren and 
visit our parents and loved ones in their nursing homes.
    Since the beginning of this pandemic, over 178,000 long-
term care facilities residents and staff have died, including 
over 8,600 in Massachusetts, representing about 35 percent of 
deaths nationwide and over 50 percent of deaths in 
Massachusetts, despite the fact that nursing home residents 
comprise less than one percent of the U.S. population.
    While there may be a sense of relief with the vaccine 
rollout and the cases and deaths in nursing homes are finally 
declining, the situation in our Nation's nursing homes and 
other long-term care facilities remain dire. In my written 
testimony, I have highlighted AARP's five-point plans, which 
include ensuring access to PPE, increasing transparency, 
allowing for safe in-person visitation, adequate staffing, and 
rejecting immunity for long-term care facilities.
    We are encouraged by the progress being made in 
distributing the vaccines to Americans. However, with low or no 
connectivity, lack of access or devices, I just do not know how 
far too many older Americans are struggling to access an 
online, biased appointment system. For those who do gain 
access, long waits and appointment queues, Web site crashes, 
and finding that ``no appointment available message,'' these 
are all frustrating.
    I have personally stayed online for over two hours before 
getting that much dreaded ``no appointment available'' message. 
We urge the Federal Government to work with states to develop 
1-800 numbers for scheduling appointments.
    Another concern to AARP, and of grave personal concern to 
me, is the wide disparities in accessing the vaccine. According 
to the CDC, of people who are fully vaccinated, almost 69 
percent are white, only seven percent are Hispanic, and almost 
seven percent are Black. AARP is committed to reducing this gap 
and has recently partnered with five of the Nation's largest 
nonprofit organizations to launch the COVID Vaccine Equity and 
Education Initiative. We have heard from many individuals who 
are homebound, who cannot leave their homes due to medical or 
other reasons. We are pleased to see the CDC addressing these 
issues and funding from FEMA to work with states in developing 
mobile clinics and getting vaccines to those homebound 
individuals.
    In addition to improving the health and safety of nursing 
home residents, Congress must take a look, longer term, to give 
older adults and people with disabilities more options to 
receive care at home, and to provide support for family 
caregivers. I wish I had the time to share with you the 
emotional and financial burdens my siblings and I are 
experiencing caring for our 92-year-old mother who is living at 
home with dementia.
    Finally, it is heartbreaking to see people waiting in long 
lines for basic necessities like food. More than 20 percent of 
people age 50 to 59, and 14 percent of Americans age 60 and 
older are struggling to just put food on the table, with Black 
and Hispanic older adults reporting even higher rates of food 
insecurity. We are so thankful for SNAP, which has been a much-
needed lifeline for so many.
    Americans over the age of 50 continue to struggle with the 
impacts of this pandemic, and we will do so for some time. We 
are thankful that some relief has arrived, but we must do more 
to protect the health and safety of America's most vulnerable, 
our seniors. We can, and we must do better.
    The Chairman. Ms. Harris, thanks very much for your 
statement. I want to thank all of our witnesses for their 
statements. Now we will move to a round of questions. I will 
start with one of our doctors, Dr. Houtrow, to ask you one 
basic question about some of the fundamentals that we are 
facing.
    As I said in my opening statement, as you pointed out, 
older adults and people with disabilities have been 
disproportionately impacted by the pandemic. People with 
disabilities are three--three times more likely to die from 
COVID-19 as the general population. Over a third of the COVID-
19 deaths that have occurred today have been in congregate 
settings, as I mentioned earlier, either residents or workers.
    There are over four million people in the United States 
with disabilities, or older adults, who now receive, right now, 
home and community-based services through Medicaid. These 
services make it possible to reduce the risk of contracting the 
virus by keeping people in their homes and supporting them in 
their own communities. The American Rescue Plan provides, as 
you mentioned earlier in your testimony, $12.7 billion in new 
funding--new funding--for home and community-based services for 
next year, including in my home State of Pennsylvania an 
estimated $730 million for those services.
    Doctor, your unique set of experiences include clinical 
care, public health knowledge, health care systems approaches, 
and, yourself, have a disability. Speaking from those multiple 
perspectives, can you look ahead and talk about the importance 
of establishing and maintaining a strong home and community-
based services network and workforce into the future?
    Dr. Houtrow. Thank you, Chairman Casey. Your question is 
particularly insightful because you asked about establishing 
and maintaining a strong network and workforce. We do not have 
a strong workforce now, we did not before the pandemic, but I 
appreciate all of your efforts to help us create one.
    In Allegheny County, Pennsylvania, where I live, the hourly 
wage for a direct service worker is $12.41 an hour. This is far 
from a living wage, which is nearly $34 an hour for a single 
mom in Pittsburgh who is raising two children. If you cannot 
support your family, you look for other employment. Direct 
service workers should be paid a living wage.
    To do this, we need Medicaid restructure reform. This will 
help bring down our turnover, a chronic problem with the direct 
service workforce. We need to provide this workforce with good 
benefits, including access to accurate PPE and sick leave. 
Transportation to work is often a barrier, so assuring that the 
workforce has transportation is essential. We have a huge, 
informal, which is code for ``unpaid'' caregiving workforce 
that should be paid as direct service workers.
    The Chairman. Well, I want to thank you for that response 
because as I made reference to, and Ranking Member Scott did as 
well, most of the people doing this work all across America, 
the high percentage are women and women in communities of 
color. If we are going to continue to have a system where they 
are not paid and have the appropriate benefits, we are not 
going to have the quality care that we all claim that we want 
to create in those settings. I appreciate you speaking directly 
to the need for home and community-based services and the 
support for the workforce.
    My last question, and I have a little over a minute to go, 
but I will direct my attention to Ms. Harris for this question. 
The crisis in nursing homes by the COVID-19 pandemic required a 
response equal to that of the crisis at hand. The Rescue Plan 
included $500 million in dedicated money for strike teams, $200 
million for technical assistance to nursing homes, and that is 
to promote infection control protocols and help with the 
vaccination process.
    I have done a good bit of work on this with a number of my 
colleagues, including, most recently, partnering with Senator 
Toomey, my colleague from Pennsylvania, on a bipartisan Nursing 
Home Reform Modernization bill.
    Ms. Harris, beyond the COVID-19 pandemic, what steps can we 
take to improve nursing home quality?
    Ms. Harris. Thank you for the question, Senator, and also 
thank you for your leadership and the new bill, the 
modernization bill. AARP certainly supports it and we look 
forward to working with you in any way that we can.
    One of the things that has truly happened is that this 
pandemic has highlighted the real issues, systemic issues in 
our long-term care nursing. I think one of the most critical 
things is that we need to have nursing home care reform. I 
think that we need to begin to look long-term as really where 
the issues are, because this is going on for much too long. I 
think in terms of that we need to make sure that we have 
adequate staffing and have programs for recruiting, retaining, 
training, and career ladders, with enough funds and benefits. I 
think it is really critical that we really need to address 
infection control, staffing, and making sure that our residents 
and frail elderly in these nursing homes are safe.
    The Chairman. Thank you very much. Ranking Member Scott.
    Senator Tim Scott. Thank you, Mr. Chairman, and thank you, 
Ms. Harris, for your last answer to the question about nursing 
home safety. It is really an issue that we should all take very 
seriously. It is one issue that I tried to address during the 
COVID markup, offering a couple of amendments around the issue 
of nursing home safety, and frankly, getting accurate 
information from states. It was very hard to watch when New 
York was not forthcoming with all the information, and I think 
that we have to make sure that we have all the information in 
order to assess the challenges in nursing homes.
    Mr. Jackson, as a health care expert I know that you have 
spent 30 years or so in the industry. Do you think we need to 
redirect or direct more resources into nursing homes, as Ms. 
Harris and Chairman Casey have both alluded to and specifically 
stated? Many of the workers in the nursing home communities are 
African American females--80 percent are females, 60 to 70 
percent African Americans.
    We see that we have a real challenge nationwide in our 
nursing home facilities. The real question is not based on race 
or income but based on the necessity of resourcing the most 
vulnerable population, where the vast majority of the deaths 
have come from, age-wise, and then 40 percent of the deaths 
specifically from nursing homes.
    Do we need more resources there or am I missing something 
there, Mr. Jackson?
    Mr. Jackson. No, I would agree that we do. I think the 
answer, while complex, really is twofold. I think one speaks to 
regulatory requirements for nursing homes, especially in South 
Carolina, coupled with the pressures of reimbursement for 
staffing. When you only have to have as a requirement one RN 
per shift, and the physician is not required to see patients 
each day, when you look at the viability of a nursing home, 
they start to move away from the responsibility for which they 
exist, which is to take care of patients from a long-term 
perspective where they have moved more to taking care of short-
term types of disease, which provides for quicker turnover and 
a better reimbursement. Certainly when you look at the way 
nursing homes are staff, there is no way they could ever be 
prepared to handle what took place with respect to this 
pandemic.
    Senator Tim Scott. Thank you, sir. Now another question for 
you, Mr. Jackson. At home in South Carolina, as you are well 
aware--frankly, let me just say thank you for your continued 
efforts around making sure that the vaccination is something 
that is available--I should say the vaccine is something that 
is available, in rural South Carolina, the inner cities, urban 
South Carolina, bedroom communities. You have been a force to 
reckon with as relates to getting the vaccine everywhere you 
possibly can and in as many arms as you possibly can.
    The good news is that Governor McMaster has unveiled a plan 
that puts our state in a position where, frankly, everybody 55 
and up can get access to the vaccine. Phase 1b has started in 
South Carolina, and, frankly, by May 2nd my understanding is 
his plan is to have everyone 16 years and older who wants the 
vaccine getting the shot.
    Given your experience in the health care industry, can you 
talk about the enormous progress being made in South Carolina 
in the last recent months and perhaps speak about the factors 
specifically that has led to that type of progress?
    Mr. Jackson. I think one of the things that we recognized 
early on, obviously this pandemic took us all by surprise. We 
recognized very quickly for the need for collaboration and to 
work together, and this became less about competition and more 
about community. We worked very hard with our other market 
hospitals and providers, not just acute cares but skilled 
facilities, assisted living facilities, working with DHC, you 
know, in and around, finding and garnering the resources and 
support to be able to address those issues as it related to the 
health and well-being of our community.
    I think the work with the South Carolina Hospital 
Association, the clarity and attempt at transparency in terms 
of gaps, mistakes, equipment, supplies, when you create an 
environment of culture where you can have those conversations, 
where everyone is truly focused on what is best for the 
community, you tend to have the success that we have seen in 
South Carolina. Not only did we get support from our state and 
local leaders, you know, having access to be able to reach out 
to your office and have them respond the way that they did, in 
terms of connecting us directly with manufacturers, to have 
conversations about the need in South Carolina, and being able 
to partner and knowing that we were all on the same page, with 
the same goal of making sure we take of those who are most 
vulnerable.
    Senator Tim Scott. Thank you, Mr. Jackson. I know my time 
is about up so I will just say this in my parting comment. I 
think Dr. Iyer hit the nail on the head as it relates to the 
importance of telemedicine being a permanent feature or 
characteristic in our health care system going forward. If I 
had more time I would spend more time on the issue of 
telemedicine with you, Mr. Jackson, and Dr. Iyer. I may ask 
questions for the record and look for your wisdom and expertise 
on how we continue unfolding telemedicine throughout this 
Nation, especially in rural America.
    Mr. Jackson. Absolutely. Thank you.
    The Chairman. I think we are trying to get our lineup here. 
We have got some Senators in the queue.
    I wanted to just take a moment, as an interlude here, to 
ask a question of Dr. Iyer. Dr. Iyer, we know the importance of 
getting the vaccine into all throughout the Nation, especially 
vulnerable populations. We also know that people across the 
country face barriers to the vaccine. One of the barriers, not 
only with regard to the vaccine but generally, is the lack of 
broadband access or familiarity with technology. That means 
that people cannot use online vaccination registration systems.
    Some systems may not have their registration information in 
plain, easily accessible language. If you do not have family or 
friends to advocate for you, these barriers often can become 
insurmountable.
    For those who are able to get the vaccine appointment, lack 
of transportation to a vaccine site or inability to stand in 
line and wait can be difficult and put them at risk. The Rescue 
Plan included funding to support vaccine outreach and 
education, including organizations like Area Agencies on Aging.
    Dr. Iyer, the question I have is in your experience, how 
can support from trusted community partners help both seniors 
and people with disabilities, and especially those in minority 
communities, help to get vaccinated?
    Dr. Iyer. Thank you for that question, Senator Casey. 
Trusted community partners can make all the difference in this 
process. As I mentioned, UAB has spent decades building 
relationships with communities around Birmingham, and this kind 
of trust and partnering with city leaders, the neighborhoods, 
the vaccination sites in underserved areas help us to deliver 
vaccine to minority communities at four times the state and 
national average. That has also happened in places like Chicago 
and elsewhere around the country, that are focusing those 
efforts to hardest hit areas.
    Trust starts from those one-on-one conversations like I 
have with my patients every week, trying to build that trust, 
answer questions, get at those concerns, but also the pillars 
