[Senate Hearing 117-110]
[From the U.S. Government Publishing Office]
S. Hrg. 117-110
EYES, EARS AND TEETH: EXPANDING
MEDICARE TO COVER WHOLE PERSON CARE
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HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
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AUGUST 30, 2021
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Serial No. 117-06
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
46-330 PDF WASHINGTON : 2022
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SPECIAL COMMITTEE ON AGING
ROBERT P. CASEY, JR., Pennslyvannia, 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
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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
PANEL OF WITNESSES
Joanne Grossi, President, AARP Pennsylvania, Philadelphia,
Pennsylvania................................................... 4
Robin Stelly, Statewide Organizer, Pennsylvania Health Access
Network, Philadelphia, Pennsylvania............................ 6
Joseph Hollander, CEO, Primary Health, Scranton, Pennsylvania.... 8
Kelly Ranieli, Executive Director, Volunteers in Medicine,
Wilkes-Barre, Pennsylvania..................................... 10
APPENDIX
Prepared Witness Statements
Joanne Grossi, President, AARP Pennsylvania, Philadelphia,
Pennsylvania................................................... 25
Robin Stelly, Statewide Organizer, Pennsylvania Health Access
Network, Philadelphia, Pennsylvania............................ 29
Joseph Hollander, CEO, Primary Health, Scranton, Pennsylvania.... 32
Kelly Ranieli, Executive Director, Volunteers in Medicine,
Wilkes-Barre, Pennsylvania..................................... 35
EYES, EARS AND TEETH: EXPANDING MEDICARE TO COVER WHOLE PERSON CARE
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MONDAY, AUGUST 30, 2021
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The committee met, pursuant to notice, at 10 a.m., in the
Luzerne County Courthouse, Wilkes-Barre, Pennsylvania, Hon.
Robert P. Casey, Jr., Chairman of the Committee, presiding.
Present: Senator Casey
OPENING STATEMENT OF SENATOR
ROBERT P. CASEY, JR., CHAIRMAN
The Chairman. Good morning, everyone. We're gathered this
morning here in Wilkes-Barre to convene a hearing of the U.S.
Senate Special Committee on Aging, and I'm grateful to be with
you this morning.
We've gathered here in Luzerne County to discuss a pressing
need for seniors. That pressing need is to strengthen and
expand the Medicare program. This field hearing has been a long
time in coming, and it's a pleasure to be with our witnesses
today in person, several of whom I've known for a long time.
This gathering, of course, is after a long and terrible 18
months for the country because of the ravages of COVID-19. This
has been, without a doubt, the greatest public health crisis of
our lifetime. I believe we must increase substantially the
number of Americans who are vaccinated to help us get past this
dark chapter in our Nation's history.
The pandemic brought into sharp focus the longstanding
challenges that American families face, challenges that they
confront each and every day of their lives. The American Rescue
Plan--which was passed back in March with only Democratic
votes, by the way--just a little side note, Luzerne County got
$196 million from the American Rescue Plan, when you add up the
dollars that went to the county itself and then the dollars
that went to the municipalities.
That rescue plan did provide a measure of relief to
families, sometimes directly and sometimes indirectly. That's
true throughout not just Luzerne County but counties throughout
northeastern Pennsylvania and throughout our Commonwealth. Many
families got checks in their pockets, shots in their arms, and
we had the opportunity, because of funding, to begin to reopen
more schools safely. I hope we can get greater cooperation in
this next round of legislating as we go back in the fall.
I think, overall, what we're trying to do, in addition to
responding to a pandemic and responding in real time--that's
why we called it the rescue plan. Next we're also trying to
continue some of those investments in American families.
Basically, if you had to boil down what we're trying to do
in the upcoming reconciliation bill, it's about one basic idea:
lowering costs for families. That's what it's about. We did
that in the rescue plan, but we've got more to do in the
reconciliation bill.
How do we lower costs? Well, obviously, one of the ways to
lower costs is to lower the cost of prescription drugs. That's
true here in northeastern Pennsylvania and around the country
as well. Second, we lower costs for families by making health
care premiums more affordable. Third--and not exclusively, but
at least these three--third, we need to invest in children. You
do that by helping families raise their children. That's why
the Child Tax Credit, the Child and Dependent Care Tax Credit,
are so important.
In addition to investing in our children, we also need to
invest in our caregivers, those heroic essential Americans who
too often are left out of policymaking in Washington. We have a
long way to go to get that legislation passed, but today we're
going to focus more intensively on the opportunities that we
have to strengthen and expand Medicare. That's another way, of
course, to get costs down for families that are enrolled in
Medicare or a loved one who's enrolled in Medicare.
Medicare, of course, is a promise. It's not just a program.
It's a promise to Americans who have done so much for us: those
who fought our wars, who worked in our factories, who raised
all of us, who created the strongest middle class in world
history, and who gave our country so much. It's a promise to
them of guaranteed access to health care after a lifetime of
hard work. It's also not just a program. It's an earned benefit
in addition to a promise.
Despite this promise, we know that many seniors, as well as
people with disabilities, still have trouble affording care and
still have trouble accessing care. Medicare is not required,
unfortunately--and that's the purpose of our hearing today--
Medicare is not required to cover needed dental, hearing, and
vision services. That's an outrage. There's no reason why that
should be the case going forward. Poor access to this basic
care poses serious health risks to older Americans. That's why
I've introduced a bill to cover dental, vision, and hearing.
We know that 15 percent of older adults have lost all of
their teeth due to untreated dental disease. Now, 15 percent
may not seem like a high number until you apply that to the
number of seniors. We've got roughly 54 million seniors in
America. You can do the math. Millions and millions and
millions of seniors are in that category of having lost all of
their teeth due to an untreated disease. There's no excuse for
that in the most powerful country in the world.
Vision loss as well is associated with an increased risk of
falls and mobility limitations. Hearing loss can lead to both
social isolation and cognitive decline. We know that. That's
what the science and the studies tell us.
I received numerous letters in my office about this issue,
letters like those from Dr. Nancy King from Monongahela,
Pennsylvania, southwestern Pennsylvania. Dr. King's letter
urges support for Medicare coverage of hearing aids and related
services. Hearing aids allow Dr. King to work, talk on the
phone, dance, grocery shop, watch television, and even go fly
fishing. Most importantly, Dr. King notes in her hearing--in
her letter that her hearing aids keep her safe.
