[Senate Hearing 117-163]
[From the U.S. Government Publishing Office]
S. Hrg. 117-163
IMPROVING CARE EXPERIENCES
FOR PEOPLE WITH BOTH
MEDICARE AND MEDICAID
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HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
FEBRUARY 10, 2022
__________
Serial No. 117-12
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
46-921 PDF WASHINGTON : 2022
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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
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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
Opening Statement of Senator Tim Scott, Ranking Member........... 3
PANEL OF WITNESSES
Jose Figueroa, MD, MPH, Assistant Professor of Health Policy and
Management, Harvard T.H. Chan School of Public Health,
Associate Physician, Brigham and Women's Hospital, Boston,
Massachusetts.................................................. 5
Eunice Medina, Chief of Staff, South Carolina Department of
Health & Human Services, Columbia, South Carolina.............. 6
Dennis Heaphy, MDiv, MEd, MPH, Policy Analyst, Disability Policy
Consortium, Malden, Massachusetts.............................. 8
Jane Doyle, Grandmother, Bartonsville, Pennsylvania.............. 10
APPENDIX
Prepared Witness Statements
Jose Figueroa, MD, MPH, Assistant Professor of Health Policy and
Management, Harvard T.H. Chan School of Public Health,
Associate Physician, Brigham and Women's Hospital, Boston,
Massachusetts.................................................. 31
Eunice Medina, Chief of Staff, South Carolina Department of
Health & Human Services, Columbia, South Carolina.............. 38
Dennis Heaphy, MDiv, MEd, MPH, Policy Analyst, Disability Policy
Consortium, Malden, Massachusetts.............................. 40
Jane Doyle, Grandmother, Bartonsville, Pennsylvania.............. 44
Questions for the Record
Jose Figueroa, MD, MPH, Assistant Professor of Health Policy and
Management, Harvard T.H. Chan School of Public Health,
Associate Physician, Brigham and Women's Hospital, Boston,
Massachusetts.................................................. 49
Eunice Medina, Chief of Staff, South Carolina Department of
Health & Human Services, Columbia, South Carolina.............. 61
Dennis Heaphy, MDiv, MEd, MPH, Policy Analyst, Disability Policy
Consortium, Malden, Massachusetts.............................. 67
Jane Doyle, Grandmother, Bartonsville, Pennsylvania.............. 97
IMPROVING CARE EXPERIENCES
FOR PEOPLE WITH BOTH
MEDICARE AND MEDICAID
----------
THURSDAY, FEBRUARY 10, 2022
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 9:30 a.m.,
virtually via Webex and in Room SD-562, Dirksen Senate Office
Building, Hon. Robert P. Casey, Chairman of the Committee,
presiding.
Present: Senators Casey, Gillibrand, Warnock, Tim Scott,
Collins, Braun, and Rick Scott.
OPENING STATEMENT OF SENATOR
ROBERT P. CASEY, JR., CHAIRMAN
The Chairman. Good morning. The hearing will come to order.
Today's hearing will focus on seniors and people with
disabilities who depend on both Medicare and Medicaid as their
lifeline.
Over 12 million Americans are eligible for both Medicare
and Medicaid, including almost half a million in Pennsylvania.
These Americans are expected to know which services Medicare
covers, which services Medicaid covers, and which services are
not covered at all. They might have one insurance card for
their primary care doctor, one for their behavioral health, and
one for prescription drugs, the list goes on and on. They might
have a doctor who takes their Medicare insurance, but not their
Medicaid insurance. Not only is this confusing and frustrating,
it creates unnecessary hurdles for people trying to get the
care that they need. All Americans deserve a health care system
they can actually use, not one rife with stumbling blocks.
We will hear today from Jane Doyle, from northeastern
Pennsylvania, not far from where I live. She lives in Monroe
County, in the northeastern corner of our State. Jane will
share her harrowing story of navigating the complexity of these
benefits, not only for herself but also as a caregiver for her
mother. She will also describe how she lives in fear that her
doctors, who she trusts to keep her healthy, will no longer
take her coverage.
We will also hear from Dennis Heaphy about how his coverage
that combines Medicare and Medicaid and how that lets him
remain independent, but it was quite a road to get to that
independence. Certainly, there is work to be done. Jane's
experience and Dennis's story make that clear. I am grateful
that our Ranking Member, Senator Scott and I agree on this
point.
Today, we are introducing the PACE Expanded Act. This bill
would reduce administrative barriers that prevent the
development and expansion of PACE programs. In Pennsylvania, we
call them LIFE programs, but in most of the country, they go by
that name, PACE. These programs enable people with Medicare and
Medicaid to receive all their benefits through a single
organization, providing primary care, long-term care and more
in one place. PACE also enables people with a high level of
need to stay in the community rather than receiving care in a
nursing home, if that is their preference. Indeed, this is the
preference for the majority of older adults, as well as people
with disabilities.
That is why I am committed to expanding access to home and
community-based services. Last year, the Senate passed the
American Rescue Plan which included $12.7 billion in emergency
funding for states for these services, these home and
community-based services. States are using these resources to
help more seniors and people with disabilities access care and
to pay the heroic home care workers the hazard pay and the
bonuses that they deserve. So this investment in the Rescue
Plan of $12.7 billion dollars was a good first step, but we
need to do more and invest more to ensure people with
disabilities and seniors can receive care in their homes.
That is why I led 40 Democratic Senators in introducing the
Better Care Better Jobs Act last year, that is Senate Bill
2210. This bill would make a permanent investment in home and
community-based services. It would help states provide better
care for seniors, people with disabilities and their families,
and it would ensure there is a strong and supported workforce
to provide those services. It would lead ultimately to better
care. These are just a few of the many issues faced by people
that have to navigate both Medicare and Medicaid. We will hear
from several witnesses today who will highlight how we can
continue to improve care for all of these Americans.
Now I will turn to Ranking Member Scott.
OPENING STATEMENT OF SENATOR
TIM SCOTT, RANKING MEMBER
Senator Tim Scott. Thank you, Mr. Chairman, for working
together on the PACE Expanded Act. Certainly, it is good for
the country to see a bipartisan coalition working on behalf of
the country, not on behalf of Democrats or Republicans, but on
behalf of Americans.
One of the things I enjoy and appreciate about this
committee is that we put seniors first, and not red ones or
blue ones, Black ones or white ones, just seniors, and that
should be a mission for our Nation and for all of those us in
elected office certainly, to follow the example that you are
leading by. I really appreciate your work on the PACE Expanded
Act, and the one-stop-shop concept is something that is really
important when you have so many layers of complexity in your
life as you age. If we can eliminate any of it, it helps all of
it become more digestible and easier to handle for the seniors,
so thank you very much for your hard work on that issue.
One of the reasons why this legislation is so important is
because we have nearly 12 million Americans and 150,000 South
Carolinians who are dual eligible. They are eligible for both
Medicaid and Medicare, and if you can imagine, as you
described, seniors with chronic conditions have multiple
caregivers, multiple places to go and if you think about
Medicare, a national program run from the Federal Government,
Medicaid is essentially a Federal program but run from the
State government, and so getting those two to work together is
not as easy as it should be. Anything that we can do in the
direction of making that happen is going to be in the best
interest of the seniors across this Nation and certainly the
seniors in South Carolina that I know and love so much.
I will say that the Biden administration needs to
consistently and continuously work on making sure that those
agencies that serve our seniors, like the Social Security
agency, is open.
I am thankful to see that after 15 of my colleagues and I
wrote a letter to President Biden asking for field offices to
reopen, that we are at least seeing that move in the direction
of telework for those agencies. I think it is really important
for us to have an opportunity to have our seniors have the
place to go, whether virtually or in-person, when the pandemic
subsides, for them to find the help they need from the agencies
that they desperately wanted.