of the community and talk about neighborhood leaders, pastors, 
barbers, that Meals on Wheels delivery driver that is coming to 
bring the meals to someone's home, the leaders at the senior 
centers. If they get on board you can see the people, they see 
representation, and they see that this could be a real way to 
get out of the pandemic.
    You know, I am from Alabama, and that is the home state of 
the infamous Tuskegee Syphilis Study. I even cared for a 
relative of a study participant during my training. When, 
again, it comes to mistrust and building trust, we definitely 
get it. We know how to build trust. It is much more nuanced. It 
really comes down to access as well as disparities in access. 
We have got to build the trust, we have got to engage those 
communities, and expand the access as well, and this will help 
for minority seniors especially.
    The Chairman. I know we want to see if Senator Warnock--I 
think we are seeing if Senator Warnock or Senator Blumenthal 
might be on?
    Senator Blumenthal. I am ready to go, Senator Casey, if you 
want to----
    The Chairman. Senator Blumenthal.
    Senator Blumenthal. Thank you, Senator Casey. First, let me 
thank Bob Casey of Pennsylvania for being such a steadfast 
champion of our seniors, of our vulnerable, and underserved 
population, and thank you, Senator Casey, for carrying on that 
work in this hearing and in so many other areas. Thank you to 
all who are attending today, particularly our witnesses. This 
topic is so central to the effort to conquer the pandemic. 
President Biden has led this effort with courage and strength, 
and the American Rescue Plan has $20 billion for vaccination 
efforts, distribution, training, administration, and I am 
excited to see this funding at work.
    In fact, I did, over just this past weekend, when I visited 
the Fair Haven Community Health Clinic, I actually went with 
members of the community out onto the streets, into homes, 
knocking on doors, seeking to recruit people who may not have 
known, may not have been able to gain access to vaccines, and 
overcome some of the hesitancy, reluctance, resistance that 
indeed can be overcome. It is on us. It is our obligation to 
overcome those kinds of hesitancies.
    These grassroots efforts, as you mentioned, Dr. Iyer, are 
so critical to ensuring that underserved populations are able 
to get vaccinated, and the practical outreach is so important. 
It has been a priority of mine in Connecticut, when I visited 
clinics, urging them to do it, more than 20 clinics that I 
visited.
    I like to ask you, Dr. Iyer, can you speak a little bit 
more about the impact of programs like Vaccinate New Haven or 
Vaccinate Fair Haven can have on both the individuals who have 
vaccine concerns and those who are ready for vaccine but simply 
do not know how to access them?
    Dr. Iyer. Thank you, Senator. Those are important points, 
and they come across as the practical aspects of this vaccine 
rollout that we need to really iron out, especially for our 
vulnerable seniors. You know, half do not have Internet access, 
or like Ms. Harris said, do not know how to log on to systems, 
and these complex and long forms. I know that exact situation 
you are describing, Ms. Harris, about feeling just upset about, 
man, this thing has been going on for two hours and I cannot 
get the vaccine. I cannot imagine seniors doing this who are 
isolated in their homes and do not have a caregiver for 
support.
    Programs like you mentioned are critical, because you are 
going door to door, you are getting out the registration to the 
people where they live, and if you talk to geriatricians who 
are doing this around the country they are actually getting the 
shots in arms in the home, and these are the programs we need 
to replicate and learn from, because they know where their 
patients are. If we can build a listserv or kind of dataset 
about who are these people, where are the ones with limited 
mobility, who do not have Internet access, I think we can go a 
long way.
    We have got to make this process simple, or simpler, and 
use those models like you described. That can have a real 
impact, especially places like rural Alabama, where you have 
got to drive 40 miles to the nearest vaccine site. That is not 
going to work. It is not going to work at all. That is already 
a barrier right there, with someone who might be hesitant.
    You know, the tides are shifting in hesitancy rates. They 
are coming down in Black and minority populations. They want it 
but they do not know how to get it. That is what I talk to my 
patients about every week. ``How can I get this, Doctor? Where 
can I get it from?'' I will work with you and I will figure out 
some places, but we just need more help down the road.
    Senator Blumenthal. That is a great answer. Thank you.
    Let me ask Dr. Jackson, very quickly. The community health 
centers, federally qualified community health centers, in my 
view are the unsung heroes of this effort, and I would like to 
ask you for your perspective on how they are positioned to 
provide the kind of access that Dr. Iyer was just discussing.
    Mr. Jackson. I certainly agree with you. Those facilities 
are key, because they are actually in communities where there 
is a tremendous need, and oftentimes they are the only access 
points for people to get access to care and those relevant 
treatments that are needed, from a community health 
perspective.
    We have worked very hard, as I shared earlier, to really 
collaborate with each provider in each market, and we go 
actually to where the need is. As we set up, certainly, a 
centralized location for vaccinations we also set up areas 
where we can go and educate, where we can communicate and 
understand that there are limitations in terms of broadband and 
things of that nature. We broke it down to the basics in terms 
of flyers, talking to pastors, going and having conversations 
and asking for a little bit of time as they are doing their 
virtual sermons on Sunday morning, giving us an opportunity to 
have those conversations.
    Again, from a total community perspective, we speak 
broadly, utilizing every opportunity for us to engage the 
community in this way, to get this vaccine out.
    Senator Blumenthal. Thank you so much. Thanks, Mr. 
Chairman. Thanks, Senator Casey, for your leadership, and 
thanks for those excellent answers.
    The Chairman. Thank you very much, Senator Blumenthal. I 
think the lineup we have now is Senator Lee and then Senator 
Warren.
    Senator Lee. Great. Thanks so much, Mr. Chairman.
    Mr. Jackson, the COVID-19 pandemic forced our whole country 
to move toward a much more virtual setting. The fact that we 
are able to do this really shows the resiliency of our 
networks, and one area that has received prominent attention 
during the pandemic involved the use telehealth. We have had 
great success with telehealth in Utah, as its advancements 
provide better opportunities for great success in this area, 
and we have seen it providing better opportunities for our 
Nation's seniors, to communicate with their doctors, within the 
privacy of their own homes, in a more risk-free environment.
    There is always room for improvement, and I think there are 
things that we can look to from the pandemic to help us 
understand how best to proceed. What lessons do you think we 
learned from the use of telehealth during the pandemic, as we 
more fully incorporate telehealth into our health care system?
    Mr. Jackson. I think that we learned, our physicians 
learned, especially those that were concerned about not being 
able to assess patients in their office, to see, feel, and 
touch them, we learned that we were able to be effective in 
terms of evaluation and treatment from a telemedicine 
perspective.
    Two years ago we began working toward this process as a 
part of our population health strategy, and quite frankly, 
there were patients that were concerned too, because they 
wanted to go to their physician's office, sit in their 
physician's office, be able to talk with them directly and see 
them and feel the energy of that connection. I think we 
learned, as a system, just how effective it can be. Certainly 
there are certain annual wellness checks and things of that 
nature that you want to have someone present for, but in terms 
of reviewing labs, ET cetera, and being able to help diagnose 
certain issues, we learned that we can do that effective via 
telemedicine.
    Again, we are a system that sees anywhere from 300,000 to 
400,000 visits in our primary care offices, and we expect, as 
we go forward, to continue, at a tip of around 20 percent with 
budgeting, as we go forward. I think the community and our 
physicians are now prepared and have the confidence that is 
needed that this can be a vehicle that will allow us to 
continue to treat the communities we serve.
    Senator Lee. Are there rules and regulatory changes that 
the Federal Government did well at adopting in the telehealth 
space that we should now look to make permanent?
    Mr. Jackson. I think if you look around the spectrum, I 
think the concern around reimbursement, because of overhead 
that hospitals face, and physicians, and the pressures in and 
around profitability, because it takes that to be able to 
provide care in the community. Some of the initiatives put into 
place, we hope that will continue. I think that will further 
provide the impetus or motivation that will allow us to even 
tag into this rural communities where there are certain 
subspecialists that is not available. We have been able to 
carry that to those communities now because there is that 
confidence.
    I think being able to support these initiatives financially 
is right now the biggest opportunity for us, is to continue 
that, even post-COVID.
    Senator Lee. That is well said. Thank you. The Joint 
Economic Committee recently published a report regarding the 
emotional and social health of seniors during the pandemic, and 
according to the report, quote, ``Most seniors seem to be 
managing well emotionally last year. Despite concern of the 
pandemic, only six percent said that they had often felt 
emotionally overwhelmed since the pandemic began, and only nine 
percent said that they have often felt stressed,'' close quote.
    It is more important, I think, than ever for seniors to 
feel connected with their loved ones and with other members of 
their community. Are you seeing seniors spending more time 
caring for their grandchildren during the pandemic due to day 
care and school closures, and also as a result of more parents 
needing to work from home?
    Mr. Jackson. Absolutely, we are seeing that. To your point 
earlier, what we have seen in Charleston, we do employ 
psychologists on our staff. We have seen a tremendous ramp-up 
in calls for consultation. In having conversations, as we have 
been able to round a bit more in our hospitals, since we are 
beginning to see the numbers begin to decrease, the 
conversations with the elderly in the hospitals and in the 
community, as those who are coming for vaccination, you know, 
they speak about the social isolation and the issue with, you 
know, they did not want us to feel like because someone can 
come to a door and wave, or a window and wave, that would 
suffice and make up for true interaction and human contact.
    Dr. Iyer mentioned earlier, or someone mentioned about, you 
know, Meals on Wheels coming by, the mailman. Quite frankly, I 
have got aunts and uncles who look forward, because they live 
in rural areas and sometimes those are the only people they 
will see, due to their limitations from a transportation 
perspective. It is their only time to really engage.
    We are preparing for community initiative where we are 
taking our positions out into the community again. We are using 
telehealth to make sure we have offerings, and we are letting 
the community know via TV, newspapers, and flyers, and again, 
leveraging the relationships with churches as well, to make 
sure there is an understanding that there is this offering.
    Senator Lee. While these data are encouraging, it is 
obviously still important for seniors who have felt isolated 
and experience greater emotional struggles to receive help 
while staying at home. I know I am out of time, but I would be 
curious if we have more time later to hear, drawing on your 
experience previously as a nursing home provider, what some of 
the ways are that community members and nursing home facilities 
could step in to offer more resources, and help those seniors 
feel better connected.
    Mr. Jackson. Absolutely.
    The Chairman. Senator Lee, thank you very much. Senator 
Warren.
    Senator Warren. Thank you, Mr. Chairman, and thank you for 
holding this hearing.
    Seniors who choose to live in nursing homes deserve the 
highest quality care, and the administration must strengthen 
nursing home standards in the wake of this pandemic. The 
coronavirus has also highlighted the critical importance of 
providing care safely in homes and communities, particularly 
through Medicaid's home and community-based service programs.
    HCBS programs have a simple premise: provide long-term care 
at individual's homes or in their communities instead of 
institutional settings like nursing homes. HCBS services 
include things like supported employment, medical equipment, 
home health aides. These services are cheaper to provide, and 
they provide a lifeline for millions of Americans, especially 
people with disabilities and the elderly.
    Here is the problem. Millions of Americans cannot access 
long-term care services at home. Ms. Harris, HCBS is provided 
through Medicaid, and every state in this country participates 
in Medicaid. Now I am looking at it this way. We do not have 
waiting lists for kids on Medicaid to get their flu shot or for 
a mom on Medicaid to get a Pap smear. Why is it so hard for 
seniors and people with disabilities to access at-home care in 
their communities, or at-home or care in their communities?
    Ms. Harris. Thank you, Senator. It is so good to see you.
    Senator Warren. Good to see you.
    Ms. Harris. The problem is Medicaid is administered by 
states, who set the regulations and the eligibility. The only 
thing that Medicaid is mandatory to cover is nursing home care, 
and home health is an option, so it is not required. If you are 
fortunate enough to live in a state where they do offer home 
health then you are lucky. In those states where it is not 
offered as an option, then there is actually no help for you.
    Senator Warren. Well, that is a really important point, 
that HCBS looks different depending on where you live, and the 
access is limited. This means hundreds of thousands of 
Americans are on HCBS waiting lists right now. They need help 
and cannot get it.
    Let's move on to Medicare and private insurance. Ms. 
Harris, do those typically cover long-term home and community-
based care, like adult day care centers or helping with 
dressing and bathing?
    Ms. Harris. No. Medicare covers limited home health care, 
for example, part-time school nursing and therapy-physical 
therapy, occupational therapy, whatever. That is the limit. It 
does not provide services that address the activities of daily 
living, like eating or bathing or dressing, and that is the 
problem.
    Senator Warren. Yes. If you are not well off and able to 
pay out of your own pocket for everything you need to live at 
home, or if you do not have a family member who can drop 
everything to help, you are pretty much on your own here.
    Dr. Houtrow, let me just ask, what happens when people with 
disabilities and seniors cannot access HCBS services, both in 
normal times and during the pandemic?
    Dr. Houtrow. Thank you, Senator Warren, for that question. 
You are highlighting an all too common problem.
    When services cannot be accessed people with disabilities 
and seniors become more limited in their activities. They are 
more likely to be depressed. Their risk of hospitalizations 
goes up. Their families feel the physical strain of doing more 
hands-on care, the emotional strain of trying to juggle the 
household's needs, and the financial strain of having to cut 