Here's what she says as she concludes her letter to me, and
I'm quoting, ``Without hearing aids, I can't even hear my water
spigot running, and it has overflowed. Also, without hearing
aids, I can't hear my phone ring. I cannot hear the cashier. I
cannot hear my home burglar alarm,'' unquote. That's what one
Pennsylvanian, Dr. Nancy King, tells us, but I think it's
emblematic of what we've heard all across the state. It's for
this reason that we introduced a bill, the Medicare and
Medicaid Dental, Vision, and Hearing Benefits Act. It's Senate
Bill 2618. It's why Congress must act to ensure that seniors
and people with disabilities can access and afford these basic
needs.
When I say ``act,'' I'm not talking about acting a few
years from now. I'm talking about right now. Now, we go back in
September and October to legislate on a larger bill that, of
course, goes by the bizarre name ``reconciliation,'' which
doesn't mean much to many people. It is the legislation, the
vehicle that will allow us to move forward as a Nation. It may
be the most important domestic legislation in the history of
the Nation. One of those component parts should be benefits for
Medicare and Medicaid recipients.
We know that we can find story after story about the need
for dental, vision, and hearing care among our seniors, just as
we hear story after story about families who can't afford care
and can't afford prescription drug benefits as well. No person
should have to choose between buying groceries and taking
needed medications, but today too many seniors face this
impossible choice. That's why I support allowing Medicare to
use its purchasing power to negotiate to bring down the cost of
prescription drugs. I've introduced legislation, separate
legislation, to allow for the safe, FDA-inspected importation
of medications from countries such as Canada.
This hearing is timely as we discuss these important
issues. Democrats are working on a bill to enact these historic
changes to Medicare and Medicaid. These bills, and all under
the broad heading of ``reconciliation,'' will help seniors and
will lower costs for families. I look forward to this hearing
today, and I look forward to learning more about these
important issues from our great panel of witnesses.
Before we begin, I want to remind our witnesses to please
keep their remarks to 5 minutes. In keeping with CDC
guidelines, I've asked all witnesses to keep their mask on and
remove them only when speaking. With these final logistical
notes, we'll turn to the introduction of our witnesses.
I'll start with Joanne Grossi. Joanne has served as the
president of AARP of Pennsylvania. She has years of experience
in the health policy--in health policy and also senior issues.
Joanne is a caregiver as well to her father. She brings
personal experience not just by way of policy but by way of her
work with her dad. Joanne, thank you for being here today and--
and taking the time to be with us and to share your expertise.
I'll introduce all of the witnesses, and then we'll go to
the testimony for each of them. Our next witness is Mr. Joe
Hollander, who's a resident of my hometown and his, Scranton,
Pennsylvania. He's the CEO of Scranton Primary Health Care
Center, a federally qualified health center serving much of
northeastern Pennsylvania. Joe, as well, has many years of
experience providing quality health care and dental care to
Pennsylvanians from throughout northeastern Pennsylvania. If
you had to look at Lackawanna County itself, it would be from
Carbondale to Moosic. We're so grateful Joe's with us. Joe,
thanks for bringing your experience today to this hearing. I
know personally of the work that you do and the work that gets
done in your center.
Witness number three, Robin Stelly. Robin is the statewide
organizer for Pennsylvania Health Access Network, known as
PHAN, P-H-A-N. Robin's work has allowed her to listen to
stories from Medicare consumers, particularly those that
experience challenges with healthcare affordability. Her
outreach gives her unique insight regarding how the lack of
dental, vision, and hearing care benefits directly affects
older Americans. Robin, I know personally, when we were
battling back in 2017 to stop the repeal of the Affordable Care
Act, how effective PHAN has been, and I'm grateful for your
presence here today.
Our fourth and final witness is Kelly Ranieli from here in
Wilkes-Barre, Pennsylvania. She's currently the executive
director for the Volunteers in Medicine clinic, which serves
Luzerne County residents and families. This clinic aims to meet
the needs of Pennsylvanians in the area of--who has no access
to ongoing health care. I want to thank Kelly for her being
with us today and for bringing her experience to this hearing
today.
We'll start with you, Joanne. You'll be our first witness.
Then, because I'll stop talking, I'll put my mask back on.
Joanne, thanks for being with us.
STATEMENT OF JOANNE GROSSI, PRESIDENT OF AARP PENNSYLVANIA,
PHILADELPHIA, PENNSYLVANIA
Ms. Grossi. Well, thank you, Senator Casey. Good morning,
everyone. My name is Joanne Grossi, and I am the volunteer
State president of AARP Pennsylvania. AARP is a nonpartisan
nonprofit nationwide organization with nearly 38 million
members in all 50 states, D.C., and the U.S. territories,
including 1.8 million members here in Pennsylvania.
For more than 30 years, I have been involved in public
health, including serving for 7 years as the regional director
of the United States Department of Health and Human Services
during the administration of President Obama, and as Deputy
Secretary of Health for the Commonwealth of Pennsylvania for 5
years during the Rendell administration. Thank you for the
opportunity to participate in today's field hearing
highlighting the importance of access and affordability of
expanded Medicare coverage for dental, hearing, and vision
benefits.
Fifty-six years ago, President Lyndon Johnson signed the
Social Security Amendment Act of 1965 and thus created
Medicare. Serving as a Federal health insurance program for
people aged 65 and older regardless of income or medical
history and for people under age 65 with permanent
disabilities, Medicare currently provides guaranteed affordable
coverage for more than 60 million Americans, including 2.8
million Pennsylvanians. AARP's founder, Dr. Ethel Percy Andrus,
played an active and important role in championing health
insurance for older Americans. She helped craft Medicare into a
successful program, and today AARP remains one of Medicare's
strongest advocates.
AARP has a long support--has long supported closing the
gaps in health coverage by including dental, hearing, and
vision coverage in the Medicare program. The lack of coverage
for these important health benefits leads to worse health
outcomes for older Americans and can actually cause higher
Medicare spending.