One of the focuses we have during this hearing, of course,
is trying to figure out this jigsaw puzzle for the dual
eligibles. I will say that the issues are quite challenging in
many ways and as opposed to thinking about how to explain it, I
just thought I would use examples of two folks who are dual
eligible in South Carolina, who have benefited from having
caregivers and case managers who understand and appreciate the
complexity of the situation.
We have in South Carolina a program known as Healthy
Connections Prime, that allows for three providers--Molina,
Centene, and AmeriHealth--to serve about 15,000 people over 44
counties, to help that dual-eligible concept become a little
easier.
Since the program started in 2015, we have seen
improvements throughout the State. One member of the program
was living in his car, homeless. His care manager noticed the
signs that something was not going well. The care manager
educated the young man about the plan benefits that assisted
him and helped him find glasses, a place to stay, hearing aids,
and dental work.
Another Molina member from Florence, South Carolina, had
been gradually declining over the past several months. His
daughter, who also serves as his caregiver, noticed he was
having more and more difficulty even with his walker and needed
more support. His care coordinator worked with his daughter and
the gentleman's doctor on the needs, and soon thereafter a
wheelchair was ordered, covered, and delivered. The member and
the daughter reported that they were relieved and felt much
safer at home, and they were able to get their appointments
scheduled because of the support being provided.
To help states further improve coverage, I have introduced
legislation to provide further assistance to State Medicaid
agencies to help integrate coverage. It creates a $100 million
grant for states to improve care coordination for their dually
eligible population.
States can use the funds to hire personnel that have
experience with the Medicare program or train existing
personnel or help beneficiaries with the enrollment process.
Initial studies have shown that integrated care improves health
outcomes such as decreased rates of hospitalization and
readmissions.
I look forward to hearing from our witnesses about what
else we can do as Congress members, Senators, to improve the
lives of our dual-eligible population.
The Chairman. Thank you, Ranking Member Scott. Before we
move to our witnesses for introduction I want to note that we
have been joined by Senator Collins, former Chair of this
Committee, and Senator Rick Scott, who was here earlier. We are
going to have Senators, as folks might know, moving in and out
because of a busy day of other hearings and engagements but we
will go as people arrive and are grateful to have everyone with
us today.
Let me start with our first witness, Dr. Jose Figueroa. Dr.
Figueroa is an Assistant Professor of Health Policy and
Management at Harvard University's School of Public Health. Dr.
Figueroa's research focuses on understanding the drivers of
health care spending and poor clinical outcomes among older,
at-risk populations with complex medical needs. He is also a
practicing hospital medicine physician at Brigham and Women's
Hospital in Boston, where he provides care to many Americans
with Medicare and Medicaid. I want to thank Dr. Figueroa for
being with us today to share his expertise with the Committee.
For our second witness I will turn to Ranking Member Scott.
Senator Tim Scott. Thank you, Mr. Chairman. I am pleased to
welcome Eunice Medina. Eunice is a new South Carolinian but
someone who has a deep background and understanding of this
critical issue.
Eunice serves as the Chief of Staff and Deputy Director of
Programs for the South Carolina Health and Human Services. The
State department of HHS is the agency responsible for running
our state's Medicaid program, which provides health coverage to
more than 1 million South Carolinians. The department also
operates the Health Connections Prime program, which
coordinates care for South Carolinians who are dually eligible.
Ms. Medina's testimony today comes from her more than 18
years of experience working on this issue in both South
Carolina and Florida, where she recently moved from. She has
dedicated her career to working on behalf of older Americans
and Americans with disabilities, those who are our most
vulnerable and who need this assistance the most.
Ms. Medina is one of the thousands of public servants who
work every single day to make the lives of South Carolinians
better. Welcome to this hearing and welcome to South Carolina.
The Chairman. Thank you, Ranking Member Scott. Next I will
introduce Dennis Heaphy. Dennis is a health justice advocate
and researcher at the Massachusetts Disability Policy
Consortium. Dennis is also a Commissioner on the Medicaid and
CHIP Payment and Access Commission, known as MACPAC, the
nonpartisan body that provides expert recommendations to
Congress on ways to improve the Medicaid program.
Mr. Heaphy also happens to have both Medicare and Medicaid.
He is on the front lines helping states create programs that
serve the needs of people with Medicaid by meeting them where
they are.
Thank you, Mr. Heaphy, for being with us today and sharing
your expertise with the Committee.
Our fourth and final witness is Ms. Jane Doyle from
Bartonsville, Pennsylvania, in Monroe County, as I mentioned in
my opening statement. Jane has two children and three
grandchildren. While they do not live close by, she is able to
connect with them through daily phone calls. Jane describes
herself as, ``an artist at heart,'' and loves to paint.
Jane happens to receive Medicare and Medicaid because of
multiple sclerosis. She also helps care for her mother who has
Medicare and Medicaid as well.
Thank you, Jane, for being with us today and sharing your
personal story with the Committee.
We will turn next to our witness statements, and we will
start with Dr. Figueroa. Dr. Figueroa, you may begin.
STATEMENT OF JOSE FIGUEROA, MD, MPH,
ASSISTANT PROFESSOR OF HEALTH POLICY
AND MANAGEMENT, HARVARD T.H. CHAN SCHOOL
OF PUBLIC HEALTH, ASSOCIATE PHYSICIAN,
BRIGHAM AND WOMEN'S HOSPITAL,
BOSTON, MASSACHUSETTS
Dr. Figueroa. Thank you, Chairman Casey, Ranking Member
Scott, and honorable members of the Committee. Thank you for
the opportunity to testify today.
My name is Jose Figueroa and I am an Assistant Professor of
Health Policy and Medicine at Harvard University. I am also a
practicing physician in hospital medicine at the Brigham and
Women's Hospital where I take care of critically ill
hospitalized patients. For my research, I focus on how best to
improve the quality of care delivered to the sickest and most
vulnerable patients in our country, including the dual-eligible
population, which are those, as mentioned, who qualify for both
Medicare and Medicaid programs.
As a physician and a researcher, I can attest to the fact
that navigating our health care system is inherently complex
for anyone. These challenges, however, are far more difficult
for the 12.3 million dual-eligible patients living with
disability, with serious mental illness, with frailty, with
multiple chronic conditions, and importantly, living in
poverty, because of these vulnerabilities, dual-eligible people
are much more likely to require hospital care, nursing home
care, long-term care, home-based care, behavioral health, and
unfortunately at increased risk for experiencing poor health
outcomes.
A great failure of our health care system is that so much
of dual-eligible patients' time is lost navigating the complex
and confusing rules and regulations of two programs, which they
must do in order to ensure they get the care they need. This is
valuable time that they could instead be spending at home with
their family and with their friends, and as a physician, one of
the most frustrating realities for caring of dual-eligible
patients is our inability to help them effectively throughout
this process. Countless hours are spent by clinicians, care
coordinators, social workers trying to determine what should be
the safest discharge plan for our patients while at the same
time trying to coordinate their care across multiple different
providers, across multiple different clinics. This often
results in prolonged hospital stays and deconditioning of our
patients while they wait.
As stewards of our health care system we have an obligation
to deliver better care for dual-eligible people. One important
way of doing so is by promoting care models that offer true
integration between both the Medicare and the Medicaid
programs, financially and clinically across the entire care
continuum. Integrated programs, when done right, have the
potential to improve the efficiency, the affordability, and the
quality of care that dual-eligible patients receive.
Today there are three major types of fully integrated care
models. They include, as mentioned, the Program of All-
Inclusive Care for the Elderly, known as the PACE program,
Medicare Advantage Dual Eligible Special Needs Plans, or the D-
SNPs, and state-level Medicare-Medicaid plans, or MMPs, under
the CMS Financial Alignment Initiative.