back or stop working. Anxiety and exhaustion are common, as is 
guilt. The weight of not getting services can result in the 
breaking point that we never want to happen--placement in a 
facility.
    Here, during the pandemic, you asked how it has changed. I 
have a single word to add: fear.
    Senator Warren. Wow. Thank you very much. It is so 
important what you are covering here and the work you are 
doing. HCBS services have been a matter of life and death 
during this pandemic. President Biden has made a commitment to 
investing in our caregiving economy. The American Rescue 
package made important investments in home and community-based 
care. Congress must do more. It must do much more. We must make 
HCBS a mandatory benefit in Medicaid and expand Medicare to 
cover more at-home, long-term care services. We should force 
private insurers to commit some of their billions of dollars in 
profits to covering long-term care. Health care including 
access to long-term care provided to people in their homes and 
communities should be a right, not a privilege.
    Thank you very much, and thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren. I wanted to give 
folks a state of play. I think the Ranking Member wanted to ask 
a question, I am told, and then after the Ranking Member we 
would have, in this order, Senator Rosen, and then we will see 
who comes after that.
    Ranking Member Scott, did you have a question?
    Senator Tim Scott. Well, thank you, Chairman, and it has 
been covered a couple of times already since I made the 
requisition. I will say this. Dr. Iyer, Mr. Jackson, I think 
Ms. Harris has made a very good point on the importance of 
coupling or fusing together our conversation around 
telemedicine, broadband access, two very critical pieces of 
creating access to specialists in rural America.
    If you all have any additional comments on the topic, I 
would love to hear really just short comments on the importance 
of Congress addressing the issue of broadband in order to have 
a springboard to a real telemedicine national conversation that 
leads to effectiveness in the delivery system, not just making 
it available but making it available in the homes that do not 
have broadband.
    Dr. Iyer. Thank you, Senator Scott. I mean, telehealth can 
improve outcomes and outreach, as long as that digital divide 
is closed, so legislation like the Accessible, Affordable 
Internet for All Act could help improve broadband access across 
the country. That is step one. The Telehealth Modernization Act 
is the big next legislation that could be supported to improve 
and continue those emergency provisions, like the geographic 
access, rural and urban areas, audio and video visits, and 
those in-home visits.
    I mean, as a pulmonary person I was able to deliver 
telehealth pulmonary and palliative care to a woman in her 80's 
from Tuskegee, Alabama, and with help from a caregiver we were 
able to set up those video visits and kept her safe and kept 
her quality of life up in the home. We even did that with our 
ICU services. I mean, imagine getting somebody off the 
ventilator 100 miles away, in Selma, Alabama. We were able to 
do that, and he was able to give me a thumbs-up virtually.
    It is credible as long as digital divide is closed, because 
you are going to leave a lot of people behind if you do not 
have adequate broadband access first.
    Senator Tim Scott. Thank you. Mr. Jackson, I will get your 
answer later.
    Chairman, I know we have people waiting and I do not want 
to have a second turn before folks have had their first, so I 
am happy to suspend my question on telemedicine and the 
broadband connection if it is okay with you. We could go to the 
next person or I could continue, but I do not want to get in 
the way of other members.
    The Chairman. Well, I want to thank the Ranking Member. If 
it is okay with him, maybe we will move to this order.
    Senator Tim Scott. Yes, sir.
    The Chairman. Far we have Senator Rosen, then Senator 
Braun, then Senator Kelly.
    Senator Rosen. Thank you, Mr. Chair, and thank you Ranking 
Member Scott. I appreciate that. Thank you for having this 
hearing, and everyone for your work in this area.
    You know, I took care of my parents and in-laws as they 
aged so I know all too well the challenges that families face, 
the choices and challenges that they face every day when they 
are going through some of these things.
    I really want to talk about seniors and social isolation, 
because now we are well over a year into COVID-19 and we know 
that seniors have been disproportionately affected by the 
virus. They are at the highest risk for severe illness and 
death, and the isolation that is required to stave off the 
infection has been devastating. In Nevada, over 25 percent of 
seniors live alone.
    Thankfully, the University of Nevada's Sanford Center of 
the Aging, they really stepped up in a big way. In addition to 
general outreach to check on general well-being, public health 
information, they have helped facilitate more than 13,000 
telehealth appointments since last March, and in Nevada Ensure 
Support Together, or NEST collective, has facilitated over 
3,000 hours of virtual services and programming for Nevada 
seniors during the same time.
    Ms. Harris, I want to ask a multi-part question. What 
program service and models have worked well in your experience, 
and I can tell you that at the Sanford Center they are using 
the creative reverse telehealth model for seniors who may not 
be able to use technology. Instead, they come to a senior 
center and see their provider virtually from there, with help 
from someone at the senior center, and that has been great. How 
can we integrate these kinds of models into our broader senior 
support systems now and going forward?
    Ms. Harris. Thank you, Senator. I guess the first thing I 
would like to say is long before the pandemic we had a 
loneliness and social isolation epidemic, and the convergence 
of the epidemic with this pandemic has certainly just worsened 
the situation. Now that there is heightened awareness of what 
it feels like to be alone, we must address this issue.
    One of the things that we have done in Massachusetts is we 
have created the Massachusetts Task Force to End Loneliness and 
Build Community. Our goal is to go out and make sure, ensure 
that all older adults have connections to the community and 
feel a sense of social well-being. We are partnered with the 
University of Massachusetts Boston as well as organizations, 
probably about 15 or 16 at this point. We have started a 
campaign, Reach Out MA, where we are encouraging all Bay 
Staters to really renew their social contracts, to remember 
what it means to be a good neighbor, and to stop and wave to 
your neighbor, send a card, pick up a telephone. That is one of 
the things that we are doing.
    We have had community conversations. We did have to pivot 
and do them virtually. We went to the communities and talked to 
them about what are the issues that you are finding; to the 
community leaders, first responders, postmen, what are you 
finding? What are the challenges? What are the things that you 
are doing that are working for you? We were able to develop an 
online resource and share with the entire state, what are the 
resources that communities are using that are making a 
difference in addressing this issue.
    We have created a Subcommittee on Technology, looking at 
the digital divide. It is a serious thing it addresses, and it 
makes all the difference in the world. Telehealth, as has been 
said earlier, if you do not have the connectivity it is a 
problem. It does really help.
    We have created a public awareness campaign, just letting 
people know that it is okay to say that you are lonely. There 
is a stigma associated with being lonely. We have created an 
intergenerational committee where we are adding 
intergenerational lens to all of the work that we are doing, 
and inviting young people, because when you look at the 
research, millennials, young people are reporting as being just 
as depressed and isolated.
    We think that we have an opportunity to work with these two 
individuals and let them help each other. It needs to be a 
reciprocal thing where the younger people help the older 
adults, but as well, the older adults, with all of the wisdom 
and everything that they have, are helping the younger people 
as well.
    Those are the things that we are seeing working for us.
    Senator Rosen. I appreciate that. I take my next question 
off the record, but Dr. Iyer, I am Chair of the Comprehensive 
Care Caucus, which focuses on palliative care. I am really glad 
you brought that up for seniors, and so we will submit that for 
the record about how telehealth and what we are doing can 
really increase access to palliative care, how important it is, 
not just for seniors but across the board, and I look forward 
to speaking with you about that offline.
    Thank you all again for the work you do. I yield back.
    The Chairman. Senator Rosen, thank you very much. We will 
next turn now to Senator Braun.
    Senator Braun. Thank you, Chairman Casey. This whole saga 
of trying to navigate through the COVID crisis was so 
disturbing, to see how disproportionately nursing homes were 
hit, I think maybe due to the three major predispositions, 
which would be age, diabetes, and maybe weight issues.
    I would like to ask Ms. Harris a couple of questions. What 
have you found--I know that you are in Massachusetts, volunteer 
State President with the AARP. I communicate with them back in 
Indiana at least once or twice a year, and one of the times 
would be through kind of a live Q&A. I have not been able to do 
that other than early on, when we did not know a lot about 
COVID.
    Being so heavily predisposed to COVID with devastating 
consequences, where are we in kind of the best practices, with 
the vaccinations that have been administered? I just read the 
other day where some of the experts are saying that we might 
have somewhere between four and five times as many cases of 
COVID that have not been tested. How are we converging on, 
especially related to nursing homes, when we can say that we 
have got some idea when that can get back to a more normal 
framework? I know that is a lot there to digest, but I want to 
give you the remaining time I have, which is probably three 
minutes or so, so weigh in.
    Ms. Harris. Okay. Thank you, Senator. We know that one of 
the problems in nursing homes, and it has been a problem for 
some time, has been that of infection control and adequate 
staffing. We feel that there are a number of things that need 
to happen, and certainly the lack of PPEs.
    In terms of trying to really address this problem and to 
begin to alleviate the problem we need to make sure that we 
have the PPE on hand and enough to cover not only the faculty 
staff but visitors and others who come to the facility.
    It is critical that we have regular and ongoing testing. It 
is critical that we have adequate staffing--that is very, very, 
very important. We also have to have transparency. We have to 
have transparency and the data, the demographical data of what 
is happening on the infection rates, broken down by age, 
ethnicity, and things like that.
    We need to make sure that we have transparency in how 
millions of federal dollars that are going to these nursing 
homes are being spent and making sure that they are being spent 
for the welfare of the residents versus going to the bottom 
line.
    We need to hold nursing homes and long-term cares 
accountable. When there is harm done because of substandard 
care, dangerous care, then they need to be held responsible for 
that.
    Senator Braun. That makes sense, transparency, making sure 
you are fully enabled to do the job right. I want you to zero 
in on this, because a lot of that still will need to be in 
place, but you can rest a little more easily when we reach herd 
immunity, through vaccinations and through acquiring, you know, 
the disease itself and getting through it. How close do you 
think we are, in the most vulnerable category, nursing homes, 
which has been given the attention of transparency, PPE.
    I think we all know that until we get to true herd 
immunity--and to me it looks like that is a confluence of 
getting anybody in a nursing home or working for it, 
vaccinated, along with the cases where you have had survival--
where are you at, in your own mind, to where we are going to 
get there? I know you need to do all the other stuff, but what 
you gauging is that point in time? If it is not soon, we need 
to put more resources there.
    Ms. Harris. Well, sir, we think one of the most important 
things is making sure that we have the transparency. We need to 
see what is happening, and I think CDC is getting the 
information out on a weekly basis. It needs to be more than 
that. We need to see this data almost daily, if possible. It 
will allow us to see what is happening, and to be able to focus 
in the specific area, identify what is it that is causing 
these, what are the problems, is there a certain thing about 
age, is this about activities? By having the data in hand, we 
can very quickly address the problems.
    I think a large portion of it, in my mind, is just knowing 
what is going on and having the information as quickly and as 
frequently as possible. That is going to be key.
    Additionally, the testing. It is very, very critical, we 
have to have them tested on an ongoing basis.
    Senator Braun. Thank you. I think my time is up and I agree 
with all that, but at some point, not only for nursing homes 
but for the rest of America, we are going to need some idea of 
when the true remedy for everything you are talking about is 
the fact that we do not need as much of that anymore because we 
have conquered the disease through vaccination, acquiring herd 
immunity. It sounds like that point in time remains to be seen.
    Thank you so much. I appreciate it.
    The Chairman. Thank you, Senator Braun. Senator Kelly.
    Senator Kelly. Thank you, Mr. Chairman.
    Ms. Harris, so this year many people in our country became 
caregivers for the very first time, and existing caregivers are 
spending more time providing care, an average, from what I 
understand, about 7.5 more hours each week since the pandemic 
began. Some of these are family members. Some are friends, or 
neighbors, and some are paid service providers. It is hard to 
hire caregivers, and it is hard to retain them. There is also 
not enough support for folks who care for their family members.
    In Arizona, there are 870,000 family caregivers who provide 
$10.6 billion worth of unpaid care every year. The Continued 
Funding for Senior Services During COVID-19 Act passed through 
the American Rescue Plan, which included $145 million for 
caregiver support services.
    Ms. Harris, this question is for you. What are the needs 
that you see these funds being able to address, and how can we 
better support those who are supporting others?
    Ms. Harris. Thank you, Senator, for that question. We think 
it is important that, number one, there is support for the 
caregivers, support, including respite care, counseling, being 
able to provide opportunities for just generally--I will share 
with you my own personal situation, as we are caring for our 
mom. We have made a decision that we are going to keep our mom 
at home. One of the things that we are doing is, one of my 
sisters had to give up her work, give up her job. She is no 
longer working. She has sacrificed her profession to be at 
home. We do have some level of home health care, but it is not 
enough. It does not provide enough care coverage. She is there 
24 hours a day.
    Being able to make sure that she has respite, being able to 
provide some levels of, for example, assistance with food 
preparation, assistance with counseling, and even online 
training, where she can begin to understand and go to sites to 
understand better how to deal with the issues that we are 
finding.
    There are a number of things that we can do and can be 
doing, and even modifying, coming up with innovative ways of 