We know the majority of Medicare spending is on the
fraction of beneficiaries with chronic conditions such as
diabetes and heart disease. Meanwhile, Medicare does nothing to
prevent infections originating in the mouth. It does nothing to
help people retain or replace their teeth in order to eat and
be properly nourished. It does little to help people speak,
smile, or build relationships to fight off loneliness. It does
little to help people hear and see obstacles, which, as you
mentioned, Senator, can result in falls. In fact, 3 million
people are treated each year in emergency rooms in America due
to falls, costing the health care system $50 billion of which
Medicare and Medicaid cover 75 percent of those costs.
In short, Medicare will cover the expensive aftermath but
not the less expensive prevention. A recently released Kaiser
Family Foundation report which analyzed dental coverage and
costs for people with Medicare shows that many people enrolled
in Medicare go without dental care, especially beneficiaries of
color. Almost half of all Medicare beneficiaries did not have a
dental visit within the past year, with higher rates among
those who are Black or Hispanic. Rates were also higher among
those who have low incomes or are in fair or poor health.
One reason Medicare beneficiaries do not seek care is a
lack of insurance. Nearly half of all people with Medicare do
not have dental coverage. The others get this coverage through
Medicare Advantage, private insurance, and Medicaid. While
these programs recognize the value of dental, hearing, and
vision in keeping people healthier longer, their coverage is
inconsistent and not nearly robust enough.
In order to achieve the best possible health outcomes and
the greatest value, Medicare should cover the entire person
from head to toe. I'd like to give a little more context about
how the lack of a dental benefit stands in stark contrast to a
positive development in health care: thinking and acting
holistically to keep a person healthy and not just treating the
symptom or disease.
The lack of the dental benefit worsens the problems of
social isolation. As you mentioned, Senator, in your remarks,
the lack of a dental benefit worsens the problem of social
isolation. Helping older adults build stronger social
connections is a top priority for AARP. One respective study
has found that the impact of prolonged social isolation is
equivalent to smoking 15 cigarettes a day. We have to ask: Why
continue a policy that ignores oral health, that leaves so many
older adults with tooth loss, that makes them embarrassed about
their smile and makes it harder for them to communicate? We
could help prevent the social isolation that comes with losing
your self-confidence and ability to connect with family and
loved ones.
Simply put, Medicare should cover dental care; vision care,
including eyeglasses; and hearing care, including hearing aids.
Medicare beneficiaries want, need, and deserve these services
and are often surprised when they learn Medicare doesn't cover
them. It is time for Congress to take action to add in these
essential benefits. AARP is fighting hard to make sure this
happens, and we appreciate your leadership in this phase. Thank
you.
The Chairman. Joanne, thank you for your statement. We'll
move now to Robin Stelly. You may begin.
STATEMENT OF ROBIN STELLY, STATEWIDE ORGANIZER,
PENNSYLVANIA HEALTH ACCESS NETWORK,
PHILADELPHIA, PENNSYLVANIA
Ms. Stelly. Good morning. Thank you. My name is Robin
Stelly. Thank you, Senator Casey, for convening this hearing to
discuss an important issue that's on the minds of seniors and
disabled people, as you mentioned, across Pennsylvania and the
country: expanding Medicare to include dental, vision, and
hearing services. I'm an organizer with PHAN. We're the only
statewide consumer-led organization focused on achieving
quality accessible, equitable, and affordable health care for
all Pennsylvanians.
Every year we talk to over 10,000 Pennsylvanians from 62 of
67 counties. We assist people in enrolling in health insurance
coverage. We also help with problems of accessibility and
affordability of health care including unaffordable medical
bills, problems accessing providers, long travel or wait times
for care, denials of medically necessary care, and other
similar issues. All of these personal interactions shows how
much Pennsylvania's families, seniors, disabled people, and
small business owners struggle to access health care, as we
have--and we have numbers to back that up.
Recently, PHAN was fortunate to partner with Altarum's
health value--Healthcare Value Hub to do the first ever
Pennsylvania-specific survey on health care affordability in
the Commonwealth. Among other findings, and the findings were
legion, but to talk about today, the results showed that 42
percent of residents involved in Medicare were concerned about
being able to afford coverage in the near future. The premiums
for Part D, Part B, and Medigap plans add up. Something we hear
more--about more frequently is the struggle to pay for services
that aren't covered by Medicaid--Medicare, and that's vision,
hearing, and dental.
As I mentioned, through our work at PHAN, we're lucky to be
able to hear firsthand from consumers. In addition to reaching
out through the telephone and in person, we also engage
consumers online via surveys. Last week we conducted an
informal online survey on this topic. In fewer than 24 hours,
we had over 200 comments, and we have almost 500 comments
this--by this morning. People from all over the State responded
to this question: What would expending Medicare to include
vision, dental, and hearing services mean to you? I'm just
going to share a few.
This is Joanne in Mechanicsburg: ``I haven't been to the
dentist in 5 years. I can't hear in my right ear, and unless
people look straight at me so I can make out what they're
saying, I have no idea what they said. I'm 72 and on Social
Security, which everyone knows is below the poverty level. This
is horrific considering I worked for 42 years.''
This is Rochelle from Philadelphia: ``Over the past few
years, I've had severe dental issues and my vision has
deteriorated. My Social Security benefits barely cover my
monthly mortgage, utility, groceries, and prescription drug
pills. In order to cover the dental and vision bills, I need to
dip into what little savings I had. I'm now dealing with new
serious dental problems that will be--likely be very costly,
along with needing new glasses immediately and the likelihood
of eye surgery in the near future. Unlike many of my peers, I
no longer have savings to pay for serious household or other
emergencies. Expansion of Medicare to include vision, dental,
and hearing services is vital to my well-being.''
Catherine from Harwick: I would be able to get dentures and
eyeglasses. I now stay home, avoid get-togethers because I'm
embarrassed to see old friends and my family in current''--I'm
sorry--``old friends and family in my current toothless State.
I also would be able to eat healthier foods, which is a
priority for me being diabetic. I could get an eye exam, which
is critical when you have diabetes.''
Last, Karen Anne, who's a nurse practitioner in Lewisburg:
The importance of dental, vision, and hearing to the health of
older adults is well noted in the medical literature. The lack
of dental care and poor dentition is known to increase heart
disease and frailty among older adults. Poor vision and hearing
is highly correlated with loneliness, depression, and injuries
such as falls. Few older adults can afford out-of-pocket costs
for both glasses and hearing aids. I paid $6,000 for my hearing
aids, and I dread coming up with the money for the next pair as
I live on a meager retirement.''