In my submitted testimony I have outlined what the
experience has been with these programs to date. The big
takeaway is that while we have limited and, at times, mixed
evidence on the success of these programs, there are some
reassuringly positive signals that suggest integrated care,
when done right, can improve the quality and the efficiency
delivered to dual patients, and with more time and experience
we expect these programs to get better.
However, to date, only 1 in 10 duals are enrolled in an
integrated care model, and nearly 50 percent of dual-eligible
patients across our country do not even have access to one.
In my written testimony I highlight recommendations of how
we can make integrated care for duals better. For example,
Congress should consider policy options that help states adopt
and expand integrated care models, especially in the 14 states
that currently do not have one program. In some states, clear
guidance, technical assistance, and financial support may be
necessary.
Integrated models must also offer meaningfully better value
than the status quo and should cover all services patients
need, from primary care, acute care, to long-term care and
behavioral health services. The enrollment process into
integrated care models must also be easy. Patients need
adequate, unbiased support to ensure that they make an informed
decision about what program is best to meet their unique needs
and preferences.
Finally, we need better transparency on performance, better
and timelier data, and we need to develop better quality
measures that capture what truly matters to patients. If and
when we do this, we can ensure a high quality and affordable
care for the millions of people who are dually enrolled in the
Medicare and Medicaid program across our country.
Thank you for your time.
The Chairman. Doctor, thank you very much. Next we will
turn to Ms. Medina. You may begin.
STATEMENT OF EUNICE MEDINA, CHIEF OF STAFF,
SOUTH CAROLINA DEPARTMENT OF HEALTH AND
HUMAN SERVICES, COLUMBIA, SOUTH CAROLINA
Ms. Medina. Good morning. Thank you, Chairman Casey,
Ranking Member Scott, and members of the Committee, for the
opportunity to participate in today's discussion. As stated, my
name is Eunice Medina and I currently serve as Chief of Staff
and Deputy Director of Programs at the South Carolina
Department of Health and Human Services.
Prior to joining South Carolina's Medicaid agency, I spent
17 years working with Florida's Medicaid population in various
capacities. I spent more than a decade of my career working
with seniors through the Florida Department of Elder Affairs
where I managed multiple home and community-based waiver
programs. In 2013, I assisted the Medicaid agency in
transitioning those Medicaid beneficiaries into what is now
known as Florida's statewide Medicaid Managed Care Program. The
following year I joined the Florida Medicaid Agency where I
worked to ensure health plans offering long-term care services
were doing so in accordance to State and Federal requirements.
I later ended up overseeing their 15 health and 3 dental plans
serving approximately 3.5 million beneficiaries.
In June 2021, I joined South Carolina's Medicaid agency and
have spent much of my first year analyzing how to best help the
State by evaluating its Medicaid program and assisting the
agency in developing a plan to improve quality of care and cost
efficiency. South Carolina's population that is eligible for
both Medicare and Medicaid, otherwise known as its dual
population, have multiple options for receiving services.
According to December 2021 data, there are over 168,000
dual-eligible beneficiaries. Within that total over 59,000 are
enrolled in a Dual Special Needs Plan; 15,000 or so are
enrolled in our state's Financial Alignment Initiative program,
our dual demonstration program; and over 22,000 are enrolled in
one of our four fee-for-service home and community-based waiver
programs, which serve the disabled over the age of 18 or the
elderly. This group may include beneficiaries with a
corresponding Medicare Advantage, Dual Special Needs Plan, or
fee-for-service Medicare.
In 2015, our State chose to participate in the Federal dual
demonstration program to evaluate opportunities for integrated
care for seniors. Unlike other states, South Carolina chose to
start off the program with a focus on those 65 years of age and
older. This month marks our seventh-year anniversary since
implementing this program, and I am happy to spend our
anniversary discussing some lessons learned.
We have found that in cases where a beneficiary did not
need home and community-based services, they typically utilized
three services that Medicare only covers a limited amount of:
home health, durable medical equipment, and behavioral health.
Access to these services through our dual demonstration program
has delayed the need for more costly home and community-based
services. Another lesson was the importance of care
coordination at the individual beneficiary level and the
importance of fully assessing beneficiary needs.
We have a big decision to make as a State in deciding
whether we want to take advantage of the alternative offered by
the proposed rule that CMS issued on Jan. 7, 2022, or explore
other options.
One reason to explore an option other than what is
available through the dual demonstration or the recently
released CMS proposed rule is the fact that Medicaid waiver
programs are made up of more than just duals. When states are
looking to integrate care, they may also need to consider the
capacity of their Medicaid agency to manage the programs they
have already committed to, which may include individuals that
are eligible for full benefits under Medicaid, meet the nursing
facility level-of-care, but are not eligible for Medicare. This
is the approach Florida took.
Florida consolidated more than 10 waiver programs that
served its Medicaid home and community-based service programs
and nursing facility population over a 5-year period. Through
this model, Florida currently serves more than 100,000
beneficiaries through seven comprehensive health plans, meaning
that if someone is enrolled in one of these plans, they could
receive both Medicaid medical and long-term care services. When
possible, the Medicaid enrollment process considered whether a
beneficiary had a Medicare product with a corresponding
Medicaid plan.
Streamlining programs and focusing efforts and funding on
an integrated program can help avoid confusion and
administrative burden among dual beneficiaries and providers.
Even still, Florida's model presents opportunities to further
coordinate care and information, chief among them being the
integration of Medicare data.
In conclusion, I truly believe each State faces its own
challenges. For our State, we will be looking for solutions
that continue to allow flexibility in how to design our
programs, access to Medicare data, opportunities to align
processes across all Medicare and Medicaid products, and time
to responsibly shift to a model that embraces these
flexibilities. Furthermore, resources that would allow states
to strengthen their agency to support these massive internal
and external changes would be most welcome.
Again, thank you for allowing me to participate in today's
discussion on a topic I truly am passionate about and a
population I have dedicated my career to serving.
The Chairman. Ms. Medina, thank you for your opening
statement and we will turn next to Mr. Heaphy. You may begin.
[Pause.]
The Chairman. Mr. Heaphy, I think you might be muted.
Mr. Heaphy. Apologies.
The Chairman. Great. Thank you.
STATEMENT OF DENNIS HEAPHY, MDIV, MED, MPH,
POLICY ANALYST, DISABILITY POLICY CONSORTIUM,
MALDEN, MASSACHUSETTS
Mr. Heaphy. Chairman Casey, Ranking Member Scott, members
of the Senate Special Committee on Aging, thank you for the
opportunity to testify about my experience as a dually eligible
enrollee in an integrated plan. To start, I want to give a
special thanks to Senator Casey for his support of the
disability community and his leadership on the COVID HCBS
Relief Act. Senator Scott, several of my family members have
moved to South Carolina and love the State.
I am here to speak to you from the perspective of a
disability advocate and member of One Care integrated model in
Massachusetts. One Care was established to improve the health
and wellness of persons 21 to 64 with Medicaid and Medicare by
better aligning both funding sources in a single health plan.
One Care was designed to place increased weight on home and
community-based services and diversionary behavioral health
services and substance use disorder services, emphasizes
independent living and recovery.
I became a member of One Care when it began in 2013, out of
fear of losing my independence and my health in a fee for
service system and/or in an algorithm-driven, short-term,
medically focused plan.
I believe in the potential of integrated care and serve as
Chair of the Massachusetts consumer-led One Care Implementation
Council, which is comprised of many stakeholders but largely
consumers and our family members, working in partnership with
the State to ensure One Care meets enrollees' needs. Truly
whole person-centered care meets the person's medical, LTSS,
recovery, and other needs, helping the person to live in
meaningful life in a community.
In my case, it also means ensuring I have the home and
community-based services I need, including personal care
attendant services, durable medical equipment, including
wheelchairs, assistive technology, and medical supplies. It
means having a care plan I have created with my care team and a
direct line of communication with my nurse practitioner or
physician assistant who can respond directly to my needs to
reduce my chances of having to go to the emergency department
or being hospitalized.