making sure that the caregivers get the respite, the breaks, 
that have the information, understand the best practices for 
dealing with whatever the medical diagnosis is. Those are the 
kinds of things that I think that additional funding will help 
to take care of.
    Senator Kelly. Well, that would be a really positive 
outcome, as some of these funds can be used to provide that 
respite you talk about for caregivers, because they are 
incredibly stressed right now.
    I think I have a couple of minutes. I actually do not see 
the timer on the Cisco Webex window. This next question is for 
Dr. Iyer.
    I know you are based in Alabama, but you mentioned the 
tremendous impact that COVID-19 has had on communities of 
color, and that is something we are seeing in Arizona as well. 
Native Americans are 70 percent more likely, and Latinos 30 
percent more likely to contract COVID-19. Arizona is the home 
of 22 tribes and is about 30 percent Latinos.
    You know, many of us now are heeding the guidance to shop 
using, you know, curbside, to limit trips to the store, to stay 
in touch via Zoom, but in some tribal communities, you know, 
nearby stores do not offer curbside pickup, a lack of a street 
address means you cannot get packages delivered or groceries, 
multiple generations live in one household, and there is not 
adequate broadband infrastructure. Or sometimes you cannot even 
get cell reception. I have experienced that. This is true in 
many rural, non-tribal communities as well.
    Dr. Iyer, could you speak to how these disparities affect 
access to health care in rural communities and how we can 
address them here in Congress?
    Dr. Iyer. Thank you, Senator Kelly. Time is very short so I 
will try to make a brief statement, and can take some more on 
the record later, if we can.
    Senator Kelly. Thank you.
    Dr. Iyer. I appreciate you bringing up the issues that 
Latino and tribal communities are facing and what rural 
communities are facing. It really is infrastructure and 
disparities and practical applications of this. I think 
expanding broadband, supporting legislation for that is going 
to be key, expanding telehealth and the Modernization Act, so 
we can continue those emergency pandemic provisions. Medicaid 
expansion in the states that have not done it, so if Senate 
could support those states, and then getting the care out to 
the rural communities is going to be key through like federally 
qualified health centers, recruiting and retaining rural health 
workers who want to leave and need to stay in those rural 
communities, getting out these vaccines and getting out help, 
in general, to the rural communities is going to be key.
    Senator Kelly. Thank you, Dr. Iyer. I appreciate that.
    The Chairman. Thank you, Senator Kelly. We will turn next 
to Senator Warnock.
    Senator Warnock. Thank you so very much, Mr. Chairman. It 
is wonderful to be here at my first Aging Committee hearing, 
and I really look forward to working with you and also the 
Ranking Member as we try to support aging Americans in Georgia, 
and for that matter, all across the country.
    The American Rescue Plan included funds to expand Medicaid. 
We were pushing hard for this. Senator Ossoff and I hail from 
the State of Georgia, a state that has yet to expand Medicaid. 
Dr. Iyer, I know you work in Alabama in the health field, and 
Alabama, unfortunately, is a state like Georgia that has yet to 
expand Medicaid. We have got nearly 500,000 people in the 
Medicaid gap in Georgia. In the American Rescue Plan, there are 
$2 billion that we have made available just for Georgia, to 
finally expand Medicaid.
    Can you talk about what it would mean for underserved and 
rural communities in states like Georgia and Alabama, to 
finally expand Medicaid?
    Dr. Iyer. Thank you, Senator Warnock. I mean, this is an 
important question for both our states, you know, us being 
neighbors. It would mean a lot for my patients and my clinic, 
my pulmonary clinic for the underserved. Like Georgia, Alabama 
would see a tremendous decrease in the number of uninsured. 
That is about 300,000 estimated in Alabama--close to what your 
numbers are.
    I mean, we come from states that are overwhelming rural, 
and access is just plain tough here. You know this very well. I 
mean, getting to the clinic, getting to hospitals, I mean, in 
Alabama, 17 rural hospitals have closed in the past decade, and 
a dozen more are on the docket. As an ICU physician, that is 
incredibly frightening, for people not to have a place to go 
when they get sick. It happened during the pandemic, and I do 
not want to see that kind of stuff happen again.
    The American Rescue Plan provides that rare opportunity to 
get this done so we can stem those rural hospital closures and 
provide people the access to mental health care, prescription 
drugs, and you name it, so we can care for them better.
    Senator Warnock. Did you say 17 hospitals have closed in 
Alabama?
    Dr. Iyer. In the past, rural hospitals have closed in the 
past decade.
    Senator Warnock. Yes, we have seen this impact is 
disproportionately impacting the rural communities. I think we 
have seen about a dozen hospitals in Georgia close over the 
last 10 years.
    Would you say, in your opinion as a medical professional, 
that to expand Medicaid in states like Georgia and Alabama, is 
it an over statement to say that it would literally save lives 
and that we are losing lives because we refuse to expand 
Medicaid? Is that an over statement?
    Dr. Iyer. No, it is not an over statement. I think it could 
save lives.
    Senator Warnock. Thank you so much.
    Dr. Iyer. Thank you.
    The Chairman. Senator Warnock, thank you very much. Senator 
Gillibrand.
    Senator Gillibrand. Thank you, Mr. Chairman. In my state we 
have seen challenges where the number of people who have passed 
in nursing homes was substantially underreported. In fact, we 
have seen that according to the recent working paper published 
by the National Bureau of Economic Research from private equity 
firms that acquired nursing homes, patients start to die more 
often, and taxpayers start paying more too. Total private 
equity in nursing homes has exploded in the last 20 years, 
going from $5 billion in 2000 to more than $100 billion in 
2018.
    To Ms. Harris, what do you think about private equity and 
the aggressive acquisition of nursing homes, and how is this 
impacting the longer-term care industry at large?
    Ms. Harris. Thank you, Senator. Generally we have found, or 
I have personally seen that not-for-profits do a much better 
job in caring and providing the quality of care and safety 
required for our elderly, where their interest and the focus 
emphasis not necessarily on the bottom line. That is just the 
limit of my experience of the situation. I am sure that we can 
have our staff take a look at this and get back to you with 
some information.
    Senator Gillibrand. Okay. Dr. Iyer, let me ask you a 
similar question. We saw patient outcomes suffer and 
affordability become more difficult with the surprise billing 
situation that many experts claim was fueled and exacerbated by 
private equity's acquisition of hospitals and urgent care 
facilities. Could we expect similar outcomes with private 
equity and nursing homes, and what does that acquisition on so 
many nursing homes mean for patients?
    Dr. Iyer. Thank you, Senator Gillibrand. This may be out of 
my scope of expertise, so I would love the opportunity to get 
back with you afterwards, after I do my research on this and 
get a better answer for you. Is that okay?
    Senator Gillibrand. Okay. Yep. Then Dr. Harris, or Ms. 
Harris, so in New York State, as of the last reporting, more 
than 170,000 Americans, including residents and workers, have 
died from COVID-19 in nursing homes and other long-term care 
facilities, and we know that on top of the Trump 
administration's failures to adequately respond to the pandemic 
his administration also let our nursing homes and long-term 
care facilities down.
    Ms. Harris, you are familiar with the under-reporting of 
the number of COVID deaths in nursing homes during the 
pandemic, and in New York State specifically the Attorney 
General confirmed an additional 3,800 nursing home residents 
died in hospitals than originally reported.
    I co-sponsored legislation by Senator Casey, the COVID-19 
Nursing Home Protection Act, that would require nursing homes 
to submit this data so that it could be commonly available on 
Nursing Home Compare Web sites. Should Congress prioritize this 
policy to address this underreporting issue, and are there 
other ways to fix it?
    Ms. Harris. Thank you, Senator. I think you said that the 
175,000 deaths were in Massachusetts?
    Senator Gillibrand. No. That was 178,000 Americans overall, 
in the whole country.
    Ms. Harris. Okay. I am sorry. I thought you said in 
Massachusetts. We have enough and we do not need more.
    Well, first of all, we certainly do, AARP certainly does 
support the bill, the Casey and Toomey bill, which is looking 
at expressly those nursing homes that have a history of 
violations and bringing that to attention. That is very, very 
important. It goes back to the whole thought and conversation, 
talking points that I have about making sure that we have the 
transparency necessary in these nursing homes.
    I do not know that without making sure that we have the 
transparency, the reports, and holding them accountable, and I 
think that the Modernization Act, bill, if enacted, will 
provide a lot of information that we need to make sure that we 
are holding these facilities accountable.
    Senator Gillibrand. The last question. The COVID-19 Nursing 
Home Protection Act also included $500 million for states to 
operate nursing home strike teams to manage COVID-19 outbreaks, 
and another $200 million for technical assistance on infection 
control and vaccinations. This funding was eventually included 
in the ARP and is making a difference. Can you talk about the 
impact this would have at large?
    Ms. Harris. A tremendous impact, because we know that the 
biggest issues are in infection control and staffing. What this 
funding will do is allow strike teams--and I call them SWAT 
teams--to go in when they are really, really needed, when they 
are much more needed, to not only help with staffing but also 
to help with infection control. It is funding that will bring 
help when it is needed the most, when there are outbreaks.
    Senator Gillibrand. Thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Gillibrand. Before we move 
to closing, I want to make sure the Ranking Member does not 
have an additional question. Otherwise, we will move to close.
    Senator Tim Scott. Closing is great, sir. Thank you.
    The Chairman. Thanks very much. Well, I want to thank 
everyone for today's hearing. I want to start with the Ranking 
Member for his work in helping us with this hearing and for all 
of us to have this opportunity to get together to talk about 
these important issues. Obviously, one hearing will not be 
enough, but we have covered a lot of ground today.
    I want to thank our witnesses, Dr. Houtrow, Dr. Iyer, Mr. 
Jackson, and Ms. Harris, for taking the time to lend us your 
expertise, your experience, and your passion to help so many 
vulnerable Americans, especially at this time.
    We know that there is no state in our Nation, no county, no 
city, no community, no town that has been spared from the 
terrible devastation of this virus and the pandemic that 
resulted. That devastation has been borne especially by 
seniors, people with disabilities, and most of all, by 
communities of color.
    We are a great Nation, and a great Nation must take care of 
its people. The American Rescue Plan will help us begin to 
provide more of the care that is needed. It will help us begin 
to heal our country by defeating the virus and helping our 
economy recovery. To do this kind of healing, pandemic 
protections, in my judgment, have to include supports that 
affect health outcomes, and that also includes funding for 
transportation, for housing, for food.
    To address the disproportionate adverse impact of this 
virus, we need to address the needs of families, and we cannot 
ignore those living in poverty or those living in rural 
communities. The Rescue Plan addresses these basic needs and 
makes it possible for families to protect themselves against 
the virus.
    On top of all that, we have got to continue to do our part 
individually. We have got to continue to wear masks, we have 
got to continue to social distance, and we also must keep 
encouraging people to get the COVID-19 vaccine when it is their 
opportunity.
    We have much more to do, and I look forward to working with 
this Committee on these and other challenges.
    Now I will turn to Ranking Member Scott for his closing 
remarks.
    Senator Tim Scott. Thank you, Chairman Casey, and good job 
on your first hearing. This has been a very strong, I think, 
informative hearing. Your job has been well done. Thank you to 
your staff and your team for their hard work in preparing all 
of us to have an effective hearing.
    I also want to, once again, reinforce my appreciation and 
our gratitude as a Nation to the health care workers who have 
been on the front line, and particularly to the CNAs, the 
certified nursing assistants, and all those in the nursing 
homes, that so often we hear so much negativity heaped upon the 
nursing home community, as if they are to blame for the deaths. 
What we are looking for are solutions and not blame, and I 
thank each and every person who have provided care to our 
seniors across this country.
    To the witnesses, thank you very much. I must concede that 
I leave this hearing excited and energized about the synergy 
from the witness testimonies, the answers to so many of the 
questions, that reinforces the importance of the American 
tradition of looking for ways to help the most vulnerable in 
our society.
    I will say, however, to some of the comments that we have 
heard, especially toward the end of the hearing, that there is 
a real concern. I think we should all be very interested and 
concerned about the number of hospitals that have closed in 
rural parts of the country, and specifically in the South. 
There is no question that if you look back on the last 10 
years, the one thing that has changed in the last 10 years is 
the ACA is front and center.
    Study after study shows that the price of being in business 
has gone up, not down, and that has caused consolidation in the 
hospital space, which has raised prices and left so many 
Americans without care. Thank God for the qualified health 
centers throughout the country that are trying to fill that 
gap. That bridge, of course, is heavy, and we need to provide 
more resources to those folks in the rural communities. That is 
why telemedicine is critically important.
    Let me finally say to the Nation, and specifically to our 
seniors who have gone through so much for so long, isolated, 
depressed, good news is coming, and Chairman Casey has been 
providing that good news in this hearing. I am thankful that we 
have heard a lot of good news about the vaccine delivery, about 
the numbers who have been vaccinated, about the importance of 
telemedicine. This is the kind of hearing that all Americans 
can be proud of.
    Thank you, Chairman, and I look forward to our next hearing 
together.
    The Chairman. Same here. I want to thank the Ranking Member 
for his good work and for working with us today on this, our 
first hearing. I will return the compliment--he did a really 
good job today as Ranking Member, and I am grateful for his 
work on these issues.
    I also again want to thank our witnesses for contributing 
their time and their expertise. Just for Senators to know, if 
any Senator has additional questions for the record for 
witnesses, or statements to be added, the hearing record will 
be kept open for seven days, until next Thursday, March 25th.
    Thank you all for participating in today's hearing.
    This concludes the hearing.
    [Whereupon, at 11:18 a.m., the Committee was adjourned.]   
     