That was a small sampling of the nearly 500 comments we've
collected. The stories were all different, but the common
themes definitely emerged. We repeatedly heard about the lack
of economic security, living on a fixed income, going without
or delaying care, digging into retirement to pay for care,
isolation in the community and in the family, a reduced quality
of life, seeking pain from pain--seeking relief from pain and
embarrassment, feeling like a burden to one's family, and the
fact that this problem is something that medical providers,
family members, and business owners see around them.
It's not hidden or difficult to understand. People age.
It's natural, and they deserve care for their entire body, not
only selected parts. In closing, thanks again to Senator Casey
for taking the time to have this hearing on this critical
problem. I want to thank you for your commitment to affordable
health care for seniors, disabled people, and all
Pennsylvanians. I'm happy to answer any questions you have.
Thank you.
The Chairman. Robin, thanks very much. We'll next turn to
Joe Hollander.
STATEMENT OF JOSEPH HOLLANDER, CEO, SCRANTON PRIMARY HEALTH,
SCRANTON, PENNSYLVANIA
Mr. Hollander. Good morning, Chairman Casey. Thank you for
the opportunity to testify this morning on the need to expand
dental coverage for seniors.
My name is Joseph Hollander. I'm proud to say for the last
seven and a half years I've been the CEO of Lackawanna County's
only federally qualified health center, Scranton Primary Health
Care. We have three offices located in Lackawanna County, and
they have been providing care to the community for over 42
years.
Scranton Primary Health Care provides care to everyone
regardless of their ability to pay. We offer pediatrics; family
medicine; internal medicine; women's health; gynecology;
perinatal care, with over 253 deliveries last year alone;
infectious disease care; behavioral health care; and general
dentistry, which includes diagnosis, treatment and management
of overall oral health care needs, including preventive
education, dental hygiene and cleanings, fluoride varnish,
sealants, gum care, fillings, root canals, extractions, crowns,
bridges, partials, full dentures, and mouth guards. All of our
providers are board certified and employees of the health
center.
We also assist members of the community in the navigating
and making application to the insurance marketplace. Our
patient base ranges from newborns to a senior who still lives
alone and will be celebrating her 104th birthday in November. I
think it is important to understand our patient demographics.
Sixty-one percent of our patients are at or below 200 percent
of the Federal poverty level. When we combine all of our
services, 14 percent of our patients are uninsured. I'm
certain, when it comes to dental, that number grows beyond 20
percent.
Sixty percent of our patients are covered by Medicare or
Medicaid, 9 percent by Medicare, 2 percent by the Children's
Health Insurance Program, and the balance have private
insurance. We take our mission very seriously, and, as a result
of that, never closed at any time during the pandemic. We
literally spent hundreds of thousands of dollars installing
HEPA filtration and UV-C filtration systems in an attempt to
keep our staff and patients safe.
We also purchased special equipment to control aerosols
generated during dental procedures in an effort to keep our
dental clinic open and safely operating throughout the pandemic
fully understanding the emergency departments in the area were
overwhelmed and not in the position to see dental emergencies.
We invested over a quarter of a million dollars in COVID-19
rapid-test equipment when the systems became overloaded and we
were literally waiting 10 to 14 days for test results. We now
have results in less than 14 minutes.
When vaccinations became available, we immediately pivoted
and added vaccinations to our already taxed health care
delivery system. Since December, we have delivered over 10,000
vaccinations and we were honored to vaccinate the Scranton fire
and police departments and many of the area's first responders
and health care workers as well as our own patients.
Now that you know a little bit about us, I would like to
talk about the purpose of today's hearing: expanding Medicare
to include dental coverage. I cannot stress to you how
important it is, the link between good oral health and good
physical health. Common sense tells us that if your diet is
severely limited because you're unable to chew your food and
eat a healthy diet, you can't get the nutrients and nourishment
you need. For some reason, this is stressed to us over and over
when we are young and ignored when it comes time to care for
our seniors.
We've always been taught to do whatever is necessary to
preserve your teeth. Extractions should be a last resort. Most
individuals, by the time they qualify for Medicare, have had
many of their teeth restored multiple times, leaving little
choices but the expensive option of root canals and/or crowns,
or the less costly and more common option of extractions.
As you can imagine, extractions cause their diet and
nutrition to suffer. This can also affect their speech as well
as their appearance, which can affect their mental health and
cause anxiety and depression. Every one of these factors
affects their physical health and well-being and ultimately
drives up the cost of medical care.
In the recent report by the Kaiser Family Foundation
mentioned earlier, it was disclosed that 40 percent--47 percent
of Medicare beneficiaries do not purchase dental coverage. That
same percentage did not have a dentist visit during the past
year, with minorities and those with low incomes at a much
higher rate. One in five Medicare beneficiaries who do visit
the dentist spend in excess of a thousand dollars for out-of-
pocket dental care.
In closing, please indulge me and allow me to read a social
media post from a gentleman who received care from our dental
clinic. In an effort to protect the individual's privacy, I
will call him ``George.'' ``I am a 68-year-old veteran of the
U.S. Navy and have been a patient of the dental clinic for the
past several months. I have been dealing with dental problems
almost my entire life, which finally culminated in the loss of
most of my teeth, which made it almost impossible to chew most
foods. Since my dental problems were not 100 percent service-
related, the Navy would not cover the cost of treatment.
``I searched far and wide for help when I came across
Scranton Primary. They were a godsend. Dr. DellAglio started my
treatment, and now I am so excited. I am just a few months away
from getting my dentures and being able to eat again. The
greatest thing about the dental clinic was they worked hard to
set up a payment--a payment plan I could afford and didn't make
me pay in advance. After they learned more about my personal
financial situation, they actually forgave my remaining debt
and thanked me for my service to our country.
``I have never been so touched in my life. Thank you, thank
you, thank you, thank you. I cannot recommend these guys
enough. With today's news being filled with man's inhumanity to
man, it's nice to know there's still people who care.'' George,
U.S. Navy, 1970 to 1974.
Thank you very much for this morning and the opportunity to
testify before you, Senator, and thank you, in general, for
caring about our seniors.