I have experienced integrated care at its best. I had truly
home-based care with my nurse practitioner coming to my home
regularly. She has taught my personal care attendants, my PCAs,
who help me my activities of daily living how to do wound care,
catheter changes, and more. When I developed a bone infection
that required surgery, many hospitalizations and over a year of
recovery, rather than going into a skilled nursing facility
rehab my care team supported my decision to do recovery at
home. My care team provided more training to my personal care
attendants and increased their number of hours.
Acupuncture was provided on a weekly to reduce pain and
control my spasticity. My autoimmune specialist, even though an
out-of-network provider, was regularly consulted. I received a
ceiling lift to transfer me from my bed to a wheelchair,
alternating air mattress, upgraded wheelchair and seating
system, and more. Most health plans do not provide people like
me these types of services or care.
Thankfully I usually do not need intensive services. What I
need most are home and community-based services and supports,
developed in a care planning process with people I know and
trust. Frustratingly, even though designed to be fully
integrated, a whole-person plan, One Care seems to be moving
away from the original model. I went to the emergency
department for the first time in years because I could not
reach a medical person at my plan, but instead could only get
to the after-hours answering service.
Not knowing what to do, I drove my wheelchair to the
hospital a mile up the road. If I had been able to reach
someone with medical knowledge I would not have gone to the
emergency department.
Other One Care members are also identifying barriers to
care, including lack of a care plan or a trusted care partner
and reduced access to services.
The State is taking these concerns seriously and working
with the Implementation Council, disability advocates, and the
One Care plans themselves to address what appears to be a
departure by the plans from the original intent of the model. I
am confident that because of the relationship between consumers
and the State we will be heard and we can make change.
Not every State is like Massachusetts, but every State
needs consumer voice to succeed in developing an integrated
care system.
Thank you again for the opportunity to speak with you
today, and I look forward to answering your questions.
The Chairman. Mr. Heaphy, thank you for your opening
statement. We will turn next to Ms. Doyle.
STATEMENT OF JANE DOYLE, GRANDMOTHER, BARTONSVILLE,
PENNSYLVANIA
Ms. Doyle. Good morning, Chairman Casey, Ranking Member
Scott, and members of the Senate Special Committee on Aging. My
name is Jane Doyle. I have lived in Bartonsville, Pennsylvania
for the past 32 years. I have two children and three
grandchildren living in the suburbs of Atlanta and Boston. I am
honored to have this opportunity to testify to help make a
positive change toward better health care for everyone.
I have experienced, for myself and my family, several
different ``kinds'' of dual eligibility when I was first
diagnosed with multiple sclerosis. I applied for Social
Security disability benefits, so I also qualified for Medicare.
I was still able to work part-time, and I also accessed
Medicaid through a special program. It allows people to work
and still earn higher incomes but otherwise qualify for
Medicaid, to pay premiums for the Medicaid benefits. It was a
relief to have affordable insurance that covered out-of-pocket
costs, and I found it quite purposeful to continue to work.
Since 2017, due to further medical circumstances, I have
been unable to work. I qualify for regular Medicaid. In 2020,
Pennsylvania required Medicaid through managed health care.
From the eight doctors I see, I do not believe any of them are
enrolled in the new system, so far, I have been fairly lucky.
Most of my doctors have continued to see me, but they must
write off the balances after Medicare.
I recently received a balance bill from a new doctor who
may not have even be aware that I they were not permitted to
balance bill because of Medicaid. My doctors say that the new
system is complicated and the rules are different across the
three different networks.
I also worry that since many doctors do not take the
managed care, and these programs try to cut costs, the quality
of care I receive suffers. During the pandemic I had to undergo
three operations, one of which resulted in irreversible nerve
damage. This resulted in me needing neurosurgery, and I had to
travel 100 miles to Philadelphia to get that care.
My mother is also dually eligible. She is enrolled in
Medicare and began to need more help. She needed the kind of
long-term care that Medicare does not cover. For some time, she
paid for home health care out of her pocket, costing around
$7,000 a month, but for 24 years as a widow, her money was
running out at 87 years of age. Thankfully, in Pennsylvania,
Medicaid does have a special program known as ``waiver.'' This
provides home care. Our family viewed this a great alternative
to a nursing home setting for our mother, but to qualify
someone must first apply for Medicaid and then apply for the
waiver.
This process was long and difficult. It involved several
applications, documentation from both Medicaid and doctors,
choosing a provider to oversee your case, and finding a
participating home health care agency with enough staff to meet
our mom's needs.
Eventually, we did not have enough money to pay for one
more day. I was fortunate to have stumbled across the
Pennsylvania Health Law Project. They helped to expedite my
mother's case. As you can imagine, the stress of not knowing
how we were going to care for our mother was insurmountable.
I have talked about the trouble my mother faced becoming
dually eligible, the challenges I experience as a dually
eligible person. I would like to tell you what would happen if
I stop being dually eligible. If I lose Medicaid, I would not
be able to buy Medigap insurance to cover my out-of-pocket
costs because I have a pre-existing condition. For those of us
with a pre-existing condition, Medigap is allowed to deny you
insurance if you have Medicaid when you first sign up for
Medicare. As a result, I am stuck. I cannot increase my income
or savings because I will no longer have Medicaid and I will
not be able to buy Medigap. I would face high costs with having
Medicare with no other insurance.
This is a lot for one person to navigate. Fortunately,
there are sources of help like the Pennsylvania Health Law
Project and the kind folks at the Medicare Rights Center's
national helpline, which I have reached out to.
I ask you today to do whatever you can to ease the burdens
of people like me and my mother, who have faced challenges.
While these programs are important, they are not easy to use.
To make these programs actually work, it needs to be much
easier for people like myself and my mother to enroll and find
the care.
Thank you again for the opportunity to speak with you
today. I look forward to answering your questions.
The Chairman. Ms. Doyle, thanks very much. I appreciate
your testimony.
Now we will move to questions, and I will actually start
with Jane Doyle for the first question. Jane, I wanted to again
thank you for your testimony. These stories that are shared by
you and other witnesses help all of us when we are trying to
formulate policy, especially on complex issues like health
care, and in this case the challenges that dual eligible
Americans face with regard to Medicare and Medicaid.
In your testimony you talked about your mother receiving
long-term care at home. You stated that your family, ``viewed
this is a great alternative to a nursing home for our mother as
it would allow her to stay independent and involved with us,''
it is so important for Americans to be able to receive care in
the setting that they prefer. Every person should have the
option to stay close and stay connected to family if that is
their choice.
Can you tell us more about why home and community-based
services were so important both to you and your mother and, of
course, your family?
Ms. Doyle. Well, in our particular situation it was my
mother's personal choice, and we wanted to honor that. Although
my mom was college educated, my mom was a homemaker and she was
not really accustomed to a lot of outside socializing, and her
home was her life, but the second piece to that question, in
short, the quality of the care that we received from both home
care and the family pitching in was far better than what we had
experienced in short stints in rehabs following
hospitalizations. Nursing homes that provide rehabilitation
were grossly understaffed, even prior to the pandemic, and I
can assure you, from a recent hospital visit, that
understaffing is even worse.
It is hard to leave your loved one and go home at night not
knowing if they are going to answer your loved one's call bell
or simply place a cup of water within their reach.
The Chairman. Thank you very much. For my second question I
will move to Dr. Figueroa. In your testimony you told us about
your experience not only as a researcher but also as a provider
for people who have both Medicare and Medicaid. Your testimony
spoke to the importance of having various options for people
when it comes to integrated care models.