      
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                                APPENDIX
     
      
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                      Prepared Witness Statements

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  Prepared Statement of Anand S. Iyer, MD, MSPH, Assistant Professor,

       Division of Pulmonary, Allergy and Critical Care Medicine,

        University of Alabama at Birmingham, Birmingham, Alabama

Recipient, Paul B. Beeson Emerging Leaders Career Development Award in 
   Aging, National Institute on Aging, National Institutes of Health

    Chairman Casey, Ranking Member Scott, and Distinguished 
Members of the Committee, thank you for the opportunity to 
speak with you today.
    I am honored to share my personal reflections on the past 
year of the COVID-19 pandemic as a pulmonologist and 
geriatrics-palliative care researcher in the Deep South. I want 
to bear witness to the challenges my patients face and discuss 
ways to improve vaccine access for them. The views today are my 
own.
    My name is Anand Iyer. I am a pulmonologist and junior 
faculty in the University of Alabama at Birmingham School of 
Medicine. I care for people in the intensive care unit (ICU) 
and founded a pulmonary clinic at Cooper Green Mercy Health 
Services Authority, an ambulatory facility down the street from 
our academic medical center that provides care for hundreds of 
underserved Jefferson County citizens. There I care for people 
living with debilitating lung diseases like chronic obstructive 
pulmonary disease (COPD), the third leading cause of death 
among older Americans. I also research ways to integrate 
geriatrics and palliative care for this population supported by 
the National Institute on Aging of the National Institutes of 
Health.
    People in my clinic are at highest risk for poor outcomes 
due to COVID-19 and are now facing immense barriers to COVID 
vaccine access. Eighty percent are Black, twenty percent are 
older than 65, and most are uninsured. One of my patients is a 
woman in her 70's with COPD. She lives alone in public housing, 
requires supplemental oxygen, has very limited mobility, and 
has no Internet, no family caregivers, and no transportation. 
Every trip outside her home is a huge ordeal.
    It is against this backdrop of caring for people like her 
in Alabama that I entered the COVID-19 pandemic. A year ago, we 
saw the first people admitted to our ICU due to severe COVID-
19. Since then, over 10,000 Alabamians have died, and countless 
family members are grieving the loss of their loved ones.
    As each surge arrived last year, we worked as teams of 
physicians, nurse practitioners, physician assistants, nurses, 
and respiratory therapists to save lives. Covered head-to-toe 
in personal protective equipment, we placed hundreds of 
Alabamians on ventilators while their families anxiously waited 
at home.
    Though the physical scars of wearing N95 masks for entire 
shifts fade, the emotional scars do not.
    I witnessed the devastating impact of COVID-19 on older 
Americans firsthand. Older adults have the highest risk for 
dying from COVID-19, especially those who are frail and have 
cognitive and physical impairments.\1\ The pandemic highlighted 
how so many of them desperately needed better access to 
proactive palliative care. The ``Palliative Care and Hospice 
Education and Training Act (H.R. 647 & S. 2080)'' could improve 
its access for a growing number of older Americans living with 
serious illnesses who require proactive advance care planning 
and much more family caregiver support.
---------------------------------------------------------------------------
    \1\ Panagiotou OA, Kosar CM, White EM, ET al. Risk Factors 
Associated with All-Cause 30-Day Mortality in Nursing Home Residents 
with COVID-19. JAMA Intern Med. Published online January 4, 2021. 
doi:10.1001/jamainternmed.2020.7968.
---------------------------------------------------------------------------
    While caring for people in the ICU at UAB, I was keenly 
aware of the struggles faced by colleagues at small, rural 
facilities. Our telehealth ICU services improved outcomes at 
these hospitals, and telehealth ambulatory care improved 
outreach across the state. Early on in the pandemic, I brought 
telehealth pulmonary and palliative care from UAB to a woman in 
her 80's who lived miles away from Birmingham and was isolated 
due to debilitating COPD. The ``Telehealth Modernization Act 
(S. 368)'' continues many of the emergency provisions enacted 
during the pandemic to support in-home visits, reimburse audio 
and video visits, and cover people from both rural and urban 
areas. The pandemic accelerated the need for innovative ways to 
safely improve healthcare outreach, and telehealth offered a 
solution. Still, barriers to equitable broadband access created 
a hurdle for many.
    The long year finally gave rise to hope in December when 
the COVID vaccines appeared. The anxiety we felt as healthcare 
workers fighting a disease with few treatment options shifted 
to relief that we could serve on the frontlines with better 
armor. Many of us shed tears of joy when we scheduled our 
vaccination appointments.
    Since then, I have spent every clinic visit encouraging my 
patients to get vaccinated. I describe my own vaccine 
experience and directly respond to their concerns about side 
effects. They have legitimate questions, yet most want a 
vaccine when it's their turn. The problem for most of my 
patients is not vaccine hesitancy. It's vaccine access.
    Alabama is the home state of the infamous Tuskegee Syphilis 
study. I have even cared for a relative of a study participant 
during my training, so the concept of hesitancy is very real 
here. However, stating that the low COVID vaccination rates 
among minority populations are only due to vaccine hesitancy 
fails to acknowledge real racial and socioeconomic disparities 
in care and barriers to vaccine access that require urgent 
solutions.
    COVID-19 also exposed significant geographic disparities in 
access to healthcare, especially in the rural South. When I was 
young I joined my father, a family physician, on house calls to 
farms in northeast Alabama. He listened to his patients' lungs, 
and I brought home baskets of tomatoes that his patients gave 
to us. I witnessed early on the isolation they experienced, the 
struggles they faced accessing care in rural Alabama, and the 
ways that our visits lifted their spirits.
    Rural Americans have a 13% higher risk of death due to 
COVID-19 than people in urban areas,\2\ and my research 
demonstrates that more and more rural Americans are dying due 
to chronic diseases like COPD.\3\ Broadband is scarce, many 
rural counties lack a retail pharmacy to deliver the COVID 
vaccine, people live miles away from a potential community 
vaccination site, and rural hospitals are closing at alarming 
rates--as many as 17 in Alabama in the past decade.\4\ \5\ 
Support for the ``Accessible, Affordable Internet for All Act 
(S. 4131)'' could improve critical broadband access to close 
the digital divide in these areas, while expansion of Medicaid 
could improve essential healthcare and medication access and 
stem the tide of rural hospital closures.
---------------------------------------------------------------------------
    \2\ Ullrich F and Mueller K. Confirmed COVID-19 Cases, Metropolitan 
and Nonmetropolitan Counties. 2021. RUPRI Center for Rural Health 
Policy Analysis Rural Data Brief. Published January 2021. Accessed 
online on March 12, 2021 from https://rupri.publichealth.uiowa.edu/
publications/policybriefs/2020/COVID%20History/
COVID%20Data%20Brief%2001272021.pdf.
    \3\ Iyer AS, Cross SH, Dransfield MT, and Warraich HJ. Urban-Rural 
Disparities in Deaths from Chronic Lower Respiratory Disease in the 
United States. Am J Respir Crit Care Med. 2020; 203(6):769-772. PMID: 
33211972.
    \4\ Berenrok LA, Tang S, Coley KC, ET al. Access to Potential 
COVID-19 Vaccine Administration Facilities: A Geographic Information 
Systems Analysis. A Report by the University of Pittsburgh School of 
Pharmacy and the Westhealth Policy Center. Published February 2, 2021. 
Accessed online on March 15, 2021 from https://s8637.pcdn.co/wp-
content/uploads/2021/02/Access-to-Potential-COVID-19-Vaccine-
Administration-Facilities-2-2-21.pdf.
    \5\ Finley B. Open Spaces, No Pharmacies: Rural US Confronts 
Vaccine Void. Associated Press. March 6, 2021. Accessed Online on March 
11, 2021 from https://apnews.com/article/health-coronavirus-pandemic-
virginia-19884014220f3697889560f0027c200f.
---------------------------------------------------------------------------
    Our country has made great strides vaccinating older 
Americans. However, millions are at risk for missing a shot. 
Gaps will widen as eligibility expands, and the most vulnerable 
are unable to compete for vaccination spots. I estimate that 
one in five community dwelling older adults could be at risk 
for missing a COVID vaccine due to aging-related barriers like 
limited mobility, lack of transportation, no caregiver support, 
digital and social isolation, and functional and cognitive 
impairments. These are the same issues that make it difficult 
for them to access care in the first place. The numbers quickly 
add up: at least two million adults 65 years and older are 
homebound or semi-homebound; a quarter live alone; 
approximately half are digitally isolated due to lack of 
Internet access; and, millions are socially isolated due to 
debilitating medical conditions.\6\ \7\
---------------------------------------------------------------------------
    \6\ Ornstein KA, Lee B, Covinksy KE, ET al. Epidemiology of the 
Homebound Population in the United States. JAMA Intern Med. 2015; 
175(7):1180-1186. doi:10.1001 jamainternmed. 2015.1849.
    \7\ Ausubel J. Older People are More Likely to Live Alone in the 
U.S. than Elsewhere in the World. Pew Research Center. Published March 
10, 2020. Accessed online on March 10, 2021 from https://
www.pewresearch.org/fact-tank/2020/03/10/older-people-are-more-likely-
to-live-alone-in-the-u-s-than-elsewhere-in-the-world.
---------------------------------------------------------------------------
    The American Rescue Plan makes many essential investments 
to improve vaccine outreach to these populations, including $20 
billion toward vaccine administration and distribution. A few 
pragmatic recommendations could make these efforts more 
successful and dismantle access barriers for vulnerable 
populations.
    First, create a centralized data system that partners with 
Area Agencies on Aging, churches, and home-based care programs 
to identify those most at risk for missing a vaccine.
    Second, simplify vaccine registration and administration 
processes and make them much more age-and disability-friendly. 
Many registration systems are internet-based and have used 
lengthy and complicated online forms that are impractical for 
older Americans who have no internet access, no e-mail 
accounts, and low digital literacy. Instead, use telephone-
based registration and proactively reach out to people through 
programs like the ``Senior Buddies'' in Washington, DC, and the 
pilot ``Vaccine Community Connecters'' going door-to-door to 
schedule vaccinations and arrange transportation.
    Third, continue to increase the supply of vaccines to 
states and centralize vaccine distribution efforts. We are 
grateful for the increasing number of vaccine doses going out 
to states each week. However, some clinics in my state that 
care for underserved populations still haven't received their 
first doses of the vaccine, and patchwork distribution 
complicates vaccine delivery.
    Finally, get the vaccine out to where people live. 
Federally supported mass vaccination sites will help to 
increase overall vaccination numbers. However, equity must be 
ensured by setting up vaccination sites directly in the hardest 
hit communities. Leaders at UAB prioritized vaccine equity from 
the beginning of the planning process and partnered with the 
city to set up a vaccination site in an underserved area of 
Birmingham. These efforts helped deliver vaccines to local 
minority communities at four times the state and national 
averages.\8\ Getting the vaccine out also involves more mobile 
vaccination programs and vaccinating people in their homes. 
Geriatricians are doing this across the country for those who 
are homebound. We should learn how they are succeeding and 
replicate their efforts.
---------------------------------------------------------------------------
    \8\ Greer T. UAB Stats Show Early, Effective COVID Vaccine Reach 
into Underrepresented Communities. Published February 17, 2021. 
Accessed online on March 12, 2021 from https://www.uab.edu/news/
research/item/11859-uab-stats-show-early-effective-covid-vaccine-reach-
into-underrepresented-communities.
---------------------------------------------------------------------------
    The COVID-19 pandemic exposed significant disparities and 
divides in our healthcare system, especially among older and 
at-risk Americans. We must ensure that vaccines are easily 
accessible to them and that the distribution process is 
equitable, not only to urgently save lives but also to have a 
long-lasting positive impact on our healthcare system going 
forward.
    I thank the Chairman and the members of this committee for 
holding this hearing to focus on issues that directly impact 
the people for whom I care.
    Many of the most vulnerable will not be able to raise their 
hands and tell us they need help.
    We must reach out and support them.
    Thank you.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
Prepared Statement of Anthony Jackson, Senior Vice President and Chief 
           Operating Officer, Roper Saint Francis Healthcare,
                       Charleston, South Carolina
    Chairman Casey, Ranking Member Scott, and members of the committee, 
thank you for inviting me to testify today. My name is Anthony Jackson 
and I am the Senior Vice President and Chief Operating Officer of Roper 
St. Francis Healthcare in Charleston, South Carolina. Roper St. Francis 
is the only private, not-for-profit, faith-based health care system in 
Charleston. We have four hospitals with 657 beds across five counties. 
We are the region's largest private employer 6,000 employees, and we 
have more than 1,000 doctors on our medical staff.
    The impact of COVID-19 on Roper St. Francis Healthcare has been 
dramatic. Since the start of 2020, there have been 455,495 confirmed 
cases of COVID in South Carolina. This pandemic has disproportionately 
affected older Americans, and that was especially true at Roper St. 
Francis Healthcare. Over the past year, we experienced many difficult 
moments as our doctors and nurses worked bravely and tirelessly to 
treat COVID patients. This includes patients such as Lethia Moore, a 
78-year-old great-great-grandmother who was admitted to Roper St. 
Francis Healthcare on April 3, and sadly passed away on April 12, 
comforted by a nurse who refused to leave her side.
    As COVID continued to spread, our hospital system adapted. While we 
already had a platform in place for telehealth, the COVID pandemic 
required us to scale up quickly. Telehealth has proven so valuable that 
we intend to continue it in the long run. We have set a goal of 
maintaining 20 percent of all visits via telehealth, which opens doors 
for many vulnerable older Americans, particularly those who are 
homebound, those living with disabilities, and those who live in rural 
areas.
    We're hopeful that this pandemic will be brought to an end this 
year with the advent of the COVID-19 vaccine. Roper St. Francis 
Healthcare is working closely with the State of South Carolina to 
administer COVID vaccinations. We received our first batch of vaccine 
in December and began administering them to our health care workers on 
December 15. In January, we opened a COVID vaccination drive-thru for 
patients in the parking lot of the North Charleston Coliseum, a site 
that is used to accommodating crowds of more than 13,000 for events. We 
have the capacity to vaccinate up to 1,500 residents per day.
    Additionally, this week, we launched a pop-up drive thru location 
in Berkeley County for residents 55 and older. This is important 
because about three-quarters of Berkeley County's 65 and older 
population has yet to be vaccinated. Vaccine drive-thru centers can 
play an integral role in expanding our vaccination campaign beyond 
urban areas to reach a population that is often left behind. 
Communities and states must be proactive and creative to reach 
residents who cannot get vaccinated through more traditional visits to 
hospitals and doctors' offices, and our drive-thru vaccination site 
would be a great model for others to follow.
    The pandemic and vaccine rollout also have shown the importance of 
treating seniors across all facets of the health care system. Whether 
its hospitals, community health centers, or nursing homes, we all have 
a role to play. Why? We know that when we consider social environmental 
factors such as social mobility, work, retirement, education, income, 
and wealth, caring for our seniors becomes even more complex. 
Healthcare for seniors is dynamic and multidimensional; and to address 
them adequately, the pandemic has taught us that care in the community 
has to be collaborative, innovative, intentional and equitable. Roper 
St. Francis is proud of the thousands of hours of community care that 
we provide in Charleston and the surrounding counties alongside our 
community partners and volunteers.
    As a former licensed nursing home provider, I understand the value 
of senior-care communities. Our patients have turned to us for guidance 
over the past year, and we cannot lose this trust. We need to continue 
to have transparency and accountability, and I am proud of the work 
that all the staff at Roper St. Francis has done and will continue to 
do as the pandemic is not over. Ensuring healthcare providers have a 
sufficient and dependable supply of COVID-19 vaccine is central to our 
ability to successfully plan and operate vaccination events, so thank 
you for your continued efforts on this issue. I am thankful to every 
member of the committee for their work to ensure that our hospitals had 
the resources they needed to fight the pandemic, and I'm looking 
forward to continuing to serve our patients in the Lowcountry.
 Prepared Statement of Sandra Harris, Volunteer State President, AARP 
                  Massachusetts, Boston, Massachusetts
    Chairman Casey, Ranking Member Scott, and members of the committee, 
thank you for inviting AARP to testify today. My name is Sandra Harris 
and I am the volunteer State President for AARP Massachusetts. On 
behalf of our 38 million members, including 776,506 in Massachusetts, 
and all older Americans nationwide, AARP appreciates the opportunity to 
provide testimony at today's hearing.
    COVID-19 has been particularly hard on Americans over the age of 50 
and people of color. Since the start of the pandemic, nearly 95 percent 
of the deaths from COVID-19 have been among people age 50 and older. 
The situation in America's nursing homes is particularly dire. Over 
175,000 long-term care facility residents and staff have died--
including over 8,600 in Massachusetts due to COVID-19, representing 
about 35 percent of the deaths nationwide and over 50 percent of deaths 
in Massachusetts, despite the fact that nursing home residents comprise 
less than one percent of the U.S. population. Further, nursing homes 
with more residents of color have reported triple the number of COVID-
19 deaths. Moreover, millions of older Americans have been socially 
isolated, spending holidays and birthdays away from loved ones, for a 
year now. AARP members are eager to see their grandchildren again, or 
visit their parents in a nursing home for the first time in a long 
time. I am one such person--I have not seen my grandchildren in over a 
year and I am very much looking forward to reuniting with them.
    Thankfully, safe and effective vaccines to combat COVID-19 have 
provided new hope to Americans over the age of 50. We cannot stress 
enough how eager many are to receive a vaccine, which offers so much 
promise for a return to normalcy. We have heard many questions from 
AARP members about when and how they can expect to be vaccinated, who 
will notify them, what information they will need to provide, and where 
they can sign up. We are encouraged by the progress being made, with 
over twenty-one million Americans over the age of 50 fully vaccinated. 
We are also very pleased with the progress that has been made in 
providing vaccines to residents and staff of long-term care facilities 
(LTCFs), including the Long-Term Care Partnership that has fully 
vaccinated 2.7 million LTCF residents and staff. In Massachusetts, 
approximately 84 percent of all nursing home residents and 71 percent 
of staff have received both doses.
    However, we continue to hear from Americans over the age of 50 who 
are having difficulty accessing COVID-19 vaccines, and in many states, 
demand continues to outstrip supply. In addition, there has been wide 
disparities in access to these vaccines, with the Centers for Disease 
Control and Prevention reporting that of those who have received both 
vaccine doses, 67 percent are White. AARP is committed to reducing this 
gap and ensuring all those who want a COVID-19 vaccine can access it. 
AARP recently joined with five of the Nation's largest nongovernmental, 
nonprofit membership organizations--which combined, reach more than 60 
million Americans--to launch a COVID vaccine equity and education 
initiative. The effort includes the American Diabetes Association, the 
American Psychological Association, the International City/County 
Management Association, the National League of Cities, and the YMCA. It 
aims to ensure that accurate and transparent information about the 
COVID-19 vaccine is available to Black Americans to help them make 
informed personal decisions about vaccination.
    Accessing the vaccine continues to be a challenge for many older 
adults who are struggling to make appointments, including those who do 
not have access to the Internet or do not regularly use the Internet. 
The appointment process varies state to state, or even county by 
county. Many Americans over the age of 50 are unsure how to make or 
confirm their appointment and are deeply frustrated and increasingly 
desperate. Furthermore, many do not have access to the Internet or do 
not have experience using online appointment systems. I consider myself 
a fairly technology-savvy individual, and yet I had significant 
difficulties in getting an appointment through Massachusetts's vaccine 
appointment Web site. In addition, some states require individuals to 
visit multiple Web sites just to monitor vaccine appointment 
availability. States like Massachusetts have moved to a pre-
registration system for vaccine appointments at the state's seven mass 
vaccination sites, which we hope will help ease the stress of competing 
for vaccine appointments. We also urge the Federal Government to work 
with states to develop 1-800 numbers for scheduling vaccine 
appointments that are centralized, well-staffed, and offer culturally 
competent customer service in several languages. states and counties 
should also set aside a specific number of vaccine appointments for 
these call centers so these individuals are not competing with those 
going online to schedule appointments.
    We are pleased that the CDC has launched an online tool that will 
allow them to use their ZIP code to search for where they can get a 
vaccine. We encourage the CDC to build on this tool and work with 
states to allow consumers to easily book a vaccine appointment after 
finding available vaccines in their area. AARP has also been 
particularly focused on ensuring vaccines are reaching homebound 
individuals. Many older Americans do not have access to transportation 
or cannot leave their home due to medical reasons. Others are unable to 
stand for long periods of time, as is required at many vaccination 
sites. It is critical that states and counties utilize mobile clinics 
and other solutions to administer COVID-19 vaccines to this population. 
The CDC released helpful guidance on vaccinating homebound individuals, 
and the Federal Emergency Management Agency has made funding available 
to states for the creation of mobile clinics. In addition, new funding 
provided by the American Rescue Plan Act to the CDC allows them to 
provide technical assistance to states as they set up mobile clinics.
    While there may be a sense of relief with vaccines rolling out, and 
cases and deaths in long-term care facilities finally declining, 
policymakers and facilities are not relieved of their responsibility to 
protect nursing home residents. AARP has heard from thousands of people 
all across the country whose loved ones lost their lives in nursing 
homes, and throughout the pandemic, we remain steadfast in advocating 
for the health, safety, and well-being of residents and staff.
    We recognize that that nursing home problems are not new. Even 
before the pandemic, many long-term care facilities struggled with 
basic infection control and adequate staffing. It is not a could act or 
should act situation, it is a must act situation. AARP has urged action 
on a five-point plan to slow the spread and save lives:

1. Ensure facilities have adequate personal protective equipment (PPE) 
for residents, staff, visitors, and others as needed, and prioritize 
regular and ongoing testing.

    Even with vaccines, we know that PPE and regular testing are still 
needed to stop the spread of coronavirus and other pathogens. AARP 
supports the funding in the American Rescue Plan Act for infection 
control and vaccine uptake support provided by quality improvement 
organizations to skilled nursing facilities.

2. Improve transparency on COVID-19 and demographic data, vaccination 
rates of residents and staff by facility, and accountability for 
taxpayer dollars going to facilities.

    AARP has called for increased transparency of COVID-19 cases, 
deaths, and vaccination rates in long-term care facilities, including 
demographic data. Better data is important for families and will help 
us effectively understand and respond to the crisis in a timely and 
focused way so that we can minimize the spread of the virus, disrupt 
disparities, and improve health outcomes now and into the future.
    We also believe there needs to be greater transparency around how 
the billions of dollars in taxpayer money that has gone to facilities 
was spent from the Provider Relief Fund. We have urged that any federal 
funding should be used for the health, safety, and well-being of 
residents and staff.

3. Ensure access to in-person visitation following federal and state 
guidelines for safety, and require continued access to facilitated 
virtual visitation for all residents.

    We were pleased that CMS issued updated nursing home visitation 
guidance on March 10, providing welcome news for families and nursing 
home residents who want and need to visit with their loved ones, while 
also continuing to emphasize that nursing homes, visitors, and others 
follow infection prevention and control practices. The guidance will 
enable more residents and their loved ones to visit more easily and 
safely in-person. For many Americans living in nursing homes and other 
facilities, their friends and family serve as a source of comfort and 
an important safety check.

4. Ensure quality care for residents through adequate staffing, 
oversight, and in-person access to long-term care ombudsman.

    We are deeply concerned about staffing shortages at residential 
care facilities. AARP's Nursing Home Dashboard has consistently found 
over 25 percent of nursing homes nationally reporting a shortage of 
direct care workers since June 2020, and in fact, many facilities had 
inadequate staffing prior to the pandemic. This is an ongoing concern, 
as higher staffing levels are associated with fewer deaths and COVID-19 
cases in nursing homes. AARP supports funding in the American Rescue 
Plan Act for state strike teams in nursing homes with COVID-19 cases. 
AARP further urges Congress to take action to ensure that staffing 
levels in long-term care facilities are adequate, such as through pay 
and other compensation, paid leave, recruitment, training, and 
retention. It also remains important for residents to have in-person 
access to long-term care ombudsmen, who play an important role in 
advocating for residents and their families.

5. Reject immunity and hold long-term care facilities accountable when 
they fail to provide adequate care to residents.

    The pandemic has put residents' lives at unprecedented risk, as 
reflected by the horrific death tolls. We know that staff in many long-
term care facilities are doing heroic work, putting their own health on 
the line to care for people in nursing homes. Sadly, AARP has heard 
from thousands of families whose loved ones were not treated with the 
compassion or dignity that every American deserves. AARP strongly urges 
Congress to protect the safety of residents, including by maintaining 
the rights of residents and their families to seek legal redress to 
hold facilities accountable when residents are harmed, neglected, or 
abused.
    In addition to reforming our Nation's long-term care facilities, we 
need to support the ability of people to remain in their homes and 
communities. Not only will this help people to live where they want to 
be, but also help to alleviate some of the challenges we are facing in 
our Nation's nursing homes. Enabling people to live in their own homes 
helps save lives in nursing homes. Furthermore, on average, for every 
one person residing in a nursing home, Medicaid can fund three 
individuals receiving community-based long-term care. AARP supports the 
10 percent enhanced FMAP for Medicaid HCBS included in the American 
Rescue Plan Act to help enable more people to live in their homes and 
communities.
    Congress must also look longer-term to give older adults and people 
with disabilities more options to live in their homes and communities, 
including more options to receive care at home, and more support for 
family caregivers who help make it possible. My family has worked to 
ensure my mother, who has dementia, has the care she needs to stay at 
home through a combination of home care services and family caregiving, 
but it has not been easy. A family caregiver tax credit, as in the 
bipartisan, bicameral Credit for Caring Act, would help provide some 
financial relief to eligible family caregivers.
    Finally, we are seeing large numbers of older adults facing hunger 
as a result of the pandemic. More than 20 percent of people age 50 to 
59 and 14 percent of Americans age 60 and older are struggling to put 
food on the table, with Black and Hispanic older adults reporting even 
higher rates of food insecurity. In 2020, grocery store food prices 
outpaced the historical average by 75 percent. For people living on a 
tight budget, including many older adults on fixed incomes, this can 
make it much harder to buy enough food. We have learned about the real 
struggle many older adults are experiencing during the pandemic--how 
they are having to rely on their kids and grandkids, and how they are 
having to make difficult decisions between paying for rent, food, or 
essential medicine.
    For older people scrambling to make ends meet, the Supplemental 
Nutrition Assistance Program (SNAP) is a much-needed lifeline. Through 
improved nutrition and decreased financial strain, SNAP participation 
is associated with better health and decreased hospitalization. 
Further, these benefits can be an important stimulus to support local 
businesses. AARP supports the 15 percent SNAP benefit increase through 
September. We also support the additional resources for state SNAP 
administration to continue support for people in need and additional 
funding to support improvements to help people buy groceries online 
using their SNAP benefits.
    With Older Americans Act (OAA) nutrition services providing more 
meals to more people, AARP supports the emergency funding to help the 
aging network meet the needs of seniors, so they can continue to stay 
safe and healthy at home. People in Massachusetts and across the 
country are also continuing to turn to food banks as a vital lifeline, 
and in many cases, those people are visiting food banks for the first 
time.
    The uncertain nature of the pandemic introduces challenges to 
forecasting future needs making it essential that we closely monitor 
food insecurity, especially as critical benefits expire and as 
supplemental funding is spent down. We also believe it will be 
important to continue the temporary SNAP boost for the duration of the 
COVID-19 crisis, adjusting the length and amount of the relief based on 
health and economic conditions.
    Americans over the age of 50 continue to struggle with the impacts 
of this pandemic and will continue to for some time. We are thankful 
that some relief has arrived, but more needs to be done to protect the 
health and safety of older Americans.
   