The Chairman. Joe, thanks very much for your testimony.
We're grateful you're here. Finally, Ms. Ranieli. Thank you
very much, Kelly, for being here.
STATEMENT OF KELLY RANIELI, EXECUTIVE DIRECTOR, VOLUNTEERS IN
MEDICINE, WILKES-BARRE, PENNSYLVANIA
Ms. Ranieli. Thank you for the opportunity to share my
personal insight and experience as executive director of a
nonprofit healthcare facility.
Volunteers in Medicine, VIM, is a 501(c)(3) community-based
nonprofit organization established to provide free medical,
dental, and behavioral health services to the working uninsured
and underinsured populations in northeastern Pennsylvania. The
clinic is not federally funded, and it does not charge for
services, so it operates solely from donations, grants, and
proceeds from special events. Individuals eligible for free
services work with an income at or below 200 percent of the
Federal poverty guidelines and has no access to affordable
health insurance or medical care.
In March 2021, approximately 7 percent of the population in
Pennsylvania was uninsured, and it's estimated that almost
three times that amount have no dental insurance. VIM is
experiencing an influx of new patients due to the pandemic. Due
to the need in the community, with the help of over a hundred
volunteers, the VIM in Wilkes-Barre began seeing patients in
June 2008. We've accomplished many milestones, including the
transition into a national certified patient medical home,
which validates the quality care.
Free services include not only primary but many specialty
services. VIM dispenses medications with a value of
approximately $50,000 a month free to those that can't afford
them. A hundred percent of patients are offered preventative
services. Lab work and imaging testing is also provided free to
the patient but a cost to the clinic to ensure continuity of
care. Translation program is also available to our non-English-
speaking patients. The behavioral health program at VIM
includes psychiatric evaluations, counseling, case management,
and resource navigation. The health equity program assists
patients with resolving transportation, housing, jobs, and food
disparities.
The VIM dental clinic was established in January 2011 and
quickly became a high-demand community resource. Many patients'
oral hygiene needs require a minimum of three appointments to
relieve the pain. Our goal is to get them out of pain, educate
on oral hygiene, and on a biannual cleaning schedule. Due to
the complexity of treatments required, we have an extensive
waiting list of those desperately needing dental services. We
have found many patients and caregivers aren't educated on
proper oral hygiene. If the adult isn't aware, then the
children in the household most likely aren't learning at a
young age.
We recently had a hardworking father of two have numerous
visits in the dental clinic for cavities. After talking with
him, he had no understanding that all the energy drinks, soda,
and packets of sugar in his coffee throughout each and every
day were causing tooth decay. In 2015, we created a healthy
smile program to educate children on good oral hygiene as well
as provide evaluations and program supplies.
Our main mission is to keep our community healthy, well,
and working. We partner with our health care systems to keep
uninsured patients out of the emergency rooms for non-emergent
issues, annually saving the hospitals millions.
According to the United Healthcare, the average cost of an
ER visit in the United States is $2,200. Research conducted by
Texas A&M, patients that go to the ER to treat preventable
dental conditions cost taxpayers, hospitals, and the government
about 2 billion a year. Uninsured patients that visit both
local emergency rooms with dental abscesses are immediately
referred to VIM for care.
The clinic is a critical community resource. In the last 6
months, we provided free health care to employees at 136
businesses in Luzerne County, and students from ten local
universities are hosted for their official internships. A
patient is eligible for free dental services at VIM if they
have Medicare and still are working, even if it's limited part-
time, and meet our income guidelines. Our primary population is
the working uninsured, but VIM currently has 275 registered
patients over the age of 65 receiving dental services. Most
older patients are in need of extractions and dentures. We have
had patients come into VIM because they previously had
removed--teeth removed and couldn't afford dentures. Many have
extreme difficulty eating solid food.
One patient had numerous health issues, needing medications
to combat her problems. After she finished her dental treatment
plan to rid her mouth of numerous infections, her medical
provider at VIM was amazed at the positive changes. Her
appearance was healthier and basically cured from her medical
symptoms, therefore able to stop taking some of her
medications. We also provided dentures to a patient a couple
days before her wedding. The patient said it was the first time
she ever smiled.
VIM staff and volunteers hear on a daily basis the
struggles from all ages and races, the challenges in finding
affordable health insurance, medical care, behavioral health,
and dental care. The services provided at--that--VIM are
otherwise unattainable to the low income population. The VIM
clinic offers a unique healthcare model that benefits the
entire community. It's important to understand that in order to
heal the entire well-being, medical, dental, and behavioral
health care needs to be provided, especially to the low income
underserved populations. Everyone benefits from a healthy
community.
Thank you, Senator Casey.
The Chairman. Kelly, thanks so much. I'll stay with you for
our first question, and then I'll go from Kelly to Robin and
then go to this side of the room. Kelly, thanks very much for
that testimony.
It's especially noteworthy and, I think, significant and
helpful that each of you provided the--us with the benefit of
your experience in the organization that you represent, but you
also brought to bear on this conversation the voices of real
people who have struggled without--without the kind of health
care that they should--they should benefit from.
Let me start, though, Kelly, with you on the question of
dental coverage. We know that the majority of people with
Medicare don't have dental coverage. It's still hard to
comprehend that, but that's actually the case. We're told that
as recently as the year 2016, 49 percent of people with
Medicare did not go to the dentist. Many older adults report
being embarrassed about their teeth. They, as you mentioned
just a moment ago, avoid smiling, and even reduce social
participation due to the condition of their mouth and their
teeth. Additionally, people with disabilities often struggle to
find dentists willing to treat them because of lack of
training.
Kelly, I'd ask you, how can we make sure that seniors and
people with disabilities are able to get access to the dental
care that they need?
Ms. Ranieli. Well, in 2019, 4.9 million over 65 years of
age fall at or under 200 percent of the Federal poverty
guidelines. Dental benefits are not covered by traditional
Medicare, as you mentioned. In 2021, it's reported that more
than 26 million people are enrolled in a Medicare Advantage
plan. The key to Medicare and these supplemental programs is it
must be affordable. It must be affordable for the most
vulnerable, which includes the elderly.