One of the models you mentioned is the PACE program, or as
I mentioned earlier, the LIFE program in Pennsylvania. We have
7,000 Pennsylvanians that rely on PACE for their care, many of
whom would otherwise be receiving care in a nursing home. There
are hundreds of thousands of others with Medicare and Medicaid
in Pennsylvania that may not live near a PACE program and may
not know that it is an option available to them.
As I mentioned, Ranking Member Scott and I have introduced
the PACE Expanded Act to reduce barriers to access and
availability of PACE programs. Could you share with the
Committee how expanding a program like PACE might be better
able to support individuals with both Medicare and Medicaid?
Dr. Figueroa. Thank you, Chairman Casey. Yes, I can. First,
the PACE program, as you mentioned, is a program that provides
all health care services for older adults who would otherwise
be in a nursing home, and the primary objective of the PACE
program is to keep patients at home as safely as possible, for
as long as possible and the key to the PACE programs are three
things. One is that they are fully integrated financially. Two,
is that they have the multi-disciplinary team, as Ranking
Member Scott mentioned, a one-stop shop that include nurses,
doctors, therapists, social workers, case managers, all with
one common goal, that they are fully accountable for the care
of the patient across the entire care pathway and then three,
is that they maximize again what matters most to patients, is
keeping them at home, in their communities, with their loved
ones, so some of the examples that they do a really good job on
is that every time someone joins a PACE program they do really
comprehensive patient assessments, full review of all of their
medical needs, they get into communication with all prior
physicians that have taken care of the person, and then they
try to ascertain what really matters to the patient, what
values do they really appreciate and what they want to really
preserve.
The second thing is that they create a plan that is unique
to each individual patient, based on those values. The third
thing is that they then coordinate all of the care, as I
mentioned, and it is usually in sort of in an adult daycare
type program, where the multi-discipline team operates and then
they are always communicating with family members and so I
think expanding the PACE program is a good option, especially
in areas where there are no integrated care models, so we can
think about ways of expanding the program. For example, one,
you can scale existing PACE programs by increasing current
capacity of existing PACE sites. The second thing you can do is
you can think about spreading the PACE program, which in order
to do so you need to offer incentives to other areas and states
where there are no integrated care programs or there is no
experience among the local health care providers in
participating in a PACE program.
As you might have mentioned, there is a big challenge for
the health care workforce to actually be certified to deliver
PACE-type care or nursing home care, and so that is an
important challenge that needs to be overcome and then the last
thing you can think about is changing the scope of the program,
which means expanding to other patient populations who do not
currently qualify, so for example, I would be really interested
in seeing if the PACE program model would be beneficial for
younger people with disabilities or younger people with serious
mental illness. I think that might be potential avenues of
exploration.
The Chairman. Okay, Doctor. Thank you very much. I will
turn to Ranking Member Scott.
Senator Tim Scott. Thank you, Mr. Chairman. As you imagine,
having the Chairman on your left and your former Chairwoman on
your right, the best I could do is defer to her first. Then I
will continue with my questions when it is my turn.
Senator Collins. First of all, thank you, Senator Scott.
You are always so gracious to me and I very much appreciate it.
I want to thank you both for holding this very important
hearing.
Dr. Figueroa, I want to start with you. As we have learned
today, listening to the testimony, and we know from our own
experiences doing casework in our State offices, the dual
eligible population is extremely diverse. Many people think of
it as, to use just three common words, as old, poor, and sick.
That really does not capture the diversity of those who are in
the dual eligible population.
For example, a dual eligible might be an 80-year-old woman
who requires assisted living services and has spent her
remaining income on medical expenses. It could be a middle-aged
woman with diabetes and pulmonary disease who requires a
variety of specialists. It could be a young person with
disabilities who lives at home and requires assistance with the
activities of daily living. Moreover, some dual-eligible people
are not actually costly, but the minority makes the duals
overall one of the most expensive groups for both Medicare and
Medicaid, so my point is that what is driving the cost is
different for each subpopulation. As we seek reforms to improve
the care and lower costs, where possible, how should we
evaluate policies that might better integrate care, knowing
that there is not one way? Could you give us some guidance on
that?
Dr. Figueroa. Thank you, Senator Collins. Yes, I think you
bring up a great point, and we should not expect, given the
diversity of the population you just described, we should not
expect that one strategy will work for everyone. A strategy
that might work in urban areas might not work in rural areas
and so what we need is we need better data to understand what
works for what specific populations, and in order to get to
that level of understanding we must do a better job at making
how we care and the different programs and the different plans
that care for dual-eligible patients, we need to understand
their effectiveness. We need to understand how well they
perform for these populations. We need to understand what
patient experience is like. We need to ask more questions of
patients to determine if they really think their care is
meaningfully different under these programs, and at the moment
we often have very lagged data that does not help us make
decisions today for how to improve care tomorrow. If you look
at a lot of evaluations out there, the evaluations are from
like data in 2012, 2013, 2014, and we are trying to make
decisions in 2022. That is very challenging for us, as
clinicians, to understand which care model to refer patients
too, and I am assuming for policymakers to figure out what
policy solutions they should be implementing at the Federal
level and at the State level.
If we can somehow make data better and more transparent and
also be able to drill down on which programs work for the young
duals with schizophrenia versus with the older, frail adult
living in a nursing home, I think we can then adopt and expand
the models that make more sense.
Senator Collins. Thank you, Doctor. The second issue I want
to touch on with you briefly is the challenges posed by the
workforce issues that we are dealing with. There was a recent
survey of long-term care facilities in Maine that found that 94
percent of Maine providers were experiencing a staffing
shortage, and more than half of the respondents replied that
their situation was at a crisis level.
At the same time, we know that these interdisciplinary
teams are an important component of integrating care for dual
eligible. So could you comment on how the workforce challenges
affect our ability to adopt and scale integrated care models
for dual eligible? Is this an area that should be more of a
focus for Congress?
Dr. Figueroa. Thank you, Senator. Yes, I agree that it
should be an area of more focus of Congress. We, as you said,
have staff shortages across the country, and I think the COVID
pandemic really exposed that vulnerability in our health care
system. For example, if you think of nursing homes, nursing
homes have significant nursing staff shortages, and the nursing
homes with those shortages were much more likely to be
decimated by COVID-19, and so one thing that we can think about
in terms of improving the workforce, one is we need to
compensate the workforce in certain areas better. We need to
provide appropriate living wages so that we have less turnover
and we have more people, good people, wanting to work in the
health care sector.
Another thing to think about is we need to think about
training a diverse workforce. We cannot expect to have doctors
in all areas of the country caring for the majority of
patients. In some areas we need collaboration with doctors and
other types of professionals. For example, you can think about
expanding community health workers to fill certain needs,
especially in low-income areas where shortages are a problem.
What kind of policies can we do to promote, for example,
more community health workers practicing across the country,
working side by side with clinicians and other health care
providers. One thing we could consider is how we pay for
community health workers, and we should think about
appropriately paying community health workers and not just them
providing volunteer services because they care about the
community and the people that live in their communities, and so
those things that I think Congress and states can consider.
Senator Collins. Thank you. Thank you again, Senator Scott.
Senator Tim Scott. Yes, ma'am.
The Chairman. Thank you, Senator Collins. I just want to
acknowledge, as well, as I said we will have Senators coming in
throughout the hearing. Senator Braun was with us and will be
joined by other Senators very soon.
I want to turn to Ranking Member Scott for his questions.
Senator Tim Scott. Thank you, Mr. Chairman. Let me ask Ms.
Medina, the Healthy Connections Prime demonstration was South
Carolina's first major effort targeted toward improving care
for dually eligible individuals. Ms. Medina, can you talk about
the lessons learned during this demonstration project, and how
do you envision its future, moving forward?
Ms. Medina. Thank you, Senator Scott. There has been great
success here in South Carolina with our duals demonstration
program. It really was here in South Carolina the first attempt
serving our duals, both in the medical services and long-term
care services together.