      
=======================================================================


                        Questions for the Record

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

                Questions for the Record To Anand Iyer 

                          From Senator Rosen 

    Palliative Care and Telehealth

    As Chair of the bipartisan Comprehensive Care Caucus, which 
I launched to raise public awareness and promote the 
availability and benefits of palliative care, I'm so pleased to 
hear about your background and work in this field.
    Question:

    Dr. Iyer, can you tell me more about the work you have been 
doing throughout the pandemic to increase access to palliative 
care, and how are you delivering this care now via telehealth? 
What more can Congress do to support you and others in these 
efforts?
    Response:

    Dear Senator Rosen,

    Thank you for your question on palliative care and 
telehealth. I am grateful for your leadership on the 
Comprehensive Care Caucus and for your continued advocacy for 
palliative care. As a pulmonary-critical care physician, I see 
firsthand the value of palliative care to improve quality of 
life for people living with serious illness in our intensive 
care unit and at my pulmonary clinic for undeserved citizens in 
Jefferson County, AL. I advocate for palliative care 
integration into my field of pulmonary medicine through 
multiple national organizations and research innovative ways to 
improve its delivery to people with chronic lung disease. My 
research, supported by a 2020 Paul B. Beeson Emerging Leaders 
Career Development Award (K76) from the National Institute on 
Aging, focuses on implementing geriatrics and palliative care 
in chronic obstructive pulmonary disease (COPD), the third 
leading causes of death among older Americans. We are 
developing the first geriatrics and palliative care framework 
for clinicians who care for patients with COPD and are testing 
an innovative telephone-based geriatrics and palliative care 
intervention for older adults with COPD and their families.
    Regarding telehealth, leadership at UAB Medicine had the 
foresight to implement telehealth before the pandemic and were 
primed to scale it last year and meet an incredible demand. I 
was excited to be a part of that revolution in healthcare 
delivery. Our division harnessed telehealth to bring 
subspecialty pulmonary care to Alabamians across the state in 
areas without routine access to pulmonologists. Given my 
devotion to palliative care, I used every opportunity during 
each telehealth visit to connect patients with my colleagues at 
the UAB Center for Palliative and Supportive Care, where my 
mentors and their teams have been working hard to develop and 
research innovative telehealth strategies long before the 
pandemic. I recall caring for a woman in her 80's who lives far 
from Birmingham and was isolated in her home due to COPD. I 
connected her with telehealth palliative care, and as a team we 
were able to improve her quality of life while keeping her safe 
at home and removing a significant barrier to in-person clinic 
visits: transportation. This outreach also extended to patients 
at my county pulmonary clinic, where I helped a gentleman who 
was suffering with severe breathlessness due to end-stage COPD 
find relief with the help of telehealth palliative care. 
Finally, our telehealth ICU teams safely cared for hundreds of 
critically ill patients last year at rural facilities across 
Alabama. It was thrilling to help an ICU team 100 miles away 
get a man off the ventilator who had respiratory failure due to 
COVID-19 and watch him give me a thumbs up over the video. 
Telehealth has immense potential but only if we can first 
expand broadband access to rural and underserved areas and 
improve digital literacy among older adults.
    In the next decade, millions of Americans with serious 
illnesses will grow older, and this will further strain our 
healthcare system. Without a parallel increase in the number of 
specialist palliative care clinicians and geriatricians, there 
will be a deficit of over 1000 clinicians needed who are 
uniquely trained to care for them. The current turnover of 
trainees in palliative care and geriatrics is insufficient to 
meet that demand, especially when physician training spots 
across the country are going unfilled. This is already creating 
a huge gap in care that requires urgent solutions. One of the 
most immediate opportunities is to pass the bipartisan 
``Palliative Care and Hospice Education and Training Act'' 
(PCHETA; S. 2080/H.R. 647) that promotes palliative care 
education, research, and workforce development. Its fate has 
hung in the balance for years, and I hope that 2021 can be the 
year that it passes. There is also the ``Provider Training in 
Palliative Care Act'' (S. 1921) proposed by you and Senator 
Murkowski to expand palliative care through the National Health 
Services Corp. Both would expand the palliative care workforce 
and provide someone like me the training in palliative care to 
deliver it on the frontline for my patients and their families. 
This would go beyond training in communication and planning 
about the end of life and extend to broad symptom management 
and caregiver support. Opportunities to expand my training in 
palliative care are very limited. A primary palliative care 
model, i.e. training frontline clinicians from diverse 
disciplines and specialties in palliative care, seems to me to 
be the most practical and actionable solution to grow the 
palliative care workforce and close the widening gap.
    The pandemic spotlighted the importance of palliative care. 
As a discipline, it is underappreciated and underutilized and 
we have a lot of work to do to increase awareness and 
acceptance. I would be honored to continue to work with you in 
the future to expand palliative care, to educate the public and 
my fellow healthcare workers, and to develop innovative 
solutions that bring palliative care to more Americans and 
their families and make it a standard of care for serious 
illness.

Sincerely,

Dr. Anand S. Iyer

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


                  Additional Statements for the Record

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

                        Meals on Wheels America

          1550 Crystal Drive, Suite 1004, Arlington, VA 22202
                      www.mealsonwheelsamerica.org

    Dear Chairman Casey, Ranking Member Scott, and Members of 
the Committee: On behalf of Meals on Wheels America, the 
national network of community-based senior nutrition programs, 
and the individuals they serve, thank you for holding the 
important hearing, ``COVID-19 One Year Later: Addressing Health 
Care Needs for At-Risk Americans.'' We are grateful for your 
leadership and commitment to addressing the needs of our 
Nation's older adults, especially as we pass the difficult one-
year anniversary of the COVID-19 pandemic, which has 
disproportionately claimed the lives of thousands of older 
Americans and has harmed the health and well-being of millions 
of others.
    Meals on Wheels America is the national nonprofit 
organization that supports the network of 5,000 community-based 
senior nutrition programs across the country that are dedicated 
to addressing senior isolation and hunger. With the support of 
committed volunteers and staff members, local Meals on Wheels 
programs deliver nutritious meals in group settings and/or the 
home, and provide friendly visits and social interaction, 
safety checks, and connections to other social and health 
services to older Americans in virtually every community 
nationwide. The individuals served through the senior nutrition 
network are among the most vulnerable to experiencing severe 
complications related to COVID-19, as well as challenges 
accessing nourishing food and social connections.
    For nearly 50 years, community-based senior nutrition 
providers have been welcomed into the homes of our Nation's 
seniors with every meal delivery. The person-centered services 
provided by this network are made possible by the federal 
funding and support authorized by the Older Americans Act (OAA) 
and are designed to specifically meet the nutritional and 
social needs of high-risk, underserved seniors. Senior 
nutrition programs have long worked on the front lines of 
combating the harmful effects of hunger, social isolation and 
loneliness in older adults, but their efforts have never been 
as essential as during the pandemic, as they continue to 
provide their communities with nutrition, social connection and 
most recently, support with accessing vaccinations.
    The variety of topics covered at the hearing and diversity 
of experiences and perspectives outlined by the witnesses were 
informative and encouraging. Well-coordinated mass vaccine 
distribution plans and outreach, expansion of broadband and 
telehealth, improved caregiver and direct workforce support, 
and funding for essential wrap-around aging services are all 
vital to ensuring the health and well-being of older adults. We 
appreciate the opportunity to submit this written testimony for 
the hearing record and will focus our statement on the senior 
nutrition network's specific experience--both the successes and 
challenges--around providing care and support to older adults 
in their homes and communities amid the pandemic.

             Addressing Senior Hunger and Isolation Before 
                          and During COVID-19

    Senior hunger, social isolation and loneliness are 
recognized as major threats to public health, though the 
awareness of these issues has grown significantly due to the 
pandemic. Before the COVID-19 crisis, nearly 9.7 million 
seniors in the United States faced the threat of hunger; among 
those, 5.3 million were food insecure or very low food 
secure.\1\ One in four older adults reported feeling lonely, 
and over 17 million lived alone, putting them at risk of social 
isolation.\2\ \3\ We know that a far more significant number of 
older adults are now experiencing food insecurity, and many 
more are lonelier than before the pandemic.
---------------------------------------------------------------------------
    \1\ Feeding America (research conducted by J. Ziliak and C. 
Gunderson), 2020, The State of Senior Hunger in America in 2018. 
Available at https://www.feedingamerica.org/research/senior-hunger-
research/senior.
    \2\ AARP, 2018, Loneliness and Social Connections: A National 
Survey of Adults 45 and Older. Available at https://www.aarp.org/
research/topics/life/info-2018/loneliness-social-connections.html.
    \3\ U.S. Census Bureau, 2020, American Community Survey 2018. 
Available on the Administration for Community Living Aging, 
Independence, and Disability Program Data Portal (AGID): https://
agid.acl.gov/CustomTables.
---------------------------------------------------------------------------
    Despite the efforts of dedicated local programs working 
tirelessly to serve their communities with limited resources, 
the gap between those struggling with hunger and those 
receiving nutritious meals through the OAA continues to widen 
across the country. Even prior to the pandemic, federal funding 
for aging services, like Meals on Wheels, was not keeping pace 
with increasing demand, rising costs and inflation. 
Consequently, the network served over 17 million fewer OAA 
meals in 2019 than in 2005, and with the onset of the health 
and economic crises caused by COVID-19, the demand for OAA 
services like Meals on Wheels has soared to unprecedented 
levels.\4\ With 12,000 individuals turning 60 every day, and 
the pandemic exacerbating existing inequities in food and 
health access, further federal investment is unequivocally 
needed.
---------------------------------------------------------------------------
    \4\ Administration for Community Living (ACL), 2021, State Program 
Reports 2005-2019. Available on the AGID: https://agid.acl.gov/
CustomTables.
---------------------------------------------------------------------------
    As we heard from witnesses in the hearing, local community-
based programs have been critical to our Nation's pandemic 
response, and Meals on Wheels programs, in particular, have 
been highly sought out for the trusted nutrition and social 
connections they offer. More than a year into this public 
health crisis, these programs are continuing to deliver these 
life-saving services at sustained high rates.

      Care During Covid: The Meals on Wheels Response and Outlook

    Practically overnight, the Meals on Wheels network faced an 
unprecedented surge in demand as the number of older adults 
sheltering in place increased and congregate centers shifted 
ways of operating. Programs quickly adapted their traditionally 
high-touch service model to continue safely offering their 
senior clients critical person-centered components that go well 
beyond the meal itself. Most Meals on Wheels programs reported 
being able to not only continue their operations, but also to 
rapidly scale up to serve more older Americans in need because 
of the hope and promise that additional emergency funding would 
be coming their way.
    The innovative approaches that Meals on Wheels programs 
have utilized during pandemic response include transitioning 
congregate services to fully home-delivered or to grab-and-go 
and curbside pick-up alternatives that allowed older adults get 
their meals from the safety of their car in senior center 
parking lots. To address social isolation, many programs that 
were temporarily unable to offer a daily touch point with in-
person deliveries pivoted to offering virtual socialization 
alternatives and wellness checks over the phone. In light of 
the challenging circumstances, Meals on Wheels programs further 
established creative community partnerships with food banks, 
restaurants and other local non-profits to meet the needs of 
the clients they serve as well as to reach other higher-risk 
populations living in rural or unserved delivery areas. Local 
providers are also proving to be critical partners in the 
national effort to improve COVID-19 vaccine awareness, access 
and distribution to homebound older adults, including through 
education and referral information to isolated individuals, 
assisting with vaccine registration, partnering with health 
departments and pharmacies, coordination of vaccine deployment, 
and use of congregate sites for vaccine administration.
    Despite the incredible response from the senior nutrition 
network to quickly scale services, challenges remain in 
addressing the full demand for services. According to a survey 
of Meals on Wheels America membership, nine in 10 local Meals 
on Wheels programs report there is unmet need for home-
delivered meals in their community, and many report increased 
numbers of seniors forced to go on waiting lists for services. 
On average, Meals on Wheels programs are serving about 60 
percent more home-delivered meals than before the onset of 
COVID-19, and the majority believe they will not be able to 
sustain their current levels of operations without additional 
emergency federal funding.\5\
---------------------------------------------------------------------------
    \5\ Meals on Wheels American (research conducted by Trailblazer 
Research), 2020, results from a COVID-19 impact survey of Meals on 
Wheels America membership.
---------------------------------------------------------------------------
    The federal relief packages passed in response to the 
widespread health and economic effects of the pandemic have 
provided the aging services network with desperately needed 
supplemental funds to continue delivering meals to and 
maintaining social connections with seniors. The Families First 
Coronavirus Response Act (FFCRA), the Coronavirus Aid, Relief, 
and Economic Security (CARES) Act of 2020, the Continuing 
Appropriations Act of 2021, and the American Rescue Plan (ARP) 
Act of 2021 delivered a cumulative total of almost $1.7 billion 
for OAA Congregate, Home-Delivered and Native American 
Nutrition Services and the flexibilities required to enable 
this crucial support to local nutrition programs in every state 
and district. However, additional congressional funding and 
action is necessary to ensure the safety and social 
connectedness of our Nation's seniors, build the capacity of 
OAA programs and services to better serve this skyrocketing 
population, and bridge the growing gaps and unmet need for 
services in communities nationwide.