At VIM, we hear many seniors State they can never--they
can't sign up for Medicare due to the costly penalty that would
be incurred by not signing up at 65. Preventative dental
coverage, including an oral exam, cleanings, dental, X-rays and
even fluoride treatments, are critical. Restorative services,
which would include fillings, are necessary to prevent
complications such as oral infections. Dentures, of course, are
a core service for the elderly population.
The Chairman. All right. Just, when you think about it in
your own life, I just--just can't imagine not having access to
a dentist when--if--especially if you have pain. All of us, I
think, at one time or another, have experienced that.
Robin, I'll move to you next. I wanted to talk to you about
the connection between hearing or hearing loss and cognition.
We know that nearly one in four people ages 65 to 74, and
one in two people over the age of 75, have hearing loss. At a
minimum, if you're not able to hear well, you can't participate
in the conversations around you, obviously. In your testimony
today, you shared stories from individuals who talked about
this issue. We know that there's a direct connection or
association between hearing loss and poor cognition. Many
seniors with hearing loss will--would benefit from hearing
aids, obviously. Yet at thousands of dollars per pair, they're
far too costly for most people with Medicare.
Robin, I was going to ask you, could you share with us what
you've heard from Pennsylvania consumers regarding the cost of
hearing aids, No. 1, and why they would benefit from hearing
coverage under Medicare?
Ms. Stelly. Sure. When we did our survey, we heard from,
like I said, almost 500 seniors. They didn't all talk about the
same things. We had people who talked about hearing issues, and
they could be split up into a small group of people who could
afford the hearing aids and then a larger group of people who
could not afford hearing aids or even going to an audiologist.
They just live with the problem.
I don't know. I mean, I'm in my 50's, so you just--it
doesn't--it isn't like you wake up 1 day and you can't hear. It
sort of stops, right, and you kind of acclimate to it. They
have hearing losses. From the people that are telling us that
they have profound hearing losses, they are profound hearing
losses. Other people are simply not knowing that they're losing
their hearing and need to see an audiologist but just--that
isn't something that they can afford to do.
The hearing aids are also a problem, and they're so
expensive. You heard from Karen Anne, who said that she had
$6,000 to pay for hearing aids, and already she's starting to
worry about how am I going to afford to pay for them again.
They're machines. They wear out, and they need to be replaced,
so this cost is recurring. The people who can't afford care at
all, they're impacted financially, emotionally, and physically.
They do. They have the falling issues. They have the constant
stress of the isolation, being left out of their family. This
is the most heartbreaking to me personally, being left out of
family interactions, falling by the wayside within one's own
family because they can't hear what's going on.
I think you really have to--if you haven't had it happen to
you, you have to kind of think hard about imagining what that
would be like. I implore people who are thinking on the fence
about this to try to go without this sense for 10 minutes.
You're unable to hear what the cashier is saying, what your
attorney is saying to you, what your doctor is saying to you.
Try it. Try it for 10 minutes, and then come back and let
us know that these are not vital services that should be
provided for, for our seniors and our disabled community, who
have paid into this for all their lives.
The Chairman. That's a good point. Walking in their shoes,
even for a few minutes, might be the best way to get the point
across.
Joe, I wanted to ask you as well about dental coverage.
Your testimony is full of references to all the work that
you've done. I noted on the first--or second full paragraph of
your testimony, where you outlined all of the ways that
Scranton Primary has provided help on dental issues, whether
it's hygiene and cleaning, sealants, fluoride, varnish,
fillings, root canals. It goes on and on. I wanted to ask you
about that.
You indicated, also, in your testimony, about the long wait
that many seniors face when seeking dental services and that
many clinics in northeastern Pennsylvania are booking 6 months
to 1 year out for appointments. Obviously, that's too long for
someone to wait, especially when they're in pain and in need of
care. We know that both good oral health is important in and of
itself, but it also has a direct connection, as you know better
than I from your experience, has a direct connection to
physical health. Could you share with us examples from your
patients where their poor oral health negatively impacted their
physical health and their mental health?
Mr. Hollander. Thank you, Senator.
As you said, poor oral health does cause oral bacteria
issues that can lead to several medical consequences, including
but not limited to poorly controlled diabetes, increased risk
of pneumonia, and endocarditis, which is an infection of the
inner lining of the heart. This can further lead to
cardiovascular disease and vascular plaque buildup.
Over the years, we have encountered several of our diabetic
patients with poor dentition and difficult-to-control blood
sugars. For example, we had a female patient, approximately 65
and a half years old who required high doses of insulin, who
said she could not afford to see a dentist. We referred her to
our dental clinic. After treatment by the dental clinic, which
resulted in her ability to see--to eat an improved diet, we
were able to correct her blood sugar levels and saw a 2 point
drop in her HbA1c.
As I stated in my testimony earlier, poor dentition also
affects personal well-being, mental health, and confidence.
More importantly in the elderly, an inability to chew properly
due to missing teeth or ill-fitting dentures can lead to
malnutrition.
Recently we had a patient, one of our elderly patients, who
had lost a significant amount of weight. Only after speaking
with one of our behavioral health counselors did we find that
he had diabetes and dentures that did not fit well. He would
take them out to eat and therefore could not tolerate any solid
foods. Once treated, his overall weight and health improved
dramatically.
Finally, we had a third senior who had been treating for
years who suddenly, when he came in for his physical health
appointment, seemed different and didn't appear to be himself.
No abnormalities were found on the physical side. During a
conversation with one of our licensed clinical social workers,
we discovered he was experiencing malaise and a lack of energy
with night sweats. When we learned he had not been to a dentist
in years, we scheduled him for a cleaning and exam. Our dentist
discovered the gentleman had a fluid connection--fluid
collection with a low-grade infection under a cracked molar.
Upon repair of the molar, the nightsweats and the mood changes
went away, and he's now once again a happy and functioning
senior.
The Chairman. Well, that--that tells it all when you just
recite those conditions, one after another, from diabetes to
pneumonia to malnutrition to weight loss and infection. It
makes the point of how important this change in policy could be
for people.
Joanne, I'll move to you on the question of disparity. One
thing that became plainly evident to most Americans in this
pandemic is not only our healthcare system but so many other
aspects of our lives, even structures within society, have
different application depending on who you are. We--if we knew
about racial disparities before, we knew a lot more after the
pandemic was upon us. Those significant disparities among
people reporting trouble with vision problems or hearing
problems or dental problems become even more--become even more
apparent when we examine them from the question of--from the
vantage point of racial disparities.