Having said that, we are at a point in the program --it is
a demonstration, and so we have been working with our partners
over at the Centers for Medicare and Medicaid Services to
figure out what are our next steps. I think there are
definitely opportunities to figure out what really works best
in the State and what we can take from the experience with
Healthy Connections into whatever we decide to design for the
future.
Senator Tim Scott. Thank you. Let me ask you another
question. I have just introduced legislation that would provide
states with one-time grant resources to improve care for dually
eligible beneficiaries. One possible use of this fund is for
State Medicaid offices to expand their understanding of the
Medicare program.
Is this something that you think states would benefit from,
and would other witnesses like to weigh in if they think it is
necessary.
Ms. Medina. For sure, I definitely think that when it comes
to Medicaid agencies obviously the focus is heavy on the
Medicaid population, Medicaid experience, and that
institutional knowledge that goes with it. As dual integration
has become such a hot topic, agencies are really looking
internally to better understand the Medicare rules and
processes, especially those states that have chosen to
participate in the dual demonstration program or that are
managing their duals special needs plans in their states.
I definitely think there is an opportunity that we would
welcome to further increase our institutional knowledge around
Medicare, so we can make the best decisions for our State.
Senator Tim Scott. Thank you. Would any other panelist like
to weigh in on the question as it relates to the benefits of
one-time resources, one-time grant money going to states to
help to bridge the gap in understanding and appreciating the
complexities of the two programs?
I will continue with Ms. Medina.
Mr. Heaphy. I am sorry.
Senator Tim Scott. Go ahead.
Mr. Heaphy. This is Dennis Heaphy. There is a potential
opportunity for increasing capacity and competency of our State
Medicaid offices to collect data that better aligns Medicaid
and Medicare information so that states can actually start
developing a data collection system that actually works, to
understand--I guess that is all I would say, is to have better
data collection systems.
Senator Tim Scott. Thank you, sir, for your comments.
With the balance of my time I would love to ask Ms. Medina
one last question here. There is always a natural tension
between the states and Federal Government about the amount of
Federal involvement in administering large programs like
Medicare. I believe that states are the best laboratories for
treating their own unique populations.
Do you believe that you have the appropriate amount of
flexibility to provide coverage to dually eligible individuals?
Ms. Medina. As a State Medicaid agency we definitely have
to navigate really complex authorities when we want to design
programs that best fit our agencies and our population.
Absolutely, there are definitely delays sometimes in new
processes or new guidance that they issue, but we continue to
work with them to figure out what are the best pathways that we
should take, especially when it comes to the various options
states have in how to implement their programs and the
corresponding authorities.
Senator Tim Scott. Thank you. Mr. Chairman, with my last 30
seconds as opposed to asking another question that someone will
not have time to answer, I think I would like to just point out
the importance of both having experts and people who are
actually dealing with the dual challenges of this complex
system. Thinking about Dennis' comments as it relates to having
to take his wheelchair a mile to a hospital, to get care, or
thinking about our other witness who has spoken so clearly
about not only Jane Doyle, her situation, but her mother's
situation.
There is something about hearing from experts who can help
illuminate the necessity of direction, but it also, I think,
incredibly informative and important to hear from witnesses who
understand the real-life pain and challenges that come with a
system built for them, but not really, and so I think having a
good balance has been helpful for me today.
The Chairman. Very well said by the Ranking Member. Very
complicated issues and very personal.
We will turn next to Senator Warnock, who is joining us
virtually.
Senator Warnock. Thank you so very much, Mr. Chair.
Medicaid is one of the most critical safety net programs in our
country, and it was created to expand access to health care for
low-income children or families or people with disability
because the Affordable Care Act allows states to expand
Medicaid, there are more than 10 million Americans who qualify
for Medicaid due to a disability. Many of these same
individuals also have Medicare, but there are currently more
than 300,000 Georgians eligible for Medicaid due to a
disability. However, that number would be higher if my home
State of Georgia would finally expand Medicaid, expand this
lifeline program to more low-income individuals, individuals
who live in the coverage gap, 275,000 Georgians in the Medicaid
coverage gap, 500,000 uninsured Georgians, 646,000 Georgians
who would qualify for free and affordable health coverage if
Georgia joined the other 38 states and the District of Columbia
in expanding Medicaid.
Mr. Heaphy, in your testimony you highlighted that not
every State has provided innovative ways to ensure people have
access to health care services like yours has. Can you talk now
about the implications of living in a State that has not
expanded Medicaid/Medicare disabilities and you are no longer
eligible for the program?
Mr. Heaphy. I would not be here testifying. I would
probably even be in a nursing home or isolated in my home or
not alive, and I am not being hyperbolic about that. It is very
challenging for anyone with a disability to be able to live,
even with Medicaid services, and without eligibility it is even
more devastating.
I think something that needs to be considered too is work
requirements, that for someone like me, I love working. The
importance of working to me is--it is important to me, and the
opportunity to work in Massachusetts is great. However, a work
requirement scares me, because it disproportionately impacts
folks with substance use disorder, folks with mental health
diagnoses, folks who may not be able to demonstrate the level
of disability that is required to be eligible for Medicaid
under the Medicaid requirements.
For me, access to Medicaid is the first step toward
accessing health care, and the lack of ability to get Medicaid
is really just--it is really just a human rights issue as well
as a civil rights issue, so I would not be able to live in
another State. I live in Massachusetts because of the health
care system here. I have been offered jobs in other states and
I have not been able to take those jobs because of the lack of
supports provided. In Massachusetts I can actually increase the
amount of money I make and still maintain my Medicaid benefits
and so the ability to maintain Medicaid benefits over time,
that supports my ability to work.
I think what is important is really to look at how to
incentivize the ability of people to get Medicaid and work at
the same time without penalizing people who cannot work. I do
not know if that answered your question or not, but that is
what came to mind as you were talking.
Senator Warnock. Sure. Absolutely it answers my question,
and to your point, after just 10 months of Arkansas' Medicaid
work requirement, for example, some 18,000 poor and disabled
folks lost their health care coverage, after just 10 months
with this work requirement. I live in a State that has an
expanded Medicaid and what I am hearing from you is that you
might not be alive if you were just in the wrong State and the
wrong ZIP code.
I happen to think that health care is a human right, and if
it is a human right it is not a human right in 38 states. It is
a human right in all 50 states, where we have an Affordable
Care Act law that has been on the books for 10 years.
Thank you so very much for your courage and for your
witness today.
Mr. Heaphy. Thank you.
The Chairman. Thank you, Senator Warnock. I will continue
with my questions and may turn to the Ranking Member after
that, and then I think we will have Senator Gillibrand after
that.
I want to turn back to Jane Doyle. Jane, you highlighted
how difficult it was to help your mother apply for and enroll
in the care that she needs. In your testimony, you talked
about, ``several applications,'' and having to attach,
``hundreds of documents,'' hundreds. You also describe your own
experience applying for Medicaid at different points in your
life while you had Medicare, while you were working and when
you could no longer work.
At various points you turned to nonprofit organizations
like the Pennsylvania Health Law Project and the Medicare
Rights Center for help. I imagine there are so many people
listening at home who can relate to your story. As Ranking
Member Scott made reference to, it is so important to hear from
people that are living through these challenges.
Jane, are there things that could have made the application
and enrollment process easier for you and easier for your
mother to navigate?
Ms. Doyle. Thank you, Senator. Well, it was a little more
clear for basic Medicaid for myself, but for my mom it was not.
In short, I think the answer would be to make the whole process
quicker, but that might be exactly realistic. A certain degree
of prudence obviously certainly needs to ensure compliance of
the programs.
I will say for what we call in Pennsylvania as nursing
home-level care Medicaid, the big issue I had was the $7,000
asset mark, and so with the $7,000 asset mark for a person with
very, very high needs, that money is spent very, very quickly.