                            Recommendations

    We hope that our insights on the response and experience of 
the senior nutrition network in providing essential services 
throughout the pandemic are valuable as the Committee considers 
further action to support older adults, their families and 
caregivers. There remains a clear need for a strong community-
based aging services and supports system as the country's older 
adult population rapidly grows. It is also essential to prepare 
for future emergencies and unknowns that may again 
disproportionately complicate and harm the lives of seniors. 
Fortunately, with adequate support, Congress can strengthen and 
leverage existing private-public programs like Meals on Wheels, 
which are already reaching and serving the most at-risk and 
vulnerable older adults--and keeping them more healthy, safe 
and independent at home and out of Emergency Rooms, hospitals 
and long-term care facilities.
    Therefore, we urge Congress to continue its tradition of 
bipartisan support for this network and consider the following 
recommendations to support local nutrition providers and the 
older adults they serve:

      Increase federal funding for the Older Americans 
Act (OAA) Nutrition Program to, at a minimum, a total level of 
$1,091,753,000 in FY 2022, which is $140 million (or 15%) above 
current levels. This simply reflects the total amount 
previously authorized for the program in the Supporting Older 
Americans Act of 2020 reauthorization legislation.
      Implement the Supporting Older Americans Act of 
2020, the law reauthorizing the OAA as the primary piece of 
legislation supporting nutrition and social services for 
individuals age 60+ and their caregivers for more than 50 
years, with consideration for the evolving needs of senior 
nutrition programs due to pandemic response and recovery.
      Strengthen other federal anti-hunger nutrition 
programs, like the Supplemental Nutrition Assistance Program 
(SNAP) and the Commodity Supplemental Food Program (CSFP), that 
provide essential services to older adults and their families.

                               Conclusion

    Thank you again for convening this important hearing and 
for the opportunity to share our unique perspectives and 
experience on this pressing issue. We would like to extend 
special appreciation to Chairman Casey, Ranking Member Scott 
and their staff for their leadership and commitment to 
bipartisan work that will benefit the health, safety and 
economic security of older adults. We hope the insights shared 
in this statement are helpful in the Committee's work to 
address and implement policies that support older Americans, in 
COVID-19 response and recovery and beyond. We look forward to 
working together to ensure that no senior is left hungry and 
isolated and realize our vision of an America in which all 
seniors live nourished lives with independence and dignity.
                              ----------                              

                   The Healthcare Leadership Council
                       Mary R. Grealy, President
    Dear Chairman Casey and Ranking Member Scott: Thank you for holding 
a hearing, ``COVID-19 One Year Later: Addressing Health Care Needs for 
At-Risk Americans.'' The Healthcare Leadership Council (HLC) 
appreciates the opportunity to share its thoughts with you on this 
important issue.
    HLC is a coalition of chief executives from all disciplines within 
American healthcare. It is the exclusive forum for the Nation's 
healthcare leaders to jointly develop policies, plans, and programs to 
achieve their vision of a 21st century healthcare system that makes 
affordable high-quality care accessible to all Americans. Members of 
HLC--hospitals, academic health centers, health plans, pharmaceutical 
companies, medical device manufacturers, laboratories, biotech firms, 
health product distributors, post-acute care providers, home care 
providers, and information technology companies--advocate for measures 
to increase the quality and efficiency of healthcare through a patient 
centered approach.
    The COVID-19 health pandemic has been an unprecedented challenge 
for all Americans. Over 28 million Americans have tested positive for 
COVID-19 and over 500,000 have tragically lost their lives. Stay-at-
home orders have resulted in millions of job losses. However, due to 
the outstanding cooperation between the private sector and federal, 
state and local officials, significant progress has been made in 
confronting the pandemic. The newly enacted American Rescue Plan Act 
will continue to strengthen healthcare quality and access during the 
public health crisis. Yet, health inequities from the pandemic continue 
to exist in this country with regard to health outcomes. Black and 
Hispanic men and women are more at risk than their white counterparts 
due to longstanding racial health inequities and social determinants of 
health (SDOH) that leave them more vulnerable. The higher rates of 
infection and fatality in communities of color are linked to existing 
health inequities facing people of color, such as higher rates of 
diabetes and hypertension, and barriers to care. The importance of SDOH 
and their impact are more apparent than ever.
    According to the Kaiser Family Foundation (KFF), ``SDOH are the 
conditions in which people are born, grow, live, work, and age that 
shape health.'' These can include income, socioeconomic status, 
education, geographic location, employment, access to healthcare, 
transportation, food and nutrition, social isolation and many more 
broad categories; but can also be specific social, behavioral, and 
functional limitations such as home-state/home safety, the ability to 
perform activities of daily living, and the level of in-home support 
available to mitigate these limitations. Addressing inclusion in the 
community and employment have a greater impact on prevention of 
exacerbated health conditions than access to healthcare alone. HLC is 
supportive of providers and payers screening people for social 
determinants to help identify those who are considered at risk and in 
need of support and services. Investments in social services have been 
shown to be a stronger predictor of health outcomes than healthcare 
spending, so it's easy to see that addressing social determinants to 
improve population health can help slow the healthcare costs growth 
curve and improve overall health for at-risk Americans.
    In addition, HLC urges Congress to pass S. 104, the ``Improving 
Social Determinants of Health Act.'' This legislation will provide 
grants to nonprofit organizations and institutions of higher education 
to conduct research on SDOH best practices, provide technical, training 
and evaluation assistance and/or disseminate those best practices. 
Recently, HLC developed a SDOH report, ``Care, Context, and Community: 
Creative Ways to Address Social Determinants of Health,'' using the 
Department of Health & Human Services's Healthy People 2030 framework 
to identify potential areas of focus for progress, and includes a large 
number of recommendations, as well as successful examples to address 
social determinants. These recommendations rest on a three-part 
foundation we believe will help collaborations across the country move 
beyond pilot programs to implement robust interventions and achieve 
significant results. The three-part foundation comprises:

      Developing a standard set of SDOH definitions using the 
Healthy People 2030 framework, giving all partners a common starting 
point and frame of reference.
      Utilizing community-based organizations that are 
positioned and equipped to act as true business partners.
      Building a national clearinghouse of program information 
and best practices.

    This national clearinghouse will leverage HLC's established 
Redefining American Healthcare criteria. It will include a dashboard, a 
set of recommended measurements, descriptions of successful pilot 
programs, tools and methods for research and evaluation, and a 
compendium of best practices. As this national clearinghouse develops, 
HLC will share any forthcoming details or information with the 
committee as we believe this work will substantially improve the health 
of at-risk populations within the country.
    Thank you for the Committee's work on addressing the healthcare 
needs of at-risk Americans. HLC looks forward to continuing to 
collaborate with you on our shared priorities.
                               __________
        Alzheimer's Association and Alzheimer's Impact Movement
    The Alzheimer's Association and Alzheimer's Impact Movement (AIM) 
appreciate the opportunity to submit this statement for the record for 
the Senate Special Committee on Aging hearing entitled ``COVID-19 One 
Year Later: Addressing Health Care Needs for At-Risk Americans.'' The 
Association and AIM thank the Committee for its continued leadership on 
issues important to the millions of people living with Alzheimer's and 
other dementia and their caregivers. This statement provides an 
overview on the long-term care policy recommendations released by the 
Association and impact COVID-19 has had on persons living with 
dementia.
    Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support, and 
research. Our mission is to eliminate Alzheimer's and other dementia 
through the advancement of research; to provide and enhance care and 
support for all affected; and to reduce the risk of dementia through 
the promotion of brain health. AIM is the Association's sister 
organization, working in strategic partnership to make Alzheimer's a 
national priority. Together, the Alzheimer's Association and AIM 
advocate for policies to fight Alzheimer's disease, including increased 
investment in research, improved care and support, and development of 
approaches to reduce the risk of developing dementia.
    The COVID-19 pandemic continues to create additional challenges for 
people living with dementia, their families, and caregivers including 
compounding the negative consequences of social isolation that many 
older adults already experience. Social isolation is an issue within 
the aging community as a whole, exacerbated due to the current public 
health crisis, and felt particularly hard in the Alzheimer's and 
dementia community. We were thrilled to see important provisions on 
long-term care strike teams, infection control, vaccine education for 
older adults, and funding for home- and community-based services and 
elder justice programs included in the American Rescue Plan.
           American Rescue Plan and Long-Term Care Provisions
    An estimated 6.2 million Americans age 65 and older are living with 
Alzheimer's dementia in 2021. Total payments for all individuals with 
Alzheimer's or other dementias are estimated at $355 billion (not 
including unpaid caregiving) in 2021. Medicare and Medicaid are 
expected to cover $239 billion or 67 percent of the total health care 
and long-term care payments for people with Alzheimer's or other 
dementias. Total payments for health care, long-term care, and hospice 
care for people with Alzheimer's and other dementias are projected to 
increase to more than $1.1 trillion in 2050. These mounting costs 
threaten to bankrupt families, businesses, and our health care system.
    At age 80, approximately 75 percent of people with Alzheimer's 
dementia live in a nursing home compared with only 4 percent of the 
general population at age 80. In all, an estimated two-thirds of those 
who die of dementia do so in nursing homes, compared with 20 percent of 
people with cancer and 28 percent of people dying from all other 
conditions. It is critical that all residents of nursing homes, 
including those in skilled nursing facilities and Medicaid nursing 
facilities, receive consistent, high-quality care, especially as people 
can live for many years in these settings.
    At least 163,000 residents and employees of nursing homes and other 
long-term care settings have died from COVID-19, representing over 30 
percent of the total death toll in the United States. These communities 
are on the frontlines of the COVID-19 crisis, where 48 percent of 
nursing home residents are living with dementia, and 42 percent of 
residents in residential care facilities have Alzheimer's or another 
dementia. Residents with dementia are particularly susceptible to 
COVID-19 due to their typical age, their significantly increased 
likelihood of coexisting chronic conditions, and the community nature 
of long-term care settings. Across the country these communities, their 
staff, and their residents are experiencing a crisis due to a lack of 
transparency, an inability to access the necessary testing and personal 
protective equipment, incomplete reporting, and more.
    To best support individuals living with Alzheimer's and dementia 
during the pandemic, the Alzheimer's Association released a 
comprehensive set of long-term care policy recommendations for federal 
and state lawmakers, Improving the State and Federal Response to COVID-
19 in Long-Term Care Settings. These recommendations focus on four 
areas: (1) rapid point-of-care testing, (2) reporting, (3) surge 
activation, and (4) providing support.
    These policies are designed to create a strong and decisive 
response to the COVID-19 crisis in all long-term care settings and we 
were heartened to see them in the American Rescue Plan Act of 2021. We 
thank you for including these important provisions and strongly believe 
these provisions are critical to our populations and represent a 
significant step forward in improving their care during this pandemic 
and beyond.
                    Recent Nursing Home Legislation
    AIM and the Alzheimer's Association have endorsed Chairman Casey 
and Senators Warnock, Whitehouse, Booker and Blumenthal's COVID-19 
Nursing Home Protection Act that would provide $750 million in funding 
to states for the purpose of establishing and implementing strike teams 
to ensure a sufficient number of aides, nurses, and other providers are 
available to care for residents. The bill would guarantee that $210 
million is available to the Secretary of Health and Human Services 
(HHS) to contract with quality improvement organizations to provide 
essential infection control assistance to nursing homes. Last, the bill 
would require HHS to collect and post on the Nursing Home Compare Web 
site demographic data on COVID-19 cases and deaths among nursing home 
residents and workers, including information on age, race, ethnicity 
and preferred language. These crucial provisions are consistent with 
the Alzheimer's Association's recently released long-term care policy 
recommendations.
    Additionally, AIM and the Alzheimer's Association have endorsed 
Chairman Casey and Senator Toomey's Nursing Home Reform Modernization 
Act which would help ensure high-quality care by establishing an 
Advisory Council on Skilled Nursing Facility Rankings under Medicare 
and Nursing Facility Rankings under Medicaid at the Department of 
Health and Human Services (HHS). This new Advisory Council would 
provide HHS with recommendations on how to rank high rated and low-
rated facilities, with information on those rankings posted publicly to 
the Nursing Home Compare Web site. Importantly, the Special Focus 
Facility Program would transition to the low-rated facility program and 
Quality Improvement Organizations would work with those low-rated 
facilities to improve their quality of care through onsite consultation 
and educational programming. When choosing a facility for themselves or 
their loved ones, families deserve to have all the information 
available in a clear, easily digestible way. We appreciate that this 
bipartisan bill also directs HHS to utilize focus groups and consumer 
testing to ensure these ratings are easily understood by older adults, 
individuals with disabilities and family caregivers.
                               Conclusion
    The Alzheimer's Association and AIM appreciate the steadfast 
support of the Committee and its continued commitment to advancing 
policies important to the millions of families affected by Alzheimer's 
and other dementia. Thank you, Chairman Casey and Ranking Member Scott, 
for your continued commitment to supporting individuals living with 
Alzheimer's disease and other dementia, and their families. We look 
forward to working with the Committee in a bipartisan way to advance 
policies that would help this vulnerable population during the COVID-19 
pandemic and beyond.

                               [all]