We know that a greater share of both Black and Hispanic
seniors and people with disabilities on Medicare went without a
dental visit in the last year, that number is a lot higher than
those Americans who happen to be white beneficiaries of
Medicare. As we've heard today about forging--or, I'm sorry,
foregoing this type of care can result in poorer health
outcomes more broadly.
Can you tell us, from the vantage point of what you know
from the work that AARP does and the initiatives that you've
undertaken to reduce these disparities, how would including
dental, hearing, and vision benefits under Medicare help to
advance not only the health issues that we talked about today
but to advance health equity goals?
Ms. Grossi. Yes, well, thank you, Senator. I appreciate
that question. You're right. AARP cares a great deal about
health equity. In fact, recently AARP Pennsylvania partnered
with the Drexel University College of Nursing and Health
Professionals, and we both conducted a study and released a
study on health disparities. It showed, not surprisingly, that
ethnic, economic, and geographic location played a significant
role in your access to health care.
As you mentioned a moment ago and as you heard in my
testimony and Joe's testimony, you know, about half the
Medicare--only about half the Medicare beneficiaries had a
dental visit last year. Well, but if you--but that number was
61 percent, though, if you're Hispanic; 68 percent if you're
African American; or 73 percent for people with low income, so
you can see, you know, as you were mentioning in your comments
and your question a moment ago, it made a big difference about
health disparities. That's actually why, you know, AARP cares
so much about this issue, about, you know, hearing, vision, and
dental access. We know that if we can--we can improve health
equity and decrease health disparities if those benefits are
included in Medicare. Other--obviously, that will--you know,
evens the playing field. It gives everyone more access to care
and improves health outcomes, as Joe was talking about a moment
ago. We actually believe it reduces the costs to the Medicare
program in the long run. We're very committed to including
these benefits for all of those reasons.
The Chairman. We appreciate that. I think those--when you
consider those numbers that you've cited, as high as they are
for the population overall, they get even higher for those
Americans who happen to be Black or Hispanic. I think it makes
a--it puts an emphasis on how grave this problem is across the
board.
I wanted to ask--it may be a question for our whole panel,
and each of you, if you can, just take a moment to add your
response. We know that with hearing loss or loss of vision or
lack of dental care, that each of them, in some way or another,
have been considered part of the aging process. They also
greatly affect people's contributions to society and their
ability to engage socially.
I believe we've got to do a lot better for our seniors, for
people with disabilities, and for their families. The way we do
better is by passing legislation, not just talking about it.
We've got to ensure that people with Medicare are able to take
on more active roles in their communities, and they could do
that only with this kind of help.
I'd ask each of you to share, based on your experience and
expertise, how would coverage of dental, hearing, and vision in
Medicare impact the quality of life for seniors and people with
disabilities. I know you've all spoken to this in one way or
another, but maybe as kind of a wrap-up. Kelly, maybe we'll
start with you.
Ms. Grossi. Senator, I was going to volunteer to start, but
to start, but
The Chairman. Oh, go ahead. Go ahead.
Ms. Grossi. Well, if you don't mind, actually
The Chairman. Yes.
Ms. Grossi [continuing]. Senator, I would like
The Chairman. Sure.
Ms. Grossi [continuing]. to tell you my own personal story.
The Chairman. Sure.
Ms. Grossi. As you mentioned in your introduction of me,
I'm a caregiver for my 90-year-old father, who actually turns
91 this week. He has experienced everything everyone has talked
about today. A number of years ago, he had significant hearing
loss. As you heard about from some of your opening comments, he
couldn't hear the telephone. He couldn't have a conversation
with his family. He couldn't go to church. He couldn't watch
TV. All the things you heard mentioned, you know, were really
lost to him until we went and got him hearing aids.
Of course, he had to pay out of pocket for those hearing
aids. At the time, it cost him $5,000 out of pocket.
Subsequently for, you know, visits since then to the
audiologist and, you know, additional batteries and things like
that, he's had additional expenses. Just the initial expense
was $5,000, which, fortunately, my father could afford. That's
with hearing.
Then last year my father was having significant teeth
problems and, in fact, in consultation with the dentist, it was
determined that he had to have all of his bottom teeth removed
and to get dental implants. This was a 9-month process of
pulling out teeth at, you know, a number of visits, and then
having the gums heal, and then finally getting the implants and
finally getting the teeth. By the way, that cost him $15,000
out of pocket. In those ensuing 9 months, it's what you heard
people talk about today.
I was worried about his nutrition. He couldn't eat
properly. He was embarrassed. You know, he didn't want to go
out. Obviously, it was the pandemic, but he didn't want to be
with people. He didn't want to have a conversation. He was
embarrassed. He was hard to hear.
You know, if it weren't for, you know, close family members
around, I think he would have been very isolated. Again, as I
mentioned already, really worried about his nutrition because
he just couldn't eat hardly anything except something like
Ensure or soup. Again, you know, my father had the means to pay
those $15,000. He's in the minority because in fact we know
that 75 percent of Medicare beneficiaries who need a hearing
aid haven't been able to get one because of the cost.
Seventy, you know, percent of the people who have had
problems with their teeth and eating also, you know, haven't
done anything about it because, again, of the cost. You know,
my dad's in the minority of those being lucky enough to afford
it, but just those two issues were over $20,000.
Like you were saying, my dad, you know, devoted a lifetime
to this country in service and raising a good family, and it's
not fair that people like him have to pay that kind of money.
It should be one of the services we include in Medicare. Again,
lucky my dad's fortunate enough to pay for it, but I appreciate
that you're taking on this case for the Americans and
Pennsylvanians who can't afford to pay this out of pocket.
The Chairman. Well, Joanne, thanks for bringing your story
to this discussion, because sometimes that's the only way for a
lot of us to relate to an issue is what's our own personal
experience.
As you were--as you were talking, I was reminded that as
much as a problem--a dental problem or a hearing problem or a
vision problem is about something physical and related to your
physical health, it's also about your dignity as well.
Ms. Ranieli. Mm-hmm.
The Chairman. It's your ability to participate, to be
engaged.