First, as I mentioned in my testimony, you have to qualify for
Medicaid, and not everyone is already qualified for Medicaid,
and then you go on to the next application of waiver, so these
dual applications can take two to 3 months, and as you can
imagine, $7,000, when $7,000 a month is going out for high
needs, that is not going to last you that duration.
Possibly, that limit may be able to be increased to allow
people the time needed to get through the process, may be one
way. The other way may be integrating. We have talked a lot
about that during this meeting, but possibly integrating that
process of applying for Medicaid and waiver together, you know,
may make that more efficient.
Also in my case, this may be local but it would really be
great if they update, you know, local government update their
websites and make sure they have the correct forms online so
that people can access those and that you can upload those
documents that we mentioned earlier. That would be far easier
than having to photocopy a book to get down to the county
assistance with your process.
The other thing that I will talk about, there are a lot of
programs for help to reach out to, but I myself found myself
making numerous phone calls before I found the correct source.
I cannot imagine that, you know, elderly people with maybe
fewer skills or a bit of confusion, I cannot imagine how they
might get through the process. I would suggest perhaps more
awareness, and designate maybe one agency that fields people to
the right resource. You know, that might be helpful.
My first resource, which unfortunately was not all that
helpful, was the local Office on Aging. I did not find them
particularly resource knowledgeable, but I think elderly might
tend to go there. That might be a good place to start for
people to find out where they need to be guided for specific
issues for this massive, massive system.
The Chairman. Jane, thank you very much, and thank you for
giving us your perspective from the perspective you have, which
is very practical.
I will turn to Ranking Member Scott.
Senator Tim Scott. Thank you, Mr. Chairman, and I will also
note that some of the comments that we have heard during the
hearing about the importance of understanding and appreciating
the path back to work for Medicaid and some of the challenges
they face, especially for folks--in Dennis' situation, I think
there is always going to be a carve-out or a second look at the
concept of Welfare-to-Work. I do believe that Bill Clinton,
President Clinton's approach to Welfare-to-Work, in his 1992
campaign, that he actually was able to pass through, was
overall good for the country and good for people, and frankly,
something I completely support.
I do believe that we should always take into consideration
special exceptions when necessary, but the path forward
certainly, I think, is a good one overall.
Dr. Figueroa, may I ask you a question about the challenges
that you find dually eligible beneficiaries facing when
receiving care? I think Chairman Casey did a really good job of
really simplifying this web of challenges of paperwork and the
streams of challenges that come along with those binders that
you are trying to find your way through when you are looking
for help in all the wrong places because the paperwork jigsaw
puzzle seems to be missing a few pieces, but beyond that, can
you talk about some of the other challenges that dually
eligible beneficiaries face when receiving care?
Dr. Figueroa. Thank you, Ranking Member Scott. As you
mentioned, the administrative web and complexity is a wall to
access health care. It is a wall that people have to climb over
to access health care. As we mentioned, these are very
vulnerable people, living in poverty, some people with limited
health literacy, some people with limited computer proficiency,
and that wall is insurmountable for some, and these are the
people that need care the most. These are the people that want
to be at home, living with family and their friends, and these
are the people that are, unfortunately, stuck behind this wall.
This wall prevents them from, for example, if they need medical
equipment to be at home and they have to call two different
insurance programs, they sometimes have to wait to be denied by
the Medicare program before they can ask the Medicaid program,
you know, can you cover this medical equipment that my doctors
and my therapists say that I need to be safe, so I can get
around my home safely, so I do not have to fall at my home?
You know, the two different programs, sometimes as well, in
getting payments for their hospital care and trying to figure
out the sharing between the two different programs, also in
terms of how long can they be in a nursing home and how many
days is covered by the Medicare program before the Medicaid
program kicks in.
It is all a wall that complicates the lives of not just
patients and families but also to us, the clinicians and the
health care providers and instead of us spending time taking
care of the patients and improving their health, we are
spending time on the phone trying to figure out how to get the
care they need, and that is a problem in our country and I
think we need to fix it and the way to do it is by integrating
everything, creating one true program, having one pot of money
where the people and the health care providers that are
responsible for the patients can use it to ensure that they can
cover everything that the person needs.
Senator Tim Scott. Thank you. Thank you very much.
Ms. Medina, dual-eligible program enrolls only a fraction
of those who are eligible for these plans. How can states
enroll more people in plans that work for them?
Ms. Medina. In South Carolina I hope to approach this in
two ways, first by streamlining our programs. As I mentioned
earlier, when you have so many options it is hard for
beneficiaries to really understand which direction to go, so if
you offer them one really good program or just a couple, I
think that makes things easier for them.
I also hope to, here in South Carolina, to bolster our
customer service approach. I think that the State Medicaid
agencies are truly a safety net for beneficiaries and providers
and we have a responsibility to be available to them when they
encounter the roadblocks that we discussed today.
Senator Tim Scott. Thanks very much. Mr. Chairman?
The Chairman. Ranking Member Scott, thank you very much. I
want to move to a question for Mr. Heaphy regarding home and
community-based services. I mentioned earlier we have got
legislation to provide more of those opportunities, and you,
Mr. Heaphy, had mentioned in your testimony the importance of
those services in keeping you independent and giving you a high
quality of life.
I note, on page 3 of your written testimony, you said,
``what I need most are home and community-based services and
supports,'' and you later noted that your personal care
attendant often participates in conversations with you and
members of your care team.
You testimony spoke to the importance of making sure that
these services are available to all who are eligible, and the
inequality in availability of these services across states, so
that is why we have introduced the Better Care Better Jobs Act.
From your perspective, Mr. Heaphy, how would a robust
investment in these services impact the lives of people with
Medicare and Medicaid across the country?
Mr. Heaphy. I think--so many things come to my mind, but
first it is to recognize HCBS has a means of offsetting
institutional bias for folks who have Medicaid and Medicare.
Myself, I am someone who is nursing home eligible, and for me I
would be in a nursing home, as I said before, if I did not have
the HCBS services I receive.
I think it is important that people be able to remain in
the community with folks they love, people in their family,
rather than being isolated in an institution and away from the
folks who provide their supports.
I also think it is important that states maintain a
commitment to allowing people to remain in the least
restrictive setting possible. There is mounting evidence that
shows increased choice, satisfaction, and personal outcome
achievements are associated with home or residential settings
of smaller size. People with disabilities living in smaller
settings are also more likely to achieve positive outcomes and
to experience improved personal support related to quality of
life than individuals living in larger settings.
I think probably the most important aspect of HCBS to
consider is that it is important to look at the lifespan
approach and recognize that the needs of children and families
are very different than folks who are adults or older folks,
and if HCBS is solely determined on medical necessity it does
not take into consideration the developmental milestones of
kids with disabilities. I think for those of us who learned how
to drive, have a driver's license, and know how important that
milestone was in our lives, to go independently and do things
for ourselves, I think this is also true of children with
disabilities, that they have the opportunity to have a
wheelchair that they can actually use, one that meets their
needs in terms of meeting a milestone as opposed to just a
medical necessity requirement is really important. An expansion
of understanding what determination of need is.
I think it is also important that day habilitation service
is not being in default for folks with high LTSS needs, whether
it be adults with developmental disabilities or a mental health
diagnosis, that the promise of integrated care is to really
provide tailored HCBS services that really meet the person's
needs and provide them the greatest opportunities to live in
the community. I have experienced that here myself, you know,
as a dual eligible, and if I were not able to shape my LTSS
services I think I would be in a very different situation.
I guess I would also say, which is really important,
personal care attendants. They are so woefully underpaid and
underappreciated. They are in the homes and they are doing work
that nobody else wants to do, a lot of folks cannot do the
work, and yet the amount of money they make is not there. My
PCAs engage in what is considered the nursing level activities.
