[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

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

                                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
                               
                               ----------
                              
                 Stacy Sanders, Majority Staff Director
                 Neri Martinez, Minority Staff Director
                          
                          
                          C  O  N  T  E  N  T  S

                              ----------                              

                                                                   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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