I think it was your testimony that had a number I've seen
before about the connection between if someone doesn't--isn't
able to engage and is isolated, prolonged isolation can lead to
terrible health problems. The one number--and I'll find in here
in your testimony, but it can be the equivalent of 15
cigarettes a day are the adverse impact, that social isolation
can have a physical impact that's equivalent to smoking 15
cigarettes a day, or whatever that number is in that study.
That just shows you the gravity of this problem for people.
Your father's circumstance is, unfortunately, all too--all too
emblematic of that.
I want to open it up for anyone else. Kelly or Robin or
Joe?
Ms. Ranieli. At Volunteers in Medicine, we witness how
important it is for comprehensive or holistic care. It's
necessary for the well-being and overall health of the patient.
The low income population, which is who we serve,
especially those that are uninsured or underinsured, are
historically sicker than those with insurance because those
that are uninsured have no access to preventative services.
According to Harvard Medical School, one in five adults
ages 65 or older have untreated tooth decay. Tooth decay and
gum disease leads to serious health problems, as Joe mentioned.
Lack of dental care can exasperate chronic medical conditions
such as diabetes and cardiovascular disease.
We at the clinic have potential new clients walking in with
swelled faces due to abscesses. This is at any age. The elderly
population who have multiple teeth extracted come to VIM
malnutritioned because they haven't been able to afford, you
know, dentures. We witness this on a regular basis. Of course,
increasing dental, hearing, and vision coverage would be, you
know, critical for older adults, absolutely critical.
The Chairman. Thanks.
Robin?
Ms. Stelly. I think you hit the nail on the head. You said
that word. That word has escaped me from the beginning of when
I was putting testimony together and doing research. It's
dignity. That was it. That's it. For the consumers. Right? It's
a loss of dignity.
For their families, it's increased stress that they don't
need to go through. When is the next hearing aid? Got Mom's
hearing aid but, you know, it's--you know, I got another one
coming up. It's only going to be three to 5 years. That's
expected. Start saving now. I also need a car, but I've got a
kid in college. Maybe she can make her hearing aid stretch.
This is not a conversation that people should have to have
around their--talking about their families. You can tell the
stress. Just imagining this is stressful. For society, it's
just lost capacity. Why are we throwing these people away? 65
is not old. It's old, but it's not done. We're throwing them
away.
A lot of the people that completed our survey and people
that we know in our own experience work. They can't work as
well if they're not fully functioning. You know, they work and
they have Medicare, so--and then, of course, there's people who
don't work--who want to retire and find out that all of this is
now lost to them and that they are lost to us. It's just not
acceptable.
Thank you.
The Chairman. No, I appreciate that. You're right. It's
that stress and that--that loss to all of us. It really does
diminish all of us in one way or another. I appreciate you
making that point.
Joe, you'll have the final word.
Mr. Hollander. Thank you, Senator.
While Medicare recipients generally have a higher risk for
medical problems simply because of age, most of their daily
quality of life and well-being revolves around dental, hearing,
and vision. When you think about it, these affect every one of
us. Seniors are no different. Not addressing these issues
adequately can lead to a number of problems. Poor communication
due to a loss of hearing can result in misdiagnosis or poor
understanding of instructions. We also see an increase in falls
due to poor vision. Of course, we've spoken earlier about poor
dental outcomes leading to or causing physical disease, all of
which can be linked to the higher cost of medical care.
During a meeting earlier this week with my medical
director, I learned we just lost a patient at the health center
last week who had severe hearing loss and an inability to
afford hearing aids. When he described her, I remembered her
well because she had been dropped off by county transportation
last week, and I happened to be walking by at the time and saw
her struggling in her wheelchair.
I assisted her and helped her get to the waiting room and
distinctly remember, no matter how loud I spoke to her, she
couldn't understand me. This is generally not a problem I have.
Most of the time, people are asking me to speak softer. She
would simply put her head down out of frustration as I tried to
speak with her. My medical director told me while she had a
number of serious health issues, he had seen her in the office
2 days before she passed away and, in retrospect, is convinced
if he had been able to communicate with her more effectively,
he may have been able to help her and present--and prevent her
demise.
Avoiding these coverages as preventive measures has the
potential of saving Medicare money in the long run much more
than the initial cost to the system. Senator, thank you very
much for sponsoring this Senate bill.
Thank you very much for taking the time to hold this very
important hearing and inviting us to participate.
The Chairman. Well, Joe, thanks for sharing that hearing--
or sharing that story. That's as good an example as any of what
can happen in one instance where someone can't communicate,
that you have a medical professional saying they might have
been able to save her life if she was able to communicate.
I know we have to wrap up, but I just want to thank each of
our witnesses. Joe, I want to thank you and Joanne for being
with us today as well as Kelly and Robin for taking the time to
be with us in bringing, as I said, both your experience and
expertise as advocates and as experts, but also to inject into
this conversation the voices of--of Pennsylvanians all across
the board. Couldn't be more important as we try to pass this
bill, the Medicare and Medicaid Dental, Vision, and Hearing
Benefits Act, Senate Bill 2618.
We all believe, I think, as Americans, that no one should
be forced to choose between affording their medication and
keeping the lights on. No one should be asked to deplete their
life savings in order to receive the dental care--the dental
care they need to be able to eat and share a meal with their
family.
No senior and no person with a disability should have to
miss out on a gathering with friends or loved ones, family
members, because they can't afford to purchase a hearing aid
that will let them participate in those conversations. As our
witnesses told us today, this is all too often the case. As
Americans, we can and we must do better. Now Congress can do
better by passing this legislation, Senate Bill 2618, to
provide these kinds of benefits to ensure this kind of care is
provided to so many millions of Americans who are not receiving
it today.
To our witnesses, I want to say thanks for being here with
us today. Your experiences and your testimony will be top of
mind as we continue to fight for these policies in the next--
especially the next 2 months. I'll continue to fight to protect
Medicare from cuts, and I'm working with Democrats in the house
and the Senate to make these benefits possible. Thanks for
being with us today, and thanks for being such strong advocates
for these benefits. Thank you.
With that, our hearing is adjourned.
[Whereupon, at 11:10 a.m., the hearing was adjourned.]
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APPENDIX
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Prepared Witness Statements
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