That includes changing my catheter, doing wound care, and
assisting with my bowel program and they are doing all this
work and not receiving the money that they really need to live
in the community.
An example would be in Massachusetts, which is very
generous--PCAs make over $17 an hour. However, the living wage
in Boston is actually over $19 an hour, and for someone who has
a child, that is over $39 an hour for a person to actually have
a living wage and so as HCBS is being though out and
determined, that the wages of folks doing this direct community
work needs to be considered.
The last thing I would say is that it is really important
that the consumer-driven model be central to HCBS. I am a
consumer employer and my PCAs work for me and not an agency, I
am able to direct my care to them and they are part of my
schedule. I am able to travel for work. I am able to do things
in the community that I would not be able to do in an agency.
There is definitely a place for the agency model. However, for
folks like myself who really need that flexibility to engage
with the community, we need that opportunity to live in the
community using these PCAs, and with COVID, if not for my
personal care attendants coming into my home, I would have been
devastated, because of the relationship my PCAs and I have with
each other, they were dedicated and came to my home during
COVID, despite putting themselves at risk, and so I cannot say
more than just making sure that these folks get reimbursed at
adequate rates.
The Chairman. Mr. Heaphy, thanks so much for your personal
testimony, based upon your own experience and being a voice for
those workers who are among the folks that we hope to be
helping with some investments in home and community-based
services that are not available today.
Mr. Heaphy. Can I just add one more thing, Senator? I am
sorry.
The Chairman. Yes, quickly, because I want to turn to the
Ranking Member.
Mr. Heaphy. Sure. I think it would be really helpful to
institute like the national core indicators across the country
and also HCBS caps, because this would give us a better sense
of the quality and access to HCBS and the outcomes. That is the
only other thing I would say, is having that national snapshot
of how states are doing and perform, where HCBS is going, is
critical.
The Chairman. Well thanks very much. We are waiting for
some other Senators who have had to juggle things. We hope they
arrive, but in the interim, Ranking Member Scott, do you have
additional questions?
Senator Gillibrand. Mr. Chairman, I just joined if you want
to call on me.
The Chairman. Oh. Senator Gillibrand, right on the money.
Senator Gillibrand. Thank you. I have competing hearings.
A quick question for the whole panel. How should we be
thinking about incorporating community health workers into
integrated Medicare-Medicaid plans, and do you have any
examples where this is already being done, particularly when it
comes to navigator and ombudsman services?
Dr. Figueroa. I can go ahead and start, if you do not mind.
Thank you, Senator Gillibrand. I think community health care
workers play an important role as the liaison, as you know,
between the health care system, social service organizations,
and the patients in their community, and they are generally
well-trusted people who understand the values of their
community as well. It is potential workforce that should tap
into, especially in areas where there is limited workforce and
limited health care infrastructure, and the key, though, for a
successful community health worker relationship with the
patient is that they must be integrated with the care team. If
they are only in the community and not necessarily integrated
with the care team it is not going to be a successful
relationship, unfortunately, and so really trying to promote
integration is key.
I do know of one example in Massachusetts, for example,
that under the 1115 demonstration Massachusetts made all of
their Medicaid patients participate in ACOs, and in that there
was a lot of funds that went into hiring community health
workers, training community health workers, operating in areas,
for example, in western Massachusetts, where there are not as
much providers as eastern Massachusetts. To date, about 1
million people are in these Medicaid ACOs, and the evidence to
date, in a recent survey, showed providers in ACOs think that
community health workers are operating well with social service
organizations and improving patient experience.
Senator Gillibrand. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Gillibrand.
We are going to move to our closing statements at this
time. I want to thank, of course, Ranking Member Scott for
hosting this hearing with me and the work that he has done on
the legislation that we have introduced, so I want to thank him
for that work.
I also want to thank our witnesses for their invaluable
input, and as we noted earlier their personal experiences.
As we heard today, people with Medicare and Medicaid face
many challenges in navigating the health care system generally,
but in particular these challenges that our witnesses outlined
today. This challenge that they face will impact their overall
health and their quality of life, so we have work to do.
The people that testified today, whether it was Jane or
Dennis or others, who shared their stories, these stories help
us in Congress to formulate policy and propose legislation to
make these programs work better. Their health care system
should provide support for them rather than adding yet another
headache and so much confusion.
Jane Doyle, for example, should not have to worry about
getting a surprise bill in the mail after a doctor visit,
wondering if she is on the hook for that bill or not. Dennis
should not have to go to the emergency room because he cannot
get hold of his plan's care team, who were supposed to be there
to help him.
We need to make sure that the care delivery models
available to people with Medicare and Medicaid meet their needs
and meet their preferences. That is why we must pass the PACE
Expanded Act that Senator Scott and I have introduced, to
increase the availability of these programs, and it is why we
should make a permanent investment in home and community-based
services to help seniors and people with disabilities remain
with their families in their communities, so we are grateful
for the testimony of our witnesses, and now I will turn to
Ranking Member Scott for his closing statement.
Senator Tim Scott. Thank you, Mr. Chairman, for holding,
once again, a really important hearing for so many Americans
who are looking for more information, and frankly, more reasons
to be hopeful as they deal with declining health and other
challenges that too often come with aging.
Today we learned about the challenges of caring for dual
eligibles. There are numerous gaps in policy and knowledge that
contribute to these challenges. As the son of a caregiver--my
mother, as I have said a number of times, has been a nurse's
assistant for her entire career. Last week I was visiting her
at the hospital and this week is her 49th year at the hospital,
and she loves her patients. She loves what she does because she
really loves the thought of making a difference, and in today's
world I think we need more people dedicated to a mission.
Whatever that mission is for you, we should all be thankful
that people have the mission of providing care for those who
cannot care for themselves.
The Supporting Care for Dual-Eligible Individuals Act will
help fill some of those gaps. This legislation will help states
provide the care this population so desperately needs, and the
testimonies today only reinforce, if not amplifies the
importance of that truth.
I will make two other points that I think are really
important. Number one, Dennis and so many others have done a
really good job of helping us to understand and appreciate the
importance of home health care. While you can sometimes get
into a senior facility or, as my mother working in a hospital,
so many people prefer their care to be given in the environment
that is best for them, and that environment so often is at
home.
I think all that we can do to help people receive the care
they need in the place of their preference is really an
important part of health, because peace of mind and health are
so often synonymous. Not only is there the mental health
component but there is the physical health being delivered in
your home, where you are comfortable, where you know where
things are cannot be overstated, to be honest with you, and I
think that very often providing home health care is actually
better overall in a system that has limited resources, and it
does not seem that we do, but when we are spending over $550
billion or so for Medicare and nearly $400 billion for
Medicaid, and over $400 billion for veterans benefits as well,
we run into the challenge of limited resources. I think we can
take our resources further by focusing on a delivery system
that is so often at home.
The final comment I would make is that as we think through
the unbelievable challenges of the pandemic, one of the more
important points is the delivery system of virtual health care.
To have patients, as we spoke about today, being able to see
their doctors from their homes, when possible, really helpful.
I hope we continue, as a Nation, to move in the direction of
providing virtual health care as a priority and as a priority
delivery system, because I believe that not only will it help
us take care of our patients, but it will also help us spend
the limited pot of resources in the most effective way
possible, providing amazing assistance of care for those who
desperately need it.
Thank you again, Mr. Chairman, for this hearing, and I look
forward to the next one.
The Chairman. Thank you, Ranking Member Scott. Thanks very
much.
I want to thank you again and thank all the witnesses again
for their expertise and their time today. If any Senators have
additional questions for the witnesses or statements to be
added the hearing record will be kept open for 7 days, until
next Thursday, February 17.
Thank you all for participating. We are adjourned.
[Whereupon, at 11 a.m., the Committee was adjourned.]
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APPENDIX
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Prepared Witness Statements
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Questions for the Record
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